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Purpose: Close relationships can be strained by losses related to independence, autonomy, and separation after diagnosis of severe illness. The perceived quality of their close relationships affects individuals' psychological adaptation in this context. We explored the level of perceived relatedness and its impact on demoralization and death acceptance. We further examined a possible protective effect of perceived relatedness on the association between tumor stage and death acceptance., Methods: For this observational study, we consecutively recruited gynecology outpatients and general surgery inpatients at the University Cancer Center Hamburg-Eppendorf and oncological inpatients at the LungenClinic Grosshansdorf, Germany. At baseline, 307 patients (age M = 59.6, 69% female, 69% advanced cancer) participated. At 6- and 12-month (T3) follow-up, 213 and 153 patients responded, respectively. Patients completed self-report questionnaires including a modified version of the Posttraumatic Growth Inventory assessing perceived relatedness, the Life Attitude Profile-Revised assessing death acceptance, the Demoralization Scale, and the Memorial Symptom Assessment Scale assessing symptom burden. We calculated multiple linear regression analyses controlling for demographic and disease-related factors., Results: Participants reported a stronger perceived relatedness at baseline (M = 3.04, SE = 0.03, possible range 0-4) than at T3 (M = 2.93, SE = 0.04; p = 0.02). Perceived relatedness significantly predicted lower demoralization at T3 but did not moderate the relationship between tumor stage and demoralization. Apart from male gender, none of the predictor or moderator variables had a significant impact on death acceptance at T3., Conclusions: The strong impact of perceived relatedness on existential distress emphasizes the importance of strengthening interpersonal relationships within psychosocial interventions.

Purpose: The diagnosis of a terminal disease bears existential challenges, which activate the attachment system. Attachment insecurity, as well as existential resources, such as spiritual well-being, influences patients' extent of psychological distress. Knowledge about the interrelation of these constructs is limited. Based on current research, we assume spiritual well-being to mediate the association of attachment insecurity and psychological distress., Methods: We obtained data from the baseline measurement of a randomized controlled trial in advanced cancer patients. Patients were sampled from the University Medical Centers of Hamburg and Leipzig, Germany. Main outcome measures included the Patient Health Questionnaire (PHQ-9), the Death and Dying Distress Scale (DADDS), the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp), and the Experience in Close Relationships Scale (ECR-M16) for assessing attachment insecurity. We tested the mediation hypothesis with two regression analyses using bootstrapping procedure., Results: A total of 190 patients were included. Spiritual well-being mediated the association of attachment insecurity and depression (R 2  = 11%), as well as death anxiety (R 2  = 15%), in fearful-avoidant attached patients. Neither dismissingly nor preoccupied attached patients differ in terms of spiritual well-being and psychological distress in comparison with secure attached patients., Conclusion: Spiritual well-being plays a relevant role in advanced cancer patient's mental health through mediating the association of attachment and psychological distress. Developing a better understanding of the interdependency of the constructs of spiritual well-being and attachment can help to develop individually tailored advanced cancer care programs and psychotherapeutic interventions., Trial Registration: NCT02051660.

Objective: Caregiving for a loved one is challenging and requires significant resources. Existential distress in family caregivers may include hopelessness, demoralization, fear of death, pre‐loss grief, or a sense of not being emotionally prepared. The aim of this systematic review is to synthesize the quantitative literature on existential distress among family caregivers of patients with advanced cancer, focusing on its prevalence, association with mental disorders, as well as with sociodemographic, disease, and treatment‐related factors. Methods: We systematically searched electronic databases for quantitative studies of the above‐described existential distress concepts in family caregivers of patients with advanced cancer. Two independent reviewers extracted data and evaluated study quality. Data were analyzed using random‐effects meta‐analysis. Results: We retrieved 17.587 records, of which 31 studies fulfilled inclusion criteria. 63% of the studies (n = 20) provided sufficient data for meta‐analysis for 5558 patients. We found an overall pooled prevalence of 30.6% for existential distress, 95% CI [24.2–37.0]. For existential distress subconcepts, prevalence rates were 57.0%, 95% CI [37.8–76.2], for death anxiety, 13.9%, 95% CI [10.8–17.0], for demoralization, 24.0%, 95% CI [18.0–30.0], for pre‐loss grief, 18.4%, 95% CI [4.0–32.7], for hopelessness, 35.2%, 95% CI [28.2–42.2], for loneliness, and 35.6%, 95% CI [13.0–58.3], for emotional unpreparedness. Conclusions: Approximately one third of the respondents were affected by high levels of existential distress. The review provides evidence for further development of support services that can reduce existential distress, focused on death anxiety, and improve the quality of life for family caregivers of patients with advanced cancer. [ABSTRACT FROM AUTHOR]

Describing the course of a short-term supportive-expressive psychotherapy of a male patient with terminal cancer, this study aimed to illustrate the clinical presentation of avoidant attachment behavior and to identify potential challenges in treating these patients from a psychoanalytic perspective. We analyzed eight therapy sessions, recorded and transcribed as part of a randomized controlled trial, following the explication technique of qualitative content analysis. We analyzed a patient with high attachment avoidance as assessed by the Experiences in Close Relationships Scale measuring adult attachment. We found that 'attachment avoidance' subsumed different defense mechanisms, which helped the patient to reduce his fear associated with (1) feelings of dependency: denial, (2) overwhelming distress: isolation of affect, displacement, (3) feelings of guilt and shame: repression, (4) regulating his interpersonal relationships: projective identification. Adding psychoanalytic interpretations to the existing material helped to identify rigid defense mechanisms interfering with sharing his fears about death and dying. Still, the low intensity setting offered him a reliable and tolerable therapeutic relationship. Contributing to the understanding of the specific challenges in treating avoidant patients, our findings underline the importance and feasibility of establishing a holding environment and fostering a positive transference relationship to engage in a joint mourning process. [ABSTRACT FROM AUTHOR]

Objective: Although a protective effect of reliable interpersonal relationships on existential distress has been established, evidence remains inconclusive for attachment insecurity as an underlying factor of persistent psychological distress. We tested a longitudinal model hypothesizing attachment avoidance as a mediator of high demoralization and anxiety over time. Methods: We studied 206 patients with advanced cancer (mean age = 59.6, 61% female) participating in an intervention trial. Patients completed self‐report measures for demoralization, anxiety, perceived relatedness, attachment insecurity, and death anxiety. Our mediated path model included perceived relatedness and death anxiety at baseline as predictors, attachment avoidance at baseline as mediator, and demoralization and anxiety at 6‐month follow‐up (N = 125) as outcomes. Results: Attachment avoidance partially mediated the relationship between death anxiety and demoralization (β = 0.07, 95% CI 0.02–0.12) and anxiety (β = 0.05, 95% CI 0.001–0.10). Findings for perceived relatedness were less conclusive. Its indirect effects through attachment avoidance were significant for both outcomes (demoralization: β = −0.07, 95% CI −0.13 to −0.02, anxiety: β = −0.05, 95% CI −0.11 to −0.003). Conclusions: Due to its trait‐like quality, attachment avoidance may play a less central role in explaining the course of existential distress over time than previous research indicated. Addressing change‐sensitive relational concerns in psychosocial interventions may be more effective to alleviate existential distress. [ABSTRACT FROM AUTHOR]

Objective: Death acceptance may indicate positive adaptation in cancer patients. Little is known about what characterizes patients with different levels of death acceptance or its impact on psychological distress. We aimed to broaden the understanding of death acceptance by exploring associated demographic, medical, and psychological characteristics.Methods: At baseline, we studied 307 mixed cancer patients attending the University Cancer Center Hamburg and a specialized lung cancer center (age M = 59.6, 69% female, 69% advanced cancer). At 1-year follow-up, 153 patients participated. We assessed death acceptance using the validated Life Attitude Profile-Revised. Patients further completed the Memorial Symptom Assessment Scale, the Demoralization Scale, the Patient Health Questionnaire, and the Generalized Anxiety Disorder Questionnaire. Statistical analyses included multinomial and hierarchical regression analyses.Results: At baseline, mean death acceptance was 4.33 (standard deviation [SD] = 1.3, range 1-7). There was no change to follow-up (P = 0.26). When all variables were entered simultaneously, patients who experienced high death acceptance were more likely to be older (odds ratio [OR] = 1.04; 95% confidence interval [CI], 1.01-1.07), male (OR = 3.59; 95% CI, 1.35-9.56), widowed (OR = 3.24; 95% CI, 1.01-10.41), and diagnosed with stage IV (OR = 2.44; 95% CI, 1.27-4.71). They were less likely to be diagnosed with lung cancer (OR = 0.20; 95% CI, 0.07-0.58), and their death acceptance was lower with every month since diagnosis (OR = 0.99; 95% CI, 0.98-0.99). High death acceptance predicted lower demoralization and anxiety at follow-up but not depression.Conclusions: High death acceptance was adaptive. It predicted lower existential distress and anxiety after 1 year. Advanced cancer did not preclude death acceptance, supporting the exploration of death-related concerns in psychosocial interventions. [ABSTRACT FROM AUTHOR]