Demoralization syndrome as a state of deprivation of basic psychological needs: the connection to self-determination theory and its relevance to healthcare contexts

That most people show considerable effort, agency, and commitment in their lives appears, in fact, to be more normative than exceptional, suggesting some very positive and persistent features of human nature. Yet, it is also clear that the human spirit can be diminished or crushed.

—Richard M. Ryan and Edward L. Deci



Demoralization Syndrome is an emerging clinical entity that has been defined as “a prolonged and generalized (i.e., at least 1-month duration) feeling state characterized by the perception of being unable to cope with some pressing problems and/or of lacking adequate support from others (helplessness), and yet the individual maintains the capacity to react emotionally to stimuli.”

First described by Frank in 1961, demoralization syndrome has been proposed as a clinical entity distinct from major depressive disorder and dysthymia. A distinguishing feature of demoralization syndrome is the involvement of environmental factors in its etiology. Fava explains that recurrent stressors “contribute to allostatic load or overload, defined as the ‘cumulative biological burden exacted on the body’s systems due to repeated adaptation to stressors over time.’ Indeed, demoralization can be conceptualized as a clinical manifestation of allostatic load/overload, rather than purely a reaction to acute stressors.”

Recent evidence obtained through modern methods in neuroscience, such as resting state fMRI, offers compelling support for demoralization being neurobiologically distinct from depression. For example, incentive salience and reward anticipation are thought to be mediated by dopamine projections from the midbrain, while hedonic tone and reactivity to stimuli may be mediated by serotonergic and noradrenergic projections from the prefrontal cortex to certain areas of the limbic system.

Directly relevant to demoralization syndrome, but not yet linked with demoralization syndrome, is self-determination theory, a leading theory of human behavior. According to self-determination theory (SDT), humans have basic psychological needs for competence, autonomy (as volition), and relatedness. Richard Ryan and Edward Deci, the co-authors of SDT, write, “Like physical needs, these [psychological] needs are said to be objective phenomena in that their deprivation or satisfaction has clear and measurable functional effects.” Satiation of basic psychological needs is strongly correlated with intrinsic motivation and social integration, while starvation of these needs is predictive of impoverished functioning and motivational depletion.

Deci and Ryan further write, “To explain the causes of such diminished functioning, SDT suggests turning first to individuals’ immediate social contexts and then to their developmental environments to examine the degree to which their needs for competence, autonomy, and relatedness are being or have been thwarted. We maintain that by failing to provide supports for competence, autonomy, and relatedness, not only of children but also of students, employees, patients, and athletes, socializing agents and organizations contribute to alienation and ill-being. The fact that psychological-need deprivation appears to be a principal source of human distress suggests that assessments and interventions would do well to target these primary foundations of mental health.”

One arena where basic psychological needs are particularly salient, and perhaps underappreciated, is healthcare. While addressing the physiological needs of patients is rightly prioritized, both patients and providers have basic psychological needs that are regularly implicated in healthcare settings and in a myriad of different ways. To the extent that environments are not respecting and supportive of these basic psychological needs, patients and providers alike are vulnerable to various forms of diminished well-being.

On the patient side, a common way for demoralization to manifest in patients is in the setting of terminal illness as terminal illness can frequently invoke feelings of hopelessness or loss of meaning. Other times, demoralization can occur in a way that is only tangentially related to the condition for which a patient is seeking care. For example, patients can become demoralized when paternalistic providers reject their patients’ health-related values or impose their own values onto patients, when governments restrict access to care that honors bodily autonomy, or when insurance companies delay or deny authorizations for lifesaving treatments.

On the provider side, healthcare works are vulnerable to a number of different occupation-related conditions such as burnout, moral injury, and second-victim syndrome. While these conditions have nuanced differences, each condition implicates basic psychological needs and, by extension, each condition may involve a component of demoralization.

In this paper, I review the literature on demoralization syndrome and the distinct definitions that have been proposed. With special attention given to healthcare contexts, I consider the social-contextual factors that facilitate versus undermine the satisfaction of basic psychological needs of patients and healthcare providers. I also consider various ways that demoralization may manifest in patients and in providers. I explore ways that environments can be more supportive of the basic psychological needs of patients and providers alike.