Over the last twenty years, more and more studies measuring the effect of loneliness suggest it is an important public health concern. For example, there is evidence that the risk of developing and dying from heart disease can depend on the strength of one's social network of friends and family, and that being recently widowed can increase one's odds of dying. And for people with Alzheimer's, even at more severe levels of the disease, cognitive function remains higher in those who have larger social networks.

After offering some examples of loneliness, this article touches on some emerging themes and issue, such as problems of defining the multidimensional nature of loneliness, some of the evidence that is driving its rising profile as a public health concern, how it differs from solitude, and lastly itemizes suggestions about how to overcome and cope with it.

Examples of Loneliness

Most of us at some point in our lives have experienced loneliness. For some it's temporary, perhaps triggered by particular events or transitions, while for others, it seems to be a permanent fact of life.

Ever since his wife died, just two weeks after their 60th anniversary, 84-year-old Bert has been practically housebound. If asked, he says "Oh, I'm OK, a neighbour pops in now and again, and kindly helps with shopping". He cleans the house and makes his own ready meals in the microwave. But lying in bed at night, or when he sees her hairbrush on the dressing table, or looks up from reading the newspaper ready to share a thought, he is overwhelmed with emptiness.

Joan is 19 and half way through her first year at university. "Everyone says their years at university were the best time of their life, they made lots of friends, went to parties. But for me, it's not like that. I am quite shy and find it hard to mix. I feel lonely and apart. I hardly see my housemates."

These two examples describe how loneliness can arise from either the loss of connection to others, or being unable to form new connections.

Emily White, author of the book "Lonely: Learning to Live with Solitude", also gives examples in her blog of how certain times of year can intensify loneliness:

"Thanksgiving can be a lonely time. Or, more accurately, the notion of everyone else getting together with loved ones can bring loneliness raging to the fore, leaving you feeling marginalized, isolated, and suffocating with feelings of disconnection."

Lonely girl clasping hands together
However, she is also critical of society and media's role in marginalizing aloneness:

"Valentine's seems to have emerged not just as a day to celebrate all things romantic, it's become a day of getting hysterical about the risks associated with loneliness."

Perhaps one of the most widely cited literary examples of loneliness are to be found in the 20th century novel "Of Mice and Men" by Nobel Prize-winning American author John Steinbeck who recounts the poignant tale of George Milton and Lennie Small, two migrant field workers caught up in the Great Depression in California, who struggle to find their place in the world, and through their itinerant life, come across people with similar struggles of their own.

Most of the plot unfolds on one ranch, where George and Lennie meet characters like Crooks, a black worker who lives in enforced solitude, Candy, an older man whose only friend is an ancient dog, and a pathetic young woman who is merely referred to as "Curley's wife".

The only thing that keep these characters going is their dream of escaping to a better life. George a cynical, intelligent man, is not lonely for most of the story, but becomes lonely when he loses his best and only friend, Lennie, a big, physically strong and mentally disabled man who comes across as too innocent to fear loneliness, although he shares George's dream of buying a little plot of land where they can keep their own animals and be their own bosses, and is quick to anger when Crooks suggests George might abandon him.

Crooks is a black stable hand with a crooked back who, because of the colour of his skin, is forced to live in solitude, away from the other men. He has an abrasive sense of humour, and comes across as bitter and proud. He wants to be friends with Lennie and proposes he come and live with him and George and hoe the garden when they get their plot of land, but he also taunts Lennie with tales of men he has seen come and go with empty dreams about owning their own plot of land.

Curley's wife is bored and lonely and dreams of becoming a film star: although she is married, her husband doesn't love her and she doesn't love him, and being the only woman on the ranch, she tries to make friends with the working men. Candy is an aging worker with an old dog that gets shot by another ranch hand in a supposed act of mercy that Candy thinks he probably should have done earlier but kept putting off, fearing the loss of his only companion. He worries about being lonely in old age, and persuades George and Lennie to let him join their plan of buying their plot of land, which could be made possible because he has some savings.

Over what is only a short episode in the lives of these characters, Steinbeck skilfully portrays various aspects of loneliness, a condition that an increasing body of scientific and medical literature is also beginning to see as having many dimensions.

Defining Loneliness

The more we study loneliness, the more it appears to be easier to describe than to define.

In 1999, Kenneth Cramer and Joanne Barry from the University of Saskatchewan in Canada, did a study of seven popular self-rating measures of loneliness, which between them contained 21 subscales or groups of questions, and found they correlated into four factors: social loneliness, emotional loneliness, negative affect or emotions, and family loneliness.

Richard Booth, a psychology professor and psychotherapist in the US wrote a paper published in Medscape 2002, where he discusses the scientific literature on loneliness to consider if it should be included in the "bible" of psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders.

He urges health professionals working in clinical settings to bear in mind that loneliness is complex and multidimensional, and that lonely people are "far from identical", and "differential levels and varying types of loneliness must be considered when dealing with lonely people".

Although Booth says there are almost as many theories of loneliness as people researching it, most of them seem to agree that it has many dimensions, which appear to include: insufficient social skills; situational problems, for example geographical or social isolation; having unrealistic expectations about oneself and others; dysfunctional attachment history, such as difficulties developing trust and affection in early family life; certain styles of thinking about the world and how to solve problems; and particular beliefs about the causes of events and other people's behavior.

Another aspect of loneliness that many researchers seem to agree on, is that it is a very intense feeling, as suggested by this definition proposed by the UK mental health charity MIND:

"To feel lonely is to be overwhelmed by an unbearable feeling of separateness, at a very deep level."

Booth agrees. He writes:

"The subjective experience of loneliness, however, is at the heart of the matter, and is sometimes so intense that lonely people can think about little else."

"When people are truly lonely, they feel miserably unhappy, vacuous, and painfully hollow," he adds.

One new and rather controversial theory of loneliness comes from the field of evolutionary psychology. This says that being connected with others is so necessary to survival, that human brains have become hard-wired to seek regular social contact.

In their book "Loneliness: Human Nature and the Need for Social Connection", John T Cacioppo, a research psychologist at the University of Chicago and a pioneer of the new field of social neuroscience, and William Patrick, editor of the Journal of Life Sciences, suggest that humans beings are more inter-dependent than our cultures would have us believe. They cite an African proverb:

"If you want to go fast, go alone, if you want to go far, go together."

They propose that social isolation goes against human nature at a deep, genetic level and can be as harmful to health as smoking or a sedentary lifestyle, and suggest that the human brain evolved to process social information and maximize survival through collaboration. Cities are an ultimate expression of this aspect of humanity; they function because people trust each other to follow rules that protect the group.

Cacioppo and Patrick also maintain that loneliness sets up a vicious cycle where the individual's perceptual and thinking becomes distorted, causing them to misread other people's attempts to include them, become less trusting, to try less hard to overcome these patterns, and become more and more withdrawn and pessimistic, reinforcing isolation and leading to early death.

But they also say that the need for social connection is so strong, it drives isolated people to form parasocial relationships with TV characters or pets.

This appears to be confirmed by a 2008 report from the UK charity Age Concern (now Age UK) that says almost half of over-65s consider the TV is their main form of company.

Loneliness and Health

The Age Concern report also suggests loneliness is reaching near epidemic proportions among older people in the UK, and that more than one in ten people over the age of 65 describes themselves as feeling lonely "always", or "often".

Mervyn Kohler, special adviser to Age UK, told The Times that it is not so much that loneliness is inevitable in old age but that it is more likely to happen as a result of bereavement, ill health, and poverty.

He said the starting point is the higher proportion of people who now live on their own, often as a result of bereavement, which can lead to isolation and then a downward spiral of self-neglect and either not participating in or having fewer opportunities to make new connections and friendships.

He said in the past, older people used to go to the corner shop, the post office, or pub, and this was a reason to dress nicely and make an effort, but because these local services are disappearing, taking the opportunities for new connections with them, this diminishes self-esteem and leads to depression and associated medical problems.

American loneliness expert James J Lynch agrees that being socially disconnected is harming our health. He has spent nearly forty years looking at how loneliness contributes to an increased risk of developing coronary heart disease prematurely.

In his book "A Cry Unheard: New Insights into the Medical Consequences of Loneliness", he also describes loneliness as a silent epidemic that is harming public health in the US, where it leads to depression and early death. He writes:

"Mortality rates in the United States for all causes of death, and not just for heart disease, are consistently higher for divorced, single, and widowed individuals of both sexes and all races."

Lynch's theory is that dialogue is essential for health, and children who fail in school are socially isolated and lack the communication skills that would help them compensate for this. This then becomes a major contributor to serious disease and premature death when they become adults.

He also says that technology like the Internet may appear to be making it easier to become more connected, but he thinks we will see more loneliness caused by technology, and this will bring more medical problems.

More recent research suggests that the route through which loneliness can make us ill is through our genes.

Steven Cole of the University of California and colleagues found that chronic loneliness is linked to a change in how genes behave. In May 2008, Scientific American described a study where Cole and colleagues showed people who scored in the top 15% of the UCLA Loneliness Scale had more gene activity linked to inflammation and less gene activity linked to antibody production and antiviral activity. Moreover, these genetic patterns were specific to loneliness, and not to depression or other negative feelings.

In a more recent study of adults in Taiwan, Cole concluded that these genetic changes may be due to the stress hormone cortisol failing to suppress genes linked to inflammation, which is a known risk factor for heart disease, cancer, and other life-threatening conditions.

Cacioppo and Patrick also suggest that some people are genetically predisposed to loneliness, and that the number of people who suffer from it is so great, that it should be regarded as a genetic disease. They refer to a joint 2005 study by the University of Chicago and the Free University in Amsterdam where researchers looked at data on over 8,000 twins taken over 12 years and found that 48% of identical twins and 24% of non-identical twins reported similar levels of moderate to extreme loneliness, and with much more agreement than in siblings who were not twins.

Loneliness and Solitude

Even though we currently don't have a universal definition of loneliness, we do know what it is not.

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Solitude, where people voluntarily enter into a state of being alone, is not the same as loneliness, which is more about "finding oneself" alone, or as Booth describes it, as a state where people feel "desperately lonely for reasons even they may not fully understand".

Voluntary solitude can be a healthy antidote to living in a world full of noise, an opportunity to retreat from the "busy-ness" of interactions that characterize modern life.

In his book "Solitude: A Return to the Self", Anthony Storr, a practising psychiatrist and Oxford scholar, emphasizes the link between solitude and creativity, and solitude and "profound and healing psychological experiences", which take place inside the person, and are only distantly related to being connected with others.

Storr challenges the idea that human relationships are the "touchstone of health and happiness". He supports the idea that what goes on in the mind of the individual when he or she is alone, especially when the imagination is engaged, is equally important to those who are capable of creative achievement.

Storr suggests that creative endeavours are traditionally defined in terms of what supports the community, but this is misleading, and overlooks those fields and interests that are necessarily individual pursuits.

Childhood loss and bereavement, depression and "repair", have shaped temperaments in adulthood that have led to some of the greatest poetry ever written, and he gives some English poets as examples.

And in old age, which Storr designates the "Third Period" of life, there is a natural waning of emotional dependence on others and a shift of focus to internal concerns, again resulting in creativity, and he cites composers and novelists as examples.

Booth agrees, and says solitude may "be sought for deep growth experiences such as meditation, visualization, listening to music, and other forms of 'doing nothing' ".

Another point that Booth makes is that you can still be lonely and have lots of connections with others. It is the quality of those connections that matter: "some lonely people have sufficient interactional networks and are, nonetheless, lonely because they are dissatisfied with those networks".

This is like another idea that is being increasingly questioned: that people who are single are lonely compared to people who are married.

A study by psychologists from Lafayette College and the University of Miami shows that single people over 40 who have never married can be just as resilient as their married peers. The study challenges the idea that marriage is always best for your health.

Lead author Jamila Bookwala, associate professor of psychology at Lafayette, said in a statement reported by Newsweek in December 2009 that:

"When single people feel control over their lives and can rely on themselves, they can have especially high levels of happiness."

But the married people who reported being very self-sufficient weren't necessarily happy about it, whearas the single people on average, felt relatively happy about it, she said.

Bella DePaulo, a visiting professor at the University of California at Santa Barbara, who wrote the book "Singled Out: How Singles are Stereotyped, Stigmatized and Ignored and Still Live Happily Ever After", told Newsweek that:

"I think that it's finally coming into our understanding that single life has changed and that it's possible to live a complete, satisfying life as a single person".

It also seems that a problem with the early research on singletons was that they were often grouped together with widowed and divorced people.

Dealing with Loneliness

So, if we find ourselves in a state of loneliness, and we know it is not "voluntary solitude", what can we do about it?

The UK mental health charity MIND, offers these suggestions for overcoming loneliness, which they say is possible if you are really determined to work at it:
  • Be prepared to give it time and energy, for instance to thinking about the reasons for it and the positive steps you can take.

  • Learn to be alone and relaxed in your own company: focus on who you really are and what you want to do. This may involve facing some difficult feelings, which are maybe the reason you keep seeking the company of others.

  • Learning to face yourself may change how you relate to others: for example, it may lead to less "hunger" after relationships, and more ability to give.

  • Learn to be with others: for instance, learn how to say "no", set boundaries in relationships, and express your feelings, wants and needs. Assertiveness and social skills training can be helpful.

  • Don't make big changes: try things one small step at a time and don't get intensely involved with one person.

  • Try small interactions first: strike up a light conversation with a shopkeeper, or a person on the bus.

  • Join a local interest group, or start a class on a topic you enjoy.

  • Volunteer for something.
A counseling session
They also suggest that talking to a counsellor or psychotherapist might be a safe way to explore and understand problems, and find the courage and support to deal with situations that feel defeating. Such talking therapies can help people for the first time build self-acceptance and confidence, and from there find out that relating to others can be enjoyable and satisfying.

And if none of these suggestions seem to fit what you are looking for, don't despair, because as Emily White says in her blog, despite some attempts by the media to portray loneliness as "some sort of freakish, dangerous disease state", it's not. Loneliness, says White, is "part of being human":

"It's what some of us came into the world with a predisposition for. It's something we have to manage and struggle our way through, but not anything to become alarmed by".

She says there is no need to be silent about loneliness, and the shame and self-blame it creates.

"There's nothing wrong with loneliness, and we need to start acknowledging this through a wider and more open discussion of the state," she adds.

Sources: Ray Hainer, "Loneliness Hurts the Heart", health.com, 21 Jun 2009; Jaap Spreeuw and Xu Wang, "Modelling the short-term dependence between two remaining lifetimes", actuaries.org.uk 27 March 2008; D A Bennett et al, "The effect of social networks on the relation between Alzheimer's disease pathology and level of cognitive function in old people: a longitudinal cohort study", Lancet Neurology May 2006; Emily White's blog, www.lonelythebook.com/loneliness-blog/; John Steinbeck, "Of Mice and Men", Penguin Modern Classic 1993, Kindle edition; Jennifer Senior "Alone Together: Is Urban Loneliness a Myth", New York Magazine, 23 Nov 2008; James Lynch "A Cry Unheard: New Insights into the Medical Consequences of Loneliness", Bancroft Press, June 2000; Victoria Stern, "Loneliness May Lead to Serious Illness, including Cancer", Scientific American, 29 May 2008; "The reason loneliness could be bad for your health", The Economist, 24 Feb 2011; US Census Bureau "Families and Living Arrangements: 2005"; Age Concern, 2008 "Being socially excluded and living alone in old age. Findings from the English Longitudinal Study of Ageing (ELSA)."; Rosemary Bennett and Mary Bowers, "Loneliness: the silent epidemic sweeping through Britain", The Times, 31 December 2009; http://scienceofloneliness.com; MIND.org.uk (website page: Diagnoses and conditions: Loneliness); Richard Booth "Loneliness as a Component of Psychiatric Disorders". Medscape General Medicine 2(2), 2000; Kenneth M. Cramer and Joanne E. Barry, "Conceptualizations and measures of loneliness: a comparison of subscales", Personality and Individual Differences, 27 (3), Sep 1999; Anthony Storr, "Solitude: A Return to the Self", HarperCollins, 1989; "Single and Loving It, Even During the Holidays", Newsweek, 22 Dec 2009.

Written by: Catharine Paddock, PhD