Peter H Brown Clinical Psychologist

The recent controversy over the still-developing DSM-5 — that compendium of mental disorders the media love to call, inappropriately, “The Bible of Psychiatry” –has gotten me thinking about loneliness. Now, thankfully, nobody has seriously proposed including loneliness in the DSM-5. Indeed, loneliness is usually thought of as simply an unpleasant part of life — one of the “slings and arrows” that pierce almost all of us from time to time. Loneliness, in some ways, remains enmeshed in a web of literary and cultural clichés, born of such works as Nathaniel West’s darkly comic novel, Miss Lonelyhearts, and the Beatles’ whimsical anthem, “Sgt. Pepper’s Lonely Hearts Club Band.”

But loneliness turns out to be a serious matter. And as psychiatry debates the diagnostic minutiae of DSM-5, all of us may need to remind ourselves that millions in this country struggle against the downward tug of loneliness. Yet even among health care professionals, few seem aware that loneliness is closely linked with numerous emotional and physical ills, particular among the elderly and infirm.

It’s easy to assume that loneliness is simply a matter of mind and mood. Yet recent evidence suggests that loneliness may injure the body in surprising ways. Researchers at the University of Pittsburgh School of Medicine studied the risk of coronary heart disease over a 19-year period, in a community sample of men and women. The study found that among women, high degrees of loneliness were associated with increased risk of heart disease, even after controlling for age, race, marital status, depression and several other confounding variables. (In an email message to me, the lead author, Dr. Rebecca C. Thurston, PhD, speculated that the male subjects might have been more reluctant to acknowledge their feelings of loneliness).

Similarly, Dr. Dara Sorkin and her colleagues at the University of California, Irvine, found that for every increase in the level of loneliness in a sample of 180 older adults, there was a threefold increase in the odds of having heart disease. Conversely, among individuals who felt they had companionship or social support, the likelihood of having heart disease decreased.

The young, of course, are far from immune to loneliness. Researchers at Aarhus University in Denmark studied loneliness in a population of adolescent boys with autism spectrum disorders (an area of great controversy in the proposed DSM-5 criteria). More than a fifth of the sample described themselves as “often or always” feeling lonely—a finding that seems to run counter to the notion that those with autism are emotionally disconnected from other people. Furthermore, the study found that the more social support these boys received, the lower their degree of loneliness. We have no cure for autism in adolescents–but the remedy for loneliness in these kids may be as close as the nearest friend.

And lest there be any doubt that loneliness has far ranging effects on the health of the body, consider the intriguing findings from Dr. S.W. Cole and colleagues, at the UCLA School of Medicine. These researchers looked at levels of gene activity in the white blood cells of individuals with either high or low levels of loneliness. Subjects with high levels of subjective social isolation—basically, loneliness — showed evidence of an over-active inflammatory response. These same lonely subjects showed reduced activity in genes that normally suppress inflammation. Such gene effects could explain reports of higher rates of inflammatory disease in those experiencing loneliness.

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Could inflammatory changes, in turn, explain the correlation between loneliness and heart disease? Inflammation is known to play an important role in coronary artery disease. But loneliness by itself may be just one domino in the chain of causation. According to Dr. Heather S. Lett and colleagues at Duke University Medical Center, the perception of poor social support — in effect, loneliness — is a risk factor for development, or worsening, of clinical depression. Depression may in turn bring about inflammatory changes in the heart that lead to frank heart disease. This complicated pathway is still speculative, but plausible.

Loneliness, of course, is not synonymous with “being alone.” Many individuals who live alone do not feel “lonely.” Indeed, some seem to revel in their aloneness. Perhaps this is what theologian Paul Tillich had in mind when he observed that language “… has created the word “loneliness” to express the pain of being alone. And it has created the word “solitude” to express the glory of being alone.” Conversely, some people feel “alone” or disconnected from others, even when surrounded with people.

Let’s admit that not everybody is capable of experiencing the “glory of being alone” or of transforming loneliness into “solitude.” So what can a socially-isolated person do to avoid loneliness and its associated health problems? Joining a local support group can help decrease isolation; allow friendships to form; and give the lonely person an opportunity both to receive and to provide help. This reciprocity can bolster the lonely person’s ego and improve overall well-being. Support groups geared to particular medical conditions can also help reduce disease-related complications. Although there are always risks in going “on line” to find support, Daily Strength appears to be a legitimate and helpful website for locating support groups of all types, including those for loneliness. Psych Central also provides opportunities to exchange ideas and “connect” with many individuals who feel isolated or alone. For those who feel lonely even in the midst of friends, individual psychotherapy may be helpful, since this paradoxical feeling often stems from a fear of “getting close” to others.

No, loneliness is not a disease or disorder. It certainly shouldn’t appear in the DSM-5 — but it should be on our minds, as a serious public health problem. Fortunately, the “treatment” may be as simple as reaching out to another human being, with compassion and understanding.