The Pathology of Loneliness: A Commentary
Kathi Norman, PA-C, MAPP
University of Pennsylvania, Philadelphia
While undertaking his emergency medicine rotation, a senior resident became frustrated when he noted a man in his late seventies had checked in to the emergency department again (Yeh, 2017). The resident carefully reviewed the chart, negative chest x-ray, negative cardiac labs, no signs of infection, and vital signs all good. The resident steeled himself to enter the room to discharge this suspected malingerer and had his senior attending physician by his side. Upon entering, they could see the old man was slouched and appeared sad. Drawing from years of wisdom, the attending physician pulled up a stool and sat in front of the patient asking how he was doing? The man revealed he had lost his wife of twenty years just a week prior. He was lonely. Though pervasive in medical school and residency, the resident had not picked up on this subtle yet widespread disease, loneliness. A sad reality of modern life is that loneliness is pervasive and on the rise, nevermore than with physicians themselves.
Loneliness is an impediment to flourishing while cultivating strong connections to others has been seen to bring meaning and wellbeing (Gable & Haidt, 2005; Vaillant, 2012). Positive psychology is the scientific study of what makes individuals and systems flourish (Snyder, 2014). Seligman, sometimes referred to as “the father of positive psychology,” proposed the PERMA model with five core elements of psychological well-being and happiness with the “R” representing relationships (Seligman, 2002; Butler & Kern, 2016). Positive psychology is concerned with flourishing and positive relationships as one important element.
Loneliness has been described as a negative emotion associated with the difference in the perception of one’s relationships, in what one has and perceives they have, sometimes leading to pessimism, unhappiness, and dissatisfaction (Perlman & Peplau, 1981). Loneliness is a strong predictor of poor health and languishing. According to the 2010 American Association for Retired Persons (AARP) survey, over a quarter of people in America live alone and loneliness is increasing with 43 percent of Americans experiencing chronic loneliness. An article released in August of 2017 by the American Psychological Association (APA) suggests that social isolation could be a greater health hazard then obesity (Sliwa, 2017). A robust study, using the data from two meta-analysis and over 300,000 participants, revealed social connectedness to be associated with greater than a 50% reduction in early death (Sliwa, 2017). These data suggest that social isolation is a greater risk for mortality then many health indicators.
In January of 2018, Britain appointed the first in the world “Minister of Loneliness (Emling, 2018).” One study in the United Kingdom (UK) showed that many elderly had not spoken to others for over a month (Emling, 2018). Over nine million people in the UK report being lonely most of the time or always. This appointment by prime minister Theresa May was in response to years of research on loneliness that demonstrated a relationship to poor health.
Most people would not think of loneliness as a public health crisis but the 19th U.S. Surgeon General, Dr. Vivek Murthy, suggests otherwise (“OPB interview,” 2017). In an interview with National Public Radio, the former surgeon general describes that the pathology of loneliness was inhibiting a full and healthy life in his patient population. He found this pathology was more debilitating then other diagnoses such as diabetes or heart disease. Dr. Murthy noted that isolation reduces the lifespan more than smoking 15 cigarettes a day. The work environment has been identified as a culprit and is partly to blame. Dr. Murthy reflected during an interview with The Washington Post that, “Our social connections are in fact largely influenced by the institutions and settings where we spend the majority of our time… that includes the workplace.” Medical school and residency can be included in this lonely group. One resident wrote on his web site about his medical school experience, “a lone astronaut wandering in space, gear and all, forcibly removed from the rest of the world. Medicine is a lonely calling” (Idiopathic Medicine, 2010). In a blog for medical students, one student wrote, “Medicine is a lonely road and one which we all travel by ourselves. But if it makes you feel better, we’re all lonely together.” Another student wrote, “Friendships are temporary. Board scores are forever,” and another, “Med school is a pressure cooker and exacerbates some people’s worst fears/feelings about themselves.” Another blog for the medical community further extrapolated loneliness in medical school (Being a Doctor: Is Loneliness escapable?, 2010):
It seems like loneliness is a topic that is constantly recurring on the minds of premeds and med students… and on this forum. Most of the doctors I know personally have related to me feelings of loneliness in med school (one of my friends, now a doctor, said she cried everyday secretly at HMS)… hopefully she’s an exception.
Becoming a physician requires one to practice dedication, discipline, and personal sacrifice in an environment where getting ahead is driven by the survival instinct. This comes at a cost. Physicians are committing suicide at a rate of nearly 400 a year (Andrew, 2017). Burnout and its effects can be seen permeating the practice of medicine. As many as 70% of medical students report being bullied and abused, including sexual and physical abuse, from other residents and providers (Chen, 2012). In 2017, The Association of American Medical Colleges (AAMC) annual medical school graduation questionnaire revealed that over 50% of 14,836 respondents noted at least sometimes a disconnect in faculty in what they are taught and experience about professional behavior/attitudes. This educational environment encourages competition and mistrust that leads to isolation.
One study suggested that lonely people look subconsciously for negativity. Social isolation can cause one’s brain to be hypersensitive to perceived social threats (Layden et al., 2017). Further research by neuroscientists in positive emotions reveals that general health and resilience can be strengthened through the cultivation of positive emotions. Dr. Marsha Snyder, is a positive psychology proponent, author of Positive Health: Visioning Health and Thriving for Doctors and their Patients (2014), and a graduate of the University of Pennsylvania’s (PENN) Master of Applied Positive Psychology program (MAPP). She explains that, in over the past 30 plus years, problem-based solutions have not worked to further understand and solve medical education’s deficits. She proposes that medical education pursue a strengths-based approach to resolving the problem. The art and science of being and understanding what it takes to be a thriving self is key. Dr. Snyder explains if concepts such as emotional intelligence, listening skills, empathy, insight, resilience, behavior change, are not taught and actively understood, flourishing in this environment becomes difficult.
The science of positive psychology provides a lens into how relationships contribute to health and well-being. We now see that strong relationships are key to a healthy and flourishing life. Beginning in medical school, the fostering of social skills is essential to cultivating flourishing physicians. The downstream benefits can be happier and healthier patients, communities, and nations.
Andrew, L. B. (2017). Physician suicide. Retrieved from https://emedicine.medscape.com/article/806779 overview
Association of American Medical Colleges. (2017). The medical school graduation questionnaire. Retrieved from https://www.aamc.org/data/gq/
Being a doctor: Is loneliness escapable? (2010, November 7). being a doctor: is loneliness escapable? [Blog post]. Retrieved from https://forums.studentdoctor.net/threads/being-adoctor-is-loneliness escapable.775056/
Businesses to benefit from addressing ’loneliness epidemic,’ doctor says. (2017). Retrieved from https://www.npr.org/2017/10/08/556546472/businesses-to-benefit-from-addressingloneliness-epidemic-doctor-says
Butler, J., & Kern, M. L. (2016). The PERMA- Profiler: A brief multidimensional measure of flourishing. International Journal of Wellbeing, 6, 1-48. https://doi.org/10.5502/ijw.v6i3.526
Chen, P. W. (2012). The bullying culture of medical school. Retrieved from https://well.blogs.nytimes.com/2012/08/09/the-bullying-culture-of-medical-school/
Emling, S. (2018). Britain appoints First ’Minister of Loneliness’. Retrieved from https://www.aarp.org/home-family/friends-family/info-2018/britain-minister-lonelinessfd.html?intcmp=AE-HP-DP1
Gable, S., & Haidt, J. (2005). What (and why) is positive psychology? Review of General Psychology, 9, 103-110. http://dx.doi.org/10.1037/1089-26220.127.116.11
Idiopathic Medicine (2010, July 10). A lonely calling [Blog post]. Retrieved from A medical residents journey: https://idiopathicmedicine.wordpress.com/2010/07/12/alonely-calling/
Layden, E. A., Capioppo, J. T., Capioppo, S., Cappa, S. F., Dodich, A., Falini, A., & Canessa, N. (2017). Perceived social isolation is associated with altered functional connectivity in neural networks associated with tonic alertness and executive control. NeuroImage, 145, 58-73. https://doi.org/10.1016/j.neuroimage.2016.09.050
Loneliness among older adults: A national survey of adults 45+. (2010). Retrieved from https://www.aarp.org/content/dam/aarp/research/surveys_statistics/general/2012/lonelines s-2010.doi.10.26419%252Fres.00064.001.pdf
Perlman, D., & Peplau, L. A. (1981). Toward a social psychology of loneliness. In R. Duck & R. Gilmour (Eds.), Relationships in disorder (pp. 32-55). Retrieved from https://s3.amazonaws.com/academia.edu.documents/40307428/Perlman___Peplau_81.pd f?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1518036146&Signature=GcP7I2x59KdMiaco6vrrG8Jn1z8%3D&responsecontentdisposition=inline%3B%20filename%3DPerlman_Peplau_81.pdf
Seligman, M. E. (2002). Authentic Happiness: Using the new positive psychology to realize your potential for lasting fulfillment. New York, NY: The Free Press.
Sliwa, J. (2017). So lonely I could die. Retrieved from http://www.apa.org/news/press/releases/2017/08/lonely-die.aspx
Snyder, M. W. (2014). Positive health, flourishing lives, well-being in doctors. Bloomington, IN: Balboa Press.
Vaillant, G. E. (2012). Triumphs of experience: The men of the Harvard Grant Study. Cambridge, MA: The Belknap Press.
Yeh, C. S. (2017). The power and prevalence of loneliness. Retrieved from https://www.health.harvard.edu/blog/the-power-and-prevalence-of-loneliness-2017011310977