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The Demoralization Scale: A Report of its Development and Preliminary Validation
Abstract
The development and elaboration of a conceptualization of existential distress in patients with advanced disease is crucial in order to optimize our clinical response within palliative medicine. Demoralization is one expression of existential distress. Its empirical study will be greatly enhanced by a self-report measure that captures its dimensions and intensity. We report here on the development and testing of the Demoralization Scale in 100 patients with cancer. Factor analysis identified five relatively distinct dimensions: loss of meaning, dysphoria, disheartenment, helplessness, and sense of failure. These factors show high internal reliability, and convergent validity with the McGill Quality of Life Scale, Patient Health Questionnaire, Beck Depression Inventory, Beck Hopelessness Scale, Hunter Opinions and Personal Expectations Scale, and the Schedule of Attitudes toward Hastened Death. Its divergent validity is demonstrated through the differentiation of a subgroup of patients with high demoralization who do not meet DSM-IV categorization for a diagnosis of major depression. Confirmatory validation is needed for the scale to be used as a measure of change in interventions designed to treat demoralization.
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In the citing paper
“Kissane et al. (13) obtained a Cronbach's alpha of this questionnaire of 0.94. In Iranian society, Sarizadeh et al. (14) Cronbach's alpha of this questionnaire in patients with cancer reported 0.82.”
From Acceptance and commitment therapy for demoralization syndrome and cancer-related trauma: A randomized clinical trial study (2021) · cites this paper as Kissane et al. (13)
In the citing paper
“The DS is a 24-item Likert scale (score range 0–96).6”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“It has five subscales: loss of meaning and purpose, dysphoria, disheartenment, helplessness, and sense of failure.6”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“and negatively associated with hopefulness (two studies, n = 200)”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“Uniformly, the evidence indicated a strong negative relationship between demoralization and quality of life (five studies, n = 675).”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“Alternatively, when the DS was used, rates of demoralization were reported dimensionally, with 13%–18% calculated as having clinically significant demoralization.6,22,30,33,35,36,39”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“There were consistent findings for a strong positive relationship between demoralization and depression (11 studies, n = 2372)”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“and a desire for hastened death (three studies, n = 442).”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“In four of the five validation studies, divergent validity was reported.6,13,30,39”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“yet palliative care has recognized the salience of pointlessness to the will to live.6,22,41”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“Establishing consistency in diagnostic criteria will presume an accepted definition of demoralization, leading to an increased opportunity to empirically validate the syndrome across clinical settings and cultures.3,6”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
In the citing paper
“Of the studies examining psychometric properties of demoralization measures, there was consistent evidence to suggest that the DS has convergent validity and internal reliability for the total scale.6,13,22,30,39”
From A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research (2015) · cites this paper as [6]
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Metadata
- Authors
- Kissane, D. W., Wein, S., Love, A., Lee, X. Q., Kee, P. L., & Clarke, D. M.
- Affiliations
- Memorial Sloan Kettering Cancer Center (US)
- The University of Melbourne (AU)
- Monash University (AU)
- Venue
- Journal of Palliative Care
- Publisher
- SAGE Publications
- Published
- 2004-12
- Volume
- 20
- Issue
- 4
- Pages
- 269-276
- ISSN
- 0825-8597 (ISSN-L)
- 2369-5293
- OpenAlex
- W1862997372
- Cited by
- 442
- References
- 33
- Citations by year
- 2026: 36 · 2025: 38 · 2024: 43 · 2023: 30 · 2022: 34 · 2021: 32 · 2020: 22 · 2019: 18 · 2018: 20 · 2017: 25 · 2016: 14 · 2015: 14 · 2014: 13 · 2013: 29 · 2012: 7
- FWCI
- 6.11
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Palliative Care (publishedVersion)
- PubMed (publishedVersion)
- FedUni ResearchOnline (Federation University Australia) (submittedVersion)
- Funders
- McGill University
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Keywords
- demoralization, existential suffering, Demoralization Scale, scale development, cancer patients, palliative care, meaninglessness, helplessness, sense of failure, dysphoria, hopelessness, major depressive disorder, self-report measures, convergent and discriminant validity
- MeSH terms
- Anger, Attitude to Death, Attitude to Health, Depression, Existentialism, Factor Analysis, Statistical, Female, Guilt, Helplessness, Learned, Humans, Male, Middle Aged, Morale, Neoplasms, Psychiatric Status Rating Scales, Psychometrics, Quality of Life, Stress, Psychological, Terminal Care, Victoria, Self Efficacy
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