Definition/Introduction

The term "empathy" (translated from the German word Einfuhlung, which means feeling into) started over 100 years ago and was introduced by psychologist Edward Titchener.[1]

Empathy is a complex, psychological-influencing social interaction; it plays a role in understanding others' feelings, suffering, and behavior with a significant link to compassion. It is a motivated phenomenon that allows people to connect emotionally by sharing experiences and feelings.[2][3][4] Not limited to the comprehension of feelings, empathy is directly linked to the fundamentals of morality and plays an important role in many social relations.[5]

The start of an empathic process is triggered by many agents such as vocalization (screaming or laughing), a body posture or facial expression, and verbal descriptions; however, it is not limited to any expression and environmental interaction that may target another person and trigger the empathic process.[5]  

Neuroanatomical Structures  

Empathy is linked to neuroanatomical structures such as the amygdala, anterior cingulate cortex, and anterior insular cortex. Furthermore, a multidimensional empathy approach classifies it as cognitive, affective, or behavioral empathy.[6]

1. The amygdala, located in the anterior medial part of each temporal lobe, consists of a diverse group of nuclei with distinct structures and functions. It serves as a recipient for sensory input from various cortical regions, including visual, auditory, somatosensory, and olfactory systems, as well as polysensory areas like the perirhinal cortex and the parahippocampal gyrus. Anatomically, the lateral nucleus segregates sensory modalities, but due to internal connections, the amygdala integrates multimodal information in regions such as the lateral, basal, and accessory basal nuclei. The amygdala's output extends to numerous target structures, encompassing the prefrontal cortex, striatum, sensory cortices (including primary sensory cortices unique to primates), hippocampus, perirhinal cortex, entorhinal cortex, basal forebrain, and subcortical structures responsible for physiological responses associated with emotions, such as autonomic and hormonal responses, as well as startle reflex. Notably, the central nucleus generates subcortical projections, while the basal, accessory basal, and sometimes lateral nuclei give rise to connections with the cortex and striatum.[7]
2. The anterior cingulate cortex (ACC) is a key brain region involved in various important functions such as emotion, action, and memory. It receives input from the orbitofrontal cortex, providing information about rewards and non-rewards. This enables the ACC to connect actions and outcomes through action-outcome learning. Additionally, the ACC's involvement in emotional processes arises from its role in connecting rewards to actions. On the other hand, the ACC also interacts with the posterior cingulate cortex, which allows for transmitting spatial and action-related information from parietal cortical areas. Moreover, the ACC's outputs to the hippocampal system contribute to memory functions. This intricate network of connectivity and its positioning within the proisocortical limbic region highlight the multifaceted nature of the ACC in the brain.[8]
3. The anterior insular cortex (AIC) is associated with a wide range of phenomena and actions, from the perception of bodily sensations like bowel distension and pleasure during orgasm to intense desires for cigarettes and maternal affection to cognitive processes such as decision-making and sudden moments of understanding. Its role in the reinterpretation of internal bodily signals provides a potential foundation for its involvement in the entirety of subjective emotions and experiences.[9]

Measuring Empathy  

To measure empathy, several scales have been designed that help identify an individual's capacity to be more empathic or less empathic. As empathy involves many psychological concepts, many scales are currently used to identify empathy. These include the Empathic Accuracy Task (EAT), Empathy Components Questionnaire, and the dated Interpersonal Reactivity Index (IRI).[10][11][12]

1. Empathic Accuracy Task (EAT): The EAT is an assessment tool used to measure cognitive empathy. It involves participants watching videos where a target individual shares a personal story, and their task is to continuously rate the valence (positive or negative) of these videos using a turning device. The EAT calculates empathic accuracy by comparing the participants' ratings with the target individual's own ratings. This correlation-based index indicates how accurately the participants can perceive and understand the emotional experiences of the target individual.[13]
2. Empathy Components Questionnaire (ECQ): The ECQ is a standardized assessment tool used to measure different components of empathy. It aims to capture empathy's cognitive and affective aspects by examining multiple dimensions. The questionnaire typically includes items that assess perspective-taking, which refers to the ability to understand and adopt the viewpoint of others, as well as empathic concern, which involves feeling compassion and concern for others' well-being. Additionally, the ECQ may include items related to personal distress, which measures the tendency to feel uncomfortable or distressed when witnessing others' negative emotions. By evaluating these various dimensions, the ECQ provides a comprehensive understanding of an individual's empathic abilities and helps researchers and practitioners gain insights into empathy-related traits and behaviors.[11]
3. Interpersonal Reactivity Index (IRI): The IRI is a widely used self-report questionnaire to measure empathy and related constructs. The IRI consists of four subscales that capture different aspects of empathy. The perspective-taking subscale assesses the ability to adopt the point of view of others and understand their feelings and thoughts. The fantasy subscale measures the tendency to imaginatively identify with fictional characters in books, movies, or other media. The empathic concern subscale evaluates feelings of compassion, warmth, and concern for others' well-being. Lastly, the personal distress subscale examines the propensity to experience discomfort and distress when witnessing others' suffering. The IRI provides a comprehensive assessment of individual differences in empathy, allowing researchers and clinicians to better understand empathic tendencies and their implications in various social and interpersonal contexts.[14]

Issues of Concern

Influence of Empathy on the Healthcare Team and Delivery 

The healthcare professional has to bring empathy to the table when dealing with a patient as it helps them comprehend the emotional and cognitive state of the patient involved. This connection can help healthcare professionals build a therapeutic relationship with the patients, eventually leading to better health outcomes. This influence is determined by the words chosen and facial expressions, body language, and vocalization. The emotional and cognitive connection is invaluable in today's healthcare delivery to achieve the best patient-provider relationship.[3][15]

As empathetic behavior by providers gets modulated by motivation, healthcare providers should also have empathic support from their institutions to deliver the same high-quality care to the patients.[4] 

Clinical Significance

Clinical Significance of Empathy

• Understanding a patient's feelings, concerns, and expectations can help a physician provide better care.
• Imagining things from the patient's point of view can reveal a different perspective to address them.
• Empathy can break down perceived barriers between the patient and the healthcare team.[16]

Increasing Empathy in the Practice

Cognitive empathy modulated by motivation can help to make better providers. There are many motivational triggers to increase empathy; those strategies apply to the interprofessional team and patient's care and are achievable by regular and thoughtful training.

• Creating a desire to alleviate suffering
• Increase kindness
• Increase positive and friendly attitude

These modulations can increase patient satisfaction and improve the diagnostic process and treatment outcome.[2]

Disorders of Empathy

Disturbance in an appropriate empathic/vicarious response can be associated with some conditions, such as [1][8]: 

• Psychopathy: Psychopathy, classified as a personality disorder, is characterized by a lack of empathy and guilt, a surface-level display of emotions, the manipulation of others, and the engagement in calculated and violent antisocial actions. Individuals with psychopathy impose significant burdens on society financially due to their criminal behavior and the disruption of normal work participation, as well as emotionally and psychologically, on their victims.[17]
• Autism spectrum disorder (ASD): ASD refers to a range of neurodevelopmental conditions that affect communication, social interaction, and behavior. People with ASD may display challenges in social skills, repetitive behaviors, and have specific interests or sensory sensitivities. ASD is a spectrum, meaning individuals can vary widely in their symptoms and level of impairment.[18]
• Alzheimer's disease: Alzheimer's disease is a progressive neurological disorder that primarily affects memory, thinking skills, and behavior. It is the most common form of dementia, characterized by the accumulation of abnormal protein deposits in the brain, leading to the loss of connections between brain cells and their eventual death. As the disease progresses, individuals may experience memory loss, confusion, difficulty completing familiar tasks, mood swings, and personality changes. Alzheimer's disease profoundly impacts individuals and their families, as it gradually impairs cognitive and daily functioning.[19]
• Frontotemporal dementia: Frontotemporal dementia is an umbrella clinical term encompassing a group of neurodegenerative diseases characterized by progressive deficits in behavior, executive function, or language. It is a common type of dementia, particularly in patients younger than 65, and can often mimic psychiatric disorders due to its prominent behavioral features. The clinical phenotype of frontotemporal dementia is caused by the selective degeneration of the frontal and temporal cortices, with various underlying neuropathological entities contributing to the disease. Additionally, genetics plays a significant role as a risk factor for frontotemporal dementia.[20]

Nursing, Allied Health, and Interprofessional Team Interventions

Training

Education and training through various seminars have been shown to train medical students for empathic communication; therefore, training healthcare professionals is essential to prepare them for excellent patient care.[21]

Nursing

Empathy for nursing is described as both a human trait and a professional state. Empathy plays a vital role in decision-making to deliver patient-centered care.[22]

Understanding and Educating

Understanding the concept of empathy and delivering patient education about it is of utmost importance in health care. Empathy, which involves understanding and sharing others' feelings and experiences, is crucial for healthcare professionals to establish meaningful connections with their patients. By comprehending patients' emotional and cognitive state, healthcare providers can build therapeutic relationships that contribute to better health outcomes. Effective communication goes beyond verbal exchanges and encompasses facial expressions, body language, and vocalization. Empathy helps healthcare professionals gain insight into patients' perspectives and breaks down barriers, fostering a stronger patient-provider relationship.

Institutions should support healthcare providers in empathic care, recognizing its clinical significance. Understanding patients' feelings, concerns, and expectations allows physicians to provide better care and consider different perspectives. By increasing empathy through motivation and training, healthcare professionals can improve patient satisfaction, diagnostic processes, and treatment outcomes. Educating and training healthcare professionals in empathic communication is essential to ensure excellent patient care. In the nursing field, empathy is considered both a human trait and a professional state, playing a vital role in patient-centered care. Additionally, understanding empathic behavior and providing proper care for patients with conditions that affect empathy, such as Alzheimer's disease and frontotemporal dementia, requires specialized training and education.

Overall, promoting understanding and education about empathy is essential for enhancing the healthcare experience and improving patient outcomes.