Existential Distress in Advanced Cancer: Comparing a Short-term Psychodynamic Psychotherapy (ORPHYS) to Treatment as Usual (TAU)

December 30, 2025 updated by: Universitätsklinikum Hamburg-Eppendorf

Existential Distress in Advanced Cancer: Pragmatic Randomized Controlled Trial of a Short-term Psychodynamic Psychotherapy (ORPHYS) Compared to Treatment as Usual (TAU)

The psychological challenges faced by patients with incurable cancer and their caregivers include an uncertain future, fear of dying and uncontrollable suffering, grief, and loneliness. In a significant subgroup, this challenge is associated with significant fear and existential distress. This distress can manifest itself, for example, in the form of demoralization, a state of despair and hopelessness in which the possibilities for coping seem exhausted. Although open discussions about fears at the end of life are becoming increasingly important, little is known about how patients with high existential distress can best be supported to promote quality of life.

The aim of the study is to test the effectiveness of the newly developed individual psychotherapy ORPHYS (ShORt-term psychodynamic psychotherapy in serious PHYSical illness) in reducing existential distress. To this end, a randomly selected half of the participants who receive ORPHYS treatment will be compared with a second group who receive the standard routine psycho-oncological treatment TAU (Treatment As Usual). The level of distress caused by demoralization will be used for the comparison. A total of 160 patients with advanced cancer will be included in the study.

Due to improved treatment options, life expectancy for advanced cancer has increased significantly. This means that patients and their families must deal with the existential tension between uncertainty and a focus on life. The treatment is intended to contribute to providing the best possible support for patients who suffer from uncertainty and fears at the end of life.

Study Overview

Detailed Description

Background: As improvements in systemic anti-cancer treatments have extended survival, patients with advanced cancer and their family caregivers face the existential tension between engaging in life and coping with uncertainty about illness trajectory and course of treatment. For a subgroup, this tension is associated with overwhelming fear and existential distress. Existential distress is often characterized by demoralization, a state of despair and hopelessness in which coping skills are exhausted and patients are unable to see something positive in the future. Such adjustment difficulties may increase the risk of poor quality of life and suicidality, as well as impair prognostic awareness and patient-clinician communication. Despite growing interest in open conversations about end-of-life issues, little is known about how clinicians can best support patients experiencing high levels of existential distress in order to facilitate psychological adaptation at the end of life.

Objective: To evaluate the effectiveness of ORPHYS (ShORt-term psychodynamic psychotherapy in serious PHYSical illness) in a pragmatic randomized controlled trial. The intervention group receives 15-31 sessions of ORPHYS, a manualized individual psychotherapy that flexibly integrates uncovering and holding treatment elements. The control group receives usual psycho-oncological care (TAU). The primary outcome is demoralization as assessed by the Demoralization Scale-II. Secondary outcomes include diagnosis of affective, anxiety and stress-related disorders, death anxiety, dignity-related distress, and quality of life.

Methods: The investigators will conduct a two-arm parallel randomized controlled trial with an active control group. Patients will be assessed pre-intervention and after 3, 6, 9, and 12 months. The target sample size is 160 participants before randomization. The investigators will recruit patients with stage III/IV solid tumors or advanced hematological cancer and clinically significant existential distress from psycho-oncology clinics and referring oncologists at Hamburg, Düsseldorf, and Würzburg Comprehensive Cancer Centers. Outcome assessments will be conducted via diagnostic interviews and self-report questionnaires. Linear mixed models will examine outcome differences between trial arms. A confirmatory test of the group contrast at 6 months-follow-up will be conducted.

Discussion: Due to an aging population and prolonged survival, there is a growing demand to help patients deal with existential challenges. The study will contribute to knowledge about how clinicians can best help patients with advanced cancer who substantially struggle with uncertainty at the end of life.

Study Type

Interventional

Enrollment (Estimated)

160

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

  • Name: Sigrun Vehling, PD Dr.
  • Phone Number: +4940741056805
  • Email: s.vehling@uke.de

Study Contact Backup

  • Name: Rebecca Philipp, PhD
  • Phone Number: +4940741056203
  • Email: r.philipp@uke.de

Study Locations

      • Düsseldorf, Germany, 40225
        • Recruiting
        • Clinical Institute for Psychosomatic Medicine and Psychotherapy, University Medical Center Düsseldorf
        • Contact:
      • Hamburg, Germany, 20246
        • Recruiting
        • University Medical Center Hamburg-Eppendorf
        • Contact:
        • Contact:
      • Würzburg, Germany, 97080
        • Recruiting
        • Psychosomatics, Psychotherapy and Psychooncology, Medicine II, University of Würzburg
        • Contact:
          • Imad Maatouk, Prof. Dr.
          • Phone Number: +49 (0)931 201- 40365
          • Email: maatouk_i@ukw.de

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • UICC stage III/IV solid tumor or advanced hematological cancer
  • Physical condition at beginning of treatment sufficient for outpatient treatment
  • Existential distress due to at least one of the following concerns: loss of hope, demoralization, fear of the future, loneliness, death anxiety, sense of isolation, death wishes
  • Severity of distress: significant subjective distress and impairment in functioning

Exclusion Criteria:

  • Acute suicidality with concrete or impending intent to follow through (suicide plan)
  • diagnosis of a substance dependence, substance abuse, or psychotic disorder (exception: tobacco-related disorders)
  • Inability to adhere to a psychotherapeutic setting
  • Other current psychotherapeutic or psycho-oncological treatment according to TAU definition
  • Insufficient German to give informed consent and complete self-report questionnaires

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: ORPHYS (ShORt term psychodynamic psychotherapy adapted to serious PHYSical illness)
ORPHYS is a manualized individual psychotherapy that was specifically designed for patients with serious physical illness (Philipp et al., 2024). Patients receive 15-31 weekly therapy sessions of 50 minutes length. ORPHYS takes into account the individual meaning of illness in the context of internalized motives and fears. ORPHYS aims to help patients gain consciousness of related existential conflict. The treatment supports reflection on current relational experiences in the context of realistic, illness-related fears. Identifying patients' dysfunctional relationship patterns, which represent patients' unconscious fantasies about the responsiveness and availability of others and making them accessible to the patient during therapy is expected to increase mentalization and, thus, emotional flexibility to balance extreme affective states. Emotional containment and supportive interventions are the basis for ORPHYS.
Active Comparator: TAU (Treatment As Usual: standard psycho-oncological care)
Patients receive routine psycho-oncological care as provided by the study centers. TAU includes individual sessions provided by physicians or master-level psychologists with experience in psycho-oncological care. There is no restriction on the minimum or maximum number of sessions.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Demoralization assessed via the Demoralization Scale-II (DS-II; Robinson et al., 2016; Koranyi et al., 2021)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored on a 3-point Likert scale from 0 (never) to 2 (often), with a total score ranging from 0 to 32. Higher scores indicate higher demoralization.
Day 0, Month 3, Month 6, Month 9, Month 12

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Diagnosis of affective disorders, anxiety disorders, trauma- and stressor-related disorders assessed via Diagnostic and Statistical Manual of Mental Disorders-5 (SCID-5; Beesdo-Baum, 2019)
Time Frame: Day 0, Month 6, Month 12
Presence of the following mental disorders is indicated with "yes" or "no" based on SCID-5 criteria: Major depression, Persistent depressive disorder, Bipolar diorders, Panic disorder, Agoraphobia, Social phobia, Generalized anxiety disorder, Simple phobia, Posttraumatic stress disorder
Day 0, Month 6, Month 12
Diagnosis of stressor-related disorders assessed via CIDI Adjustment Disorder Module (Perkonigg et al., 2019)
Time Frame: Day 0, Month 6, Month 12
Presence of Adjustment disorder is indicated with "yes" or "no" based on ICD-11 criteria.
Day 0, Month 6, Month 12
Death anxiety assessed via Death and Dying Distress Scale (DADDS; Lo et al., 2011)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored on a 6-point Likert scale from 0 (no distress) to 5 (extreme distress), with a total score ranging from 0 to 75. Higher scores indicate higher levels of death anxiety.
Day 0, Month 3, Month 6, Month 9, Month 12
Dignity-related distress assessed via the Sense of Dignity Item (SDI; Chochinov et al., 2002)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Item is scord on a 7-point Likert-scale from 0 (no sense of loss of dignity) to 6 (extreme sense of loss of dignity).
Day 0, Month 3, Month 6, Month 9, Month 12
Dignity-related distress assessed via the Patient Dignity Inventory (PDI; Chochinov et al., 2008)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
The following subscales of the PDI are used: 1) Physical Symptom Distress, 2) Body Image and Loss of Autonomy. Items are scored on a 5-point Likert-scale from 0 (no problem) to 5 (an overwhelming problem). Higher scores indicate a higher sense of loss of dignity.
Day 0, Month 3, Month 6, Month 9, Month 12
Quality of life assessed via the Quality of Life at the End of Life-Cancer-Psychosocial Questionnaire (QUAL-EC-P)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Subscales used: 1) Life completion, 2) Preparation for the end of life. Items are scored on a 5-point Likert scale from 0 (not at all) to 4 (completely), with a total score ranging from 0 to 36. Higher scores indicate higher quality of life.
Day 0, Month 3, Month 6, Month 9, Month 12

Other Outcome Measures

Outcome Measure
Measure Description
Time Frame
Prognostic awareness assessed via semistructured interview for subjective goal of oncological treatment (El-Jawahri et al., 2020; DeMartini et al., 2019)
Time Frame: Day 0, Month 6, Month 12
Patients are asked about perceived goals of the cancer treatment and what they perceive to be their oncologists' goals for their treatment.
Day 0, Month 6, Month 12
Subjective experience of end-of-life discussions with health care provider assessed via semi-structured interview (El-Jawahri et al., 2020)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Patients are asked whether they discussed their wishes regarding medical treatment with their oncologist and how they experienced these conversation.
Day 0, Month 3, Month 6, Month 9, Month 12
Perceived relationship with healthcare provider assessed via Quality of Life at the End of Life-Cancer-Psychosocial Questionnaire (QUAL-EC-P)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Subscale Relationship with Healthcare Provider. Items are scored on a 5-point Likert scale from 0 (not at all) to 4 (completely), with a subscale score ranging from 0 to 20. Higher scores indicate a stronger relationship with health care providers.
Day 0, Month 3, Month 6, Month 9, Month 12
Flexibility of coping with incurable cancer assessed via Loss Orientation and Life Engagement in Advanced Cancer Scale (LOLES; Vehling et al., 2018)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored on a 5--point Likert scale from 0 (not at all) to 4 (nearly all the time). High scores indicate high levels of loss orientation, life engagement and coping efforts, respectively.
Day 0, Month 3, Month 6, Month 9, Month 12
Receipt of medical treatment in last 30 days of life assessed via Medical Chart Review (Abedini et al., 2019)
Time Frame: Month 12
Chemotherapy, immunotherapy, targeted therapy, hormonal therapy, inpatient treatment, emergency room visits, intensive care treatment, receipt of ambulatory or inpatient specialized or general palliative care
Month 12
Subjective experience and psychological adaptation of family caregivers assessed via semistructured qualitative interviews, diagnostic interviews, and self-report questionnaires
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Measures include a) identical versions of the measures used for patients, b) complementary versions of patient measures adapted for caregivers, c) caregiver-specific instruments
Day 0, Month 3, Month 6, Month 9, Month 12
Desire for hastened death assessed via Schedule of Attitudes Toward Hastened Death (SAHD; Kolva et al., 2017)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored with either being true (1) or false (0). For the total score, number of endorsed items are counted, ranging from 0 to 6. Higher scores indicate higher levels of desire for hastened death.
Day 0, Month 3, Month 6, Month 9, Month 12
Suicidality assessed via Beck Scale for Suicidal Ideation (BSS; Beck & Steer, 1993; Kliem & Brähler, 2015)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Intensity of suicidal tendencies is measured with three statements for each item. Statements are scored from 0 to 2. If screening items for active and passive suicidal ideation are scored with 0, participants are asked to skip to the items regarding previous suicidal attempts. The screening score ranges from 0 to 10, the total score ranges from 0 to 38. Higher values indicate stronger suicidal tendencies.
Day 0, Month 3, Month 6, Month 9, Month 12
Depressive symptoms assessed via Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored on a 4--point Likert scale ranging from 0 (not at all) to 3 (nearly every day), with a total score ranging from 0 to 27. Scores ≥10 indicate moderate, scores ≥15 severe depression.
Day 0, Month 3, Month 6, Month 9, Month 12
Anxiety symptoms assessed via Generalized Anxiety Disorder Questionnaire-7 (GAD-7; Spitzer et al., 2006)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored on a 4--point Likert scale ranging from 0 (not at all) to 3 (nearly every day), with a total score ranging from 0 to 21. Scores ≥10 indicate moderate, scores ≥15 severe anxiety.
Day 0, Month 3, Month 6, Month 9, Month 12
Adverse events assessed via Inventory for the Balanced Assessment of Negative Effects of Psychotherapy (INEP, Ladwig, Rief & Nestoriuc, 2014)
Time Frame: Month 3, Month 6, Month 9, Month 12, Weekly through treatment completion (median of 9 months)
Six items are scored on a scale from 7-point scale from -3 (worsening) to 3 (improvement), fifteen items are scored on a 4-point Likert-scale from 0 (not at all) to 4 (completely). If patients attributed changes to the therapy itself, frequencies, means, and standard deviation of negative (-3 to 1), no (0), and positive changes (1 to 3) are calculated.
Month 3, Month 6, Month 9, Month 12, Weekly through treatment completion (median of 9 months)
Adverse events assessed via therapy session protocols
Time Frame: Month 3, Month 6, Month 9, Month 12, Weekly through treatment completion (median of 9 months)
Therapists document adverse events on a standardized form after each therapy session.
Month 3, Month 6, Month 9, Month 12, Weekly through treatment completion (median of 9 months)
Therapeutic alliance assessed via Working Alliance Inventory - short revised (WAI-SR; Wilmers et al., 2024)
Time Frame: Month 3, Month 6, Month 9, Month 12, Weekly through treatment completion (median of 9 months)
Items are scored on a 5-point Likert-scale from 1 (never) to 5 (always), with a total score ranging from 12 to 60. Higher scores indicate a stronger working alliance.
Month 3, Month 6, Month 9, Month 12, Weekly through treatment completion (median of 9 months)
Agency assessed via Therapeutic Agency Inventory (TAI; Huber et al., 2019)
Time Frame: Weekly through treatment completion (median of 9 months)
Items are scored on a 5-point Likert-scale from 1 (not true) to 5 (very true), with a total score ranging from 15 to 75. Higher scores indicate a stronger sense of agency.
Weekly through treatment completion (median of 9 months)
Interpersonal problems assessed via Inventory of Interpersonal Problems - German Version (IIP-D-32; Horowitz et al., 1994)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored on a 5-point Likert-scale from 0 (not) to 4 (very much), with the total score ranging from 0 to 128. Higher total scores indicate higher distress due to interpersonal problems.
Day 0, Month 3, Month 6, Month 9, Month 12
Emotional dependence on others assessed via Depressive Experiences Questionnaire (DEQ; Blatt et al., 1976)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored on a 7-point Likert scale from 1 (strongly disagree) to 7 (strongly agree), with a total score ranging from 18 to 126. Higher scores indicate higher dependence on others to regulate emotional distress.
Day 0, Month 3, Month 6, Month 9, Month 12
Perceived communication in partnership assessed via Couple Communication Scale (CCS; Conrad et al., 2019)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), with a total score ranging from 10 to 50. Higher scores indicate better communication in relationships.
Day 0, Month 3, Month 6, Month 9, Month 12
Therapy adherence assessed via Penn Adherence/Competence Scale for Supportive-Expressive Dynamic Psychotherapy (Barber & Crits-Christoph, 1996), therapists' session protocols, supervision protocols, and therapists' diagnostic protocols
Time Frame: Weekly through treatment completion (median of 9 months)
Rating by trained observers.
Weekly through treatment completion (median of 9 months)
Insight into repetitive dysfunctional relationship patterns assessed via rating of therapy session transcripts with Insight into Conflictual Relationship Patterns Scale (ICR; Jennissen et al., 2020)
Time Frame: Weekly through treatment completion (median of 9 months)
Trained observers rate each audio recorded therapy session on a 5-point Likert-scale from 0 (not at all) to 4 (very much), with a total score ranging from 0 to 48. Higher scores indicate a more complex understanding of internal states and interpersonal processes.
Weekly through treatment completion (median of 9 months)
Defense mechanisms assessed via rating of therapy session transcripts with Defense Mechanisms Rating Scale (DMRS; Perry & Henry, 2004)
Time Frame: Weekly through treatment completion (median of 9 months)
Therapy session transcripts are rated by trained observers, Items are scored on a 5-point Likert-scale from 0 (not at all) to 4 (very much). A percentage score of defensive functioning is calculated.
Weekly through treatment completion (median of 9 months)
Perceived coping resources assessed via Questionnaire for Patient Competence in Coping with Cancer (PCQ, Aderhold et al., 2019)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Subscales used: 1) coping competence, 2) adaptability. Items are scored on a 6-point Likert scale from 0 (not at all) to 5 (completely), with a total score ranging from 0 to 35, and subscale scores ranging from 0 to 20 and 0 to 15. Higher scores indicate better coping.
Day 0, Month 3, Month 6, Month 9, Month 12
Medical parameters of oncological disease and treatment
Time Frame: Day 0, month 6, month 12
Day 0: Tumor site, date of first diagnosis, type of disease, date of diagnosis of recurrence/second tumor, stage of disease, Charlson Comorbidity Index (CCI); Day 0, month 6 and month 12: oncological treatments received, number of therapy lines, psychopharmacological medication, performance status (ECOG Status/Karnofsky Index), presence and date of disease progression
Day 0, month 6, month 12
Physical symptom distress assessed via Memorial Symptom Assessment Scale - Short Form (MSAS-SF; Chang et al., 2000)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Items are scored on a 5-point Likert-scale ranging from 0 (not at all distressed) to 4 (very much distressed). The average symptom score is calculated. Higher scores indicate higher physical symptom burden.
Day 0, Month 3, Month 6, Month 9, Month 12
Frequency and technique of psychooncological treatment assessed via semistructured interview and modified version of Multitheoretical List of Therapeutic Interventions-30 (Solomonov et al., 2019)
Time Frame: Day 0, Month 3, Month 6, Month 9, Month 12
Scale expanded by frequent intervention techniques used in psycho-oncologyícal treatments. Items are scored on a 5-point Likert-scale from 1 (not at all typical of the session) to 5 (very typical of the session), with a total score ranging from 39 to 195. Higher scores indicate a rather typical use of intervention techniques.
Day 0, Month 3, Month 6, Month 9, Month 12
Type and frequency of utilization of other psychosocial support services assessed via semistructured interview
Time Frame: Day 0, Month 6, Month 12
Day 0, Month 6, Month 12

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Publications and helpful links

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General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

October 24, 2025

Primary Completion (Estimated)

December 1, 2026

Study Completion (Estimated)

December 1, 2027

Study Registration Dates

First Submitted

December 5, 2025

First Submitted That Met QC Criteria

December 30, 2025

First Posted (Actual)

December 31, 2025

Study Record Updates

Last Update Posted (Actual)

December 31, 2025

Last Update Submitted That Met QC Criteria

December 30, 2025

Last Verified

December 1, 2025

More Information

Terms related to this study

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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