When you ask people with a psychotic disorder, like schizophrenia, what challenges them most in daily life they are likely to say – ‘loneliness’. As nearly everyone can attest, loneliness is painful. It’s the distressingfeeling,当你不觉得社会接受or connected. Loneliness is different therefore from simply being alone, or only having a limited social network – as the saying goes “you can live alone but not feel lonely, or you can be surrounded by friends and still feel disconnected”.

Fig. 1. Distribution of responses (%) to the assessment of loneliness across different psychotic disorders.

A sense of belonging has been described as a basic human need to feel connected to, and accepted by, others and is vital for good mental health. So, perhaps not surprisingly loneliness has been shown to have a strong relationship with mental illness. Research on loneliness and psychological problems has most often focused on its relationship with depression. In fact, loneliness and depression are often conflated and treated as if they were the same thing. A major consequence of this assumption is that loneliness tends to be overlooked as a problem needing specific assessment and treatment. However, whilst loneliness and depression are highly correlated, they are separate constructs. Studies have shown, for example, that loneliness predicts depression in older adults but depression doesn’t predict loneliness.

Researchers are now looking beyond the link with depression to examine the prevalence of loneliness in other mental disorders. Of particular concern, summary data from the second Australian National Survey of Psychosis showed the extent of loneliness in psychotic illness, with the majority (80.1%) of adults with a diagnosis of psychosis endorsing feeling lonely in the past 12 months and loneliness being ranked as one of the greatest challenges (after financial concerns) to be faced in the year ahead.

In this paper, we examined this issue in much more detail. First, we wanted to know whether loneliness in psychosis was more common than in the general community, and whether it varied across different ‘types’ of psychotic illness. The results showed that the rates of loneliness were high, ranging from 74.7% in people with delusional disorders to 93.8% in those with depressive psychosis (see Fig. 1.) and was significantly higher than the estimated prevalence of loneliness in the general population – which is around 35%.

Loneliness was also associated with particular symptoms including anhedonia (representing an ongoing loss of pleasure) and disordered thoughts.
Previous evidence also indicates that loneliness is associated with poor cognitive functioning and cognitive decline. Cognitive dysfunction is now understood to be a core problem for people with psychotic illnesses. So here we also examined whether loneliness in people with psychotic disorders was associated with poorer cognitive functioning. The results showed that patients feeling socially isolated and lonely for company had significantly lower cognitive ability than those who only felt lonely occasionally – though poor cognitive functioning was not inevitably associated with loneliness.

These findings highlight a need for effective interventions specifically tailored to the needs of people with psychotic illness. Currently, no such evidence-based interventions exist. It’s easy to assume that loneliness can be ‘fixed’ by simply increasing opportunities for social support and participation. However, investment in services grounded in assumptions rather than evidence may be misplaced. For example, data from the Adult Psychiatric Morbidity Survey, 2007, in England suggest that such strategies have minimal positive impact on alleviating loneliness. Developing effective interventions to build resilience and minimize loneliness in people with psychotic disorders will require a much better understanding of the nature of loneliness and its impact on the emergence of psychotic symptoms informed by rigorous psychological research.

Prof. Johanna C. Badcock, Winthrop Prof. Vera Morgan
School of Psychiatry and Clinical Neurosciences, The University of Western Australia

Publication

Loneliness in psychotic disorders and its association with cognitive function and symptom profile.
Badcock JC, Shah S, Mackinnon A, Stain HJ, Galletly C, Jablensky A, Morgan VA.
Schizophr Res. 2015 Dec

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