Humanizing questions. Exploration of the existential dimension in psychiatry through research on demoralization in patients with schizophrenia

Humanizing questions. Exploration of the existential dimension in psychiatry through research on demoralization in patients with schizophrenia. 

(Doctoral thesis offered to obtain the degree of Doctor of Psychological Sciences, 2019). Supervisors: Prof. dr. Jozef Corveleyn and Prof. dr. Bernard Sabbe (UAntwerp). Co-supervisor: Prof. dr. Patrick Luyten.

Background In patients with a severe psychiatric disorder, it is not uncommon to see signs of mental suffering, disheartenment, loss of hope, and suicidality, sometimes in spite of due treatment and psychosocial rehabilitation. This is also called demoralization.

Question Does this concern symptoms of a psychiatric disorder, such as depression, which must be treated as such, or does it concern mental suffering in the perspective of an existential problem due to the disruptive effect of the severe psychiatric disorder on life and the perspective of life?

Method Based on this question, we carried out a systematic literature review on hopelessness in patients with schizophrenia and on the concept of demoralization. Accordingly, a literature review on the concept of hopelessness was carried out, as well. In addition, empirical research was carried out on demoralization in as large a sample as possible in a Flemish population of adult patients suffering from schizophrenia (n=81) with the aim of examining (1) the factor structure of the demoralization scale, which has already been studied in several target groups, but not yet in a group of patients with schizophrenia, (2) the internal consistency of the subscales found, (3) the construct validity of the demoralization scale with a special focus on the demoralization/depression distinction, (4) the prevalence of demoralization in the population studied, and (5) the possible role of demoralization in the association between insight and suicidality.

Results The literature review reveals the concept of demoralization as a set of concurrent phenomena: (1) meaninglessness and purposelessness, (2) hopelessness and helplessness, (3) problems with coping and meeting one’s own expectations and those of others, (4) sense of failure or pointlessness, leading to a tendency to give up, to withdraw, or to end one’s life.

The literature points to a number of descriptive differences between demoralization and depression; empirical research indicates that depression and demoralization are related yet distinct concepts.

For some authors, demoralization is a psychiatric disorder; others contest this and claim that demoralization is an existential suffering.

The findings of our research confirm the validity of the demoralization scale for measuring demoralization in schizophrenia. Our findings confirm that demoralization and depression are two related yet distinct concepts. Demoralization occurs to a large extent in the studied population. The association between insight and suicidality appears to be fully mediated by demoralization.

The occurrence of demoralization requires a tailored approach with, in addition to the most effective treatment of the severe psychiatric disorder, the development of a caring relationship with relational depth, all kinds of actions in terms of cognition and behaviour, the promotion of connectedness and trying to integrate the disorder and its consequences into the life history.

Conclusion The phenomenon of demoralization points to the importance of the concern and care for the existential dimension in psychiatry and for fostering and sustaining hope. Failure to respect the existential dimension fails patients and is harmful to person-centred psychiatric care.