Psychosis is a broad term for a mental state where a person sees reality differently from those around them. It may involve hallucinations (like hearing voices), delusions (false but firmly held beliefs), and difficulties in thinking or communicating clearly. Psychosis can occur in conditions like schizophrenia or as a response to trauma, extreme stress, or substance use.

These symptoms often interfere with relationships, leading to social withdrawal and feelings of loneliness. Misunderstandings and stigma surrounding psychosis can further isolate individuals with psychotic experiences or a diagnosis. This type of loneliness isn’t just emotionally challenging; it can also make psychotic symptoms worse. Despite this, loneliness in psychosis is often overlooked in mental health care. While loneliness has been widely studied in conditions like depression, much less is known about how it affects people with psychosis; that’s where this study comes in.

Researchers wanted to understand how people with psychosis experience loneliness and what contributes to it. Understanding this is crucial because loneliness can become a vicious cycle, worsening symptoms and making it even harder to reconnect with others. By identifying key factors, researchers hope to develop better ways to support people in breaking this cycle and improving their well-being.

Methods

This was a systematic review of qualitative studies that examined the experiences of loneliness in individuals with psychosis. The researchers conducted a meta-synthesis, combining the results from various qualitative studies to create a comprehensive review.

The researchers followed a series of steps adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines and their pre-registered protocol on PROSPERO (CRD42022335801):

• Searched for studies: They used databases influential in psychological research, such as MEDLINE and PsycINFO, to find studies relevant to loneliness and psychosis.
• Selected studies: Identified studies focused on individuals with lived experience of psychosis, particularly examining their feelings, thoughts, and experiences of loneliness.
• Extracted data: Important information from each study was gathered, including personal accounts of loneliness and details about participants.
• Synthesised data and identified key themes: The researchers categorised similar experiences and thoughts into common themes using NVivo.
• Quality checked the studies: To ensure this review was based on accurate data, the researchers assessed the quality of the studies they included. They recognised that poor-quality studies might not have accurately captured individuals’ experiences of loneliness. Studies were appraised with the use of Critical Appraisal Skills Programme (CASP) checklist; a widely used and accessible tool for evaluating the quality of qualitative studies. CASP assessment indicated a median score of 17. According to researchers “most studies stated aims and findings clearly, and employed appropriate qualitative research design, however, many received low scores for reflexivity”.
• Gathered lived experience input: Advisors with lived experience of psychosis were part of the research team. Their role was to ensure that interpretations accurately reflected the real-life experiences of loneliness in psychosis.

Results

A review of 701 studies examined loneliness in people with psychosis, its causes, and ways to reduce it. Researchers analysed 41 qualitative studies and identified six key themes:

1. Feeling Disconnected

• Many participants felt emotionally isolated, even in company.
• They often felt misunderstood or unsupported by loved ones, though trusted relationships (e.g., with family) sometimes helped.

2. Rejection and Stigma

• Societal stigma, bullying, and parental neglect were key drivers of loneliness.
• People internalised negative labels like “dangerous,” contributing to shame and withdrawal.

3. Loneliness During Psychotic Episodes

• Psychotic symptoms made socialising more difficult. Some feared being perceived as strange.
• However, connecting with others who had similar experiences was often helpful in reducing loneliness.

4. Wanting Connection but Facing Barriers

• Many longed for acceptance but faced obstacles like anxiety, low confidence, financial hardship, or exclusion.

5. Fearing Connection

• People often want connection, but fear rejection or emotional pain.
• To protect themselves, they avoid relationships, which deepens their loneliness.

6. The Importance of Social Connections

• Meaningful relationships and activities were crucial for reducing loneliness and promoting recovery.
• Peer support and compassionate professionals made a difference.

Conclusions

This research shows that loneliness is deeply intertwined with the experience of psychosis, as it is associated with feelings of disconnection, the experience of stigma, and a deep, often frustrated desire for connection. Worryingly, loneliness and psychosis can create a vicious cycle where social withdrawal leads to loneliness, which can subsequently worsen symptoms, making it even harder for individuals to reach out for help.

The key takeaway from this research is that addressing loneliness should be a priority in mental health care. One-size-fits-all support is not effective; people with psychosis require tailored interventions that help them rebuild meaningful connections. Loneliness is not merely a side effect of psychosis; it is central to the experience, and we must give it the attention it deserves.

Strengths and limitations

Strengths

• Lived experience involvement: People who had experienced psychosis themselves reviewed the research and shared their insights, helping to ensure that the findings were meaningful and reflective of real-world experiences.
• Potential for broader applicability: Although most of the research came from high-income countries, it included studies from different cultural contexts, making the findings applicable to more individuals experiencing psychosis.

Limitations

• Gaps in available research: The review could only analyse existing studies, leaving some questions unanswered. It lacked detailed accounts of how loneliness might vary based on different types or stages of psychosis, the nature of hallucinations or delusions, or personal factors like ethnicity, income, or sexuality.
• Lack of long-term perspective: The studies in this review only captured people’s experiences at a single point in time, making it unclear how loneliness changes throughout psychosis or if it worsens symptoms or results from them. Understanding this relationship could be key to designing better support and treatment, especially for those in the early stages of psychosis.
• Broad diagnostic criteria: The study included a wide range of psychotic disorders, making it harder to distinguish how loneliness differs across conditions. For example, loneliness in schizophrenia may not be the same as in brief psychotic disorders, yet these differences weren’t explored in depth.
• Potential for publication bias: The review only included published studies, which may introduce publication bias. Studies with positive or novel findings are more likely to be published, while those with less striking results may be overlooked.

Implications for practice

Mental health professionals should routinely assess for loneliness in individuals with psychosis. It’s not enough to focus solely on symptom reduction.

Meaningful interventions could include:

• Peer support groups to build trust and shared understanding.
• Social skills training to improve confidence in interactions.
• Community programmes that promote inclusion and engagement.
• Psychological therapy, like CBT, targets self-esteem and challenges unhelpful beliefs that hinder connection.

These approaches offer more than just temporary relief — they may support long-term recovery and reduce the burden of psychosis.

Statement of Interests

As MSc Clinical Mental Health Sciences students at UCL, we want to clarify that while some individuals involved in the discussed research are UCL faculty, we have no direct involvement in the study, its review, or publication. This blog was created independently for our coursework and reflects our interpretation. We have no conflicts of interest beyond our academic relationship with the study.

Contributors

Thanks to the UCL Mental Health MSc students who wrote this blog from Morant Student Group: Aurelia Hodes, Ahmeda Kalla-Kalokoh, Maryam Gurwara, Mayra Jasani, Anna Liguori, Katya Proctor, Maria Ravani, Sara Zamora-Grant, Emma Blackman, Vien Zhou and Vanessa Jasinska.

UCL MSc in Mental Health Studies

This blog has been written by a group of students on the Clinical Mental Health Sciences MSc at University College London. A full list of blogs by UCL MSc students can be found here.

We regularly publish blogs written by individual students or groups of students studying at universities that subscribe to the National Elf Service. Contact us if you’d like to find out more about how this could work for your university.

Links

Primary paper

Lee, C. Y., Ahmed, N., Ikhtabi, S., Duffett, P., Alhilow, Y., Richardson, L., Pitman, A., Lloyd-Evans, B., & Johnson, S. (2024). The experience of loneliness among people with psychosis: Qualitative meta-synthesis. PLoS ONE, 19(12), e0315763. https://doi.org/10.1371/journal.pone.0315763

Other references

 Correll, C. U., & Schooler, N. R. (2020). Negative symptoms in schizophrenia: a review and clinical guide for recognition, assessment, and treatment. Neuropsychiatric disease and treatment, 519-534.

Lim, M. H., Gleeson, J. F., Alvarez-Jimenez, M., & Penn, D. L. (2018). Loneliness in psychosis: a systematic review. Social psychiatry and psychiatric epidemiology, 53, 221-238.

Lim, M. H., & Gleeson, J. F. (2014). Social connectedness across the psychosis spectrum: current issues and future directions for interventions in loneliness. Frontiers in psychiatry, 5, 154.

Michalska da Rocha, B., Rhodes, S., Vasilopoulou, E., & Hutton, P. (2018). Loneliness in psychosis: a meta-analytical review. Schizophrenia bulletin, 44(1), 114-125.

Photo credits

• Photo by Carolina on Unsplash
• Photo by Michael Proctor on Unsplash
• Photo by RU Recovery Ministries on Unsplash