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r> From a theoretical perspective, the presumed role of attachment styles for SP 600125 to bereavement [40] may have value in under-standing adaptation to existential loss and death in advanced cancer [4]. Attachment security may interfere with the ability to shift flexibly between facing the losses and threats of advanced cancer and con-tinuing to engage in meaningful activities in daily life, an experience that has been referred to as “middle knowledge”, the “living-dying-phase”, or “double awareness” [41–43]. Those with more attachment anxiety may be preoccupied with their fears of isolation and distress, impairing flexibility in life engagement, while those who tend to be more avoidant and self-reliant may have difficulty processing their grief and sharing their sense of loss with close others, impairing flexibility in loss orientation [44]. In the context of a shortened life expectancy, the cultivation of such flexibility toward both orientations may support regulation of difficult emotions and counter demoralization and its characteristic sense of being trapped and inability to imagine a per-sonally meaningful future.
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 [12]. 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 adaptation 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 [12], 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.
5. Conclusion
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.