of non-familial sociality, we may now

of non-familial sociality, we may now add physiological benefits. A 1979 population-based study showed that adults lacking social ties were 1.9 to 3.1 times more likely to die during a 9-year follow-up than those who had more social contacts, all else being equal (2). Since then, at least five population-based prospective studies (3) and numerous smaller studies have found positive associations between social integration and either survival or improved health outcomes. The mechanisms by which social integration enhances survival are several and include improved health behaviors, increased access to resources and material goods, and strengthened immunity against infection (4). Whereas sociality is a normal state, loneliness is an unusual state, akin to hunger, thirst, or pain (5). As with those states, loneliness is unpleasant and serves to remind us that we should change the status quo. Therefore, loneliness can be an adaptive motivator for increased social surveillance and interaction. Unfortunately, not all individuals succeed at achieving the level of social connectedness they desire and suffer instead from chronic feelings of loneliness. Cacioppo and others have shown that lonely individuals interpret events and social interactions more negatively than non-lonely individuals. As aresult, they unconsciously develop defense mechanisms, including social barriers, which shield them from insults and rejection. While this approach may achieve its goals of self-protection, it also reduces opportunities for positive social interactions and perpetuates feelings of social isolation (5). John Bunyan, a 17” century Christian writer and preacher, described the barriers associated with loneliness when he wrote of a vision in which he 131 Page “saw the people set on the sunny side of some high mountain, there refreshing themselves with the pleasant beams of the sun, while I was shivering and shrinking in the cold, afflicted with frost, snow, and dark clouds. Methought, also, betwixt me and them, I saw a wall that did compass about this mountain (6).” For chronically lonely people, the wall between themselves and others is partly of their own making and reflects continuous surveillance for negative signals from others (5). The challenge is to help lonely individuals break down the barriers between themselves and others and ultimately return to the normal state of sociality. In his vision, Bunyan achieved this, but only through great effort: “About this wall I thought myself, to go again and again, still prying as I went, to see if I could find some way or passage, by which I might enter therein, but none could I find for some time. At the last, I saw, as it were, a narrow gap, like a little doorway in the wall, through which I attempted to pass; but the passage being very strait and narrow, I made many efforts to get in, but all in vain, even until I was well-nigh quite beat out, by striving to get in; at last, with great striving, methought I at first did get in my head, and after that, by a sidling striving, my shoulders, and my whole body; then I was exceeding glad, and went and sat down in the midst of them, and so was comforted with the light and heat of their sun (6).” HOUSE_OVERSIGHT_021377