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Social Isolation and Health

Chapter for The Wiley Encyclopedia of Health Psychology

Mona Moieni, M.A. & Naomi I. Eisenberger, Ph.D.

Abstract: Decades of research have examined the relationship between social

isolation and health. In this entry, we discuss the impact of social isolation on

physical health, mental health, and mortality. We also outline some potential

behavioral, psychological, and biological mechanisms behind these relationships.

Finally, we discuss some interventions that have been proposed for targeting

social isolation.

Keywords: Social isolation, loneliness, mental health, physical health

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“I don’t know if anyone has noticed, but I only ever write about one thing: being
alone. The fear of being alone, the desire to not be alone… the devastation of
being left alone. The need to hear the words: You are not alone.”
--Shonda Rhimes, Television writer and producer

What drives a compelling story? What pushes people to tune in each

week to watch a story unfold on their televisions? Shonda Rhimes, an award-

winning writer, producer, and creator of multiple widely successful television

shows such as Grey’s Anatomy and Scandal, revealed her secret for creating a

narrative that millions of people around the world want to follow each week:

writing about loneliness. Her answer also tapped into the idea that humans have

a “need to belong” – a fundamental need or drive to seek out and maintain social

relationships (Baumeister & Leary, 1995). It has been suggested that this desire

to connect with others is as essential to our existence as other basic needs such

as food, water, and shelter, providing us with advantages for survival

(Baumeister, Brewer, Tice, & Twenge, 2007; Baumeister & Leary, 1995).

If being social is such a crucial aspect of being human, then we would

expect that not having social relationships would be associated with

disadvantages and detrimental outcomes for our health and survival. Indeed,

decades of research support the notion that lacking social connections has

consequences for physical and mental health, including a significantly higher risk

for all-cause mortality. In this chapter, we first briefly discuss measurement

issues relevant to social isolation and then highlight health outcomes associated

with social isolation. We follow this by a discussion of mechanisms that have

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been proposed to explain the relationship between social isolation and health, as

well as consideration of interventions to reduce social isolation.

Measuring Social Isolation

Social isolation can be conceptualized in many ways. To assess whether

an individual is socially isolated, we could ask whether she is living with other

people, how often she gets together with or talks to people, or in how many

organizations or social activities (e.g., work, volunteering) she participates. These

kinds of measures that tap into an individual’s social network size are typically

referred to as measures of objective social isolation. Thus, someone who lives

alone, has few social ties, participates in few social activities, and/or has minimal

contact with others would be considered objectively socially isolated.

Rather than asking how many people comprise a person’s social network,

we could also ask about how satisfied the person is with their network by asking

them how connected they feel. We could ask them things like “How often do you

feel alone?” or “How often do you feel that your relationships with others are not

meaningful?” (Russell, 1996). These subjective feelings of social disconnection,

or loneliness, are measures of perceived or subjective social isolation.

Loneliness is distress resulting from the discrepancy between what an individual

wants out of social relationships and what he or she is receiving (Peplau &

Perlman, 1982). For example, people who say they often lack companionship,

feel isolated from others, and feel there is no one they can turn to would be

considered lonely.

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 Although these variables are related, they are separable and distinct. For

example, it is possible to imagine someone who has only one confidant (and thus

may appear socially isolated on objective measures) but feels perfectly content

and socially satiated. Conversely, someone may be surrounded by people and

participate in numerous social activities but still feel isolated or unsatisfied with

these social relationships and thus feel lonely. While it is important to note that

social isolation can be measured in numerous ways, this chapter covers the

effects of isolation on health regardless of the way it was measured.

Impact of Social Isolation on Health

Starting with Berkman and Syme (1979) and House and colleagues

(1982) and continuing through today, decades of work have documented the

impact of social isolation on morbidity and mortality. In fact, social isolation is a

mortality risk factor comparable to traditional risk factors such as smoking or

obesity (Holt-Lunstad, Smith, Baker, Harris, & Stephenson, 2015; Holt-Lunstad,

Smith, & Layton, 2010). Interestingly, a recent meta-analysis also found that

there was no difference between objective and subjective measures of social

isolation in terms of predicting mortality risk (Holt-Lunstad et al., 2015),

suggesting that social isolation is a powerful predictor of mortality regardless of

how it is measured.

In addition to mortality, social isolation is related to lower levels of self-

rated physical health (Cornwell & Waite, 2009), risk of cardiovascular disease

(Caspi, Harrington, Moffitt, Milne, & Poulton, 2006), elevated blood pressure

(Hawkley, Thisted, Masi, & Cacioppo, 2010), risk of poor outcomes post-stroke

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(Boden-Albala, Litwak, Elkind, Rundek, & Sacco, 2005), metabolic syndrome

(Horsten, Mittleman, Wamala, Schenck-Gustafsson, & Orth-Gomér, 1999),

increased frequency of doctor visits (Qualter et al., 2013), and functional decline

and disability (Perissinotto, Cenzer, & Covinsky, 2012).

There are also many associations between social isolation, in particular

subjective social isolation or loneliness, and mental health. Loneliness is

associated with depressive symptoms (J. T. Cacioppo, Hughes, Waite, Hawkley,

& Thisted, 2006), suicidal ideation (Stravynski & Boyer, 2001), social anxiety

(Anderson & Harvey, 1988), substance abuse (Åkerlind & Hörnquist, 1992),

eating disorders (Coric & Murstein, 1993), and psychosis (Deniro, 1995).

Loneliness is also related to poorer cognitive performance (J. T. Cacioppo &

Hawkley, 2009), cognitive decline (Shankar, Hamer, McMunn, & Steptoe, 2013),

and increased risk of Alzheimer’s Disease (Wilson et al., 2007).

Potential Mechanisms

Overall, social isolation is associated with a wide array of mental and

physical health issues, as well as mortality. Many mechanisms have been

proposed to explain the relationship between social isolation and adverse health

outcomes. We briefly outline some of the theorized behavioral, psychological,

and biological mechanisms below. Although we discuss these mechanisms

separately for ease of presentation, in reality one mechanism is unlikely to fully

explain the complex relationships between social isolation and health. These

proposed pathways, along with other mechanisms not mentioned here, likely

interact with and build off each other.

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 Behavioral

Health behaviors have been discussed as potential pathways through

which social isolation can impact health (Hawkley & Cacioppo, 2010; Taylor,

2011; Thoits, 2011). For example, friends and family can help individuals start

and maintain healthy habits, and they can also provide meaning in life, which can

have a positive impact on health behaviors (Thoits, 2011). Socially isolated

individuals may thus be at risk for poor health outcomes in part because they are

lacking a significant source of modeling of good health behaviors and a sense of

purpose related to having close relationships.

Additionally, loneliness may impair executive control and self-regulation

(Hawkley & Cacioppo, 2010), which could have a direct impact on health

behaviors such as substance use, physical activity, and eating behavior. Indeed,

social isolation is related to smoking and drinking more (Broman, 1993), and

there also appears to be a relationship between loneliness and alcohol abuse

(Åkerlind & Hörnquist, 1992). In addition to substance use, loneliness is related

to obesity. Lonely individuals are more likely to be overweight than non-lonely

individuals (Lauder, Mummery, Jones, & Caperchione, 2006). Furthermore,

feeling disconnected can also impair self-control over eating behavior

(Baumeister, DeWall, Ciarocco, & Twenge, 2005), and loneliness is predictive of

reductions in physical activity (Hawkley, Thisted, & Cacioppo, 2009).

Sleep is another behavior that may be a potential mechanism through

which social isolation can impact health. Loneliness is related to poor sleep

quality throughout the lifespan (reviewed in Hawkley & Capitanio, 2015), and it is

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also associated with fatigue and low energy (Hawkley, Preacher, & Cacioppo,

2010; Jaremka, Fagundes, Glaser, et al., 2013). Given the importance of sleep

for health and mortality (Irwin, 2015), this may be another behavior that may

partially explain the social isolation-health association.

Psychological

Many potential psychological mediators of the social ties-health link have

also been proposed (Hawkley & Cacioppo, 2010; Thoits, 2011; Uchino, Bowen,

Carlisle, & Birmingham, 2012). One psychological mechanism that has been

proposed is maladaptive social cognition. That is, lonely individuals may have

certain social cognitive biases, such as generally seeing the world as a more

socially threatening place, which may set off a vicious, self-feeding cycle of

psychobiological reactions that may ultimately contribute to poor health outcomes

(Hawkley & Cacioppo, 2010). Socially isolated individuals may also lack the

sense of purpose or meaning in life that is provided by social connection, which

can lead to impairments in psychological well-being and physical health (Thoits,

2011). Those who are isolated may also lack socially supportive others who may

“buffer” the impact of stressful life events on well-being and health (Cohen &

Wills, 1985).

Besides these mechanisms, some other proposed psychological

mediators explaining the impact of social isolation on health include positive

affect, social influence, self-efficacy, and self-esteem (Thoits, 2011; Uchino et al.,

2012). However, some have found that existing models of psychological

mechanisms linking social ties to health are generally not supported by evidence

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(Uchino et al., 2012), indicating that there is still room for further research to

better understand the psychological pathways that may underlie the social

isolation-health link.

Biological

Numerous biological pathways have also been proposed to explain the

effect of social isolation on health (Eisenberger & Cole, 2012; Hawkley &

Cacioppo, 2010; Thoits, 2011; Uchino et al., 2012). For example, lonely

individuals have immune system impairments (Glaser, Kiecolt-Glaser, Speicher,

& Holliday, 1985; Pressman et al., 2005), suggesting that immune alterations

may be one pathway through which loneliness operates to damage health.

Inflammation, the body’s first line of defense against infection or injury, is

one potential immunological process through which loneliness may exert its

effects. Inflammatory processes are implicated in a wide array of physical and

mental health conditions (Coussens & Werb, 2002; Finch, 2007; Haffner, 2006;

Hansson, 2005), as well as mortality (Collaboration, 2010). Lonely individuals

have increased pro-inflammatory reactivity (Jaremka, Fagundes, Peng, et al.,

2013), as well as up-regulated pro-inflammatory gene expression (Cole et al.,

2007). This heightened inflammatory activity in lonely individuals indicates that

inflammation may be mediating some of the effects of social isolation on health.

Interestingly, inflammation can also lead to feelings of social disconnection

(Eisenberger, Inagaki, Mashal, & Irwin, 2010; Moieni et al., 2015), suggesting

that inflammation and loneliness may engage in a dangerous, mutually

reinforcing cycle.

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 Related to inflammation, loneliness may also operate through

neuroendocrine pathways. For example, lonely individuals have impairments

related to the hypothalamus-pituitary-adrenal (HPA) axis, including increased

levels of cortisol (Adam, Hawkley, Kudielka, & Cacioppo, 2006; Doane & Adam,

2010; Kiecolt-Glaser et al., 1984; Steptoe, Owen, Kunz-Ebrecht, & Brydon,

2004). Chronic social isolation may also lead to glucocorticoid insensitivity (Cole

et al., 2007; Hawkley & Cacioppo, 2010), inhibiting the ability of cortisol to have

an anti-inflammatory effect.

Finally, neural mechanisms have also been proposed to mediate the

social isolation-health link. A set of neural regions which are involved in threat

detection, including the amygdala, dorsal anterior cingulate cortex (dACC),

anterior insula, and periaqueductal gray, are thought to play a role in the

relationship between social isolation and health (Eisenberger & Cole, 2012).

These regions may serve as a neural alarm system to detect social threat (e.g.,

social isolation, social exclusion), and in turn, activation of these regions may

have an impact on HPA and sympathetic nervous system activity, ultimately

impacting health. For example, social exclusion or rejection activates the dACC

and anterior insula (Eisenberger, 2015; Eisenberger, Lieberman, & Williams,

2003). Activation of these neural regions is related to both heightened

inflammation (Slavich, Way, Eisenberger, & Taylor, 2010), which is involved in

many physical and health disorders, and cortisol (Wang et al., 2005), a hormone

involved in the body’s stress response.

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 While the existing evidence lends support to these particular biological

mechanisms, more work is needed to flesh out the details of these pathways, as

well as how they may interact with behavioral and psychological processes, to

impact health.

Interventions

Given the influence of social isolation on health, it is not surprising that

multiple types of interventions targeted at reducing social isolation have been

conducted. Interventions have included offering social skills training, social

cognitive training, mind-body interventions, opportunities for social contact or

activities, or social support programs. The mode of delivery has ranged from

group interventions to one-on-one interventions, from in-person to online, and

lasting from a few weeks to multiple years. There have been multiple reviews on

this topic (e.g., Dickens, Richards, Greaves, & Campbell, 2011; Masi, Chen,

Hawkley, & Cacioppo, 2010), so we will highlight a few examples of effective

interventions that have been tested using randomized trials.

One type of intervention that has shown positive effects on social isolation

are those promoting social support and social activities. In one study, older adults

who were randomly assigned to an intervention intended to increase peer

support and social activity showed decreases in social isolation (Routasalo,

Tilvis, Kautiainen, & Pitkala, 2009); those in the intervention group became more

socially active and found new friends significantly more often than the control

group. However, the intervention did not lead to decreases in loneliness or

increases in social network size. Other interventions have examined the effect of

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animal-assisted therapy to increase socialization and decrease loneliness (Banks

& Banks, 2002; Banks, Willoughby, & Banks, 2008). Participants who were

randomly assigned to the animal-assisted therapy group (i.e., regular visits from

a dog) showed decreases in loneliness (Banks & Banks, 2002).

Another type of intervention that has shown promise for reducing

loneliness is social cognitive training (Masi et al., 2010). For example, one study

examined the effect of “reminiscence therapy” (vs. a wait-list control) on

loneliness in nursing home patients (Chiang et al., 2010). Over the course of 8

weeks, those in the therapy condition participated in activities such as discussing

how to be more aware and expressive of feelings, identifying positive social

relationships, and recalling family history and life stories; those in this condition

showed improvements in loneliness. Although these interventions have shown

promise in reducing feelings of isolation, additional studies examining the effect

of this type of intervention, particularly in different samples (e.g., isolated

adolescents) are still needed.

Creswell et al. (2012) took yet another approach, examining the effect of a

mindfulness-based stress reduction (MBSR) training on loneliness in older

adults. They found that an 8-week MBSR program, compared to a wait-list

control, led to reductions in loneliness, as well as reductions in pro-inflammatory

gene expression. This finding suggests that other mind-body interventions may

be successful in reducing loneliness, as well as biological mechanisms such as

inflammation that may be driving some of the health effects associated with

social isolation.

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 Indeed, there is certainly room to develop additional targeted interventions

addressing social isolation based on these kinds of successful interventions.

Some have suggested that interventions that incorporate some sort of social

cognitive training are likely to be the most effective (S. Cacioppo, Grippo,

London, Goossens, & Cacioppo, 2015; Masi et al., 2010), while others have

found that interventions with a social activity or social support component, and

delivered at a group level (compared to one-on-one), may be the most effective

(Dickens et al., 2011). Still others have suggested tailoring new interventions for

particular developmental stages and thus focusing interventions on aspects of

social isolation that are most important across different times of the lifespan

(Qualter et al., 2015). Overall, it appears that testing new evidence-based

interventions, particularly using randomized trials, is an important area for future

research in this field.

Conclusion

In summary, social isolation has detrimental effects on a wide range of

physical and mental health problems, as well as mortality. Numerous

mechanisms have been proposed for the relationship between social isolation

and health, but future work is needed to more fully flesh out these pathways.

Finally, some interventions aimed at decreasing social isolation have been

successful. However, given that social isolation can have such a powerful

influence on our physical health and well-being, developing new low-cost,

effective, and easy-to-implement interventions is an important area for further

research that could ultimately have significant public health implications.

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Further Reading:

Cacioppo, S., Grippo, A. J., London, S., Goossens, L., & Cacioppo, J. T. (2015).

Loneliness Clinical Import and Interventions. Perspectives on

Psychological Science, 10(2), 238-249. doi: 10.1177/1745691615570616

Eisenberger, N. I., & Cole, S. W. (2012). Social neuroscience and health:

neurophysiological mechanisms linking social ties with physical health.

Nature neuroscience, 15(5), 669-674. doi: doi:10.1038/nn.3086

Hawkley, L. C., & Cacioppo, J. T. (2010). Loneliness matters: a theoretical and

empirical review of consequences and mechanisms. Annals of Behavioral

Medicine, 40(2), 218-227. doi: 10.1007/s12160-010-9210-8

Holt-Lunstad, J., Smith, T. B., Baker, M., Harris, T., & Stephenson, D. (2015).

Loneliness and Social Isolation as Risk Factors for Mortality A Meta-

Analytic Review. Perspectives on Psychological Science, 10(2), 227-237.

doi: 10.1177/1745691614568352

Thoits, P. A. (2011). Mechanisms linking social ties and support to physical and

mental health. Journal of Health and Social Behavior, 52(2), 145-161. doi:

10.1177/0022146510395592

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Biographical Notes:

Mona Moieni is a doctoral student in the Department of Psychology at the

University of California, Los Angeles (UCLA). Her research focuses on the

relationships between biological and social psychological processes, as well as

how these relationships may be relevant for physical and mental health.

Naomi I. Eisenberger is an Associate Professor of Psychology at the University

of California, Los Angeles (UCLA). She specializes in social neurocognitive

aspects of emotion and behavior and how these processes relate to health-

relevant biomarkers.

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