Interviewer: Laurie Scudder, DNP, NP; Interviewee: Amy Banks, MD Disclosures
June 12, 2017
Spurred by a recent study published in Health Psychology that examined the link between self-reported loneliness and viral illness, Medscape set out to examine the current state of evidence on the links between social connectedness and physical health. We invited Amy Banks, MD, director of advanced training at the Jean Baker Miller Training Institute at the Wellesley Centers for Women, to speak with us. Dr Banks has devoted her career to understanding the neurobiology of relationships.
What Do We Know About Relationships and Health?
Medscape: Your research has examined the neurobiology of relationships—the physiology of emotional connections. How has that improved knowledge helped us to understand the role of social relationships in health?
Dr. Amy Banks
Dr Banks: That is a big question that touches on several fields of science. "Relational neuroscience" refers to the intersection of interpersonal neurobiology, relational cultural theory, and neuroplasticity and has emerged in the past 20 years. Technological advances, including functional MRI, single-photon emission CT, and PET, have allowed us to finally see the brain in action and the way in which relationships turn the brain on.
And lo and behold, what has emerged is the identification of very specific neural networks that are dedicated to interpersonal relationships, to connecting, and to all of the specific skills that we need to be in healthy human connection.
Popular Western theories of human development focus on the belief that we are born dependent, and the task of socialization is to raise increasingly independent, individualistic people. This process of development describes separation from others as a sign of maturity. Individuals in this model are able to "stand on their own two feet." My colleagues and I believe that this developmental process has disintegrated or weakened the position of relationship in our culture.
Other cultures, primarily Eastern, focus on the centrality of relationships to all human health and well-being. When human beings are built within the context of human relationships, a much more sophisticated interpersonal neural network is built that allows a person to participate in relationships in a way that calms the stress response system, builds the immune system, and creates a sense of belonging. In this setting, when a person is separated from his group, a warning alarm of pain is issued, telling him that he is in danger.
So, there's a whole physiology there just waiting to be tapped into, if we are setting up social societies in a way that really focuses on the centrality of relationships to health and well-being.
[T]here's a whole physiology there just waiting to be tapped into, if we are setting up social societies in a way that really focuses on the centrality of relationships to health and well-being.
Medscape: Is it too simplistic to compare this with the concept of "use it or lose it"? That is, if these neuropathways are not used, they won't develop?
Dr Banks: That is exactly right. You are referring to the relatively new concept of neuroplasticity—that the human nervous system is malleable, and we can change and develop our brains throughout life.
We are born with rudimentary but profound neural networks that orient an infant to the mother or caregivers. The more these networks are supported by positive, responsive interactions, the more they will blossom into rich neural networks.
The first developmental task of an infant is to develop trust. When trust in others is wired into the autonomic nervous system, the stress response system or the sympathetic nervous system is modulated by contact with safe people. The more safe people an infant and child is in contact with, the stronger the modulation of the stress response.
The first 3 years of life are particularly important for laying down healthy, robust neural pathways for connection. Ongoing responsive relationships lead to the development of complex social skills, such as give-and-take and conflict resolution. However, for children in families with little safety in relationship or poor communication skills, these networks won't develop as fully. This is how the neuroplastic concept of "use it or lose it" plays out on a day-to-day basis through our interactions with others What Is Chronic Disconnection?
Medscape: You have also studied chronic disconnection. Can you explain that concept?
Dr Banks: Individuals who are chronically disconnected are existentially isolated. There's a difference between being isolated and being alone. A lot of people can be alone, but still have a rich relational neural network that allows them to carry others inside of them in their thoughts and feelings. This is vastly different from a state of isolation, where a person has not had the healthy relationships to develop the pathways needed to feel safe when alone. For a human being, isolation is a lethal state, because we are interdependent creatures and our physiology functions best when we are part of a group.
For a human being, isolation is a lethal state, because we are interdependent creatures and our physiology functions best when we are part of a group.
When trauma and abuse are a part of a person's relational experience, then fear, distrust, and isolation are coded into the nervous system. People in abusive relationships feel unsafe and have difficulty building lasting relationships. These folks exist in a state of chronic disconnection that does not allow them to feel safe in any human connection. This can be lethal over time.
Medscape: How does this disconnection affect the management of such conditions as anxiety, depression, or dementia? It would seem that it would make management all but impossible until the fundamental underlying issue is addressed.
Dr Banks: That's correct. Isolation induces a state of fear, right? The messages are clear: You are on your own, no one can help you, and no one wants to help you. These messages are depressing and anxiety-provoking. It's scary out there when you're on your own. That not only makes anxiety and depression worse, it makes all physical illnesses both more likely and worse.
One of my favorite books is called Love and Survival: How Good Relationships Can Bring You Health and Well-being, by Dean Ornish. In it, he documents all of the studies up to that point that link isolation and disconnection to an increased rate of illness of all kinds. He writes, "I'm not aware of any other factor in medicine: not diet; not smoking; not exercise; not stress; not genetics; not drugs; not surgery that has a greater impact on our quality of life, incidence of illness, and premature deaths from all causes."
He's talking about relationships.
Medscape: How does the clinician distinguish a person who may live alone, for example, and yet have a very rich interactive life, from the individual who is chronically disconnected?
Dr Banks: Your question relates to another question that I hear all the time, which is: How does an introvert fit in?
The idea is that if you have had enough healthy relationships in your life all along, then you will develop neural pathways in a sophisticated way so you can live alone, but know you have people out there. If you really are feeling lonely, as opposed to isolated, then you can call a friend or reach out to someone. So I think it is important to ask our patients about their relationships.
Medscape: What is known about the effects of loneliness and lack of connection on physical health?
Dr Banks: There is definitely a strong connection. As I mentioned before, strong relationships help build an internal regulatory system that modulates your stress response. In contrast, when those pathways haven't been or are not being stimulated, that internal modulating system for stress weakens. And with ongoing isolation, the firing of your stress response increases, leading to a state of chronic stress. Chronic stress weakens the immune system, which ultimately leads to more illnesses of all kinds.
Naomi Eisenberger and Matthew Lieberman at UCLA have examined the neurocognitive overlap between physical and social pain. In their study, subjects participated in a virtual ball-tossing game over the Internet. The game was programmed so that the ball was thrown to the subject at some points and that same person was excluded in another round of the game.
The investigators obtained recorded functional images during the game, looking at the area of the brain that was activated when the person was socially excluded or left out of the game. They found that for most people, being left out felt bad, and the bad feeling correlated with activation of the dorsal anterior cingulate gyrus, which is an area of the brain already known to be activated by physical pain.
[P]eople with chronic disconnection and physical pain will eventually end up in the same place, with more illness and less well-being.
What the researchers postulate is that being disconnected—being apart from your tribe, if you will—is as important as being physically injured or hurt. The pain pathway is one and the same. So let's start treating it like that. We need an action plan, just as we would use for a physical pain syndrome. Because people with chronic disconnection and physical pain will eventually end up in the same place, with more illness and less well-being. What Should Clinicians Do?
Medscape: It is recognized that for some older adults, an appointment with a medical professional is one of their major social connections. That's quite a burden for busy primary care providers. Recently, a major insurer launched a program for these adults that provides regular phone contact to offer support. Are there other ways that busy clinical practices can practically provide social support to seniors who may lack supportive relationships at home?
Dr Banks: I think that every primary care clinician needs to be connected to resources in their own community. That may be a social worker, a community center, social clubs, or other agencies that work with our aging population. Older adults need to be assessed for isolation. Are they isolated because their friends are dying? Or because of a mental illness that has never allowed them to connect?
The solution has to involve relationships. Fundamentally, though, our culture undermines our health by promoting the belief that being separate, being an individual, and standing on your own two feet is what mature adults do. This implicitly says that you have less value if you need someone else. And I would argue that it is unrealistic for a medical provider to foster social connectedness. However, I do think that all medical providers need to assess for loneliness, isolation, and loss and to understand the very real impact this will have on their patient's physical well-being. If you have a patient who has diabetes and is isolated, then 9 times out of 10, their diabetes is going to be worse.
That is true regardless of the patient's age. For example, the College Diabetes Network is a program available in hundreds of colleges across the country. It was formed in recognition that the transition to college can be a challenging time for teens, who are needing to take more responsibility for their lives and their health. Chronic illnesses, such as diabetes, can make them feel different at their new college. In an effort to belong, they may overlook the challenges of their medical condition and, with no parents to remind them to check sugars or monitor what they eat, their A1C levels can rise dramatically.
Within this network, college students with diabetes text each other their blood sugars. The results are impressive: Simply reaching out in this way universally helps students keep their blood sugars under control by interpersonal accountability.
Unfortunately, as a society, we have drifted away from the idea that our elders have great wisdom to contribute to the next generation. So many aging people have lost a sense of meaning or purpose, and as friends die, there is great risk for isolation. This should be a major health concern for all practitioners.
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