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Loneliness in patients with somatic symptom disorder

  • Anique E.C.C. Vos , Ellen M.M. Jongen EMAIL logo , Anja J.H.C. van den Hout and Jacques J.D.M. van Lankveld
Published/Copyright: December 16, 2022
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 23 Issue 2

Abstract

Objectives

Patients with somatoform disorders often experience loneliness. They feel misunderstood and socially rejected. Whereas loneliness is related to several medical conditions, social support can minimize loneliness. In the current study, differences in loneliness and the evaluation of social support between patients with Somatic Symptom Disorder (SSD) and healthy controls were investigated using standardized questionnaires. In addition, the relation between loneliness and somatic symptoms was investigated.

Methods

In a cross-sectional study design, a group of patients with SSD (n=75) was compared to a healthy control group (n=112). It was hypothesized that [1] patients with SSD experience more loneliness and evaluate their social support more negatively than healthy controls and [2] loneliness will correlate positively with experienced somatic symptoms.

Results

In comparison to healthy controls, patients with SSD experienced more loneliness and their evaluation of social support was more negative. In addition, loneliness correlated positively with the degree of experienced somatic symptoms.

Conclusions

Patients with SSD experienced lower social support, more loneliness, and across the two groups loneliness was positively associated with somatic symptoms. Effect sizes were all large. Therefore, these results may have implications for the treatment of SSD.

Keywords: loneliness; mental health; social support; somatic symptom disorder; somatic symptoms

Introduction

Patients with medically unexplained somatic symptoms are quite prevalent: in primary healthcare one in three somatic symptoms are medically unexplained, and in secondary healthcare these numbers are even higher [1], [2], [3]. Whereas medically unexplained somatic symptoms fell under the diagnosis of ‘somatoform disorders’ in the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV), in the 5th Edition (DSM-5) these symptoms fall under the diagnosis ‘somatic symptom and related disorders (SSD)’ [4, 5]. Patients who experience medically unexplained somatic symptoms tend to persist in searching for an explanation or treatment of their symptoms by visiting different medical doctors. This may lead not only to an extensive burden on health care resources [6], but also involves a significant burden on an individual level, with feelings of misunderstanding, social rejection, and loneliness [7], [8], [9], [10], [11]. These patients run a larger chance for being socially excluded, because other people tend to see the absence of a medical explanation as deviant [12, 13]. Not only in their own social environment, but also in healthcare, stigmatization can occur. In addition to the lack of an explanation for the symptoms, the invisibility of the symptoms also plays a role in the difficulty with acceptance and understanding by others. This decreases patients’ perceived social support whereas it increases the chance of loneliness. Importantly, loneliness, social support, and health are strongly interrelated [14].

Loneliness can be defined as an unpleasant feeling when a discrepancy is experienced between the desired and the actual social network of a person [15]. The quantity and/or the quality of one’s social relationships do not match one’s needs [16, 17]. The problem of loneliness is of growing global concern [18]. In The Netherlands, a high prevalence of loneliness has been found. In 2016, 43% of the adult population (19 years and older) indicated to be lonely, 10% experienced severe loneliness, based on a questionnaire filled in by 457,153 Dutch citizens [19]. Loneliness has been associated with poorer health and several medical issues. People who feel lonely have a greater probability to develop heart diseases than people who feel socially connected. Loneliness has also been shown a risk factor for the development of chronic pain, depression, and fatigue, which are common symptoms in SSD [14, 20], [21], [22], [23].

Social support has been associated with better health and can minimize loneliness [24, 25]. The Social Support Theory of Cohen [26] explains the relation between social support and well-being. First, being part of a social network provides positive experiences and stable, socially rewarding roles. Second, a social network enables resources to respond to the needs of a person during stressful events. Social epidemiology has shown that, among others, the absence of positive social relationships is a significant risk factor for broad-based morbidity and mortality.

Although loneliness is a risk factor for developing and maintaining somatic symptoms, it is unclear how loneliness is related to SSD. The question arises whether the experience of loneliness is higher in patients with SSD compared to the healthy population. In the current study, differences in loneliness and the subjective evaluation of social support between patients with SSD and healthy controls were investigated using standardized questionnaires. It was hypothesized that [1] patients with SSD experience more loneliness and evaluate their social support more negatively in comparison to healthy controls and [2] the degree of loneliness will correlate positively with the degree of experienced somatic symptoms.

Methods

Design

In a cross-sectional design, patients with SSD and healthy controls were compared with regard to their average level of loneliness and their evaluation of the current social support they experience.

Participants

Participants for the SSD group were recruited at the department of Clinical and Medical Psychology of Zuyderland Medical Center. Participants in the SSD-group had to meet the DSM-5 criteria of a SSD. Recruitment took place directly after an SSD diagnosis was established. Participants for the healthy control group were recruited in the general population. A diagnosis of a mental disorder during participation was an exclusion criterion for the healthy control group. Participation in the study occurred on a voluntary basis and informed consent was obtained before enrollment. Both men and women were included if having an age of at least 18 years and sufficient understanding of the spoken and written Dutch language. A medical history of psychosis or bipolar disorder, substance abuse, and cognitive impairment that hampers understanding of the questionnaires, were exclusion criteria for all participants. There was no compensation for participation.

Procedure

All participants of the study were asked to fill in the informed consent. Then four questionnaires, the HADS-NL, the SCL-90, the De Jong Gierveld Loneliness scale and the SSL were presented. The SSD-group could complete these as part of the diagnostics within the intake procedure. In the control group this happened at home.

Materials

Demographic variables

Demographic variables of gender (male or female), age, marital status (single, living together, married, long distance relationship), work status (working, not working, student or retired), and educational status based on Verhage [27, 28] were collected.

Symptom Checklist 90 (SCL-90)

The Dutch version of the Symptom Checklist-90 [29] is a self-assessment scale for psychopathology. It consists of 90 descriptions of complaints. The participant must indicate to what extent he or she suffered these complaints in the last week. A five-point scale is used (0. Not at all, 1. A little bit, 2. Moderately, 3. Quite a bit, 4. Extremely). The total score gives an indication of the overall level of mental and somatic dysfunctioning. The higher the score, the more mental and somatic dysfunctioning. In this study, both the total score and the subscale Somatic complaints will be used. Research has revealed a Cronbach’s alpha of 0.93 for the total scale [30], [31], [32]. In the current study, a Cronbach’s alpha of 0.99 was found for the total scale. For the subscale Somatic complaints, a Cronbach’s alpha of 0.93 was found.

Hospital Anxiety and Depression Scale (HADS-NL)

The Dutch version of the Hospital Anxiety and Depression Scale is a self-report screening scale to indicate the possible presence of anxiety and depression. It consists of 14 items in total, 7 to measure depression and 7 to measure anxiety. On a four-points scale (0–3), people can indicate the extent to which an item matches their feeling of the past week. A score of 8–10 indicates a possible depression and/or anxiety disorder and calls for alertness. A score above 11 indicates a suspected depression and/or anxiety disorder. Research has found a Cronbach’s alpha of 0.71–0.90 [33], [34], [35]. In current research, a Cronbach’s alpha of 0.95 was found for the total score. A Cronbach’s alpha of 0.91 was found for the anxiety scale and 0.93 for the depression scale.

De Jong Gierveld Lonelinessscale

The de Jong Gierveld Loneliness scale [36], [37], [38] consists of 11 items to measure overall, emotional and social loneliness. The scale consists of five positively worded statements and six negatively formulated statements. Not agreeing with the positively worded statements and agreeing with the negatively formulated statements is considered indicative for the experience of loneliness Each item is scored on a five-points scale (yes!, yes, more or less, no, no!). The neutral and positive answer (yes!, yes, more or less) on item 2,3,5,6,9 and 10 count as one point. The neutral and negative answers on item 1, 4, 7, 8,and 11 (more or less, no, no!) count as one point. Summation of the answers on the 11 items provides a score between 0 and 11. The higher the score, the lonelier someone is. A score of 3 to 9 indicates a moderate level of loneliness, and a score of 9 or higher means a severe level of loneliness. The total score of the scale will be used. The psychometric properties of this questionnaire have proven to be valid and reliable. The scale’s reliability ranges between 0.80 and 0.90 (Cronbach’s alpha [36]). In the current study, a Cronbach’s alpha of 0.90 was found.

Social Support List – Interactions (SSL-I) and Social Support List – Discrepancies (SSL-D)

The Social Support List – Interactions and Social Support List – Discrepancies [39] consist of 34 items. For the statistical analyses of current study, the SSL-D items were used. The SSL-D measures the extent to which the obtained support corresponds with the need of the respondent. These items are also rated on a four-points scale with the following options: 1. I miss, I would like more, 2. I do not really miss, but it would be nice if it happened more often, 3. Just right like that; I would not want it more or less often, 4. Happens too often; it would be nice if it happened less often. The sum scores indicates the extent to which the respondent experiences shortages in social support. The higher the score, the more lack of support is experienced. The psychometric properties of both lists are satisfactory. Previous research has shown a Cronbach’s alpha of 0.83 was found [40]. In the current study, for the subscale SSL-D, a Cronbach’s alpha 0.94 was found.

Statistical analyses

The Statistical Package for Social Science (SPSS, version 26.0) was used to perform statistical analyses. p-value was set at 0.05 to determine statistical significance. First, outlier analyses were conducted. Outliers were defined as individuals scoring more than three standard deviations from the mean on two or more variables. To evaluate whether the SSD-group and healthy controls were similar in terms of age, and other demographic variables, an independent t-test and chi-square analyses were conducted, respectively. In addition, to evaluate whether the SSD-group and healthy controls were similar in terms of psychological variables, ANOVAs were conducted on HADS anxiety, HADS depression, and SCL total score. Partial eta squares were computed as measures of effect size. Hypothesis 1 was tested using a MANOVA, and in case of significant main effects, post hoc univariate tests were performed. Partial eta square was again computed as a measure of effect size. Hypothesis 2 was investigated using linear regression analysis, including somatic complaints as dependent variable and overall loneliness as predictor variable. R Square was computed as a measure of effect size.

Results

Participants

See Tables 1 and 2 for descriptive statistics on demographic variables and psychological variables of both groups, respectively. In total, 187 of the 199 participants met the inclusion criteria, consisting of 75 patients with SSD and 112 healthy controls. The groups differed significantly on the SCL-90 total score, indicating that on a summarized measure of mental and physical dysfunctioning, the group of patients scored higher than the group of controls. More specifically, a comparison of the results of both groups with normative scores showed that 53% of the scores of SSD patients were ‘above average’ or ‘high’ on the level of dysfunctioning compared to 17% of the control group [29]. In addition, anxiety and depression scores on the HADS-NL showed a suspected anxiety disorder (score above 11) in 64% of the SSD patients compared to 2% of the control group, and a possible anxiety disorder (score between 8 and 10) in 20% compared to 9%. Finally, a suspected depression was found in 56% of the SSD patients compared to 1% of the control group, and a possible depression disorder in 23% compared to 3%. Effect sizes for the group differences of anxiety, depression and SCL-90 total were all large (>0.14).

Table 1:

Demographic variables of both groups.

Patients with SSD (n=75) Controls (n=112) Statistics
M SD M SD t p-Value
Age 45.15 12.50 41.54 13.87 1.80 0.07
n % n % X2 p-Value
Gender 0.01 0.92
 Male 28 37.3 41 36.6
 Female 47 62.7 71 63.4
Educational status 55.31 ≤0.001
 3 5 6.7 0 0
 4 8 10.7 3 2.7
 5 45 60.0 26 23.2
 6 14 18.7 37 33.0
 7 3 4.0 46 41.1
Marital status 8.70 0.034
 Single 29 38.7 23 20.5
 Living together 11 14.7 25 22.3
 Married 33 44.0 56 50.00
 LDR 2 2.7 8 7.1
Working status 78.34 ≤0.0001
 Working 27 36.0 98 87.5
 Not working (incapacitated) 12 16.0 0 0
 Not working (sickness law) 26 34.7 0 0
 Student 4 5.3 11 9.8
 Retired 6 8.0 3 2.7
Table 2:

Psychological variables of both groups; univariate statistics on estimated marginal means.

Patients with SSD (n=75) Controls (n=112) Statistics Partial eta squared
HADS-NL M SE M SE F p-Value
Anxiety disorder 12.0 0.41 4.0 0.34 225.8 ≤0.001 0.55
Depression 11.3 0.41 2.1 0.34 300.0 ≤0.001 0.62
SCL-90
Total score 222.7 5.2 112.1 4.2 272.6 ≤0.001 0.60

In the group of patients, no outliers were found. The control group showed two outliers. A comparison of the statistical analyses with and without these outliers, showed that these outliers did not affect the results significantly. Therefore, these individuals were included in the current study. Patients and healthy controls were comparable with regard to gender and age. Differences were found regarding marital status, work status, and educational status as SSD patients showed a higher frequency of being single, living alone, and being unemployed and had a lower educational level than controls.

Hypotheses testing

The results of the MANOVA showed a significant main effect of Group (Pillai’s trace F(2, 184)=47.5, p<0.001). Univariate statistics are reported in Table 3. As hypothesized, there was a significant difference between the group of patients with SSD and the control group on the De Jong Gierveld Loneliness scale and the SSL-D, indicating that the group of SSD patients experience more loneliness and a more negative evaluation of their social support, compared with the control group. Effect sizes for both loneliness and social support were large (>0.14). Results of the linear regression analysis are reported in Table 4. Results showed that loneliness was positively associated with somatic complaints, with a large effect size (B=2.24, p<0.001, R=0.66).

Table 3:

Between group differences in trait loneliness and social support; univariate statistics on estimated marginal means.

Patients with SSD (n=75) Controls (n=112) Statistics Partial eta squared
De Jong- Gierveld Eenzaamheidsschaal M SE M SE F p-Value
Total score 5.1 0.32 1.1 0.26 94.7 ≤0.001 0.34
SSL-D
Total score 52.5 1.3 41.1 1.1 44.4 ≤0.001 0.19
Table 4:

Results of the linear regression analysis.

Dependent variable R 2 Predictor B β 95% CI for B
Somatic complaints 0.44 Overall loneliness 2.24 0.662 1.87–2.60

  1. R 2, explained variance; B, unstandardized beta-coefficient; B, standardized beta-coefficient.

Discussion

In the current study, group differences between patients with SSD and healthy controls in the experience of loneliness, mental and physical dysfunctioning, and the evaluation of their social support were investigated. In addition, the relation between loneliness and somatic symptoms was investigated. As hypothesized, SSD patients showed a higher level of loneliness than healthy controls. More specifically, the level of patients’ scores could be categorized as moderate vs. the absence of loneliness in the control group. In line with previous research showing a relation between loneliness and physical and mental health [7], [8], [9], [10], [11, 41, 42], our results also revealed a strong relation between loneliness and mental and physical dysfunctioning. In addition, the results indicated a higher level of overall mental and physical dysfunctioning for SSD patients compared to controls. Whereas a suspected anxiety or depression was an exception in the control group, it was present in more than half of the SSD group. Also, current research can prove a strong relation between loneliness and somatic symptoms. With regard to depression a causal relationship was found between loneliness and depression [43]. With regard to SSD, prospective research is necessary to gain more insight into the causal relationship between loneliness and somatic complaints. A previous study [43] showed that social support had an important contribution in the relation between loneliness and depression.

The current results showed that SSD patients evaluated their social support as more negatively than the healthy control group. In the literature it has been described in what way such negative evaluations might actually affect feelings of loneliness. In social situations, lonely people tend to feel unsafe and develop alertness for social threat. This alertness has various consequences that contribute to the feeling of being lonely. First, it makes people perceive the world as more threatening relative to non-lonely people. Second, it makes people expect more negative social interactions. Lastly, it makes people remember more negative social information. Therefore, lonely people tend to keep a distance from possible social partners; they believe that the cause of the social distance is attributable to others and beyond their control [16, 17]. So, the way lonely people think about their environment might actually maintain feelings of loneliness. An important criterion for diagnosing SSD is the maladaptive response to the somatic symptoms, involving excessive thoughts, emotions and behavior [4]. Loneliness has been related to maladaptive thinking as well. More specifically, lonely people tend to feel worse when they are sick in comparison to non-lonely people [44]. Furthermore, feeling lonely may propel individuals into a spiral of maladaptive thinking about pain and poor coping with their pain as the day goes on [45].

Altogether, these results demonstrate the importance of investigating loneliness when treating SSD. It could be one of the maintaining factors in SSD that hamper recovery. A diagnostic model for SSD is the Consequence Model based on the cognitive behavioral theory, in which the current somatic symptom, ideas about the somatic symptom and the consequences are mapped [46]. The consequences are split up into emotional, behavioral, physical and social consequences. Furthermore, attention is given to cognitive restructuring, changing patterns of avoidance behavior and learning new coping skills. CBT also appears to be an appropriate treatment to reduce loneliness [47]. Our results support the conclusion to broaden the focus of CBT in a SSD treatment and incorporate loneliness.

Limitations and future research

Limitations of the current research are the observed group differences in marital status, work status, and educational status. Because living alone, unemployment and a lower education level have been associated with loneliness [48, 49], group differences in loneliness may be partly due to these demographic differences. Whether SSD and loneliness are directly related or rather mediated by the social consequences of SSD, such as living alone or being unemployed, remains unanswered. Given the cross sectional design, conducting mediation analyses was not valid now, and would lead to biased conclusions [50]. Similarly, group differences were not entered as covariates in the analysis, because group membership was determined nonrandomly [51]. In the case of mediation, besides treating SSD, efforts should also be taken to change the social consequences of SSD in order to diminish loneliness. A prospective study in newly diagnosed SSDs could give a deeper insight into such a mediation hypothesis.

Further research is necessary to determine the direction of the relation between loneliness and somatic symptoms. An observational design using ESM (experience sampling method) could additionally determine whether there are fluctuations of loneliness and somatic symptoms during the day and elucidate more about the relation between loneliness and somatic symptoms.

Further research might also shed more light on the specific type of loneliness when investigating group differences between SSD patients and controls and the relation to somatic complaints. In the current study, in line with the idea of loneliness as a unitary construct, one measure of loneliness was used, referring to the discrepancy in quality and/or quantity of relations [15]. In addition to this summarized measure of loneliness, social and emotional loneliness can be discriminated [52]. As for social loneliness, this refers to the feeling of missing a wider social network. Emotional loneliness refers to the perceived lack of an intimate relationship. As described before, patients with SSD often experience feelings of misunderstanding and social rejection [7], [8], [9], [10], [11], and stigmatization can occur. The results of the current paper indeed show lower perceived social support in the group of patients. Therefore it may be expected that especially social loneliness is responsible for group differences in loneliness between the patient group and healthy controls, and is related to somatic complaints. Future research may further shed light on this. Apart from gaining theoretical insights, this will be relevant for intervention development [53].

Corresponding author: Ellen M.M. Jongen, Open University, Postbus 2960 6401DLHeerlen, The Netherlands, E-mail:

Acknowledgements

The authors acknowledge C. M. Vergeer and Eva Lena (Evelien) de Kam for their help in collecting the data of the control group.

  1. Research funding: Authors state no funding involved.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent has been obtained from all individuals included in this study.

  5. Ethical considerations: The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Zuyderland and Zuyderland Hogeschool (protocol code NL657669.096.18, 26 July 2018).

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Received: 2022-04-11
Accepted: 2022-11-27
Published Online: 2022-12-16
Published in Print: 2023-04-25

© 2022 Walter de Gruyter GmbH, Berlin/Boston

Articles in the same Issue

  1. Frontmatter
  2. Editorial Comment
  3. Chronic pain and health inequalities: why we need to act
  4. Systematic Reviews
  5. Resilience as a protective factor in face of pain symptomatology, disability and psychological outcomes in adult chronic pain populations: a scoping review
  6. Is intravenous magnesium sulphate a suitable adjuvant in postoperative pain management? – A critical and systematic review of methodology in randomized controlled trials
  7. Topical Review
  8. Pain assessment 3 × 3: a clinical reasoning framework for healthcare professionals
  9. Clinical Pain Researches
  10. The treatment lottery of chronic back pain? A case series at a multidisciplinary pain centre
  11. Parameters of anger as related to sensory-affective components of pain
  12. Loneliness in patients with somatic symptom disorder
  13. The development and measurement properties of the Dutch version of the fear-avoidance components scale (FACS-D) in persons with chronic musculoskeletal pain
  14. Observational Studies
  15. Can interoceptive sensitivity provide information on the difference in the perceptual mechanisms of recurrent and chronic pain? Part I. A retrospective clinical study related to multidimensional pain assessment
  16. Distress intolerance and pain catastrophizing as mediating variables in PTSD and chronic noncancer pain comorbidity
  17. Stress-induced headache in the general working population is moderated by the NRCAM rs2300043 genotype
  18. Does poor sleep quality lead to increased low back pain the following day?
  19. “I had already tried that before going to the doctor” – exploring adolescents’ with knee pain perspectives on ‘wait and see’ as a management strategy in primary care; a study with brief semi-structured qualitative interviews
  20. Problematic opioid use among osteoarthritis patients with chronic post-operative pain after joint replacement: analyses from the BISCUITS study
  21. Worst pain intensity and opioid intake during the early postoperative period were not associated with moderate-severe pain 12 months after total knee arthroplasty – a longitudinal study
  22. Original Experimentals
  23. How gender affects the decoding of facial expressions of pain
  24. A simple, bed-side tool to assess evoked pressure pain intensity
  25. Effects of psychosocial stress and performance feedback on pain processing and its correlation with subjective and neuroendocrine parameters
  26. Participatory research: a Priority Setting Partnership for chronic musculoskeletal pain in Denmark
  27. Educational Case Report
  28. Hypophosphatasia as a plausible cause of vitamin B6 associated mouth pain: a case-report
  29. Short Communications
  30. Pain “chronification”: what is the problem with this model?
  31. Korsakoff syndrome and altered pain perception: a search of underlying neural mechanisms
https://doi.org/10.1515/sjpain-2022-0057
Keywords for this article
loneliness; mental health; social support; somatic symptom disorder; somatic symptoms

Articles in the same Issue

  1. Frontmatter
  2. Editorial Comment
  3. Chronic pain and health inequalities: why we need to act
  4. Systematic Reviews
  5. Resilience as a protective factor in face of pain symptomatology, disability and psychological outcomes in adult chronic pain populations: a scoping review
  6. Is intravenous magnesium sulphate a suitable adjuvant in postoperative pain management? – A critical and systematic review of methodology in randomized controlled trials
  7. Topical Review
  8. Pain assessment 3 × 3: a clinical reasoning framework for healthcare professionals
  9. Clinical Pain Researches
  10. The treatment lottery of chronic back pain? A case series at a multidisciplinary pain centre
  11. Parameters of anger as related to sensory-affective components of pain
  12. Loneliness in patients with somatic symptom disorder
  13. The development and measurement properties of the Dutch version of the fear-avoidance components scale (FACS-D) in persons with chronic musculoskeletal pain
  14. Observational Studies
  15. Can interoceptive sensitivity provide information on the difference in the perceptual mechanisms of recurrent and chronic pain? Part I. A retrospective clinical study related to multidimensional pain assessment
  16. Distress intolerance and pain catastrophizing as mediating variables in PTSD and chronic noncancer pain comorbidity
  17. Stress-induced headache in the general working population is moderated by the NRCAM rs2300043 genotype
  18. Does poor sleep quality lead to increased low back pain the following day?
  19. “I had already tried that before going to the doctor” – exploring adolescents’ with knee pain perspectives on ‘wait and see’ as a management strategy in primary care; a study with brief semi-structured qualitative interviews
  20. Problematic opioid use among osteoarthritis patients with chronic post-operative pain after joint replacement: analyses from the BISCUITS study
  21. Worst pain intensity and opioid intake during the early postoperative period were not associated with moderate-severe pain 12 months after total knee arthroplasty – a longitudinal study
  22. Original Experimentals
  23. How gender affects the decoding of facial expressions of pain
  24. A simple, bed-side tool to assess evoked pressure pain intensity
  25. Effects of psychosocial stress and performance feedback on pain processing and its correlation with subjective and neuroendocrine parameters
  26. Participatory research: a Priority Setting Partnership for chronic musculoskeletal pain in Denmark
  27. Educational Case Report
  28. Hypophosphatasia as a plausible cause of vitamin B6 associated mouth pain: a case-report
  29. Short Communications
  30. Pain “chronification”: what is the problem with this model?
  31. Korsakoff syndrome and altered pain perception: a search of underlying neural mechanisms
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