Loneliness: A disease?

New York Times, 25th March 2009 quoted “loneliness leads to poorer physical and mental health”. Similarly, BBC news on January 31st, 2011 pronounced loneliness as a “hidden killer” of elderly. Loneliness has been defined in different ways. A common definition is “A state of solitude or being alone”. The other definition is “Loneliness is not necessarily about being alone. Instead, “it is the perception of being alone and isolated that matters most” and is “a state of mind”. “Inability to find meaning in one's life”, “Feeling of negative and unpleasant” and “A subjective, negative feeling related to the deficient social relations” “A feeling of disconnectedness or isolation.” etc., are the other ways to define loneliness.

Loneliness may be pathognomic of depression in old age. It is reported to be more dangerous than smoking[1]; high degree of loneliness precipitates suicidal ideation and para-suicide,[2] Alzheimer's disease, and other dementia[34] and adversely affects the immune and cardio-vascular system.[5] It is a generally accepted opinion that loneliness results in a decline of well-being and has an adverse effect on physical health, possibly through immunologic impairment or neuro-endocrine changes.[6] Loneliness is thus, among the latent causes of hospitalization and of placement in nursing homes.[7]

Till date loneliness is being treated as a symptom of mental health problems; however, for elderly (aged 60 years and above), loneliness has become a disease in itself. There are epidemiological, phenomenological, and etiological reasons to say that.

Loneliness being a common human emotion is, however, a complex and unique experience to each individual. It has no single common cause, so the prevention and treatment for this damaging state of mind considerably differs. A child, who tries to make friends at school, needs different strategies to resolve his/her problems than an elderly person who has lost his/her spouse in the recent past. To understand loneliness, it is important to have a closer look at exactly what we mean by the term “lonely” as well as the various causes, health consequences, symptoms, and potential treatments for loneliness. A person, who experiences loneliness does not find anyone with him/her and thus increases risk for developing biological dysfunctions, psychological distress, and behavioural problems as well. It is commonly seen in older adults and has its phenomenology, complications, aetiology which needs proper diagnosis, care and management. This may be called as ‘pathological loneliness’.

The pathological loneliness has its roots in medical model consisting of a host, an agent, and an environment and is thus, a disease. The problem due to pathological loneliness is increasing worldwide and needs to be handled as a disease; not just as a situation or a symptom of a disease or mere a social concept. It has been described as the major problem associated with old age[8]; and therefore, has been identified as an appropriate condition for therapeutic intervention[91011121314] or prevention.[91112141516] Studies show that loneliness is found to be more common among those who live alone.[171819]

The current Indian demographic scenario is testimony to the fact that the population of the elderly is growing fast, both in terms of proportion and absolute numbers (5.3%-12.5 million in 1951 to 7.6%-92 million in 2011, respectively). In addition to increasing population of elderly, changing living situations (living alone or living with relations and non-relations) are the main demographic breeders of loneliness. Some other factors like widowhood, increasing dependency ratio (10.9% in 1961 to 13.1% in 2001)[20] as well as economic dependency (86% rural and 83% urban females and 51% rural and 56% urban males);[21] and solvency are major contributors for developing loneliness. Further, environmental factors like type of family, social network,[22] transportation issues and place of residence,[23] population migrations etc., are also some other significant correlates of loneliness. Women are reported to be more at risk for loneliness and isolation than men.[24] NSSO of India on the condition of aged in 2004 indicated that 1.23 million men and 3.68 million women are living alone[21] and faced loneliness. Another Indian statistics reveal that about 2-3% of elderly men live alone while another 3% live with other relations and non-relations and among elderly females 7-8% live alone and another 6-7% reported to live with other relations or non-relation.[20] This number is increasing day by day.

Loneliness may be categorized into three types according to its causes.

Situational loneliness: Socio-economic and cultural milieu contributes to situational loneliness. Various environmental factors like unpleasant experiences,[25] discrepancy between the levels of his/her needs and social contacts, and migration of population, inter personal conflicts, accidents, disasters or emptiness syndrome, etc., lead to loneliness in old age. The increased life expectancy and feminization of elderly population is a significant factor in developing situational loneliness in females.

Developmental loneliness: Every one of us has an innate desire of intimacy or a need to be related to others. This need is essential for our development as a human being. Apart from this need, a higher level of need for individualism also exists which is related to knowing and developing our own real self that requires some solitude too. For optimum development, there should be a balance between the two. When a person is not able to balance these needs properly, it results in loss of meaning from their life which in turn leads to emptiness and loneliness in that person. Personal inadequacies, developmental deficits, significant separations, social marginality, poverty, living arrangements, and physical/psychological disabilities often lead to developmental loneliness.

Internal loneliness: Being alone does not essentially make a person lonely. It is the perception of being alone which makes the person lonely. People with low self-esteem and less self-worth are seen to feel lonelier than their counterparts. Reasons for this type of loneliness are personality factors, locus of control, mental distress, low self-esteem, feeling of guilt or worthlessness, and poor coping strategies with situations.

Loneliness, which leads to distress and dysfunction in the elderly, may be assessed in many ways and is, thus, can be diagnosed as a disease entity. A lonely person often feels low, helpless, separated, or discriminated; finds difficulty during interactions; feels abandoned and alone. For diagnosing loneliness in elderly following measures may be used.

Level of experience of separateness

Levels of cumulative wear and tear

Complete physical/mental health status

Social network

Frequency and degree of loneliness.

Several researchers report interventions for loneliness. These interventions are to be individualized to control expectations as per personal efficiency[26] and improve capacities to socialize,[27] Behavioral training and feedback regulate behavior and improve the frequency and degree of loneliness positively.[2829] Studies reported that members of intervention groups favorably responded on social contacts and loneliness in comparison to controls.[30] Thus, loneliness is a treatable, rather than an irreversible condition. Apart from planned interventions, there are some other useful strategies to fight against loneliness like keeping self-busy, sharing feelings, involving self in some activities (spending time together, discussing problems, maintaining interactions), helping others, avoiding escapes, developing quality relationships with people who share similar attitudes, interests and/or values, collecting good thoughts and managing unfortunate happenings, joining groups of self interest, pharmacological management of physical ailments, and staying in contact with family and friends.

It is generally accepted that loneliness frequently results in a decline of well-being and may cause depression, suicidal behaviour, sleep problems, disturbed appetite, and so on. The pathological consequences of loneliness are found more among those adults who develop personality and adaptation disorders, such as overconsumption of alcohol, loss of self-esteem, extreme forms of anxiety, powerlessness, and stress.[31] Loneliness predisposes a person to physical diseases too as it has an adverse impact on immune, cardiovascular, and endocrine system.[32] Consistent, overwhelming and pervasive loneliness develops stress and ultimately culminates into serious physical disease. Feeling of loneliness and being alone were found to be independent predictors of motor decline in old age.[33] Loneliness was also found to be an independent predictor of mortality and functional decline after controlling for depression.[34] It also leads to memory impairment and learning difficulties, and makes the person prone to Alzheimer's disease.[35] A Dutch study reports that people who feel lonely are more likely to develop clinical dementia over a period of 3 years compared to those who do not experience loneliness.[36]

Solitude and loneliness should not be explained in similar ways. Solitude is enjoyed by people and it leads to creativity, self realization, and is totally an approach for developing once own individual space. It is often considered as an essential component for spirituality and self growth but loneliness is a state of mind, a feeling of emptiness, separateness, and it often becomes a compulsion. When it develops dysfunction, is perceived as stressful combined with physical ageing, the situation turns out to be a toxic cocktail.

Loneliness has now become an important public health concern. It leads to pain, injury/loss, grief, fear, fatigue, and exhaustion. Thus, it also makes a person sick and interferes in day to day functioning and hampers recovery. A few years back Mother Teresa quoted: “the greatest disease in the West today is not TB or leprosy; it is being unwanted, unloved, and uncared for. We can cure physical diseases with medicine, but the only cure for loneliness, despair, and hopelessness is love...” Loneliness, therefore, is no more an event or concept or factor. Loneliness with its epidemiology, phenomenology, etiology, diagnostic criteria, adverse effects, and management should be considered a disease and should find its place in classification of psychiatric disorders.