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Table of Contents
REVIEW
Year : 2021  |  Volume : 35  |  Issue : 2  |  Page : 59-63

Loneliness in patients with schizophrenia


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 Submission13-Jan-2021
Date of Decision06-Feb-2021
Date of Acceptance09-Feb-2021
Date of Web Publication22-Jun-2021

Correspondence Address:
M.D., Ph.D Cheng- Fang Yen
No. 100, Tzyou First Road, Kaohsiung 807
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tpsy.tpsy_14_21

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  Abstract 


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

How to cite this URL:
Liao HY, Lee Y, Hsu ST, Yen CF. Loneliness in patients with schizophrenia. Taiwan J Psychiatry [serial online] 2021 [cited 2021 Sep 22];35:59-63. Available from: http://www.e-tjp.org/text.asp?2021/35/2/59/318958




  Introduction Top


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 Top


Baumeister et al. [1] 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 [2]. One study also showed that disrupted attachment pattern, such as insecurity avoidance, is associated with loneliness [3]. 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 [4]. 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 [5]. 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 [6]; likewise, even if one lacks social support or network, he or she may not necessarily have the feeling of loneliness [7].


  The Negative Impact of Loneliness in the General Population Top


The positive meaning of loneliness is that it can prompt a person to seek more satisfying social interaction, thereby increasing the chances of survival [8]. 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 [8],[9].

Follow-up studies indicated that long-term feeling of chronic loneliness activates automatic nerve system and hypothalamus–pituitary–adrenal axis, and changes genetic expressions [10], thereby increasing hostility, stress, pessimism, high blood pressure, and insomnia [11], and predicting the occurrence of many physical and mental illnesses in the future, including heart diseases, immune diseases, depression, anxiety, and drug abuse [12],[13]. Loneliness is also one of the early symptoms of neurocognitive disorder in the elderly [14].


  The Prevalence of Loneliness among Patients Suffering from Schizophrenia Top


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 [15],[16]. 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 [9],[17]. Some existing studies have investigated the same phenomenon in patients with psychotic disorders. For example, the studies of Stain et al. [18] and Badcock et al. [19] 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. [20] 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 [9],[17], the United Kingdom [21], or Japan [22], 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 Top


Compared to general population studies, the association between loneliness and physical and mental health problems in patients with schizophrenia has been less studied [17]. The greater degree of loneliness in patients with schizophrenia, the more susceptible to depression [9],[17], anxiety [9],[23], suicide [24], use of addictive substances [17], high perceived stress [9], low self-esteem [22], low sense of pleasure [9], pessimism [9], and low resilience [9] 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 [20].


  The Association between Loneliness and Physical Health Problems in Patients with Schizophrenia Top


The greater degree of self-reported loneliness in patients with schizophrenia, the higher chance of developing hypertension [17] and high blood level of glycated hemoglobin [17]. The preliminary hypothesis is that loneliness activates the hypothalamus–pituitary–adrenal axis [10]. Loneliness also contributes to the poor subjective quality of life in patients with schizophrenia [9],[25],[26]. 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 Top


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 [27]. 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. [20] 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 [20].

Regarding the symptoms, the positive symptoms of schizophrenia, such as the severity of delusions [9],[23],[28], 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 [29]. Gayer-Anderson and Morgan [30] 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 [9]. In general psychopathology, loneliness has a positive significant association with guilty feeling [31], depression [9],[17], and anxiety [9],[23].

Regarding the side effects of medications and institutionalization, both are positively associated with loneliness [32],[33].

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 [22] or severe psychotic disorders [31],[34] showed that there is a significant negative association between self-esteem and loneliness. However, there is a study having not found significant association [20]. Stigma means that society has a negative stereotype of people or groups with certain characteristics, thus discriminates against them or degrades their social status [35]. Patients with schizophrenia are susceptible to social stigma, which is then internalized as self-stigma [36]. Studies showed that a significant positive association exists between internalized self-stigma and loneliness in patients with schizophrenia [20],[37],[38].

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 [39],[40],[41]. Studies of patients with schizophrenia were found that persons with frequent feelings of loneliness have more serious neurocognitive function impairment, such as coding performance [19]. The researchers hypothesized that the limitation of social interaction causes loneliness, resulting in further weakening neurocognitive function [39].

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 [42].

Community integration

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 [43],[44],[45]. Past studies showed that a significant negative association exists between community integration and loneliness [46], but poor community integration is not exactly the same concept as loneliness.

Residence

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 [47].


  Clinical and Policy Implications Top


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 [48]. For example, social prescribing projects have proliferated in the UK [49]. 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 [50]. As yet however, social prescribing models are numerous and poorly defined [49], and a lack of robust evidence exists for their effectiveness [50]. Psychological approaches, such as cognitive behavioral therapy and mindfulness, have also been used to help people change their thinking about social relationships [51].

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 [51]. Research proposes that positive psychology interventions (PPIs) may be an alternative approach in combatting loneliness [52]. PPIs focus on enhancing the person's functioning [53]. Rather than aiming at correcting deficits, PPIs take a strength-based approach to psychotherapy, which may be more engaging and less pathologizing [54],[55]. PPIs can be applied to improve personal and social relationships [56]. A PPI that promotes positive affect and facilitates the use of positive interpersonal skills can plausibly improve relationship quality [57]. 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 [52]. 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. [58], 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.

Summary

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 Top


None.


  Conflicts of Interest Top


The authors declare no conflicts of interest in writing this article.



 
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