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Empathy Ability Is Impaired in Alcohol-Dependent Patients

Giovanni Martinotti a; Marco Di Nicola a; Daniela Tedeschi a; Sante Cundari a; Luigi Janiri a a Department of Psychiatry, Catholic University Medical School, Rome, Italy Online Publication Date: 01 March 2009

To cite this Article Martinotti, Giovanni, Nicola, Marco Di, Tedeschi, Daniela, Cundari, Sante and Janiri, Luigi(2009)'Empathy Ability Is

Impaired in Alcohol-Dependent Patients',American Journal on Addictions,18:2,157 161

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The American Journal on Addictions, 18: 157161, 2009 Copyright C American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1080/10550490802544391

Empathy Ability Is Impaired in Alcohol-Dependent Patients

Giovanni Martinotti, MD, PhD, Marco Di Nicola, MD, Daniela Tedeschi, DR, Sante Cundari, DR, Luigi Janiri
Department of Psychiatry, Catholic University Medical School, Rome, Italy

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Empathy is a complex form of psychological inference in which observation, memory, knowledge and reasoning are combined to yield insights into the thoughts and feelings of others. The aim of this study was to evaluate the level of empathy in a sample of alcohol-dependent patients in comparison to a control sample. One hundred and fty alcoholdependent subjects were consecutively recruited. All of the subjects successfully detoxied have been evaluated with the Empathy Quotient (EQ) and then compared with 107 control subjects. The level of empathy was signicantly lower in the group of alcohol-dependent subjects than in the control sample (p < .001). Differences with respect to gender and psychiatric comorbidity have also been observed. A low level of empathy could be a psychological trait typically observed in pre-morbid alcoholic personalities. Further, the lack of empathy could lead latent abusers to nd in the alcohol misuse something enabling them to compensate for their intrinsic weakness. (Am J Addict 2009;18:157161)

INTRODUCTION The word empathy is the translation of the German word Einfuhlung, a term from aesthetics meaning to project yourself into what you observe. Only at the beginning of the twentieth century, following the important contribution of Theodor Lipps and Edith Stein, did the term empathy become incorporated within the eld psychology with the meaning of the way in which we perceive what the others feel.1,2 According to Ickes,3 empathy is a complex form of psychological inference in which observation, memory, knowledge, and reasoning are combined to yield insights into the thoughts and feelings of others. Zahn-Waxler and Radke-Yarrow4 believed that empathy is central to what it means to be fully human. It allows us to tune into how someone else is feeling,
Received April 13, 2008; revised May 22, 2008; accepted July 2, 2008. Address correspondence to Dr. Giovanni Martinotti, Clinica Villa Maria Pia, Via del Forte Trionfale 36, Rome 00135, Italy. E-mail: giovanni.martinotti@libero.it

or what they might be thinking. It allows us to understand the intentions of others, predict their behavior, and experience emotion triggered by their emotions. In other words, empathy allows us to interact effectively in the social world. It is also the glue of social relations, drawing us to help others and stopping us from hurting others.5 Humans can feel empathy for other people in a wide variety of conditions: in response to basic emotions and sensations such as anger, fear, sadness, joy, pain, and lust, as well as to more complex emotions such as guilt, embarrassment, and love.6 Over time, various denitions of empathy have been proposed reecting its multidimensional nature. Research in this area follows two main trends: researchers that consider empathy basically as an affective response to another person or an understanding of another persons feeling,711 and those who have taken a more cognitive approach, regarding empathy as a cognitive capacity to take the perspective of the other person while keeping self and other differentiated.1219 This last conceptualization is actually developed using the concept of theory of mind (ie, the ability to think about the contents of other minds20,21 ) and the concept of mind reading.22,23 The social role of empathy has been largely emphasized in literature. It has been related with sense of morality, altruism, pro-social behavior, and cooperation. Some authors believe that a decit in this ability may invalidate the development and the formation of sustainable human social structures.24 As such, it is critical to moral development and to the implementation of justice, thereby acting as a catalyst for societal cohesion and unity.25 Different dimensional traits are associated to empathy, such as alexithymia,26 the inability to talk about feelings due to a lack of emotional awareness, or impulsiveness.27 Individuals with empathy decits are more likely to display aggressive and antisocial behaviors toward others,28 while the absence of empathy is what characterizes specic disorders such as autism and Asperger Syndrome.5,29,30 Furthermore, an impaired empathy ability can be found in schizophrenia31,32 ; in personality disorders such as antisocial personality disorder,33,34 which can be characterized by the tendency to hurt others without feeling guilt or remorse35 ; and in narcissistic36 and borderline
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personality disorders, in which empathy is driven principally by the desire to have needs satised. The role of empathy in a psychotherapeutic relation is a key factor that needs to be assessed in order to plan the suitable approach for the patient. The addiction service providers should not ignore this dimension, considering that a good therapeutic relation is probably at the basis of the clinical improvement. The aim of this study was to evaluate the level of empathy in a sample of alcohol-dependent patients in comparison to a healthy control sample. The potential roles of sex, age, multiple substance abuse and Axis I and II diagnoses in relation to empathy represented the secondary endpoints.
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METHODS One hundred and fty subjects meeting clinical criteria for alcohol dependence (DSM-IV-TR) were consecutively recruited from the Day-Hospital of Psychiatry and Drug Dependence of the University General Hospital A. Gemelli in Rome. Enrollment started in July 2006 and was completed in September 2007. Inclusion criteria were an age of 1865 years, a diagnosis of Alcohol Dependence, and prociency in spoken and written Italian language. Comorbidity with schizophrenic disorder, cognitive impairment, and inability in the reality test resulted in exclusion from the study. Patients were evaluated by attending psychiatrists and psychologists using the Structured Clinical Interview for DSM-IV (SCID I, SCID II) in order to assess their comorbid psychiatric disorders and personality. All subjects included were detoxied for a exible period of 510 days with benzodiazepines according to established and validated protocols.37 Forty-three subjects did not complete the detoxication period and were excluded from the study. Finally, all detoxied subjects were evaluated using the Empathy Quotient (EQ) after a period of at least three weeks from last alcohol intake. The EQ is a questionnaire that can be self-administered, has a forced choice format, and is straightforward to score because it does not depend on any interpretation.5 It comprises 60 randomized questions, broken down into two types: 40 questions tapping empathy and 20 ller items included to distract the participant from a relentless focus on empathy.5 Each of the empathy items scores 1 point if the respondent records the empathic behavior mildly, or 2 points if the respondent records the behavior strongly. Approximately half of the items were worded to produce a disagree response and half to produce an agree response for the empathic behavior being examined. This was to avoid a response bias either way. The EQ score can be divided into four ranges: 032, 3352, 5363, and 6480, respectively indicating a below average, average, above average, and very high ability to understand how other people feel and to respond appropriately.5
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The EQ was also used to evaluate 107 healthy control subjects who were recruited in random modality from among the staff of Universit` a Cattolica del Sacro Cuore and the general public. Control subjects were matched with the experimental group for age, sex, and level of education. Both study and control subjects gave written informed consent to take part in the study, for which they voluntarily participated without receiving any form of payment. Anonymity was guaranteed to all the participants. All study procedures were submitted and approved by Institutional Review Board of Universit` a Cattolica del Sacro Cuore in Rome. Students t-test and chi-square test were employed in order to compare socio-demographic and clinical data. Differences between group scores were analyzed using the t-test for independent samples. The analysis of variance (ANOVA) was used to analyze the differences between subjects in the different range of EQ scores. The Pearson Product Moment Correlation was used in order to assess the relationship between EQ scores and the age of subjects. RESULTS In Table 1, the socio-demographic and clinical characteristics of the alcohol-dependent and healthy control groups are showed. The level of empathy as measured by the Empathy Quotient (EQ) was signicantly lower (p < .001) in the group of alcohol-dependent subjects (40.27 9.2) than in the control sample (46.58 10.0; see Figure 1). Figure 2 shows the division of subjects in both groups into the four different ranges of EQ scores. Signicant differences were found (F = 19.18; df = 3; p < .005), with a signicantly larger number of alcohol-dependent subjects scoring in range 1 (below average level of empathy), and a signicantly larger number of control

FIGURE 1. EQ scores in the sample of alcohol-dependent and control subjects. *p < .001.

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TABLE 1. Socio-demographic and clinical characteristics of the two samples of alcohol-dependent and control subjects Alcoholdependent subjects N Sex (males) Age (mean SD) <30 3050 >50 Marital status Single Married Separated/divorced Level of education Elementary school Lower secondary school High school education Degree Employment condition Regular job Occasionally employed Unemployed Student Duration of alcohol misuse (years) Duration of abstinence (days) Multiple substance abuse Dual diagnosis (axis I) Affective disorders Impulse-control disorder Anxiety disorders Dual diagnosis (axis II) Cluster A Cluster B Cluster C NAS 107 58 (54.2%) 43 10.7 14 (13%) 71 (66.4%) 22 (20.6%) 34 (31.8%) 59 (55.1%) 14 (13%) 12 (11.2%) 37 (34.5%) 53 (49.5%) 5 (4.7%) 46 (43%) 9 (8.4%) 24 (22.4%) 28 (26.2%) 10 8.1 49.3 12.5 24 (22.5%) 20 (18.7%) 12 (11.3%) 4 (3.7%) 4 (3.7%) 19 (17.7%) 3 (2.8%) 13 (12.1%) 2 (1.9%) 1 (0.9%) Control subjects 107 51 (47.7%) 42 14.2 20 (18.7%) 58 (54.2%) 29 (27.1%) 40 (37.4%) 58 (54.2%) 9 (8.4%) 9 (8.4%) 31 (28.2%) 58 (54.2%) 9 (8.4%) 60 (56.1%) 3 (2.8%) 20 (18.7%) 24 (22.4%)

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subjects scoring in ranges 3 and 4 (high and very high levels of empathy). Across the whole sample of both experimental subjects and healthy controls, the average EQ score was signicantly higher (p < .001) in females (45.96 10.4) than in males (41.19 9.3). This difference was not observed in the sample of alcoholdependent subjects, where the average EQ score was almost the same in females (n = 39; EQ = 40.35 8.7) and males (n = 68; EQ = 40.22 9.6). The average EQ score was signicantly higher (p < .001) in female controls (49.32 9.9) than in alcohol-dependent females (40.35 8.7), while the average EQ scores of males were not signicantly different between groups (alcoholics: 40.22 9.6; controls: 43.02 8.7). The age of all the subjects evaluated did not signicantly correlate (r = 12; p < .079) with levels of empathy as measured by the EQ. In the sample of alcohol-dependent subjects, the subgroups with a comorbid Axis I disorder (n = 15; EQ = 38.80 9.1) had an average EQ score that was signicantly lower (p < .05) than that of the subgroup without an Axis I disorder (EQ = 43.05 8.9). The Axis I psychiatric diagnoses reported were Major Depression (n = 3), Bipolar Disorder type II (n = 4), Impulse-Control Disorder (n = 3), General Anxiety Disorder (n = 2), Bipolar Disorder type I (n = 1), Cyclothymic Disorder (n = 1), and Panic Disorder (n = 1). The average EQ score in the subgroup with a comorbid Axis II disorder (n = 19; EQ = 41.25 9.4) was not signicantly different (p= .51) from that in the subgroup without an Axis II disorder (EQ = 39.92 9.2). The Axis II psychiatric diagnoses reported were Borderline Personality Disorder (n = 5), Narcissistic Personality Disorder (n = 3), Antisocial Personality Disorder (n = 3), Histrionic Personality Disorder (n = 2), Paranoid Personality Disorder (n = 1), Dependent Personality Disorder (n = 1), Depressive Personality Disorder (n = 1), Schizotypal Personality Disorder (n = 1), Schizoid Personality Disorder (n = 1), and Avoidant Personality Disorder (n = 1). The average EQ score in the subgroup of alcohol-dependent patients also reporting abuse of other substances (n = 24; EQ = 41.61 9.9) did not differ signicantly (p = .30) from

FIGURE 2. Percentage of alcohol-dependent and control subjects in the different ranges of EQ score. Abbreviations: EQ range: 032 = low level of empathy; 3352 = average empathic ability; 5363 = high empathic ability; 6480 = very high level of empathy. *signicant differences between groups (p < .005).

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the sample of alcoholics not using any other substances (EQ = 41.60 8.9). Other reported substances of abuse were cocaine,7 benzodiazepine,6 cannabis,6 multiple substances,3 amphetamines,1 and MDMA.1

DISCUSSION The present study was the rst to examine the level of empathy in abstinent alcohol-dependent patients. In this study, we employed a newly introduced scale for the assessment of empathy, which is a controversial dimension that has proven difcult to evaluate. Several scales have been developed to measure empathy but each has signicant weaknesses. Of these, the Empathy Quotient (EQ)5 is the most recent addition, and unlike previous scales, it was specically designed for clinical application and to be sensitive to a lack of empathy as a feature of psychopathology. A strength of this study is that all the patients evaluated were abstinent at the time of the assessment and therefore not inuenced by alcohol in terms of their performance. Furthermore, as stipulated by the inclusion criteria, the time since the last alcohol intake was longer than three weeks in order to eliminate any possible bias caused by withdrawal symptoms. In this study, subjects with alcohol dependence demonstrated reduced empathy, as measured by the EQ. The hypothesis that this data may be inuenced by the large number of abusers with a cluster B Personality Disorder, a cluster usually characterized by a low level of empathy, is not in line with our data, given the nding that there were no signicant differences between the subgroups of alcoholics with and without an Axis II disorder. The presence of a dual diagnosis of an Axis I disorder is a factor that should nonetheless be taken into account, as it can be considered a state condition capable of lowering the ability to feel empathy. However, despite the potential inuence of comorbidity as a confounding factor in the observed reduction in empathy levels, we do not believe that the lower EQ scores in the experimental group can be explained by comorbidity alone, and hypothesize that a diagnosis of alcohol dependence is intrinsically characterized by an impaired capacity for empathy. This characteristic may be a psychological trait of the variety typically observed in pre-morbid alcoholic personalities.38,39 An impairment in the ability to understand the mental and affective state of others could be at the root of the high levels of impulsivity, aggression, and antisocial behavior, which represent key characteristics of some typologies of alcoholics.19,40 It is also possible that a lack of empathy could lead latent abusers to seek something that could compensate for their intrinsic weakness; intriguingly, some substances of abuse are called empathogenic drugs (generating a state of empathy).41 By these, we mean those psychoactive compounds that cause a transient rise in lucidity, a higher sensibility for the environments aesthetic properties, and a better ability
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to communicate and to understand others (for instance, ecstasythat is, MDMAwas, at the beginning, called empathy).42 The role of alexithymia is another factor to take into account. Because the awareness of ones emotional states is a prerequisite to recognizing such states in others, alexithymia, or the difculty in identifying and expressing ones own emotional states, presumably involves impairment in the ability to feel empathy.26,43 Different studies have shown the association of alcohol and substance misuse with alexithymic traits,4447 and, based on our ndings, we extend this hypothesis to also include an association of substance misuse with reduced capacity for empathy. Another issue that emerges from this study is that the differences in EQ scores between alcoholics and controls is mostly determined by the female subgroup. This nding is difcult to interpret, but we hypothesize that females are typically more empathic than males,4851 and, when impaired in this trait, they may search for something capable of improving their ability to communicate and understand others. From the psychosocial point of view, commonly held stereotypes and popular culture suggest that women tend to show a greater capacity for understanding others thoughts and feelings than do men.52 Therefore females are expected to behave and act in an empathic way, and a lack of emotional awareness of others may be seen to represent a maladaptive trait. Alcohol use could satisfy this need for a compensatory dynamic. However, it is also possible that a long history of alcoholism could overcome the constitutional personality features of patients and modify them in a way that could give rise to homogeneous subpopulations of alcoholics. In fact, although impaired empathy could be a characteristic of a premorbid alcoholic personality and therefore represents a risk factor for the development of alcohol dependence, we cannot forget that the long-term misuse of alcohol might be itself responsible for the development of an impaired empathic ability. This might be determined by a direct neurobiological effect or by an acquired psychological habit. With regard to treatment, because empathy and constructive interpersonal relations are contingent upon the willingness to take anothers perspective,53 an impaired empathic ability could be at the root of a non-functional therapeutic alliance, a low adherence to pharmacological treatments, and a higher relapse rate, given that the therapeutic relationship was described as one of the strongest predictors of drop-out.54,55 These ndings may represent a basis for better understanding of the impaired ability of alcoholics to engage in social and interpersonal interactions, such as problems between couples and co-dependent dynamics, and highlight an opportunity for the introduction of specic psychotherapeutic interpersonal techniques capable of improving the expression of empathy in these patients. The authors wish to thank Lamia Nayeb and Jan Lewis for language revision.
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