Loneliness in Psychosis: A Meta-analytical Review

Beata Michalska da Rocha; Stephen Rhodes; Eleni Vasilopoulou; Paul Hutton


Schizophr Bull. 2018;44(1):114-125. 

In This Article

Abstract and Introduction


Loneliness may be related to psychotic symptoms but a comprehensive synthesis of the literature in this area is lacking. The primary aim of the current study is to provide a systematic review and meta-analysis of the association between loneliness and psychotic symptoms in people with psychosis. A search of electronic databases was conducted (PsychINFO, MEDLINE, EMBASE, and Web of Science). A random effects meta-analysis was used to compute a pooled estimate of the correlation between loneliness and psychotic symptoms. Study and outcome quality were assessed using adapted versions of the Agency for Healthcare Research and Quality (AHRQ) tool and GRADE approach, respectively. Thirteen studies were included, providing data from 15 647 participants. A moderate association between psychosis and loneliness was observed (k = 13, N = 15 647, r = .32, 95% CI 0.20, 0.44; I 2 = 97.56%; moderate quality evidence). Whether loneliness was assessed by a single-item or a more comprehensive measure had no moderating effect on the estimate. Results indicate that there is a significant positive relationship between loneliness and psychosis. Further studies are needed to determine the causal status of this relationship, but this robust finding should be considered in clinical practice and treatment provision for those with psychotic disorders.


People with psychotic disorders frequently feel lonely and many expect to be lonely in the future.[1] Stain et al[2] report that as many as 80% of adults with a diagnosis of psychosis in Australia endorsed feeling lonely in the past 12 months. People with psychosis often struggle to develop and preserve functioning relationships, have limited social networks and restricted access to social support outside of what is provided by mental health services.[3,4]

Although feelings of loneliness and social isolation are generally thought to reflect the negative impact of psychotic experiences,[5] more recently it has been reported that loneliness may also play a causal role in the development of psychotic experiences.[6] A self-perpetuating cycle of exclusion may develop, whereby the disorder limits connections and support, which then leads to a removal of important buffers, thereby increasing risk of relapse and causing an escalation of psychotic episodes, further social disengagement, and so forth.[7]

The majority of studies examining social support in psychosis have concentrated on quantitative features of the social network such as size and reciprocity instead of more functional aspects such as loneliness or satisfaction with relationships.[7] This is of particular relevance, as objective features of social support are related but distinct from these more subjective aspects of social relationships. Loneliness is an unpleasant and distressing experience resulting from a perceived deficiency in the quantity or quality of one's social relationships.[8] While social isolation can be measured objectively, loneliness is a subjective emotional state of the individual, which may be present in individuals with large social networks, and absent in isolated individuals with minimal social contact.[9]

Loneliness has been associated with depression and suicide ideation,[10] lower life satisfaction,[11] elevated blood pressure levels,[12] increased stress hormone levels,[13] and compromised immune system.[14] Loneliness has also been related to an increased tendency to experience subclinical and clinical hallucinations[15,16] and to nonclinical paranoid thinking.[17,18] Interested readers may consult Hawkley and Cacioppo for a comprehensive review of loneliness.[19]

There are several possible mechanisms linking loneliness to psychotic symptoms such as hallucinations. For example, loneliness may directly increase anxiety and depression[10] which in turn may exacerbate symptoms of psychosis.[20] Loneliness may also perpetuate negative beliefs about oneself and other people, which may in turn increase the frequency of paranoid thoughts. Another pathway may involve "anthropomorphism," whereby social isolation and feelings of loneliness might lead to increased human agency detection in one's immediate environment, therefore increasing likelihood of hearing voices or perceiving human agency in nonhuman stimuli.[21] This relationship may also work in the other direction, whereby psychotic symptoms lead one to experience feelings of exclusion and stigma, which in turn increases likelihood of feeling lonely. Some authors report case-studies where hallucinating patients actually perceived their imaginary companions as helpful in managing their sense of loneliness.[22] Similar findings have been reported with otherwise healthy children who have imaginary companions.

Although there has been much focus on the co-occurrence of loneliness and psychosis, their relationship is still unclear. While there is a consensus that loneliness is a prominent feature in psychosis, some researchers report correlations near zero between psychotic symptoms and loneliness.[23] Additionally, while some authors report a high prevalence of loneliness in people with psychosis,[15] this conclusion is often derived from a single-item measure of loneliness, rather than a valid and reliable instrument, which might lead to confusion and limited replicability of studies. There also appears to be no gold standard in regards to how single-item measures are conceptualized and interpreted, with various authors asking for feelings of loneliness across the past week, past 2 weeks or past 12 months, or taking a measure of the number of "lonely days in a week." Some researchers divide Likert scale measures of loneliness into a dichotomous measure, while others keep it as a continuous variable.

Improving our understanding of the relationship between psychosis and loneliness has important theoretical and practical implications. In order to design effective interventions for loneliness, and potentially enable services to best organize their resources to support the wellbeing of individuals with psychosis, a deeper understanding of the nature of loneliness and its impact on mental functioning in this population is needed. An important first step is to provide a definitive estimate of the magnitude of the relationship, taking into account study quality. Whether the results depend on the way loneliness is measured is also important to consider, both for interpreting the available evidence and for planning future research. Therefore, the primary aim of the current study is to provide a systematic review and meta-analysis of the association between loneliness and psychotic symptoms in people with psychosis.