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Addressing Loneliness in Complex PTSD

Dagan, Yael, MD*; Yager, Joel, MD

The Journal of Nervous and Mental Disease: June 2019 - Volume 207 - Issue 6 - p 433–439
doi: 10.1097/NMD.0000000000000992
Original Articles

Loneliness impacts both physical and psychological health and is associated with increases of all-cause mortality and suicidal behavior. Because loneliness may result from a variety of developmental, interpersonal, and intrapersonal factors, distinguishing its components, origins, and sustaining factors as it manifests in various psychopathological states are important steps in formulating interventions to alleviate these conditions. To date, loneliness has not been widely studied in relation to complex posttraumatic stress disorder (PTSD), which is newly delineated in the International Classification of Diseases, characterized by PTSD symptoms in the context of significant early trauma, as well as “disturbances in self-organization” marked by affective dysregulation, negative self-concept, and disturbances in relationships. In this article, illustrating with case material, we suggest that loneliness plays a major role in the development of complex PTSD and in the preservation of its symptoms. Consequently, therapies for complex PTSD should include interventions that address loneliness.

*Jerusalem Mental Health Center, Kfar Shaul Psychiatric Hospital, The Hebrew University–Hadassah School of Medicine, Jerusalem, Israel; and

Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado.

Send reprint requests to Yael Dagan, MD, Jerusalem Mental Health Center, Kfar Shaul Psychiatric Hospital, The Hebrew University–Hadassah School of Medicine, Givat Shaul, Jerusalem 91060, Israel. E-mail:

Online date: May 3, 2019

The need to belong, a fundamental component of human motivation and behavior, affects our thoughts and emotions, and drives us to maintain positive, long-lasting interpersonal relationships (Baumeister and Leary, 1995; Rokach, 1989). In attachment theory, this need initially relate to a child's relationship with the mother, who provides physical care (handling) and emotional support (holding). Later in life, these attachments ordinarily expand to friends, romantic partners, group leaders, or supervisors, and through these paths, attachments to work organizations, religious groups, civic groups, or political groups (Bowlby, 1969). When the need to belong is thwarted, its lack of fulfillment may lead to feelings of loneliness.

The pervasive deleterious impacts of loneliness on physical and psychological health, estimated to chronically afflict about nine million British citizens (Jopling, 2017), have stimulated sufficient public health concern to result in the appointment of Britain's Undersecretary for Sport and Civil Society to serve as Minister of Loneliness (Yeginsu, 2018). Public health concerns have focused on loneliness as experienced by growing aging populations (Cohen-Mansfield et al., 2016) and, conversely, on loneliness induced by extensive use of social media among adolescences and young adults (Berryman et al., 2018).

Loneliness is likely to be even more of a problem for individuals suffering from psychiatric disorders, many of which are associated with poor interpersonal relationships, both prior to and consequent to the onset of specific disorders. Although such loneliness might be considered a “nonspecific” accompaniment to psychiatric disorders, in fact, we believe that it can serve as a specific agent in the pathogenesis and sustainability of psychiatric disorders. In this article, we propose to examine loneliness in the context of a specific psychiatric disorder where its presence is particularly prominent—complex posttraumatic stress disorder (PTSD), a disorder recently delineated in the International Classification of Diseases (ICD-11), whose concept was first introduced by Judith Herman (Herman, 1992) who also described the “utter aloneness” of the patients' self-perception. Using case material, we suggest that loneliness plays a major role in the development of complex PTSD, in preserving and sustaining its symptoms, and, in some cases, impeding progress in psychotherapy. Consequently, the treatment of complex PTSD should include interventions that address loneliness.

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The following cases offer clinical context for the major role of loneliness in the treatment of patients with complex PTSD; both patients have histories of childhood sexual abuse, which strongly correlates with this diagnosis (Herman, 1992):

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Case 1

Mr. A., a 32-year-old Israeli man with complex PTSD and major depression, was admitted to a closed psychiatric ward because of suicidal ideation several months after the death of his wife in an accidental fire. As children, he and his sisters were physically and sexually abused by their father. When one of his sisters finally disclosed the abuse as adolescent and the father was sent to therapy, his mother kept supporting the abusive father. Mr. A. disconnected from his family at the age of 21 years and thereafter rarely responded to their attempts to contact him.

Mr. A.'s complex PTSD symptoms included vivid dreams, avoiding places or people that reminded him of the traumas, hypervigilance, and difficulties regulating his emotions; he used cannabis and alcohol several times weekly to mitigate his emotional pain and to help him fall asleep. Expelled from high school for low academic achievements (difficulties concentrating in class due to hypervigilance and irritability) and behavioral difficulties (disregarding religious school rules he saw as meaningless because he connected religiosity with his father's immoral behavior), he felt generally worthless. He felt disconnected from people in general and had virtually no friends until meeting his wife at the age of 22 years. After his wife's death, he isolated himself, withdrawing from the world; his mood deteriorated significantly to the point where he stayed in bed continuously and stopped eating.

When his employer eventually insisted that he should seek psychiatric assessment, he was admitted. After treatment with venlafaxine 300 mg/d, quetiapine 200 mg/d, and psychotherapy, his depressive symptoms gradually improved, and he became less suicidal; however, for nearly 2 months, he refused to leave the hospital for even a short walk or overnight pass, feeling there was nothing or no one in the world to which or to whom he could feel connected.

In psychotherapy, he described being lonely, feeling disconnected from his mother and sisters from early childhood onward, since being secretly abused by his father. When his family moved to another city, he felt even lonelier; he was forced to leave the only teacher who he felt could understand him. Enrolled in a series of religious boarding high schools, he felt not only lonely but disconnected from his religion as well. Assigned to a combat unit during mandatory army service, he was defined as a “lonely soldier,” receiving extra support from the army's social services. The only times he did not feel lonely were when he was with his wife. She had also suffered childhood abuse from a mother who was diagnosed with schizophrenia.

After his wife's death, Mr. A. was convinced that his future life would be irrevocably lonely, a vision he abhorred. He kept trying to convince his therapist to give up on him and let him leave the ward and end his life. However, in contrast to how he experienced his emotionally inattentive mother and then his wife after her demise, his therapist refused to abandon him, gradually awakening the hope that he might not be completely alone in the world and that he might be able to accept help from another person. Because the relatively brief course of psychotherapy possible during inpatient stays, emphasis was given to short-term cognitive-behavior interventions, exploring symptoms of his complex traumas and discussing possible methods for affective regulation as alternatives to cannabis or alcohol. Cognitive biases toward low self-esteem were challenged, and his feelings of loneliness were identified, validated, and put in context, given his life traumatic experiences and his maternal neglect. Talking about the special connection he had with his wife allowed him to start expressing deep grief and anger about her loss, and once again, reflect on his feelings of loneliness. With interventions, mostly behavioral activation for depression, he started leaving the hospital for nature walks and visits to restaurants or museums, almost always by himself.

Although his depressive symptoms improved, his feelings of loneliness and alienation, which tend to be more tenacious (Zanarini et al., 2007), still significantly affected his ability to connect with people outside the ward, impairing his motivations to rent his own place, and even to secure the financial and psychological support to which he was entitled as a widower. Only after the therapy addressed and challenged his specific feelings of loneliness, which were linked to his thoughts and feelings of being unattractive, unlovable, and socially incompetent, and also toward perceiving other people as untrustworthy, uninteresting, and unsupportive, was he able to even imagine the possibilities of ever perceiving the future more realistically or hoping that he might feel connected to people again. With progress in these areas, he became more open to contacting a new outpatient treatment team (consisting of a social worker-treatment coordinator and counselors who supported psychiatric patients in their own community-based apartments); with their assistance, he rented an apartment, went back to school, and completed a preparatory program. Later that year, he was accepted to law school, and for the first time in his life, he felt somewhat proud of himself and worthy. Nevertheless, still feeling very lonely in his apartment, he returned to alcohol and cannabis use to avoid the pains of loneliness and to fall asleep.

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Case 2

Ms. B., a 24-year-old woman with complex PTSD and bulimia nervosa, was hospitalized more than 10 times in her early 20s because of self-mutilation and frank suicide attempts. Physically abused by her father and sexually abused by an older brother from ages 13 to 18 years, she was raised in a close ultraorthodox community, always surrounded by family and friends. Although the family was aware of the brother's predatory behaviors and tried to send him away to study, the abuse continued and the family never sought professional help, concerned about their reputation along with the children's chances for decent marital matches, which might be damaged if the abuse was revealed in their closed religious community.

Twice admitted to an eating disorder unit for bulimia nervosa during adolescence, at age 17 years, Ms. B. first disclosed the abuse during a hospitalization, but she was released back home since her parents denied it. After several repeated suicide attempts and failed attempts at outpatient treatment at the age of 18 years, she ran away from her parents' house. For a while, she lived with religious families willing to host her, but once she turned secular and rejected religion, these families would no longer accommodate her, at which time she lost all connection with her family and friends; they ritually mourned her as dead, an accepted practice in ultraorthodox families when a family member decides to leave religious life.

Now essentially shunned, Ms. B. felt profoundly lonely. At age 20 years, unable to maintain relationships with her new academic preparatory school dormitory apartment roommates due to almost daily bulimic episodes, and grappling with ongoing self-mutilation and abuse of several prescription medications, she was admitted to a special unit for sexually abused women diagnosed with complex PTSD. Treatment in this unit consisted of group therapy related to the trauma, dialectical behavioral therapy (DBT) skills group, individual psychotherapy, and medication stabilization. With these treatments, to which was added fluoxetine 20 mg/d and quetiapine 200 mg/d to address mood instability and impulsivity (Black et al., 2014; Van den Eynde et al., 2008), her bulimic episodes and self-mutilation behaviors gradually improved, and her medication abuse was controlled. After discharge, she was able to continue twice weekly psychodynamic psychotherapy and psychiatric follow-up with staff from this unit. However, lacking support and feeling isolated and lonely in the dormitory, she was encouraged to move to a residential home offering 24/7 availability of counselors. Most of the home's residents suffered from schizophrenia. There, unanticipated, she even felt lonelier, more isolated, and inadequate—as a child in her family, in the dorms among students her own age, and now, additionally, even among people with mental disabilities. Feeling lost, desperate, and hopeless, she made a serious suicide attempt, resulting in readmission, after which she returned to live in the dormitory.

In psychotherapy, she recovered traumatic memories, gradually experienced less dissociation, and was better able to understand and reconnect to her childhood feelings of emotional distress, confusion, rage, and helplessness. Her complex relationships with her perpetrator and her parents were enacted through transference-countertransference interactions, discussed and interpreted in the consultation room, during which time she was able to work through positions often noted in abuse survivors (Davies and Frawley, 1994). These encounters allowed her to experience more trust and openness in the therapeutic relationship and within herself. However, during weekends, when most students returned home, she remained alone in the dorm rooms, experiencing strong feelings of loneliness and flare-ups of her complex PTSD symptoms (vivid dreams, flashbacks, considerable hypervigilance, and anxiety) and feelings that her room was virtually haunted by abusive figures from her family. She could not stand being alone, had great difficulty regulating her emotions, and often self-mutilated, through which she attempted to alleviate her emotional pain. During those times, although she was encouraged to use more effective DBT skills to better tolerate her distress, she also abused medications and repeatedly binged and purged. During some of these weekends, trying to regulate her emotions, she used to call or visit the nurses on the psychiatric ward to reduce feeling so lonely and helpless.

Generally distant from other students, Ms. B. considered herself to be less intelligent and less knowledgeable than the others, accepting responsibility and blame for failures and conflicts that were not her fault, taking on subservient roles similar to those she previously enacted within her family. Nevertheless, one of the male students in her study group noticed her loneliness and invited her to join him during his family visits on several weekends and vacation periods. Gradually feeling genuinely welcomed and cared for by his family, Ms. B. started spending some weekends with them even when he was not present. Although she previously had difficulties maintaining trusting and respectful relationships with host families, lying to them or by bingeing, purging, and self-mutilating during visits to their homes, this time, thanks to gaining better insight into her past behaviors in the context of her traumatic experiences, she made great efforts to respect this welcoming family and not act according to her impulses. The opportunity to spend time with them and feel their caring alleviated her loneliness.

As these aspects of loneliness were addressed, progress in treatment became easier for her. No longer having to bear long lonely nights and weekends alone, she permitted herself increased expressions of anger toward her perpetrator and grief for the loss of her family and her community. Yearning for a partner she could love and trust, she did not yet feel ready for such a relationship. However, when she subsequently encountered a gentle, patient, and understanding student who was willing to be open with her as well, she revealed her story of abuse to him; they grew close, fell in love, recently moved in together, and plan to marry. Although certain aspects in their relationship (e.g., overt expression of anger or a certain kind of physical touch) can still evoke flashbacks, anxiety, rage, and shame that are difficult to regulate, the relief of not being alone and not feeling emotionally lonely enabled her to process distressing material that emerged in therapy, feel increasingly safe and self-contained, and achieve substantial progress.

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Situating Loneliness as a Psychological Condition

Phenomenologically linked to alienation, loneliness can be defined as a condition in which a “sense of apartness and distance is accompanied by feelings of pain and discomfort regardless of the reality of being alone” (Greene and Kaplan, 1978). Important qualities of loneliness are the juxtaposed psychic discomforts resulting from being alone conjoined with unfulfilled cravings for closeness with others.

Three dimensions of loneliness have been described (Cacioppo et al., 2015; Weiss, 1974): intimate loneliness occurs when one is aware and uncomfortable about the absence of a significant other, an individual who can be relied on for emotional support during crises and who affirms one's value as a person; relational loneliness occurs when one is aware and uncomfortable about the absence of friendships or family connections with partners whom we see regularly and who can provide emotional and instrumental support; collective loneliness occurs when one is aware and uncomfortable about the absence of the social networks wherein the individual can connect to similar others based on shared values or fields of interest (school, team, religious). In all instances, degrees of discomfort can range from mild to extreme anguish.

Impulsive behaviors might also occur as maladaptive, ineffective, and frequently self-defeating attempts to combat loneliness. As our cases demonstrate, loneliness is related to negative affective states (desperation, depression, boredom, and self-deprecation), cognitive biases toward low self-esteem (being inferior, worthless, unattractive, unlovable, and socially incompetent), and cognitive biases toward perceiving others unfavorably (less trustworthy, less supportive, and less socially desirable (Heinrich and Gullone, 2006). These inclinations may lead individuals to perceive others as hostile or unaffectionate and to cope passively and ineffectively with their loneliness (Weiss, 1974), diminishing the likelihood of creating meaningful personal connections that might alleviate loneliness. These emotions, cognitions, and coping mechanism become tenacious as loneliness is experienced as a chronic stable trait (Heinrich and Gullone, 2006).

With regard to negative health consequences, loneliness has been associated with impaired immunity, for instance, less increase in natural killer cells in response to stress (Steptoe et al., 2004) and less increase in antibodies in response to vaccination (Pressman et al., 2005), increase in cardiovascular health risks (body mass index, systolic blood pressure, cholesterol levels (Caspi et al., 2006; Hawkley et al., 2010; Richard et al., 2017; Shiovitz-Ezra and Parag, 2018), cardiovascular morbidity (Olsen et al., 1991; Valtorta et al., 2016), and increases in overall morbidity and all-cause mortality (Rico-Uribe et al., 2018; Shiovitz-Ezra and Ayalon, 2010; Stickley and Koyanagi, 2018).

In relation to psychopathology, loneliness predicts increases in depressive symptoms (Beutel et al., 2017; Cacioppo et al., 2006; Richard et al., 2017), sleep disturbances (Cacioppo et al., 2002; Kurina et al., 2011), and cognitive decline in patients with Alzheimer disease (Wilson et al., 2007). Furthermore, loneliness is an independent significant risk factor for suicidal behavior, not necessarily mediated by depression or other common mental disorders (Li et al., 2016; Stickley and Koyanagi, 2016; Stravynski and Boyer, 2001). In British general population surveys comparing individuals reporting strong feelings of loneliness versus not feeling lonely, the odds ratios for past 12 months or lifetime suicide attempts among lonely individuals were 3.45 and 17.37, respectively. Moreover, similarly elevated odds ratios for engaging in suicidal behavior have been reported in lonely individuals with no common mental disorders compared with individuals with common mental disorders who were not lonely, suggesting that loneliness might contribute equivalently to mental disorders to increased risk for suicidal behavior (Stickley and Koyanagi, 2016).

Finally, loneliness is distinguished from the aloneness of solitude, in which the isolated individual enjoys being alone without suffering from a lack of ongoing contact (Perlman and Peplau, 1982). Further, some socially isolated individuals, even hermits, can feel enveloped, nurtured, loved, and protected by an introjected pseudo-community, or, spiritually, by a sense of closeness with God, angels, saints, and so on.

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Loneliness and Trauma

Connections between loneliness and trauma have been studied in veteran populations, where difficulties in sharing traumatic experiences can potentially lead to feelings of alienation and loneliness (Stein and Tuval-Mashiach, 2015). PTSD specifically is associated with loneliness in various veterans' populations, an association consistently observed even many years after the traumatic experience (Solomon et al., 2008). For instance, in the National Health and Resilience in Veterans study, loneliness was associated with PTSD, whereas social support, secure attachment, and being married were negatively associated with loneliness (Kuwert et al., 2014). Furthermore, the link between posttraumatic stress symptoms and marital adjustment in veterans was found to be mediated by feelings of loneliness, and even secure pattern of attachment did not moderate the influence of loneliness (Itzhaky et al., 2017). These findings suggest that a well-established, strong sense of loneliness and isolation in trauma survivors can interfere with the ability to adjust to marriage; obviously, for a variety of reasons, individuals can feel lonely even within marriage. Data from this study also showed associations between combat service, PTSD, and suicidal ideation in elderly veterans (Fanning and Pietrzak, 2013), a population in which co-occurrence of PTSD and loneliness might be especially synergistic in contributing to poor health and increased risk of suicide. We can assume that these findings might similarly apply to other trauma survivors who typically experience difficulties in sharing stories about their traumas and the aftermaths.

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Complex Posttraumatic Stress Disorder

Complex PTSD, a disorder now recognized in the 2018 ICD-11, is characterized by PTSD symptoms (re-experiencing, nightmares, avoidance, startle, hypervigilance) originating in the context of significant early trauma, to which are added “disturbances in self-organization” marked by affective dysregulation, negative self-concept, and disturbances in relationships (Karatzias et al., 2017a). Complex PTSD may develop after exposure to an event or series of extremely threatening or horrific, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g., torture, prolonged domestic violence, repeated childhood sexual, or physical abuse) (World Health Organization, 2018).

Women exposed to physical and sexual abuse in childhood or adolescence are especially vulnerable, as exposure to multiple forms of interpersonal childhood trauma increases risk to development of complex PTSD symptoms and suicidal behaviors (Herman, 1992; Hyland et al., 2017). Addressing the complex clinical symptoms as complex PTSD, as opposed to borderline personality disorder, reduces stigma and judgment and enables clinicians to better treat the patients focusing on the interpersonal traumatic events they have experienced (Herman, 1992). Furthermore, women who were sexually abused in childhood are lonelier and less likely to use their social network to obtain support compared with women who were not abused (Gibson and Hartshorne, 1996). Longer period of abuse and multiple abuse incidents correlate with stronger feelings of loneliness and reduced likelihood to use social networks. Notably, in this study, abused women receiving treatment in special trauma centers were exposed to more frequent incidents and longer period of past abuse, and were significantly lonelier than abused women who were not in treatment; these findings are consistent with the possibility that more severe abuse leads to greater difficulties in trust, less use of social support, stronger feelings of loneliness, and greater impetus to seek treatment.

Among women exposed to physical or sexual abuse before the age of 14 years or to a recent interpersonal crime, appraisals of alienation including “I feel lonely,” “Even though I have friends, I still feel lonely,” and “I am disconnected from people” correlated significantly with PTSD symptoms severity as well as with higher dissociation and depression scores (DePrince et al., 2011).

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How Might Loneliness Interact With Complex PTSD?

Based on previous literature and our own clinical observations, we conjecture that loneliness and complex PTSD appear to interact iteratively, each capable of reinforcing the other, via deleterious, mutually enhancing feedback cycles.

Loneliness acts as both a mediator and as a moderator for complex PTSD. As a mediator, loneliness constitutes a vulnerability factor that increases an individual's risk of being victimized and targeted by predators who contribute to trauma burdens, furthering complex PTSD. For instance, our patient Ms. B. was exposed to much more sexual harassments at periods when she was lonely, searching for a place to live, compared with other times in her life. As a moderator, loneliness can impede the ability of patients to constructively address challenges imposed by complex PTSD. We and others have repeatedly observed that lonely patients who are simultaneously emotionally incapable of seeking and/or successfully engaging social support, for instance, lacking physical companionship at night while feeling lonely and unsafe, may experience increased hypervigilance (Cacioppo and Hawkley, 2009), resulting in difficulty falling asleep and greater re-experiencing of the traumas and associated distress. Decreased capacity to access helpful and caring others to help regulate emotional distress can increase the risks of reckless behaviors, as shown in our second case. In some patients, deficient mentalization may be associated with emotional dysregulation and contribute to experiences of lonely alienation. Combinations of loneliness compounded with socially avoidant coping patterns typical in complex PTSD decrease possibilities for positive behaviorally activating experiences, reinforcing and further contributing to negative self-concepts, depressive symptoms, suicidal ideation, and self-harming behaviors (Amir et al., 1999).

Concurrently complex PTSD can make loneliness worse and diminish patients' abilities to cope with loneliness. Patients who experienced childhood abuse have experienced the most horrific betrayal from a close trusted person, and as a result would find it difficult to trust people and feel safe again. Disturbed relationships, as reflected in the ICD-11 Trauma Questionnaire (Karatzias et al., 2017b), manifested by feeling distant from people, difficulty in staying close to people, and tendencies to avoid relationships because they end up being painful, are clearly connected to the patients' difficulty to trust and feel safe, but at the same time contribute to greater social isolation and feelings of loneliness. In addition, symptoms of emotional dysregulation such as experiencing intense reactions, requiring long periods to calm down, being easily hurt, and feeling uncontrollable anger (expressions of the hyperactivation pattern of dysregulation) or being numb and shut down (expressions of the deactivation pattern) also contribute to adversities in relationships that lead to loneliness. Negative self-concept and inadequate feelings of shame and guilt along with exaggerated startle and hypervigilance and avoidant coping patterns can also contribute to patients' loneliness.

Patients with complex PTSD often face all three dimensions of loneliness (Cacioppo et al., 2015; Weiss, 1974). In complex PTSD, intimate loneliness (concerning the absence of a significant other one can rely on for emotional support and affirmation during crises) might result from difficulties of trusting and being open after abuse and betrayal by significant caregivers who were presumably responsible for health and welfare in the past, who were either abusers, or who failed to stop abuse. Internalization of deleterious object relations experienced in times of abuse, often reenacted within intimate relationships later in life, may lead to instability and potential challenges for both survivor and her partner. In addition, intimate relationships that ordinarily involve sex might be particularly intimidating for trauma survivors (Bigras et al., 2015; Rellini et al., 2012). Relational loneliness (concerning the absence of friendships or family connections with regularly seen individuals who can provide emotional and instrumental support) in patients with complex PTSD often results from dynamics developed around disclosure of the abuse. Children who disclose their traumatic experiences, especially sexual abuse, to a significant caregiver within a close circle of family or friends too often do not get the support or protection they expect (Ullman, 2003). They might face blatant denials, be accused of fantasizing or lying about what happened, or even be blamed for the events. The inability of caregivers or other family members to acknowledge the assault and support the child can lead to severe rifts between trauma survivors and their families later in life as in our cases; treatment-seeking patients with complex PTSD often feel isolated from their families (Lew, 1988). Finally, we often see collective loneliness (concerning alienation from social networks that ordinarily connect individuals with like-minded others based on shared values or fields of interest as in school, team, civic, and religious groups) in patients with complex PTSD as abandoning their families and leaving offensive surroundings often keeps them apart from their broader social and religious environments. Concurrently, the avoidance and hypervigilance seen in PTSD together with low self-esteem and perceiving other people unfavorably prevent patients from participating in social activities that could potentially involve them in new social networks.

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Treatment Approaches Targeting Loneliness in Complex PTSD

Given that loneliness includes elements of psychic pain, social isolation, and anxiety, biological perspectives suggest that administration of selective serotonin reuptake inhibitors (SSRIs) might be at least symptomatically beneficial. In animal studies, for example, SSRIs have improved behavior effects of social isolation, anxiety-like behavior, and fear response through elevated corticolimbic levels of allopregananolone (ALLO) and brain-derived neurotrophic factor mRNA expression (Mayo-Wilson et al., 2014; Pinna, 2010); the neurosteroid ALLO plays a major role in a few physiological processes involved in loneliness such as exaggerated fear response, hypothalamic-pituitary-adrenal (HPA) dysfunction, and impaired hippocampal neurogenesis (Cacioppo et al., 2015). Animal studies involving oxytocin, a hypothalamic neuropeptide highly linked with social affiliation processes, attachment, social support, and trust, have led to suggestions that oxytocin might potentially benefit physiological and emotional changes associated with loneliness (Grippo et al., 2009). Similarly, in the context of early-life trauma, SSRI treatment was found to reverse some persistent neurobiological effects, such as overstimulation of the HPA axis associated with increased corticotrophin-releasing hormone secretion and reduced hippocampal volume (Heim et al., 2010; Nemeroff and Vale, 2005), and lower cerebrospinal fluid oxytocin levels were found in women who experienced childhood abuse (Heim et al., 2009), suggesting common pathways to the influence of childhood abuse and loneliness. However, in contrast to beneficial effects of SSRIs in adults with histories of childhood abuse, oxytocin has failed to show benefits in either animal or human studies, and even reportedly exacerbated symptoms of anxiety and depression (Toepfer et al., 2017).

Psychotherapeutically, findings that lonely individuals (compared with nonlonely people) have lower self-worth, tend to blame themselves as social failures, approach social encounters with greater distrust, and expect to be rejected have suggested that loneliness should be approached via a focus on these maladaptive social cognitions. In this regard, a study contrasting intervention strategies for loneliness found that addressing maladaptive social cognitions had a larger effect size on reducing loneliness compared with other suggested interventions such as improving social skills, enhancing social support, and increasing opportunities for social contact (Masi et al., 2011). Because those very same maladaptive cognitions are characteristic of complex PTSD per the new criteria, similar interventions might be worthwhile for these patients as well. Notably, several of the social skills mentioned here are addressed in DBT, a well-established evidence-based treatment for emotionally dysregulated patients who often suffer from complex PTSD and its variants (Hempel et al., 2018; Wilks et al., 2016).

From the perspective of Interpersonal Psychoanalytic theory, Sullivan described loneliness as an “exceedingly unpleasant and driving experience connected with inadequate discharge of the need for human intimacy, for interpersonal intimacy” (Sullivan, 1953); this perspective was further elaborated by Fromm-Reichmann: “The longing for interpersonal intimacy stays with every human being from infancy throughout life; and there is no human being who is not threatened by its loss” (Fromm-Reichmann, 1959).

Why are people so pained by loneliness? Buechler suggested that the experience of aloneness is shaped, partially, “by who we are with when we are alone” (Buechler, 2012), in other words by the nature and quality of internal object relationships we experience when we are alone. The internal object relationships in patients with complex PTSD can be intimidating and offensive, provoking feelings of terror, shame, and guilt; thus, being alone with those internal objects can naturally lead to feelings of loneliness and substantial distress. Facing those internal relationships and their enactments in therapy, processing their complexities, and dealing with their consequences on other relationships in one's life generally require longer processes and strong psychotherapeutic relationships. When intimate and relational loneliness are prominent and the individual lacks external emotional and social supports, attempting such processes in psychotherapy is extremely difficult and odds of ineffective therapy increase.

Other psychotherapeutic approaches potentially addressing loneliness that might assist patients with complex PTSD can include interpersonal psychotherapy (Markowitz et al., 2017), acceptance and commitment therapies (Woidneck et al., 2014), existentially oriented psychotherapies (Popescu, 2015; Stolorow, 2015) and, as tolerated, PTSD-oriented prolonged exposure therapies (Hendriks et al., 2018), eye movement desensitization and reprocessing (Chen et al., 2018), and their combination (Van Woudenberg et al., 2018).

Furthermore, as patients develop emotional capacity, increasing benefits can be obtained from social network interventions such as support groups and behavioral activations using psychosocial clubs, self-help groups, mutual help groups, and even interacting with trained volunteers (Perese and Wolf, 2005). For some, service animals—therapeutic pets—are useful for alleviating loneliness and for helping individuals construct better capacities for attachments with humans (Friedman and Krause-Parello, 2018).

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Loneliness impacts both physical and psychological health and is associated with increases of all-cause mortality and suicidal behavior. To date, loneliness has not been widely studied in the context of complex PTSD, a disorder now recognized in ICD-11. We suggest that loneliness plays a major role in the development of complex PTSD and in the preservation of its symptoms. Consequently, interventions used in the treatment of complex PTSD should specifically address experiences of loneliness and their interactions with the multiple cognitive and emotional features of these conditions.

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The authors declare no conflict of interest.

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Loneliness; trauma; complex PTSD; psychotherapy; interventions

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