Demoralisation and adjustment to medical illness — structured clinical viva

Open with a syndrome map. Hold demoralisation (pointless, burden, trapped; retained reactivity), possible adjustment disorder after prognostic stressor, major depression (must be positively confirmed or excluded), and DHD as concurrent possibilities — do not collapse them into one label.[1][2][4]

Define demoralisation. Clarke and Kissane: subjective incompetence and meaning collapse under illness threat. Kissane demoralisation syndrome is a clinically useful construct in progressive disease even without a DSM code.[1][2]

Measure. Name Demoralisation Scale / DS-II; high scores support severity tracking but do not replace clinical diagnosis of MDD.[3]

DHD. Treat as signal: depression, hopelessness, demoralisation, uncontrolled symptoms. Breitbart: depression and hopelessness independently predict DHD.[4]

Therapies. Name dignity therapy, meaning-centred psychotherapy, CALM — not "supportive chat."[5][6][7]

Antidepressants. Indicated for full MDD with trial window (Rayner) — e.g. sertraline 25–50 mg oral daily start — not automatic for pure demoralisation.[8]

Capacity. Decision-specific for chemotherapy refusal: understand, retain, weigh, communicate. Severe depression or demoralisation-related hopelessness may distort weighing; optimise symptoms and mood, reassess, document — dying does not equal incapacity.[4][8]

Demoralisation ≠ MDD ≠ normal grief ≠ delirium. Adjustment disorder has DSM/ICD stressor-timing rules. Demoralisation is construct/syndrome language (Clarke/Kissane), measurable (DS/DS-II).[1][2][3]

Symptom control + safety + meaning therapies first for demoralisation/adjustment; antidepressants when MDD criteria met; reassess DHD after treating drivers; joint oncology–palliative–psychiatry plan.[4][5][7][8]