"Lonely young adults in modern Britain"

"Lonelier young adults were more likely to experience mental health problems, to engage in physical health risk behaviours, and to use more negative strategies to cope with stress."

Those were some of the conclusions reached in the study published by Timothy Matthews and colleagues [1] who relied on data from the "Environmental Risk (E-Risk) Longitudinal Twin Study, which tracks the development of a birth cohort of 2232 British children" to "examine the profile of loneliness in a prospective, contemporary, nationally representative cohort of 18 year-olds living in the UK." The specific focus was on how loneliness might impact on various domains: "mental health, physical health and health risks, coping and functioning, and career prospects."

Results: first and foremost, when it came to the question(s) of loneliness, and the prevalence of loneliness as measured by the UCLA Loneliness Scale, Version 3, "23–31% of participants reported experiencing any of these feelings ‘some of the time’, and 5–7% reported feeling them ‘often’." Sex/gender and socio-economic status did not seem to show any statistically significant relationship to reports on loneliness.

In terms of possible or actual psychopathology, we are told that: "Lonelier 18 year-olds were more likely to meet diagnostic criteria for depression, anxiety, ADHD [attention-deficit hyperactivity disorder], conduct disorder, alcohol and cannabis dependence, to have self-harmed, and to have attempted suicide." Depression and anxiety came out with the strongest *association* in relation to loneliness, and insofar as the 'attempted suicide' bit, I'm wondering whether it may tie into other recent quite shocking findings (see here). Researchers also noted that: "lonelier individuals engaged in less day-to-day physical activity and were more likely to be daily smokers."

Whilst realising that the various associations mentioned in the context of loneliness do not necessarily tie directly into loneliness (e.g. loneliness does not necessarily 'cause' anxiety and depression or indeed, vice-verse), these are important results. They add to a bank of peer-reviewed research which suggests that loneliness - chronic loneliness - is probably not great for anyone (see here). They also observe that increasing social contact with others, whilst not without benefits, is not necessarily all that can be done to combat this state and it's rather negative correlations.

And it is perhaps timely that at the time of writing this post, loneliness is highlighted as being over-represented when it comes to certain diagnostic labels as part of a package of issues affecting quality of life (see here)...

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[1] Matthews T. et al. Lonely young adults in modern Britain: findings from an epidemiological cohort study. Psychological Medicine. 2018. April 24.

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Loneliness --> low self-esteem ---> depression?

It was the findings reported by James McCauley and colleagues [1] that prompted today's post. Working on the basis that "there have been few comprehensive investigations of self-esteem in children and adolescents with autism spectrum disorder (ASD)" researchers set out "to assess how youth with ASD rate their self-esteem compared to age-matched TYP [typically developing] youth." Further, how levels of self-esteem (or not) might onward influence "internalizing psychopathology", the fancy phrase for issues such as depression and anxiety.

I don't typically go for grand theories and sweeping generalisations on this blog, particularly when referencing the very large and very diverse autism spectrum. I've not moved over to the 'dark side' of generalisation in this post but am particularly interested in the some of the *associations* talked about my McCauley et al.

Specifically how: "youth with ASD rated their self-esteem significantly lower than did TYP youth" and how self-esteem was "strongly related to depression." Add in the findings reported by Micah Mazurek [2] who observed that "loneliness was associated with increased depression and anxiety and decreased life satisfaction and self-esteem" and some potentially important processes emerge as per the equation titling this post: Loneliness --> low self-esteem ---> depression?

McCauley and colleagues do also talk about how Theory of Mind (ToM) also showed some possible *associations* to elements of their results but I'm not really minded to go into this part of their findings with any great detail. It's not that I don't believe that ToM might not be an issue for some on the autism spectrum, but rather as other results have suggested [3], questions still remain about what ToM actually means and whether other issues (i.e. alexithymia) might predominate in relation to some autism [4] (where the stress is on 'some').

I don't doubt that there are several other important elements potentially influencing things like self-esteem in relation to autism and how it can lead to issues such as depression (see here). Further studies are needed on this topic, including drawing on the autism-not-specifically-mentioned research literature [5]. But insofar as the simplistic relationship set out in the post, there is an obvious area ripe for intervention: loneliness. And on that point, there are options available (see here) if and when desired; accepting that not everyone wants (or needs) lots of people around them all of the time. This perhaps is also where the online world (in moderation) can also come into it's own [6] (I repeat 'in moderation').

Finally, I'll be coming to the findings reported by Cage and colleagues [7] in the not-too-distant-future talking about how "personal acceptance significantly predicted depression" in the context of autism and what role self-esteem might play here too (minus too much psychological fluff and ToM chatter)...

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[1] McCauley JB. et al. Self-Esteem, Internalizing Symptoms, and Theory of Mind in Youth With Autism Spectrum Disorder. J Clin Child Adolesc Psychol. 2017 Oct 19:1-12.

[2] Mazurek MO. Loneliness, friendship, and well-being in adults with autism spectrum disorders. Autism. 2014 Apr;18(3):223-32.

[3] Oakley BF. et al. Theory of mind is not theory of emotion: A cautionary note on the Reading the Mind in the Eyes Test. J Abnorm Psychol. 2016 Aug;125(6):818-23.

[4] Trevisan DA. et al. Alexithymia, but not autism spectrum disorder, may be related to the production of emotional facial expressions. Mol Autism. 2016 Nov 11;7:46.

[5] Sowislo JF. & Orth U. Does low self-esteem predict depression and anxiety? A meta-analysis of longitudinal studies. Psychol Bull. 2013 Jan;139(1):213-240.

[6] Sundberg M. Online gaming, loneliness and friendships among adolescents and adults with ASD. Computers in Human Behavior. 2017. Nov 1.

[7] Cage E. et al. Experiences of Autism Acceptance and Mental Health in Autistic Adults. J Autism Dev Disord. 2017 Oct 25.

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Patients with psychiatric disorders who request euthanasia (continued)

Once again the uncomfortable topic of euthanasia and assisted suicide (EAS) is covered on this blog (see here for the last entry) as I discuss the findings reported by Scott Kim and colleagues [1] who reported on the "characteristics of patients receiving EAS for psychiatric conditions and how the practice is regulated in the Netherlands."

Accompanied by some media interest (see here), the Kim paper provides an important overview of the: "Clinical and social characteristics of patients, physician review process of the patients’ requests, and the euthanasia review committees’ assessments of the physicians’ actions" in relation to EAS. As per other countries, certain legal protections are currently in place in the Netherlands when it comes to EAS. Although it is widely assumed that EAS is generally 'linked' to the presentation of physical conditions, either limiting life or causing extreme suffering, there is an increasing number of people turning to such options on the basis of the effects of psychiatric and/or behavioural conditions/labels/disorders. Before you form any snap opinions about the 'rights and wrongs' of this, it is worth bearing in mind the far-reaching effects that psychiatric conditions can have on a person and how this manifests in relation to issues such as suicide rates for example. I say that last sentence whilst making no personal value judgements on the provision of EAS.

Kim et al analysed data on 66 people who received EAS. 66 people who are no longer with us. Most were women (70%) and most had some history of 'psychiatric admission' (80%). About half of the cohort had a history of suicide attempt(s). The types of diagnoses/labels applied to the cohort ranged from depression (35%) to psychotic disorder(s) (8%). As per the last occasion when EAS was discussed on this blog, mention of the autism spectrum is made in 2 of the 66 cases reported on. Also: "In 37 patients (56%), the reports mentioned the patients’ social isolation or loneliness, some with striking descriptions such as the following: “The patient indicated that she had had a life without love and therefore had no right to exist” (case 2012-46), and “The patient was an utterly lonely man whose life had been a failure” (case 2013-21)." I might add that those are words actually included in the case reports analysed.

"The patients’ psychiatric conditions were chronic. In 10 patients (15%), the duration of their illness was described qualitatively (“years,” “decades,” or “longstanding”)." Alongside the psychiatric or behavioural presentation of cases, Kim and colleagues also report on the presence of various comorbid medical conditions. Many (58%) had a least one medical condition. Some (18%) had 3 or more including: "cancer, suspected malignancy, chronic obstructive pulmonary disease, cardiac disease, diabetes mellitus, stroke, prior brain tumor surgery, arthritis, orthopedic problems, chronic fatigue, fibromyalgia, migraines, neurological disorders (stroke, Meniere disease, pain syndrome, Parkinson disease, diaphragm paralysis, or gait disturbance), pancreatitis, medical complications of severe weight loss, vision loss, hearing loss, incontinence, and decubitus or other ulcers."

Various other points are covered in the Kim paper which I would encourage interested readers to peruse. The bottom line is that procedures pertinent to EAS in relation to psychiatric/behavioural manifestations are being utilised and a degree of diversity is present among those seeking such an extreme alternative. That social isolation and loneliness are part of the reasons why EAS is being sought is also an important point to reiterate.

The accompanying editorial on the Kim paper (see here) also makes for an important read. Questions are raised: "Will psychiatrists conclude from the legalization of assisted death that it is acceptable to give up on treating some patients? If so, how far will the influence of that belief spread?" that have some really important repercussions particularly in view of the discussions on a good death (see here).

I do finally want to pass comment specifically on the inclusion of autism or autism spectrum disorder (ASD) in amongst the Kim case files. My view is the same as it was the last time I discussed this topic:

'I know the idea of modifying the presentation of autism is not palatable for everyone, and that society also needs to play a role in how people with autism / autistic people are welcomed and supported. When however a label such as autism potentially leads, or is contributory, to a path whereby a person considers ending their own life by suicide or euthanasia, I find it difficult to say that we should just stand back and watch from the sidelines.'

More research on this uncomfortable topic is of course implied.

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[1] Kim SYH. et al. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016. Feb 10.

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Kim, S., De Vries, R., & Peteet, J. (2016). Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014 JAMA Psychiatry DOI: 10.1001/jamapsychiatry.2015.2887

Is loneliness bad for your health?

A few weeks back I posted an entry on hikikomori, a 'condition' characterised by withdrawal from social life and the active pursuit of isolation for a period of 6 months or more. The gist of the post was that this phenomenon whilst having a cultural connection to places like Japan and Korea, might not necessarily be an exclusively socially-mediated condition as per the various explanations put forward for it but rather be reflective of other biological and/or psychiatric processes also involved.

This post got me thinking about lots of things, most notably what happens to the physical and mental health of those people undertaking hikikomori and whether the lack of physical contact might be detrimental to them and their overall health. The answer: probably, but its complicated. The New Scientist recently carried an interesting opinion piece about loneliness and how aside from the the psychological aspect to it, loneliness might be have some physiological effects also, at least according to John Cacioppo of the University of Chicago.

As with articles such as this one, there is always a quote which is designed to grab your attention. In the case of Prof. Cacioppo it is this one "curing loneliness is as good for your health as giving up smoking". Mighty big words indeed. But does the literature back him up and if so, what are the implications for states like hikikomori? Indeed what about the social aspects of autism spectrum conditions; are there implications to be had?

Whilst not wishing to turn this into some kind of mega-post on loneliness and physical health, there are a few studies to suggest some correlation between health and loneliness. I say suggesting some correlation, but as with many things, people don't just live in a vacuum, so it is difficult (impossible?) just to say that loneliness causes this, that or the other. Indeed, as per the paper by Shankar and colleagues highlighted above, loneliness may not directly affect health, but rather health behaviours, so things like smoking and exercise and diet. They do however make an interesting differentiation between loneliness and social isolation and note some individual correlations based on social isolation.

Cacioppo is not without some research interest in this area. As per the New Scientist article, a recent study of his indicated some interest genetic features potentially attached to loneliness in areas of stress and inflammation (inflammation is a key feature of some of his other work) suggesting some evolutionary mechanisms at work. For me the most tantalising aspect to this work is the suggestion that our behaviour, our biochemistry and our genes work in unison; so behaviour can guide our biochemistry much like the suggestion that it might guide our gut bacteria also.

As to autism spectrum conditions is there any overlap with this line of research? Well I suppose it depends on where you look. Outside of language, problems with social interaction is one of the primary features for a diagnosis of autism, although like many things, this varies from person to person. Certainly loneliness and feelings of social isolation are present for quite a few people on the autism spectrum, particularly adults, but the question of whether this is related to their autism or partly mediated by a lack of opportunities to engage in social activities like employment, social networks (not the computer variety), etc is fundamental to any question of causation.  As to the physiological correlates, well autism does have more than a passing relationship with inflammation in its various forms, but would it be too much to suggest that this is 'caused' by social isolation and loneliness outside of the myriad of other possible correlates?

Given the number of times I have used a question mark in this post, readers can perhaps see that this is an area requiring a lot more thought and research and I have very few answers to offer. What I perhaps would like to see more research on is how the social interactive side of autism links into loneliness, links into other health behaviours, links into things like depression links into inflammation. If (and it is still a very big 'if') there was some possible connection between these elements, can we intervene and would a doctor ever be able to prescribe social interaction and community as a 'cure' for loneliness? Would every person with autism necessarily want such a prescription?