Hostname: page-component-7f64f4797f-d7bbv Total loading time: 0 Render date: 2025-11-11T08:29:53.880Z Has data issue: false hasContentIssue false
  • English
  • Français

Demoralization in essential tremor: prevalence, clinical correlates, and dissociation from tremor severity

Published online by Cambridge University Press:  03 April 2019

Tess E. K. Cersonsky Open the ORCID record for Tess E. K. Cersonsky [Opens in a new window] ,
Sarah Kellner ,
Sarah Morgan ,
Stephanie Cosentino ,
Brian B. Koo ,
John M. de Figueiredo  and
Elan D. Louis
Tess E. K. Cersonsky
Affiliation:
Division of Movement Disorders, Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
Sarah Kellner
Affiliation:
Division of Movement Disorders, Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
Sarah Morgan
Affiliation:
Division of Movement Disorders, Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
Stephanie Cosentino
Affiliation:
Department of Neurology, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, New York, USA
Brian B. Koo
Affiliation:
Center for Neuroepidemiology and Clinical Neurological Research & Division of Movement Disorders, Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
John M. de Figueiredo
Affiliation:
Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
Elan D. Louis*
Affiliation:
Center for Neuroepidemiology and Clinical Neurological Research & Division of Movement Disorders, Department of Neurology, Yale School of Medicine & Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
*
*Address correspondence to: Elan D. Louis, Yale Neurology, Division of Movement Disorders, LCI 710, 15 York Street, PO Box 208018, New Haven, CT 06520-8018, USA. (Email: elan.louis@yale.edu)
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective.

Essential tremor (ET) is associated with psychological difficulties, including anxiety and depression. Demoralization (feelings of helplessness, hopelessness, inability to cope), another manifestation of psychological distress, has yet to be investigated in ET. Our objectives are to (1) estimate the prevalence of demoralization in ET, (2) assess its clinical correlates, and (3) determine whether demoralization correlates with tremor severity.

Methods.

We administered the Kissane Demoralization Scale (KDS-II) and several psychosocial evaluations (ie, scales assessing subjective incompetence, resilience, and depression [eg, Geriatric Depression Scale]) to 60 ET subjects. Tremor was assessed with a disability score and total tremor score. KDS-II >8 indicated demoralization.

Results.

Among 60 ET subjects (mean age = 70.2 ± 6.8 years), the prevalence of demoralization was 13.3%, 95% confidence interval = 6.9–24.2%. Although there was overlap between demoralization and depression (10% of the sample meeting criteria for both), 54% of depressed subjects were not demoralized, and 25% of demoralized subjects were not depressed. Demoralization correlated with psychological factors, but demoralized subjects did not have significantly higher total tremor scores, tremor disability scores, or years with tremor.

Conclusions.

Demoralization has a prevalence of 13.3% in ET, similar to that in other chronic or terminal illnesses (eg, cancer 13–18%, Parkinson’s disease 18.1%, coronary heart disease 20%). Demoralization was not a function of increased tremor severity, suggesting that it is a separable construct, which could dictate how a patient copes with his/her disease. These data further our understanding of the psychological and psychosocial correlates of ET.

Keywords

Demoralizationdepressionessential tremormovement disordersresiliencetremor severity

Information

Type
Original Research
Information
CNS Spectrums , Volume 25 , Issue 1 , February 2020 , pp. 16 - 23
Copyright
© Cambridge University Press 2019

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

Footnotes

This work was supported by the National Institutes of Health (grant number NINDSR01NS086736). This funding body played no role in the design of the study, the collection, analysis, and interpretation of data, or the writing of the manuscript. None of the authors had conflicts of interest.

References

REFERENCES:

Louis, ED, Ferreira, JJ. How common is the most common adult movement disorder? Update on the worldwide prevalence of essential tremor. Mov Disord. 2010; 25(5): 534–541. doi: 10.1002/mds.22838Google Scholar
Louis, ED, Ottman, R. How many people in the USA have essential tremor? Deriving a population estimate based on epidemiological data. Tremor Other Hyperkinet Mov (N Y). 2014; 4: 259. doi: 10.7916/D8TT4P4BGoogle Scholar
Putzke, JD, Whaley, NR, Baba, Y, Wszolek, ZK, Uitti, RJ. Essential tremor: predictors of disease progression in a clinical cohort. J Neurol Neurosurg Psychiatry. 2006; 77(11): 1235–1237. doi: 10.1136/jnnp.2006.086579Google Scholar
Zesiewicz, TA, Elble, RJ, Louis, ED, et al.Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards subcommittee of the American Academy of Neurology. Neurology. 2011; 77(19): 1752–1755. doi: 10.1212/WNL.0b013e318236f0fdGoogle Scholar
Schuurman, PR, Bosch, DA, Bossuyt, PM, et al.A comparison of continuous thalamic stimulation and thalamotomy for suppression of severe tremor. N Engl J Med. 2000; 342(7): 461–468. doi: 10.1056/NEJM200002173420703Google Scholar
Louis, ED. Essential tremors: a family of neurodegenerative disorders? Arch Neurol. 2009; 66(10): 1202–1208. doi: 10.1001/archneurol.2009.217Google Scholar
Dogu, O, Louis, ED, Sevim, S, Kaleagasi, H, Aral, M. Clinical characteristics of essential tremor in Mersin, Turkey. J Neurol. 2005; 252(5): 570–574. doi: 10.1007/s00415-005-0700-8Google Scholar
Sengul, Y, Sengul, HS, Yucekaya, SK, et al.Cognitive functions, fatigue, depression, anxiety, and sleep disturbances: assessment of nonmotor features in young patients with essential tremor. Acta Neurol Belg. 2015; 115(3): 281–287. doi: 10.1007/s13760-014-0396-6Google Scholar
Chandran, V, Pal, PK, Reddy, JYC, Thennarasu, K, Yadav, R, Shivashankar, N. Non-motor features in essential tremor. Acta Neurol Scand. 2012; 125(5): 332–337.Google Scholar
Louis, ED. Non-motor symptoms in essential tremor: a review of the current data and state of the field. Parkinsonism Relat Disord. 2016; 22: S115–S118. doi: 10.1016/j.parkreldis.2015.08.034Google Scholar
Puertas-Martín, V, Villarejo-Galende, A, Fernández-Guinea, S, Romero, JP, Louis, ED, Benito-León, J. A comparison study of cognitive and neuropsychiatric features of essential tremor and Parkinson’s disease. Tremor Other Hyperkinet Mov (N Y). 2016; 6: 431. doi: 10.7916/D86H4HRNGoogle Scholar
Fabbrini, G, Berardelli, I, Falla, M, et al.Psychiatric disorders in patients with essential tremor. Parkinsonism Relat Disord. 2012; 18(8): 971–973. doi: 10.1016/j.parkreldis.2012.05.005Google Scholar
Louis, ED, Huey, ED, Gerbin, M, Viner, AS. Depressive traits in essential tremor: impact on disability, quality of life, and medication adherence. Eur J Neurol. 2012; 19(10): 1349–1354. doi: 10.1111/j.1468-1331.2012.03774.xGoogle Scholar
Li, Z-W, Xie, M-J, Tian, D-S, et al.Characteristics of depressive symptoms in essential tremor. J Clin Neurosci. 2011; 18(1): 52–56. doi: 10.1016/j.jocn.2010.05.021Google Scholar
Huey, ED, Cosentino, S, Chapman, S, et al.Self-report depressive symptoms are dissociated from tremor severity in essential tremor. Parkinsonism Relat Disord. 2018; 50: 87–93. doi: 10.1016/j.parkreldis.2018.02.031Google Scholar
Louis, ED, Benito-León, J, Bermejo-Pareja, F. Neurological Disorders in Central Spain (NEDICES) Study Group. Self-reported depression and anti-depressant medication use in essential tremor: cross-sectional and prospective analyses in a population-based study. Eur J Neurol. 2007; 14(10): 1138–1146. doi: 10.1111/j.1468-1331.2007.01923.xGoogle Scholar
Lenka, A, Benito-León, J, Louis, ED. Is there a premotor phase of essential tremor? Tremor Other Hyperkinet Mov (N Y). 2017; 7: 498. doi: 10.7916/D80S01VKGoogle Scholar
Smeltere, L, Kuzņecovs, V, Erts, R. Depression and social phobia in essential tremor and Parkinson’s disease. Brain Behav. 2017; 7(9): e00781. doi: 10.1002/brb3.781Google Scholar
Graff-Radford, J, Foote, KD, Mikos, AE, et al.Mood and motor effects of thalamic deep brain stimulation surgery for essential tremor. Eur J Neurol. 2010; 17(8): 1040–1046. doi: 10.1111/j.1468-1331.2010.02958.xGoogle Scholar
Louis, ED, Cosentino, S, Huey, ED. Depressive symptoms can amplify embarrassment in essential tremor. J Clin Movem Disord. 2016; 3(1): 11. doi: 10.1186/s40734-016-0039-6Google Scholar
Musacchio, T, Purrer, V, Papagianni, A, et al.Non-motor symptoms of essential tremor are independent of tremor severity and have an impact on quality of life. Tremor Other Hyperkinet Mov (N Y). 2016; 6: 361. doi: 10.7916/D8542NCHGoogle Scholar
Clarke, DM, Kissane, DW, Trauer, T, Smith, GC. Demoralization, anhedonia and grief in patients with severe physical illness. World Psychiatry. 2005; 4(2): 96–105.Google Scholar
Clarke, DM, Mackinnon, AJ, Smith, GC, McKenzie, DP, Herrman, HE. Dimensions of psychopathology in the medically ill: a latent trait analysis. Psychosomatics. 2000; 41(5): 418–425.Google Scholar
Clarke, DM, Smith, GC, Dowe, DL, McKenzie, DP. An empirically derived taxonomy of common distress syndromes in the medically ill. J Psychosom Res. 2003; 54(4): 323–330.Google Scholar
Sansone, RA, Sansone, LA. Demoralization in patients with medical illness. Psychiatry (Edgmont). 2010; 7(8): 42–45.Google Scholar
Frank, JD. Psychotherapy: the restoration of morale. Am J Psychiatry. 1974; 131(3): 271–274. doi: 10.1176/ajp.131.3.271Google Scholar
Clarke, DM, Kissane, DW. Demoralization: its phenomenology and importance. Aust N Z J Psychiatry. 2002; 36(6): 733–742.Google Scholar
de Figueiredo, JM. Depression and demoralization: phenomenologic differences and research perspectives. Compr Psychiatry. 1993; 34(5): 308–311.Google Scholar
Arts-de Jong, M, DeJong, CAJ, Hermens, RP, Kissane, DW, Massuger, LM, Hoogerbrugge, N. High demoralization in a minority of oophorectomized BRCA1/2 mutation carriers influences quality of life. J Psychosom Obstet Gynaecol. 2018; 39(2): 96–104.Google Scholar
Koo, BB, Chow, CA, Shah, DR, et al.Demoralization in Parkinson disease. Neurology. 2018; 90(18): e1613–e1617. doi: 10.1212/wnl.0000000000005425Google Scholar
Kissane, DW, Wein, S, Love, A, Lee, XQ, Kee, PL, Clarke, DM. The Demoralization Scale: a report of its development and preliminary validation. J Palliat Care. 2004; 20(4): 269–276.Google Scholar
Robinson, S, Kissane, DW, Brooker, J, et al.Refinement and revalidation of the demoralization scale: The DS-II—external validity. Cancer. 2016; 122(14): 2260–2267. doi: 10.1002/cncr.30012Google Scholar
Tecuta, L, Tomba, E, Grandi, S, Fava, GA. Demoralization: a systematic review on its clinical characterization. Psychol Med. 2015; 45(4): 673–691. doi: 10.1017/S0033291714001597Google Scholar
Cockram, CA, Doros, G, de Figueiredo, JM. Diagnosis and measurement of subjective incompetence: the clinical hallmark of demoralization. Psychother Psychosom. 2009; 78(6): 342–345.Google Scholar
de Figueiredo, JM, Frank, JD. Subjective incompetence, the clinical hallmark of demoralization. Compr Psychiatry. 1982; 23(4): 353–363. doi: 10.1016/0010-440X(82)90085-2Google Scholar
Smith, BW, Dalen, J, Wiggins, K, Tooley, E, Christopher, P, Bernard, J. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med. 2008; 15(3): 194–200. doi: 10.1080/10705500802222972Google Scholar
de Figueiredo, JM. Resilience and prevention of demoralization. Int J Cult Ment Health. 2015; 8(1): 72–78. doi: 10.1080/17542863.2014.892522Google Scholar
Louis, ED, Barnes, LF, Wendt, KJ, et al.Validity and test-retest reliability of a disability questionnaire for essential tremor. Mov Disord. 2000; 15(3): 516–523. doi: 10.1002/1531-8257(200005)15:3<516::AID-MDS1015>3.0.CO;2-J3.0.CO;2-J>Google Scholar
Linn, BS, Linn, MW, Gurel, L. Cumulative Illness Rating Scale. J Am Geriatr Soc. 1968; 16(5): 622–626. doi: 10.1111/j.1532-5415.1968.tb02103.xGoogle Scholar
Miller, MD, Paradis, CF, Houck, PR, et al.Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale. Psychiatry Res. 1992; 41(3): 237–248. doi: 10.1016/0165-1781(92)90005-NGoogle Scholar
Louis, ED, Ottman, R, Ford, B, et al.The Washington Heights-Inwood Genetic Study of Essential Tremor: methodologic issues in essential-tremor research. Neuroepidemiology. 1997; 16(3): 124–133. doi: 10.1159/000109681Google Scholar
Louis, ED, Ford, B, Bismuth, B. Reliability between two observers using a protocol for diagnosing essential tremor. Mov Disord. 1998; 13(2): 287–293. doi: 10.1002/mds.870130215Google Scholar
Louis, ED, Wendt, KJ, Albert, SM, Pullman, SL, Yu, Q, Andrews, H. Validity of a performance-based test of function in essential tremor. Arch Neurol. 1999; 56(7): 841–846.Google Scholar
Folstein, MF, Folstein, SE, McHugh, PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12(3): 189–198.Google Scholar
Nasreddine, ZS, Phillips, NA, Bédirian, V, et al.The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005; 53(4): 695–699. doi: 10.1111/j.1532-5415.2005.53221.xGoogle Scholar
Yesavage, JA, Brink, TL, Rose, TL, et al.Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982; 17(1): 37–49. doi: 10.1016/0022-3956(82)90033-4Google Scholar
Spitzer, RL, Kroenke, K, Williams, JBW, Löwe, B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006; 166(10): 1092–1097. doi: 10.1001/archinte.166.10.1092Google Scholar
Lawton, MP, Brody, EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9(3): 179–186. doi: 10.1093/geront/9.3_Part_1.179Google Scholar
Morris, JC. Clinical dementia rating: a reliable and valid diagnostic and staging measure for dementia of the Alzheimer type. Int Psychogeriatr. 1997; 9(Suppl 1): 173–176; discussion 177–178.Google Scholar
Mehnert, A, Vehling, S, Höcker, A, Lehmann, C, Koch, U. Demoralization and depression in patients with advanced cancer: validation of the German version of the demoralization scale. J Pain Symptom Manage. 2011; 42(5): 768–776. doi: 10.1016/j.jpainsymman.2011.02.013Google Scholar
Mullane, M, Dooley, B, Tiernan, E, Bates, U. Validation of the demoralization scale in an Irish advanced cancer sample. In: Breitbart, W, ed. Palliative and Supportive Care. Vol. 7. New York: Cambridge University Press; 2009: 323–330. doi: 10.1017/S1478951509990253Google Scholar
Koo, B, Chow, C, Shah, D, et al.Demoralization in Parkinson disease. Neurology. 2017; 88(16 Supplement): e1613–e1617.Google Scholar
Benito-León, J, Louis, ED, Mitchell, AJ, Bermejo-Pareja, F. Elderly-onset essential tremor and mild cognitive impairment: a population-based study. J Alzheimer’s Dis. 2011; 23(4): 727–735.Google Scholar
Blank, K, Gruman, C, Robison, JT. Case-finding for depression in elderly people: balancing ease of administration with validity in varied treatment settings. J Gerontol A Biol Sci Med Sci. 2004; 59(4): 378–384.Google Scholar
Laprise, R, Vézina, J. Diagnostic performance of the Geriatric Depression Scale and the Beck Depression Inventory with nursing home residents. Can J Aging. 1998; 17(4): 401–413. doi: 10.1017/S0714980800012678Google Scholar
Lyness, JM, Noel, TK, Cox, C, King, DA, Conwell, Y, Caine, ED. Screening for depression in elderly primary care patients. A comparison of the Center for Epidemiologic Studies-Depression Scale and the Geriatric Depression Scale. Arch Intern Med. 1997; 157(4): 449–454. doi: 10.1001/archinte.1997.00440250107012Google Scholar
McGivney, SA, Mulvihill, M, Taylor, B. Validating the GDS depression screen in the nursing home. J Am Geriatr Soc. 1994; 42(5): 490–492. doi: 10.1111/j.1532-5415.1994.tb04969.xGoogle Scholar
Van Marwijk, HWJ, Wallace, P, De Bock, GH, Hermans, J, Kaptein, AA, Mulder, JD. Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the geriatric depression scale. Br J Gen Pract. 1995; 45(393): 195–199.Google Scholar
Robinson, S, Kissane, DW, Brooker, J, Burney, S. A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research. J Pain Symptom Manage. 2015; 49(3): 595–610. doi: 10.1016/j.jpainsymman.2014.07.008Google Scholar
Vehling, S, Kissane, DW, Lo, C, et al.The association of demoralization with mental disorders and suicidal ideation in patients with cancer. Cancer. 2017; 123(17): 3394–3401. doi: 10.1002/cncr.30749Google Scholar
Rafanelli, C, Roncuzzi, R, Milaneschi, Y, et al.Stressful life events, depression and demoralization as risk factors for acute coronary heart disease. Psychother Psychosom. 2005; 74(3): 179–184. doi: 10.1159/000084003Google Scholar
Lee, C-Y, Fang, C-K, Yang, Y-C, et al.Demoralization syndrome among cancer outpatients in Taiwan. Support Care Cancer. 2012; 20(10): 2259–2267. doi: 10.1007/s00520-011-1332-4Google Scholar
Mangelli, L, Fava, GA, Grandi, S, et al.Assessing demoralization and depression in the setting of medical disease. J Clin Psychiatry. 2005; 66(3): 391–394. doi: 10.4088/JCP.v66n0317Google Scholar
Schmale, AH, Engel, GL. The giving up-given up complex illustrated on film. Arch Gen Psychiatry. 1967; 17(2): 135–145. doi: 10.1001/archpsyc.1967.01730260007002Google Scholar
McDaniel, JS, Brown, FW, Cole, SA. Assessment of depression and grief reactions in the medically ill. In: Fogel, BS, Greenberg, DB, eds. Psychiatric Care of the Medical Patient. 2nd ed. New York: Oxford University Press; 2000: 149–164.Google Scholar
Katon, WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003; 54(3): 216–226.Google Scholar
Krishnan, KRR, Delong, M, Kraemer, H, et al.Comorbidity of depression with other medical diseases in the elderly. Biol Psychiatry. 2002; 52(6): 559–588.Google Scholar
Sutor, B, Rummans, TA, Jowsey, SG, et al.Major depression in medically ill patients. Mayo Clin Proc. 1998; 73(4): 329–337.Google Scholar
Fava, GA, Sonino, N. Depression associated with medical illness. CNS Drugs. 1996; 5(3): 175–189. doi: 10.2165/00023210-199605030-00004Google Scholar
de Figueiredo, JM. Distress, demoralization and psychopathology: diagnostic boundaries. Eur J Psychiatry. 2013; 27(1): 61–73.Google Scholar
Kissane, DW, Clarke, DM, Street, AF. Demoralization syndrome—a relevant psychiatric diagnosis for palliative care. J Palliat Care. 2001; 17(1): 12–21.Google Scholar
Griffith, JL, Gaby, L. Brief psychotherapy at the bedside: countering demoralization from medical illness. Focus (Madison). 2010; 8(1): 143–150. doi: 10.1176/foc.8.1.foc143Google Scholar
Clarke, DM. Depression, demoralization, and psychotherapy in people who are medically ill. In: Alarcón, RD, Frank, JB, eds. The Psychotherapy of Hope: The Legacy of Persuasion and Healing. Baltimore, MD: Johns Hopkins University Press; 2012: 125–157.Google Scholar