What is empathy?
Awareness of effect of own actions on others
Comprehension of others’ perspectives
Understanding others’ experiences and motivations
Empathy is as ubiquitous as it is undefined. We are quick to talk about empathy and quick to argue its definition. My favourite definition of empathy comes from the Alternative Model for Personality Disorders in the DSM-5. Empathy is broken into three components: awareness of the effect of one’s actions on others, comprehension of others’ perspectives and understanding others’ experiences and motivations.
Empathy impairment exists on a spectrum: the DSM-5 outlines the five stages between zero and total impairment. Above, the green represents no impairment, yellow clinically significant impairment and red absolute impairment. It is popular fiction that those with personality disorders, especially the dramatic-erratic (borderline, histrionic, narcissistic and antisocial), are unable to experience empathy. This stereotype is harmful in that it provides justification for the maltreatment of these patients and the lack of therapeutic treatments for these disorders, and promotes the myth that people with BPD are incapable of participating in functional relationships.
The thing about stereotypes is they are built around a single grain of truth. It’s true that empathy impairment is a core feature of personality disorders. It’s true that people with BPD pay more attention to threatening emotions like anger or rejection, or that we interpret neutral emotions as threatening, assuming others are angry or disappointed in us. It’s true that taking the perspective of others and imagining those close to us as complex beings with intricate inner lives is challenging, as we often assume the intention is to harm, abandon, or attack. However, it is incorrect to portray these impairments as complete or universal characteristics of personality disorders. Empathy impairment is not necessary or sufficient for the diagnosis of any personality disorder, despite its common occurrence. Recently, in an online discussion group amongst people with BPD, individuals expressed confusion about the concept of impaired empathy in BPD.
“How can I be empathy-impaired when I experience everyone else’s emotions?”
“I wish this was true, please, someone take my empathy”.
The reason for this dissonance is that empathy is not a clear unidimensional construct. Generally, empathy follows a two-factor model of cognitive and affective empathy. Cognitive empathy describes the ability to imagine another’s perspective by integrating their verbal and nonverbal expressions with cues from the environment. For example, imagine Sally and Jenny are having coffee and discussing events of the past week, when Jenny inadvertently mentions Sally’s ex-boyfriend, John. Sally immediately becomes withdrawn and offers little to the conversation. If Jenny has intact cognitive empathy, she might recognize Sally is feeling negative emotions about John and being reminded of him. However, if Jenny does not have intact cognitive empathy, she might interpret Sally’s negative emotions as directed toward her and become threatened or hurt by Sally due to her inability to integrate the emotions with the context. A number of tests have been developed to target cognitive empathy, or social cognition, one of which is the Movie for the Assessment of Social Cognition. This task consists of a short film broken into 40 clips with an associated multiple-choice question probing the subject to identify actors’ emotions, thoughts, and intentions. Individuals with BPD score lower than healthy comparisons on this test and show pronounced deficits in the task of accurately identifying actors’ intentions (Preißler et al., 2010).
Affective empathy, on the other hand, describes the ability to perceive and experience other people’s emotions, or to imagine the emotions of someone in a given situation. The extreme of affective empathy is emotion contagion: the phenomenon of emotional states catching and spreading across individuals. While cognitive empathy is often impaired in individuals with BPD, affective empathy is often accentuated (Jeung et al., 2014). Individuals with BPD are highly attuned to others’ emotions. However, affective empathy impairment might present as hypersensitivity to negative emotions or perception of negative emotions when neutral emotions are present. People with BPD pay biased attention to threatening facial expressions and show hyperactive amygdala responses to angry faces (See https://borderlinetalksback.com/2018/11/08/borderline-brains/).
Treatment for empathy impairment
Oxytocin (OT) administration is a promising avenue for the treatment of empathy impairment across disorders. OT is a neuropeptide that is implicated in social cognition, attachment, social learning and prosocial behaviour. To date, intranasal OT administration has been studied in patients with autism spectrum disorders, schizophrenia, and BPD. These studies are limited by the fact that OT molecules are too large to cross the blood-brain barrier and assessments of OT using blood or saliva do not accurately reflect levels of OT in the brain. Despite these limitations, OT is known to have effects in the peripheral nervous system and has resulted in several behavioural results. In BPD, OT ameliorates biased attention and amygdala hyper-response to threatening facial expressions and improves recovery from a social stress task. There are limited studies of these effects, however, and many replications must be conducted to draw definitive conclusions about the efficacy of OT in treating social cognition in BPD
The Interpersonal Effectiveness module of Dialectical Behaviour Therapy (DBT) teaches skills that can improve how individuals with BPD relate to others. While the goal of these skills is not to enhance empathy per se, they teach how to avoid assumptions of others’ internal states, how to communicate needs effectively. There is currently a clinical trial investigating the efficacy of OT administration concurrently with DBT therapy, under the rationale that OT might enhance patients’ ability to learn the interpersonal skills taught in DBT. https://clinicaltrials.gov/ct2/show/NCT01243658
What we talk about when we talk about empathy
Online, discussions of empathy are often reduced to whether or not a particular diagnosis results in the inability to experience empathy. We have learned that empathy is a multidimensional construct, meaning that empathy impairment can look different across individuals and can vary in severity. We also learned that empathy impairment can be cognitive or affective; in BPD, cognitive empathy is challenged while affective empathy is accentuated. Treatments for empathy include the Interpersonal Effectiveness module of DBT and potentially the administration of oxytocin.
American Psychiatric Association. (2013). Alternative DSM-5 Model for Personality Disorders. In Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. doi:10.1176/appi.books.9780890425596.AlternatePersonalityDisorders
Brüne, M. (2016). On the role of oxytocin in borderline personality disorder. The British Journal of Clinical Psychology, 55, 287–304. doi:10.1111/bjc.12100
Jeung, H., Herpertz, S.C. (2014). Impairments of Interpersonal Functioning: Empathy and Intimacy in Borderline Personality Disorder. Psychopathology, 47, 220-234. doi: 10.1159/000357191
Preißler, S., Dziobek, I., Ritter, K., Heekeren, H. R., & Roepke, S. (2010). Social Cognition in Borderline Personality Disorder: Evidence for Disturbed Recognition of the Emotions, Thoughts, and Intentions of others. Frontiers in Behavioral Neuroscience, 4, 1–8. doi:10.3389/fnbeh.2010.00182