Download Neurobiology of Compassion

Neurobiology of Compassion
Mallory Taylor
Geisel School of Medicine
Medicine is changing. This assertion is undeniable, and has routinely been
relayed to medical students, physicians, and the broader public. But another branch
of this story exists that is less often told, but no less true: medicine is changing us.
The healthcare system has been under society’s microscope in recent times, as the
American public engages in the discussion of reform. With the passage and
impending implementation of the Affordable Care Act, debates surrounding
insurance coverage and physician reimbursement have dominated the news.
As policymakers attempt to mend our broken system, a new component is emerging
as a major contributor to its failure – damaged physicians.
An unfortunate body of evidence is beginning to surface about the condition
our medical students, residents, and physicians are in. Nearly half of all medical
students and practicing physicians report symptoms of burnout. And the
consequences of this unfortunate statistic are numerous: including increased
medical error, poorer patient satisfaction, depression, and what is termed
“compassion fatigue.” (Shanafelt, et al.)
The degree of burnout was actually not associated with hours worked or
unattained work-life balance. Instead, the only factor that was predictive of burnout
risk was practicing in a primary care specialty. This correlation seems to indicate
that our system level “healthcare crisis” is intimately tied to the endemic
“compassion crisis” in the US. So, what can be done to address this facet of the
problem? In addition to bureaucratic changes to alleviate unnecessary provider
stress, new insights into the science of empathy and compassion may help us
address the issue on an individual level.
The neurological home of compassion
Compassion, as defined by Merriam Webster, is the sympathetic
consciousness of others’ distress together with a desire to alleviate it. Compassion,
as defined by neurophysiologists, is the network biology of cortical and subcortical
regions relevant to interoceptive and emotional processing. We can relate to the
subjective feeling of wanting to help end another’s suffering, but it is a little harder
to get in touch with the sensation of our neurons firing in the superior temporal
sulcus. However, oftentimes the key to understanding behavior is delineating its
origin, right down to the synapse.
Dr. William Mobley, a trained child neurologist and co-founder of Stanford’s
Center for Compassion and Altruism Research and Education, has done extensive
research on the neurological correlates of empathy and compassion. His work has
focused on the network of the anterior insular cortex (AIC) and anterior cingulate
cortex (ACC). The AIC serves as a center for interoceptive awareness – subjective
feelings, attention, choices, and intentions. Dr. Mobley has hypothesized, then, that
the AIC is the seat of emotional sensory processing, or self-awareness, a key
component of compassion.
Neuroanatomically, the AIC shares rich connection to the ACC, which has
been dubbed the ‘emotional motor system.’ Therefore, activation of the AIC in
response to emotional stimuli results in concomitant activation of the ACC, which
may encourage accurate and appropriate responses to those emotional stimuli. The
AIC/ACC network is a unique connection. It does not exist in this form in nonhuman primates. It is also the only region containing cells called Von Economo
neurons, which have recently evolved only in big-brained mammals whose
environment requires social interaction. Interestingly, these neurons also
selectively degenerate in Frontotemporal Dementia, a disease marked by
diminished empathy.
Another branch of study approaches the question from another angle: what
is necessary for empathetic accuracy? Most social cognition data to this point has
followed one of two fairly different paths. The first hypothesis is that shared
representations (SR’s) of experienced and observed responses allow perceivers to
vicariously experience what it is like to be the target of their perception. Activation
of your mirror neurons in the limbic and motor regions, therefore, reproduces a
similar experience in yourself that you’re observing in another, and you are able to
understand their emotions. Almost literally ‘putting yourself in someone else’s
shoes.’
The second path has focused on the cortical regions activated when we make
specific attributions about the intentions, beliefs, and feelings of others, or mental
state attribution (MSA). Brain regions recruited during MSA includes temporal and
parietal regions thought to control shifts in attention to social cues, as well as medial
prefrontal regions that derive MSAs from integrated combinations of semantic,
contextual, and sensory inputs.
These two mechanisms appear to be relatively independent, but are both
indicated in the quest for interpersonal understanding. A recent study by Zaki, et al
used fMRI to delineate which mechanism(s) might be at play during accurate
inferences about the emotions of another. Whole-brain fMRI was collected from
subjects while they watched videos of people talking and rated their perceived
emotional state. This was then compared to how the taped subjects rated their own
emotions while speaking. The outcome was termed emotional accuracy (EA).
Not entirely surprisingly, they found that both systems of shared
representation and mental status attribution were implicated. The more
emotionally accurate subjects had sustained attention to targets’ verbal and
nonverbal affect cues (processed by the mirror neuron system), and inferences
about targets’ states based on integration of these cues (likely occurring in the
medial prefrontal cortex). (Zaki, et al.)
Another recent study from MGH used fMRI to explore physicians’ brains
when they believed they were treating patients’ pain. They found that the same
areas of the brain that are activated with the placebo effect are also activated in the
brains of doctors when they believe they are relieving the suffering of their patients.
Thus, successful relief of patient suffering is therapeutic for the practitioner, as well.
Interestingly, those doctors who self-identified as being able to take things from
another’s perspective experienced higher satisfaction during patients’ treatments.
(Jensen, et al)
Closing the compassion gap
Now that we recognize the problem, and science is beginning to elucidate
where the root of the problem may be, what (if anything) can be done? Can
something like compassion be taught or improved, or are we simply born with a
fixed capacity? If compassion is actually a malleable psychological component, are
there real benefits to the individual and society that justify allocation of resources to
its development?
Many psychological interventions seek to compensate for a negative
emotional state – decrease depressive symptoms, eliminate psychoses, deter
pathological thought loops, etc. However, there is now growing interest in
cultivating and promoting positive emotional states and qualities. Narrowing the
focus on Seligman’s “Positive Psychology Movement,” there is particular interest in
the idea of training the quality of compassion.
An innovative consortium from Stanford University, called the Center for
Compassion and Altruisim Research and Education (CCARE, mentioned above) has
developed a 9-week compassion cultivation training (CCT) program. The structured
program consists of a 2-hour introductory orientation, eight once-weekly 2-hour
classes, and daily compassion-focused meditation exercises. Although the structure
parallel’s other well-known meditation protocols (ie, Kabat-Zinn’s MindfulnessBased Stress Reduction), the CCT program is specifically focused on elucidating and
cultivating one’s skills in compassion.
The operational definition of compassion, according to the CCT model, is a
multidimensional entity consisting of: 1) an awareness of suffering, 2)
sympathetic/emotionally moved by suffering, 3) a wish to see the relief of that
suffering, 4) a readiness to help relieve that suffering. Throughout the classes,
students are guided through 6 steps of compassion cultivation, culminating in an
integrative daily practice.
A recent randomized controlled study sought to delineate the possible effects
of the CCT program. A group of 100 healthy adults were randomized to either the
CCT protocol or a wait list group and assessed on two self-report compassion scales.
The results are compelling. Compared to wait list controls, those who completed
the CCT showed significant improvement in three orientations of compassion:
compassion for self, compassion for others, and compassion from others. The
authors also noted that the amount of formal meditation correlated with improved
compassion for others. (Jazaieri, H. et al)
Another investigation in Boston used a novel empathy awareness training
model rooted in neurobiology of emotions. Residents and fellows at MGH were
randomized to either an intervention group or standard residency training group.
Those in the intervention arm received three 60-minute classes aimed at exploring
the neurobiology and physiology of empathy training, increase emotional
awareness, and teach empathetic behavioral responses. The primary outcome
measure was patients’ blinded scoring of their perceptions of the residents’ level of
compassion and empathy before and after training. The treatment arm showed an
increase in patient-rated empathy after training, with a greater change in women
than in men. The control group actual showed a decline in patient empathy rating
over the same time course. (Riess, et. al). This study, coupled with the
aforementioned paper, indicate that compassion and empathy may in fact be a
trainable skill.
Although there are many intuitive and anecdotal advantages to increased
compassion and empathy, supplying evidence for its objective benefits would be
useful in considering implementation at a systems level. A recent study from Emory
set out to answer that very question. A group of 61 healthy adults were randomized
to either 6 weeks of compassion meditation training or a health discussion control
group, followed by a standard laboratory stressor. Plasma IL-6 and cortisol
measures, as well as scores on the Profile of Mood States questionnaire determined
physiological and behavioral responses to the stressor. There were no preintervention baseline measures of these variables, but results indicated no main
effect of group assignment on IL-6, cortisol, or POMS score. However, within the
meditation group, increased meditation practice was significantly correlated with
decreased stress-response IL-6 and POMS scores. Although these results lack a
certain robustness, they may indicate that significant compassion meditation
practice could reduce stress-related immune and behavioral responses. More
research in these objective domains is clearly warranted. (Pace, T. et al.)
Conclusions
Medicine has changed. Becoming a physician in today’s healthcare
environment is so vastly different from what it was in the past that it is virtually a
new profession. In addition to commanding medical knowledge and clinical skill,
today’s physicians must have sufficient managerial, business, and political talent to
survive in an emaciated healthcare system. Coupled with these administrative
strains, as a more emotionally aware society is beginning to note, are some very real
psychological and personal consequences for today’s doctors.
However, as we are beginning to uncover and understand these issues, more
energy is also being devoted to developing solutions. And not a moment too soon,
as it is becoming clear that this matter has moved beyond an optional amenity:
finding ways to promote the health and happiness of physicians is a necessary
component for the entire system to function. Because, a healthcare system drained
of its empathetic and compassionate core simply cannot be sustained.
Resources
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Stanford Center for Compassion and Altruism Research and
Education: http://ccare.stanford.edu/ (option to join listserv, get
notifications for events/conferences/lectures on website)
Riess, Helen, MD. "Empathy Training for Resident Physicians: A
Randomized Controlled Trial of a Neuroscience-Informed
Curriculum." J Gen Intern Med 26.1 (2011): n. pag. Web.
Mobley, William, MD, PhD. "Toward a Neurobiology of Empathy and
Compassion for Physicians: How Do We Educate Them?" Arnold P.
Gold Society Biennial Conference. Chicago. Lecture. (Slides available
from Gold Society upon request)
Zaki, Jamil. "The Neural Bases of Empathetic Accuracy." PNAS 106.27
(2009): 11382-1387.
Pace, Thaddeus, PhD. "Effect of COmpassion Meditation on
Neuroendocrine, Innate Immune and Behavioral Responses to
Pyschosocial Stress."Psychoneuroendocrinology 34.1 (2009): 87-98.
Jazaleri, Hooria. "Enhancing Compassion: A Randomized Controlled
Trial of a Compassion Cultivation Training Program." J Happiness
Stud (2012): n. pag. Web.
Shanafelt, et. al. Burnout and Satisfaction With Work-Life Balance
Among US Physicians Relative to the General US Population. Arch
Intern Med. 2012;172(18):1377-1385)
Jensen, Karen. "Sharing Pain and Relief: Neural Correlates of
Physicians during Treatment of Patients." Molecular
Psychiatry (2013): Advanced web publication