The world is, and has always been, an interesting place − although I guess we do not have another one to compare it with. Over many centuries, humans have done what no other species have been able to do to a similar scale: we can travel all around the world, and that relatively quickly and inexpensively. We are able to discover or visit foreign places that may be far away or much closer from home. The advent of mass transportation of people means that we are able to interact with many different communities, who are likely to speak a different language to your own, who may have different value systems and may have different social systems, different rules of interactions, behaviours etc. This thirst for travel and discovery that has existed for generations seems to be unique to humans and is not seen in any other species. Indeed, travels in non-human species are primarily related to survival, either for reproduction purposes − such as those seen in the migratory patterns of species as varied as salmons, monarch butterflies, Canadian geese − or to find new territory or feeding grounds or in response to natural events (floods, drought). In other words, it seems that travel for travel’s sake forms a unique human behaviour. One wonders whether our need for travel derives in part from what Aristotle described that humans are by nature social animals; and in effect, the need to travel may indicate a need to connect socially with other groups, groups that may or may not share values with you.
The onset of the COVID-19 pandemic early in 2020 has turned this modus operandi on its head. International travel, and in many instances even local travel, was banned. The ability and freedom to go wherever we want, whenever we want and for how long that we had taken from granted, was suddenly removed from us, dramatically redefining our possible ‘world space’. All of a sudden, the possible world space was no longer the world but, for many, was limited to the four walls of our own home or the very close neighbourhood, and that for many weeks or even months. In addition, this physical restriction and limitations of movements leading to physical isolation has also had a dramatic impact on our social interactions and social isolation.
The direct impact of the SARS-CoV-2 virus on human health is well documented: with an increased in mortality and morbidity, particularly in vulnerable populations; for example, populations with pre-existing other medical conditions, older populations or communities with limited access to medical infrastructure, technologies or limited access to vaccines (Fajnzylber et al., Reference Fajnzylber, Regan, Coxen, Corry, Wong and Rosenthal2020). In addition, it is likely that this impact will be seen for many years to come (e.g. so called long COVID; Huang et al., Reference Huang, Huang, Wang, Li, Ren, Gu and Cao2021), even as we are (seemingly) slowly taking control of the situation through mass vaccination and infection control procedures.
What is becoming increasingly evident is that restrictions to our social interactions due to the COVID-19 pandemic have had dramatic effects on our physical and mental wellbeing, resulting in an increase in rates of depression, suicide and anxiety levels (Phiri et al., Reference Phiri, Ramakrishnan, Rathod, Elliot, Thayanandan, Sandle and Delanerolle2021). This increase in psychological disorders further reflects the disruption social isolation has on our ability to carry out our usual social roles and, by extension, our identity. Indeed, rather than we are because we think, to (mis)quote Descartes, we are because of what we do, and because of how others see what we do; Indeed, the way we exist as individual (i.e. ‘being’, ‘self’) is primarily defined by the many (or few) roles that we carry out in our day-to-day activities. As we are adapting to this new world order of restricted movements, this has been accompanied by a change in our roles. For me, as I am adding a new role to my repertoire in becoming the president of ASSBI, this provided me with the impetus to review some of the aspects that are fundamental to our sense of being, our identity and contribute to making who we are.
Before going any further, a word of warning: this presentation is not intended to be a comprehensive review of all aspects that contribute to our sense of self or of being. I will focus primarily on the social and psychological aspects and, as such, I will not discuss the biological and genetic dimensions here. This is not to ignore or diminish the central role that our biological self and our genetic makeup play in shaping who we are and who we will be as a person, in defining our biological needs, strengths and weaknesses, and how we respond to changes in the natural and social environment. What I will review are some of cardinal features that shape/contribute to our sense of being, as they provide a framework for shared values, shared expectations and shared experiences, which we know are among the basic building blocks of social identity and, by extension, of social groups.
Language
With the increasing mass movements of people around the world in recent decades for work or pleasure, language has become one of the most obvious defining features that denotes group identity, and possibly more so than race or ethnicity. The language spoken by an individual provides undeniable signals as to the group of affiliation, which maybe bring a range of preconceived ideas and biases about that particular group (e.g. ‘Swiss people are tidy’). Having lived in Australia for over 30 years but from a non-English speaking background, one of the first questions that I often get when I meet new people is about my origins. Whether I want it or not, others see me through this lens and part of my identity is defined by the fact that I was born and raised overseas and that I still have a foreign accent despite all these years spent in Australia.
Whilst it provides a crude, yet obvious instrument for categorisation (e.g. English speaking vs non-English speaking; British vs American English), by this very nature, language also provides a framework for communication and communication enables social relations. Language affords shared values which then promote a sense of identity and belonging. When meeting another person speaking the same language will derive a set of expectations with regard to values and meanings.
Place of Origin (Background and Culture)
Whilst overlapping with language, a second important feature is related to one’s own background and culture. This variable is unusual insofar that it will contribute to the sense of identity even for those who may have never lived in their place of origin. For example, second-generation migrants are good examples of this situation. They commonly straddle their personal background and culture, sharing language and culture of their peers, and that of their parents, which may be very different, and can potentially lead to familial tensions, because of different value systems and frames of references. Nevertheless, the transmission of cultural and background knowledge about the place of origin of one’s parents will undoubtedly colour how one sees the world and how one processes and understands some world events.
Education, Shared Social Rules and Hobbies/Interests
Although clearly different, I have grouped these three variables in a single domain in that all three reflect shared past (or current) experiences. Where we went to school and the type of school we attend (public, private) will establish a framework for common knowledge and social interactions. Again, this knowledge will be accompanied by a range of perceptions and (mis)understandings (‘oh, she went to Harvard’). School reunions exist in part for that reason; this is an occasion to relive past events and strengthen social bonds by re-experience or reminiscing about specific episodes. Apart from our upbringing and schooling which are the most salient environments for learning social rules, participation in clubs (e.g. sports, Scouts, etc.), churches are also important structures where rules are acquired. In addition to providing a social structure in which members can navigate and interact, this knowledge will enable rapid social bonds with other individuals sharing these same experiences or background, even in a different environment.
The same process applies for hobbies and interests, with the most important one being music and musical taste. Shared musical experience and preferences will provide a common social space for interactions and defining self-identity. Most of us will have special musical pieces that are associated with specific events (e.g. wedding, University days) or specific moods and associated with a certain time period (early adulthood appears to be often the critical period defining our taste in music). Conversations around music can lead to heated debates ('of course, the Beatles were more influential than the Rolling Stones'), which hint at something more profound than just musical preferences, such as group membership, social values and distinction from other groups. The fights between mods and rockers in the 60s and between the rudeboys, skinheads and punks in the late 70s in England, or those between West coast and East coast hip hop outfits in the 90s in the USA are prime examples that go well beyond the music itself and relate to shared social rules and experiences more broadly (Cohen, Reference Cohen1972). Finally, our world views, that comprise political, moral or religious opinions, and even our sense of humour are other important variables that will have a major influence on social integration and social interactions and will contribute to defining who we are as individuals and our sense of self.
In addition to these broad social variables, our identity and sense ‘self’ is also shaped by our cognitive skills in general and our social cognitive skills, more specifically. Attention, memory, language capacity, as well as our capacity for empathy, theory of mind and high-level emotion processing all contribute to this sense of self and for which we may not be necessarily aware. This becomes particularly obvious when the system is disrupted, for example following a stroke, a traumatic brain injury or with the onset of a dementia syndrome. Often, the presence of (social) cognitive deficits will be accompanied by widespread changes in how the self is apprehended by the individual themself but also by the people they interact with.
Social Integration
As was described above, social integration is a complex process involving many different variables, but one that is underpinned primarily by two integrated processes that work in parallel: social grooming and a cognitive component (Dunbar, Reference Dunbar2012). The social grooming represents our emotional platform, which is primarily based on the time spent with other people and will lead to social bonds and relationships and associated with neurochemical changes involved in bonding, reward etc… such as oxytocin, dopamine and other endorphins. This process is, however, not trivial and is not without costs. Indeed, fostering of such relations require significant investments in time, generally over long periods.
The second process of this social integration involves cognition. It enables and facilitates aspects of high-level social behaviour such as trust, obligation and reciprocity. This can be viewed as a second level cognitive framework on which to organise the emotional platform. For example, trust implies a recognition of the value that a person brings to the social interactions with the potential benefits that this can bring in the future. Independent but somewhat related constructs are those of obligations and reciprocity. As a member of a social group, I am expected (obliged) to behave in a certain way and follow certain rules. Similarly, I am also expected to return favours after having been the recipient of a positive outcome (e.g. someone lending you something or doing you a favour; Sutcliffe et al., Reference Sutcliffe, Dunbar, Binder and Arrow2012). All these aspects will contribute to maintaining or enhancing the strength of the relations within the group and emphasise the singularity of the group in comparison to other groups. Importantly, failure to follow these rules may result in penalties or in the exclusion from the group. This system of checks and balances is cognitively costly in that it requires the involvement of various cognitive processes, such as memory, attention and executive function. From a research viewpoint, and certainly as neuropsychologists, we seem to know more about the cognitive component than the social grooming aspects of social integration, despite the fact that the latter forms the foundation of this process.
Recent research has also uncovered important stable traits regarding the structure of our social network. In particular, Dunbar (Reference Dunbar2018) demonstrated that we navigate a series of nested friendship spaces that vary in the number of members and in the intensity of the relationship, ranging between 1–2 (intimate partners), 5 (the very close friends one would call on in times of emotional needs and support), 15 (the core social group variably labelled the ‘sympathy group’) to our larger group of acquaintances and people we would recognise, which tend to be around 150 individuals. Not all these groups are created equal in that the time and effort that we invest in each will vary markedly. Indeed, it is estimated that about 40% of our total social effort is dedicated to our two closest circles: our intimate partners and our very close friends, in order to maintain this emotional closeness. Further, this emotional closeness is closely associated with the frequency of contact; in other words, we will see more frequently our very close friends but will be satisfied with the occasional visit to our more distant friends. Because of these variable investments, these social circles tend to be very stable in size. A corollary is that the movement of members across these different groups is not without consequences. A promotion of one member from one distant to a closer social circle will generally lead to the demotion of one member of that circle to a lower-order circle.
Importantly, evidence now indicates that close social relationships have widespread effects on mental and physical health. People with positive close relationships are more content with life, report better mental health and also tend to recover more quickly from physical health problems or surgical interventions. These benefits are also seen through indirect bonding activities, such as eating with friends, sharing hobbies (singing, dancing) that increase endorphin levels (Dunbar et al., Reference Dunbar, Launay, Wlodarski, Robertson, Pearce, Carney and MacCarron2017).
Social Behaviour in Lockdown: Impact on Dementia
After outlining these aspects of social behaviour, the negative impact of physical and social isolation as means to contain the pandemic becomes then evident. Lockdown measures have been very effective at containing the spread of the SARS-CoV-2 virus but have highlighted the fragility of mental health of many individuals and the importance of social interactions for a sense of being complete. I believe that illegal social gatherings during lockdowns, such as beach parties or engagement parties as documented in the media reflect this need for social interactions rather than necessarily a desire to flaunt the rules. ‘Freedom day’ celebrations as recently experienced in the UK or in Sydney are another expression of this basic need. Indeed, the haircut at 12.01 am on ‘freedom day’ is likely to be less important than the re-connection with social peers.
Lockdown measures have also had a dramatic impact on individuals diagnosed with dementia, particularly those living in supported accommodations or in nursing homes. Cognitive deficits affecting the domains of memory, language, executive function and attention are common with the unfolding of dementia, often accompanied by behavioural changes, such as apathy, disinhibition, impulsivity (Piguet & Kumfor, Reference Piguet and Kumfor2020). In addition, many individuals with dementia also experience changes in social cognition with reduction in the capacity to process, understand emotional information and express emotional needs (Mendez, Reference Mendez2021). Unfortunately, nursing homes are often under-resourced and struggle to provide the optimal level of social support and engagement that would benefit their residents. As such, social interactions are primarily provided by family members and friends. The onset of lockdown rules has created a perfect storm for this vulnerable population. Already socially isolated, these new rules prevented all social contacts that we now know are a central component towards mental health and contributing to the sense of self. The situation was further compounded by the presence of cognitive deficits which often made it difficult for residents to understand the needs and reasons behind these rules (e.g. the need for handwashing, the lack of physical contacts, wearing of masks or personal protective equipment). In addition, the wearing of the masks and PPE by staff and (the few) visitors, meant that facial social cues, such as smiles, raising eyebrows etc… were no longer visible and available, making the already compromised processing of social information even more difficult (Grundman, Epstude & Scheibe, Reference Grundmann, Epstude and Scheibe2021). It is therefore not surprising that many have reported a marked decline over the course of the lockdown periods in general functioning, cognitive abilities and capacity to perform various activities of daily living in individuals with dementia living in nursing homes and supported accommodations.
Lester Bangs, the famous music journalist for Rolling Stone magazine, one day said: ‘The only questions worth asking today are whether humans are going to have any emotions tomorrow and what the quality of life will be if the answer is "no"’. Far from being a health professional interested in mental health and social integration, Lester Bangs’ quote nevertheless hit the nail on the head, by highlighting an issue that is very real for many individuals diagnosed with dementia or other neurological conditions, and because of external circumstances are unable to live in an environment that encourages, promotes, supports social interactions. This is also particularly relevant as social isolation, depression and inactivity are variables that have been identified as risks factors for dementia, risk factors that are modifiable (Livingston et al., Reference Livingston, Huntley, Sommerlad, Ames, Ballard, Banerjee and Mukadam2020). These are the same variables that also increase the level of severity of dementia if left unaddressed, as alluded to above. Evidence further has demonstrated that the strength of one’s social network has widespread benefits, including faster recovery from illness, life satisfaction and reduced susceptibility to disease, likely arising from the effects of endorphins on the immune system, benefits which have also been observed in other social species, such as baboons or zebras (House, Reference House2001; Silk et al., Reference Silk, Beehner, Bergman, Crockford, Engh, Moscovice and Cheney2010).
The events of the past 2 years have identified a number of challenges and shown that, as clinicians, we have become experts at measuring changes in cognition and behaviour, and functional capacity, but that we are much less well equipped to measure sense of self, of identity and sense of belonging, which are all critical components of who we are as individuals. The next challenges will be for us to integrate these aspects in our general practice and start measuring features such as changes in friendship networks, changes in shared social rules or changes in world views (e.g. political or religious), as they may indicate disturbance in the sense of self-identity and personal identity. We also need to become even more mindful of the cultural differences and how these differences will contribute to, or modulate, performance on testing and in daily activities.
Financial Support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflicts of Interest
Author has no conflicts of interest to disclose.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
