Addressing Loneliness in Dementia Patient’s Caregiver Through Spiritual Aspect

Introduction: In this brief case report, we aim to focus on the spiritual aspect and how it may benefit in addressing loneliness. Case: The case is a female 62 years old, diagnosed with generalized anxiety disorder with a psychosocial stressor of perceived isolation (loneliness), treatment approach consists of medication and spiritual-integrated cognitive behavioral therapy focused on her loneliness. Discussion: According to the definition spirituality is related to a transcendental being (vertical) and relation with others, the environment, and oneself (horizontal). In loneliness, the psychosocial symptom of perceived social isolation might be caused by the falling apart of a spiritual relation, either vertical or horizontal. Conclusion: Loneliness might be prolonged by a change in spiritual value and addressing loneliness through a spiritual aspect is an area that needs to be explored in future studies.

Keywords: Spirituality, Loneliness, Spiritual Intervention, Caregiver, Mental Health

INTRODUCTION

Loneliness can be seen as a stressor alleviated by using spiritual coping. This would explain why we often find high loneliness and high spiritual well-being together[1][2]. But what if we take a look from the perspective of spirituality as a part of the holistic aspect? Can changes in spiritual aspect value (due to life experience) affect the psychosocial in such a way that creates loneliness?

CASE

Mrs. FXH, 62 years old, is a college graduate, she used to work in the management of a big factory and now she is on her pension. She came to the psychogeriatric outpatient clinic with a sleep problem that has been around for about 1 year, she complained of difficulty to sleep for almost every day. She was worrying nonstop about unclear things, accompanied by tremors on her hands, sweating, and palpitation. This problem occurred since she became the sole caregiver for her husband which diagnosed with dementia in the last 2 years, to the point the husband cannot manage any of his daily activities without her help.

She only lived with her husband and refused to have a helper for household chores because she could do it. She had 5 sons with whom she had good relations, she was conflicted about wanting them to help her but she also didn't want to disturb them, because each already had their own family. She felt lonely, angry, and overwhelmed by her husband (and sons) but she pushed herself to do everything. She had relief from religious group support, but she believed that she could not depend on other people.

She is diagnosed with generalized anxiety disorder and treated with Sertraline 25mg and Lorazepam 1mg. Nonpharmacology therapy includes relaxation techniques and spiritual-integrated cognitive behavior therapy. CBT targets the improvement of her daily stress ultimately points back to the feeling of suffocating loneliness and subsequent decisions that keep her isolated.

Discussion

Loneliness definition.

Loneliness is easily seen in this case, in which the patient perceives herself in social isolation. As per definition, loneliness is a psychosocial symptom of perceived social isolation (living alone, no transportation, subjective distressing feeling of being alone) and is associated with lower HRQOL. But what caused loneliness to spike in this case, multifactor might be the answer but if we look at a specific direction we might find that spirituality might have something to do with this[3][4].

Evolutionary Theory of Loneliness

Evolutionary Theory of Loneliness (ETL) posits that loneliness is an adaptive evolutionary signal. When the organism is in an environment with a low chance of mutual benefit or altruism in the environment, there is an automatic signal that causes the organism to perceive social isolation. This signal is an adaptive function that fosters short-term survival, but in the modern world can have long-term deleterious consequences[3][4]

ETL explains:

1. How feelings of loneliness emerge and are maintained over time.

There is a strong need for connection in humans. While the important bonds are absent, under threat, or low in quality, loneliness emerges as a response to motivate people to repair the deficient bonds. When loneliness subsides, it becomes an internal reward and renewed social connection. This evolutionary process increases individuals’ chances of survival and opportunities to pass genes to the next generation.

But, loneliness can also interfere with the motivation to repair bonds. The bad experience (or lack of protection/assistance from others) that comes from loneliness promotes an emphasis on short-term self-preservation (hypervigilance for social threats and increased concern for one own interest which leads to a behavior of avoiding other people to avoid further rejection and can cause them to miss out on opportunities for reconnection or rewarding social interaction. In short, loneliness is a signal for people to renew their connection. Loneliness causes a feeling of lack of protection or assistance. It may cause increased self-preservation, lead to a strong avoidance behavior, and a decreased desire to affiliate, which causes the loneliness to become chronic [3 - 6].

Another explanation of the ETL theory of how loneliness emerges and is maintained is that loneliness sets off a multistep process. For the first step, people withdraw from initial social interaction to ponder their options. In the second step, they are hypervigilant for social cues, both opportunities for social reconnection and threats. When people notice such opportunities quickly, they regulate their behavior effectively reconnect to others and their feelings of loneliness are short-lived. But when they interpret their social situation potentially threatening, they will withdraw further from social interactions, and leads to prolonged loneliness[7].

1. How loneliness can affect physiological functioning and health.

There are known physiological changes that come with loneliness, research on older adults has confirmed the association with greater reactivity of stress system, cardiovascular problems, and early mortality [8 - 10]. The increase of HPA activity and fragmented sleep as an evolutionary process can be understood as an optimal response to the bad experience of a deficient and unsafe environment[11]. These changes can be adaptive in the short term, but not in the long term.

1. How loneliness changes how people process information in the brain,

There are changes in the interpretation of social cues that signal a threat or an opportunity to renew a connection. There was increased activation of brain regions involved in emotion processing (limbic system) in lonely people which reflects hypervigilance to all sorts of social

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