The Demoralization Scale: a Report of Its Development and Preliminary Validation DAVID W. KISSANE, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York, USA, and Centre for Palliative Care, Department of Medicine, University of Melbourne (Sl. Vincent's and Peter MacCallum Cancer Institute), Melbourne; SIMON WEIN, Centre for Palliative Care, Department of Medicine, University of Melbourne (Sl. Vincent's and Peter MacCallum Cancer Institute), Melbourne; ANTHONY LOVE, Centre for Palliative Care, Department of Medicine, University of Melbourne (Sl. Vincent's and Peter MacCallum Cancer Institute), Melbourne, and School of Psychological Sciences, La Trobe Liniversity, Bundoora; XIU QING LEE and PEl LEE KEE, Centre for Palliative Care, Department of Medicine, University of Melbourne (Sl. Vincent's and Peter MacCallum Cancer Institute), Melbourne; DAVID M. CLARKE, Department of Psychological Medicine, Monash University, Clayton, Australia 269 Abstract I 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. De- moralization is one expression of existential distress. Its empirical study will be greatly enhanced by a self- report measure that captures its dimensions and in- tensity. We report here on the development and test- ing of the Demoralization Scale in 100 patients with cancer. Factor analysis identified five relatively dis- tinct dimensions: loss of meaning, dysphoria, dis- heartenment, helplessness, and sense of failure. These factors show high internal reliability, and con- vergent validity with the McGill Quality of Life Scale, Patient Health Questionnaire, Beck Depression Inven- tory, Beck Hopelessness Scale, Hunter Opinions and Personal Expectations Scale, and the Schedule of Attitudes toward Hastened Death. Its divergent valid- ity 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. Resume I Le developpernent, l'elaboratlon et la con- ception d'un instrument pour mesurer la detresse existentielle chez les patients en phase avancee de la maladie est une etape cruciale vers I'optimisation des soins cliniques en medeclne palliative. L'etat de demoralisation est un des signes de detresse existentielle et son etude empirique pourrait en etre grandement amelloree en ulilisant un instrument d'autoevaluatlon qui en capturerait toutes les dimen- sions et l'intensite, Cet article porte sur Ie developpe- ment d'une echelle destinee a mesurer la demorali- sation que nous avons vallde aupres de 100 patients atteints du cancer. Lors de I'analyse de facteurs de demoralisation nous avons identitie cinq dimensions relativement distinctessoit la perte du sens de la vie, la dysphorie, Ie decouraqement, les sentiments d'lrnpuls- sance et d'echec, Ces facteurs demontrent un haut deqre de fiabillte et de convergence avec l'Echelle d'evaluatlon de quante de vie de McGill, I'lnventaire des signes de depression de Beck, I'Echelle de l'etat de decouraqernent de Beck, l'Echelle portant sur les opin- ions et attentes personnelles de Hunter de rnerne que son Echelle mesurant Ie desir de mourir chez les pa- tients en phase terminale. Sa valldlte divergente apparait a travers la differentiation d'un sous-groupede patients ayant dernontre un haut niveau de demorali- sation tout en ne satisfaisant pas a la cateqorle DSM- IV de diagnostic de depression majeure. II faudrait que I'echelle soit a nouveau valldee aupres d'autres pa- tients pour qu'elle puisse etre utilisee comme instru- ment valide pour mesurer Ie deqre de demoralisation et ainsi soigner cet etat. INTRODUCTION Demoralization is an important expression of existential distress within palliative care (1). As a mental state, its dimensional nature spans a spectrum from disheartenment at one end through despondency to profound despair at the other. Its importance conceptually is not only be- cause of the suffering it entails, but because it can be differentiated clinically from depression in a subset of patients. While demoralization may be a harbinger of severe depression or a subthreshold depressive state, and indeed might coexist with anhedonic depression, its capacity to exist sepa- rately and independently highlights the need for further empirical delineation (2). Based on both an extensive review of the litera- ture and our clinical experience, we proposed in this journal that demoralization syndrome be rec- ognized as a distinct psychiatric disorder in which loss of meaning and hope can potentially spoil any sense of a worthwhile life and future (1).The demoralized patient expresses nonspecific dys-