Case Study
Evelyn is a 35-year-old woman who presented to a psychiatrist with complaints of marriage difficulties. As she described some of these difficulties, she leaned forward, and her psychiatrist responded by changing her body posture and unfolding her arms. Evelyn explained that she had been brought up to be stoic in the face of difficulties. When she described some of the family’s early circumstances, her expression became sad and her psychiatrist responded by furrowing her brow. Evelyn’s parents had encouraged the kids to be self-reliant and independent; problems were not complained about, they were simply dealt with. At present, however, her situation felt overwhelming. She felt embarrassed to have to talk with a stranger about her marriage. Her psychiatrist reflected back, saying that her early family had obviously given her many strengths, and that it must be difficult to have to ask for help. At that point in the conversation, Evelyn’s eyes misted over with tears.
Cognitive-Affective Neuroscience of Empathy
How does anyone know what anyone else is feeling or thinking? The question of whether there are other minds, and whether they have the same kinds of consciousness as our own, is as old as philosophy. The question of how best to understand our patients and their emotions and thoughts is old as the practice of medicine and has long been a focus of theory and research in psychotherapy. Recent research1-5has also provided the initial outlines of a cognitive-affective neuroscience of empathy, often including the idea that perceptions of behaviors, emotions, and cognitions in others activate one’s own representations of these phenomena.
An immediate question is whether such a schema is the best way to conceptualize empathy. Many authors have contributed to a rich literature on empathy, including philosophers,6,7biologists,8,9psychotherapists,10-13and social psychologists.14Different strands within this writing have emphasized the affects involved in empathy (eg, involving emotional contagion and resonance),15and the cognitions involved in empathy (eg, involving imagination and projection). There is, however, an increasing interest in theories which integrate behavioral, affective, and cognitive elements of empathy.1,16,17
Neuroanatomy/Neurochemistry
Given the range of affective and cognitive processes thought to be required for empathy, the relevant neurocircuitry is likely to be complex. It requires the inclusion of limbic areas, which underpin rapid processes such as emotional resonance, and frontal areas, which underpin slower processes such as imagination and projection. Functional brain imaging research has demonstrated somatotopic activation of premotor cortex during action observation18and of similar areas during face imitation5and intention understanding.19A growing series of parallel studies2,3,20-22on empathy confirm the importance of pathways in and between the amygdala, insula, and inferior frontal cortex (Figures 1 and 2). Anterior cingulate, in particular, appears activated by empathy for pain.21-23Related data24-26explores the neurocircuitry required for social cognition and for a theory of mind (Figure 3).
The absence of empathy in certain neurological and psychiatric disorders, including autism and antisocial personality disorder, may also provide some clues about the relevant neurocircuitry.25,27,28In lesions of the amygdala, patients are less able to recognize emotions in others (an affective part of empathy); in lesions of the somatosensory-related cortices there is impairment of emotional concept retrieval (a cognitive part of empathy).29While social cognition ordinarily encompasses satisfaction from altruistic punishment after the violation of social norms,30certain neurological lesions may be associated with abnormal enjoyment in inflicting pain on others.31
There is also increasing work at a molecular and cellular level. The discovery of mirror neurons has suggested the possibility that certain neurons are particularly important in empathy.32,33Electrophysiological recordings have demonstrated that single neurons can be activated when a subject observes pain in others.34Behavioral and physiological changes in animals exposed to the physical pain of conspecifics have been investigated and are similarly relevant to understanding the psychobiology of empathy.35The molecular underpinnings of basic cognitive-affective processes, such as attachment, are becoming clearer and, again, may be useful for understanding some aspects of empathy.36
Gene/Environment
To what extent is empathy an inherited or a learned phenomenon? There appears to be inter-individual variability in the capacity to respond empathically in both humans and other animals. Studies of human infants suggest that there is some innate capacity for the affective processes involved in empathy (eg, imitating facial expressions).37However, learning is also important, with infants gradually developing themselves as agents that can change their physical environment and reciprocate in social exchanges. Understanding the other can be conceptualized as a form of embodied practice.38Empathy develops and improves gradually over time in laypersons and in clinicians.17,39
Evolutionary Approaches
Empathy has been conceptualized from an evolutionary perspective as a “concern mechanism” that enhances survival.40Darwin8and McDougall14have suggested that emotional contagion exists to enhance mother-infant bonding. In a tour de force, Preston and de Waal1 place the emphasis differently, noting that empathic processes allow infants to perceive and learn from the expressions of the caregiver, and allow caregivers to be affected by the emotions of infants. They argue that the nervous system has evolved to perceive and act not only in the physical environment but also in the social environment; in non-human primates, and especially humans, development of the frontal cortex and of cognitive-affective capacity has allowed the emergence of increasingly sophisticated empathic processes.1
Clinical Implications
DSM-IV-TRDiagnosis
Should we have a section inDiagnostic and Statistical Manual of Mental Disorderson empathy disorders? There is a rich literature on disordered empathy in autism.25Cluster B personality disorders also seem to involve a failure of empathy, with disordered empathy particularly relevant to psychopathy and to narcissism. Speculatively, there may also be disorders characterized by exaggerated empathy. These remain to be defined. (One theory, for example, posits that social anxiety disorder might involve increased awareness of negative social cues).
Assessment/Evaluation
Deficits in empathy in antisocial and narcissistic personality disorders are unlikely to be validly assessed using self-rating scales, given that relatively few people with these conditions are able to volunteer that they have such lacunae. Problems in empathy may be included on some clinician-rated instruments addressing these disorders. However, more focused questionnaires are available to assess individual differences in empathy.41,42Furthermore, empathy in the clinical process can be assessed using scales, such as the Consulation and Relational Empathy measure.43
Pharmacotherapy/Psychotherapy
Empathy has been argued to have several key advantages in the clinical context: it may encourage patients to provide better histories and so improve diagnosis; it may increase patients’ self-efficacy and so lead to increased participation in treatment; and it may lead to therapeutic interactions that directly improve symptoms.44Conversely, it has been suggested17that empathy allows clinicians to make better connections with their patients, and so gain more professional satisfaction. Although much additional data on this area is needed, a number of authors have therefore advocated techniques for enhancing clinicians’ empathy.17,45
Conclusion
While the question of other minds is an old one, the psychobiology of empathy is a new field of investigation. There has, however, been convergent evidence, providing the framework for a cognitive-affective neuroscience of empathy.1-3Additional research is needed to build on these conceptual and empirical foundations, and also to extend them to the clinical arena. Such work is crucial, not only because certain psychiatric disorders may be characterized by disordered empathy but because empathy lies at the very core of the clinical encounter.
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Dr. Stein is professor and chair at the University of Cape Town in South Africa and visiting professor at the University of Florida in Gainesville.
Disclosure: Dr. Stein has received grant support/honoraria from AstraZeneca, Eli Lilly, GlaxoSmithKline, Lundbeck A/S, Orion, Pfizer, Pharmacia, Roche, Servier, Solvay, Sumitomo, and Wyeth.
Funding/Support: Dr. Stein receives support from the Medical Research Council of South Africa.
Author’s note: The current case is based on an amalgam of the author’s experiences.
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