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Well-integrated pain observers modulate aversive arousal through late top-down neural processes


Walter Van der Broek

There is a significant decline in empathy occurs during the third year of medical school. This decline occurs during a time when the curriculum is shifting toward patient-care activities.

  • There is a significant decline in empathy during third year of medical school, regardless of gender or specialty interest.
  • Every year women scored significantly higher than men.This seems to be regardless of population studied. It also appeared in Italian Physicians and Japanese medical students.
  • Except for scores at baseline, students interested in people-oriented specialties scored significantly higher than students interested in tech-oriented specialties.
  • The magnitude of the decline (effects) was much smaller for women and students interested in people oriented specialties. 

Why is empathy important?
Responsiveness to the emotional state of another plays a fundamental role in the patient doctor relationship (PDR) as well as in other human interaction. Sympathy and empathy are not the only responses in the PDR. Other responses can be consolation, kindness, politeness,compassion, and pity.

What is empathy (the long version)?
The most clarifying definition of empathy is based on viewing it as a process. This process of empathy consists of the following stages.

  • The patient expresses feelings by way of verbal and non-verbal communication. Patients are not always aware of these expressions.
  • The doctor also notices these emotions in himself more or less voluntary, more or less conscious. He or she coming aware of these feelings usually comes after the fact (affective empathy).
  • Realizing these feelings as being from the patient is the cognitive empathy. Together with everything the doctor knows about the patient as a patient and as a person, he or she is coming to know the inner feelings of the patient(cognitive empathy).
  • The doctor can now express these feelings for the patient or act on them for the patient(expressed empathy).
  • The patient receives this empathy (received empathy).

More here.

JM Livengood,

The author, a psychologist in a pain control center, was asked by the editor of The Clinical Journal of Pain to relate her personal experience with neuropathic pain. Her chronic pain began six years previously when her car was rear-ended by a large tractor-trailer truck. After several weeks of traction, rest, and a cervical collar, healing began. One year later she was re-injured in a fall and in addition to the cervical injury also injured her lumbar spine. She experienced right upper and lower extremity numbness, loss of fine motor skills in the right hand, and difficulty walking. Despite her neurosurgeon’s urging to maintain strict bed rest for two months, she put herself on a walking program to prevent muscle atrophy. She continued to have chronic pain with occasional flare-ups.

Several months later, in the process of building a patio lounge chair, her already weakened spine was again injured. She required surgery, including a fusion at C4-5, along with removal of a ruptured disc and removal of several fragments from the spinal canal. Presurgical nerve damage caused prolonged motor weakness and numbness. Also, when the bone graft was removed from the iliac crest, injured nerves left her with neuropathic pain in the left thigh and leg. During the subsequent healing months, the author learned personally about definitions of complex regional pain syndrome (CRPS), allodynia, dysesthesia, hyperesthesia, and about listening to patients in pain and believing their story. She discusses several “do’s and don’ts” for surgeons and for patients, related to her personal experience. Probably the most valuable advice for pain management professionals is to listen to your patients. Ask them what is wrong and they will tell you. It is common to ask patients questions which relate to the experience of chronic pain, but do not seem to relate to CRPS symptoms. For example, “When is your pain worse?” “What positions worsen pain?” While these activities do relate to chronic pain, there is no mention of experiences that affect neuropathic pain such as encountering a sudden blast of water while in the shower, walking into an air conditioned room, or walking outside on a windy day. Also, questionnaires contain descriptions of chronic pain symptoms but not CRPS symptoms such as crawling ants, stinging bees, and soft cotton being rubbed across one’s skin. The author describes the feeling of cold air from air conditioning or wind contacting her skin feeling like lightning-sharp goose bumps like cactus spikes. She experienced an intense burning, stinging sensation as though a swarm of angry yellow jackets was stinging profusely and unrelentingly. Areas of her skin felt hot and cold simultaneously. She had a feeling of soft puffs of cotton containing shards of razor-sharp steel being rubbed agonizingly slowly over her skin where the bone graft was taken. Also, she described a feeling of a soft feather being rubbed tortuously slowly and softly over her skin. These are symptoms which the author feared no one would believe if she actually described how they felt.

As a psychologist, she never actually disbelieved, but did doubt patients who told her they hurt too badly to comply with their relaxation and visual imagery exercises. She never disbelieved, but did doubt patients who reported that their pain “moved” or increased after receiving a nerve block. As a patient, she learned what they meant.

She emphasizes the importance of treating patients with empathy, respect, and explanations of treatments. One of the most beneficial things she gained by being a patient is to listen to her patients and try to actually hear what they are telling her, instead of listening for what she thinks the patients should say in order for her to impose a known treatment on a familiar sounding problem. She believes persons stereotyped as “professional” patients may simply be patients seeking professional help.

Journal: Clin J Pain, 12(2):90-93, 1996. 0 References Vanderbilt Pain Control Center, 401 Medical Arts Bldg., 1211 21st Ave., South, Nashville, TN 37232 (Dr JM Livengood) JAC.03 OC9608/278 ©1996.

Carrie Vance, opednews.

While white Cambridge Police Officer Sgt. Crowley teaches classes on profiling, his surprise at Prof. Gates agitation belies a lack of the gut understanding of what it feels like. His approach speaks of a mechanical one hatched out of P.C., rather than what it actually means to be Black in America. While there’s been a gradual advance in understanding the nature of institutional racism, our news reports are replete with the drumbeat of misunderstandings, even death, because we keep sliding over what’s behind it: something much deeper, denied only to pop out and catch us in another maelstrom, something systemic yet to be rooted out of the American psyche.
We’ve trashed the real meaning of empathy. An empathic person is one who can imagine themselves in someone else’s shoes, even when they disagree with that person or don’t understand what they’ve done. How do you teach constructive empathy? 
Can empathy root out the systemic racism that operates, often to our dismay, on an unconscious level? Do we know what’s happening in the mind of a white grandmother who freezes with suspicion at the sight of a black man walking towards her? How do we address what’s happening in the mind of a white mother who’s watching her children at the Valley Pool, only to be filled with fear that a visiting group of black children might steal from them?
More here.  

The study published in Pain by Makikio Yamada and Jean Decety [19] investigates the unexplored relation of perceived pain to the emergence of empathic concern. According to the authors, the question itself appears problematic. For, how can detected pain at once urge observers to avoid the source of threat and also instigate approach-behaviors in the form of empathy and provision of care? In this letter, we claim that the pathway to empathy for pain is not paradoxical, but is paved by the human capacity to separate perceptions from aversive self-oriented responses and, thereby, to free up those perceptions to acquire symbolic and interactive meaning. 

Pain warns of physical threat and danger on the one hand and also signals an opportunity to care for and heal the person in pain on the other [17]. The protective function of pain instigating behavioral escape perhaps is more primitive, because self-focus likely precedes the care of others [2]. Intense self-focus in observers perceiving another person’s state is linked to aversive self-oriented emotions (e.g., discomfort, anxiety) that may be negatively associated with regulatory capacities [7]. By contrast, sympathy for others is positively related to the capacity of observers to voluntarily limit their emotional response to a zone that is arousing but not aversive [8]. With respect to pain, higher levels of aversive self-focus have been found in individuals who experience the threat-value of pain in their child [9] or their spouse [15] in a personally distressing way. These individuals would be expected to have a reduced capacity to voluntarily regulate their emotional state and an initial tendency to focus on their own emotional needs [6]. Other-oriented emotional responses such as empathy would likely be inhibited or delayed [1; 9]. Since sympathy is positively associated with regulatory capacities, sympathy for pain should promote recognition of the other’s state because the observer’s regulation of her own emotions is the basis for identification with the emotions of others [5]. The ability to manage or ‘tame’ an emotion-based response to the other in pain therefore permits an observer to attend to the emotional needs of the other and may facilitate sympathy for pain and helping behaviors [7]. Put another way, a response that remains ‘catastrophic’ tends to undermine interpersonal exchanges and empathy; but a regulated emotion can be used for interacting with others [13].  

Observers able to control their response to detected pain in others can voluntarily reflect on their own emotions, and the possible emotions of the other in pain. Adults and older children can say, ‘Are you hurt?’, and see how the other person responds to this statement. Or perhaps an observer thinks to herself, ‘Help him now’. In both situations, the observer is exploring options based on a process of reflective thinking involving the use of symbols rather than an aversive emotional response based on the perception of pain in the other and a potential threat to oneself [13]. Consulting a symbol enables an observer to know consciously the state he is in; he can now reflect on the emotion rather than let it overwhelm him [13]. We propose that emotion-based reactions and voluntary regulatory capacities are positively linked [6] to the degree in which an emotion is transformed into a symbolic and interactive form [13]. By contrast, if an emotional reaction remains catastrophic, it pushes for an aversive response; there is awareness of the physiologic states but not an understanding of other emotions or reactions. For example, an observer to pain in another person might think, ‘My heart is beating fast. I need to get out of here because I am scared’ (and then the person runs) [6]. But individuals who can fully symbolize the emotion and reflect on the feeling can describe how it feels to be distressed and can connect it with similar experiences in oneself or even others [13]. This pattern may link accessing long-term memories to process emotional responses at a deeper level [13], and planning effective helping and caring behaviors [7]. 

In healthy development, emotions such as fear and anger tend to be transformed from fixed catastrophic reactions into interactive patterns and symbols in the second half of year one and the second year of life and thereafter [11;12;13]. The catastrophic responses of infants to tissue pathology become shaped by parents and caregivers into differentiated and socially responsive patterns of behavior [14]. The infant who looks to a parent or caregiver when in pain is learning to show distress, to negotiate [16], and to get her needs met [4; 10]. As this happens, emotional responses are no longer locked into patterns of intense self-focus; preschoolers able to bring a parent to provide help when others are in pain can modulate their aversive response through interactions with others [4; 10]. The development of normal language allows children to use words and sentences to symbolize pain. This may facilitate other-oriented interactions and reflective thinking through sharing emotions and ideas. For example, a toddler may represent painful distress in role-playing scenarios to direct or manipulate the attention of parents and siblings [4]. Just as a baby or infant exists in the social circumstance of a baby/caregiver relationship [18], an emotional response that has become an interactive symbol exists in the circumstance of its interactive pattern [11]. Without the modulating influence of an interaction, the child’s response to a person in pain may grow more intense and she may be left using the aversive self-oriented feelings. Her expression of emotion is, therefore, not part of a fine-tuned regulated symbolic system: it may be simply a self-oriented emotional response. We argue that the separation of a perception from its aversive response may explain how perceived pain shapes its threat values and instigates empathic behavior.  



  1. Cano, A, Leonard, MT, and Franz, A. The significant other version of the Pain Catastrophizing Scale (PCS-S). Pain 2005; 119: 26-37.
  2. Craig, KD. The Social Communication Model of Pain. Canadian Psychology 2009; 50: 22-32.
  3. Craig, KD, McMahon, RS, Morison, JD, and Zaskow, C. Developmental changes in infant pain expression during immunization. Social Science and Medicine 1984; 19: 1331-1337.
  4. Craig, KD, and Korol, CT. Developmental issues in understanding, assessing, and managing pediatric pain. In: Walco G,  Goldschneider K, editors. Pain in Children: a practical guide for primary care. Totowa, NJ, The Humana Press, Inc, 2008. pp. 9-20.
  5. Decety J, and Jackson, PL. The functional architecture of human empathy. Behavioral and Cognitive Neuroscience Reviews 2004; 3: 71-100.
  6. Eisenberg, N. Distinctions among various modes of empathy-related reactions: A matter of importance in humans. Behavioral and Brain Sciences 2002; 25: 33-34.
  7. Goubert, L, Craig KD, and Buysse, A. Perceiving pain in others: Experimental and Clinical Evidence on the Role of Empathy. In: Ickes W, Decety J, editors. The social neuroscience of empathy. Cambridge, MA: MIT Press, 2009.  pp. 153-165.
  8. Goubert L, Vervoort T, and Crombez G. Pain demands attention from others: The approach/avoidance paradox. Pain 2009; 143: 5-6.
  9. Goubert L, Vervoort T, Sullivan, MJL, Verhoeven, K, and Crombez G. Parental emotional responses to their child’s pain: the role of dispositional empathy and parental catastrophizing about their child’s pain. Pain 2008; 9: 272-279.
  10. Goubert, L, Craig, KD, Vervoot, T, Morley, S, Sullivan, MJL, Williams, ACdeC, Cano, A and Crombez, G. Facing others in pain: the effects of empathy. Pain 2005; 118: 285-288.
  11. Greenspan, I. Intelligence and adaptation: An integration of psychoanalytic and Piagetian developmental psychology. Psychological Issues Monograph Series, nos. 47-48. New York: International Universities Press, 1979.
  12. Greenspan, I. The development of the ego: Implications for personality theory, psychopathology, and the psychotherapeutic process. New York: International Universities Press, 1989.
  13. Greenspan, I, and Shanker, SG. The first idea: How symbols, language, and intelligence evolved from our primate ancestors to modern humans. Cambridge, MA: Da Capo Press, 2004.
  14. Hermann, C. Modeling, social learning of pain. In: Schmidt, RF, Willis, WD, editors. The Encyclopedia of Pain. Heidelberg: Springer-Verlag, 2007. p. 13.
  15. Leonard, MT, and Cano, A. Pain affects spouses too: Personal experience with pain and catastrophizing as correlates of spouse distress. Pain 2006; 126: 139-146.
  16. Sullivan, MD. Finding pain between minds and bodies. The Clinical Journal of Pain 2001; 17: 146-156.
  17. Williams, C. de C, A. Facial expression of pain: an evolutionary account. Behavioral and Brain Sciences 2002; 25: 439-488.
  18. Winnicott, DW. The child, the family and the outside world. Reading, Mass.: Addison-Wesley, 1987.
  19. Yamada, M, and Decety, J. Unconscious affective processing and empathy: An investigation of subliminal priming on the detection of painful facial expressions. Pain 2009; 143: 71–75. 

Nicolas Danziger, Isabelle Faillenot, and Roland Peyron.

Theories of empathy differ regarding the relative contributions of automatic resonance and perspective taking in understanding others’ emotions. Patients with the rare syndrome of congenital insensitivity to pain cannot rely on ‘‘mirror matching’’ (i.e., resonance) mechanisms to understand the pain of others. Nevertheless, they showed normal fMRI responses to observed pain in anterior mid-cingulate cortex and anterior insula, two key regions of the so-called ‘‘shared circuits’’ for self and other pain. In these patients (but not in healthy controls), empathy trait predicted ventromedial prefrontal responses to somatosensory representations of others’ pain and posterior cingulate responses to emotional representations of others’ pain. These findings underline the major role of midline structures in emotional perspective taking and understanding someone else’s feeling despite the lack of any previous personal experience of it—an empathic challenge frequently raised during human social interactions.

Article here.

An observer feels more empathy for someone in pain when that person is in the same social group, according to new research in the July 1 issue of The Journal of Neuroscience.   The study shows that perceiving others in pain activates a part of the brain associated with empathy and emotion more if the observer and the observed are the same race.

The findings may show that unconscious prejudices against outside groups exist at a basic level.   The study confirms an in-group bias in empathic feelings, something that has long been known but never before confirmed by neuroimaging technology. Researchers have explored group bias since the 1950s. In some studies, even people with similar backgrounds arbitrarily assigned to different groups preferred members of their own group to those of others. This new study shows those feelings of bias are also reflected in brain activity.  

‘Our findings have significant implications for understanding real-life social behaviors and social interactions,’ said Shihui Han, PhD, at Peking University in China, one of the study authors.

More here.

There are patients with congenital insensitivity to pain (CIP) this is a rare condition. They don’t feel pain, cognition and sensation is otherwise normal; for instance they can still feel discriminative touch (though not always temperature), and there is no detectable physical abnormality. They offer a unique opportunity to test the model of empathy. Does the lack of self-pain representation influence the perception of others’ pain.

CIP patients globally underestimate the pain of others when emotional cues were lacking, and that their pain judgments, in contrast with those of control subjects, are strongly related to interindividual differences in empathy trait. More empathy better pain judgment.

Patients with CIP showed normal fMRI responses to observed pain. The same regions for observed pain in anterior mid-cingulate cortex and anterior insula, were activated. In contrast to healthy controls their empathy trait predicted ventromedial prefrontal responses to somatosensory representations of others’ pain and posterior cingulate responses to emotional representations of others’ pain. CIP patients can acknowledge the pain of others. The amount strongly correlates with their empathic capacity which mainly relies on the engagement of anterior the ventromedial prefrontal cortex (vmPFC) and posterior the ventral posterior cingulate cortex (vPCC) midline structures, which may in part compensate for the patients’ lack of automatic resonance mechanisms.

More here.



P: Does empathy need a face? 

S: Well, observers of emotional pain faces show some activity in the facial musculature that appears to indicate empathy via mimicry, although inattention to the emotional quality of the expression, as when doubting its sincerity, may impair this response. 

P: Suppose a person with Möebius Syndrome observes a person in pain. There can be no activity in her facial muscles. Is the capacity for empathy for pain thereby reduced or diluted in this individual? 

S:  There is qualitative evidence suggesting that the experience of emotion in some adults with Möebius might be diluted and reduced. In some cases, emotion is intellectualized: people think happy, or think sad. One person told me: 

‘I have to say this thought is a happy thought and therefore I am happy. When there are things that are sad I tell the person that I feel very sorry for you but I’m thinking that rather than feeling it’. 

In other cases, there is an almost disconnection from emotion in oneself and from others, and possibly, a reduced capacity for empathy and sympathy. 

P: Why is this? 

S:  I stated earlier that the face is for human interactions a rich and primary source of information. In these encounters, the face provides a dynamic, embodied representation of emotion, sharing feelings and moods from moment to moment. Human interactions are, in part, facial conversations, usually mutually reinforcing. Through facial conversation, an individual can enter into the subjective experience of another, sharing feelings and moods. 

P: An inability to engage in facial interaction and to receive reinforcement from others may reduce the capacity for empathy. 

S: It appears that congenital facial paralysis reduces self-awareness. Reduced self-awareness with regard to one’s own emotions may diminish empathy for pain in others because the individual’s recognition of her own feelings is the basis for identification with the feelings of others. 

P: Here is a question: is empathy conceived as ‘emotional resonance’ related to the instigation of effective helping behavior? 

S: Certainly, in professional settings dispassionate concern for the patient is encouraged in the interests of objective care. 

P: This may be worth exploring: does similarity in facial expression mean greater similarity in affective responses, thereby affecting helping behavior? By contrast, do children and adults with Möebius typically instigate care? 

S: Earlier, I noted that the reactions of infants to pain are shaped and transformed during development into socially responsive patterns of behavior. I sense that these transformations may answer our question: does empathy need a face? 

Infant reactions to pain are global and non-reflective, as previously mentioned. They experience pain in a ‘catastrophic’ way. Catastrophic pain pushes for direct discharge in fixed responses. For example, apathetic or tense immobility, intense writhing or squirming.

In human development, however, infants can learn to ‘tame’ catastrophic pain patterns. Early to midway in the first year of life, caregivers help babies begin to learn how to transform catastrophic pain into interactive signals. 

The mother turns to look at her baby as he cries out in distress. She approaches him vocalizing concern, and he turns to look at her. She responds with a soft soothing facial expression of ‘what’s the matter’, and, with hands out, an offer to pick him up and cuddle him. Baby moves his head to find her and greets her eyes with a softening of his facial grimace and a look of expectation. Mother responds with soothing sounds and they continue to exchange calming facial expressions and sounds. Later, the parent is holding the baby, snuggling, and patting his back, and the baby relaxes. The tension in his face and body dissipates and he has a look of calm. 

P: Contrast this pattern with one in which signaling does not occur. A baby cries in pain and a mother, preoccupied with her own thoughts, ignores the overture. Baby tries again with more intensity, vocalizing more loudly, and squirming even more, but with obvious strain. The mother still ignores the overtures. Soon, the baby becomes passive and disinterested. 

S: For the signaling to occur in the first case, the baby needs to have been wooed into an intimate relationship with one or a few caregivers so that there is another human being toward whom he experiences deep emotions and, therefore, with whom he wants to communicate. 

P: The baby needs to have his facial display become part of a back-and-forth interaction by being responded to. 

S: Yes. Through his relationship to his caregiver(s), he is becoming more intentional. I think the baby is learning to signal with his emotions to mean intent rather than engage in a catastrophic response. Is that right? 

P: In the first case, facial signaling interrupts a fixed response. Mother responded to the baby’s signal of threat, not intent. He responded back and together they negotiated an outcome characterized by shared soothing calm rather than an intense pain-display. 

In development, the baby becomes better and better able to signal danger and threat without escalating into direct action. 

S: Let’s put it like this: by having his expression of danger responded to, the baby learns to modulate the intensity of his distress and pain. He is learning to regulate his state. The baby is learning to show distress, to negotiate, and to get his needs met. There is less of a tendency to explode into desperate action. Infants and toddlers quickly sense that they and their caregivers are regulating one another when there is a back-and-forth, finely-tuned nuance system of emotional interaction involving lots of mutual exchanges. 

P: How does this relate to empathy? 

S: First, it is likely that excessively empathic observers would be characterized as catastrophic, agonizing unduly and having difficulty in delivering effective helping behavior. 

P: I see. To provide effective care, an observer must have the ability to regulate her own aversive distress, since this may lead observers to focus primarily upon their own needs. 

This is really important in health-care. Health care professionals face the challenge of finding the balance that allows them to pay attention to the details of a patient’s pain experience and resonate with the patient’s pain experience without becoming emotionally over-involved. Catastrophic reactions may well preclude effective medical management and even lead to burnout. 

S: I think effective regulation of empathy, such as keeping distress at a moderate level, may promote other-oriented affective responses. Empathy for others comes from investing other human beings with one’s own feelings. This capacity, I claim, begins with first relationships. It depends on nurturing care that creates, through mutual facial expressions with caregivers, a sense of intimacy. 

P: Since a sense of ‘self’ is crucial for empathy, how does the infant develop it? 

S: When an adult responds reciprocally, the baby makes a discovery: ‘I can make something happen’. This teaches the baby to take initiative: crying in pain gets a concerned look from mom or dad. A sense of ‘self’ is developing, for it’s ‘me’ making something happen. As a toddler’s repertoire of emotional signaling grows richer and she begins to discern patterns in her own and others’ behavior, she adds these observations to the map delineating herself as a person. Her mother usually responds when she is pain, but not when she’s cranky. Her father likes to play, but not to sing lullabies. Grandmother is a good deal less strict than either parent. With the growing capacity to perceive and organize patterns, these types of experiences continue to define a developing sense of self even before words are used. 

P:   Why the interest in facial expression? 

S:   Well, the face is for human interactions a rich source of information: one can often appreciate features of another person’s emotions, motives, thoughts, attention, and intentions by scanning his or her face. 

P:   I think my spouse’s face is a work of fiction. 

S:   At least fiction is more interesting than autobiography. 

P:   Touché. 

S:   Imagine being unable to monitor and correctly interpret the ongoing patterns of your spouse’s facial activity. You would be vulnerable to serious social deficits. 

P:   Like divorce? 

S:   Not exactly. Consider Möebius Syndrome, a congenital condition of facial paralysis. These individuals often have great difficulty detecting and monitoring in others inner states on the face. As a result, they tend to experience rejection and lack of reinforcement from others, and may become withdrawn and highly introspective. 

P:   The plasticity of the face must make it very difficult for them. 

S:   Facial expression matters. There tends to be added value even when others are communicating verbally, as the information conveyed by the face is unlikely to be entirely redundant with the content of speech. 

P:   I see where your interest in pain comes in now. Facial expression may prove useful when attending to others who have been hurt, or another person’s facial grimaces may signal danger and allow one to avoid looming personal threat. 

S:   There is a general tendency to situate oneself so as to be able to attend to facial activity. 

P:   Just think of mothers who become utterly absorbed in their babies’ facial expressions! 

S:   That’s a great illustration. And, infants are equally attentive to their caretakers’ facial expressions. The capacity to attend to and use facial activity persists throughout life. 

P:   The child learns facial expressions in attending to and interacting with a caregiver. 

S:   Children are acculturated to social standards and normative patterns consistent with the social environments in which they grow up. 

P:   This means that behavior – including facial displays – conforms to cultural expectations. 

S:   Through observation, instruction and reinforcement, children learn facial displays that follow familial and social rules. 

P:   Fine. I think this is fairly uncontroversial, however. I mean, what determines the link between subjective states and overt behavior? Do first relationships connect mind and behavior? 

S:   That’s a fundamental question. Consider the response of very young infants to tissue damage. The reactions are relatively global – involve the whole body – and are reflexive in nature. Various studies report that the reactions of infants to pain are shaped and transformed during development into socially responsive patterns of behavior. Facial expressions of pain develop as part of this transformation. 

P:   That is an interesting observation, but uncontroversial. And, you haven’t addressed my question. You seem to be suggesting that the possibility of pain is conditioned by the possibility of its expression. I mean, isn’t the pain given – whether it can be expressed and how it is expressed seem to be further matters. 

S:   I am not certain it is quite so simple to divide facial displays neatly into inner and outer aspects. Isn’t pain given in expressive displays? Facial expression makes pain visible to others, and also for the patient. Facial activity may also contribute to the experience of pain. 

P:     I am not convinced. 

S:   Well, I am speculating that modulation of facial expression may alter the pain-sensation. The vigor of the facial display influences the magnitude of the subjective experience. 

P:   Oh, you mean:  ‘grin and bear it’, and all that? 

S:   Right:  ‘keep a stiff upper lip’. It is relatively easy to acknowledge this point, at least intuitively. 

P:   I can see benefits here: attenuated facial expression of pain decreases subjective distress, and increases pain tolerance. 

S:   Research on individuals with Möebius Syndrome reveals that they have high pain tolerance and decreased distress in pain because they cannot make facial expressions. 

P:   Or, more precisely: ‘…because they cannot experience facial feedback’. 

S:   So, here is an idea: feedback from the face may permit subjective differentiation of inner states. 

P:   This idea may have the following negative consequence, however: if attenuated facial expression of pain decreases inner distress in the individual, is detection of pain in others thereby weakened? Does perception need a face? 

S:   Studies on adults with Möebius Syndrome show that they have no impairment in emotional facial expression recognition. This means that the ability to produce facial expressions is not a necessary prerequisite of their recognition. 

P:   It follows that the inability to experience facial feedback in oneself does not inhibit facial recognition of emotion in others. I guess the same point applies to perception of pain. 

S:    I believe so. We can illustrate this point further. Are you familiar with CIP? 

P:    What is it? 

S:   CIP: congenital insensitivity to pain. It is characterized by dramatic impairment of pain perception since birth. Painless events include wounds, burns, bone fractures, deliveries, and so on. There are some residual pain experiences like headaches and low back pain in these individuals, however. 

What is noteworthy is that these people can perceive pain in others despite their own congenital insensitivity to pain. 

P:   An experience of pain is not required for perceiving pain in others. 

S:   We might put it like this: to perceive pain in others, we do not need a pain, nor even a face, but the concept of pain. 

P:   We do not feel the sensory aspects of another’s pain, but we may resonate with the agony of a person in pain when we encounter facial expression. 

S:   The degree to which we ‘share’ another’s agony depends on empathy. 

P:   Does empathy need a face? 

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