The phenomenon of acute social withdrawal (ASW) is becoming more common and widespread nowadays and can be characterized by complete solitude/alienation from society for 6 months or longer. Previous studies of the ASW included patients with mental disorders and were focused on the psychopathological features of secondary ASW caused by depression, social phobia, or bulimia.
To increase the effectiveness of acute social withdrawal differential diagnostics by determining the etiopathogenetic factors of its development and psychopathological features to improve further management of this condition.
At the Department of Psychosomatic Medicine and Psychotherapy of Bogomolets National Medical University 70 patients with ASW were examined: the first experimental group (EG1) - patients with mental disorders and ASW (n = 42), and the second (EG2) - a mentally healthy contingent with primary ASW (n = 28). Healthy people without ASW (n=56, control group, CG) as well were examined. The following methods were used: Buss Durkee Hostility Inventory, Victim Behavior Questionnaire, Toronto Alexithymia Scale (TAS-26), Leongard-Schmishek Accentuated Personality Trait Questionnaire, Life Event Questionnaire (LEQ), Chaban Quality of Life Scale.
Comparing EG and CG regarding significance, there were determined several differences. The level of alexithymia in the EG was significantly higher than in the CG (p<0.005). The quality of life in the EG was significantly lower than in the CG (p<0.005). According to the Leongard-Schmishek test in EG accentuated personality traits such cyclothymia, hyperthymia, dysthymia, anxiety (p<0.005), pedantic (p<0.05), demonstrativeness (p<0.1) were significantly higher than in the CG. According to the Buss-Durkee Hostility Inventory, such indicators as resentment (p<0.005), irritability (p<0.05), suspicion (p<0.05) and, as a consequence, an index of aggression (IA), (p<0.05) were significantly higher than in CG. The results of Life Traumatic Events Questionnaire (LEQ) demonstrated that the impact of traumatic events index (p<0.05) and the trauma index (TI) (p<0.05) in EG were significantly higher than in the CG. As a result of the comparison of the correlation matrices of the E1 and the E2, it was found that the groups differ both in the number of statistically significant links and in the correlation structure.
In this study, the psychopathological features of patients with ASW were determined in comparison with healthy control group. It was confirmed that the patients with primary ASW differ from patients with secondary ASW and have other antecedents of this behaviour.
Recently, in many countries, which have similar contemporary socioeconomic environments, including a social change movement, financial unsafety, economic crisis, irregular employment opportunities, increase of unemployment, a stopped or downward social mobility movement among the youth and the widespread use of the Internet and virtual reality the acute social withdrawal (ASW) phenomenon has emerged, and Ukraine is not an exception
The concept of a hermit or a recluse exists in many cultures for a long time. But the phenomenon of social isolation is becoming more common in the context of increasing global communication. Communication via the Internet and using cell phones with multifunction reduces personal contacts, which leads to an exacerbation of social withdrawal
The phenomenon of ASW describes a psychopathological and sociological behaviour, which is characterized by complete isolation/withdrawal from society for 6 months or longer, not caused by psychosis or mental retardation. This behaviour contains elements of social withdrawal (withdraw from society, avoid attending school or work, at least six months), and social isolation (termination of a relationship outside the family during isolation).
Scientists distinguish secondary acute social withdrawal (by aetiology), for example caused by mental disorders such as social phobia, depression, dementia or autistic spectrum disorders; or chronic physical illnesses, injuries. Patients with a major depressive disorder feel difficult to maintain a conversation because of anhedonia, problems with concentration or decreased vital functions during the exacerbation of the disease. A patient with an eating disorder, especially bulimia nervosa, often wants to avoid the gaze of others, the threat of being observed by others makes him remain at home when the weight of the body has risen contrary to the expectations. The fear of panic attack (sudden development of symptoms like palpitations, lack of air caused by acute anxiety) in patients with panic disorder, tend them to remain at home, as a safe place, avoiding places of uncertainty in the situation of emergency
Comorbidity of with other psychiatric disorders (affective and behavioural disorders, substance abuse, anxiety, phobia, personality disorders) is 54.5%, and in half of the cases, acute social withdrawal occurs without comorbid mental disorders or physical illness
Previous studies of ASW included patients with mental disorders and were focused on the psychopathological features of secondary ASW (e.g., comparing social anxiety disorder patients with or without ASW)
Loneliness is a prolonged state of emotional distress that occurs when a person feels alienated, misunderstood or rejected by others. We assume that in a case of ASW in anamnesis there was a fact of directed aggression or rejection from others, as well as the experience of such situations as traumatic, and person might feel him/herself as a victim. In order to evaluate victimization, we have used a questionnaire to detect the tendency toward victim behaviour created by O. Andronnikova
For statistical analysis used descriptive statistical methods, Student criteria (T-test) for unrelated variables, and one-factor analysis of variance ANOVA. The data is presented as the mean (M) ± standard deviation (SD) for continuous variables and numbers (percentages) for categorical variables. Statistical significance was considered to be with the probability p <0,05. The correlation was determined by the Pearson method for a two-way mixed model. IBM SPSS Statistics Version 22 software packages were used for analysis. Copyright IBM Corporation 2013.
The study was conducted at the clinical base of the Psychosomatic Medicine and Psychotherapy Department at the Bogomolets National Medical University. During the study 126 people were examined. Patients with acute social withdrawal (n = 70) that meet the inclusion criteria (see
There were no significant differences between groups by age and sex (
Group | n | Mean (SD) | Min | Max |
---|---|---|---|---|
CG | 56 | 26.8 (9) | 19 | 46 |
EG | 70 | 25.4 (6) | 18 | 40 |
EG 1 | 42 | 25.2 (5.6) | 18 | 39 |
EG 2 | 28 | 25.6 (6.8) | 19 | 40 |
EG | CG | ||||
---|---|---|---|---|---|
n | % | n | % | ||
Gender | Male | 24 | 34.3 | 22 | 39.3 |
Female | 42 | 65.7 | 34 | 60.7 | |
Family status | Single | 48 | 68.6* | 22 | 31.4 |
In relationship | 14 | 38.9 | 22 | 61.1 | |
Married | 8 | 44.4 | 10 | 55.6 | |
Divorced | 0 | 0 | 2 | 100 | |
Educational level | Secondary incomplete | 2 | 100 | 0 | 0 |
Secondary complete | 12 | 35.3 | 22 | 64.7 | |
Vocational training | 4 | 33.3 | 8 | 66.7 | |
Higher incomplete | 28 | 82.4* | 6 | 17.6 | |
Higher complete | 24 | 54.5 | 20 | 45.5 | |
Occupation | Unemployed | 38 | 67.9* | 18 | 32.1 |
Part time | 16 | 50 | 16 | 50.0 | |
Full Time | 6 | 21.4 | 22 | 78.6 | |
Free-lance | 10 | 100* | 0 | 0 |
The mean age of acute social withdrawal manifestation in EG was 21.3 (±6.3) y. o., (EG1: 20.5 (±5.9) EG2: 22.7 (±6.9). In EG at least one diagnosis had 60% of participants (n=42). Personality disorder (15.7%), PTSD (11.4%), major depressive disorder (7.2%), social phobia (7.2%), obsessive-compulsive disorder (7.2%), bulimia nervosa (4.2%) were the most common. Comparing EG and CG in terms of significance (according to T-test), following features were determined:
The level of alexithymia in the EG is significantly higher than in the CG (p<0.005); (M = 71.7, SD = 10.7 vs M = 61.2, SD = 13.4).
The quality of life in the EG is significantly lower than in the CG (p<0.005); (M = 12.5, SD = 3 vs M = 19.3, SD = 3.5).
According to the Leongard-Schmishek test such accentuated personality traits as cyclothymia, hyperthymia, dysthymia, anxiety (p<0.005), hyper-exactness (p<0.05) demonstrativeness (p<0.05) were significantly higher in the EG than in the CG.
According to the BDHI, such indicators as resentment (p <0.005), irritability (p <0.05), suspicion (p<0.05) and, as a consequence, an index of aggression (p<0.05) were significantly higher than in CG; (Index of aggression: M = 22.7, SD = 7 vs M = 18, SD = 7.4).
LEQ found that the total impact of traumatic events (p<0.05) and the trauma index (TI) (p<0.05) were significantly higher than in the CG (TI: M = 2.97 SD = 0.95 vs M = 2.23, SD = 1).
The level of alexithymia among males was on average higher than among female in all study groups (
Group | Gender | Mean | SD |
---|---|---|---|
ЕG | Male | 74.5 | 9.9 |
Female | 70 | 11.1 | |
Total | 71.7 | 10.7 | |
ЕG 1 | Male | 74.7 | 11.9 |
Female | 68.8 | 11.4 | |
Total | 70.7 | 11.6 | |
ЕG 2 | Male | 74.3 | 7.9 |
Female | 72.6 | 10.7 | |
Total | 73.4 | 9.2 | |
CG | Male | 64.8 | 13.3 |
Female | 58.6 | 13.3 | |
Total | 61.2 | 13.4 |
According to the Life Event Questionnaire (LEQ), a gender difference was found, the amount of lifespan traumatic events (a), the total impact of trauma (b) and trauma index (c) among women (EG and CG) was higher than among men (p≥0.05). A statistically significant difference was found in total impact of trauma between EG and CG (predominantly because of a male gender in EG 2 group (EG1 M=7,715,4 vs EG2 M=1911,5), although total number of traumatic events was not statistically different between these study groups. Impact of trauma on patients with ASW without any psychiatric disorders (EG 2) was self-evaluated significantly higher than in EG 1 and CG. Trauma index (Total impact of trauma/Total number of traumatic events) was significantly higher (p = 0.019) in EG than in CG, which indicates the presence of traumatic stress (
Group | Mean | SD | Мin | Маx | |
---|---|---|---|---|---|
Total number of traumatic events | CG | 4.4 | 4 | 0 | 16 |
M | 3.3 | 2.4 | 0 | 9 | |
F | 5.2a | 4.1 | 0 | 16 | |
ЕG | 6 | 3.9 | 1 | 19 | |
M | 4.7 | 2.7 | 1 | 12 | |
F | 6.9a | 4.3 | 2 | 19 | |
EG 1 | 5.5 | 4 | 1 | 19 | |
M | 3.4 | 1.6 | 1 | 6 | |
F | 6.5a | 4.5 | 2 | 19 | |
EG 2 | 7 | 5 | 3 | 15 | |
M | 6.2 | 3.1 | 3 | 12 | |
F | 7.7a | 4.1 | 3 | 15 | |
Total impact of trauma | CG | 11.2 | 10.6 | 0 | 45 |
M | 7.6 | 8.2 | 0 | 30 | |
F | 13.9b | 11.5 | 0 | 45 | |
EG | 18.4 | 13.9 | 3 | 61 | |
M | 12.9 | 10.2 | 3 | 13 | |
F | 21.8b | 14.9 | 6 | 61 | |
EG 1 | 16.2 | 13.6 | 3 | 61 | |
M | 7.7 | 5.4 | 3 | 17 | |
F | 20.5b | 14.6 | 6 | 61 | |
EG 2 | 22* | 14 | 5 | 49 | |
M | 19* | 11.5 | 5 | 39 | |
F | 24.6b* | 16.3 | 7 | 49 | |
Trauma index | CG | 2.23 | 1.08 | 0 | 4.2 |
M | 1.81 | 0.9 | 0 | 3.3 | |
F | 2.52c | 1.1 | 0 | 4.2 | |
EG | 2.97* | 0.95 | 1 | 4.3 | |
M | 2.64 | 1.1 | 1 | 4.2 | |
F | 3.18c | 0.8 | 1.75 | 4.3 | |
EG 1 | 2.99 | 1 | 1 | 4.3 | |
M | 2.38 | 1.2 | 1 | 4.2 | |
F | 3.26c | 0.7 | 2 | 4.3 | |
EG 2 | 2.98 | 0.8 | 1.66 | 4.3 | |
M | 2.95 | 0.8 | 1.66 | 4 | |
F | 3.00c | 0.9 | 1.75 | 4.3 |
M=male; F=felale; CG=control group; EG=experimental group; * p≥0.05
After comparison EG1 and EG2 with the T-test, significant differences in the mean were found only in the indicators of the Buss-Durkee Hostility Inventory: assault (p<0.05), and negativism (p<0.05).
The analysis has shown the following:
The groups differ both in the number of statistically significant links and in the correlation structure. The number of such links is interpreted as the complexity of the correlation structure of the group (
In a group of patients without a psychiatric diagnosis (EG2), there were fewer links (68 versus 78). Therefore, it can be stated that its structure is simpler. One of the possible reasons is the lack of formation of the correlation structures in this group.
In EG1 only one characteristic, affectivity/exaltation, with 7 significant correlations was found to be the most connected. In EG2 there were two characteristics found to be the most connected to others: index of hostility and resentment (8 significant correlations).
The most significant characteristic from the EG1 affectivity/exaltation was not found among significant links of the EG2 at all, which may indicate to qualitative differences in the correlation structures of these two groups.
It is worth to emphasize the characteristics with the maximum number of strong paths (p<0.01). In EG1, they coincide with the most connected characteristics - the index of hostility and the index of aggression (6 total significant correlations) have 4 strong paths, and resentment - 3. In EG2, the situation is radically different. A quantitatively significant characteristic of affectivity/exaltation has only one strong connection from eight. The strongest was the total number of traumatic events, which has 4 strong paths with 4 significant ones. On the second place, there was the characteristic hyper perseverance, in which there are 3 strong paths out of three.
In the other group, there was at least one clearly defined structure and two - less pronounced. In
The following correlation structure of EG1 includes index of hostility, which is supported by the index of trauma, dysthymia, suspiciousness, negativism, victimization, hyper perseverance and resentment. The latter is linked to irritability, excitability, indirect hostility and the general index of aggression.
Finally, the structure of characteristics associated with hostility is visually separated.
No. | EG1 | ЕG2 | ||
---|---|---|---|---|
Feature | Number of sign. links | Feature | Number of sign. links | |
1 | Index of hostility (ІH) | 8 | Affectivity/Exaltation (Аf) | 7 |
2 | Resentment (R) | 8 | Total impact of trauma (TIm) | 5 |
3 | Index of aggression (ІА) | 6 | Cyclothymia (C) | 5 |
4 | Negativism (N) | 6 | Verbal Hostility (VH) | 4 |
5 | Dysthymia (Dy) | 6 | Excitability (Ex) | 4 |
6 | Indirect hostility (InH) | 5 | Index of hostility (ІH) | 4 |
7 | Irritability (Ir) | 5 | Irritability (Ir) | 4 |
8 | Hyper perseverance (HP) | 4 | Total number of traumatic events (ТNu) | 4 |
9 | Hyperthymia (Hy) | 4 | Dysthymia (Dy) | 3 |
10 | Excitability (Ex) | 4 | Hyper perseverance (HP) | 3 |
11 | Alexithymia (Аl) | 3 | Index of aggression (ІА) | 3 |
12 | Verbal Hostility (VH) | 3 | Resentment (R) | 3 |
13 | Suspicion (S) | 3 | Suspicion (S) | 3 |
14 | Total impact of trauma (TIm) | 3 | Trauma index (TrI) | 3 |
15 | Victimization (V) | 2 | Indirect hostility (InH) | 2 |
16 | Assault (As) | 2 | Negativism (N) | 2 |
17 | Total number of traumatic events (ТNu) | 2 | Guilt (G) | 2 |
18 | Guilt (G) | 1 | Emotivity (Е) | 2 |
19 | Trauma index (TrI) | 1 | Alexithymia (Аl) | 1 |
20 | Anxiety (An) | 1 | Victimization (V) | 1 |
21 | Quality of life (QoL) | 1 | Hyper-exactness (He) | 1 |
22 | Quality of life (QoL) | 1 | ||
23 | Assault (As) | 1 |
For patients from EG 1, the total number of traumatic events and their impact on life were inversely related to the level of alexithymia. People who retain the ability to distinguish their feelings marked a higher number of traumatic events and were aware of their impact on life. But this correlation structure is separated from other indicators in the correlation matrix. It is difficult to apply the theory regarding this category of patients that traumatic events affect the manifestations of alexithymia, hostility, victim behaviour or personality traits.
The distribution of other links seems to be logical, the level of assault, verbal and indirect hostility forms an index of aggression, in combination with excitability and irritability creates an aggressive outward reaction, as a protective mechanism, but this can increase loneliness. Resentment and hyper-perseverance lead to suspicion, together with mistrust and negativism predict the increase of hostility index, and as a consequence - the victimization, which manifests itself in aggression directed inwards. People with secondary ASW angry at themselves for their inferiority and for the fact that they can’t overcome their problems. The self-aggressive behaviour became widespread (scars, micro-cuts, suicide attempts), they become hostile to their parents and relatives, especially when they require to leave the apartments. All this reduces the ability to provide themselves with an adequate psychological protection, take care of their own safety. These persons are not aware of the fact that they become victims of violence repeatedly (re-victimization). Individuals with secondary acute withdrawal are intensely lonely, and have a lack of social support, lose the ability to maintain meaningful social bonds and close relationships through inferiority, vulnerability, fear and shame for their condition.
Patients with primary ASW have entirely different picture. The strongest link was the total number of traumatic events. The higher the number of traumatic events and the higher their impact on real life (as a consequence, traumatic stress in life), the higher the level of cyclothymia on the one hand, the index of hostility and suspicion on the other, which causes isolation from the aggressive environment. The high trauma index predicts higher levels of dysthymia (pessimism, isolation, decreased mood), the high dysthymia level predicts the low quality of life.
On the second place regarding significance was the characteristic of hyper perseverance, it was related to the quantitatively most significant characteristic of affectivity/exaltation. Such patients have a high plasticity, the speed of mental processes. They react intensively to any (even minor) events, falling at the same time into depression, then into the euphoric mood - from the gloomiest to the most dreamy and happy state. Even a small fear covers the whole nature of an exultant person. A public rating of their physical or other disadvantages is a primary stressor for this type; a common way to overcome stress is verbal hostility. But in combination with hyper perseverance, characterized by a tendency to experience strong feelings for a long time, including resentment, anger, fear, especially when they were not expressed in real life because of any external circumstances (or high level of alexithymia), it would be observed a dysfunctional pattern of behaviour. These feelings can live for weeks, months, even years. Such patients have weakened self-control (irritability, excitability) as a result of the avoidance of problem and due to hyper-exactness (resistance to change), because it is difficult to switch to something new.
The affectivity/exaltation combined with cyclothymia, irritability, excitation, and negativism, as can be observed in
Upon studying the antecedents of the manifestation of acute social isolation, it was found that the biopsychosocial approach gives a most comprehensive answer to isolation development. Biological factors comprise of temperament features (e.g., shyness), psychological factors involve difficulties in school, such as bullying, the experience of physical and emotional violence by peers, or a sense of failure at their workplace. The social factors include an overprotective style in dysfunctional families
The psychological path of acute social isolation development relies on the theory of attachment
Social isolation aims to protect fragile self-esteem. Loneliness is also associated with an underestimation of self and self-blame in situations of social failures. Social interaction is the central source of feedback from others and forms a self-image, some people with low self-esteem choose dysfunctional interpersonal strategies because of the desire to minimize the risks of negative feedback. Withdrawal from society and the departure of interpersonal relations is protecting from the threat of criticism or impairment, eliminating social contacts in general. Thus, it is essential to understand that the motivation to avoid threatening feedback may be stronger than motivation to restore social relationships
Therefore, in this study, the psychopathological features of patients with ASW were determined in comparison with healthy control group. It was confirmed that the patients with primary ASW differ from patients with secondary ASW regarding antecedents of this behaviour.
The author declares that no competing interests exist.
No. | Question (item) | Yes | No |
---|---|---|---|
1 | Do you currently spend most of the day and nearly every day at home? If ‘YES,’ when did it start? | ||
2 | Have you ever in the past spent most of the day and nearly every day at home? If ‘YES,' when did the longest past period start and end? | ||
If 1 is ‘NO’ and 2 is ‘NO’ mark ‘Ineligible.' If symptoms occurred less than 6 months ago and duration is less than 6 months, mark ‘Ineligible’ in Step 2. | |||
3 | Do you currently avoid social situations, such as attending school or going to a workplace? If ‘YES,' what are a couple (two) examples? When did it start? | ||
4 | Have you ever in the past avoided social situations? If ‘YES,' when did the longest past period start and end? | ||
If 3 is ‘NO’ and 4 is ‘NO,' mark ‘Ineligible.' If started less than 6 months ago and longest period is less than 6 months, mark ‘Ineligible.' | |||
5 | Do you currently avoid social relationships, such as friendships or contact with family members? If ‘YES,' what are a couple (two) examples? When did it start? | ||
6 | Have you ever in the past avoided social relationships? If yes, when did the longest past period start and end? | ||
If 5 is ‘NO’ and 6 is ‘NO’ mark ‘Ineligible.' If started less than 6 months ago and longest period is less than 6 months, mark ‘Ineligible.' | |||
7 | Considering your most severe period of social isolation, (did/does) it do any of the following: a) interfere significantly with your normal routine; b) interfere significantly with your ability to work or attend school; c) interfere significantly with social activities or relationships; or d) bother you a lot? | ||
If NO, mark ‘Ineligible.' | |||
8 | Briefly, what is/was the reason you started being socially isolated? | ||
If all episodes due to a chronic physical illness or injury, mark ‘Ineligible.' | |||
9 | Do you have a history or have you been told you have any of the following conditions: Schizophrenia, Dementia (any type), Mental Retardation, Asperger Syndrome, Autistic Disorder (Autism). | ||
If any of the above conditions checked, mark ‘Ineligible.' |