Altered empathic responding in major depressive disorder: Relation to symptom severity, illness burden, and psychosocial outcome
Introduction
Empathy refers broadly to the ability to infer and share the feeling states of others in reference to oneself (Decety and Moriguchi, 2007), playing a central role in successful interpersonal engagement and higher social functioning (Baron-Cohen and Wheelwright, 2004). Investigators have adopted a multidimensional approach to the study of empathy, proposing that this psychological construct involves both cognitive (e.g., inferring another's mental state) and affective (e.g., affective response to the feeling state of another) components (Davis, 1983; for a review see McKinnon et al., 2007). Critically, many of the same cognitive (e.g., executive functioning; working memory) and affective (e.g., emotion comprehension) processes are affected in patients with MDD (Mikhailova et al., 1996, Landro et al., 2001, Surguladze et al., 2004, Gualtieri et al., 2006), rendering it probable that patients with this disorder will demonstrate reduced empathic abilities that rely on these same processing resources. To date, however, few studies of empathic responding have been conducted in patients with MDD. Here, we examine empathic responding in a sample of outpatients with MDD, examining the relation of performance to symptom severity, illness burden, and psychosocial function.
Studies examining social cognitive performance in patients with MDD reveal a conflicting pattern of performance impairment and sparing. For example, a wide body of evidence reveals that patients with MDD are impaired in the recognition of affective facial expressions (see Leppänen, 2006 for a review). Here, individuals with MDD demonstrate a mood-congruent bias during facial emotion recognition tasks, showing deficits in the recognition of happy faces (Mandal and Bhattacharya, 1985, Rubinow and Post, 1992, Mikhailova et al., 1996, Suslow et al., 2001, Gotlib et al., 2004, Surguladze et al., 2004, LeMoult et al., 2009), enhanced recognition of sad facial expressions (Mandal and Bhattacharya, 1985, David and Cutting, 1990, Surguladze et al., 2004, Goeleven et al., 2006), as well as a tendency to identify neutral faces as sad relative to healthy controls (David and Cutting, 1990, Wright et al., 2009). A number of studies, however, fail to show evidence of alterations in the processing of emotional faces among patients with MDD (Gaebel and Wolwer, 1992, Mogg et al., 2000, Kan et al., 2004, Hertel et al., 2009). Patients with MDD also demonstrate a negative bias during the processing of affective prosodic stimuli by interpreting neutral prosodic emotions as negative (Kan et al., 2004) and showing enhanced recognition of sad emotional tones (Uekermann et al., 2008a). Few studies have examined theory of mind, the ability to infer the mental states (e.g., belief, intentions, emotions) of others to understand and predict their behavior (Premack and Woodruff, 1978) in patients with MDD. Theory of mind is a term related to but dissociable from the construct of ‘cognitive empathy’, and involves a cognitive understanding and appreciation of another's mental state. In these studies, actively ill patients show impairment on a variety of theory of mind tasks placing demands on cognitive and affective processing resources (Lee et al., 2005, Uekermann et al., 2008b, Wang et al., 2008). Overall, the literature concerning social cognitive performance in MDD reveals a mixed pattern of findings, underscoring the need for further investigation. The primary goal of this study is to examine specifically empathic responding in a sample of patients with MDD, an area of social cognitive performance remaining underexplored in this population.
Deficits in empathic responding have been reported in neuropsychiatric populations such as schizophrenia (Montag et al., 2007, Shamay-Tsoory et al., 2007) and autism spectrum disorders (Baron-Cohen et al., 2001, Rogers et al., 2007), however, to date, very few studies have assessed empathic responding in patients with mood disorders. Early evidence of reduced empathic capacity has been reported in individuals with bipolar disorder (Shamay-Tsoory et al., 2009, Cusi et al., 2010). Both Shamay-Tsoory et al. (2009) and our group (Cusi et al., 2010) found that relative to healthy controls, patients with bipolar disorder (BD) reported decreased cognitive empathy (‘Perspective Taking’) and elevated levels of affective personal discomfort in response to others' distress (‘Personal Distress’), as assessed by the Interpersonal Reactivity Index (IRI; Davis, 1983). In our study, impaired affective empathic abilities were associated with greater depressive severity but not number of past mood episodes or illness duration suggesting that changes in empathic responding in bipolar disorder may represent a state, rather than trait, marker of illness. Interestingly, these alterations in affective distress were associated with reduced psychosocial functioning (as assessed at the time of testing) in our sample of BD patients, most of whom were mildly ill; it is unclear at present whether further reductions in psychosocial function would arise with more severe illness or remit over the course of euthymia.
Prior investigations provide preliminary evidence of alterations in abilities associated with empathic responding in individuals with MDD. For example, Donges et al. (2005) found that inpatients with acute MDD showed intact awareness of their own emotions, but reduced awareness of others' emotions compared to matched controls. This decrease in emotional awareness for others was associated with elevated symptoms of depression. Interestingly, emotional awareness improved significantly following treatment in a psychotherapeutic program targeted at recognizing emotional responses and their situational origins (Donges et al., 2005). Only one study has assessed directly the cognitive and affective components of empathy in patients with MDD. O'Connor et al. (2002) found that depressed inpatients reported elevated levels of distress and discomfort in response to other's negative situations on the IRI Personal Distress subscale; greater levels of depression severity were associated with higher scores on this subscale. These patients also scored significantly higher than healthy controls on self-rated measures of altruism, a process linked closely to empathy, although not directly analogous to it.
In the present study, we conducted a preliminary assessment of empathic responding in a sample of MDD outpatients in varying states of illness. First, we used two standardized self-rated measures of empathic responding, the Toronto Empathy Questionnaire (TEQ; Spreng et al., 2009) to assess empathic ability broadly and the IRI to specifically assess cognitive and affective facets of empathic responding. We expected that depressed patients would show impaired cognitive and affective empathic abilities, as a result of well-documented deficits in cognitive (e.g., perspective taking) and affective (e.g., emotion recognition) processing found in this patient population (Phillips et al., 2003, Lee et al., 2005, Uekermann et al., 2008a). Notably, impairments on tests of social cognition, most prominently, theory of mind (Inoue et al., 2006), is associated with poor functional outcome in individuals with mood disorders. To date, however, there have been no studies examining the relation between cognitive and affective empathic responding and standardized measures of social functioning in patients with MDD. Hence, we examined the relation between empathic abilities and psychosocial functioning using a well-validated measure of functional outcome, the Social Adjustment Scale Self-Report (SAS-SR; Weissman and Bothwell, 1976). We predicted that similar to patients with BD, altered empathic performance in patients with MDD would be associated with impaired functioning. Finally, in light of recent findings showing that patients with a chronic and recurrent illness history show greater impairment on tests of social (McKinnon et al., 2010) and cognitive function, (e.g., Basso and Bornstein, 1999, MacQueen et al., 2002), we examined the relation between illness burden (e.g., number of depressive episodes, illness duration) and empathic responding.
Section snippets
Participants
Twenty patients who had experienced at least one prior episode of MDD (6 males and 14 females) and 20 age- and education-matched controls (7 males and 13 females) with no history of psychiatric illness participated in the present study. The demographic and clinical characteristics of the study sample are summarized in Table 1. Patients were tested in varying states of illness, allowing for an examination of the relation between symptom severity and empathic responding. Current level of symptom
Materials
The IRI (Davis, 1980, Davis, 1983) is a 28-item self-report instrument that measures both cognitive and emotional aspects of empathy. Items are rated on a scale ranging from 0 (does not describe me well) to 4 (describes me very well). The cognitive subscales comprise the Perspective Taking and Fantasy scales. Whereas the Perspective Taking (PT) scale measures the tendency to spontaneously understand the psychological point of view of others (i.e. I sometimes find it difficult to see things from
Performance on the TEQ
Relative to controls, the MDD group reported reduced levels of empathic responding as assessed by the TEQ [F (1, 38) = 6.96, P = 0.01, ηp2 = 0.16].
Performance on the IRI
Table 2 displays the participants' performance on the IRI. Patients with MDD reported lower levels of Perspective Taking [F (1, 38) = 7.65, P = 0.009, ηp2 = 0.17] and Empathic Concern [F (1, 38) = 4.86, P = 0.03, ηp2 = 0.11] than did healthy controls. No other significant effects emerged.
Psychosocial functioning
As expected, the Work/Academic functioning [F (1, 13) = 12.59, P = 0.004, ηp2 = 0.49],
Discussion
To our knowledge, this is the first report of altered empathic abilities in a sample of outpatients with MDD. Critically, we found preliminary evidence that patients with MDD reported significantly lower levels of both cognitive (Perspective Taking) and affective (Empathic Concern) empathy relative to matched controls. A higher number of depressive episodes were also associated with reduced perspective taking abilities, suggesting a gradual worsening in the ability to mentalize about other's
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