S1 Episode 49: Hope for the Lonely

The pandemic has produced a dramatic new wave of loneliness for those coping with loss, grief, and social isolation. Although the feeling of loneliness is not a medical condition, it can easily transition into the clinical disorders of depression and anxiety.  Dr. Richard Friedman, Professor of Clinical Psychiatry at Weill Cornell Medicine, explains how the upheaval of prolonged loneliness can affect the brain and heart, and how loneliness can be more quickly remedied than one would think. 

  

Dr. Phil Stieg: Today, we’re going to talk about a universal human condition that has been significantly amplified with the COVID crisis. For the 37 million Americans who live alone. And for all of us who have been struggling with the multiple months of quarantine the numbers of people who are experiencing loneliness and the separation from friends, family, and loved ones is particularly hard. And even more concerning loneliness can have profound effects on our brain and heart health, making this condition a more serious predictor for early mortality. I’m very happy to welcome back our frequent guest and expert on this critical topic. Dr. Richard Friedman, Richard is Professor of Clinical Psychiatry and Director of the Psychopharmacology Clinic at Weill Cornell Medical College . He is also an op-ed contributor to the New York Times. Richard, glad to have you back.

Dr. Richard Friedman: Pleasure to be here Phil.

Dr. Stieg: So let’s start off by clarifying what you as a psychiatrist define as loneliness.


Dr. Friedman: 
Loneliness really is the subjective experience of feeling socially isolated and disconnected from other people and unhappy about that, which is very different than just being alone. You could be alone and not feel lonely. And you know, you can be in the middle of a crowd of lots of people let’s say at a party and experience loneliness. It’s a subjective experience.


Dr. Stieg: 
Personally, I tend to think about this stuff as a spectrum of being alone, solitude and loneliness. Can you differentiate that for us?


Dr. Friedman:
 You can be physically isolated from other people, loved ones and friends, and be perfectly content because you enjoy your own company and you don’t feel actually disconnected from them. Or, you can actually be with people physically but feel emotionally lonely because you don’t feel connected to them. So it’s really an emotional state, loneliness. It doesn’t have to do so much with the presence of people. It’s not whether people are around you it’s whether you actually feel connected or disconnected from your social network. That’s what loneliness is all about.


Dr. Stieg: 
 I’ve found that during the COVID crisis, I thoroughly enjoy after a busy day of work or a very active weekend of exercise, getting home from work, pouring a scotch and smoking a cigar. I shouldn’t feel badly about that, right?


Dr. Friedman: 
No, you should enjoy that because it’s a period of relaxation after work. And then maybe you’ll feel that you want to connect to people or perhaps not. If you’re so socially stimulated with work during the day, you might actually disconnecting.


Dr. Stieg: 
When might I note to myself that I’ve crossed that divide from enjoying solitude to being lonely? What would I see in myself?


Dr. Friedman: 
You would feel like you miss your friends and loved ones, you would feel sad or anxious or distressed. You would think a lot about all the people that you miss. So you experience being alone as an unhappy state and not a pleasurable state.


Dr. Stieg: 
Prior to that happening. If I looked in the mirror and tried to do a little bit of self-analysis, might I look for particular psychological States that would make me prone to loneliness?


Dr. Friedman: 
Well, I mean, one of them isn’t so much a psychological one, it’s a physical one, and that is quarantine. So if I said to you, you know, you’ve got to stay inside as much as possible. And when you go out and you have to wear a mask and you’re going to spend most of your day inside, not around human beings, it’s a set up actually for being isolated. And also it’s more likely that you will feel lonely.


Dr. Stieg: 
 I can’t imagine that a lot of people walk in your office as a psychiatrist and say, “You know, Dr. Friedman, I’m lonely.” What do they say to you that triggers you to think, “Aha, I’ve got to deal with loneliness.”


Dr. Friedman: 
Usually they will say they feel anxious or they’re sad, or they feel they’re not effective in doing what they want to do, but mainly their complaints, which makes me wonder about their social isolation and whether they’re lonely, is they’re sad and anxious.


Dr. Friedman: 
Loneliness is a normal response to being disconnected socially. Not everybody, but most people are social. We’re social animals. And if you separate us from other people, we’re not happy about that. Eventually at some point, and that’s normal. That’s a normal response to social isolation, but depression is not. Depression is a pathological state and you don’t have to be isolated in order to get depressed. In fact, most people get depressed, even when they’re not in quarantine, obviously. That’s actually, that’s a medical illness, depression.


Dr. Stieg:
 So you don’t treat loneliness then, as a disease?


Dr. Friedman:
 No, I treat it as a normal response to social disconnection, the treatment for which is: go see your friends, go connect with the world.


Dr. Stieg: 
So there isn’t a biochemical imbalance ?What’s the emotional component to loneliness?


Dr. Friedman: 
Well, there’s a biological substrate to social isolation. I mean, you know, for example, it’s known that if you put people together with animals, they will have an increase in certain hormones that make them feel more trusting, like oxytocin. There is a set of biological changes that occur with socializing that make us feel good that make us want more of it.


Dr. Stieg: 
Is there a scale in your mind that you work from, or is it just you’re lonely or you’re not lonely?


Dr. Friedman: 
Well, yes. I mean, it’s like temperature. You can have a little, or a lot of it . At extreme, ends it verges on distress levels that can trigger in people who are genetically loaded depression or anxiety disorders. So I do think of it on a scale, but I’ve, most of the people that I see who are lonely are experiencing normal, emotional response to separation.


Dr. Stieg: 
 So then the risk associated with the loneliness would be related to the duration of the loneliness?


Dr. Friedman: 
Yes. And the risk, the medical and the demographic risk of a person. So older people are more sensitive.


Dr. Stieg: 
And those risks would be what? Stress, anxiety, uncertainty, and you know —the physiologic effects that that can have on your heart and your lungs?


Dr. Friedman: 
Yes, exactly. I mean, the medical effects of isolation, you know, in older people is well known and the cognitive effects also, I mean, you know, people with richer social networks have a fraction, really a fraction of the cognitive decline of people who have rich social networks because they’re, they’re stimulated.


Dr. Stieg: 
For me, it was kind of a chicken or the egg question is, does isolation come first or does loneliness come first?


Dr. Friedman: 
I think they’re, self-reinforcing and in a bad way. If you normally feel lonely, it would drive you to want to seek people. But if it’s severe and you’re actually being quarantined like with COVID-19, you don’t have access in the same way that you do before. And so you may not be able to do that. And you may not be able to relieve your loneliness, which means, you know, you, you might try connecting virtually with FaceTime or Zoom or WebEx or WhatsApp or whatever in order to relieve your loneliness in order to connect with other people.


Dr. Stieg: 
What I’m hearing from you is that you’re not overly concerned about loneliness in terms of psychological spectrum. It’s a, a normal response to a set of external circumstances, correct?


Dr. Friedman: 
Yes. I’m not worried about it. I’m more worried about whether most people who feel lonely can solve their problem by socializing and getting out of it.


Dr. Stieg: 
And there’s no genetic basis to this right?


Dr. Friedman: 
It’s part of the human condition.


Dr. Stieg: 
How about age? Do young people experience loneliness differently than, than old people?


Dr. Friedman: 
I would think that, you know, there’s probably good data about the benefits of being social, but because as you age, you tend to lose your networks, your social networks get smaller. You’re more likely to be vulnerable to loneliness and isolation. Whereas, you know, when you’re young, it’s like a school of fish, you know, in school, you’re surrounded by people in college, in your workforce. So younger people are less likely to be isolated and probably less likely to be lonely.


Dr. Stieg: 
Are patients coming to you talking about their loneliness? Has the incidents been increased?


Dr. Friedman: 
Yes, many of my patients are talking about how difficult it’s been to be stuck inside. And even though they can virtually see their friends and family, it’s not quite the same, which is an interesting question. And they’re dying to get outside. And I think that is what’s driving what we’re seeing now in the second wave of young people saying, we’ve had enough isolation, we’re going to go out, go to bars, go to the beach, go to parties. So I’m seeing that.


Dr. Stieg: 
What do you anticipate will happen if there is a second wave? Will their response be different or not?


Dr. Friedman: 
It’s an interesting question. It might be that for young people, they will basically throw their hands up and say, okay, we know there’s going to be a second wave. And we’re part of it. We are young and we are less likely to get really sick and less likely even still to die. We will take our chances. We’ll contribute to herd immunity, but at least we’ll be social. That’s not how people who are older will feel they’ll feel more frightened. And they will probably be even more compliant with that isolation.


Dr. Stieg: 
Tell me about patients that come to you with this issue.I have a lot of meetings in my life aside from being a neurosurgeon, and now every meeting is being held by Zoom or WebEx. There’s a distance, a lack of human contact. How have you noticed that that’s affected individuals and their relationships with other individuals?


Dr. Friedman: 
Such a great question. Nobody knows whether, and to what extent have virtual connection with people by zoom or FaceTime or WebEx counts, you know, emotionally and neurobiologically. The same as a direct face to face connection. There’s no evidence yet. You know, it hasn’t been studied. It’s too new a phenomenon. But my own observation is, it’s more exhausting to connect by Zoom and FaceTime because in order to read people and how they’re feeling, you have to stare at the screen constantly. When you’re with people, you, you know, they, they, they move, they have expressions that are so easily detected by being in their presence that it’s easy. You can look out the window for a second without losing it. When you’re talking to someone on zoom, all of a sudden, they’re quiet. Are they quiet because they are thinking about something or is it a tech flaw? It’s that kind of thing.


Dr. Stieg: 
And I also find that it’s difficult in terms of the flow of the conversation. You know. Because the person doesn’t necessarily hear you because the mic is filled with their voice, the body language, it’s hard because they’re only looking at your face. It really makes conversation, dialogue and making difficult decisions, which we have to make now more complex.


Dr. Friedman: 
Yes. I completely agree.


Dr. Stieg: 
As I thought about it. However I said, maybe we do have some experience with this. I mean, let’s, what did the telephone do us? It created the ability to speak around the world. It distanced us. It did allow us to be sitting home alone, but talking with all of our friends. How have things like that, you know, living great distances, living in a nursing home, using telephones. I mean, all of those things also tend to isolate us.


Dr. Friedman: 
In some way. Yes. But in some way, they connect us in a way that might be different than in-person visits. And my own feeling is I often would rather talk to someone on the phone as I’m talking to you, then FaceTime with them because the tech flaws and the strange things that happen when the speech and the visual images are not in sync is very strange. But on the phone, you’re likely to have a fluent conversation in some way. It’s just more familiar. We grew up with the telephone. The other thing about the phone is because you can’t see people, some people are more comfortable talking on the phone and they will reveal more about themselves on the phone. Then if they’re visually made to see you, because they feel more scrutinized and it’s like a dark room, they feel more comfortable just revealing, you know, what it is they’re thinking and feeling. It may be the opposite of what most people think.


Dr. Stieg: 
I don’t know about you, but certainly in my practice, we’ve had to do many more video visits. I found the patients actually love it. You know, they’re sitting at home in their pajamas and talking to me about whatever their problem is.


Dr. Friedman: 
I’m laughing because you know one of the problems that we’ve always had in psychiatry in the clinic is, you know, poor attendance with some patients, you know, they make an appointment, but they don’t show. The no show rate is almost zero now because they’re home, they’re isolated.


Dr. Friedman: 
They want contact and they have no barrier to getting to their appointment. They just have to pick up the phone or turn on the computer. So the no show rate is practically zero.


Dr. Stieg: 
So you’re basically stating that video visits and zooming is positive in terms of the practice of medicine.


Dr. Friedman: 
I think so for psychiatry, it’s a little tricky just with new patients and many patients prefer in, in person visits, but it goes along with risk preferences. My patients who are older, have no desire to come to see me in the hospital. They’re perfectly content to be up in their house, wherever it is, and connect with me on, on Zoom, where it’s safe and easy. And I think it will change medicine for the near future. I think we’re going to do more telemedicine than we did in the past. And probably that’s a good thing. It extends our extends our reach and makes it easier for people.


Dr. Stieg: 
What physical effects should they be worried about or trying to manage, particularly in regard to brain health and heart health?

Dr. Friedman: I think if it’s transient loneliness, they don’t need to worry. I don’t want people worrying unnecessarily about a little loneliness, but if it goes on for weeks and weeks and they experience emotional stress, meaning that it’s getting in the chronic range, then it’s unhealthy for cardiac health. Then it’s not great for cognitive health. Although the cognitive effects are in adults reversible. So I don’t think that they need to worry so much about not feeling so sharp when they’re socially isolated.


Dr. Stieg: 
I was thinking about asking the question, can someone die from loneliness? But as you’ve described it, I would think not. But I’m thinking a little bit more about, I’ve been married for 70 years. My loved one dies. And I’m sure this is not an uncommon phenomena that that individual passes on within a year or so shortly thereafter. Is that loneliness or is that something else?

Dr. Friedman: Oh, that’s one of the great mysteries of life. How, yes, I think it’s, there’s no question that, you know, when you’re so attached to another human being and you lose them, that’s grief and loneliness. And there isn’t any question. I mean, it’s just, it’s part of so much clinical evidence that when people lose loved ones, they’re at a much higher risk of grief, anxiety, depression, and mortality. And you hear that all the time. I’ve seen it in my grandparents who were married for 65 years in completely healthy. When one died, my grandmother got pneumonia two months later, was a vibrant, healthy person at 98, and was dead within a month.


Dr. Stieg: 
Any suggestions on what to do in that scenario as a family member, I would presume the individual is consumed so they can’t manage it so well. So what can we have family members do?


Dr. Friedman: 
The only thing to do? You know, what the real cure for grief is? It’s love. You have to surround people with social connection and soothe them and do your best to make them feel loved and cared for and acknowledged that it’s a terrible, terrible blow. And that things will never be the same again. And hopefully you’ll relieve them of some of their grief, but you may not be able to stop that.

Dr. Stieg: Listening to you. I’m thinking wouldn’t love be a solution to a lot of the social problems we’re having right now, if everybody could just introduce some of that into their lives?

Dr. Friedman: Yes, or at least some of them.


Dr. Stieg: 
I see that I’m lonely. I feel that I’m lonely. I want to do something about it. Who do I go to? Do I go to a pastor priest, rabbi, psychologist, psychiatrist? Just go to friends and do group talk? What’s the best thing to do?

Dr. Friedman: Well, the first thing is to recognize that you’re unhappy because you’re alone and not to medicalize it. I wouldn’t go rushing off to a doctor, much less a psychiatrist. I would go rushing off to my friends and I’d first ask myself, “Well, I’ve been feeling lonely. What happened? What changed? Did I lose my connection to my friends? Have I ignored them? Have I been not calling them back? Have I not initiated things? Did I do something to alienate people so that I’m not connected to them? What happened?” I would think about that first. And then I would start calling up friends and making social dates and doing things.


Dr. Stieg: 
It sounds to me like the important factor in loneliness, not pathologic loneliness, but loneliness is that we as individuals have insight into our loneliness versus other psychological disorders where you lose insight into what’s really going on. And that’s what distinguishes loneliness from other issues, correct?


Dr. Friedman: 
Yes. You usually, when you’re lonely, know why you feel bad, whereas often when you’re anxious or depressed, you may not actually know the reason why that’s happened.


Dr. Stieg: 
I want to give people hope. “I’m lonely. I do something about it. I get some help, whatever.” What’s the likelihood that you’re going to get better?

Dr. Friedman: Oh, the prognosis is excellent because the remedy for most people is readily available and easy. It’s called social interaction.


Dr. Stieg:
 It’s really helpful for all of us to know that it’s a passing phenomena and as the COVID passes, so will this sense of loneliness. Thank you so much for enlightening us.

Dr. Friedman: A pleasure, Phil.