br The interpretation and generalizability of our findings a
The interpretation and generalizability of our findings are limited by their cross-sectional nature and by the sample, which consists of outpatient participants in a psychosocial intervention study at a large regional cancer centre. The prevalence of demoralization was some-what higher in the study sample compared to rates reported in a sys-tematic review . It is possible that the size of the association be-tween demoralization and attachment security in the present study was positively aﬀected by a higher proportion of demoralized patients seeking support for relational problems. Replication in prospective studies and with other existential outcomes, such as death anxiety, the loss of the sense of dignity, the desire for hastened death and lower spiritual well-being would strengthen these findings. Additionally, a more targeted investigation of how attachment styles aﬀect 74515-25-6 processes in the context of existential threat would be of great value to inform the development or modification of psychosocial and palliative interventions. A study design that allowed for a real-time observation of adjustment processes in patients' daily lives and that reduces bias from recall diﬃculty and inadequate time resolution of limited questionnaire assessments would help to improve its rigour. The higher demoraliza-tion levels in female patients in the present study are in accordance with the literature on existential distress and psychosocial burden in cancer more generally , as well as with the greater interest in and utilization of psychosocial support services among women. All of our analyses statistically controlled for gender diﬀerences, showing that the associations of interest were independent of this potential confounder. Although the sample is not representative of all patients with advanced Journal of Psychosomatic Research 116 (2019) 93–99
cancer, the results of this study may help to inform psychosocial in-terventions with patients with advanced disease.
The findings of the present study support the view that attachment security protects from demoralization in patients with advanced cancer. This state is more likely to occur when physical suﬀering increases, particularly when it is less buﬀered by attachment security. Attachment security may facilitate relationship-seeking and the flexible use of at-tachment relationships, serving to diminish the sense of isolation and to sustain the sense of meaning and hope among individuals facing the progressive and unavoidable threat of disease progression and mor-tality. Future research may test the assumption that psychotherapeutic interventions can relieve existential distress by helping patients to re-negotiate attachment relationships and to derive a greater sense of meaning and morale from them. The consideration of individual dif-ferences in attachment needs can inform such interventions to facilitate the processing of subjective experience in response to existential threat and may contribute to a better understanding of demoralization and other forms of existential distress in advanced disease.
University Health Network Research Ethics Board.
This study was funded by research grants from the Canadian Institutes of Health Research (CIHR #MOP 106473) and the German Research Society (DFG). This research was also supported in part by the Princess Margaret Cancer Foundation (Al Hertz, Kirchmann and Kirsh Family Funds), the Princess Margaret Cancer Centre and Research Institute, and by the Ontario Ministry of Health and Long Term Care (OMOHLTC). Dr. Rodin is also supported by the University of Toronto/ UHN Harold and Shirley Lederman Chair in Psychosocial Oncology and Palliative Care. The funders had no role in the final design, analysis, and writing of dendrites study. The views expressed do not necessarily reflect those of the funders.
Conflicts of interest
The authors declare no conflict of interest.
We would like to thank the participants for their time and eﬀort.
Appendix A. Supplementary data
 P.R. Shaver, M. Mikulincer, An attachment perspective on coping with existential concerns, in: P.R. Shaver, M. Mikulincer (Eds.), Meaning, Mortality, and Choice: The Social Psychology of Existential Concerns, American Psychological Association, Washington, DC, 2012, pp. 291–307 ((The Herzliya series on personality and social
S. Vehling et al.
 S. Robinson, D.W. Kissane, J. Brooker, C. Hempton, S. Burney, The relationship between poor quality of life and desire to hasten death: a multiple mediation model examining the contributions of depression, demoralization, loss of control, and low self-worth, J. Pain Symptom Manag. 53 (2017) 243–249.
 S. Vehling, C. Lehmann, K. Oechsle, et al., Is advanced cancer associated with de-moralization and lower global meaning? The role of tumor stage and physical problems in explaining existential distress in cancer patients, Psychooncology 21 (2012) 54–63.