According to the Oxford Dictionary, loneliness is defined as sadness because one has no friends or company.1 I chose this topic because loneliness is a rising issue in our modern society and its effects on health are often underestimated by many others. Here are some statistics: 60 million people in the United States alone (20% of total population) feel lonely2 and 7.5 million people in the United Kingdom are living by themselves according to the Office of National Statistics. A simple web search of link between loneliness and disease would yield about 12,200,000 results. I hope that by understanding what lies behind loneliness and its effects, I will be able to treat patients as individuals whilst applying the principles of whole person care in my future medical practice.

The majority of people have been through times of loneliness despite having loved ones around us. Looking back at the definition given by the Oxford English Dictionary, is it true that we only experience loneliness when we have no company? For me, this feeling is very subjective and different for each individual. A clearer definition of loneliness would be the combination of the experiences of negative feelings due to inadequacy of existing relationships (De Jong-Gierveld and Havens, 2004) and situations in which number of existing relationships are smaller than is considered desirable or admissible to the individual (De Jong-Gierveld, 1987). Unlike solitude, where you can be alone but not feel lonely and can also have positive effects such as identity building and religious experiences, loneliness has detrimental effects which can dominate a persons lifestyle and well-being completely.

Conventional medicine relies greatly on physical examinations such as x-rays and blood tests and only treat the problem as it appears.3 However, there are illnesses without lesional pathology and loneliness is one of them. For example, a doctor might prescribe diuretics to a patient with high blood pressure and possibly advise him to decrease his alcohol intake. However, this will not solve the source of the problem, which is loneliness.

Typology and Causes of loneliness

Humans tend to have a habit of classifying things. Robert Weiss classified loneliness based on type (Emotional vs Social loneliness) and time (Transient vs Chronic loneliness). Emotional isolation is the result of lack of a close, intimate attachment to another person. (eg. Individuals who have been recently divorced or children that has been separated from their parents.) Social isolation is due to the lack of a network of social relationships in which the person is part of a group of friends who share common interests and activities.5 (eg. Individuals who recently moved to a new city, stigma or have different strong cultural beliefs.) To further elaborate social loneliness, I have picked on a sociological phenomenon that occurs frequently in Japan called Hikikomori. The Japanese Ministry of Health, Labour and Welfare defines hikikomori as people who refuse to leave their room or house, isolating themselves from society, for a period exceeding six months.6 It is estimated that in 2010, there are roughly 700,000 individuals (average age of 31 years old) who are in this state of complete social withdrawal in Japan.7 This can be caused by being bullied in school, a victim of child abuse and other traumatic social failure. In extreme cases, an individual can be in the state of hikikomori for years or even decades.

When the person has been in isolation for a long period of time, it is considered chronic and if it is only temporary, it is transient. Transient loneliness is usually caused by changes in the environment (moving to a new city) and can be easily relieved by adapting and making new social networks. A symptom of transient loneliness that most of us had experienced is home sickness.

A more surprising finding is that genes can also contribute to loneliness. In 2004, a twin-study in Netherlands found evidence that genetics account for approximately half of measurable difference in loneliness and found no common environmental contributions to adult loneliness.

Some popular effects of loneliness are depression, schizoid character type due to complete social withdrawal (eg. hikikomori), alcoholism and substance abuse. There are also findings that loneliness can cause elevated blood pressure2, higher risk of stroke and cardiovascular diseases9 due to raised Interleukin-6 levels. Other lesser known effects of loneliness are higher risk of cancer10, alters DNA transcription in immune cells and impairs cognition and willpower.2

Doctors cannot cure these effects without treating the source which is loneliness. In an article in the Express titled Loneliness: Contagious like a bad cold, there is a quote by a Chicago University psychologist who led a research on the spread of loneliness, Dr John Cacioppo who said, Our research also shows that as people become lonely, they become less trustful of others a cycle develops. 11 In the Whole Person Care element: Systemic Thinking, we have learned to play close attention to cycles in a system. For example, feeling lonely might be influenced by the whole of modern society.

Treatment of loneliness

When doctors treat the individual, not the disease, narrative based medicine comes to play. During consultations, doctors should ideally encourage empathy and promote understanding between themselves and the patient when trying to understand the cause of the problem. This will break down the wall between doctors and patients and allow for better diagnostics as patients are more willing to talk about the hidden problems and the bigger picture. During the therapeutic process, doctors could use a holistic approach to management. Of course, drugs such as antidepressants are useful and can be used in conjunction with therapy to cure loneliness. However, drugs may be more effective in helping transient loneliness. Hence, long term treatments such as home-share programmes and pet therapy (or recently called animal assisted therapy) may offer a significant positive contribution. It is found that pet owners are associated with lower blood pressure, cholesterol and triglycerides. Pet owners can also increase their opportunity for socialising with other pet owners.12 Mind-Body medicine also plays a role in treatment of loneliness. The individual may choose to undretake self-healing through breathing techniques, exercise, a change in diet and just looking on a brighter side of life. All these activities and attitudes can help elevate the feeling of loneliness and depression. Integrative medication like electro-shock therapy, acupuncture and herbs are also useful in this treatment.

Loneliness may also play an important role in the creative process. This is seen by famous personas such as the poet, Emily Dickinson and many musicians. By linking the Whole Person Care element: Arts and Creativity in Medicine and the topic of loneliness, I came up with a short experiment to simulate artificial loneliness. For my personal activity, I isolated myself for three and a half days from people and other social networks. This includes turning off my cellphone, avoiding conversations and disconnecting myself from the internet. For the duration of the personal activity, it gave me a good insight, although arguably not exact, into how one feels loneliness.

Day 1: I did not experience anything unpleasant but without people to talk to, there was not much to do and the rest of the day felt dull. This lead me to a realisation that having company made my day felt brighter and that we take them for granted. I depicted this in Inverted by drawing a shadow behind and around the individual experiencing loneliness (person in white) symbolising the bleakness associated with it. By applying this into the clinical situation, it is no wonder why some elderly patients like to frequently visit their GPs despite not having any major problems and just enjoy being in the company of someone they trust. The elderly tend to be lonely as their children often live and/or work in another city.

Day 2: I started to feel a little down and bored. To cope with this, I decided to fill my time with activities such as doing some work and revising. This plan backfired, making me more stressed, resulting in inefficient studying. So instead of working, I performed activities that I enjoy such as reading a book, listening to music and sketching. The pile of papers, the opened book and headphones in Inverted symbolise these tasks. It was obvious that my mood elevated almost immediately. Listening to music (specifically Upside down by Jack Johnson) was also the source of inspiration for my drawing, Inverted. This made me understand that loneliness can hinder work drastically and giving time off to individuals that are lonely would greatly benefit to his/her treatment and resilience. This again shows that doctors could use an empathetic holistic approach during consultations to understand his/her patient’s background and life. For example, by offering sick leave, a patient may choose to spend time with his/her family and loved ones, hence decreasing the feeling of loneliness that might be the cause of other illnesses such as high blood pressure.

Day 3 and a half: At this point, listening to music and sketching no longer helped that much. The feeling of emptiness and isolation started to engulf me. This is shown in Inverted where everything is filled with bright colours except the lonely person who is colourless. My life also felt completely different and due to loneliness, had been turned upside down. This was the main idea behind Inverted and is clearly shown that the lonely person feels like he/she is living on a different plane of existence compared to others. To beat this feeling, I decided to go out for a jog and that helped tremendously. With that, I understand how important the concept of mind-body medicine really is. By jogging outdoors, I was able to clear my mind out in the open and breathe in the clean fresh air. In Inverted, I drew windows showing the outside world and buildings representing society to symbolise that there are other alternative treatments out there and that we should not only look at the problem presented in the room.

Outcome of my social experiment: As this is only a three day environmental isolation, it can be only classified as a transient loneliness. The feeling of loneliness quickly disappeared as I started to meet and converse with friends. At the end of this experiment, I was more aware of the things that I previously considered the norm such as friendship and how exercise can improve lifestyle drastically. Another aspect I noticed was that despite after three and a half days of avoiding contact with my friends, none of them enquired about my disappearance. This made me realise that this might be the same for individuals experiencing loneliness as it is not apparent and shown physically. That is why patients should not be treated like broken machines but as an individuals and the only way to diagnose the hidden source of illness is through building trust and interaction with their patients.

This exercise has given me a great insight into what I initially thought was only a small part of medicine. By experiencing loneliness during my personal case-study and transforming this experience into an artwork proved that the art is also as important as the science behind medicine. Thinking of whole person care during clinical cases has given me a new perspective on medicine. Not only will these lessons be useful during my medical career but also for me as a human being in general.

References

1 Oxford Dictionaries. Oxford University Press. loneliness. [Online] Available from: http://oxforddictionaries.com/definition/loneliness [Accessed 18th March 2012]

2 Cacioppo JT, Patrick W. Loneliness: Human Nature and the Need for Social Connection, New York: W.W. Norton & Co. 2008.
3 Dr Trevor Thompson. The Big Ideas in Whole Person Care. Lecture at the University of Bristol. Bristol, 2012
4 Wikipedia. Maslow’s hierarchy of needs. [Online] Available from: http://upload.wikimedia.org/wikipedia/commons/thumb/6/60/Maslow%27sHierarchyofNeeds.svg/450px-Maslow%27sHierarchyofNeeds.svg.png [Accessed 18th March 2012]
5 Dan R, Carolyn EC, Jayne R, Karen Y. Social and Emotional Loneliness: An Examination of Weiss’s Typology of Loneliness. Journal of Personality and Social Psychology 1984; 46(6): 1313-1321
6 Itou, Junichirou. Shakaiteki Hikikomori Wo Meguru Tiiki Seisin Hoken Katudou No Guide-line (Guideline on Mental Health Activities in Communities for Social Withdrawal). Tokyo: Ministry of Health, Labor, and Welfare. 2003.
7 Michael Hoffman. Nonprofits in Japan help shut-ins get out into the open. [Online] Available from: http://www.japantimes.co.jp/text/fd20111009bj.html [Accessed 18th March 2012]
8 Boomsma D I, Willemse G, Dolan CV, Hawkley LC, Cacioppo JT. Genetic and environmental contributions to loneliness in adults: The Netherlands Twin Register Study. Behavior Genetics 2005.
9 Ronald G, Janice KK, Carl ES, Jane EH. Stress, Loneliness, and Changes in Herpesvirus Latency. Journal of Behavioral Medicine 1985; 8(3): 249-260
10 BBC News. Loneliness makes cancer more likely and deadly. [Online] Available from: http://news.bbc.co.uk/1/hi/health/8398728.stm [Accessed 17th March 2012]
11 Jo Wiley. Express.co.uk. Loneliness: Contagious like a bad cold. [Online] Available from: http://express.co.uk/posts/view/143326/Loneliness-Contagious-like-a-bad-cold [Accessed 17th March 2012]
12 Centers for Disease Control and Prevention. Health Benefits of Pets. [Online] Available from: http://www.cdc.gov/healthypets/health_benefits.htm [Accessed 17th March]