http://www.personalityresearch.org/papers/clark.

html
Social support is one of most important factors in predicting the physical health and wellbeing of everyone, ranging from childhood through older adults. The absence of social support
shows some disadvantage among the impacted individuals. In most cases, it can predict the
deterioration of physical and mental health among the victims. The initial social support given is
also a determining factor in successfully overcoming life stress. The presence of social support
significantly predicts the individual's ability to cope with stress. Knowing that they are valued by
others is an important psychological factor in helping them to forget the negative aspects of their
lives, and thinking more positively about their environment. Social support not only helps
improve a person's well-being, it affects the immune system as well. Thus, it also a major factor
in preventing negative symptoms such as depression and anxiety from developing.
The social support and physical health are two very important factors help the overall
well-being of the individual. A general theory that has been drawn from many researchers over
the past few decades postulation that social support essentially predicts the outcome of physical
and mental health for everyone. There are six criteria of social support that researchers use to
measure the level of overall social support available for the specific person or situation (Cutrona,
Russell, & Rose, 1986). First, they would look at the amount of attachment provided from a
lover or spouse. Second, measuring the level of social integration that the individuals involved
with, it usually comes from a group of people or friends. Third, the assurance of worth from
others such as positive reinforcement that could inspires and boosts the self-esteem. The fourth
criterion is the reliable alliance support that provided from others, which means that the
individual knows they can depend on receiving support from family members whenever it was
needed. Fifth, the guidance of assurances of support given to the individual from a higher figure
of person such as a teacher or parent. The last criterion is the opportunity for nurturance. It
means the person would get some social enhancement by having children of their own and
providing a nurturing experience.
This paper organizes studies of social support into three age-appropriate categoriesadolescents, middle-aged adults, and older adults. For example, an experiment related to social
support and physical health that empathizes cancer is assigned to the older adult category. If the
specific area of concern can be applied to everyone, then it is placed into middle-aged adult
group for generalization purpose. After reviewing those studies and experiments, it should be
clearly shown that social support is very important factor in determining the status of physical
health, mental health, and immune system functioning for everyone.

Adolescents
Adolescents could develop some kinds of sensitive feelings, which may impact on their health if
they do not get adequate social attention from others. They may become involved in an
unfortunate situation that makes them feel overwhelmed or awkward. The adolescent is still
developing, could easily experience some strain to their emotion if no help is immediately

available. Anxiety and depression are two main psychological disorders that often can be seen
among the adolescents.
Family and Peer Support
For adolescents, family support is the most important element in their lives. As part of their
growth experience, adolescents usually expect a lot of things from their parents. Inadequate
support from the parents will likely increase the chance of getting depression among adolescents
who get into unfortunate situation with their parents. This occurs because adolescent usually
become confused when they expect to get plenty of help and positive reinforcement from their
parents, but it does not happen (Stice, Ragan, & Randall, 2004).
Beside family support, peer support also is very important factor for adolescents. Children can
expect a lot from their friends. Peer support can be considered as an alternate method of getting
social support if the adolescents receive inadequate attention from their parents. This social
support method is not as reliable as family support because young children could easily withdraw
from their own friends if they become depressed. Another problem arises in this area, when the
depressed students isolate themselves from public gatherings. This would prevent those suffering
adolescents from getting any social support at all (Stice et al., 2004). Receiving social support is
very essential for adolescents to become successful with themselves and achieve a satisfactory
level at school.
Gifted Adolescents
Gifted adolescents also can encounter plenty of problems if they do not get adequate social
support. In some cases, intelligent students are sent to residential schools that offer special
programming for students who are gifted in math and science. Oftentimes, the family support
would be severely limited for those adolescents, because the residential school usually lies far
away from home. This kind of schooling is a totally new experience for gifted students, because
they are living in the dormitory. Normally, students would experience the dormitory living for
the first time when they go to college. At those ages, students are looking forward to seeking
independence from their parents. This usually leaves a hole for those adolescents with reduced
social support, whereas they have to rely on some people from the residential school (Dunn,
Putallaz, Sheppard, & Lindstrom, 1987).
Gifted adolescents usually have to rely on counselors and peers at the school. The counselors
usually help those students to ease the transition from home to a residential living situation. In
contrast to students who attend regular school, there is a better chance for those gifted students to
experience emotional well-being, be in a good physical health, and have a good immune system
as long as adequate social support can be provided at the school to prevent or lessen the chance
for those people from getting depressed (Dunn et al., 1987).
Middle-Aged Adults
The importance of social support continues well into adulthood for everyone. It would benefit a
person's general health and immune systems, regardless of whether or not they have a lot of

stress. For example, the cardiovascular system would function much better in those adults who
have better social support (Uchino, Cacioppo, & Kiecolt-Glaser, 1996). The social contact,
familial support, and involvement with leisure activities have significantly demonstrated a
relationship with lowering of blood pressure. Contact among family members is the best method
of reliving stress. The fellowship among friends is adequate, but not as powerful as family.
Strangers have a negative effect on reducing blood pressure. In one study cited in Uchino's
article, the individual with many siblings and experiencing low stress was found to be the best
possible combination for lowering the blood pressure.
Health
Many studies indicate that anyone who has high social support tends to have less chance of
getting depression and anxiety disorders. In contrast, only a handful of studies show that there is
no relationship between social support and lowering the blood pressure. The level of social
support also has been found to be related to a lower rate of disease and early death. The familial
support is a psychological enhancement to help the individual reduce their stress. These findings
are somewhat weak and further studies need to be done to gather more specific information
about the influence of social support on physical health (Uchino et al., 1996).
There is a significant relation between emotions and health. Anyone who has positive emotion
and beliefs is likely to enhance their physical health. As expected, being in a good mood will
cause refreshed mind to relieve some of the stresses. Laughing is said to have a good deal of
influence on reducing or forgetting about the hassles of daily life. Strong social support is
necessary to help succeed in achieving these traits of overall physical well-being (Salovey,
Detweiler, Steward, & Rothman, 2000).
Personality Type
There are some aggressive adults living in our society. This would probably mean those adults
are diagnosed with Type A personality. Anger, aggressiveness, and hostility are the common
characteristics of this type of personality. These are unhealthy personality traits, which could
adversely affect the general health of those adults. Eventually, the research finds that there is
some direct link between Type A personality and coronary heart diseases (Friedmann & BoothKewley, 1987). There is no scientific evidence yet, but researchers have suggested a general
hypothesis that low social support may cause Type A personality. The researchers also revealed a
strong relationship between social support and the absence of coronary heart diseases. More
social support would soothe the individuals with Type A personality, leading to better physical
health, thus reducing the risk of developing coronary heart diseases. Environmental stress is
likely to increase the chance of getting physical illness (Maddi, Bartone, & Puccett, 1987).
Socioeconomic Status
One's socioeconomic status also is a major factor in whether or not an individual gets enough
social support. The socioeconomic status is the measurement of level of income each person has
to determine their level of economic status in our society. For example, if the specified person's
income is rather low, compared to nationally average, that person would be considered as a part

of the low socioeconomic status. As expected, anyone who comes from a lower socioeconomic
class would be more likely to receive less social support. They basically do not have enough
resources in their environment available to assist with social support. The individuals with low
socioeconomic status also tend to have less self-control. Consequently, they become more
sensitive to stressors in their environment and less able to control their reactions. It means those
adults would trigger some frustrations when they face any kind of stress. Unfortunately, the
social strain, which is common in their daily lives, increases the risk for lower social class
individuals to develop some kinds of physical and mental illness or a lower sense of well-being.
This should not come to surprise that adults who have higher socioeconomic status tend to
receive more social support (Gallo, Bogart, Vranceanu, & Matthews, 2005).
Mothers of Children With Disabilities
Mothers with children who have permanent and chronic diseases usually become overwhelmed
with all of the demands. They often feel burdened because it takes too much responsibility to
take care of disabled children and meet such social demands as work at same time. Hope and
good social support are very important elements to help reinforce those affected mothers. Hope
serves as a psychological factor and social support serves as a comfort factor. As mentioned
above, by thinking positively, hope should be able to take away the affected mothers' obsessions
and make them think about something else for better. One interesting note from a study shows
the stress level for those mothers varies widely. It greatly depends on the independent skills the
disabled children have. For example, if the children have a very serious disability such as
cerebral palsy, it would indicate their mothers will have to take all of the responsibilities as
caregivers. On other hand, those children who have milder symptoms of disease would be able to
function more independently. In this case, the affected mothers would be in a much better shape,
but they still have to deal with some caregivers' responsibilities along with social demands such
as daily hassles. The availability of social support from others, especially family members, helps
the affected mothers to adjust to environmental demands (Horton & Wallander, 2001).
Stressors at Work
Many adults normally deal with a lot of stress at work. The high demands and low social
contact/support within the workforce tend to cause the development of depressive symptoms
among workers over a period of time. A high level of social support from a supervisor may help
prevent depression from developing. This is not a guarantee, especially if the high demands
continue to overwhelm the workers. To accomplish a satisfactory stress level in a high demand
environment surely would require plenty of support and reinforcement from supervisors. The
surprise finding in this specific study shows that the best combination for workers would be low
stressors and low social contact. This study, which was taken place in Germany, shows that there
is not much correlation of social support and stressors among the co-workers. These findings are
still vague. This study included a limited number of workers. The researchers will need to study
more workers in a greater variety of work environments over the place before they can
generalize this result (Dormann & Zapf, 1999).
Some unfortunate adults experience the impact of job losses due to firings or layoffs. The
unexpected layoffs usually are huge stressors among those workers who were impacted. Those

displaced workers are likely to develop some problems that could influence their physical or
mental health. For example, those affected workers normally report the loss of self-esteem and
locus of control. This spikes the chance of those workers becoming depressed. The depression
itself could signal the beginning of deterioration in health and well-being among those displaced
workers (Mallinckrodt & Bennett, 1992).
The layoffs also make a big impact on the workers' life. Now, they have to worry about the
financial support of their family. Worrying about the financial ability only add, more problem,
for those who are unemployed. The social supports from family members benefit those
individuals. By providing adequate social support, the displaced workers' physical and mental
health is enhanced. This also prevents deterioration in physical/mental functioning down the
road. Social support also would reinforce the displaced workers to make some adjustments into a
new life (Mallinckrodt et al., 1992).
Older Adults
The physical functioning of older adults usually weakens as they become older. It is the key
factor in predicting the health outcome of older adults is their status at the time they retire. The
body and immune system of older adults usually become fragile as they become older. The
resource of social support also tends to decrease somewhat. These several factors combined are
the key to predict and control the health of older adults.
Employment Status
Older adults usually face significant changes when they reach their retirement ages. As they are
basically done with their career, this stage of the life establishes a new focus for older adults. The
retired workers have several choices to make; fully retire from the workforce, continue working
part-time and collect some money, or focus primarily on non-paying jobs or volunteer activities.
Volunteering is a big factor relating to social support for older adults. This element will help
build companionship and interact with more people in the community. This step may become
necessary as older adults lose some social support from their family members. This group of
people needs to keep themselves busy by connecting with other people as often as needed. This
method leads to better overall mental and physical health and better well-being. The amount of
social support is the key to determine life satisfaction among the older adults. As expected, older
adults who elect not to do any working during their retirement experience a lower level of life
satisfaction. Their body function would deteriorate more quickly compared to other older adults
who keep themselves busy (Aquino, Russell, Cutrona, & Altmaier, 1996).
Health
The initial level of social support essentially predicts the outcome of older adults' general health
in the following years. Inadequate initial social support at the beginning of retirement would
predict that older adults will develop depressive symptoms over time. Older adults would be able
to ignore the negative effects in their lives with help and reinforcement from others. This is
considered a psychological effect. Not enough social support would likely make the individuals
notice their daily hassles and life stressors much more clearly. This step could accelerate the

deteriorating effect of their physical and mental health. Unfortunately, there is no relationship
found between social support and major life events. Whatever happens to older adult as they
nearing to their death, it will happen, regardless the amount of social support available in the
environment (Russell & Cutrona, 1991).
Cancer
The spouses of older adults who are fighting cancer usually get overwhelmed with all of the
demands and stressors. They often worry about their loved ones prognosis with cancer. On a
positive side, social support is said to be a huge psychological factor for these affected spouses.
As more social support becomes available to those victims, the better the individuals' immune
system and well-being will become. This should improve the bodily function of those impacted
spouses and allow them to be able to handle the stress much more efficiently. It is very important
for those impacted individuals being able to switch back and forth between two different worlds:
the world of their ill spouses and the real world outside of the house or nursing home. Social
support is widely known to buffer the stress level among those impacted spouses. Knowing that
others are there to help makes the big difference. For those caring for spouses with cancer who
have low social support usually report a deterioration in their general health. As widely known,
low social support available usually means the impacted spouses have to rely on themselves
more than usual. It is essentially focusing attention between the stressful spouses and their loved
ones. The unfortunate situation often comes to impair the function of those affected spouses
when they become overwhelmed with their stress, along with the deteriorating conditions among
the cancer patients they are caring for. It is evident here that the spouses usually cannot handle
taking care of the cancer patients by themselves. This is the primary reason why plenty of social
support should be given to those impacted families. If the immediate family members or relatives
are not available to help the burdened spouses, outside help should be immediately given; this
can be someone who are nurses, counselors, or social workers. It should be marked clearly that
social support is only a psychological factor because the cancer patients usually progresses as
expected toward the end regardless of all of the hopes (Baron, Cutrona, Hicklin, Russell, &
Lubaroff, 1990).
Stress
Initial mental health is a very important predictor for all older adults at the time they enter their
retirement ages. Good mental health would predict a healthy social support and fairly good
physical health for the years to come (Cutrona et al., 1986). Once an individual's mental health
declines at any point during their retirement ages, it would increases the likehood for negative
elements to persist with the impacted individuals. It has been found that it will be very difficult
for those older adults to get out of the slump and have a positive perspective in their life once
again. Knowing that they are valued by others makes a big difference in predicting the outcome
of mental health for those older adults. If the impacted individuals demonstrate negative life
events such as divorces, or any other kinds of daily stress, it becomes obvious to outsiders that
inadequate social support is available for those people.
Conclusion

There is evidence that social experience is very essential in predicting the well-being for
everyone, ranging from childhood through older adults (Cohen & Willis, 1985). After a few
decades of studying, the researchers have finally gained some understanding about the
relationship between social support and physical health. Nonetheless, some areas of research still
face some problems because they sometimes focus too specify on one population, ignoring the
generalization rules for using the random samples to generalize the result to a whole population.
The continuity of research on the relation between social support and physical health will enable
us to understand better about the effect of good social support toward physical and mental health,
along with a general well-being. Many studies have been shown that if a high level of social
support becomes available to everyone, it will benefit their overall health in a long run. The
importance of social support implies to everyone in our society, ranging from young childhood
through older adulthood. The providers of social support can be anyone in society who brings the
positive environment and reinforcement to the individuals, especially from their family
members. The amount of social support available in the environment for the individual can be
determined by looking at the six criterions of social support, and set up observational scores from
each category then find the average score from all six categories. The higher average score it gets
means the better social support the person has in their life, thus reducing their chance of
developing any negative outcome in their health.
Factors Involved in Social Support
Corey M. Clark
Rochester Institute of Technology
I would like to thank to those who have evaluated my paper and helped reinforce it by
elaborating some essential points that I failed to discuss. Beattie elaborated on the description of
six criteria of social support that affect the physical health in all three age groups. He discovered
several questions that I left unanswered in my paper. For instance, Beattie made the point that
every social support criteria do not fit into all three age groups. Originally, I was trying to make
this paper a focus on middle-aged adulthood. When I added the adolescent and older adulthood
sections, I tried to explain the background and significance of the relations between social
support and physical health in these age groups. The consequence was that I left out several
criteria that did not apply to adolescents and older adults. As Beattie pointed out, I could have
explained the absence of several criteria in adolescents and older adults. For example, older
adults do not have any role models to look up to build on their social support and physical health
status; therefore, they have to rely on five other criteria for their well-being.
Cuff discovered that my paper did not include some important examples of causation. Once
again, the relation between social support and physical health is a widely publicized topic. This
topic contains a lot of background on the relations between social support and physical health. I
tried to cover all of those areas as much as possible. Unfortunately, this left my paper missing
some of the important points and examples that I could have added. All of the points about casual
relation that Cuff presented are very important points that I could have added to my paper.

Gorman's peer commentary filled in some information that I failed to discuss in my paper. I
explained the transition of older adults from work into retirement. Gorman's peer commentary
added information about the decision-making steps necessary before moving on into retirement,
such as the types of residence to live in. Because this topic has been widely discussed, I could
not put all of the information and examples into this paper. Consequently, I never include the
life-threatening conditions of middle-aged adulthood as an example of the relation between
social support and physical health. Gorman's peer commentary provided a great example of
recovering from life-threatening conditions by being involved in the community and support
groups that share common interests and problems.
Kilpatrick was concerned about the missing discussion of negative relations between social
support and physical health in my paper. As she pointed out, I basically discussed only the
positive aspects of this topic. My paper discussed how social support affected physical health in
positive ways. It is widely known that there is a positive correlation between social support and
physical health. As Kilpatrick pointed out, the reality is that social support can also have negative
influences on physical health, especially among those who have psychological disorders. I
should have acknowledged the negative aspects of social support in my paper.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921311/
Social Support and Resilience to Stress

Introduction
Social support is exceptionally important for maintaining good physical and mental health.
Overall, it appears that positive social support of high quality can enhance resilience to stress,
help protect against developing trauma-related psychopathology, decrease the functional
consequences of trauma-induced disorders, such as posttraumatic stress disorder (PTSD), and
reduce medical morbidity and mortality.1 However, despite strong evidence demonstrating the
beneficial effects of social support on medical and psychological wellbeing, the field of
psychiatry has contributed relatively little to developing, testing, and implementing effective
evidence-based interventions aimed at increasing social support for patients and at-risk
populations. In this review article, we aim to summarize key studies on social support in the
context of resilience to stress and explore possible brain mechanisms mediating social support's
positive influence on mental health outcomes. We will begin with a brief overview of the
neurochemistry of the stress response and resilience to stress. Within this framework, we will
then review the emerging literature on the neurobiology and the behavioral mediators of social
support. Next, we will review studies that have investigated the effects of social support on
medical illness, and finally, conclude with a discussion on social support's clinical significance
for psychiatry.
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Resilience to Stress: Putative Mechanisms
Psychological resilience represents a process of adapting well in the face of adversity. The
psychosocial and neurobiologic characteristics of resilience to stress are extremely complex, and
their discussion is beyond the scope of this article (for a thorough review see Southwick, et al.1).
However, the literature suggests the sympathetic nervous system and hypothalamic-pituitaryadrenocortical (HPA) system are extensively involved in stress response and resilience.2
The sympathetic nervous system (SNS) responds to stress by increasing heart rate, constricting
blood vessels, increasing blood pressure, and slowing digestion. Numerous lines of evidence
from psychophysiology and neuroendocrine studies indicate that the noradrenergic system is
often dysregulated in PTSD. For example, chronic PTSD is associated with high baseline

cerebrospinal fluid NE concentrations.3 McFall, et al., demonstrated that subjects with combatrelated PTSD had greater increases in plasma epinephrine, pulse, and blood pressure in response
to viewing a combat movie.4 Notably, the heightened autonomic activity of PTSD patients
peaked during the resting period after the combat film, and the authors argued that an impairment
of the mechanisms involved in terminating the noradrenergic response to stressors was
implicated in the pathophysiology of PTSD. When the SNS is strongly activated, neuropeptide Y
(NPY) and galanin are released with norepinephrine to maintain SNS activity within an optimal
activation range (reviewed by Southwick, et al.5). Indeed, highly resilient special operations
soldiers tend to have high levels of NPY6,7 in contrast to combat veterans diagnosed with PTSD
who have reduced levels.8 The overall net effects of NE hyperactivity thus may depend on the
balance between NE, NPY, and galanin. This supports the notion that resilience to stress is
associated with the regulation of noradrenergic activity within an optimal window.
In response to acute and chronic stress, the hypothalamus secretes corticotropin-releasing factor
(CRF), which in turn induces the release of adrenocorticotropin hormone (ACTH). ACTH
stimulates the synthesis and release of cortisol and dehydroepiandrosterone (DHEA) from the
adrenal gland. In the short run, cortisol mobilizes and replenishes energy stores and contributes
to increased arousal.9 However, if stress remains chronic, prolonged elevations of
glucococorticoids may cause serious adverse effects, such as immunosuppression, hypertension,
dyslipidemia, and osteoporesis.10 In contrast to cortisol, DHEA exerts antiglucocorticoid and
antiglutamatergic activity in the brain and may confer neuroprotection (reviewed by Charney2).
For example, a negative correlation has been demonstrated between DHEA levels and PTSD
symptom severity in women.11 Morgan, et al., found a positive correlation between
DHEA/cortisol ratio and performance among special forces soldiers during high stress
training.12 Similarly, allopregnalolone, another neuroactive steroid, dampens the HPA activity.
Rasmusson, et al., has reported lower cerebrospinal fluid levels of allopregnanolone in those
diagnosed with PTSD compared to controls.13 In conclusion, DHEA and allopregnalolone may
confer resilience to stress by helping to terminate HPA-activation and preventing harmful effects
of prolonged exposure to glucocorticoids.
In summary, stress resilience seems to be associated with an ability to keep the HPA-axis and
noradrenergic activity within an optimal range during stress exposure and terminate the stress
response once the stressor is no longer present. Based on these findings, we may postulate that
for social support to increase stress resilience, it should enhance the ability to optimize the
neurochemical stress response summarized above.
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What is Social Support?

Social support has been described as support accessible to an individual through social ties to
other individuals, groups, and the larger community.14 The National Cancer Institute's
Dictionary of Cancer Terms defines social support as a network of family, friends, neighbors,
and community members that is available in times of need to give psychological, physical, and
financial help (www.cancer.gov). Theoretical models of social support specify the following
two important dimensions: (1) a structural dimension, which includes network size and
frequency of social interactions, and (2) a functional dimension with emotional (such as
receiving love and empathy) and instrumental (practical help such as gifts of money or assistance
with child care) components.2 Most research has found that quality of relationships (functional
dimension) is a better predictor of good health than quantity of relationships (structural
dimension), although both are important.1
It should be noted that the optimal source of social support may depend on the developmental
stage of the person who is receiving the support. For example, parental support seems to be more
valuable in early adolescence than it is in late adolescence.15 It has been shown that the
perception of social support is associated with the degree of social interaction in the elderly and
with instrumental support in younger adults.16 Moreover, the type of social support seems to be
important in conferring resilience to stress. In a sample of childhood sexual abuse survivors, a
combination of self-esteem support (the individual perceives that he or she is valued by others)
and appraisal support (the individual perceives that he or she is capable of getting advice when
coping with difficulties) was most useful in preventing the development of PTSD.17
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The Psychobiological Mediators of Social Support
Investigators have explored the ways in which social support may enhance mental and physical
health. It has been argued that rich social networks may reduce the rate at which individuals
engage in risky behaviors,18prevent negative appraisals,19 and increase treatment adherence. In
general, resilient or hardy individuals are thought to use active coping mechanisms when dealing
with stressful life situations.20 Using a time lag model for the prediction of depression, Holohan,
et al.,21 found that high social support predicted less subsequent depression in patients with acute
and chronic cardiac illness and that this relationship was partly mediated by the use of an active
coping style. Importantly, in this cohort, social support preceded and facilitated the use of active
coping mechanisms.
There is an emerging literature on social support and the neurobiological pathways through
which it acts to foster resilience and reduce the risk for developing mental illness. In preclinical
studies, social isolation has been associated with increased heart rate and blood pressure,
hypercortisolemia, and atherosclerosis. For example, among cynomolgus monkeys, resting heart

rate increases during separation and isolation but returns to normal when monkeys are reunited
with their social group;21 cortisol rises in squirrel monkeys22 and wild baboons23 during isolation;
at postmortem examination, atherosclerosis has been significantly greater in swine24 and in
female monkeys21 living alone vs those living in social groups. Further, evidence suggests
chronic stress and lack of social support increases cardiac risk (e.g., endothelial injury, increases
platelet accumulation), in part, through prolonged sympathetic activation.25
In human studies, low social support has been associated with physiological and neuroendocrine
indices of heightened stress reactivity, including elevated heart rate,26 increased blood
pressure,27 and exaggerated cardiovascular and neuroendocrine responses to laboratory stressors.
For example, in laboratory studies mental arithmetic28 and public speaking tasks29,30 cause
significantly smaller rises in heart rate, blood pressure, and cortisol among subjects supported by
another person compared to subjects who are alone. These findings are consistent with the results
of a study conducted by Steptoe, et al., who reported an overall increased noradrenergic and HPA
reactivity in lonely individuals.31
The brain mechanisms, including the neural circuits and neurotransmitter systems, that underlie
the acquisition and processing of social information are extremely complex and far from being
completely understood. However, animal studies indicate that the regulation of social attachment
and promotion of positive social interactions may be heavily dependent on two neuropeptides
known as oxytocin and vasopressin.32 Oxytocin is critical for learning social cues and has been
shown to enhance maternal care in rats.33 Differential oxytocin and vasopressin receptor
expression patterns in specific areas of the brain (ventral pallidum and medial amygdala) have
been shown to influence the type and duration of social attachments formed by voles. For
example, montane voles typically avoid social contact except while mating; they have lower
levels of oxytocin receptors in the nucleus accumbens compared to prairie voles, which are
highly social and typically monogamous.34 Oxytocin also exerts anxiolytic effects that are
associated with attenuated secretion of corticosterone in lactating rodents.35
The role of oxytocin in human social behavior has been investigated as well. The Trier Social
Stress Test is a laboratory stressor that involves simulation of an aversive job interview and
public speaking with negative feedback, resulting in a robust increase in anxiety and salivary
cortisol. Both oxytocin and social support reduced anxiety in healthy men undergoing this
procedure.36 Interestingly, the same study showed that subjects who received the combination of
oxytocin and social support had the least amount of anxiety and lowest cortisol responses to
stress. Taken together, these results suggest that oxytocin promotes social behavior and may
inhibit the HPA axis reactivity to stress.
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The Impact of Social Support on Health Outcomes

Social isolation and low levels of social support have been shown to be associated with increased
morbidity and mortality in a host of medical illnesses. For example, in the well-known Alameda
County Studies, men and women without ties to others were 1.9 to 3 times more likely to die
from ischemic heart disease, cerebral vascular disease, cancer, or a host of other diseases within a
nine-year period compared to individuals with many more social contacts.37 The effect of social
support on life expectancy appears to be as strong as the effects of obesity, cigarette smoking,
hypertension, or level of physical activity.25
Numerous epidemiological studies have reported that poor social support is associated with the
onset and relapse of depression,38 negative treatment response to dysthymia,39 seasonality of
mood disorder,40 and the presence of depression comorbid in several medical illnesses, such as
multiple sclerosis,41 cancer,42 and rheumatoid arthritis.43
The Vietnam War may serve as an important example of failed social support during times of
high stress and trauma. Johnson and colleagues found that many Vietnam veterans experienced
homecoming as a highly stressful experience.44 These veterans reported being insulted, feeling
angry, resentful, and alone. In this cohort of treatment-seeking, outpatient veterans with PTSD,
homecoming stress was the strongest predictor of the frequency and intensity of their PTSD
symptoms. The authors concluded that the lack of social support confirmed the veterans'
perception of rejection and lead to feelings of detachment.44
In contrast to low social support, high levels appear to buffer or protect against the full impact of
mental and physical illness. The relationship between good social support and superior mental
and physical health has been observed in diverse populations, including college students,
unemployed workers, new mothers, widows, and parents of children with serious medical
illnesses.45
Strong social support has been shown to be an important factor in decreasing functional
impairment in patients with depression46 and in increasing the likelihood of recovery.47 Further,
the risk of developing PTSD upon exposure to combat trauma is inversely correlated with social
support. For example, Boscarino, et al.,48 after controlling for trauma exposure, found that
Vietnam veterans with high levels of social support were 180-percent less likely to develop
PTSD as compared to those with low levels of social support.
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Conclusion

The literature reviewed above clearly demonstrates the harmful consequences of poor social
support and the protective effects of having access to rich and functional social networks on
maintaining physical and psychological health. The exact biopsychosocial mechanisms
underlying the positive influence of social support on resilience to stress are unknown. There is
undoubtedly a complex interplay of various environmental and genetic factors that mediate the
effects of social support on health outcomes. Evidence for such a gene-environment interaction
involving social support comes from a pioneering study by Kaufman and her colleagues who
have shown that social support may confer resilience to stress by moderating genetic risks for
depression in maltreated children.49 In this study, the combination of the met allele of the brainderived neurotrophic factor (BDNF) gene and the two short alleles of the serotonin transporter
(5-HTT) gene predicted the highest depression scores in maltreated children; and this
vulnerability was moderated by the presence of social support.49 This important finding
demonstrates that an individual's environment may be modified to attenuate his or her genetic
risk for developing mental illness even in the presence of environmental stressors, possibly by
modifying gene expression. In fact, animal studies suggest maternal care can alter the expression
of the glucocorticoid receptor gene via affecting DNA methylation and chromatin structure.50
Dampening HPA activity may be another major mechanism through which social support
enhances resilience to stress. In fact, findings from animal and translational studies reviewed
above show that social support reduces stress-induced cortisol release. It is possible that stressinduced oxytocin release augments social affiliation, which in turn reduces negative appraisals
and arousal. It is open to speculation whether social support affects DHEA and/or NPY levels,
which may then help to regulate HPA and noradrenergic systems, respectively.
In summary, social support seems to moderate genetic and environmental vulnerabilities for
mental illness, possibly by effects through other psychosocial factors, such as fostering effective
coping strategies, and through effects on multiple neurobiological factors. It will be important for
psychiatric researchers to conceptualize, test, and apply effective interventions specifically aimed
at increasing social support for psychiatrically ill or at-risk populations. This represents an
important challenge for our field.

http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-to-eliminatecardiovascular-health-disparities/about/influences_on_health/family_social_support.html
Family and Social Support
Positive social support (family or friends) plays an important role in ones ability to make
healthier choices. Social support means being able to access people that a person can rely upon if
needed.
The support of family and friends during a crisis has long been seen to have a positive emotional
effect on people. However, this support also has a physical benefit as well. During stressful
times, people tend to experience higher blood pressure and heart rates. However, the presence of
friends or family members has been shown to reduce these rates among people during difficult
periods.
In terms of chronic disease, the support of family or friends has been shown to lessen the chance
that one will become sick or die from heart disease. Research conducted at Brigham Young
University and the University of North Carolina showed that people who did not have strong
social support were 50% more likely to die from illness than those who had such support.1
Family and friends are also important for those who have been diagnosed with chronic disease
such as heart disease, high blood pressure and diabetes.2 Having such support systems is
beneficial in helping patients follow a physician's recommendations. Strong social support will
help patients adhere to their medical regimen by reminding them to:

Keep their medical appointments

Monitor their blood sugar and blood pressure

Take their medicines

Get regular exercise

Eat healthier foods

Finally, family and friends can also provide practical support, such as rides to the doctor or
pharmacy, going to the supermarket, and offering childcare during health care visits. The
encouragement of friends and co-workers can motivate people who have been ill to take steps to
be more active and get back to work more quickly than those who do not have a strong support
system.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729718/

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INTRODUCTION
During the last 30 years, researchers have shown great interest in the phenomena of social
support, particularly in the context of health. Prior work has found that those with high quality or
quantity of social networks have a decreased risk of mortality in comparison to those who have
low quantity or quality of social relationships, even after statistically controlling for baseline
health status1. In fact, social isolation itself was identified as an independent major risk factor for
all-cause mortality2. Current research has focused on expanding several areas of knowledge in
this area. These include (1) social support influences on morbidity, mortality, and quality of life
in chronic disease populations, (2) understanding the mechanisms responsible for such
associations, and (3) how we might apply such findings to design relevant interventions.
It is important to note that social support in these studies is operationalized in several different
ways. Most broadly, support can be conceptualized in terms of the structural components (e.g.
social integration: being a part of different networks and participating socially3) and the
functional components (e.g. different types of transactions between individuals, such as
emotional support or favors4). How the functional components are measured often varies
between studies; transactions may be summarized by actual support received (often ascertained
by asking the support providers5), perceived support received or available6, or the discrepancy
between perceived support and received support7. Support is often further broken into different

types for instance instrumental support and emotional supportas often people have
preferences for different types of aid depending on the circumstances. This diversity of ways in
which support is defined is important and can provide greater specificity (context) to research
findings.
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MORBIDITY AND MORTALITY STUDIES

An important line of research in this area centers on extending our understanding of links
between social support in its various forms and morbidity and mortality. For instance, social
integration has been shown to affect mortality from diseases such as diabetes,8 while belonging
support (characterized by interaction with friends, family, and other groups) was a consistent
predictor of self-reported disease outcomes (included diabetes, hypertension, arthritis and
emphysema) in an elderly population9. Most research in this area, however, has focused on links
between structural aspects of support and cardiovascular disease outcomes. In one longitudinal
study, social participation was shown to predict incidence of first-time acute myocardial
infarction (MI), even after adjusting for demographic and health variables. In this study, those
who had lower social involvement were 1.5 times more likely to have a first MI10. Other studies
also found support for social integrations protective effect on MI morbidity, though the
relationship of integration and all-cause mortality was not significant3. These researchers found
that those with moderate or low social integration were almost twice as likely to be readmitted to
the hospital post-MI then those with high social integration. In fact, social integration showed a
positive dose-response association that was equivalent to other known predictors of rehospitalization3. Another study also showed an association between integration (conceptualized
by living alone) and mortality after hospital release post-MI even after controlling for basic
health and clinical care variables 11. There was also an interaction with gender in that men who
lived alone were at the greatest risk.
Beyond cardiovascular disease, other studies have taken a less structural approach and focused
on perceived and received support, particularly emotional support. One such population survey
showed that for elderly women, low perceived emotional support predicted higher mortality
controlling for baseline demographics and health6. In addition, larger discrepancies between
perceived and received support was found to predict mortality in dialysis patients7. These studies
suggest that emotional support, in addition to structural aspects of support, may reduce mortality.
Although these results are consistent with a large prior body of epidemiological research, there
have been some studies that have shown inconsistent associations. In the context of breast cancer
survival, higher perceived support availability in tandem with low anxiety, what would appear to
be a positive state, actually predicted higher mortality12. The authors suggest that this may be due

to patients restricting negative emotions. Additionally, in one prospective study social support
did not explain risk of stroke beyond established risk factors13. However, support was not a major
focus of this study and was assessed only at work. This is important as prior studies suggest
familial sources of support have stronger associations to health outcomes14.
One interesting trend to emerge recently is the importance of being a support provider on health
and well-being15. For instance, one study found that feelings of social usefulness in the elderly
predicted lower disability and mortality16. Similarly, a study on church-based support showed that
providing support, not receiving it, reduced the effects of ones financial strain on mortality17.
These findings are consistent with a recent ambulatory study4 that showed giving support was
related to lower systolic and diastolic blood pressure. Interestingly, those who reported giving
more support also reported getting more support. The authors postulate that giving and receiving
support have unique pathways to stress: giving is mediated by increased efficacy, leading to
lower stress, while receiving support has a direct effect on stress. Taken together, studies such as
these suggest that there is something potentially unique about giving support. It may be that
people experience positive affect while helping others, which may improve their health18, or it
may suggest that it is in the context of a high-quality relationship in which one feels valued and
can reciprocate by providing support that benefits occur. Future research will be needed to
examine these intriguing findings in the recent literature.
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FOCUS ON POTENTIAL PATHWAYS

More recently, researchers have also been working on elucidating the potential mechanisms that
might explain how social support can influence such noteworthy health outcomes. One area of
particular interest is related to biological mechanisms, especially inflammatory processes19.
However, research on such outcomes has thus far produced inconsistent findings. Researchers in
the Framingham Heart Study attempted to correlate social integration with serum markers of
inflammation (i.e., monocyte chemo-attractant protein-1, C-reactive proteins (CRP), IL-6,
soluble intercellular adhesion molecule-1)20. Controlling for age and potential confounders (some
of which may be mechanisms such as health behaviors, see below), only IL-6 was found to be
inversely associated with social integration in men. An association with IL-6 was not shown in a
study of pregnant mothers, although CRP levels were lower as a function of support during the
third trimester of pregnancy21. Another study found that aspects of social support predicted lower
stimulated levels of IL-8, IL-6, and TNF-alpha, However, statistically controlling for standard
risk factors (including health behaviors), showed that only the link between support and IL-8 was
still significant22. Finally, the Chicago Health, Aging, and Social Relations Study did not find a

link between perceived support and CRP levels while statistically controlling for demographics
and health behaviors23.
The inconsistencies in these findings may be due to a variety of issues including sample
demographics (ranging from young pregnant women to a mixed sample of the very old), the
different types of support measures (ranging from structural measures to functional measures), or
the differences in power within studies (Ns ranging from 17 to >3000). The study with the most
consistent evidence that social support predicts inflammation had the largest sample of older
adults20, This study had the most statistical power and is consistent with data indicating that
psychosocial influences on immune function may be more apparent in older individuals24.
Additionally, this is a newer area of research and cytokines often have complex effects on the
regulation of inflammation. Recent research aimed at examining links between social support
and fMRI activation of specific brain regions that may orchestrate these biological responses
may also help clarify these results 25.
A second potential pathway of interest relates to the influence of social support on health
behaviors 26. Although many prior studies treat such health behaviors as confounds (see above),
recent models of support emphasize its potential role as mechanisms19. For instance, support can
be seen as an encouragement to engage in health behaviors. Conversely, the lack of support or
isolation can become a barrier to health behavior adherence or adherence more generally, as was
reported in a qualitative study of cancer survivors27and HIV patients28. Social support is also
related to broader types of health behavior, including fruit and vegetable consumption,
exercising29, and smoking cessation30. This beneficial support may also come in a health context,
such as ones physician, as those who viewed the patient-provider bond as one characterized by
collaboration, liking and trust were more likely to adhere to treatment for various long-term
medical issues31.
In addition to social supports positive influence on health behaviors and adherence, better
relationship quality also has been shown to have a positive effect on long-term married couples
health promotion behaviors32. These data suggest that the dyadic context may be an important
area that needs additional emphasis in future work. Furthermore, one study contrasted partner
support (aiding and reinforcing a partners own efforts) with partner control behaviors (inducing
change in ones partner). Results showed that supportive behaviors predicted better mental
health, while control behaviors predicted worse mental health and health behavior in their
partners5. Consistent with social control models, these data suggest that effective support may
need to act as a more gentle guiding force that will motivate behavioral change for the better.
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INTERVENTIONS

As we learn more about the effectiveness of social support in affecting health outcomes, it
becomes appealing to use this information to directly help clinical populations. This may explain
why the largest proportion of recent research in social support and health involved interventions,
with many focused on chronic disease populations such as cancer patients.
There are different types of interventions being implemented, many of which include elements of
education and understanding, such as within a context of a support group. Support groups may
be particularly useful because of the gaps they may fill in the support needs of patients and the
experiential similarity within the group. For instance, one qualitative study in cancer support
groups identified the unique role of such groups to be sources of available community,
information, and acceptance; in contrast to waning support from overburdened family and
friends. Additionally, these are situations in which patients can offer support to others and
patients report that belonging to these groups provided an element of support that augmented
other-network support33.
In addition to support groups, some interventions focus on teaching general psychosocial skills
and capitalizing on support within existing networks (e.g., cognitive behavioral therapy). In one
study, caregivers of AD patients were enrolled in a randomized intervention trial designed, in
part, to teach support seeking skills. In comparison to a usual-care control group, those who were
in the treatment group were better at fostering their emotional ties and were more satisfied with
support34. This type of intervention has also been shown to work in child patient populations. For
instance, children with cystic fibrosis were involved in a randomized intervention trial that
educated the children about their disease and taught them relevant social skills. Those in the
treatment group improved their quality of life and peer relationships, and decreased their
loneliness and the perceived impact of the disease35. These findings are especially important due
to the potential isolation faced by children in some chronic disease contexts. In another
intervention, Type 2 diabetes patients improved their use of social resources and social
integration (though perceived support did not change) compared to usual care36. Moreover, such
changes mediated effects on physical activity, percentage of calories from fat, and blood glucose
levels. It should be noted, however, that the use of such general or complex interventions,
although successful in altering risk factors37,38, does not allow us to conclude which specific
component may have been driving the beneficial outcomes.
Of course, the practicality and cost-effectiveness of an intervention are also important to
consider. Recent research is examining these issues by focusing on telephone and internet-based
support interventions. Although no physical health outcomes were measured, one study found
that an education and coping intervention over the phone for patients awaiting lung-transplant
increased quality of life and lowered depression39. Additionally, using a randomized control
design, other researchers40 studied a telephone support group and found it to reduce depression in

older caregivers compared to no-intervention control group caregivers. These data suggest the
potential usefulness of alternative support interventions which may be especially important for
those with practical (e.g., transportation), physical (e.g., disability), or social (e.g., anxiety)
barriers.
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CONCLUSION
The literature on social support and health is robust and continues to be an active area of
research. However, the next generation of studies must be able to explain the contexts and
mechanisms for why such associations exist. Such research is in its infancy but is currently being
fostered by increasing interdisciplinary perspectives on social support and health. We believe that
such approaches will be crucial in order to better tailor primary or secondary support
interventions that have beneficial influences on physical health outcomes