Letters to the Editor  |   October 2010
Author Affiliations
  • Charles R. Perakis, DO
    Maine-Dartmouth Family Medicine Residency, Augusta, Maine; University of New England College of Osteopathic Medicine, Biddeford, Maine
Article Information
Letters to the Editor   |   October 2010
The Journal of the American Osteopathic Association, October 2010, Vol. 110, 609-610. doi:
The Journal of the American Osteopathic Association, October 2010, Vol. 110, 609-610. doi:
I appreciate the comments made by Dr Tobe about my article in the June JAOA.1 He rightfully points out the need to be aware of those patients who have serious mood disorders. Such patients require appropriate treatment, including both counseling and pharmacologic interventions. However, rather than downplaying the need for comprehensive diagnosis of patients with unexplained symptoms, as Dr Tobe alleges, I am advocating for appropriate recognition of the problems faced by these patients and for addressing these problems while considering serious mood disorders. 
Certainly, unipolar depression and organic brain changes associated with mood disorders can present in a similar manner and may be primarily responsible for, or seen in conjunction with, soul sickness (ie, demoralization). My suggestion is that physicians look for the subjective incompetence that categorizes this condition. 
De Figueiredo2 elaborates on the distinction between demoralization and depression, and he distinguishes between symptoms of endogenomorphic depression and exogenomorphic depression. Symptoms of endogenomorphic depression (eg, distress, disturbances in sleep and appetite) typically appear to people experiencing them as abnormal conditions originating within themselves. By contrast, symptoms of exogenomorphic depression (eg, grief, loss of self-esteem) are often normal, self-limiting emotional states that are triggered by such “outside” sources as chronic disappointment or failure.2 
Exogenomorphic depression may also be part of demoralization and associated with subjective incompetence (ie, a feeling of being trapped or blocked because of an inability to plan and initiate concerted action toward a goal or goals). In addition to the presence of subjective incompetence, the magnitude and direction of the patient's motivation to act can be used to distinguish demoralization from depression. Individuals who perceive themselves as incompetent with respect to goals are puzzled, indecisive, and uncertain as to the direction of action they should take, making them feel as though they are in a quandary.2 
Both the depressed person and the demoralized person lack motivation. However, the depressed person may know the appropriate direction of action but lacks motivation to pursue it. The demoralized person, by contrast, is inhibited from acting by uncertainty over the appropriate direction of action.2 
Much unnecessary testing, with associated problems (such as additional diagnostic uncertainties), can be avoided. Some authors have advocated for the inclusion of demoralization in the Diagnostic and Statistical Manual of Mental Disorders.3 Such inclusion would help draw the attention of psychiatrists to the value of “digging” for the real obstacles to a happier and more meaningful life for patients struggling with this condition. 
Perakis CR. Soul sickness: a frequently missed diagnosis. J Am Osteopath Assoc. 2010;110(6):347-349. Accessed September 20, 2010.
de Figueiredo JM. Depression and demoralization: phenomenologic differences and research perspectives. Compr Psychiatry. 1993;34(5):308-311.
Kissane DW, Clarke DM, Street AF. Demoralization syndrome—a relevant psychiatric diagnosis for palliative care. J Palliat Care. 2001;17(1):12-21.