Is loneliness a psychological dysfunction?

A literary study of the phenomenon of loneliness

. Lindstro den1 PhD, RN Brita Nilsson1 PhD, RN, Unni A m2 PhD, RN and Dagnn Na
1

bo Akademi, Vasa, Finland Faculty of Nursing, Oslo University College, Oslo, Norway and 2Department of Caring Science, A

Scand J Caring Sci; 2006; 20; 93101 Is loneliness a psychological dysfunction? A literary study of the phenomenon of loneliness The purpose of this investigation was to explore how loneliness is described in literature and research. The study employed a hermeneutic approach rooted in the ideology of humanistic science in a caritative nursing tradition. Data sampling for the study was completed over two different periods of time (1998 and 2004). The main ndings are that loneliness is understood as a complex dimension in our lives and it can be experienced at many levels. Through the survey of the theoretical material, loneliness may be understood as a structural dimension of existence and not as an illness. The deep dimension of loneliness,

however, can entail suffering that is possibly so intolerable that it may turn towards becoming an illness. Loneliness is assumed as something we are, an ontological structure in our existence. Loneliness can therefore be turned into suffering as well as into health. It is perhaps in the silent reective loneliness that we paradoxically develop a greater understanding of the benets of togetherness. Our conclusion is therefore, that the phenomenon of loneliness is not a psychological dysfunction. Keywords: loneliness, solitude, philosophy, psychology, caring, nursing. Submitted 27 January 2005, Accepted 19 December 2005

Introduction
This article is the rst of several on the phenomenon of loneliness drawn from a larger subject in which the purpose was to develop a deeper understanding of the signicance of loneliness in human existence in a nursing-scientic psychiatric context. Prior understanding of loneliness is perceived not only as a common phenomenon but also a mysterious one. It was the mysterious and multifaceted aspects of the phenomenon that disturbed and motivated to undertake the study of loneliness (1). The study is done with a caring-scientic perspective and a general hermeneutic approach based on Gadamers thinking (2).

approach to the comprehension of loneliness in a hermeneutic understanding, where Gadamer (2) is the source of inspiration. The research eld is of an existential character and the pre-understanding is specially emphasized in the ontological, epistemological and methodical deliberations.

Loneliness and modern society

Loneliness as a theme and specic area of interest was not developed as an area of research in Western history before the advent of the modern age around the 1700s (1, 4). However, loneliness as a theme was described early on in ctional works (5, 6), as well as in poetry and painting (Munch; Hertervig), in patient literature and autobiographies (7, 8). Loneliness as a theme for research does not have a long history. In the Nordic countries and the USA, research groups and individual researchers emerged in the late 1970s and studied loneliness rst as subthemes and subsequently as the subject for independent studies. It appears that the inuence of modern research had asserted itself. In a contextual meta perspective, Western industrialized society is termed a Narcissistic Age (9), but it is also referred to as The Age of Loneliness, in which the phenomenon of loneliness, regardless of victims age, has become almost epidemic (10, 11). Loneliness as a dysfunction in modern times is revealed partially in surveys concerning societys technological advancement (11), in 93

The paradigm of the study

The rst authors personal paradigm was earlier based on Heideggers philosophy (3), viz. his ontological concept of caring. This fundament has gradually directed itself towards caring sciences paradigm within the concept of caritas ethical and metaphysical understanding of the human being. The study is based on the human science ideographical school, and seeks a boundary breaking and creative
Correspondence to: Brita Nilsson, Faculty of Nursing, Oslo University College, Oslo, Norway. E-mail: brita.nilsson@su.hio.no

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B. Nilsson et al. 2004. Search terms used earlier, as well as expanded and modied search terms, were used in the area of solitude. This resulted in the emergence of new articles that had escaped our notice during the rst sampling, as well as the reappearance of many of the earlier searched articles. The results from the last search period were startling, since in 2001 there was a veritable explosion of articles. For the search term loneliness, there were 2890 hits. In this jungle of research articles the following inclusion and exclusion criteria were made. Inclusion criteria 1 Research articles and books that specically examined loneliness as a phenomenon. 2 Research articles and books which specically examined the meaning of solitude (the positive dimension of loneliness). 3 Empirical articles which directly examines loneliness in a psychiatric clinical context. 4 Articles which included loneliness as a phenomenon related to different types of disease. Exclusion criteria 1 Articles which were beside research questions. 2 Articles which merely mentioned loneliness indirectly in relation to different somatic diseases. 3 Nonscientic articles. In the great majority of cases, an in-depth description of loneliness per se was lacking, in that loneliness was related only to various types of dysfunctions. This present article will distinguish between philosophical and empirical articles and books.

the use of Internet and its relation to loneliness (12). Cultural background plays a signicant role in studies of loneliness. As an example, one might mention the difculties ethnic groups have in readjusting, their loneliness in a new country, new schools, new social relationships, as well as their homesickness (13). Loneliness is further regarded as an important factor in the development of medical dysfunctions, such as psychosomatic disorders, breast cancer, cardiovascular dysfunctions, etc. (14). In the great majority of cases, an in-depth description of loneliness per se was lacking, in that loneliness was related only to various types of dysfunctions.

Purpose
The purpose of this article is to provide an overview for how loneliness is described by different disciplines as a phenomenon, as well as to show how loneliness has been represented in a nursing-scientic psychiatric context during the period extending from 1980 to the present day. The research topic of this study is: (i) How is loneliness described in literature and research? (ii) How is loneliness understood in relation to psychological dysfunction in a clinical, nursing science context?

Method
The focus of this study is twofold, comprising on the one hand studies of literature that treats loneliness as a phenomenon, and on the other hand, studies of loneliness in research articles on nursing and caring science in a psychiatric context, as well as how loneliness is described in newer psychology and psychiatry literature. Data sampling for studies on loneliness was completed over two different periods of time, in 1998 and in 2004. The data sampling periods may be seen as an expression of the hermeneutical process, since access to classical literature on loneliness was gained through articles that in turn yielded new search terms. Therefore, several of the references will be older than from 1980. The texts that are used were reviewed a number of times through a hermeneutical process, from the whole to the part and back again to the whole, etc. to get a deeper understanding of loneliness as a phenomenon described in literature. An examination of texts is not performed using a determined technique or method, but rather relies on the examiners degree of instinctive understanding of loneliness as suffering. At the same time, this instinct entails the necessity of being placed at risk (2), open-mindedly towards a new emerging understanding.

Loneliness as a phenomenon in a philosophical, psychiatric and psychological context

Denitions of loneliness
There are a number of denitions of loneliness that more or less derive from forms of expression and causal relationships. Well-known researchers on loneliness such as Peplau and Perlman (15) have sought to look behind the intuitive understanding of loneliness by, among other means, reviewing 12 denitions of loneliness from which they synthesize three common elements such as: loneliness is a subjective and distressing negative experience and occurs in a persons social relations out of a withdrawal from human contact based on a need for psychological security. Loneliness, therefore, is not synonymous with objective social isolation. People are able to be alone without feeling lonely, both in a crowd and in twosome ness. The denitions, in our understanding, did not provide a deeper description of the phenomenon of loneliness, beyond the fact that the experience of loneliness was related to distress and that it is a personal experience in the

Criteria for inclusion and exclusion of literature

In 1998, a data search was completed on Medline, Cinahl and Bibsys; subsequently, another data search was done in

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A literary study of the phenomenon of loneliness individuals life. But what was the make-up of this distress? And what social relations precipitate the need for psychological security? These questions led me to further studies on loneliness in the elds of philosophy and psychiatry. However, access was gained via the articles references to classics in the eld of loneliness research, to more in-depth descriptions of loneliness as a phenomenon.

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Loneliness in a philosophical context

Authors of books such as Gotesky (16), Weiss (17), Mijuskovic (4), Hartog et al. (18) and Peplau and Perlman (15) are examples of important researchers on loneliness. A common denominator is the individuals experience of loneliness in various types of isolation. Loneliness is thus shown to be both a subjective and a shared common phenomenon among humans. Weiss (17), Yalom (19) and Gotesky (16) all expound on various forms of loneliness. Weiss makes a distinction between two forms of loneliness: emotional isolation, as a result of the loss of intimately close persons (parents, loved one or children), and social isolation, as a consequence of a loss of, for example, friends, neighbours, colleagues, etc. (17). Yalom asserts, based on his own clinical practice as a psychiatrist, to have identied three types of isolation as related to the experience of loneliness: (i) interpersonal isolation normally experienced as loneliness resulting from a number of factors, such as geographic isolation, lack of social experience and personality type; (ii) intrapersonal isolation, emphasized as a central dimension in all psychopathology, and is not only linked to psychological defence mechanisms, but also construed to have an even deeper form such as a fragmenting of the self; and (iii) existential isolation which Yalom perceives as a separation from the world, where the person is confronted with an anxiety in the face of nothingness, but also his own freedom. Loneliness is regarded as the deepest source of normal anxiety (19). Gotesky differentiates between four forms of loneliness, listing them as: (i) physical solitude, i.e. a physical cuttingoff from others; (ii) the feeling of loneliness that occurs when one is excluded by others an estrangement; (iii) a feeling of isolation resulting from the persons experience of himself as an outsider; and (iv) solitude, linked to a persons own desire for loneliness. Solitude is positive and not linked with pain, since the person actively seeks this type of loneliness for various reasons, such as contemplation, artistic endeavours, etc. (16). We note, then, that all three researchers divide loneliness into different categories, which in turn have common traits and discrepancies among them. The common denominator is the individuals experience of loneliness in various types of isolation, an isolation of both inner and outer nature. Differences become apparent in Goteskys model, which introduces two relationships. The rst is that

the individual is physically cut-off from other people and is, in other words, wrapped up in his own bodily envelope. The other is that the individual seeks solitude, and this is corroborated by Gadamer (20) whereby loneliness may be experienced as essentially good. It is at this juncture that we are in the presence of a term that is selfcontradictory, since loneliness on the one hand is experienced as deeply painful and bad, while on the other it is something good something we actively seek.

Is loneliness a meaningful dimension in the existence?

Through this study, we gradually became aware of the positive dimension of loneliness, an aspect that does not appear in the aforementioned synthesized 12 denitions (15). The question is whether lonely is a description of what one is or rather what one becomes? Put another way: Is loneliness an inherent dimension in humans or is loneliness something that one experiences sporadically? The question led to the philosopher B. Mijuskovic, who maintains that there is a tendency to consider loneliness as a modern phenomenon. Mijuskovic thinks this as a misconception, since people have suffered from acutely pervasive feelings of loneliness since time immemorial. The human being is a thoroughly lonely creature that seeks desperately to nd an escape from its loneliness. But what is it about the phenomenon itself that entails the impulse to ee ones loneliness? And why do humans feel cut-off from other peoples consciousness and their existence? People have this experience of loneliness because of their own consciousness. Loneliness, according to Mijuskovic (4, 21) is a construct of the consciousness, both as a concept and as an emotion. In our understanding of Mijuskovic, he seems to think that the human being is metaphysically and psychologically alone in the world, and that loneliness is one basic structure in the human consciousness (4). Here we approach a central point, since loneliness thus far is considered by Mijuskovic as a basic structure in the human consciousness. This is reinforced by Yaloms thesis that the source of existential anxiety is loneliness. But what is it about humans that precipitate this keen experience of loneliness? Mijuskovic leads us to look at human consciousness and development of consciousness in the Western culture and asks to what extent a person is consciously aware of his loneliness? Authors Moustakas (22), Mijuskovic (4, 21, 23), Yalom (19) and Rouner (24) indicate both common and different forms of loneliness. They conceptualize loneliness from an existentialist perspective, whereby one may regard loneliness on the one hand as a life quality, by thinking through ones own values, and on the other hand, as a source of inner pain. What was bafing for us was the duality of loneliness, in that loneliness as a dysfunction and loneliness as a meaningful dimension in existence crossed over and intersected one another. In other words, there was an

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B. Nilsson et al. mentioned in professional psychiatric literature; the latter was later conrmed by Leidermann (33), Cohen (34) and le Roux (13). Studies in loneliness and psychiatry in articles showed even less loneliness as a theme. Most of them were concerning loneliness among the elderly, young people and alcoholics. Loneliness and schizophrenia yielded 17 ndings, of which only one article specically addressed loneliness in schizophrenic patients, and then only in conjunction with social isolation (35). Thus the remaining articles touched on the phenomenon in its relationship to: treatment, general needs, group therapy, pathological suspicion, etc. However, still they were interesting because of their diffusion between loneliness as a psychological dysfunction as well as a common feeling (36 38). Other studies found were associated to primary empirical themes, such as alcohol abuse, the elderly, sexuality, depression, suicide and serious illnesses (3942). At the same time, the need for more research was emphasized by Cohen (42). There are, however, authors in psychiatrys human science eld who indirectly treat the theme of loneliness in persons with serious psychological dysfunctions, where loneliness emerges as a result of psychological and psychiatric problems (19, 4347). In the Nordic countries we have Sandin (48) and Brudal (49) who also touch loneliness indirectly in their understanding of people with serious mental illness. In other words, despite the above authors psychodynamic view they seem to understand loneliness as something which occurs because of psychological problems and not as a phenomenon in it self.

inadequate distinction between loneliness as a dysfunction and loneliness as a benecial quality. This led us to do a data sampling using the search term solitude, to locate books and articles treating the more meaningful connotations of loneliness. Important authors found both in books and articles were Tillich (25), Rouner (24), Thorsen (26), Grifn (27), Younger (28) and Rocach (29, 30). Rocach (29) describes, among other things, the subjective dimension of loneliness as related to life cycles, noting that it is ineffective to distance oneself from ones loneliness, which can thereby be alleviated only temporarily. Her interesting articles illustrated well the tension between the meaningfulness of loneliness and loneliness as a dysfunction. Classics in the eld of research on loneliness drew attention to philosophers who seemingly were able to provide a deeper answer to the question What is loneliness?, i.e. the ontological dimension of loneliness. In other words, what might provide an in-depth understanding of loneliness? Mijuskovic was important for his texts from 1977 to 1988 on the phenomenon of loneliness. His book and articles from that period have been read and studied for this investigation. Likewise, Heidegger (3) was an important source, particularly for his interpretation of the human solus ipse. The interest that was awakened concerning loneliness benecial nature led to an examination of the texts of philosopher Powys (31), in which he provides insight towards an understanding of the meaningful encounter with benecial loneliness in oneself through an opening of the senses and towards the metaphysical mystery of life.

Summary and conclusion Summary and conclusion

Our pre-understanding of loneliness as suffering was changed through the examination in philosophical literature. This change in our pre-understanding made us open for the possibilities in which loneliness could have health potential. In other words, we regarded that loneliness was a subjective experience and that it could be expressed in suffering as well as in health. But what was it about the modern Western society which emerged loneliness as suffering? The question seemed important. Literature in books and research articles from 1980 to 2004 on the phenomenon of loneliness has been examined for a philosophical, psychiatric and psychological context. Loneliness as a phenomenon appears diametrical, since it is seen on the one hand as a dysfunction and on the other as meaningful for existence. The dominant general impression in philosophical books is that loneliness is regarded as a category of existence and not as an illness. Allowances must be made, however, for the fact that loneliness is seen mainly as a dysfunction. The problem is that there appears to be a lack of distinction between loneliness as a dysfunction and loneliness as a benecial factor. A number of different denitions of loneliness are presented, and this is interesting in itself, since multiple interpretations may conrm the fact that loneliness as a phenomenon, its meaning, its emotive content and form of expression are neither easy to understand nor to dene. Beginning in 2001, there is a proliferation of articles on loneliness linked partially to various traits resulting from modern development and partially to different somatic dysfunctions. In psychological and psychiatric literature, there is a curious lack of specic research on loneliness related to psychological dysfunction. To the extent that loneliness is

Loneliness in psychological and psychiatric articles and books

Within the eld of developmental psychology and psychiatric professional literature related to persons with severe psychological dysfunctions, there is a surprising lack of specic theme-focused discussion of loneliness, per se. The lack of specic studies on loneliness within the elds of professional psychology and psychiatry had already been noted in 1959 by Fromm-Reichman (32), who maintained that loneliness was one of the least satisfactorily described phenomena in psychology, and that it was indeed not even

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A literary study of the phenomenon of loneliness described, it is related to other primary psychiatric diagnoses; in only a minor degree do descriptions of loneliness appear, and then it is understood as a tendency in psychiatric illness or as a factor in a causal relationship (19, 44, 45, 47). One can therefore conclude that loneliness in philosophy is assumed as a category of existence, while there in psychology and psychiatric literature is a dominant understanding of loneliness which emerges from a psychological dysfunction, and at the same time the phenomenon loneliness is very poorly described.

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Nursing and caring science studies on loneliness related to serious psychological dysfunctions
How is loneliness described in nursing and caring scientic research articles related to serious psychological dysfunction? The theme of loneliness, which is treated by a number of nursing and caring scholars both inside and outside of the Nordic countries (5052) are related to: general health, illness, the relationship of loneliness and well-being, stress and age. Hagerty and Williams (53) demonstrate, among other things, that a low degree of belonging is associated to a higher level of depression and loneliness. Peplaus article is also interesting, since she focuses on an understanding of the development of loneliness from a social perspective (54). These two perspectives, the individual and the social aspect, are the basis for the nurses approach to the patient. In Norway, Bondevik (55) has in her PhD made a study of loneliness related to the oldest old, where among other things, their relationships between loneliness and social contacts were investigated. The results show that the elderly are not as lonely as we think they are. In Thorsens study (26), the primary theme is loneliness among the elderly, in conjunction with contact and health conditions. In Finland, Lindstro ms (56) qualitative study of loneliness and the patients perception of the caritative environment, as well as the latters relation with patients, is important and interesting. Different descriptions of psychiatric patients loneliness are expounded here, as well as descriptions in particular of schizophrenic patients loneliness. Likewise, loneliness appears as a partial implication in Eriksson (57), in connection with perception of suffering. Loneliness also emerges as a theme in Lindholm (58). In Lindholm et al.s study (59), the heuristic value is found in the discovery of the fact that loneliness in young people is related to both suffering and desire. The sample groups for the study comprised two groups of young people, and the study itself has a nursing science application in its hermeneutical approach. Likewise, Lindstro m and Lindholms (60) study shows that loneliness is one category of existence. Furthermore, the same authors demonstrate the existential meaningfulness of loneliness and write: It belongs to the mystery of love that one attempts to uphold anothers loneliness and create a free space in

which existential loneliness can be transformed into a mutually shared loneliness (60, p. 41). Erdner et al. (61) describe in their article the disadvantages that long-term psychiatric patients experience in the Swedish community where they live. The study is ethnographic and the sample group comprises four patients. In the content analysis of 12 interviews, loneliness emerges as one of three primary themes. Moreover, Nystro ms (62) study of the daily existence of persons with serious psychological dysfunctions shows that loneliness is one of the categories of experience. Within psychiatric nursing, serious psychological dysfunctions and loneliness there were the two ndings that concerned in part the psychiatric patients experience of loneliness in hospital (63), and in part, poetry as an approach (64). De Niros (65) article discusses the alienation of schizophrenic patients, where loneliness is one implied aspect. Three articles were of interest indirectly, through an examination of the rst authors studys empirical focus: loneliness in persons living alone with serious psychological dysfunctions (1). One of the articles concludes that it is positive for the psychiatric patient to live in his own home (66). The second article may be seen contextually in relation with the rst and concerned what may be predicted about the welfare of elderly long-term psychiatric patients in their home community and how patients welfare is improved if varied types of assistance are provided (67). The third article concerned a 3-year comparative study on the treatment of schizophrenic patients living alone as opposed to living with the family; the study concludes that treatment is most effective in cases where the patient resides with a family (66). In Thesens study (68), psychiatric patients in local community healthcare facilities and their professional caregivers were surveyed to determine the presence of stigmatization, seen from both the caregivers and the patients point of view. In the studies as a conclusion, the lack of and need for an examination of the term stigmatization was emphasized. For patients in local community healthcare facilities, a self-stigmatizing tendency arises through the use of medical psychiatric terms, and anxiety and loneliness follows in the wake of stigmatization. Borge et al. (69) in their study of quality of life, investigated persons with serious psychological dysfunctions who were released to live on their own in the care of their local community psychiatric facility after having been institutionalized for a period of 6 years. The result showed that health personnel became the single most important network for the patients, corroborating Kristoffersens (70) ndings. Patients outside the institution were the most socially active and had the most satisfactory contact with their own families. Loneliness was one of the variables in the survey and 63% of the patients expressed a feeling of well-being in the neighbourhood, and in the use of their time. Loneliness was not perceived as a persistent problem.

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B. Nilsson et al. example in their understanding of loneliness. Here one nds the expression risk for loneliness, which seems to indicate that loneliness is regarded as a disease.

In nursing studies, there are few studies concerning the specic signicance of loneliness in terms of psychological dysfunction. On the other hand, the following articles are indirectly applicable. Killeen (10) asserts, as do several other authors, that loneliness is a little-discussed theme, and that it is therefore difcult to dene. She touches on the taboo of loneliness (the shamefulness in expressing ones loneliness). Killeen illustrates two conditions. The one is that loneliness in different patient types and different illness types can be alleviated practically using various means, from bringing objects from home to the institution, to pets, to different groups, etc. But as Killeen states, we have not come closer to an understanding of the phenomenon of loneliness itself. She concludes her article by stating that loneliness requires a sensitive presence to the patient, rather than practical measures. Like Thesen and Killeen, Vuokila-Oikkonen et al. (71) discuss the relationship between loneliness and shame, wherein shame over ones psychological dysfunction engenders feelings of differentness and loneliness. The patients feelings of shame, however, are ignored by the caregivers. Data sampling using the search term solitude yielded a very modest number of articles. Wilkins (72) views solitude as a creative force. Larsson (73) sees a positive developmental potential in children who seek solitude and who are not over stimulated. Polcino (74) sees solitude as a possibility for contemplation and meaningful friendship. Articles examined institutionalized patients experiences with loneliness and the effect of loneliness on psychological illness is Vuokila-Oikonen et al. (71), Parkkila (75) and Old (76). They reveal that loneliness is a continual, painful companion, and causes the patient to regard his afiction as a personal defect or deciency. In this respect, the experience of loneliness exacerbates the psychological dysfunction. In the classication of nursing diagnoses from 1982, one nds the term social isolation. Isolation is dened here as: Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatened state. In 1994, the term risk for loneliness is applied, and is dened as a subjective state in which an individual is at risk of experiencing vague dysphoria. The latter appears in NANDA Nursing Diagnoses (77). NANDA seems vague in its reference to loneliness.

Discussion
The results from this studys topic concerning how loneliness is described and how loneliness is understood in relation to psychological dysfunction show that the literature contains various perceptions and, in part, contradictory descriptions of loneliness. The contradictions line of division appears to run, on the one hand, between the general understanding of loneliness as an illness that can be treated (35, 37, 39, 63, 77) and, on the other hand, loneliness as an inherent dimension in human existence (3, 4, 22, 25, 31, 32). In the eld of philosophy, loneliness appears to be regarded as a category of existence, whereby loneliness in a nursing and caring scientic perspective can be said to belong to the domain of life suffering. The philosopher Mijuskovic (4) is relevant in his development of the deeper dimension of loneliness. The phenomenon of loneliness is illustrated from a historical perspective, as well as from subjectivitys and consciousnesses existential perspective. His interesting result leads to the conclusion that loneliness is not only a category of existence, but also an ontological dimension in the individual. He regards the ontological dimension of loneliness, however, as essentially painful for the human being. Ehrlich (47) and Powys (31), on the contrary, emphasize the meaningfulness of loneliness. We must say that we are in agreement with Ehrlich (47), who identies the dilemma in trying to dene loneliness. The dilemma arises out of two conditions. The one is that loneliness is perceived differently in different countries. The other is the lack of a specic distinction between loneliness as benecial/meaningful (solitude) and loneliness as suffering. Solitude is described, for example, both as suffering and benet (29, 30, 33). Loneliness as both suffering and health quality exist as a multidimensional phenomenon. The most surprising nding was the lack of treatment of loneliness as a theme in recent psychological and psychiatric professional literature. Fromm-Reichmans article suggests a rationale for the lack of professional studies in the eld: Either the psychotherapist does not know anything about the inexplicable, uncanny quality of the patients loneliness, or the psychotherapist himself is afraid of it (32, p. 32). One might ask why the professional eld of modern developmental psychology has dealt to such a small extent with a specic treatment of the phenomenon of loneliness. It is almost as if existential and metaphysical questions have been removed, thereby reducing an understanding of human psychology.

Conclusion
In nursing and caring literature from the Nordic and European countries there is a dominant general impression that loneliness is regarded as a category of existence and not as a psychological dysfunction. But here as well, loneliness is poorly and indirectly described in a psychiatric context. In American articles the dominant impression seems to indicate that loneliness is a psychological dysfunction. Also NANDA (77) can be used as a classical

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A literary study of the phenomenon of loneliness In nursing and caring scientic literature, loneliness is described as both suffering, meaning illness, and as desirable, meaning health. The existential dimension of loneliness emerges to a larger extent in the caring science literature than in the nursing science literature. In caring science loneliness is also related to suffering and health and not to specic types of illnesses. In nursing literature, loneliness emerges as an existential dysfunction lined to different kinds of illness, including psychological illnesses. In other words there seems to be a difference between caring and nursing science literature concerning the relationship between the existential dimension and different types of illnesses. Loneliness can be understood as an existential category of life, and therefore not as an illness, even though suffering in loneliness is exacerbated by the psychological dysfunction. In our understanding, there is nothing which explicitly examines the active and existentially dynamic signicance of loneliness in conjunction with serious psychological disorder. What occurs is that loneliness is indirectly illustrated in connection with various illnesses and phenomena. To the extent that loneliness is described and addressed, it is illustrated predominantly by association with different somatic and psychiatric contexts. Is it possible that this is due to the perception of loneliness as a general and common human phenomenon? Can this be the reason why the inner and outer nature of loneliness has not attracted focused attention from professional scholars in the elds of nursing, psychology and psychiatry? The fact that loneliness as a phenomenon in its own right has not become the object of specic research in a Westerncultural perspective seems paradoxical, in light of the explosion of articles in which loneliness is described as a component in various modern lifestyles. In modern society, increasingly more people live alone and loneliness results in all its multidimensional complexity and subjective forms of expression. The latter situation may be related, on the one hand, to increasing individualism and independencemindedness, along with the demand for time efciency. An increased dependence from others has occurred, based on technological advancements. Halvorsen (78) maintains that in societies with a low degree of condence, one sees a tendency towards distrust combined with adversarial scepticism, which in turn can lead to social isolation and a subsequent feeling of painful loneliness. The possibility for restored trust risks being further reduced. Mutual trust between citizens, therefore, seems to be increasingly more important. On the other hand, since a cultural liberation has occurred, this, in an existential perspective, may offer people positive opportunities to ponder their loneliness in existence, an existence that loneliness is, and that does not necessarily constitute a suffering loneliness. The present examination of literature seems to present the view of an individualistic position which, on the one hand, can contribute to a subjective experience of consciousness about

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the depth of loneliness. On the other hand, one sees the contours of a helpless uncertainty about the type of fellowship that might offer favourable conditions for a meaningful loneliness.

Conclusion
The study of research entailed an unanticipated and altered understanding of the phenomenon of loneliness. Since preconception was dominated by an understanding of loneliness as suffering, theoretical studies entailed questions as to the inherent health possibilities of loneliness. Loneliness is understood as a complex and mysterious dimension in peoples lives and it can be experienced at many levels. Loneliness appears, in other words, to manifest itself through different subjective expressions, both in terms of general health as well as in the domain of life and illness suffering. Although there are a number of denitions of loneliness, we choose, based on this study, neither to dene nor to concur with any of the denitions of loneliness. In our understanding, loneliness appears multifaceted and paradoxical. Any briey formulated denition therefore risks obstructing an understanding of the phenomenon, rather than opening to comprehension of so abstract a phenomenon as loneliness. In the review of the theoretical eld today, what emerges is a particular lack of studies on the specic signicance of loneliness for persons with serious psychological dysfunctions. Through the survey of theoretical material, loneliness may be understood as a structural dimension of existence and not as an illness. The deep dimension of loneliness, however, can entail pain that is possibly so intolerable that it may turn towards becoming an illness. In a nursing and caring scientic perspective, the following conclusions are drawn: 1 Loneliness of the suffering type may appear at an outer level, as well as on an existential and ontological level. 2 At the outer level, one experiences the discomfort of loneliness that entails ones seeking to distance oneself from it through fellowship with people one does not always have something in common with. 3 At an existential level, loneliness is experienced as emptiness and alienation, with various associated emotional qualities, such as shame and guilt in the wake of loneliness. 4 At the ontological level, loneliness may manifest itself outwardly as a deep feeling of abandonment by something or someone. 5 In loneliness that is healthy and therapeutic, one can tolerate oneself and others; loneliness is experienced as both good and bad, often through loss, grief, longing and hope. One experiences pleasure in solitude through reading a good book, listening to music or walking in natural surroundings. Through our senses, we are able to

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experience nature around us in all its transformations. We experience the beauty of existence in an eternal perspective. It is perhaps in this silent loneliness that we paradoxically develop a greater understanding of the benets of togetherness. Our conclusion is therefore, that the phenomenon of loneliness is not a psychological dysfunction.

Author contributions
den have conceptualized the Brita Nilsson and Dagnn Na idea of the larger project, which this article is part of. Brita . Lindstro den and Unni A Nilsson, Dagnn Na m have all given contributions in the process of constructing the design of the total study. Brita Nilsson has drafted/written den has revised and given comthe article. Dagnn Na ments included in the article.

Funding/sponsorship
We thank Faculty of Nursing, Oslo University College, for nancing this research.

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