title: Symptom burden, loss of dignity, and demoralization in patients with cancer: a mediation model.
abstract: BACKGROUND
  Demoralization is a syndrome of existential distress that occurs in a substantial minority of cancer patients and is associated with a higher number of physical problems. Loss of dignity refers to a range of specific existential concerns. This study examines whether the association between number of physical problems and demoralization is mediated by loss of dignity.
  
  
  METHODS
  This cross-sectional study examined N = 112 inpatients with mixed tumor sites at early and advanced disease stages using the following standardized self-report questionnaires: Physical problems list of the National Comprehensive Cancer Network (NCCN) Distress Thermometer (DT), Patient Dignity Inventory (PDI), Demoralization Scale (DS), Patient Health Questionnaire-9 (PHQ-9) and Illness-Specific Social Support Scale Short Version-8 (ISSS-8). The mediation hypothesis was tested by multiple regression analyses controlling for age, gender, curative versus palliative treatment phase, and social support.
  
  
  RESULTS
  Patients reported M =  .7 (SD = 6.0) dignity-related problems; 20% showed moderate to severe demoralization. Loss of dignity significantly mediated 81% of the effect of the number of physical problems on demoralization (Sobel zs = 4.4, p < .001). Testing the reverse direction, we found that demoralization mediated only 53% of the association between physical problems and loss of dignity (zs = 3.7, p < .001).
  
  
  CONCLUSIONS
  By supporting the mediation hypothesis, our results indicate that loss of dignity partially explains the association between physical problems and demoralization. Early recognition of dignity-related existential concerns and interventions to enhance the sense of dignity may prevent demoralization in patients with cancer. Results provide a conceptual link between existential concerns (loss of dignity) and existential distress (demoralization) as two approaches to existential suffering in patients with cancer.
authors.affiliation: Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Sigrun
authors.initials: S
authors.lastname: Vehling
authors.forename: Anja
authors.initials: A
authors.lastname: Mehnert
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D000368:Aged; D017281:Cost of Illness; D003430:Cross-Sectional Studies; D003863:Depression / Q000209:etiology / Q000523:psychology*; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D009013:Morale; D009369:Neoplasms / Q000523:psychology* / Q000628:therapy; D010166:Palliative Care / Q000523:psychology; D028723:Personhood; D011788:Quality of Life; D012044:Regression Analysis; D013315:Stress, Psychological / Q000150:complications / Q000175:diagnosis / Q000523:psychology*; D011795:Surveys and Questionnaires; D019452:Terminally Ill / Q000523:psychology*
keywords: cancer; demoralization; existential distress; loss of dignity; oncology; physical symptoms