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Loneliness, warmth-seeking behavior, and posttraumatic stress among survivors of the Sichuan earthquake.

Loneliness has been described as a complex set of feelings that occur when intimate and social needs are not adequately met, characterized by feelings of social pain and isolation (Russell, Peplau, & Cutrona, 1980). Following the 2008 Sichuan earthquake, posttraumatic stress disorder (PTSD), a debilitating mental disorder, has received increased attention from mental health professionals in China. Loneliness is one of the most common symptoms described by people diagnosed with PTSD (Baumeister, Twenge, & Nuss, 2002), especially for those who had been exposed to a serious natural disaster and experienced the loss of close family members (Andrews, Brewin, & Rose, 2003). The influence of loneliness on chronic PTSD symptoms has gained increased attention. The mechanisms by which loneliness impacts chronic PTSD symptoms have yet to be determined, in part because the physiological effects of loneliness, including excessive stress reactivity and inadequate physiological repair processes, persist over a relatively long time period (Hawkley, Burleson, Berntson, & Cacioppo, 2003). Another possible factor contributing to this complexity is that the social nature of loneliness may play a role in mediating the link between PTSD and impaired social function, such as adjustment in the marital relationship, following trauma (Solomon & Dekel, 2008).

It should be noted that the question of how people diagnosed with PTSD may be predisposed to developing loneliness has been investigated in few empirical studies. An improved understanding of the relationship between loneliness and current PTSD symptoms would be helpful not only for predicting loneliness in people receiving treatment for PTSD, but also for providing support for therapies that promote loneliness-alleviating skills in the treatment of PTSD. A newly developed five-factor dysphoric arousal model (Elhai & Palmieri, 2011) has been created to account for current PTSD symptoms in people exposed to various traumatic events. Recent findings suggest that the five-factor dysphoric arousal model accurately represents PTSD symptom structures (Pietrzak, Tsai, Harpaz-Rotem, Whealin, & Southwick, 2012; Wang, Long, Li, & Armour, 2011). Considering that loneliness is strongly associated with distress and depression, it is reasonable to speculate that loneliness may occur as a result of depression- related PTSD symptoms. This supposition forms the hypothesis in the present study.

Loneliness, as a complex psychological experience, is partially dependent upon physical sensations (e.g., cold; Fay & Maner, 2012; Steinmetz & Mussweiler, 2011). Priming loneliness through the recall of an experience involving social exclusion has been shown to lead to an individual giving a lower estimation of room temperature as well as feeling an increased desire for warm foods, in comparison with the recall of an experience of social inclusion (Zhong & Leonardelli, 2008). Higher levels of chronic loneliness have been found to be associated with an increased tendency to take warm baths (Bargh & Shalev, 2012). Experiencing physical warmth promotes interpersonal warmth, and people tend to self-regulate their feelings of personal warmth through the application of physical warmth (Steinmetz & Mussweiler, 2011; Williams & Bargh, 2008). Although these findings in studies of healthy populations have consistently provided support for the relationship between loneliness, physical coldness, and warmth-seeking behavior, the theoretical and empirical approaches used have not been designed to be applicable to clinical populations. Considering the impact of physical warmth on interpersonal warmth and the paramount importance of interpersonal warmth in the recovery from PTSD, as shown in clinical research (see e.g., Rafaeli & Markowitz, 2011), we believe it is important to examine the relationships among loneliness, physical coldness, and the tendency to seek physical warmth. Our aim was to shed new light on improved therapy methods for PTSD, such as the application of physical warmth. We hypothesized that feelings of loneliness would be strongly associated with physical coldness and would precipitate physical warmth-seeking behavior in people diagnosed with PTSD, represented by an increased affinity for warm, rather than cold, food or drinks.

Method

Participants

We recruited 73 participants from a psychology workstation clinic established by the Institute of Psychology, Chinese Academy of Sciences, in the Deyan district, an area severely damaged by the Sichuan earthquake. All participants had been directly exposed to the earthquake. The protocol for this study was approved by the International Review Board of the Institute of Psychology, Chinese Academy of Sciences.

Among the participants, 50.7% (n = 37) had been diagnosed with PTSD, 23 (62.16%) of whom were female, with ages ranging from 25 to 60 years (M = 46.49, SD = 1.12); and 49.3% (n = 36) were non-PTSD control participants, 21 (58.33%) of whom were female, with ages ranging from 25 to 60 years (M = 42.81, SD = 1.20). Inclusion criteria for the PTSD group included a) diagnosis of PTSD according to the Mini International Neuropsychiatric Interview (Sheehan et al., 1998) following evaluation by an experienced psychiatrist, b) the PTSD Checklist Stressor Specific Version (PCL-S; Weathers, Litz, Herman, Huaka, & Keane, 1993) scale scores greater than 35, c) level of education above elementary school, and d) the absence of comorbid physical diseases. A chi square test and an independent samples t test conducted to examine differences between the PTSD and the control groups in terms of gender, age, and educational levels, revealed no significant differences between the groups across these variables.

The control participants were recruited from individuals who presented at the clinic for free physical examinations. These participants completed the UCLA Loneliness Scale (Russell, 1996), but time limitations did not allow for their participation in temperature evaluation experiments. This lack of data for the control participants hampered our ability to draw strong conclusions regarding the relationship between loneliness and perceptions of physical coldness among the PTSD patients. To address this problem, PTSD patients were divided randomly into two groups for the temperature evaluation experiment: the priming-loneliness condition group (PLP, n = 19) and the nonpriming-loneliness condition group (NPLP, n = 18). We then compared temperature evaluation variables between these two PTSD groups.

Measures

The PCL-S (Weathers et al., 1993) consists of 17 items that correspond directly to PTSD symptom criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994), with each item yielding a score from 1 (not at all) to 5 (extremely). For the Chinese version (Yang, Yang, Liu, & Yang, 2007), the internal consistency (Cronbach's [alpha] = 0.77) was sufficient.

The short version of the UCLA Loneliness Scale (Russell, 1996) consists of 20 items and was developed for use with adult populations. Each item is rated on a 4-point Likert-type scale with anchors of 1 (not at all) and 4 (always) and higher overall scores reflect a greater degree of loneliness. For the Chinese version, a high internal consistency (Cronbach's a = 0.92) and test-retest reliability (12-week internal, r = 0.74) for the total scale have been reported (Li, Jiang, & Li, 2006).

The Warmth-Seeking Rating Scale (Zhong & Leonardelli, 2008) is a 4-item self-report measure. In our study, one item was a warm drink (hot soup), and the other three at room temperature included two control foods (apple and cookie) and a control drink (cola). Each item was rated on a 7-point Likert scale ranging from 1 (extremely undesirable) to 7 (extremely desirable), reflecting the extent to which the food or drink item was preferable to the respondent.

Procedure

After giving their informed consent, participants in the control group completed questionnaires regarding demographic variables as well as the UCLA Loneliness Scale. According to Hicks, Schlegel, and King (2010), who utilized a lexical decision task, the term loneliness was successfully primed with words such as alone, lonely, outcast, isolated, and abandoned. Therefore, some of the negative words or sentences described in the UCLA Loneliness Scale may serve as a catalyst to feeling lonely. The PLP PTSD group first completed the UCLA Loneliness Scale to prime loneliness and subsequently completed the temperature evaluation experiment. The converse protocol was used for the NPLP PTSD group, members of which took part in the temperature evaluation experiment prior to completing the UCLA Loneliness Scale. The experiment room was air conditioned with the temperature set to 24[degrees]C. The actual indoor temperature was measured with a thermometer. Participants' temperature estimates ranged from 12 to 40[degrees]C.

Data Analysis

The statistical analysis was performed using SPSS version 17.0 for Windows. Results from the control and PTSD groups were compared using independent samples t tests. Differences between the estimated and real room temperature in the PTSD groups were compared using paired samples t tests. One-way analysis of variance (ANOVA) was used for the warm food/drink desirability analysis in the PTSD groups. Regression analysis was used to examine which PTSD symptom structures from the three aforementioned models could account for differences in loneliness. Statistical significance was set at p < .05.

Results

Differences in Loneliness Between the PTSD and Control Groups

As expected, the PTSD participants (M = 50, SD = 10.17) yielded higher scores on the UCLA Loneliness Scale (t = -6.31, p < .001) than did the control group (M = 36.44, SD = 8.01). Scores on the UCLA Loneliness Scale did not differ significantly between the PLP and the NPLP PTSD groups.

Estimated Room Temperature and Warmth-Seeking Behavior in the PTSD Group

Participants in the PTSD groups estimated the room temperature to be lower, on average (M = 21.97, SD = 4.39) than it actually was (M = 23.68, SD = 1.08) [t(37) = -2.48, p = .018]. As predicted, participants in the PLP group estimated significantly lower room temperatures (M = 20.68, SD = 3.95) than did those in the NPLP group (M = 24.00, SD = 3.65) [t(37) = -2.60, p = .014].

A one-way ANOVA indicated there were significant differences in the desirability ratings for the two food items and two drinks in the PTSD group [F(3, 144) = 4.61, p < .01]. A further post hoc test revealed that PTSD group members desired hot soup (M = 4.23, SD = 2.61) significantly more than control foods (apple: M = 3.16, SD = 2.40, p < .05; cookie: M = 2.16, SD = 1.99, p < .001) and the control drink (cola: M = 3.08, SD = 2.50, p < .05). Although there was a clear tendency for desirability rating for hot soup in the PLP PTSD group (M = 5.06, SD = 2.16) compared with that in the NPLP group (M = 3.83, SD = 2.83), scores on the Warmth-Seeking Rating Scale did not differ significantly between the two groups (all p > .05).

Relationship Between Loneliness and PTSD Symptom Structures

A regression analysis showed that the factors of numbing and dysphoric arousal significantly predicted loneliness ([beta] = .034, p < .05; [beta] = .43, p < .01, respectively), with the exception of intrusion (P = -.03, ns) and avoidance ([beta] = -.20, ns).

Discussion

Previous researchers have found that loneliness is strongly associated with high physiological responses to stress, such as higher levels of autonomic activity (e.g., higher resting blood pressure), poor immunosurveillance (e.g., lesser natural killer cell lysis), and higher basal levels of stress hormones (e.g., urinary catecholamine), and suicidal behavior (Chang, Sanna, Hirsch, & Jeglic, 2010), and may have great importance in predicting the occurrence of chronic PTSD symptoms that lead to a low lifetime recovery rate from PTSD symptoms (Solomon & Dekel, 2008). In the present study, we found that individuals with PTSD experienced a much greater degree of loneliness than did control participants. Thus, loneliness, as a PTSD-related symptom, deserves special consideration when evaluating the severity and prognosis of PTSD cases.

Our findings also extend the view of embodied cognition to the clinical population. Ambient temperature has previously been reported to affect cognitive processes among healthy individuals, an effect possibly mediated through mood (Knez, 1995). In the present study, our finding that people diagnosed with PTSD who were primed with loneliness cues reported colder estimates of ambient temperature than did a group of people diagnosed with PTSD who had not been primed provides experimental support for the relationship between loneliness and physical coldness.

Our findings also imply that behaviors such as preferring hot soup may be physiologically meaningful coping strategies by which people diagnosed with PTSD are unconsciously buffering feelings of loneliness. The PTSD participant group significantly preferred warm food over the control drink and foods. The lack of a significant difference that we observed in desirability rating for hot soup between the PLP and the NPLP PTSD group may be partially attributed to the small sample size involved, and partially attributed to loneliness level being equal in these two groups. Thus, application of physical warmth should be considered in therapy for PTSD. A warm environment could compensate for the feelings of coldness associated with feeling lonely. Additionally, a warm environment that reduces feelings of loneliness may be beneficial to the building of healthy companionship, as loneliness can induce hostile reactivity towards others (Fay & Maner, 2012). Controlling ambient temperature may, thus, be a relatively inexpensive and nonintrusive way to promote recovery from PTSD.

The results in the present study indicate that the numbing and dysphoric arousal factors significantly predict loneliness. According to recent researchers (Elhai & Palmieri, 2011; Wang et al., 2011), intrusion, avoidance, and anxiety arousal factors represent anxiety-related PTSD symptoms, and the numbing factor is a depression-related construct. The dysphoric arousal factor is defined as both an anxiety- and a depression-related PTSD construct. Thus, our results suggest that high levels of loneliness are a result of depression-related PTSD symptoms rather than anxiety-related PTSD symptoms, and this finding provides further support for the external discrimination validity of Elhai and Palmieri's (2011) five-factor dysphoric arousal model.

http://dx.doi.org/10.2224/sbp.2013.41.10.1605

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HUANHUAN LI

Renmin University of China

XIAOLAN LIAO

The University of Oklahoma

Huanhuan Li, Department of Psychology, Renmin University of China; Xiaolan Liao, Department of Psychology, The University of Oklahoma.

This research was financially supported by Basic Research Funds, Renmin University of China, from the Central Government of China (12XNK039).

Correspondence concerning this article should be addressed to: Huanhuan Li, Department of Psychology, Renmin University of China, Room 1004, Suite D, Huixian Building, 59 Zhongguangcun Street, Haidian District, Beijing 100872, People's Republic of China. Email: psylihh@ruc.edu.cn
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Author:Li, Huanhuan; Liao, Xiaolan
Publication:Social Behavior and Personality: An International Journal
Article Type:Report
Geographic Code:9CHIN
Date:Nov 1, 2013
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