Psychological spiral under the double burden of chronic diseases: An ego depletion model in elderly patients with heart failure and cancer
Abstract
Elderly patients experiencing the dual burden of chronic heart failure and cancer face complex physical and psychological challenges that can accelerate psychological decline. This study aimed to examine how fatigue and emotional dysregulation contribute to ego depletion, while assessing the potential moderating or mediating role of resilience. A cross-sectional survey was conducted with 200 patients using four validated instruments: The Fatigue Severity Scale (FSS), Difficulties in Emotion Regulation Scale–16 (DERS-16), Connor–Davidson Resilience Scale–10 (CD-RISC-10), and the Self-Regulatory Fatigue Scale–Short Form (SRF-S). Results showed that both fatigue and emotional dysregulation were positively associated with self-regulatory fatigue, whereas resilience was inversely related. To our knowledge, this is the first study to apply the ego depletion model to elderly patients simultaneously managing chronic heart failure and cancer. The findings highlight self-regulatory fatigue as a critical psychological outcome in this population and suggest that strengthening resilience may represent an effective nursing intervention target to mitigate psychological exhaustion and improve overall well-being.
Copyright (c) 2026 Jiale Liu, Wanqi Li, Tingting Zhu, Jiao Hua
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
1. Baxter R, Sirois FM. Self‐compassion and psychological distress in chronic illness: A meta‐analysis. British Journal of Health Psychology. 2024; 30(1). doi: 10.1111/bjhp.12761
2. Ji Q, Zhang L, Xu J, et al. The relationship between stigma and quality of life in hospitalized middle-aged and elderly patients with chronic diseases: the mediating role of depression and the moderating role of psychological resilience. Frontiers in Psychiatry. 2024; 15: 1346881. doi: 10.3389/fpsyt.2024.1346881
3. Coutinho M, Trindade IA, Ferreira C. Experiential avoidance, committed action and quality of life: Differences between college students with and without chronic illness. Journal of health psychology. 2021; 26(7): 1035-1045. doi: 10.1177/1359105319860167
4. Lu Y, Jin X, Feng L-W, et al. Effects of illness perception on negative emotions and fatigue in chronic rheumatic diseases: Rumination as a possible mediator. World Journal of Clinical Cases. 2022; 10(34): 12515. doi: 10.12998/wjcc.v10.i34.12515
5. Ebrahimgol F, Khanjani MS, Abdi K, et al. Psychological adjustment measures for chronic illness: A narrative review. Iranian Journal of Psychiatry. 2025; 20(2): 241. doi: 10.18502/ijps.v20i2.18205
6. Chen CYC. Roles of physical functioning and comorbid mental illness of chronically ill parents and their spouses’ health status in adolescent functioning. Journal of Adolescence. 2024; 96(2): 381-393. doi: 10.1002/jad.12282
7. Hamdan-Mansour AM, Aboshaiqah AE, Thultheen IN, et al. Psychological wellbeing of Saudi patients diagnosed with chronic illnesses. Psychology. 2015; 6(1): 55-62. doi: 10.4236/psych.2015.61006
8. Karimi S, Moradimanesh F, Asgari P, et al. The effectiveness of acceptance and commitment therapy on the illness perception in dialysis patients. Journal of Pharmaceutical Research International. 2019: 1-8.
9. Clesse C, Yaqoob MM, Jayakumar S, et al. Investigating inflammation in depression in the chronically ill: Theoretical model and perspectives. Journal of the Royal College of Physicians of Edinburgh. 2022; 52(3): 247-252. doi: 10.1177/14782715221115776
10. Chen CY-C. Educational functioning of children of parents with chronic physical illness: A systematic review. School Psychology International. 2016; 37(6): 606-626. doi: 10.1177/0143034316672705
11. Landi G, Pakenham KI, Benassi M, et al. A model of the effects of parental illness on youth adjustment and family functioning: The moderating effects of psychological flexibility on youth caregiving and stress. International journal of environmental research and public health. 2021; 18(9): 4902. doi: 10.3390/ijerph18094902
12. Kovács KE, Boris P, Nagy BE. Psychological well-being and life satisfaction in children and adolescents with chronic illness: the role of depression, nonproductive thoughts, and problematic internet use. Children. 2025; 12(5): 657. doi: 10.3390/children12050657
13. Al ASA, Alqudah A. Examine the role of psychological resilience in predicting social and professional performance in patients with diabetes, multiple sclerosis, and rheumatism. Health Psychology Research. 2023; 11: 73350. doi: 10.52965/001c.73350
14. Çelik E, Baltacı S, Yaman N. Psychological effects of the pandemic on Turkish university students during the period of returning to universities. Turkish Psychological Counseling and Guidance Journal. 2023; 13(68): 61–74. doi: 10.17066/tpdrd.1198897e
15. Enzin F, Dikici İC, Tülüce D. The relationship between kinesiophobia and adaptation to illness in different chronic illnesses. Chronic Illness. 2024; 20(3): 504–514. doi: 10.1177/17423953231221837
16. Berglund S, Danielsson A, Jakobsson Støre S, et al. Illness stigma and shame in people with chronic illnesses vs. SARS‐CoV‐2 survivors: Associations with psychological distress through psychological flexibility and self‐compassion. Clinical Psychology & Psychotherapy. 2024; 31(6): e70009. doi: 10.1002/cpp.70009
17. Kukay A, McKinney C. Chronic illness and psychopathology in emerging adults: Moderation by parent–child relationship quality. Chronic Illness. 2025; 21(1): 81-93. doi: 10.1177/17423953231200681
18. Obadeji A, Oluwole L, Dada M, et al. Alcohol use and psychological wellbeing of health workers in a Nigerian Hospital: An exploratory study. Malawi Medical Journal. 2018; 30(1): 31–36. doi:10.4314/mmj.v30i1.7
19. Hards E, Orchard F, Khalid S, et al. Self-evaluation and depression in adolescents with a chronic illness: A systematic review. Clinical child psychology and psychiatry. 2023; 28(1): 382–397. doi: 10.1177/13591045221115287
20. Knowles SR, Apputhurai P, Jenkins Z, et al. Impact of chronic kidney disease on illness perceptions, coping, self-efficacy, psychological distress and quality of life. Psychology, Health & Medicine. 2023; 28(7): 1963–1976. doi: 10.1080/13548506.2023.2179644
21. Ferro MA, Boyle MH, Avison WR. Association between trajectories of maternal depression and subsequent psychological functioning in youth with and without chronic physical illness. Health Psychology. 2015; 34(8): 820.
22. Baumeister R F, Bratslavsky E, Muraven M, et al. Ego depletion: Is the active self a limited resource? Self-regulation and self-control. Routledge. 2018; 16–44. doi:10.1037//0022-3514.74.5.1252.
23. Bonk D, Tamminen KA. Dysregulated gaming and emotion regulation flexibility. Psychology of Popular Media. 2025; doi: 10.1037/ppm0000591
24. Blanco‐Donoso LM, Amutio A, Moreno‐Jiménez B, et al. Incivility at work, upset at home? Testing the cross‐level moderation effect of emotional dysregulation among female nurses from primary health care. Scandinavian journal of psychology. 2019; 60(3): 267–276. doi: 10.1111/sjop.12535
25. Tristania OC, Hanurawan F. The correlation between emotional dysregulation and deliberate self-harm among college students in Malang. KnE Social Sciences. 2022: 325–336–325–336. doi: 10.18502/kss.v7i18.12398
26. Liu J, Tan RHS, Chang SSH, et al. Pathological personality explains individual differences in global emotion dysregulation within the pathway between child maltreatment and severe depressive symptoms. Psychological Trauma: Theory, Research, Practice, and Policy. 2024; 16(S1): S233.
27. Bell KM, Howard L, Cornelius TL. Emotion dysregulation as a moderator of the association between relationship dependency and female-perpetrated dating aggression. Journal of interpersonal violence. 2022; 37(5–6): NP2891-NP2911. doi: 10.1177/0886260520945678
28. Banovic I, Montreuil L, Derrey-Bunel M, et al. Toward further understanding of crohn’s disease-related fatigue: the role of depression and emotional processing. Frontiers in psychology. 2020; 11: 703. doi:10.3389/fpsyg.2020.00703
29. Taccini F, Rossi AA, Mannarini S. Understanding the role of self‐esteem and emotion dysregulation in victims of intimate partner violence. Family Process. 2024; 63(4): 2258–2275. doi: 10.1111/famp.12966
30. Eres R, Lim MH, Bates G. Loneliness and social anxiety in young adults: The moderating and mediating roles of emotion dysregulation, depression and social isolation risk. Psychology and Psychotherapy: Theory, Research and Practice. 2023; 96(3): 793–810. doi: 10.1111/papt.12469
31. Samson AC, Phillips JM, Parker KJ, et al. Emotion dysregulation and the core features of autism spectrum disorder. Journal of Autism and Developmental Disorders. 2014; 44(7): 1766–1772. doi: 10.1007/s10803-013-2022-5
32. Dolan M, Slavish DC, Weiss NH, et al. The role of emotion dysregulation in the relationship between sleep disturbances and PTSD symptom severity. The Journal of nervous and mental disease. 2023; 211(3): 203–215. doi: 10.1097/NMD.0000000000001631
33. Richardson T, Egglishaw A, Sood M. Does childhood trauma predict impulsive spending in later life? An analysis of the mediating roles of impulsivity and emotion regulation. Journal of Child & Adolescent Trauma. 2024; 17(2): 275–281. doi: 10.1007/s40653-023-00600-7
34. Trombetta T, Balocco V, Santoniccolo F, et al. Internalized homonegativity, emotion dysregulation, and isolating behaviors perpetration among gay and lesbian couples. International journal of environmental research and public health. 2023; 20(2): 1593. doi: 10.3390/ijerph20021593
35. Xu M, Johnson LN, Anderson SR, et al. Emotion dysregulation and couple relationship satisfaction of clinical couples: An actor‐partner interdependence model. Family process. 2023; 62(4): 1555–1573. doi: 10.1111/famp.12828
36. Lubben A, Gecha T, Cano K, et al. Emotion dysregulation and parent emotion socialization in mothers with borderline pathology. Research Square. 2025: rs. 3. rs-6355485. doi: 10.21203/rs.3.rs-6355485/v1
37. Gilchrist JD, Mitchell J, Qian W, et al. Bidirectional associations between sleep duration and emotion dysregulation across adolescence. Developmental Psychology. 2023; 59(6): 1087.
38. Monell E, Högdahl L, Mantilla EF, et al. Emotion dysregulation, self-image and eating disorder symptoms in University Women. Journal of Eating Disorders. 2015; 3(1): 44. doi: 10.1186/s40337-015-0083-x
39. Greidanus‐Jongejan JE, van Gorp M, van Litsenburg RR, et al. Fatigue mediates the relationship between emotional and cognitive functioning in children post‐cancer treatment. Pediatric Blood & Cancer. 2023; 70(10): e30594. doi: 10.1002/pbc.30594
40. Jiang Y, Lin X, Zhou Q, et al. Longitudinal dyadic analyses of emotion dysregulation and mother–child relationship quality in Chinese children with teacher‐reported oppositional defiant disorder. Social Development. 2020; 29(1): 217–231. doi: 10.1111/sode.12388
41. McLaughlin KA, Hatzenbuehler ML, Mennin DS, et al. Emotion dysregulation and adolescent psychopathology: A prospective study. Behaviour research and therapy. 2011; 49(9): 544–554. doi: 10.1016/j.brat.2011.06.003
42. Cavalli JM, Cservenka A. Emotion dysregulation moderates the association between stress and problematic cannabis use. Frontiers in psychiatry. 2021; 11: 597789. doi: 10.3389/fpsyt.2020.597789
43. Cao Q, Zhang Q, Chen Y, et al. The relationship between non-suicidal self-injury and childhood abuse in transgender people: a cross-sectional cohort study. Frontiers in psychology. 2023; 14: 1062601. doi: 10.3389/fpsyg.2023.1062601
44. Von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (strobe) statement: Guidelines for reporting observational studies. The Lancet. 2007; 370(9596): 1453-1457. doi: 10.1016/S0140-6736(07)61602-X
45. Green SB. How many subjects does it take to do a regression analysis. Multivariate Behavioral Research. 1991; 26(3): 499–510. doi: 10.1207/s15327906mbr2603_7
46. Krupp LB, LaRocca NG, Muir-Nash J, et al. The fatigue severity scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of neurology. 1989; 46(10): 1121–1123. doi: 10.1001/archneur.1989.00520460115022
47. Valko PO, Bassetti CL, Bloch KE, et al. Validation of the fatigue severity scale in a swiss cohort. Sleep. 2008; 31(11): 1601–1607. doi: 10.1093/sleep/31.11.1601
48. Learmonth Y, Dlugonski D, Pilutti L, et al. Psychometric properties of the fatigue severity scale and the modified fatigue impact scale. Journal of the neurological sciences. 2013; 331(1-2): 102–107. doi: 10.1016/j.jns.2013.05.023
49. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of psychopathology and Behavioral Assessment. 2004; 26(1): 41–54. doi: 10.1023/B:JOBA.0000007455.08539.94
50. Bjureberg J, Ljótsson B, Tull MT, et al. Development and validation of a brief version of the difficulties in emotion regulation scale: the DERS-16. Journal of Psychopathology and Behavioral Assessment. 2016; 38(2): 284–296. doi: 10.1007/s10862-015-9514-x
51. Hallion LS, Steinman SA, Tolin DF, et al. Psychometric properties of the Difficulties in Emotion Regulation Scale (DERS) and its short forms in adults with emotional disorders. Frontiers in Psychology. 2018; 9: 289634. doi: 10.3389/fpsyg.2018.00539
52. Campbell‐Sills L, Stein MB. Psychometric analysis and refinement of the connor–davidson resilience scale (CD‐RISC): Validation of a 10‐item measure of resilience. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies. 2007; 20(6): 1019-1028. doi: 10.1002/jts.20271
53. Ye ZJ, Qiu HZ, Li PF, et al. Validation and application of the chinese version of the 10-item connor-davidson resilience scale (cd-risc-10) among parents of children with cancer diagnosis. European Journal of Oncology Nursing. 2017; 27: 36–44. doi: 10.1016/j.ejon.2017.01.004
54. Liu JJ, Reed M, Girard TA. Advancing resilience: An integrative, multi-system model of resilience. Personality and Individual Differences. 2017; 111: 111–118. doi: 10.1016/j.paid.2017.02.007
55. Nes LS, Ehlers SL, Whipple MO, et al. Self-regulatory fatigue in chronic multisymptom illnesses: scale development, fatigue, and self-control. Journal of pain research. 2013: 181–188. doi: 10.2147/JPR.S40014
56. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford publications; 2017.
