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The effects of loneliness: A review of the literature
The Effects of Loneliness: A Review of the Literature Donald A. West, Robert Kellner, and Maggi Moore-West The literature on loneliness is reviewed in regard to prevalence, demographics, its relationship to psychiatric disorders, and physical disease. Loneliness was found to be a problem for a significant portion of the population, reported more in the young and in women with the exception of older unmarried men. Studies which examine the relationship between loneliness, depression, alcoholism, child abuse, and bereavement are discussed. Studies of the relationship of loneliness with other psychiatric disorders are lacking. There are data relating loneliness to physical disease and possible mechanisms for this relationship are reviewed.
OR MOST OF HISTORY, loneliness has remained a phenomenon universally recognized and experienced by many people, but little studied. In the 1970s new interest developed in the field. Until that time, there were myths and assumptions about loneliness, for example, that the elderly are more lonely or that schizophrenics are more lonely. There were a few theoretical papers,’ but little data to support or contradict them. Likewise, there have been accepted beliefs, usually inferred from observation or clinical experience, about the effects of loneliness on physical and mental well-being. Only in the last two decades has there been a hint of the potential long-term effects of loneliness on health.2-5
F
DEFINITION
To examine loneliness, one must clearly distinguish between the subjective feeling of loneliness, spending time alone, and circumstances that induce a feeling of loneliness, such as depression or bereavement. Various definitions have been suggested. Harry Stack Sullivan6 defined loneliness as “the exceedingly unpleasant and driving experience connected with inadequate discharge of the need for human intimacy, for interpersonal intimacy.” Peplau and Perlman’ suggest as a working definition: “Loneliness is the unpleasant experience that occurs when a person’s network of social relations is deficient in some important way, either quantitatively or qualitatively.” Some studies have focused on isolation and aloneness with the implication that they were the same as loneliness. 8,g But physical isolation alone is not adequate to cause loneliness. Studies have shown that people must perceive themselves as lonely in order for loneliness to occur regardless of physical or social circumstances. lo Weiss” states “Loneliness is caused not by being alone but by being without some definite needed relationship or set of relationships.” He divides loneliness into two types: emotional loneliness, characterized by the absence of an attachment figure, and social isolation, manifested by the absence of a social network. The elements on which most loneliness researchers agree are that: (1) loneliness results from perceived deficiencies in a person’s social relationships; (2) it is a
From the Department of Psychiatry and the Department of Family, Community, and Emergency Medicine, University of New Mexico School of Medicine, 2400 Tucker NE, Albuquerque. Address reprint requests to Donald A, West, M.D.. University of New Mexico School of Medicine, 2400 Tucker NE, Albuquerque, NM 87131. @I 1986 by Grune & Stmtton. Inc. 0010-440X/86/2704-0011%03.00/0 Comprehensive Psychiafry, Vol. 27, No. 4 (July/August),
1986: pp 351-383
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subjective experience, and distressing. ’
not synonymous
with social isolation;
and (3) it is unpleasant
PREVALENCE Rubenstein et al., l2 in a study designed to determine the prevalence of loneliness, conducted a newspaper survey in cities and towns of various sizes throughout the US. Readers, whether they were lonely or not, were asked to complete an 84 item questionnaire printed in the newspaper and to mail a preceded answer sheet in for computer analysis. Twenty five thousand persons responded. Fifteen percent said they felt lonely most or all the time. Only 6% said they never felt lonely. All other respondents felt lonely on occasion. Bradburn I3 in another survey found 26% of his respondents said they felt “very lonely or remote from other people” in the preceeding few weeks. Sermati4 found that between 10% and 30% of individuals in various samples had experienced a pervasive feeling of loneliness during much of their lives. He also determined that 80% of people who call crisis centers complain of loneliness. Thus, a large proportion of people report feeling lonely frequently. Some report feeling lonely a large part of their lives. Since those reporting loneliness may be more likely to seek care, mental health professionals and those responsible for medical care should be particularly alert to loneliness, its demography, and potential effects. DEMOGRAPHICS In regard to age and loneliness, Rubin, I5 in a study in which preschool children were observed directly, concluded that children as young as 3-years-old can experience the loneliness of social isolation. No estimate of prevalence is given however. Most studies of loneliness and age have shown adolescents and persons of college age to be the most lonely. A number of studies of age prevalence12~16-18 found that loneliness peaked at adolescence and then decreased as subjects grew older. Brennen and Auslander, i7 in a study of self-reported loneliness in 9,000 adolescents in ten US cities found that between 10% and 15% were seriously lonely, 45% had less severe levels of chronic loneliness, and 54% stated “I often feel lonely.” Ostrov and Offer’* tested over 5,000 adolescents of both sexes, normal and disturbed, of various ethnic groups in the United States, Australia, and Ireland. Twenty-two percent of boys and 20% of girls, aged 12 to 16 years, agreed with the self-report statement “I am so very lonely” as did 14% of boys and 12.3% of girls between the ages of 16 and 20. They also found emotionally disturbed adolescents of both sexes were more lonely than normals. Collier and Lawrence l9 found social isolation occurring in 65% of adolescents studied and concluded that the feeling of social isolation could be called a typical experience of adolescence. The findings in the elderly are confusing. A review of the literature,*O as well as other work on older adults and the widowed,2’-24 examined the issue of whether being older automatically results in loneliness. The conclusion was that the elderly are not more lonely than others. This conclusion is supported by a number of other studies. 25-33 Revson and JohnsorG3 analyzed survey data from newspaper questionnaires in three northern American cities (N = 2,026). They found that loneliness
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decreased across the adult life cycle with respondants of age 65 and older reporting the least loneliness. In contrast to these findings, WoodM found loneliness to be directly correlated with age in her study of adults between the ages of 18 and 54. Two studies35*36 present data which show that the very elderly (generally those over 80) are significantly more lonely than other elderly. This is likely due to physical incapacity and/or decreased money or transportation. Marital status among the elderly has an effect on loneliness which will be discussed below. According to Revson and Johnson,” it is desolation or the loss of an intimate attachment rather than physical isolation which is the major correlate of loneliness in late life. To summarize the effects of age, studies indicate that loneliness occurs throughout the life cycle. It is reported most frequently among adolescents and young adults, possibly because this is the time of life when being included, accepted, and loved is of such major importance to the formation of one’s identity. In contrast to stereotype, the elderly do not generally report a high degree of loneliness, unless they are physically or financially unable to maintain contact with others. A possible explanation for this is that the elderly have learned to adjust to solitude or may prefer it. They, therefore, may not perceive their state as a lonely one until or unless they either lose an intimate companion or are unable to seek the company of others because of physical or financial reasons. Gender and marital status are difficult to examine separately. Ostrov and Offer l8 found essentially no difference in self-reported loneliness between adolescent boys and girls in several countries. Brennan, I6 however, reports a higher rate of selfreported loneliness among adolescent girls. A study of medical students” found women students experienced more feelings of social isolation than men and suggested that married women students may experience more social isolation in medical school than single women. The authors use the terms social isolation and loneliness interchangeably, however, in their questionnaire, loneliness is not mentioned. Whether the social isolation reported here is gender determined or more a function of the medical training environment interacting with gender is not known. Svanborg 38 studied a population of 70-year-old Swedish people and found that 12% of the males and 25% of females suffered from loneliness. Other studies have noted a greater degree of loneliness in women34,39*” while RussellZ5 found no significant differences overall in loneliness between the sexes. In developing the UCLA Loneliness Scale, Russell 2s found loneliness scores were lower for college undergraduates who were married or dating regularly than for those who were not dating at all or were dating casually. In her study of 18- to 54-year-olds, WoodM found loneliness higher in the unmarried. Rubenstein and Shaver41 found that when those who said they had been lonely in the past year were asked to identify the reasons, “being unattached” (having no spouse or sexual partner or having broken up with a spouse) accounted for 44% of the common variance, the largest portion in the sample. Among older adults, there is evidence that the married are less likely to report loneliness than the unmarried.” Perlman et al .43 found widowed men significantly lonelier than married men but there was no difference between widowed and married women. Bikson and Goodchilds” found that single older adults were more lonely than older couples and that single men were the loneliest group while married men
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were the least lonely. Married and single women scored in the middle. DeJongGierveld,45 suggesting that subjectively perceived social isolation is the same as or similar to loneliness, found that unmarried males showed the most subjective social isolation when compared to married males and to married and unmarried women. In regard to marital status alone, Lynch6 reviewed multiple studies on marital status and found that married people are healthier and live longer than those who are single, widowed, or divorced. The data show an association of mortality with not being married, rather than self-reported loneliness. Vinick, 46 in a study of older adults who had remarried, found the men had a greater motivation to remarry to ease the loneliness than the women. In general, women, when they are younger, report loneliness more than men, but in later life and when marital status is considered, unmarried men, whether widowed, divorced, or never married, report loneliness more than unmarried women. Marital status and emotional involvement play a role regardless of gender; generally, those married or emotionally attached are less lonely regardless of age. There have been studies which have examined loneliness in relation to ethnicity, l* socioeconomic status, 17g4’and education.34 However, the data are too sparse for conclusions. LONELINESS
AND PSYCHIATRIC
DISORDERS
In a study of patients in a general medical clinic, those who were judged to be in need of psychiatric treatment spent significantly more time alone than those patients judged not in need of psychiatric care.48 While what was measured was not actual self-reported loneliness, the implications are similar. Other studies as well have found relationships between loneliness and reported psychological problems 41 or psychological distress.42 Logic and clinical experience have resulted in a widespread assumption that loneliness is likely in patients with various psychiatric problems. Depression, anxiety, personality disorders, schizophrenia, alcoholism, bulimia, and child abuse are among the diagnoses frequently mentioned. Normal bereavement, though not a psychiatric disorder must also be examined in relation to loneliness because the grieving survivor experiences painful longing. Research data in these areas is minimal. There are only a few research studies dealing with loneliness and psychiatric disorders and they are reviewed below. A computer search of the literature revealed no studies specifically addressing loneliness in several psychiatric disorders including schizophrenia, anxiety disorders, and personality disorders. LONELINESS
AND DEPRESSION
Ostrov and Offer l8 suggest that the difference between loneliness and depression is that while both are filled with helplessness and pain, loneliness is characterized by the hope that all would be perfect if only the lonely person could be united with another longed for person. Young49 states that many clinicians believe that loneliness is a subset of depression and not a distinct concept worthy of study. The literature fails to support either of these ideas. In an effort to distinguish between loneliness and depression, Weeks et a1.50 administered loneliness and depression scales to undergraduate college students.
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Using data from 333 subjects, they concluded that loneliness and depression, though correlated with each other, were “clearly different constructs.” Neither was a direct cause of the other, though they were thought to share some origins. Various studies have shown correlations between loneliness and depression ranging from .3gs1 to .71.52 In a study of “prototypes of loneliness” and “prototypes of depression,” Horowitz et al. 53 found depression to be a “broader, more variegated concept” which included most of the features of the lonely prototype. The study found the probability that a lonely person would be described as depressed by a naive rater was .45, while the probability that a depressed person would be described as lonely was only .29. In a recent similar study, the same authors54 using the Beck Depression Inventory and the UCLA Loneliness Scale found that both lonely and depressed persons ascribed interpersonal failures to unchangeable defects within themselves, but that the lonely showed higher correlations with this attributional style. The authors hypothesize this is because the prototype of a lonely person is more singularly interpersonal than the depressed prototype. More recently, in a study of 110 depressed patients, EisemanS5 found that depressed patients felt lonelier and suffered more from their loneliness than controls. He also found that experienced loneliness was negatively correlated with the number of regular contacts with family members for all depressed patients and that the number of friends was negatively correlated with feelings of loneliness only for unipolar and bipolar groups. In a second report, apparently from the same 110 patient group, he found that feelings of loneliness correlated positively with personality variables such as suspicion, somatic anxiety, psychasthenia, psychic anxiety, detachment, hostility, muscular tension, inhibition, and irritability. Feelings of loneliness were negatively correlated with the extent of socialization and social desirability. The major conclusions from these studies is that loneliness and depression are separate but, in some way, overlapping constructs which may contribute to each other. In patients who are both lonely and depressed, the loneliness is positively correlated with negative feelings and negative judgement of personality attributes and negatively correlated with socialization. LONELINESS
AND ALCOHOLISM
Four studies specifically address the relationship between loneliness and alcoholism. Calicchia and Barressi 57 found both male and female alcoholics to experience significantly more social isolation than a control group in their study of alcoholism and alienation. The study, however, does not specifically measure loneliness. Allen et al. 58 compared acute, chronic, and recovering alcoholics on the Sisenwein Loneliness Scale and found the acute group demonstrated more loneliness than the recovering group. The chronic group showed no significant differences from either of the other groups. The study did not include a nonalcoholic control group. Nerviano and Gross,5q assuming that alcoholics experienced a high degree of loneliness, attempted a revision of the Bradley Loneliness Scale into subscales for a group of chronic alcoholics. The study emerged with two revised loneliness scales for work with alcoholics but with only inferential data thus far on actual loneliness in alcoholics.
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mental Andrews 60 compared 30 alcoholics seeking treatment at a community health clinic with 30 patients seeking treatment at the same center for disorders other than alcoholism. No significant differences emerged between the two groups on the Bradley Loneliness Scale. The author suggests that the factors which impinge on alcoholics to produce loneliness impinge on other patients seeking treatment as well. The study had no control group of patients not seeking care. At present, there are no controlled studies comparing loneliness in alcoholics with loneliness in nonalcoholics who are not patients. One controlled study deals with social isolation and not self-reported loneliness, the other used nonalcoholic psychiatric patients as controls. LONELINESS
AND CHILD ABUSE AND NEGLECT
the Child Abuse Potential Inventory to Milner and Wimberley6*,62 administered abusing and nonabusing parents. The loneliness measure was one of seven factors which distinguished abusers from nonabusers; however, it had no appreciable independent effect on abuse (it was not judged to be the “catalyst” for abuse). Spinetta63 in a study comparing six groups of mothers, both abusers and nonabusers from various socioeconomic groups, found “a tendency toward isolation and loneliness” to be one of six categories which differentiated abusers from nonabusers using the Michigan Screening Profile for Parenting. Polansky et al.” in a study of rural black and white child neglect families, found that neglectful mothers were more lonely than controls regardless of race. The results of the few available studies are congruent. They indicate that loneliness is more prevalent among child abusers and those who neglect than in those who take better care of their children. The cause for this association are unknown. LONELINESS
AND BEREAVEMENT
Loneliness is expected when people grieve the loss of someone to whom they were closely attached. Lopata25 confirms this in her reports of loneliness in widowhood comparing two samples of widows from two different cities. She reports that widows who expressed loneliness usually associated it with the absence of a spouse, companion, or social support. Up to 86% of widows reported experiencing loneliness, though the proportion decreased with the increasing number of children and with the support which they provided. Neither of the samples studied had a comparison group of married women. As with depression, while loneliness is likely to be a part of grief, the converse is not necessarily true. In general, the loneliness in grief is associated with the acute absence of an attachment figure rather than the absence of a social network. *I Clayton 65 studied a group of widows and widowers who were followed for a year after the death of a spouse. Results showed that the bereavement itself rather than the effects of living alone influenced the occurrence of depressive symptoms at 1 month. Data also supported the idea that younger people who lose a spouse suffer more symptoms than nonbereaved controls or older widows or widowers at 1 year. The tentative conclusion regarding loneliness and bereavement from the few studies that address the question is that loneliness is a part of grief rather than a
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manifestation of the absence of a social network l* although social isolation makes the prognosis worse& such that grief becomes a depressing, frightening, and painful ordeal. 67 LONELINESS
AND OTHER PSYCHIATRIC
PROBLEMS
Some other studies related to psychiatric problems merit mention. In a study by Finlay-Jones and Murphy,68 the General Health Questionaire, an instrument designed to aid in the detection of nonpsychotic psychiatric illness, misclassified 26% of women as having psychiatric illness when they did not. Self-reported loneliness was one of the reasons for the misclassification. Wenz69 investigated the relationship between loneliness and seasonality of suicide attempts in 110 subjects who had attempted suicide. The mean scores for loneliness were greatest for spring and winter, reported as the peak seasons for suicide attempts. Czernik and Steinmeyer ‘O examined the reported feelings of loneliness in 112 healthy and 56 neurotic German subjects. They found that neurotics suffered more deeply from loneliness than normals to a highly significant degree. The loneliness variables studied identified neurosis with 78% accuracy. Dasberg, ” studying both patients seen and case histories of Israeli soldiers who experienced breakdown in battle, reported intense loneliness to be a core phenomenon to such cases. The report was not a controlled study. Russell25 using the UCLA Loneliness Scale identified a number of groups at higher risk than expected for loneliness. Besides college students and divorced adults, as mentioned above, the list included adult psychiatric inpatients and participants in social skills workshops. The existing studies on psychiatric disorders and loneliness show a consistent association. The interactions are likely to be complex and are discussed below. LONELINESS
AND PHYSICAL
DISEASE
Researchers and theorists have been suggesting for years that loneliness has serious effects on health. Among the earliest studies were those of Spitz and Wolf’* almost 40 years ago who documented the physical decline and death of a number of infants who lost their parents early in life in spite of adequate feeding and physical care. The cause of the excess morbidity and mortality was postulated to be the lack of holding and cuddling. One can speculate that this may well be the infant equivalent of loneliness. Lynch, in his monograph The Broken Heart: The Medical Consequences of Loneliness * reviews studies of marital status, other relationships, community composition, and clinical observations to support the theory that those who live alone and are less socially involved are at higher risk for severe physical disease resulting in early death. However, his findings are based on marital status and not on selfreported loneliness. Rubenstein and Shaver,4’ in research based on an extensive newspaper survey, found that self-identified lonely persons reported more medical problems than the less lonely even though those reporting loneliness might be living with others. These were reports by the respondents. Their reported physical disease was not confirmed. A number of other studies have found relationships between loneliness and perceived
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physical health. Schill et al. 73 found a relationship between loneliness and somatic distress among those with an internal locus of control, using the Cornell Medical Index and a loneliness scale. Perlman et a1.43 found that among a group of senior citizens, loneliness was linked with poor hearing ability and poor health. Kivett74 found that one of the factors discriminating among levels of loneliness in rural widows was a measure of physical isolation as determined by self-perceived health and availability of transportation. In these two studies, health seems to be contributing to loneliness rather than the reverse. In a larger study, Kivetta confirmed again the association of loneliness with self-reported health status as well as poor vision. In contrast, Dubrey and Terril175 interviewed 50 terminally ill cancer patients to learn of possible feelings of loneliness. Most subjects did not report loneliness as such. Those who did cited night time as the most frequent occasion for loneliness with sleep as the major relief. In Svanborg’s study of elderly Swedish people,3s the lonely women reported feeling sick more often and visited physicians more frequently than men. Disorders such as coronary insufficiency had no demonstrated relationship to loneliness in this study. LeShan,76 in research over a 1Zyear period evaluated the “emotional lives” of 450 adult cancer patients using questionnaires, serial interviews, and intensive psychotherapy. He developed a hypothesis of an emotional life history pattern associated with the development of neoplastic disease which included loneliness as a major etiologic factor. In a rare prospective study, of interest in light of LeShan’s hypothesis, Thomas and Duszynski” studied 1,337 Johns Hopkins medical students graduating between 1948 and 1964. Those white male students who later developed malignant tumors demonstrated a statistically significant relationship between a lack of closeness to parents when they were younger and the development of malignancies which did not occur in the control group or in those who later developed hypertension or coronary artery disease. The relationship between the lack of closeness in early life and the presence of loneliness in adult life is unclear, but the results suggest a similarity. The relationship of this phenomenon to physical disease merits further study. In summary, studies reveal that loneliness is linked with reported feelings of ill health, somatic distress, and visits to physicians as well as physical disease. A few findings suggest a relationship of loneliness to the development of cancer and cardiovascular disease, but the studies are too few to warrant conclusions. LONELINESS,
STRESS, AND THE IMMUNE
SYSTEM
Recently, there has been extensive research on psychosocial effects of stress on the neuroendocrine and immune systems. 78 Whether loneliness qualifies as stress may be debateable, however some data is emerging which may begin to explain how loneliness could affect physical health. Locke et al. 79 studied the association of natural killer cell activity with life change and stress as well as somatic, affective, and other behavioral symptoms. Natural killer cells are lymphoid immune cells that appear to be involved in cancer protection and to have specific antitumor and antiviral activity. They have been shown to
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have vital importance in preventing the development and spread of tumors.80 Locke’s study79 found natural killer cell activity lower for those with high life change and stress scores and high symptom scores over a year long interval. The study suggests that chronic stress resulted in lowered killer cell activity. More recently and more specifically, I&colt-Glaser et al.2 found associations between loneliness, urinary cortisol levels, and cellular immunocompetency in psychiatric outpatients. Patients with loneliness scores above the median had significantly higher urinary cortisol levels than those below. Those with high loneliness scores had significantly lower levels of natural killer cell activity and poorer lymphocyte response to phytohemaaglutinin (an in vitro T lymphocyte stimulator). In a second study, Kiecolt-Glaser et al. 3 studied medical students who had blood samples drawn 1 month before final examinations and again on the first day of final exams. They also took the UCLA Loneliness Scale. Those with higher loneliness scores had significantly lower levels of natural killer cell activity. D’Enes5 examined 48 elderly subjects divided into “lonely” and “partially lonely” categories for immunoglobulin status (IgG, IgA, IgM). The lonely group showed a more vigorous decline of immunoglobulin levels than the less lonely group and over 5 years had a higher mortality rate. In another report on medical students, Kiecolt-Glaser et al4 found a “high” score on the UCLA Loneliness Scale to be associated with lower levels of transformation of B lymphocytes into lymphoblastoid cell lines (LCL) on exposure to a strain of transforming Epstein-Barr virus (EBV), a measure of decreased immunologic function. Thus, though the data comes from only two sets of investigators and would be strengthened by replication by others, loneliness shows an association with physiologic changes in humans, particularly immunosuppression. This may be the beginning of an explanation for the impact of loneliness on physical health. Peripherally related to the effect of loneliness on physical health are the effects of bereavement on physical health. A number of studies have found a higher rate of mortality 81-84or morbidityE5 in the first 6 months to 2 years following the death of a close relative. One studyE found no difference in mortality in widows, but did find an increased morbidity. One can speculate that the loneliness which occurs as a part of the more complex process of bereavement may have played some part in the increased mortality and morbidity. DlSCUSSlON
The study of loneliness raises a number of issues and problems. First and most important of these is that loneliness must be perceived and reported whether on scales or by interview to be studied. It is unlikely that loneliness is the same for any two people and it is not possible to know what is meant exactly when loneliness is reported. It is also difficult to separate loneliness from other emotional states such as depression which makes reliability a major problem for studying loneliness. The knowledge of the effects of loneliness is complicated by studies which measure constructs that are similar to loneliness or may include aspects of loneliness such as “being alone “48 “lack of closeness,“53 “ lack of a confiding relationship,“87 and
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social isolation. 19,44The latter probably comes closest to being synonomous with loneliness. The effects of lack of contact with other people, living alone, marital status, and bereavement can be objectively studied and are associated with reports of feeling lonely, but these effects do not appear identical with the effects of loneliness. The relationship of loneliness with psychiatric disorders is, at present, difficult to evaluate. There is little question that loneliness may induce psychiatric disorders, or that the disorders may result in patients being lonely. There are few controlled studies in the area. The few available studies show consistent associations, but the nature of the interactions has not been adequately investigated. It is likely that these vary from one psychiatric disorder to another and between individuals with the same disorder. The studies have implications for psychosomatic medicine. There are data from psychological and immunologic studies that suggest possible mechanisms for the way loneliness produces physical disease, opening an interesting and potentially productive field for research. SUMMARY From the studies reviewed, the following conclusions can be drawn. 1. Loneliness is a problem for a significant portion of the population. 2. In general, adolescents and young adults report more loneliness than older adults. 3. In most studies, women reported more loneliness than men, and the unmarried were more lonely than the attached. However, unmarried older men, whether widowed, divorced or never married, reported more loneliness than unmarried older women. 4. There is inadequate data regarding socioeconomic or cultural factors and loneliness to warrant any conclusions. 5. Though it is believed to occur in many psychiatric patients, there are no studies relating loneliness and several of the psychiatric disorders. 6. Loneliness, although a separate construct from either depression or bereavement, may contribute to, be a consequence of, or overlap with both. 7. The relationship between loneliness and alcoholism suggests a relationship between the two, but remains inconclusive because of a lack of controlled studies. 8. Loneliness appears to be one of the factors helpful in distinguishing parents who abuse or neglect their children from those who do not. 9. There are data which suggest that loneliness has an adverse effect on physical health, possibly through immunologic impairment or neuroendocrine changes. REFERENCES 1. Fromm-Reichmann F: Loneliness. Psychiatry 22:1- 15, 1959 2. Kiecolt-Glaser JK, Ricker D, George J, et al: Urinary cortisol levels, cellular ixmnunocompetency, and loneliness in psychiatric inpatients. Psychosom Med 46:15-23, 1984 3. Kiecolt-Glaser JK, Garner W, Speicher C, et al: Psychosocial modifiers of immunocompetency in medical students. Psychosom Med 46:7-14, 1984 4. Kiecolt-Glaser JK, Speicher CE, Holliday JE, et al: Stress and the transformation of lymphocytes by Epstein-Barr virus. J Behav Med 7: 1- 11, 1984 5. D’Enes Z: Loneliness in old age. Zeitschrift Altemsforschung 35:475-480, 1980
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6. Sullivan HS: The Interpersonal Theory of Psychiatry. New York, Norton, 1953, P 290 7. Peplau LA, Perlman D: Perspectives on loneliness, in Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, p 4 8. Lynch JJ: The Broken Heart: The Medical Consequences of Loneliness. New York, Basic Books, 1979 9. Fischer CS, Phillips SL: Who is Alone? Social Characteristics of People with Small Networks in Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, pp 21-39 10. Sermat V, Schmidt N, Wood L: Coping with loneliness. Paper read at IX International Congress on Suicide Prevention and Crisis Intervention, Helsinki Finland, June 20-23, 1977 11. Weiss R: Loneliness: The Experience of Emotional and Social Isolation. Cambridge, Mass, MIT Press, 1973, p 17 12. Rubenstein C, Shaver P, Peplau LA: Loneliness. Hum Nature 2:38-65, 1979 13. Bradburn NM: The Structure of Psychological Well Being. Chicago, Aldine, 1969 14. Sermat V: Some situational and personality correlates of loneliness, in Hartog J, Audy JR, Cohen YA (eds): The Anatomy of Loneliness. New York, International Universities Press, 1980 15. Rubin A: Children without friends, in Peplau LA, Perlman D (eds): Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, pp 255268. 16. Brennan T: Loneliness at adolescence, in Peplau LA, Perlman D (eds): Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, p 273 17. Brennan T, Auslander N: Adolescent Loneliness: An Exploratory Study of Social and Psychological Predispositions and Theory, vol 1. Prepared for the National Institute of Mental Health, Juvenile Problems Division, Grant #RO l-MH289 12-01 Behavioral Research Institute, 1979 18. Ostrov E, Offer D: Loneliness and the adolescent, in Feinstein S (ed): Adolescent Psychology. Chicago, University of Chicago Press, 1978 19. Collier RM, Lawrence HP: The adolescent feeling of psychological isolation. Educ Theor 1:106-115, 1951 20. Peplau LA, Bikson TK, Rook KS, et al: Being old and living alone, in Peplau LA, Perlman D (eds): Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, pp 327-347 21. Lopata HZ: Loneliness: Forms and components. Sot Prob 17:248-262, 1969 22. Lopata HZ: Widowhood in an American City. Cambridge, Mass, Schenkman, 1973 23. Lopata HZ: Women as Widows: Support Systems. New York, Elsenor, 1979 24. Lopata HZ, Hennemann GD, Baum J: Loneliness: Loneliness antecedents and coping strategies in the lives of widows, in Peplau LA, Perlman D (eds): Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, pp 310-326 25. Russell D: The measurement of loneliness, in Peplau LA, Perlman D (eds): Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, pp 81104 26. Dyer BM: Loneliness - There’s no way to escape it. Alpha Gamma Delta Quarterly Spring, 1974, p. 2-5. 27. Lowenthal ME, Thruner M, Chirboga D: Four Stages of Life. San Francisco, Joffey Bass, 1975 28. Rosow I: Retirement housing and social integration, in Tibbits C, Donahue N (eds): Social and Psychological Aspects of Aging. New York, Columbia University Press, 1962 29. Rubenstein C, Shaver P, and Peplau LA: Loneliness. Hum Nature 2:59-65, 1979 30. Shanas E, Townsend P, Wedderburn D, et al: Old People in Three Industrial Societies. New York, Atherton, 1968 31. Nahemous N: Residence, kinship and social isolation among the aged Baganda. Marriage Fam 41:171-183, 1979 32. Knipscheer CP: Social integration: A problem for the elderly. Nederlands Tijdschrift Voor Gerontologie 6:138-148, 1975
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33. Revenson TA, Johnson JL: Social and demographic correlates of loneliness in late life. Am J Community Psychiatry 12:71-S% 1984 34. Wood LA: Loneliness, social identity and social structure. Essence: Issues in the Study of Aging, Dying and Death (Canada) 2:259-270, 1978 35. Dean LR: Aging and the decline of affect. J Gerontol 17440446, 1962 36. Tunstall J: Old and Alone. London, Routledge & Kegan Paul, 1967 37. Hoferek JJ, Samoroski AA: Feelings of loneliness in women medical students. J Med Educ 56:397-403, 1981 38. Svanborg A: Variables related to affective mental disorders in the elderly. Aktuel Gerontol 66:479-492, 1979- 1980, Winter. 39. Clark M, Anderson BG: Loneliness and old age, in Hartog J, Audy JR, Cohen YA (eds): The Anatomy of Loneliness. New York, International Universities Press, 1980 40. Kivett VR: Discriminators of loneliness among the rural elderly. Gerontologist 19: 108115, 1979 41. Rubenstein C, Shaver P: The experience of loneliness, in Peplau LA, Perlman D (eds): loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, p 213 42. DeJong-Gierveld, J. and Raadschelden, J. Types of loneliness, in Peplau, LA and Perlman D (eds): Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, pp 105-119 43. Perlman D, Gerron AC, Spiunner B: Loneliness among senior citizens: An empirical report. Essence 2:239-249, 1978 44. Bikson TK, Goodchilds JD: Old and alone. Paper presented at the annual meeting of the American Psychological Association, Toronto, August, 1978 45. DeJong-Gierveld J: Social isolation and the image of the unmarried. Sociologia Neerlandica 7:1-14, 1971 46. Vinick BH: Remarriage in old age. J Geriatr Psychiatry 11:75-77, 1978 47. Williams EG: Adolescent loneliness. Adolescence 1851-66, 1983 48. Meyer E, Derogatis LR, Miller MJ, et al: Medical clinic patients with emotional disorders. Psychosomatics 19:61 l-619, 1978 49. Young JE: An Instrument for Measuring Loneliness. Paper presented at the annual meeting of the American Psychological Association, New York, September 1979 50. Weeks DG, Michels JL, Peplau LA, et al: Relation between loneliness and depression: A structural equation analysis. J Pers Sot Psycho1 39:1238- 1244, 1980 5 1. Russell D, Peplau LA, Ferguson M: Developing a measure of loneliness. J Pers Assess 42:290-294, 1978 52. Young JE: Loneliness, depression and cognitive therapy: Theory and application, in Peplau LA, Perlmann D (eds): Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York, Wiley, 1982, pp 381-382 53. Horowitz LM, Frenst RDS, Anderson CA: The Prototype of a Lonely Person, in Peplau LA and Perlman D (eds): Loneliness: A Sourcebook of Current Theory, Research, and Therapy. New York, Wiley, 1982, pp 183-205 54. Anderson CA, Horowitz LM, French RD: Attributional style of lonely and depressed people. J Pers Sot Psycho1 45: 127- 136, 1983 55. Eisemann M: Contact difficulties and experience of loneliness in depressed patients and non-psychiatric controls. Acta Psychiatr Stand 70~160-165, 1984 56. Eisemann M: The relationship of personality and social network aspects and loneliness in depressed patients. Acta Psycbiatr Stand 70~337-341, 1984 57. Calicchia JP, Bar& RM: Alcoholism and alienation. J Clin Psycho1 31:770-775, 1975 58. Allen HA, Peterson JS, Whipple S: Loneliness and alcoholism: A study of three groups of male alcoholics. Int J Addict 16:1255-1258, 1981 59. Nerviano VJ, Gross WF: Loneliness and locus of control for male alcoholics. J Clin Psycho1 32:479-484, 1976 60. Andrews M: The prevalence of loneliness in alcoholic versus non-alcoholic treatment populations. Dissertation Abstracts International 42:4935, 1982
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61. Mimer JS, Wimberley RC: An inventory for the identification of child abusers. J Clin Psycho1 3595-100, 1979 62. Milner JS, Wimberley RC: Prediction and explanation of child abuse. J Clin Psycho1 36875-884, 1980 63. Spinetta JJ: Parental personality factors in child abuse. J Consult Clin Psycho1 46: 14091414, 1978 64. Polansky NA, Ammons PW, Gaudin JM: Loneliness and isolation in child neglect. Sot Casework 66:38-47 1985 65. Clayton P: Effects of living alone on bereavement symptoms. Am J Psychiatry 132: 133137, 1975 66. Raphael B: Preventive intervention with the recently bereaved. Arch Gen Psychiatry 34:1450-1454, 1977 67. Parkes CM: The first year of bereavement. Psychiatry 33444-452, 1971 68. Finlay-Jones RA, Murphy E: Severity of psychiatric disorder and the 30 item general health questionnaire, Br J Psychiatry 134609-616, 1979 69. Wenz FV: Seasonal suicide attempts and forms of loneliness. Psycho1 Rep 40:807110, 1977 70. Czemik A, Steinmeyer E: Experience of loneliness in normal and in neurotic subjects. Archiv fur Psychiatric und Nervenkrankheiten 2 18: 141- 159, 1974 71. Dasberg H: Belonging and loneliness in relation to mental breakdown in battle with some remarks on treatment. Israel Ann Psychiatry Related Disciplines 14:307-321, 1976 72. Spitz R, Wolf KM: Anaclitic depression. Psychoanalytic Study of the Child, vol 2. New York, International Universities Press, 1946, pp 313-342 73. Schill T, Tover C, Ramaniah N: Coping with loneliness and locus of control. Psycho1 Rep 47:1054, 1980 74. Kivett VR: Loneliness and the rural widow. Fam Coordinator 27:389-394, 1978 75. Dubrey RJ, Terre11 LA: The Loneliness of the dying person: An exploratory study. Omega: J Death Dying 6:357-371, 1975 76. Le Shan L: An emotional life-history pattern associated with neoplastic disease. Ann NY Acad Sci 125:780-793, 1966 77. Thomas CB, Duszynski KR: Closeness to parents and the family constellation in a prospective study of five disease states: Suicide, mental illness, malignant tumor, hypertension, and coronary artery disease. Johns Hopkins Med J 134251-270, 1974 78. Ader R: Psychoneuroimmunology. Orlando, Fla, Academic, 1981 79. Locke SE, Hurst MW, Heisel JS, et al: The influence of stress and other social factors on human immunity. Presented at American Psychosomatic Meeting. Cited in Psychoneuroimmunology. Orlando, Fla, Academic, 1981, pp 138-139 80. Heberman RB, Natural killer cells. Hosp Pratt [Gffl 17:93-103, 1982 81. Young M, Bernard B, Wallis C: The mortality of widowers. Lancet 2:454-456, 1963 82. Cox PR, Ford JR: The mortality of widows shortly after widowhood. Lancet 1:163164, 1964 83. Rees WD, Lutkins SG: Mortality of bereavement. Br Med J 413-16, 1967 84. Parkes CM, Benjamin B, Fitzgerald RG: Broken heart: a statistical study of increased mortality among widowers. Br Med J 1: 740-744, 1969 85. Parkes CM, Brown RJ: A controlled study of young Boston widows and widowers. Psychiatry 33:444-467, 1970 86. Clayton PJ: Mortality and morbidity in the first year of widowhood. Arch Gen Psychiatry 30:747-750, 1974 87. Brown GW, Bhrolchain MN, Harris T: Class and psychiatric disturbance in women in an urban population. Sociology 9:225-254, 1975
OR MOST OF HISTORY, loneliness has remained a phenomenon universally recognized and experienced by many people, but little studied. In the 1970s new interest developed in the field. Until that time, there were myths and assumptions about loneliness, for example, that the elderly are more lonely or that schizophrenics are more lonely. There were a few theoretical papers,’ but little data to support or contradict them. Likewise, there have been accepted beliefs, usually inferred from observation or clinical experience, about the effects of loneliness on physical and mental well-being. Only in the last two decades has there been a hint of the potential long-term effects of loneliness on health.2-5
F
DEFINITION
To examine loneliness, one must clearly distinguish between the subjective feeling of loneliness, spending time alone, and circumstances that induce a feeling of loneliness, such as depression or bereavement. Various definitions have been suggested. Harry Stack Sullivan6 defined loneliness as “the exceedingly unpleasant and driving experience connected with inadequate discharge of the need for human intimacy, for interpersonal intimacy.” Peplau and Perlman’ suggest as a working definition: “Loneliness is the unpleasant experience that occurs when a person’s network of social relations is deficient in some important way, either quantitatively or qualitatively.” Some studies have focused on isolation and aloneness with the implication that they were the same as loneliness. 8,g But physical isolation alone is not adequate to cause loneliness. Studies have shown that people must perceive themselves as lonely in order for loneliness to occur regardless of physical or social circumstances. lo Weiss” states “Loneliness is caused not by being alone but by being without some definite needed relationship or set of relationships.” He divides loneliness into two types: emotional loneliness, characterized by the absence of an attachment figure, and social isolation, manifested by the absence of a social network. The elements on which most loneliness researchers agree are that: (1) loneliness results from perceived deficiencies in a person’s social relationships; (2) it is a
From the Department of Psychiatry and the Department of Family, Community, and Emergency Medicine, University of New Mexico School of Medicine, 2400 Tucker NE, Albuquerque. Address reprint requests to Donald A, West, M.D.. University of New Mexico School of Medicine, 2400 Tucker NE, Albuquerque, NM 87131. @I 1986 by Grune & Stmtton. Inc. 0010-440X/86/2704-0011%03.00/0 Comprehensive Psychiafry, Vol. 27, No. 4 (July/August),
1986: pp 351-383
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subjective experience, and distressing. ’
not synonymous
with social isolation;
and (3) it is unpleasant
PREVALENCE Rubenstein et al., l2 in a study designed to determine the prevalence of loneliness, conducted a newspaper survey in cities and towns of various sizes throughout the US. Readers, whether they were lonely or not, were asked to complete an 84 item questionnaire printed in the newspaper and to mail a preceded answer sheet in for computer analysis. Twenty five thousand persons responded. Fifteen percent said they felt lonely most or all the time. Only 6% said they never felt lonely. All other respondents felt lonely on occasion. Bradburn I3 in another survey found 26% of his respondents said they felt “very lonely or remote from other people” in the preceeding few weeks. Sermati4 found that between 10% and 30% of individuals in various samples had experienced a pervasive feeling of loneliness during much of their lives. He also determined that 80% of people who call crisis centers complain of loneliness. Thus, a large proportion of people report feeling lonely frequently. Some report feeling lonely a large part of their lives. Since those reporting loneliness may be more likely to seek care, mental health professionals and those responsible for medical care should be particularly alert to loneliness, its demography, and potential effects. DEMOGRAPHICS In regard to age and loneliness, Rubin, I5 in a study in which preschool children were observed directly, concluded that children as young as 3-years-old can experience the loneliness of social isolation. No estimate of prevalence is given however. Most studies of loneliness and age have shown adolescents and persons of college age to be the most lonely. A number of studies of age prevalence12~16-18 found that loneliness peaked at adolescence and then decreased as subjects grew older. Brennen and Auslander, i7 in a study of self-reported loneliness in 9,000 adolescents in ten US cities found that between 10% and 15% were seriously lonely, 45% had less severe levels of chronic loneliness, and 54% stated “I often feel lonely.” Ostrov and Offer’* tested over 5,000 adolescents of both sexes, normal and disturbed, of various ethnic groups in the United States, Australia, and Ireland. Twenty-two percent of boys and 20% of girls, aged 12 to 16 years, agreed with the self-report statement “I am so very lonely” as did 14% of boys and 12.3% of girls between the ages of 16 and 20. They also found emotionally disturbed adolescents of both sexes were more lonely than normals. Collier and Lawrence l9 found social isolation occurring in 65% of adolescents studied and concluded that the feeling of social isolation could be called a typical experience of adolescence. The findings in the elderly are confusing. A review of the literature,*O as well as other work on older adults and the widowed,2’-24 examined the issue of whether being older automatically results in loneliness. The conclusion was that the elderly are not more lonely than others. This conclusion is supported by a number of other studies. 25-33 Revson and JohnsorG3 analyzed survey data from newspaper questionnaires in three northern American cities (N = 2,026). They found that loneliness
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decreased across the adult life cycle with respondants of age 65 and older reporting the least loneliness. In contrast to these findings, WoodM found loneliness to be directly correlated with age in her study of adults between the ages of 18 and 54. Two studies35*36 present data which show that the very elderly (generally those over 80) are significantly more lonely than other elderly. This is likely due to physical incapacity and/or decreased money or transportation. Marital status among the elderly has an effect on loneliness which will be discussed below. According to Revson and Johnson,” it is desolation or the loss of an intimate attachment rather than physical isolation which is the major correlate of loneliness in late life. To summarize the effects of age, studies indicate that loneliness occurs throughout the life cycle. It is reported most frequently among adolescents and young adults, possibly because this is the time of life when being included, accepted, and loved is of such major importance to the formation of one’s identity. In contrast to stereotype, the elderly do not generally report a high degree of loneliness, unless they are physically or financially unable to maintain contact with others. A possible explanation for this is that the elderly have learned to adjust to solitude or may prefer it. They, therefore, may not perceive their state as a lonely one until or unless they either lose an intimate companion or are unable to seek the company of others because of physical or financial reasons. Gender and marital status are difficult to examine separately. Ostrov and Offer l8 found essentially no difference in self-reported loneliness between adolescent boys and girls in several countries. Brennan, I6 however, reports a higher rate of selfreported loneliness among adolescent girls. A study of medical students” found women students experienced more feelings of social isolation than men and suggested that married women students may experience more social isolation in medical school than single women. The authors use the terms social isolation and loneliness interchangeably, however, in their questionnaire, loneliness is not mentioned. Whether the social isolation reported here is gender determined or more a function of the medical training environment interacting with gender is not known. Svanborg 38 studied a population of 70-year-old Swedish people and found that 12% of the males and 25% of females suffered from loneliness. Other studies have noted a greater degree of loneliness in women34,39*” while RussellZ5 found no significant differences overall in loneliness between the sexes. In developing the UCLA Loneliness Scale, Russell 2s found loneliness scores were lower for college undergraduates who were married or dating regularly than for those who were not dating at all or were dating casually. In her study of 18- to 54-year-olds, WoodM found loneliness higher in the unmarried. Rubenstein and Shaver41 found that when those who said they had been lonely in the past year were asked to identify the reasons, “being unattached” (having no spouse or sexual partner or having broken up with a spouse) accounted for 44% of the common variance, the largest portion in the sample. Among older adults, there is evidence that the married are less likely to report loneliness than the unmarried.” Perlman et al .43 found widowed men significantly lonelier than married men but there was no difference between widowed and married women. Bikson and Goodchilds” found that single older adults were more lonely than older couples and that single men were the loneliest group while married men
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were the least lonely. Married and single women scored in the middle. DeJongGierveld,45 suggesting that subjectively perceived social isolation is the same as or similar to loneliness, found that unmarried males showed the most subjective social isolation when compared to married males and to married and unmarried women. In regard to marital status alone, Lynch6 reviewed multiple studies on marital status and found that married people are healthier and live longer than those who are single, widowed, or divorced. The data show an association of mortality with not being married, rather than self-reported loneliness. Vinick, 46 in a study of older adults who had remarried, found the men had a greater motivation to remarry to ease the loneliness than the women. In general, women, when they are younger, report loneliness more than men, but in later life and when marital status is considered, unmarried men, whether widowed, divorced, or never married, report loneliness more than unmarried women. Marital status and emotional involvement play a role regardless of gender; generally, those married or emotionally attached are less lonely regardless of age. There have been studies which have examined loneliness in relation to ethnicity, l* socioeconomic status, 17g4’and education.34 However, the data are too sparse for conclusions. LONELINESS
AND PSYCHIATRIC
DISORDERS
In a study of patients in a general medical clinic, those who were judged to be in need of psychiatric treatment spent significantly more time alone than those patients judged not in need of psychiatric care.48 While what was measured was not actual self-reported loneliness, the implications are similar. Other studies as well have found relationships between loneliness and reported psychological problems 41 or psychological distress.42 Logic and clinical experience have resulted in a widespread assumption that loneliness is likely in patients with various psychiatric problems. Depression, anxiety, personality disorders, schizophrenia, alcoholism, bulimia, and child abuse are among the diagnoses frequently mentioned. Normal bereavement, though not a psychiatric disorder must also be examined in relation to loneliness because the grieving survivor experiences painful longing. Research data in these areas is minimal. There are only a few research studies dealing with loneliness and psychiatric disorders and they are reviewed below. A computer search of the literature revealed no studies specifically addressing loneliness in several psychiatric disorders including schizophrenia, anxiety disorders, and personality disorders. LONELINESS
AND DEPRESSION
Ostrov and Offer l8 suggest that the difference between loneliness and depression is that while both are filled with helplessness and pain, loneliness is characterized by the hope that all would be perfect if only the lonely person could be united with another longed for person. Young49 states that many clinicians believe that loneliness is a subset of depression and not a distinct concept worthy of study. The literature fails to support either of these ideas. In an effort to distinguish between loneliness and depression, Weeks et a1.50 administered loneliness and depression scales to undergraduate college students.
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Using data from 333 subjects, they concluded that loneliness and depression, though correlated with each other, were “clearly different constructs.” Neither was a direct cause of the other, though they were thought to share some origins. Various studies have shown correlations between loneliness and depression ranging from .3gs1 to .71.52 In a study of “prototypes of loneliness” and “prototypes of depression,” Horowitz et al. 53 found depression to be a “broader, more variegated concept” which included most of the features of the lonely prototype. The study found the probability that a lonely person would be described as depressed by a naive rater was .45, while the probability that a depressed person would be described as lonely was only .29. In a recent similar study, the same authors54 using the Beck Depression Inventory and the UCLA Loneliness Scale found that both lonely and depressed persons ascribed interpersonal failures to unchangeable defects within themselves, but that the lonely showed higher correlations with this attributional style. The authors hypothesize this is because the prototype of a lonely person is more singularly interpersonal than the depressed prototype. More recently, in a study of 110 depressed patients, EisemanS5 found that depressed patients felt lonelier and suffered more from their loneliness than controls. He also found that experienced loneliness was negatively correlated with the number of regular contacts with family members for all depressed patients and that the number of friends was negatively correlated with feelings of loneliness only for unipolar and bipolar groups. In a second report, apparently from the same 110 patient group, he found that feelings of loneliness correlated positively with personality variables such as suspicion, somatic anxiety, psychasthenia, psychic anxiety, detachment, hostility, muscular tension, inhibition, and irritability. Feelings of loneliness were negatively correlated with the extent of socialization and social desirability. The major conclusions from these studies is that loneliness and depression are separate but, in some way, overlapping constructs which may contribute to each other. In patients who are both lonely and depressed, the loneliness is positively correlated with negative feelings and negative judgement of personality attributes and negatively correlated with socialization. LONELINESS
AND ALCOHOLISM
Four studies specifically address the relationship between loneliness and alcoholism. Calicchia and Barressi 57 found both male and female alcoholics to experience significantly more social isolation than a control group in their study of alcoholism and alienation. The study, however, does not specifically measure loneliness. Allen et al. 58 compared acute, chronic, and recovering alcoholics on the Sisenwein Loneliness Scale and found the acute group demonstrated more loneliness than the recovering group. The chronic group showed no significant differences from either of the other groups. The study did not include a nonalcoholic control group. Nerviano and Gross,5q assuming that alcoholics experienced a high degree of loneliness, attempted a revision of the Bradley Loneliness Scale into subscales for a group of chronic alcoholics. The study emerged with two revised loneliness scales for work with alcoholics but with only inferential data thus far on actual loneliness in alcoholics.
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mental Andrews 60 compared 30 alcoholics seeking treatment at a community health clinic with 30 patients seeking treatment at the same center for disorders other than alcoholism. No significant differences emerged between the two groups on the Bradley Loneliness Scale. The author suggests that the factors which impinge on alcoholics to produce loneliness impinge on other patients seeking treatment as well. The study had no control group of patients not seeking care. At present, there are no controlled studies comparing loneliness in alcoholics with loneliness in nonalcoholics who are not patients. One controlled study deals with social isolation and not self-reported loneliness, the other used nonalcoholic psychiatric patients as controls. LONELINESS
AND CHILD ABUSE AND NEGLECT
the Child Abuse Potential Inventory to Milner and Wimberley6*,62 administered abusing and nonabusing parents. The loneliness measure was one of seven factors which distinguished abusers from nonabusers; however, it had no appreciable independent effect on abuse (it was not judged to be the “catalyst” for abuse). Spinetta63 in a study comparing six groups of mothers, both abusers and nonabusers from various socioeconomic groups, found “a tendency toward isolation and loneliness” to be one of six categories which differentiated abusers from nonabusers using the Michigan Screening Profile for Parenting. Polansky et al.” in a study of rural black and white child neglect families, found that neglectful mothers were more lonely than controls regardless of race. The results of the few available studies are congruent. They indicate that loneliness is more prevalent among child abusers and those who neglect than in those who take better care of their children. The cause for this association are unknown. LONELINESS
AND BEREAVEMENT
Loneliness is expected when people grieve the loss of someone to whom they were closely attached. Lopata25 confirms this in her reports of loneliness in widowhood comparing two samples of widows from two different cities. She reports that widows who expressed loneliness usually associated it with the absence of a spouse, companion, or social support. Up to 86% of widows reported experiencing loneliness, though the proportion decreased with the increasing number of children and with the support which they provided. Neither of the samples studied had a comparison group of married women. As with depression, while loneliness is likely to be a part of grief, the converse is not necessarily true. In general, the loneliness in grief is associated with the acute absence of an attachment figure rather than the absence of a social network. *I Clayton 65 studied a group of widows and widowers who were followed for a year after the death of a spouse. Results showed that the bereavement itself rather than the effects of living alone influenced the occurrence of depressive symptoms at 1 month. Data also supported the idea that younger people who lose a spouse suffer more symptoms than nonbereaved controls or older widows or widowers at 1 year. The tentative conclusion regarding loneliness and bereavement from the few studies that address the question is that loneliness is a part of grief rather than a
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357
manifestation of the absence of a social network l* although social isolation makes the prognosis worse& such that grief becomes a depressing, frightening, and painful ordeal. 67 LONELINESS
AND OTHER PSYCHIATRIC
PROBLEMS
Some other studies related to psychiatric problems merit mention. In a study by Finlay-Jones and Murphy,68 the General Health Questionaire, an instrument designed to aid in the detection of nonpsychotic psychiatric illness, misclassified 26% of women as having psychiatric illness when they did not. Self-reported loneliness was one of the reasons for the misclassification. Wenz69 investigated the relationship between loneliness and seasonality of suicide attempts in 110 subjects who had attempted suicide. The mean scores for loneliness were greatest for spring and winter, reported as the peak seasons for suicide attempts. Czernik and Steinmeyer ‘O examined the reported feelings of loneliness in 112 healthy and 56 neurotic German subjects. They found that neurotics suffered more deeply from loneliness than normals to a highly significant degree. The loneliness variables studied identified neurosis with 78% accuracy. Dasberg, ” studying both patients seen and case histories of Israeli soldiers who experienced breakdown in battle, reported intense loneliness to be a core phenomenon to such cases. The report was not a controlled study. Russell25 using the UCLA Loneliness Scale identified a number of groups at higher risk than expected for loneliness. Besides college students and divorced adults, as mentioned above, the list included adult psychiatric inpatients and participants in social skills workshops. The existing studies on psychiatric disorders and loneliness show a consistent association. The interactions are likely to be complex and are discussed below. LONELINESS
AND PHYSICAL
DISEASE
Researchers and theorists have been suggesting for years that loneliness has serious effects on health. Among the earliest studies were those of Spitz and Wolf’* almost 40 years ago who documented the physical decline and death of a number of infants who lost their parents early in life in spite of adequate feeding and physical care. The cause of the excess morbidity and mortality was postulated to be the lack of holding and cuddling. One can speculate that this may well be the infant equivalent of loneliness. Lynch, in his monograph The Broken Heart: The Medical Consequences of Loneliness * reviews studies of marital status, other relationships, community composition, and clinical observations to support the theory that those who live alone and are less socially involved are at higher risk for severe physical disease resulting in early death. However, his findings are based on marital status and not on selfreported loneliness. Rubenstein and Shaver,4’ in research based on an extensive newspaper survey, found that self-identified lonely persons reported more medical problems than the less lonely even though those reporting loneliness might be living with others. These were reports by the respondents. Their reported physical disease was not confirmed. A number of other studies have found relationships between loneliness and perceived
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physical health. Schill et al. 73 found a relationship between loneliness and somatic distress among those with an internal locus of control, using the Cornell Medical Index and a loneliness scale. Perlman et a1.43 found that among a group of senior citizens, loneliness was linked with poor hearing ability and poor health. Kivett74 found that one of the factors discriminating among levels of loneliness in rural widows was a measure of physical isolation as determined by self-perceived health and availability of transportation. In these two studies, health seems to be contributing to loneliness rather than the reverse. In a larger study, Kivetta confirmed again the association of loneliness with self-reported health status as well as poor vision. In contrast, Dubrey and Terril175 interviewed 50 terminally ill cancer patients to learn of possible feelings of loneliness. Most subjects did not report loneliness as such. Those who did cited night time as the most frequent occasion for loneliness with sleep as the major relief. In Svanborg’s study of elderly Swedish people,3s the lonely women reported feeling sick more often and visited physicians more frequently than men. Disorders such as coronary insufficiency had no demonstrated relationship to loneliness in this study. LeShan,76 in research over a 1Zyear period evaluated the “emotional lives” of 450 adult cancer patients using questionnaires, serial interviews, and intensive psychotherapy. He developed a hypothesis of an emotional life history pattern associated with the development of neoplastic disease which included loneliness as a major etiologic factor. In a rare prospective study, of interest in light of LeShan’s hypothesis, Thomas and Duszynski” studied 1,337 Johns Hopkins medical students graduating between 1948 and 1964. Those white male students who later developed malignant tumors demonstrated a statistically significant relationship between a lack of closeness to parents when they were younger and the development of malignancies which did not occur in the control group or in those who later developed hypertension or coronary artery disease. The relationship between the lack of closeness in early life and the presence of loneliness in adult life is unclear, but the results suggest a similarity. The relationship of this phenomenon to physical disease merits further study. In summary, studies reveal that loneliness is linked with reported feelings of ill health, somatic distress, and visits to physicians as well as physical disease. A few findings suggest a relationship of loneliness to the development of cancer and cardiovascular disease, but the studies are too few to warrant conclusions. LONELINESS,
STRESS, AND THE IMMUNE
SYSTEM
Recently, there has been extensive research on psychosocial effects of stress on the neuroendocrine and immune systems. 78 Whether loneliness qualifies as stress may be debateable, however some data is emerging which may begin to explain how loneliness could affect physical health. Locke et al. 79 studied the association of natural killer cell activity with life change and stress as well as somatic, affective, and other behavioral symptoms. Natural killer cells are lymphoid immune cells that appear to be involved in cancer protection and to have specific antitumor and antiviral activity. They have been shown to
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have vital importance in preventing the development and spread of tumors.80 Locke’s study79 found natural killer cell activity lower for those with high life change and stress scores and high symptom scores over a year long interval. The study suggests that chronic stress resulted in lowered killer cell activity. More recently and more specifically, I&colt-Glaser et al.2 found associations between loneliness, urinary cortisol levels, and cellular immunocompetency in psychiatric outpatients. Patients with loneliness scores above the median had significantly higher urinary cortisol levels than those below. Those with high loneliness scores had significantly lower levels of natural killer cell activity and poorer lymphocyte response to phytohemaaglutinin (an in vitro T lymphocyte stimulator). In a second study, Kiecolt-Glaser et al. 3 studied medical students who had blood samples drawn 1 month before final examinations and again on the first day of final exams. They also took the UCLA Loneliness Scale. Those with higher loneliness scores had significantly lower levels of natural killer cell activity. D’Enes5 examined 48 elderly subjects divided into “lonely” and “partially lonely” categories for immunoglobulin status (IgG, IgA, IgM). The lonely group showed a more vigorous decline of immunoglobulin levels than the less lonely group and over 5 years had a higher mortality rate. In another report on medical students, Kiecolt-Glaser et al4 found a “high” score on the UCLA Loneliness Scale to be associated with lower levels of transformation of B lymphocytes into lymphoblastoid cell lines (LCL) on exposure to a strain of transforming Epstein-Barr virus (EBV), a measure of decreased immunologic function. Thus, though the data comes from only two sets of investigators and would be strengthened by replication by others, loneliness shows an association with physiologic changes in humans, particularly immunosuppression. This may be the beginning of an explanation for the impact of loneliness on physical health. Peripherally related to the effect of loneliness on physical health are the effects of bereavement on physical health. A number of studies have found a higher rate of mortality 81-84or morbidityE5 in the first 6 months to 2 years following the death of a close relative. One studyE found no difference in mortality in widows, but did find an increased morbidity. One can speculate that the loneliness which occurs as a part of the more complex process of bereavement may have played some part in the increased mortality and morbidity. DlSCUSSlON
The study of loneliness raises a number of issues and problems. First and most important of these is that loneliness must be perceived and reported whether on scales or by interview to be studied. It is unlikely that loneliness is the same for any two people and it is not possible to know what is meant exactly when loneliness is reported. It is also difficult to separate loneliness from other emotional states such as depression which makes reliability a major problem for studying loneliness. The knowledge of the effects of loneliness is complicated by studies which measure constructs that are similar to loneliness or may include aspects of loneliness such as “being alone “48 “lack of closeness,“53 “ lack of a confiding relationship,“87 and
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social isolation. 19,44The latter probably comes closest to being synonomous with loneliness. The effects of lack of contact with other people, living alone, marital status, and bereavement can be objectively studied and are associated with reports of feeling lonely, but these effects do not appear identical with the effects of loneliness. The relationship of loneliness with psychiatric disorders is, at present, difficult to evaluate. There is little question that loneliness may induce psychiatric disorders, or that the disorders may result in patients being lonely. There are few controlled studies in the area. The few available studies show consistent associations, but the nature of the interactions has not been adequately investigated. It is likely that these vary from one psychiatric disorder to another and between individuals with the same disorder. The studies have implications for psychosomatic medicine. There are data from psychological and immunologic studies that suggest possible mechanisms for the way loneliness produces physical disease, opening an interesting and potentially productive field for research. SUMMARY From the studies reviewed, the following conclusions can be drawn. 1. Loneliness is a problem for a significant portion of the population. 2. In general, adolescents and young adults report more loneliness than older adults. 3. In most studies, women reported more loneliness than men, and the unmarried were more lonely than the attached. However, unmarried older men, whether widowed, divorced or never married, reported more loneliness than unmarried older women. 4. There is inadequate data regarding socioeconomic or cultural factors and loneliness to warrant any conclusions. 5. Though it is believed to occur in many psychiatric patients, there are no studies relating loneliness and several of the psychiatric disorders. 6. Loneliness, although a separate construct from either depression or bereavement, may contribute to, be a consequence of, or overlap with both. 7. The relationship between loneliness and alcoholism suggests a relationship between the two, but remains inconclusive because of a lack of controlled studies. 8. Loneliness appears to be one of the factors helpful in distinguishing parents who abuse or neglect their children from those who do not. 9. There are data which suggest that loneliness has an adverse effect on physical health, possibly through immunologic impairment or neuroendocrine changes. REFERENCES 1. Fromm-Reichmann F: Loneliness. Psychiatry 22:1- 15, 1959 2. Kiecolt-Glaser JK, Ricker D, George J, et al: Urinary cortisol levels, cellular ixmnunocompetency, and loneliness in psychiatric inpatients. Psychosom Med 46:15-23, 1984 3. Kiecolt-Glaser JK, Garner W, Speicher C, et al: Psychosocial modifiers of immunocompetency in medical students. Psychosom Med 46:7-14, 1984 4. Kiecolt-Glaser JK, Speicher CE, Holliday JE, et al: Stress and the transformation of lymphocytes by Epstein-Barr virus. J Behav Med 7: 1- 11, 1984 5. D’Enes Z: Loneliness in old age. Zeitschrift Altemsforschung 35:475-480, 1980
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