"All the Lonely People" The Beatles

Dr. Philip Grossi
Wednesday, 16 October 2013

Recently I saw a very lonely freshman college student who had come to the Bay Area from another state leaving family and high school friends behind to make her way in a new social ecosystem. That experience got me thinking about a number of papers I had read about loneliness over especially the last ten years. The first paper I read about social isolation and its effects on mortality was in the Science in the late 1980s. Following that were a steady stream of papers documenting the unhealthy changes in cardiovascular, immune, and nervous system which is undoubtedly related to the reduction in life expectancy of lonely people.  I should add that it is not the number of social contacts that is important but the subjective experience of loneliness. Feeling alone and being alone are not identical concepts.  Some people are socially isolated but don't feel lonely.

Lonely people tend to show changes in physiology, e.g., higher vascular tone leading to increased resistance to blood flow and thus imposing an added burden to cardiac function. They also tend to have higher cortisol and epinephrine levels in urine and saliva.  These are signs of an overly active sympathetic nervous system. From an evolutionary standpoint this makes good sense because it signals that the social ties to the tribe are too weak and thus one's genetic contribution is in danger (decreased fitness) because the individual has abandoned the protection of the group. So it's an aversive signal that will increase the chances of passing on the individual's genes (increased fitness). So it's adaptive in the short term but unhealthy over the long term. 

Several papers from geneticists at UCLA have demonstrated increased activity of a number of genes promoting inflammation and decreased activity of genes that retard inflammation and thus cardiovascular disease associated with inflammation. Genes affecting the immune system are also suppressed leading to increased susceptibility to viral infections.

Loneliness also has an effect on sleep.  Lonely people sleep a normal number of hours but tend to awaken unrest-ed and fatigued. They also get less enjoyment from leisure activities. Social psychologists have characterized lonely people's view of social interactions as negative and their view of others as negative. They pay more attention to negative social cues than others do.  As with other mental states, certain researchers are using MRIs and other tools to tie a specific brain region to the feeling. In this case the ventral striatum was found to be less active.

In the 2008 book, Loneliness: Human Nature and the Need for Social Connection,  John Cacioppo, the author and a social psychologist at the University of Chicago, postulated that there is a "genetic thermostat" for loneliness that has different set points in different people. He further states, "You're not inheriting loneliness; you're inheriting how painful it feels to be alone."

How does this inform me about treating patients such as the abovementioned college freshman? It leads to specific advice about lifestyle choices and further to challenge the negative view of social situations with alternative explanations which over time should result in a more positive experience.

Positive Aspects of Mental Illness

Dr. Philip Grossi
Friday, 06 September 2013

Whenever I discuss mental illness, my patients and colleagues invariably focus on the negative and harmful effects and the associated stigma.  This is especially true with regard to bipolar illness which is potentially disabling and life threatening.  What is often overlooked by professionals and public alike is that mental illness can have some positive aspects, e.g., positive emotional responses and increased achievement of ambitious goals. Other characteristics that are generally viewed as positive include spirituality, creativity, realism, resilience, and empathy.  Mitchell and Romans describe bipolar patients as more reliant on spiritual beliefs which are reported to have an influential effect on the course of illness.  Moran and Diamond have described increased empathy in depressed patients.  In spite of bipolar disorder being associated with negative financial, social, and interpersonal outcomes, a large number of patients describe positive experiences of sensitivity, alertness, productivity, social relations, sexuality, and creativity.  Akiskal et. al. who have published many articles in this area note that samples of creative individuals have an over representation of affective disorder. Cases of full blown manic depressive illness are less common.  Cyclothymic and hyperthymic temperaments abound. 

These positive psychological aspects of bipolar disorder are of importance to the public and professional community because of the relationship to social stigma and quality of life in patients suffering from major psychiatric disorders.  People with bipolar illness have to cope with their illness as well as the negative attitudes about them.  Paying attention to the positive psychological characteristics may help to secure better clinical results.




Progression in Illicit Drug Usage

Dr. Philip Grossi
Friday, 06 September 2013

Our current failure or poor success in treating drug use disorder is partially due to our poor understanding of the complex natural history and its development and change over time.  If we consider three potential transitions from non-use to asymptomatic use and to problem use and abandon the older designations of abuse and addiction, then we may more meaningfully arrive at fruitful conclusions.

Crompton et al. published recently in the American Journal of Psychiatry the findings of a study they carried out  in which they made two assessments of individuals done at three year intervals.  Less than 5% started using during the three year interval but of those over 50% had trouble at the three year follow-up. Of those asymptomatic users at the first assessment, 66% had stopped at follow-up while 20% progressed to problem usage.  Of the problem users at baseline, 49% had stopped at the three year follow-up, 40% returned to problem usage, and 11% became asymptomatic users.

A variety of factors appear to influence transitions.  Drug initiation appears to be linked to younger age, alcohol and nicotine usage and major depressive disorder.  Drug initiation progression to problem usage seems related to lack of health insurance, poor physical and psychological health, and a family history of substance abuse.  Higher persistent drug abuse is associated with child abuse and schizotypal and narcissistic personality disorders. 

The study demonstrates that the course of drug use and problem use is influenced by factors at many levels including sociodemographic, family history of substance use, history of child abuse, current physical/psychological health and psychopathology.