When pain really matters: A vicarious-pain brain marker tracks empathy for pain in the romantic partner

Neuronal and therapeutic perspectives on empathic pain: A rational insight

Empathy is the capacity to experience and understand the feelings of others, thereby playing a key role in a person's mental well-being essentially by promoting kindness and a sense of belongingness to the group. However, too much empathy may result in psychological problems such as empathic distress, compassion fatigue, and burnout, collectively termed empathic pain. Several brain regions are implicated in processing empathic pain perception. Neuroimaging investigations bring in the context of brain structures involved in this emotional exchange, pointing toward the anterior insula (AI) and anterior cingulate cortex (ACC), indicating an overlap between the neural representation of direct and simulative pain. To discern such overlaps, therapeutic techniques for managing empathic pain require understanding different brain regions and their respective neural networks. At the moment, empathic pain is being treated using various methods, including pharmacological treatments such as antidepressants and psychological treatments such as mindfulness or meditation. For instance, researchers have been exploring the modulatory effects of neurotransmitters like serotonin, norepinephrine, and oxytocin on individuals' responses to empathic pain experience. Importantly, this review focuses on the specific brain parts and their unique roles in neurobiological pathways associated with emphatic pain and how shared neural networks play into available treatment options, suggesting possible future health benefits. Such an understanding of empathy can lead to more efficient management of types of care, focusing on enhancing social connections and mental well-being.

I feel your pain: higher empathy is associated with higher posterior default mode network activity

ABSTRACT

Empathy is characterized as the ability to share one's experience and is associated with altruism. Previous work using blood oxygen level-dependent (BOLD) functional MRI (fMRI) has found that empathy is associated with greater activation in brain mechanisms supporting mentalizing (temporoparietal junction), salience (anterior cingulate cortex; insula), and self-reference (medial prefrontal cortex; precuneus). However, BOLD fMRI has some limitations that may not reliably capture the tonic experience of empathy. To address this, the present study used a perfusion-based arterial spin labeling fMRI approach that provides direct a quantifiable measurement of cerebral blood flow (1 mL/100 g tissue/min) and is less susceptible to low-frequency fluctuations and empathy-based "carry-over" effects that may be introduced by BOLD fMRI-based block designs. Twenty-nine healthy females (mean age = 29 years) were administered noxious heat (48°C; left forearm) during arterial spin labeling fMRI. In the next 2 fMRI scans, female volunteers viewed a stranger (laboratory technician) and their romantic partner, respectively, receive pain-evoking heat (48°C; left forearm) in real-time and positioned proximal to the scanner during fMRI acquisition. Visual analog scale (0 = "not unpleasant"; 10 = "most unpleasant sensation imaginable") empathy ratings were collected after each condition. There was significantly ( P = 0.01) higher empathy while viewing a romantic partner in pain and greater cerebral blood flow in the right temporoparietal junction, amygdala, anterior insula, orbitofrontal cortex, and precuneus when compared with the stranger. Higher empathy was associated with greater precuneus and primary visual cortical activation. The present findings indicate that brain mechanisms supporting the embodiment of another's experience is associated with higher empathy.

Neural circuits and therapeutic mechanisms of empathic pain

Empathy is the capacity to understand and share the experiences of others. This ability fosters connections between individuals, enriching the fabric of our shared world. One notable example is empathy for the pain of others. Such experiences facilitate the identification of potential dangers, both for oneself and for others. Neuroimaging studies have helped to pinpoint brain regions that modulate empathic pain. Recently, there has also been a surge in studies exploring the neural mechanisms of empathic pain in rodent models. Neuropsychiatric disorders such as autism, psychosis, and schizophrenia often exhibit empathy deficits. Targeting the modulation of empathic pain holds potential for alleviating core symptoms in these patients. Interestingly, empathy research may also benefit pain management, leading to new approaches for understanding the negative emotions associated with pain. This review summarizes recent advances in neuroimaging for the study of empathic pain, outlines the underlying neurocircuit mechanisms, describes therapeutic strategies, and explores promising avenues for future research. This article is part of the Special Issue on "Empathic Pain".

Placebo treatment affects brain systems related to affective and cognitive processes, but not nociceptive pain

Drug treatments for pain often do not outperform placebo, and a better understanding of placebo mechanisms is needed to improve treatment development and clinical practice. In a large-scale fMRI study (N = 392) with pre-registered analyses, we tested whether placebo analgesic treatment modulates nociceptive processes, and whether its effects generalize from conditioned to unconditioned pain modalities. Placebo treatment caused robust analgesia in conditioned thermal pain that generalized to unconditioned mechanical pain. However, placebo did not decrease pain-related fMRI activity in brain measures linked to nociceptive pain, including the Neurologic Pain Signature (NPS) and spinothalamic pathway regions, with strong support for null effects in Bayes Factor analyses. In addition, surprisingly, placebo increased activity in some spinothalamic regions for unconditioned mechanical pain. In contrast, placebo reduced activity in a neuromarker associated with higher-level contributions to pain, the Stimulus Intensity Independent Pain Signature (SIIPS), and affected activity in brain regions related to motivation and value, in both pain modalities. Individual differences in behavioral analgesia were correlated with neural changes in both modalities. Our results indicate that cognitive and affective processes primarily drive placebo analgesia, and show the potential of neuromarkers for separating treatment influences on nociception from influences on evaluative processes.

Healthcare experience affects pain-specific responses to others' suffering in the anterior insula

Medical students and professional healthcare providers often underestimate patients' pain, together with decreased neural responses to pain information in the anterior insula (AI), a brain region implicated in self-pain processing and negative affect. However, the functional significance and specificity of these neural changes remains debated. Across two experiments, we recruited university medical students and emergency nurses to test the role of healthcare experience on the brain reactivity to other's pain, emotions, and beliefs, using both pictorial and verbal cues. Brain responses to self-pain was also assessed and compared with those to observed pain. Our results confirmed that healthcare experience decreased the activity in AI in response to others' suffering. This effect was independent from stimulus modality (pictures or texts), but specific for pain, as it did not generalize to inferences about other mental or affective states. Furthermore, representational similarity and multivariate pattern analysis revealed that healthcare experience impacted specifically a component of the neural representation of others' pain that is shared with that of first-hand nociception, and related more to AI than to other pain-responsive regions. Taken together, our study suggests a decreased propensity to appraise others' suffering as one's own, associated with a reduced recruitment of pain-specific information in AI. These findings provide new insights into neural mechanisms leading to pain underestimation by caregivers in clinical settings.

Placebo treatment affects brain systems related to affective and cognitive processes, but not nociceptive pain

Placebo analgesia is a replicable and well-studied phenomenon, yet it remains unclear to what degree it includes modulation of nociceptive processes. Some studies find effects consistent with nociceptive effects, but meta-analyses show that these effects are often small. We analyzed placebo analgesia in a large fMRI study (N = 392), including placebo effects on brain responses to noxious stimuli. Placebo treatment caused robust analgesia in both conditioned thermal and unconditioned mechanical pain. Placebo did not decrease fMRI activity in nociceptive pain regions, including the Neurologic Pain Signature (NPS) and pre-registered spinothalamic pathway regions, with strong support from Bayes Factor analyses. However, placebo treatment affected activity in pre-registered analyses of a second neuromarker, the Stimulus Intensity Independent Pain Signature (SIIPS), and several associated a priori brain regions related to motivation and value, in both thermal and mechanical pain. Individual differences in behavioral analgesia were correlated with neural changes in both thermal and mechanical pain. Our results indicate that processes related to affective and cognitive aspects of pain primarily drive placebo analgesia.

Brain-to-brain mechanisms underlying pain empathy and social modulation of pain in the patient-clinician interaction

Social interactions such as the patient-clinician encounter can influence pain, but the underlying dynamic interbrain processes are unclear. Here, we investigated the dynamic brain processes supporting social modulation of pain by assessing simultaneous brain activity (fMRI hyperscanning) from chronic pain patients and clinicians during video-based live interaction. Patients received painful and nonpainful pressure stimuli either with a supportive clinician present (Dyadic) or in isolation (Solo). In half of the dyads, clinicians performed a clinical consultation and intake with the patient prior to hyperscanning (Clinical Interaction), which increased self-reported therapeutic alliance. For the other half, patient-clinician hyperscanning was completed without prior clinical interaction (No Interaction). Patients reported lower pain intensity in the Dyadic, relative to the Solo, condition. In Clinical Interaction dyads relative to No Interaction, patients evaluated their clinicians as better able to understand their pain, and clinicians were more accurate when estimating patients' pain levels. In Clinical Interaction dyads, compared to No Interaction, patients showed stronger activation of the dorsolateral and ventrolateral prefrontal cortex (dlPFC and vlPFC) and primary (S1) and secondary (S2) somatosensory areas (Dyadic-Solo contrast), and clinicians showed increased dynamic dlPFC concordance with patients' S2 activity during pain. Furthermore, the strength of S2-dlPFC concordance was positively correlated with self-reported therapeutic alliance. These findings support that empathy and supportive care can reduce pain intensity and shed light on the brain processes underpinning social modulation of pain in patient-clinician interactions. Our findings further suggest that clinicians' dlPFC concordance with patients' somatosensory processing during pain can be boosted by increasing therapeutic alliance.

Processing of pain by the developing brain: evidence of differences between adolescent and adult females

ABSTRACT

Adolescence is a sensitive period for both brain development and the emergence of chronic pain particularly in females. However, the brain mechanisms supporting pain perception during adolescence remain unclear. This study compares perceptual and brain responses to pain in female adolescents and adults to characterize pain processing in the developing brain. Thirty adolescent (ages 13-17 years) and 30 adult (ages 35-55 years) females underwent a functional magnetic resonance imaging scan involving acute pain. Participants received 12 ten-second noxious pressure stimuli that were applied to the left thumbnail at 2.5 and 4 kg/cm 2 , and rated pain intensity and unpleasantness on a visual analogue scale. We found a significant group-by-stimulus intensity interaction on pain ratings. Compared with adults, adolescents reported greater pain intensity and unpleasantness in response to 2.5 kg/cm 2 but not 4 kg/cm 2 . Adolescents showed greater medial-lateral prefrontal cortex and supramarginal gyrus activation in response to 2.5 kg/cm 2 and greater medial prefrontal cortex and rostral anterior cingulate responses to 4 kg/cm 2 . Adolescents showed greater pain-evoked responses in the neurologic pain signature and greater activation in the default mode and ventral attention networks. Also, the amygdala and associated regions played a stronger role in predicting pain intensity in adolescents, and activity in default mode and ventral attention regions more strongly mediated the relationship between stimulus intensity and pain ratings. This study provides first evidence of greater low-pain sensitivity and pain-evoked brain responses in female adolescents (vs adult women) in regions important for nociceptive, affective, and cognitive processing, which may be associated with differences in peripheral nociception.

Dissociation between individual differences in self-reported pain intensity and underlying fMRI brain activation

Pain is an individual experience. Previous studies have highlighted changes in brain activation and morphology associated with within- and interindividual pain perception. In this study we sought to characterize brain mechanisms associated with between-individual differences in pain in a sample of healthy adolescent and adult participants (N = 101). Here we show that pain ratings varied widely across individuals and that individuals reported changes in pain evoked by small differences in stimulus intensity in a manner congruent with their pain sensitivity, further supporting the utility of subjective reporting as a measure of the true individual experience. Furthermore, brain activation related to interindividual differences in pain was not detected, despite clear sensitivity of the Blood Oxygenation Level-Dependent (BOLD) signal to small differences in noxious stimulus intensities within individuals. These findings suggest fMRI may not be a useful objective measure to infer reported pain intensity.

The neurologic pain signature responds to nonsteroidal anti-inflammatory treatment vs placebo in knee osteoarthritis

Supplemental Digital Content is Available in the Text.

fMRI-based measures, validated for nociceptive pain, respond to acute osteoarthritis pain, are not sensitive to placebo, and are mild-to-moderately sensitive to naproxen.

Introduction:

Many drug trials for chronic pain fail because of high placebo response rates in primary endpoints. Neurophysiological measures can help identify pain-linked pathophysiology and treatment mechanisms. They can also help guide early stop/go decisions, particularly if they respond to verum treatment but not placebo. The neurologic pain signature (NPS), an fMRI-based measure that tracks evoked pain in 40 published samples and is insensitive to placebo in healthy adults, provides a potentially useful neurophysiological measure linked to nociceptive pain.

Objectives:

This study aims to validate the NPS in knee osteoarthritis (OA) patients and test the effects of naproxen on this signature.

Methods:

In 2 studies (50 patients, 64.6 years, 75% females), we (1) test the NPS and other control signatures related to negative emotion in knee OA pain patients; (2) test the effect of placebo treatments; and (3) test the effect of naproxen, a routinely prescribed nonsteroidal anti-inflammatory drug in OA.

Results:

The NPS was activated during knee pain in OA (d = 1.51, P < 0.001) and did not respond to placebo (d = 0.12, P = 0.23). A single dose of naproxen reduced NPS responses (vs placebo, NPS d = 0.34, P = 0.03 and pronociceptive NPS component d = 0.38, P = 0.02). Naproxen effects were specific for the NPS and did not appear in other control signatures.

Conclusion:

This study provides preliminary evidence that fMRI-based measures, validated for nociceptive pain, respond to acute OA pain, do not appear sensitive to placebo, and are mild-to-moderately sensitive to naproxen.

Expressive suppression to pain in others reduces negative emotion but not vicarious pain in the observer

Although there are situations where it may be appropriate to reduce one's emotional response to the pain of others, the impact of an observer's emotional expressivity on their response to pain in others is still not well understood. In the present study, we examined how the emotion regulation strategy expressive suppression influences responses to pain in others. Based on prior research findings on expressive suppression and pain empathy, we hypothesized that expressive suppression to pain expression faces would reduce neural representations of negative emotion, vicarious pain, or both. To test this, we applied two multivariate pattern analysis (MVPA)-derived neural signatures to our data, the Picture Induced Negative Emotion Signature (PINES; Chang, Gianaros, Manuck, Krishnan, and Wager (2015)) and a neural signature of facial expression induced vicarious pain (Zhou et al., 2020). In a sample of 60 healthy individuals, we found that viewing pain expression faces increased neural representations of negative emotion and vicarious pain. However, expressive suppression to pain faces reduced neural representations of negative emotion only. Providing support for a connection between neural representations of negative emotion and pain empathy, PINES responses to pain faces were associated with participants' trait-level empathy and the perceived unpleasantness of pain faces. Findings suggest that a consequence of suppressing one's facial expressions in response to the pain of others may be a reduction in the affective aspect of empathy but not the experience of vicarious pain itself.

Multivariate spatial feature selection in fMRI

Multivariate neuroimaging analyses constitute a powerful class of techniques to identify psychological representations. However, not all psychological processes are represented at the same spatial scale throughout the brain. This heterogeneity is apparent when comparing hierarchically organized local representations of perceptual processes to flexible transmodal representations of more abstract cognitive processes such as social and affective operations. An open question is how the spatial scale of analytic approaches interacts with the spatial scale of the representations under investigation. In this article, we describe how multivariate analyses can be viewed as existing on a spatial spectrum, anchored by searchlights used to identify locally distributed patterns of information on one end, whole brain approach used to identify diffuse neural representations at the other and region-based approaches in between. We describe how these distinctions are an important and often overlooked analytic consideration and provide heuristics to compare these different techniques to choose based on the analyst’s inferential goals.

Interplay Between the Salience and the Default Mode Network in a Social-Cognitive Task Toward a Close Other

Social cognition relies on two main subsystems to construct the understanding of others, which are sustained by different social brain networks. One of these social networks is the default mode network (DMN) associated with the socio-cognitive subsystem (i.e., mentalizing), and the other is the salience network (SN) associated with the socio-affective route (i.e., empathy). The DMN and the SN are well-known resting state networks that seem to constitute a baseline for the performance of social tasks. We aimed to investigate both networks' functional connectivity (FC) pattern in the transition from resting state to social task performance. A sample of 38 participants involved in a monogamous romantic relationship completed a questionnaire of dyadic empathy and underwent an fMRI protocol that included a resting state acquisition followed by a task in which subjects watched emotional videos of their romantic partner and elaborated on their partner's (Other condition) or on their own experience (Self condition). Independent component and ROI-to-ROI correlation analysis were used to assess alterations in task-independent (Rest condition) and task-dependent (Self and Other conditions) FC. We found that the spatial FC maps of the DMN and SN evidenced the traditional regions associated with these networks in the three conditions. Anterior and posterior DMN regions exhibited increased FC during the social task performance compared to resting state. The Other condition revealed a more limited SN's connectivity in comparison to the Self and Rest conditions. The results revealed an interplay between the main nodes of the DMN and the core regions of the SN, particularly evident in the Self and Other conditions.

Empathic responses to unknown others are modulated by shared behavioural traits

How empathically people respond to a stranger's pain or pleasure does not only depend on the situational context, individual traits and intentions, but also on interindividual factors. Here we ask whether empathic responses towards unknown others are modulated by behavioural similarity as a potential marker of genetic relatedness. Participants watched two supposed human players who were modelled as having a strong (player LP) or weak (player NLP) tendency to lead in social situations executing penalty shots in a virtual reality robot soccer game. As predicted, empathic response were modulated by shared behavioural traits: participants whose tendency to lead was more similar to player LP's tendency to lead experienced more reward, and showed stronger neural activity in reward-related brain regions, when they saw player LP score a goal, and participants whose tendency to lead was more similar to player NLP's tendency to lead showed stronger empathic responses when they saw player NLP score a goal. These findings highlight the potentially evolutionary grounded role of phenotypic similarity for neural processes underlying human social perception.

Representation, Pattern Information, and Brain Signatures: From Neurons to Neuroimaging

Human neuroimaging research has transitioned from mapping local effects to developing predictive models of mental events that integrate information distributed across multiple brain systems. Here we review work demonstrating how multivariate predictive models have been utilized to provide quantitative, falsifiable predictions; establish mappings between brain and mind with larger effects than traditional approaches; and help explain how the brain represents mental constructs and processes. Although there is increasing progress toward the first two of these goals, models are only beginning to address the latter objective. By explicitly identifying gaps in knowledge, research programs can move deliberately and programmatically toward the goal of identifying brain representations underlying mental states and processes.

Agent-specific learning signals for self-other distinction during mentalising

Humans have a remarkable ability to simulate the minds of others. How the brain distinguishes between mental states attributed to self and mental states attributed to someone else is unknown. Here, we investigated how fundamental neural learning signals are selectively attributed to different agents. Specifically, we asked whether learning signals are encoded in agent-specific neural patterns or whether a self–other distinction depends on encoding agent identity separately from this learning signal. To examine this, we tasked subjects to learn continuously 2 models of the same environment, such that one was selectively attributed to self and the other was selectively attributed to another agent. Combining computational modelling with magnetoencephalography (MEG) enabled us to track neural representations of prediction errors (PEs) and beliefs attributed to self, and of simulated PEs and beliefs attributed to another agent. We found that the representational pattern of a PE reliably predicts the identity of the agent to whom the signal is attributed, consistent with a neural self–other distinction implemented via agent-specific learning signals. Strikingly, subjects exhibiting a weaker neural self–other distinction also had a reduced behavioural capacity for self–other distinction and displayed more marked subclinical psychopathological traits. The neural self–other distinction was also modulated by social context, evidenced in a significantly reduced decoding of agent identity in a nonsocial control task. Thus, we show that self–other distinction is realised through an encoding of agent identity intrinsic to fundamental learning signals. The observation that the fidelity of this encoding predicts psychopathological traits is of interest as a potential neurocomputational psychiatric biomarker.

In order for people to have meaningful social interactions, they need to infer each other’s beliefs. Converging evidence from humans and nonhuman primates suggests that a person’s brain can represent a second person’s beliefs by simulating that second person’s brain activity. However, it is not known how the outputs of those simulations are identified as ‘yours and not mine’. This ability to distinguish self from other is required for social cognition, and it may be impaired in mental health disorders with social cognitive deficits. We investigated self–other distinction in healthy adults learning about an environment both from their own point of view and the point of view of another person. We used computationally identified learning variables and then detected how these variables are represented by measuring magnetic fields in the brain. We found that the human brain can distinguish self from other by expressing these signals in dissociable activity patterns. Subjects who showed the largest difference between self signals and other signals were better at distinguishing self from other in the task and also showed fewer traits of mental health disorders.

Transforming Pain With Prosocial Meaning: A Functional Magnetic Resonance Imaging Study

OBJECTIVE

Contextual factors can transform how we experience pain, particularly if pain is associated with other positive outcomes. Here, we test a novel meaning-based intervention. Participants were given the opportunity to choose to receive pain on behalf of their romantic partners, situating pain experience in a positive, prosocial meaning context. We predicted that the ventromedial prefrontal cortex (vmPFC), a key structure for pain regulation and generation of affective meaning, would mediate the transformation of pain experience by this prosocial interpersonal context.

METHODS

We studied fMRI activity and behavioral responses in 29 heterosexual female participants during (1) a baseline pain challenge and (2) a task in which participants decided to accept a self-selected number of additional pain trials to reduce pain in their male romantic partners ("accept-partner-pain" condition).

RESULTS

Enduring extra pain for the benefit of the romantic partner reduced pain-related unpleasantness (t = -2.54, p = .016) but not intensity, and increased positive thoughts (t = 3.60, p = .001) and pleasant feelings (t = 5.39, p < .0005). Greater willingness to accept the pain of one's partner predicted greater unpleasantness reductions (t = 3.94, p = .001) and increases in positive thoughts (r = .457, p = .013). The vmPFC showed significant increases (q < .05 FDR-corrected) in activation during accept-partner-pain, especially for women with greater willingness to relieve their partner's pain (t = 2.63, p = .014). Reductions in brain regions processing pain and aversive emotion significantly mediated reductions in pain unpleasantness (q < .05 FDR-corrected).

CONCLUSIONS

The vmPFC has a key role in transforming the meaning of pain, which is associated with a cascade of positive psychological and brain effects, including changes in affective meaning, value, and pain-specific neural circuits.