|Year : 2021 | Volume
| Issue : 2 | Page : 59-63
Loneliness in patients with schizophrenia
Hui- Yuan Liao1, Yu Lee2, Su- Ting Hsu3, Cheng- Fang Yen4
1 Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
2 Department of Psychiatry, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
3 Department of Community Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
4 Department of Psychiatry, Kaohsiung Medical University Hospital; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
|Date of Submission||13-Jan-2021|
|Date of Decision||06-Feb-2021|
|Date of Acceptance||09-Feb-2021|
|Date of Web Publication||22-Jun-2021|
M.D., Ph.D Cheng- Fang Yen
No. 100, Tzyou First Road, Kaohsiung 807
Source of Support: None, Conflict of Interest: None
Background: The treatment goals for patients with schizophrenia are to address subjective well-being, quality of life, and recovery in recent decades. Loneliness is a negative subjective feeling and related to social isolation, which is thought to be a barrier to recovery. Few research exist to study loneliness in-depth in patients with schizophrenia. Methods: In this review, the authors intend to address the issues of the prevalence, the impacts, the associated factors, and the interventions of loneliness in patients with schizophrenia. Results: Studies showed that patients with schizophrenia have a greater degree of loneliness than those without. The physical and mental health problems associated with loneliness in patients with schizophrenia include hypertension, high blood level of glycated hemoglobin, activated hypothalamus–pituitary–adrenal axis, poor subjective quality of life, depression, anxiety, suicide, use of addictive substances, high perceived stress, low self-esteem, low sense of pleasure, pessimism, and low resilience. From an ecological approach, loneliness in patients with schizophrenia is associated with several personal disease factors, personal cognitive factors, personal socioeconomic factors, community integration, and residence. Social prescribing projects, cognitive behavioral therapy, mindfulness, and positive psychology interventions have been used to reduce loneliness in patients with schizophrenia. Conclusion: Loneliness is an important indicator of the physical and mental health in patients with schizophrenia. Several factors associated with loneliness in patients with schizophrenia have been identified in the past studies. Further intervention research are required for establish effective methods to reduce loneliness in patients with schizophrenia.
Keywords: mental health, physical health, quality of life, subjective well-bein
|How to cite this article:|
Liao HY, Lee Y, Hsu ST, Yen CF. Loneliness in patients with schizophrenia. Taiwan J Psychiatry 2021;35:59-63
| Introduction|| |
Schizophrenia is a devastating and lifelong disorder, causing impairment in several dimensions, including thinking, perception, behavior, emotion, and cognition. The treatment targets have evolved from institutionalization, reduction of positive and negative symptoms, and cognitive rehabilitation, to addressing quality of life, subjective well-being, and recovery. In the past, we tended to think that patients with schizophrenia are unable or lack of the willing to experience emotion or feelings under the influence of negative symptoms. But recent studies indicated that loneliness in patients with schizophrenia is a common phenomenon. Furthermore, loneliness is associated with several mental and physical health problems, and also a big hinder to recovery. The purpose of this review article is to explore the significance of loneliness in patients with schizophrenia, to investigate associated factors, and to identify further clinical interventions.
| The Concept of Loneliness|| |
Baumeister et al.  hypothesized that as social animals, human beings have the neurobiological instincts and needs of “belonging to a certain group,” and the neurobiology mechanisms of this desire for interpersonal attachment have been identified . One study also showed that disrupted attachment pattern, such as insecurity avoidance, is associated with loneliness . When the needs are not met, the loneliness may arise. Loneliness is the negative subjective feeling that arises when one is isolated, misunderstood, or rejected from others, or when one is not satisfied with his or her own social relationship . Meanwhile, loneliness is also the emotional consequence of the cognitive evaluation of social interactions. When one's expectations of the quality and quantity of social interaction and network are not met, the negative emotional reactions ensue . The concept of loneliness is different from social isolation. Even if one has abundant social networks and social contacts, he or she may still have the feeling of loneliness ; likewise, even if one lacks social support or network, he or she may not necessarily have the feeling of loneliness .
| The Negative Impact of Loneliness in the General Population|| |
The positive meaning of loneliness is that it can prompt a person to seek more satisfying social interaction, thereby increasing the chances of survival . But analyzed by Social Information Processing model, loneliness is not only an individual's negative cognition and emotion but also affects one's interpretation of social cues. Individuals with prominent loneliness are hypervigilant to social threatening stimuli, expect to experience negative social interaction, have an automated negative evaluation process for themselves and others, remember more past negative messages than positive ones, have a low self-efficacy, and endorse prevention – other than promotion-oriented future goals ,.
Follow-up studies indicated that long-term feeling of chronic loneliness activates automatic nerve system and hypothalamus–pituitary–adrenal axis, and changes genetic expressions , thereby increasing hostility, stress, pessimism, high blood pressure, and insomnia , and predicting the occurrence of many physical and mental illnesses in the future, including heart diseases, immune diseases, depression, anxiety, and drug abuse ,. Loneliness is also one of the early symptoms of neurocognitive disorder in the elderly .
| The Prevalence of Loneliness among Patients Suffering from Schizophrenia|| |
The common manifestations of impairment in social functioning in schizophrenia include deficits in social skill and motivation, poor social cognition, and difficulty in experiencing positive emotion from social interaction ,. Hence, a high proportion of patients with schizophrenia may have the feeling of loneliness. But compared with the general population, the loneliness in patients with schizophrenia has been less studied in depth ,. Some existing studies have investigated the same phenomenon in patients with psychotic disorders. For example, the studies of Stain et al.  and Badcock et al.  indicated that the prevalence of loneliness in patients with psychotic disorders is 2–3 times as the general population; the study of Chrostek et al.  indicated that the severity of loneliness in patients with psychotic disorders is remarkably higher than that of the general population. In the studies of patients purely diagnosed of schizophrenia, whether it is from the United States ,, the United Kingdom , or Japan , they all indicated that patients with schizophrenia have a greater degree of loneliness than those without.
| The Association between Loneliness and Mental Health Problems in Patients with Schizophrenia|| |
Compared to general population studies, the association between loneliness and physical and mental health problems in patients with schizophrenia has been less studied . The greater degree of loneliness in patients with schizophrenia, the more susceptible to depression ,, anxiety ,, suicide , use of addictive substances , high perceived stress , low self-esteem , low sense of pleasure , pessimism , and low resilience  for them. But cross-sectional studies are difficult to determine the temporality. Some studies proposed that the association between loneliness in patients with schizophrenia and depression results from other psychosocial factors, such as internalized stigma and lack of social support or social skills. After adjusting for these factors, the association between loneliness and depression lost significance .
| The Association between Loneliness and Physical Health Problems in Patients with Schizophrenia|| |
The greater degree of self-reported loneliness in patients with schizophrenia, the higher chance of developing hypertension  and high blood level of glycated hemoglobin . The preliminary hypothesis is that loneliness activates the hypothalamus–pituitary–adrenal axis . Loneliness also contributes to the poor subjective quality of life in patients with schizophrenia ,,. But no study exists to investigate whether other factors exist, such as delayed timing to seek medical diagnosis and treatment due to loneliness, thereby exacerbate the physical condition.
Taken together the results of the above research, we suggest that loneliness is not only a subjective feeling but also an important indicator of the physical and mental health in patients with schizophrenia.
| Factors Associated with Loneliness in Patients with Schizophrenia: from an Ecological Approach|| |
Understanding factors associated with loneliness in patients with schizophrenia is the basic step to develop the strategies for prevention and intervention. Ecological approaches hold that the individual's subjective experience is the result of interaction between the individual and the environment, and the whole picture must be fully considered . The followings are based on the classification of personal and socio-environmental factors, organizing the previous studies on factors associated with loneliness in patients with schizophrenia.
Personal disease factors
Regarding the course of disease, Chrostek et al.  found that the more number of past hospitalization in acute ward, the greater degree of loneliness. Possible reasons include that repeated hospitalizations would interrupt social contacts, or represent poor disease control, which results in difficulty establishing or maintaining good interpersonal relationships .
Regarding the symptoms, the positive symptoms of schizophrenia, such as the severity of delusions ,,, positively associated with self-reported loneliness. A meta-analysis of 13 studies on patients with psychotic disorders showed that psychotic symptoms are moderately associated with loneliness . Gayer-Anderson and Morgan  hypothesized that psychotic symptoms, such as delusions, and loneliness will affect each other. Especially in the early stage of the disease, delusions will aggravate the individual's feeling of loneliness, and the misinterpretation of social cues that accompany with loneliness will strengthen the delusions. Only one study exists to investigate the association between negative symptoms of schizophrenia and loneliness, and no significant association has been shown . In general psychopathology, loneliness has a positive significant association with guilty feeling , depression ,, and anxiety ,.
Regarding the side effects of medications and institutionalization, both are positively associated with loneliness ,.
Personal cognitive style and neurocognitive factors
Regarding the psychological cognitive factors, more studies are focused on self-esteem and stigma. Most studies of patients with schizophrenia  or severe psychotic disorders , showed that there is a significant negative association between self-esteem and loneliness. However, there is a study having not found significant association . Stigma means that society has a negative stereotype of people or groups with certain characteristics, thus discriminates against them or degrades their social status . Patients with schizophrenia are susceptible to social stigma, which is then internalized as self-stigma . Studies showed that a significant positive association exists between internalized self-stigma and loneliness in patients with schizophrenia ,,.
Regarding the neurocognitive factors, loneliness is related to defects in overall neurocognition, processing speed, visual memory, and immediate and delayed memory in the general population ,,. Studies of patients with schizophrenia were found that persons with frequent feelings of loneliness have more serious neurocognitive function impairment, such as coding performance . The researchers hypothesized that the limitation of social interaction causes loneliness, resulting in further weakening neurocognitive function .
The results of research so far cannot determine the causality of the association between loneliness, self-esteem, stigma, and neurocognitive function, but self-esteem, stigma, and neurocognitive function all may affect the predictive effect of loneliness on physical and mental health and medical seeking behavior. Therefore, these variables must be controlled in research.
Personal socio-economic factors
Personal socio-economic factors such as low income, unmarried status, and unemployment are positively related to loneliness .
The concept of community integration includes the four dimensions of assimilation, support, occupation, and independent living. It is the foundation of individuals to connect with the environment and to acquire a sense of belonging and remote support ,,. Past studies showed that a significant negative association exists between community integration and loneliness , but poor community integration is not exactly the same concept as loneliness.
The study showed that patients with schizophrenia living alone had a greater degree of loneliness than those living in group homes, such as halfway house, but reported a higher level of social support .
| Clinical and Policy Implications|| |
The results of previous studies highlight the need to pay sufficient attention to the loneliness in people with schizophrenia. The development of effective interventions to reduce loneliness is required. A systemic review for the associations between loneliness and perceived social support and outcomes of mental health problems showed that potential interventions for older population or patients with depression are becoming available in a variety of sectors . For example, social prescribing projects have proliferated in the UK . Social prescribing is not precisely defined but typically refers to navigation – the process of linking support for people to access community activities helpful to well-being and participation, and/or funding and providing these activities in a community or group setting . As yet however, social prescribing models are numerous and poorly defined , and a lack of robust evidence exists for their effectiveness . Psychological approaches, such as cognitive behavioral therapy and mindfulness, have also been used to help people change their thinking about social relationships .
The approaches mentioned above trying to alleviate the adverse effects of loneliness are not developed or tested for people with psychotic disorders. Interventions for loneliness should include enhancing social support and opportunities, improving social skills, and addressing maladaptive social cognition . Research proposes that positive psychology interventions (PPIs) may be an alternative approach in combatting loneliness . PPIs focus on enhancing the person's functioning . Rather than aiming at correcting deficits, PPIs take a strength-based approach to psychotherapy, which may be more engaging and less pathologizing ,. PPIs can be applied to improve personal and social relationships . A PPI that promotes positive affect and facilitates the use of positive interpersonal skills can plausibly improve relationship quality . Intervention studies using the positive psychology approach have yet to specifically target loneliness. Given that digital tools are increasingly used within mental health treatment, a recent study developed a digital smartphone application (app) to delivers positive psychology content daily . The preliminary findings indicated that a six-week intervention for young patients with psychotic disorders using the app can increase their social confidence, enjoy life, look forward to being with other people, and feel more connected with others.
Whether other interventions used to mitigate loneliness in the general population mentioned in the review of Cacioppo et al. , such as group therapy, social skills training, and pharmacological treatments (selective serotonin reuptake inhibitors, allopregnanolone, and oxytocin), are beneficial for reducing loneliness in patients with schizophrenia needing further investigation.
The concept of recovery in schizophrenia not only includes alleviation of clinical symptoms but also addresses the improvement of personal and social functions. If the third level of Maslow's hierarchy of needs, belonging and love, was not achieved, loneliness may ensue. The mental and physical problems associated with loneliness further complicate the way to recovery. Therefore, to facilitate the progress of recovery, investigating the associated factors and developing interventions of loneliness in patients with schizophrenia are imperative tasks.
Although some projects and psychological approaches have been used as the intervention methods, more guidelines and evidence are needed to establish the efficacy for patients with schizophrenia. To our knowledge, no relevant intervention study exists regarding the personal disease factors associated with loneliness in patients with schizophrenia. More research that integrate the impact of psychopathology, cognitive function, and psychosocial aspects are required for having a more comprehensive understanding of loneliness in schizophrenia, and for developing appropriate and effective interventions.
| Financial Support and Sponsorship|| |
| Conflicts of Interest|| |
The authors declare no conflicts of interest in writing this article.
| References|| |
Baumeister RF, Leary MR: The need to belong: desire for interpersonal attachments as a fundamental human motivation. Psychol Bull
1995; 117: 497.
Insel TR, Young LJ: The neurobiology of attachment. Nat Rev Neurosci
2001; 2: 129-36.
Fransson M, Granqvist P, Marciszko C, et al.: Is middle childhood attachment related to social functioning in young adulthood? Scand J Psychol
2016; 57: 108-16.
Andersson L: Loneliness research and interventions: a review of the literature. Aging Ment Health
1998; 2: 264-74.
Peplau LA, Perlman D: Loneliness: A Sourcebook of Current Theory, Research, and Therapy.
New York: Wiley, 1982.
Cornwell EY, Waite LJ: Measuring social isolation among older adults using multiple indicators from the NSHAP study. J Gerontol B Psychol Sci Soc Sci
2009; 64: i38-46.
Macdonald E, Hayes R, Baglioni A Jr.: The quantity and quality of the social networks of young people with early psychosis compared with closely matched controls. Schizophr Res
2000; 46: 25-30.
Spithoven AW, Bijttebier P, Goossens L: It is all in their mind: a review on information processing bias in lonely individuals. Clin Psychol Rev
2017; 58: 97-114.
Eglit GM, Palmer BW, Martin AS, et al.: Loneliness in schizophrenia: construct clarification, measurement, and clinical relevance. PLoS One
2018; 13: e0194021.
Cacioppo JT, Cacioppo S, Capitanio JP, et al.: The neuroendocrinology of social isolation. Annu Rev Psychol
2015; 66: 733-67.
Cacioppo JT, Hawkley LC: Perceived social isolation and cognition. Trends Cogn Sci
2009; 13: 447-54.
Abebe DS, Hafstad GS, Brunborg GS, et al.: Binge drinking, cannabis and tobacco use among ethnic Norwegian and ethnic minority adolescents in Oslo, Norway. J Immigr Minor Health
2015; 17: 992-1001.
Hawkley LC, Cacioppo JT: Loneliness matters: a theoretical and empirical review of consequences and mechanisms. Ann Behav Med
2010; 40: 218-27.
Donovan NJ, Okereke OI, Vannini P, et al.: Association of higher cortical amyloid burden with loneliness in cognitively normal older adults. JAMA Psychiatry
2016; 73: 1230-7.
Fulford D, Campellone T, Gard DE: Social motivation in schizophrenia: how research on basic reward processes informs and limits our understanding. Clin Psychol Rev
2018; 63: 12-24.
Green MF, Horan WP, Lee J: Social cognition in schizophrenia. Nat Rev Neurosci
2015; 16: 620-31.
Trémeau F, Antonius D, Malaspina D, et al.: Loneliness in schizophrenia and its possible correlates: an exploratory study. Psychiatry Res
2016; 246: 211-7.
Stain HJ, Galletly CA, Clark S, et al.: Understanding the social costs of psychosis: the experience of adults affected by psychosis identified within the second Australian National Survey of Psychosis. Aust N Z J Psychiatry
2012; 46: 879-89.
Badcock JC, Shah S, Mackinnon A, et al.: Loneliness in psychotic disorders and its association with cognitive function and symptom profile. Schizophr Res
2015; 169: 268-73.
Chrostek A, Grygiel P, Anczewska M, et al.: The intensity and correlates of the feelings of loneliness in people with psychosis. Compr Psychiatry
2016; 70: 190-9.
Neeleman J, Power M: Social support and depression in three groups of psychiatric patients and a group of medical controls. Soc Psychiatry Psychiatr Epidemiol
1994; 29: 46-51.
Shioda A, Tadaka E, Okochi A: Loneliness and related factors among people with schizophrenia in Japan: a cross-sectional study. J Psychiatr Ment Health Nurs
2016; 23: 399-408.
Sündermann O, Onwumere J, Kane F, et al.: Social networks and support in first-episode psychosis: exploring the role of loneliness and anxiety. Soc Psychiatry Psychiatr Epidemiol
2014; 49: 359-66.
Depp CA, Moore RC, Perivoliotis D, et al.: Social behavior, interaction appraisals, and suicidal ideation in schizophrenia: the dangers of being alone. Schizophr Res
2016; 172: 195-200.
Roe D, Mashiach-Eizenberg M, Lysaker PH: The relation between objective and subjective domains of recovery among persons with schizophrenia-related disorders. Schizophr Res
2011; 131: 133-8.
Weiner A, Roe D, Mashiach-Eizenberg M, et al.: Housing model for persons with serious mental illness moderates the relation between loneliness and quality of life. Community Ment Health J
2010; 46: 389-97.
Bennett J: Vibrant Matter: A Political Ecology of Things.
Durham, North Carolina, USA: Duke University Press, 2010.
Lamster F, Lincoln TM, Nittel CM, et al.: The lonely road to paranoia: a path-analytic investigation of loneliness and paranoia. Compr Psychiatry
2017; 74: 35-43.
Michalska da Rocha B, Rhodes S, Vasilopoulou E, et al.: Loneliness in psychosis: a meta-analytical review. Schizophr Bull
2018; 44: 114-25.
Gayer-Anderson C, Morgan C: Social networks, support and early psychosis: a systematic review. Epidemiol Psychiatr Sci
2013; 22: 131.
Ludwig KA, Nye LN, Simmons GL, et al.: Correlates of loneliness among persons with psychotic disorders. Soc Psychiatry Psychiatr Epidemiol
2020; 55: 549-59.
Boydell KM, Gladstone BM, Crawford ES: The dialectic of friendship for people with psychiatric disabilities. Psychiatr Rehabil J
2002; 26: 123.
Davidson L, Stayner D: Loss, loneliness, and the desire for love: perspectives on the social lives of people with schizophrenia. Psychiatr Rehabil J
1997; 20: 3-12.
Świtaj P, Grygiel P, Anczewska M, et al.: Experiences of discrimination and the feelings of loneliness in people with psychotic disorders: the mediating effects of self-esteem and support seeking. Compr Psychiatry
2015; 59: 73-9.
Goffman E: Stigma: Notes on the Management of Spoiled Identity.
Englewood Cliffs, New Jersey, USA: Prentice-Hall, 1963.
Dickerson FB, Sommerville J, Origoni AE, et al.: Experiences of stigma among outpatients with schizophrenia. Schizophr Bull
2002; 28: 143-55.
ampropoulos D, Fonte D, Apostolidis T: Exploring the link between stigma and social representations among people with and without schizophrenia in the French context. Psychiatry Res
2019; 272: 595-601.
Yildirim T, Kavak Budak F: The relationship between internalized stigma and loneliness in patients with schizophrenia. Perspect Psychiatr Care
2020; 56: 168-74.
Ayalon L, Shiovitz-Ezra S, Roziner I: A cross-lagged model of the reciprocal associations of loneliness and memory functioning. Psychol Aging
2016; 31: 255.
O'Luanaigh C, O'Connell H, Chin AV, et al.: Loneliness and cognition in older people: the Dublin Healthy Ageing study. Aging Ment Health
2012; 16: 347-52.
Shankar A, Hamer M, McMunn A, et al.: Social isolation and loneliness: relationships with cognitive function during 4 years of follow-up in the English Longitudinal Study of Ageing. Psychosom Med
2013; 75: 161-70.
Marwaha S, Johnson S: Schizophrenia and employment - a review. Soc Psychiatry Psychiatr Epidemiol
2004; 39: 337-49.
Cohen CI, Pathak R, Ramirez PM, et al.: Outcome among community dwelling older adults with schizophrenia: results using five conceptual models. Commu Ment Health J
2009; 45: 151-6.
McColl MA, Davies D, Carlson P, et al.: The community integration measure: development and preliminary validation. Arch Phys Med Rehabil
2001; 82: 429-34.
Wieland ME, Rosenstock J, Kelsey SF, et al.: Distal support and community living among individuals diagnosed with schizophrenia and schizoaffective disorder. Psychiatry
2007; 70: 1-11.
Shioda A, Tadaka E, Okochi A: Reliability and validity of the Japanese version of the Community Integration Measure for community-dwelling people with schizophrenia. Int J Ment Health Syst
2017; 11: 29.
Schwartz C, Gronemann OC: The contribution of self-efficacy, social support and participation in the community to predicting loneliness among persons with schizophrenia living in supported residences. Isr J Psychiatry Relat Sci
2009; 46: 120-9.
Wang J, Mann F, Lloyd-Evans B, et al.: Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatry
2018; 18: 156.
University of Westminster: Report of the Annual Social Prescribing Network Conferenc
e. London, UK: University of Westminster, 2016.
Booth A, Bickerdike L, Wilson P: Evidence to Inform the Commissioning of Social Prescribing.
York, UK: University of York, 2015.
Masi CM, Chen HY, Hawkley LC, et al.: A meta-analysis of interventions to reduce loneliness. Pers Soc Psychol Rev
2011; 15: 219-66.
Lim MH, Gleeson JF, Rodebaugh TL, et al.: A pilot digital intervention targeting loneliness in young people with psychosis. Soc Psychiatry Psychiatr Epidemiol
2020; 55: 877-89.
Sin NL, Lyubomirsky S: Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis. J Clin Psychol
2009; 65: 467-87.
Rashid T: Positive psychotherapy: a strength-based approach. J Posit Psychol
2015; 10: 25-40.
Xie H: Strengths-based approach for mental health recovery. Iran J Psychiatry Behav Sci
2013; 7: 5-10.
Linley P, Joseph S, Harrington S, et al.: Positive psychology: past, present, and (possible) future. J Posit Psychol
2006; 1: 3-16.
Lim MH, Gleeson JF: Social connectedness across the psychosis spectrum: current issues and future directions for interventions in loneliness. Front Psychiatry
2014; 5: 154.
Cacioppo S, Grippo AJ, London S, et al.: Loneliness: clinical import and interventions. Perspect Psychol Sci
2015; 10: 238-49.