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


Mark Gertskis

The growing misuse of powerful prescription opioids has prompted calls for the approach of managing chronic pain to be reconsidered.

Dr Penelope Briscoe, Dean of the Faculty of Pain Medicine at Australia and New Zealand College of Anaesthetists (ANZCA), said Australia was heading towards the situation in the United States, where more people were abusing prescription drugs than cocaine, heroin, hallucinogens, ecstasy and inhalants combined.

She said there was anecdotal evidence emerging of the growing abuse of strong opioids such as morphine and OxyContin (oxycodone), despite a lack of a comprehensive study.

“It’s really hard to know and that is something that we should be looking at,” Dr Briscoe told Pharmacy News.

More here.

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.

Jeanna Bryner,

A social snub can deliver a seemingly painful blow. Now, it turns out that sting may be real. A gene linked with physical pain is also associated with a person’s sensitivity to rejection, a new study finds.

The discovery doesn’t suggest that being chosen last for a pick-up ball game, say, will send you limping off the field. Rather, a rare form of the so-called mu-opioid receptor gene (OPRM1) is likely involved in the emotional aspect of physical pain — essentially, how much a person is bothered by a throbbing leg, for instance.

In the study, 122 participants indicated how much they agreed or disagreed with statements, such as “I am very sensitive to any signs that a person might not want to talk to me.” Their saliva was also analyzed for OPRM1. (People with a rare form of OPRM1 experience more physical pain than others.)

Then, the researchers used functional magnetic resonance imaging (fMRI) to scan the brains of 31 of the participants during a virtual ball-tossing game. Initially, each participant was included with two virtual players before being excluded when the virtual players stopped throwing the ball to them.

Individuals with the rare OPRM1 variant were more sensitive to social rejection. The mutant-gene carriers also showed more activity in brain regions linked with physical and social pain, including the dorsal anterior cingulate cortex and anterior insula.

Such social pain may have benefited our ancestors. “Because social connection is so important, feeling literally hurt by not having social connections may be an adaptive way to make sure we keep them,” said study researcher Naomi Eisenberger of UCLA.

She added, “Over the course of evolution, the social attachment system — which ensures social connection — may have actually borrowed some of the mechanisms of the pain system to maintain social connections.”

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.

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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