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1.  Self-reported empathy and neural activity during action imitation and observation in schizophrenia 
NeuroImage : Clinical  2014;5:100-108.
Although social cognitive impairments are key determinants of functional outcome in schizophrenia their neural bases are poorly understood. This study investigated neural activity during imitation and observation of finger movements and facial expressions in schizophrenia, and their correlates with self-reported empathy.
23 schizophrenia outpatients and 23 healthy controls were studied with functional magnetic resonance imaging (fMRI) while they imitated, executed, or simply observed finger movements and facial emotional expressions. Between-group activation differences, as well as relationships between activation and self-reported empathy, were evaluated.
Both patients and controls similarly activated neural systems previously associated with these tasks. We found no significant between-group differences in task-related activations. There were, however, between-group differences in the correlation between self-reported empathy and right inferior frontal (pars opercularis) activity during observation of facial emotional expressions. As in previous studies, controls demonstrated a positive association between brain activity and empathy scores. In contrast, the pattern in the patient group reflected a negative association between brain activity and empathy.
Although patients with schizophrenia demonstrated largely normal patterns of neural activation across the finger movement and facial expression tasks, they reported decreased self perceived empathy and failed to show the typical relationship between neural activity and self-reported empathy seen in controls. These findings suggest that patients show a disjunction between automatic neural responses to low level social cues and higher level, integrative social cognitive processes involved in self-perceived empathy.
•Comparable activation patterns were present in both groups for finger and facial stimuli.•There were no group differences on any of the activation tasks.•Self-reported empathy differentially related to neural activation in the two groups.•Empathy related to right inferior frontal activity in controls but not in patients.•Patients showed a disconnect between low- and high-level social cognitive processes.
PMCID: PMC4087183  PMID: 25009771
Imitation; Observation; Simulation; Schizophrenia; Mirror neuron system; Empathy
2.  Association between somatic amplification, anxiety, depression, stress and migraine 
The aim of this study is to investigate the associations between migraine related disability and somatosensory amplification, depression, anxiety, and stress.
Fifty-five migraine patients who applied to the outpatient unit of the Neurology Department of Acibadem University School of Medicine, Maslak Hospital in Istanbul, Turkey, and twenty-eight subjects without migraine were recruited for the study. The participants were asked to complete a sociodemographic form, Migraine Disability Assessment Scale (MIDAS), Depression Anxiety Stress Scale, Somatosensory Amplification Scale (SSAS).
Somatosensory amplification scores were significantly higher in the migraineurs than in the control group (29.85+/−6.63 vs 26.07+/−7.1; p=0.027). Somatosensory amplification scores and depression scores were significantly higher in migraineurs with moderate and severe disability than in patients with minimal and mild disability (31.7+/−6.4 vs 27.71+/−5.49; p=0.01, 11.27+/−8.7 vs 7.38+/−8.11; p=0.04, respectively). A significant positive correlation was found between the frequency of migraine attacks for at least three consecutive months (MIDAS A scores) and the SSAS scores (r=0.363, p=0.007) in migraineurs. The MIDAS total scores were also significantly correlated with the DASS depression subcale scores (r=0.267, p=0.04), and the DASS stress subscale scores (r=0.268, p=0.05).
Psychological factors, and vulnerability to bodily sensations may incease the burden of migraine. We point out that the timely assessing of somatic amplification and the evaluation of mental status would help improve the quality of life of in migraineurs.
PMCID: PMC3695888  PMID: 23799958
Migraine; Somatosensory amplification; Migraine disability; Depression; Anxiety; Stress
3.  Anatomical Alterations of the Visual Motion Processing Network in Migraine with and without Aura 
PLoS Medicine  2006;3(10):e402.
Patients suffering from migraine with aura (MWA) and migraine without aura (MWoA) show abnormalities in visual motion perception during and between attacks. Whether this represents the consequences of structural changes in motion-processing networks in migraineurs is unknown. Moreover, the diagnosis of migraine relies on patient's history, and finding differences in the brain of migraineurs might help to contribute to basic research aimed at better understanding the pathophysiology of migraine.
Methods and Findings
To investigate a common potential anatomical basis for these disturbances, we used high-resolution cortical thickness measurement and diffusion tensor imaging (DTI) to examine the motion-processing network in 24 migraine patients (12 with MWA and 12 MWoA) and 15 age-matched healthy controls (HCs). We found increased cortical thickness of motion-processing visual areas MT+ and V3A in migraineurs compared to HCs. Cortical thickness increases were accompanied by abnormalities of the subjacent white matter. In addition, DTI revealed that migraineurs have alterations in superior colliculus and the lateral geniculate nucleus, which are also involved in visual processing.
A structural abnormality in the network of motion-processing areas could account for, or be the result of, the cortical hyperexcitability observed in migraineurs. The finding in patients with both MWA and MWoA of thickness abnormalities in area V3A, previously described as a source in spreading changes involved in visual aura, raises the question as to whether a “silent” cortical spreading depression develops as well in MWoA. In addition, these experimental data may provide clinicians and researchers with a noninvasively acquirable migraine biomarker.
A structural abnormality in the network of motion-processing areas could account for, or be the result of, the cortical hyperexcitability seen in people who have migraine.
Editors' Summary
Migraine is a disabling brain disorder that affects more than one in ten people during their lifetimes. It is characterized by severe, recurrent headaches, often accompanied by nausea, vomiting, and light sensitivity. In some migraineurs (people who have migraines), the headaches are preceded by neurological disturbances known as “aura.” These usually affect vision, causing illusions of flashing lights, zig-zag lines, or blind spots. There are many triggers for migraine attacks—including some foods, stress, and bright lights—and every migraineur has to learn what triggers his or her attacks. There is no cure for migraine, although over-the-counter painkillers can ease the symptoms and doctors can prescribe stronger remedies or drugs to reduce the frequency of attacks. Exactly what causes migraine is unclear but scientists think that, for some reason, the brains of migraineurs are hyperexcitable. That is, some nerve cells in their brains overreact when they receive electrical messages from the body. This triggers a local disturbance of brain function called “cortical spreading depression,” which, in turn, causes aura, headache, and the other symptoms of migraine.
Why Was This Study Done?
Researchers need to know more about what causes migraine to find better treatments. One clue comes from the observation that motion perception is abnormal in migraineurs, even between attacks—they can be very sensitive to visually induced motion sickness, for example. Another clue is that aura are usually visual. So could brain regions that process visual information be abnormal in people who have migraines? In this study, the researchers investigated the structure of the motion processing parts of the brain in people who have migraine with aura, in people who have migraine without aura, and in unaffected individuals to see whether there were any differences that might help them understand migraine.
What Did the Researchers Do and Find?
The researchers used two forms of magnetic resonance imaging—a noninvasive way to produce pictures of internal organs—to examine the brains of migraineurs (when they weren't having a migraine) and healthy controls. They concentrated on two brain regions involved in motion processing known as the MT+ and V3A areas and first measured the cortical thickness of these areas—the cortex is the wrinkled layer of gray matter on the outside of the brain that processes information sent from the body. They found that the cortical thickness was increased in both of these areas in migraineurs when compared to healthy controls. There was no difference in cortical thickness between migraineurs who had aura and those who did not, but the area of cortical thickening in V3A corresponded to the source of cortical spreading depression previously identified in a person who had migraine with aura. The researchers also found differences between the white matter (the part of the brain that transfers information between different regions of the gray matter) immediately below the V3A and MT+ areas in the migraineurs and the controls but again not between the two groups of migraineurs.
What Do These Findings Mean?
This study provides new information about migraine. First, it identifies structural changes in the brains of people who have migraines. Until now, it has been thought that abnormal brain function causes migraine but that migraineurs have a normal brain structure. The observed structural differences might either account for or be caused by the hyperexcitability that triggers migraines. Because migraine runs in families, examining the brains of children of migraineurs as they grow up might indicate which of these options is correct, although it is possible that abnormalities in brain areas not examined here actually trigger migraines. Second, the study addresses a controversial question about migraine: Is migraine with aura the same as migraine without aura? The similar brain changes in both types of migraine suggest that they are one disorder. Third, the abnormalities in areas MT+ and V3A could help to explain why migraineurs have problems with visual processing even in between attacks. Finally, this study suggests that it might be possible to develop a noninvasive test to help doctors diagnose migraine.
Additional Information.
Please access these Web sites via the online version of this summary at
The MedlinePlus encyclopedia has several pages on migraine
The US National Institute of Neurological Disorders and Stroke offers patient information on migraine and other headaches
The NHS Direct Online contains patient information on migraine from the UK National Health Service
MAGNUM provides information from The US National Migraine Association
The Migraine Trust is a UK charity that supports research and provides support for patients
The Migraine Aura Foundation is a site about aura that includes a section on art and aura
PMCID: PMC1609120  PMID: 17048979
4.  Migraine Care Among Different Ethnicities: Do Disparities Exist? 
Headache  2006;46(5):754-765.
Evaluate whether, in a primary care setting, Caucasians (C) and African Americans (AA) with moderately to severely disabling migraines differed in regards to: utilizing the health-care system for migraine care, migraine diagnosis and treatment, level of mistrust in the health-care system, perceived communication with their physician, and perceived migraine triggers.
Research has documented ethnic disparities in pain management. However, almost no research has been published concerning potential disparities in utilization, diagnosis, and/or treatment of migraine. It is also important to consider whether ethnic differences exist for trust and communication between patients and physicians, as these are essential when diagnosing and treating migraine.
Adult patients with headache (n = 313) were recruited from primary care waiting rooms. Of these, 131 (AA = 77; C = 54) had migraine, moderate to severe headache-related disability, and provided socioeconomic status (SES) data. Participants completed measures of migraine disability (MIDAS), migraine health-care utilization, diagnosis and treatment history, mistrust of the medical community, patient–physician communication (PPC), and migraine triggers. Analysis of covariance (controlling for SES and recruitment site), chi-square, and Pearson product moment correlations were conducted.
African Americans were less likely to utilize the health-care setting for migraine treatment (AA = 46% vs. C = 72%, P < .001), to have been given a headache diagnosis (AA = 47% vs. C = 70%, P < .001), and to have been prescribed acute migraine medication (AA = 14% vs. C = 37%, P < .001). Migraine diagnosis was low for both groups, and <15% of all participants had been prescribed a migraine-specific medication or a migraine preventive medication despite suffering moderate to severe levels of migraine disability. African Americans had less trust in the medical community (P < .001, η2 = 0.26) and less positive PPC (P < .001, η2 = 0.11). Also, the lower the trust and communication, the less likely they were to have ever seen (or currently be seeing) a doctor for migraine care or to have been prescribed medication.
Migraine utilization, diagnosis, and treatment were low for both groups. However, this was especially true for African Americans, who also reported lower levels of trust and communication with doctors relative to Caucasians. The findings highlight the need for improved physician and patient education about migraine diagnosis and treatment, the importance of cultural variation in pain presentation, and the importance of communication when diagnosing and treating migraine.
PMCID: PMC2443411  PMID: 16643578
migraine; ethnicity; health-care disparities; utilization; migraine diagnosis and treatment; patient–physician communication
5.  The Effect of Paroxetine on the Reduction of Migraine Frequency is Independent of Its Anxiolytic Effect 
Background and purpose
Anxiety is the most important precipitating factor of migraine attacks, and more than half of migraineurs have coexisting anxiety disorders. Paroxetine, an antidepressant, is one of the selective serotonin reuptake inhibitors (SSRIs) that has an anxiolytic effect, and is also known to be effective for migraine prophylaxis. The aim of this study was to determine the role of the anxiolytic effect of paroxetine on the prevention of migraine.
This study investigated migraineurs with a general anxiety disorder who visited the neurological clinic. The following efficacy variables were assessed at baseline and after taking paroxetine (20 for 12 weeks: headache frequency, Hamilton Anxiety Rating Scale (HAM-A), Headache Management Self-Efficacy Scale (HMSE), and Headache Disability Inventory (HDI). The correlation between the headache responsiveness to paroxetine and improvement in anxiety levels was analyzed.
Twenty-four patients (aged 54.96±12.09 years, mean±SD) were included in this study. Paroxetine reduced headache frequency by 49.1% within 12 weeks (p<0.05 vs baseline). HAM-A and HMSE scores also showed an improvement, whereas there was no significant change in HDI score. The baseline HAM-A scores did not differ between paroxetine responders and nonresponders. In addition, the improvement in HAM-A score was not correlated with the reduction in headache frequency.
Paroxetine decreased the headache frequency and reduced anxiety levels. However, the anxiolytic effect of paroxetine was not correlated with the migraine prevention effect. These observation indicate that the anxiolytic effect of paroxetine does not contribute strongly to its prophylactic effect on migraine frequency in migraineurs with anxiety disorder.
PMCID: PMC2854974  PMID: 20396527
Paroxetine; Migraine; Anxiety disorder; Headache frequency
6.  Trimester-Specific Blood Pressure Levels and Hypertensive Disorders among Pregnant Migraineurs 
Headache  2011;51(10):1468-1482.
We evaluated the influence of physician-diagnosed migraine on blood pressure levels and the risk of hypertensive disorders of pregnancy in a clinic-based prospective cohort study of 3,373 healthy pregnant women.
The relationship between migraine and blood pressure is controversial with results from several studies suggesting positive associations, while others suggest null or inverse associations. To our knowledge, no previous study has investigated blood pressure profiles among pregnant migraineurs.
We abstracted blood pressure values and delivery information from medical records of women presenting to prenatal clinics in Washington State. Mean blood pressure differences for pregnant migraineurs and non-migraineurs were estimated in regression models, using generalized estimating equations. We calculated, odds ratios (OR) and 95% confidence intervals (95%CIs) for gestational hypertension and preeclampsia in relation migraine status.
Mean first, second and third trimester systolic blood pressure (SBP) were elevated among pregnant migraineurs as compared with non-migraineurs. Migraineurs had higher mean third trimester SBP (4.08 mm Hg) than non-migraineurs. Trimester-specific diastolic blood pressure (DBP) values were variably related with migraine status. Mean first (0.82 mm Hg) and third(2.39 mm Hg) trimester DBP were higher, and second trimester DBP values were lower (−0.24) among migraineurs as compared with non-migraineurs. Migraineurs had a 1.53-fold increased odds of preeclampsia (95%CI 1.09 to 2.16). Additionally, migraineurs who were overweight or obese had a 6.10-fold increased odds of preeclampsia (95%CI 3.83 to 9.75) as compared with lean non-migraineurs.
Pregnant migraineurs had elevated blood pressures, particularly SBP measured in the third trimester, and a higher risk of preeclampsia than pregnant women without migraine. Observed associations were more pronounced among overweight or obese migraineurs. Our findings add to the accumulating evidence of adverse pregnancy outcomes among migraineurs.
PMCID: PMC3217104  PMID: 21797858
Migraine; Blood Pressure; Hypertension; Preeclampsia; Pregnancy
7.  Empathy levels among health professional students: a cross-sectional study at two universities in Australia 
Empathy is paramount in the health care setting, optimizing communication and rapport with patients. Recent empirical evidence suggests that empathy is associated with improved clinical outcomes. Therefore, given the importance of empathy in the health care setting, gaining a better understanding of students’ attitudes and self-reported empathy is important. The objective of this study was to examine self-reported empathy levels of students enrolled in different health disciplines from two large Australian universities.
Materials and methods
A total of 1,111 students from two different universities enrolled in eight different health professions were administered the Jefferson Scale of Physician Empathy – Health Profession Students version, a 20-item 7-point Likert scale questionnaire to evaluate self-reported empathy levels.
A total of 1,111 students participated in this study. The majority of participants were from Monash University (n=771), with 340 students from Edith Cowan University. No statistically significant differences were found between universities: Monash University (mean 110.1, standard deviation [SD] 11.8); Edith Cowan University (mean 109.2, SD 13.3, P=0.306). The mean female empathy score (mean 110.8, SD 11.7) was significantly higher than the mean male score (mean 105.3, SD 13.5; P<0.0001; d=0.44). Paramedic students had significantly lower empathy scores (mean 106.3, SD 12.73) than all other participants except nursing students (P<0.0001).
Results relating to sex are reflective of previous studies. There is some discrepancy in results relating to empathy and its incline/decline as students progress through a program. Further study is warranted to explore why there are variations in empathy levels in students of different health disciplines.
PMCID: PMC4014368  PMID: 24833947
empathy; health care professions
8.  Prevalence and risk factors for depression and anxiety among outpatient migraineurs in mainland China 
The Journal of Headache and Pain  2012;13(4):303-310.
This study aimed to investigate the prevalence and risk factors for anxiety and depression symptoms in outpatient migraineurs in mainland China. In addition, we evaluated whether the Hospital Anxiety and Depression Scale (HADS) provided sufficient validity to screen depression and anxiety. A cross-sectional study was conducted consecutively at our headache clinic. Migraine was diagnosed according to International Classification of Headache Disorders, 2nd edition (ICHD-II). Demographic characteristics and clinical features were collected by headache questionnaire. Anxiety and depression symptoms about migraineurs were assessed using HADS. Several questionnaires were simultaneously used to evaluate patients with depressive disorder including the Hamilton Depression Rating Scale-17 (HAMD), Hamilton Anxiety Rating Scale (HAMA) and HADS. Pearson correlation analysis was applied to test the validity of HADS. 176 outpatients with migraine (81.8 % female) were included. Overall, 17.6 and 38.1 % participants had depression and anxiety, respectively. Possible risk factors for depression in migraineurs included headache intensity of first onset of migraine, migraine with presymptom, migraine with family history and migraine disability. The possible risk factors for anxiety included fixed attack time of headache in one day and poor sleeping, and age represented a protective factor for anxiety. The correlation coefficient of HADS-A and HADS-D with HAMA and HAMD was 0.666 and 0.508, respectively (P < 0.01). This study demonstrates that depression and anxiety comorbidity in our mainland Chinese migraineurs are also common, and several risk factors were identified that may provide predictive value. These findings can help clinicians to identify and treat anxiety and depression in order to improve migraine management.
PMCID: PMC3356469  PMID: 22466285
Anxiety; Cross-sectional study; Depression; Migraine; Risk factor
9.  Empathy in Chinese medical students: psychometric characteristics and differences by gender and year of medical education 
BMC Medical Education  2013;13:130.
In recent years in China, the tense physician-patient relationship has been an outstanding problem. Empathy is one of the fundamental factors enhancing the therapeutic effects of physician-patient relationships and is significantly associated with clinical and academic performance among students.
This cross-sectional study used the JSPE-S (The Student Version of the Jefferson Scale of Physician Empathy) to assess 902 medical students from 1st year to 4th year at China Medical University. The reliability of the questionnaire was assessed by Cronbach’s alpha coefficient. We performed an exploratory factor analysis to evaluate the construct validity of the JSPE-S. Group comparisons of empathy scores were conducted via the t-test and one-way ANOVA. Statistic analysis was performed by SPSS 13.0.
The Cronbach’s alpha coefficient was 0.83. The three factors emerging in the factor analysis of the JSPE-S are “perspective taking”, “compassionate care” and “ability to stand in patients’ shoes”, which accounted for 48.00%. The mean empathy score was 109.60. The empathy score of medical students had significant differences between different genders (p < 0.05) and academic year level (p < 0.05).
This study provided support for the validity and reliability of the Chinese translated version of the JSPE-S for medical students. Early exposure to clinical training and a curriculum for professional competencies help to enhance the empathy of medical students. We suggest that the curriculum within Chinese medical schools include more teaching on empathy and communicational skills.
PMCID: PMC3848862  PMID: 24053330
Medical students; Empathy; Professionalism; Validity and reliability
10.  Attachment styles as predictors of empathy in nursing students 
Previous studies have traced a relationship between the attachment styles of nurses working as in healthcare teams and their empathy which is an essential characteristic required of people concerned with managing relationships, supporting social events, and improving the of nurse-patient relationships. Since determining the effective variables in the quality of nurse-patient relationships in clinical settings is of paramount importance, current investigation is an effort to examine the relationship between attachment styles and empathy in nursing students.
260 university students (male = 130 and female = 130) were chosen as the sample of the study based upon specific inclusion criteria. All participants completed the Attachment Style Questionnaire (ASQ) and the Interpersonal Reactivity Index (IRI). Data was collected and analyzed using Pearson correlation coefficient and regression analysis with SPSS (v.18).
The results showed that secure and insecure attachment styles have significant positive and negative correlation with empathy respectively. Based on the results of regression analysis, it was shown that secure attachment style is predicting 53% of the variance empathy variable, whereas insecure attachment styles are explaining up to 76% of the variance empathy variable collectively.
The increase of attention to instructions that focus on empathetic relationships with patients and that are based upon the secure attachment style can result in positive changes in the area of nurse-patient relations and in increasing attention to medical ethics. Findings are consistent with prediction derived from attachment theory and add to our understanding of relationship between attachment styles with empathy in nursing students. The meaning and limitations of this study and suggestions for further research are also discussed.
PMCID: PMC3715012  PMID: 23908761
Attachment styles; Empathy; Personality; Nurses
11.  Associations between Medical Student Empathy and Personality: A Multi-Institutional Study 
PLoS ONE  2014;9(3):e89254.
More empathetic physicians are more likely to achieve higher patient satisfaction, adherence to treatments, and health outcomes. In the context of medical education, it is thus important to understand how personality might condition the empathetic development of medical students. Single institutional evidence shows associations between students' personality and empathy. This multi-institutional study aimed to assess such associations across institutions, looking for personality differences between students with high empathy and low empathy levels.
Participants were 472 students from three medical schools in Portugal. They completed validated adaptations to Portuguese of self-report measures of the NEO-Five Factor Inventory(NEO-FFI) and the Jefferson Scale of Physician Empathy(JSPE-spv). Students were categorized into two groups: “Bottom” (low empathy, N = 165) and “Top” (high empathy, N = 169) according to their empathy JSPE-spv total score terciles. Correlation analysis, binary logistic regression analysis and ROC curve analysis were conducted.
A regression model with gender, age and university had a predictive power (pseudo R2) for belonging to the top or bottom group of 6.4%. The addition of personality dimensions improved the predictive power to 16.8%. Openness to experience and Agreeableness were important to predict top or bottom empathy scores when gender, age and university were considered.” Based on the considered predictors the model correctly classified 69.3% of all students.
The present multi-institutional cross-sectional study in Portugal revealed across-school associations between the Big5 dimensions Agreeableness and Openness to experience and the empathy of medical students and that personality made a significant contribution to identify the more empathic students. Therefore, medical schools may need to pay attention to the personality of medical students to understand how to enhance the empathy of medical students.
PMCID: PMC3956603  PMID: 24637613
12.  Comparative cross-sectional study of empathy among first year and final year medical students in Jimma University, Ethiopia: Steady state of the heart and opening of the eyes 
BMC Medical Education  2012;12:34.
There is general consent that empathy is crucial for the physician-patient relationship and thus an important issue in medical education. This comparative study was designed to examine the differences in empathy between first year and final year medical students in Jimma University, Ethiopia.
A comparative cross-sectional study among 131 first year and 106 final year medical students was conducted in Jimma University, Ethiopia on academic year 2010/11. The study subjects were selected using simple random sampling technique from the list of the students. Study participation was voluntary. The Balanced Emotional Empathy Scale (BEES) was used for the detection of “heart-reading”, i.e. emotional empathy and the Reading the Mind in the Eyes test (RME-R test) to evaluate “mind-reading”, i.e. cognitive empathy. We performed t-test to compare the mean difference in empathy and RME-R scores between the two groups of students. A linear regression was computed to identify potential factors influencing the BEES and RME-R.
Out of the total 237 students, 207 (87.3%) were males. The mean age of first year and final year students was 19.3 ± 1.1 and 24.0 ± 1.4 years respectively. First year students have scored 40.6 ± 23.8 while final year students scored 41.5 ± 20.8 mean in the BEES measuring emotional empathy score. However, this difference was not statistically significant (t = −0.30, df = 231, P-value >0.05). Final year students had significantly higher mean cognitive empathy score (17.8 ± 4.5) than first year students (14.4 ± 4.8) [β = 2.7, 95%CI (1.20, 4.13)]. Males had scored lower cognitive [β = −2.5, 95%CI (−4.37, −0.66)] and emotional empathy [β = −12.0, 95%CI (−21.66, −5.46)].
Low emotional (BEES) and cognitive empathy sores were found in first year and final year students of Jimma University could have implications on the medical education curricula. Medical education targeted at enhancing emotional empathy and increasing cognitive empathy is required by segmenting with gender for effective physician-patient interaction. The influence of empathy on clinical competence should be studied using more rigorous design.
PMCID: PMC3432612  PMID: 22624580
Cognitive empathy; Emotional empathy; Medical education; Jimma University
13.  Empathy Training for Resident Physicians: A Randomized Controlled Trial of a Neuroscience-Informed Curriculum 
Journal of General Internal Medicine  2012;27(10):1280-1286.
Physician empathy is an essential attribute of the patient–physician relationship and is associated with better outcomes, greater patient safety and fewer malpractice claims.
We tested whether an innovative empathy training protocol grounded in neuroscience could improve physician empathy as rated by patients.
Randomized controlled trial.
We randomly assigned residents and fellows from surgery, medicine, anesthesiology, psychiatry, ophthalmology, and orthopedics (N = 99, 52% female, mean age 30.6 ± 3.6) to receive standard post-graduate medical education or education augmented with three 60-minute empathy training modules.
Main Measure
Patient ratings of physician empathy were assessed within one-month pre-training and between 1–2 months post-training with the use of the Consultation and Relational Empathy (CARE) measure. Each physician was rated by multiple patients (pre-mean = 4.6 ± 3.1; post-mean 4.9 ± 2.5), who were blinded to physician randomization. The primary outcome was change score on the patient-rated CARE.
Key Results
The empathy training group showed greater changes in patient-rated CARE scores than the control (difference 2.2; P = 0.04). Trained physicians also showed greater changes in knowledge of the neurobiology of empathy (difference 1.8; P < 0.001) and in ability to decode facial expressions of emotion (difference 1.9; P < 0.001).
A brief intervention grounded in the neurobiology of empathy significantly improved physician empathy as rated by patients, suggesting that the quality of care in medicine could be improved by integrating the neuroscience of empathy into medical education.
PMCID: PMC3445669  PMID: 22549298
empathy; randomized controlled trial; communication skills; graduate medical education; patient–physician relationship
14.  Effectiveness of empathy in general practice: a systematic review 
Empathy as a characteristic of patient–physician communication in both general practice and clinical care is considered to be the backbone of the patient–physician relationship. Although the value of empathy is seldom debated, its effectiveness is little discussed in general practice. This literature review explores the effectiveness of empathy in general practice. Effects that are discussed are: patient satisfaction and adherence, feelings of anxiety and stress, patient enablement, diagnostics related to information exchange, and clinical outcomes.
To review the existing literature concerning all studies published in the last 15 years on the effectiveness of physician empathy in general practice.
Design and setting
Systematic literature search.
Searches of PubMed, EMBASE, and PsychINFO databases were undertaken, with citation searches of key studies and papers. Original studies published in English between July 1995 and July 2011, containing empirical data about patient experience of GPs’ empathy, were included. Qualitative assessment was applied using Giacomini and Cook’s criteria.
After screening the literature using specified selection criteria, 964 original studies were selected; of these, seven were included in this review after applying quality assessment. There is a good correlation between physician empathy and patient satisfaction and a direct positive relationship with strengthening patient enablement. Empathy lowers patients’ anxiety and distress and delivers significantly better clinical outcomes.
Although only a small number of studies could be used in this search, the general outcome seems to be that empathy in the patient–physician communication in general practice is of unquestionable importance.
PMCID: PMC3529296  PMID: 23336477
empathy; general practice; general practitioner
15.  A curriculum focused on informed empathy improves attitudes toward persons with disabilities 
Empathy is an important component of the provider-patient relationship. In the United States one in five persons has a disability. Persons with disabilities perceive gaps in health care providers’ understanding of their health care preferences and needs. The purpose of this study was to use valid and reliable assessment methods to investigate the association between empathy and attitudes toward persons with disabilities and advocacy. An educational module was developed to enhance health care students’ capacity for informed empathy. Pre- and post-assessment measures included the Attitude toward Disabled Persons scale (ATDP), the Attitudes toward Patient Advocacy Microsocial scale (AMIA) and the Interpersonal Reactivity Index (IRI). ATDP (t(94) = −5.95, p = .000) and AMIA (t(92) = −5.99, p = .000) scores increased significantly after the education module. Correlations between the pre- or post-module ATDP or AMIA scores and the IRI scores were not significant. Empathy in general may not be sufficient to ensure optimal attitudes toward persons with disabilities or advocacy in pre-health care professionals. However, a curriculum based on informed empathy and focused on the experiences of persons with disabilities can result in more positive attitudes toward and advocacy for people with disabilities.
PMCID: PMC3722372  PMID: 23670683
Advocacy; Attitudes toward persons with disabilities; Disability; Education; Empathy
16.  A curriculum focused on informed empathy improves attitudes toward persons with disabilities 
Empathy is an important component of the provider-patient relationship. In the United States one in five persons has a disability. Persons with disabilities perceive gaps in health care providers’ understanding of their health care preferences and needs. The purpose of this study was to use valid and reliable assessment methods to investigate the association between empathy and attitudes toward persons with disabilities and advocacy. An educational module was developed to enhance health care students’ capacity for informed empathy. Pre- and post-assessment measures included the Attitude toward Disabled Persons scale (ATDP), the Attitudes toward Patient Advocacy Microsocial scale (AMIA) and the Interpersonal Reactivity Index (IRI). ATDP (t(94) = −5.95, p = .000) and AMIA (t(92) = −5.99, p = .000) scores increased significantly after the education module. Correlations between the pre- or post-module ATDP or AMIA scores and the IRI scores were not significant. Empathy in general may not be sufficient to ensure optimal attitudes toward persons with disabilities or advocacy in pre-health care professionals. However, a curriculum based on informed empathy and focused on the experiences of persons with disabilities can result in more positive attitudes toward and advocacy for people with disabilities.
PMCID: PMC3722372  PMID: 23670683
Advocacy; Attitudes toward persons with disabilities; Disability; Education; Empathy
17.  Effect of preventive (β blocker) treatment, behavioural migraine management, or their combination on outcomes of optimised acute treatment in frequent migraine: randomised controlled trial 
Objective To determine if the addition of preventive drug treatment (β blocker), brief behavioural migraine management, or their combination improves the outcome of optimised acute treatment in the management of frequent migraine.
Design Randomised placebo controlled trial over 16 months from July 2001 to November 2005.
Setting Two outpatient sites in Ohio, USA.
Participants 232 adults (mean age 38 years; 79% female) with diagnosis of migraine with or without aura according to International Headache Society classification of headache disorders criteria, who recorded at least three migraines with disability per 30 days (mean 5.5 migraines/30 days), during an optimised run-in of acute treatment.
Interventions Addition of one of four preventive treatments to optimised acute treatment: β blocker (n=53), matched placebo (n=55), behavioural migraine management plus placebo (n=55), or behavioural migraine management plus β blocker (n=69).
Main outcome measure The primary outcome was change in migraines/30 days; secondary outcomes included change in migraine days/30 days and change in migraine specific quality of life scores.
Results Mixed model analysis showed statistically significant (P≤0.05) differences in outcomes among the four added treatments for both the primary outcome (migraines/30 days) and the two secondary outcomes (change in migraine days/30 days and change in migraine specific quality of life scores). The addition of combined β blocker and behavioural migraine management (−3.3 migraines/30 days, 95% confidence interval −3.2 to −3.5), but not the addition of β blocker alone (−2.1 migraines/30 days, −1.9 to −2.2) or behavioural migraine management alone (−2.2 migraines migraines/30 days, −2.0 to −2.4), improved outcomes compared with optimised acute treatment alone (−2.1 migraines/30 days, −1.9 to −2.2). For a clinically significant (≥50% reduction) in migraines/30 days, the number needed to treat for optimised acute treatment plus combined β blocker and behavioural migraine management was 3.1 compared with optimised acute treatment alone, 2.6 compared with optimised acute treatment plus β blocker, and 3.1 compared with optimised acute treatment plus behavioural migraine management. Results were consistent for the two secondary outcomes, and at both month 10 (the primary endpoint) and month 16.
Conclusion The addition of combined β blocker plus behavioural migraine management, but not the addition of β blocker alone or behavioural migraine management alone, improved outcomes of optimised acute treatment. Combined β blocker treatment and behavioural migraine management may improve outcomes in the treatment of frequent migraine.
Trial registration Clinical trials NCT00910689.
PMCID: PMC2947621  PMID: 20880898
18.  Evidence of increased restless legs syndrome occurrence in chronic and highly disabling migraine 
Functional Neurology  2012;27(2):91-94.
The existence of an association between migraine and restless legs syndrome (RLS) has recently been reported, although the possible implications of this for migraine clinical presentation remain poorly understood. The objectives of this study were to determine RLS frequency in a population of migraineurs compared with healthy subjects and to assess RLS occurrence in episodic versus chronic migraine patients; the relationship between migraine-related disability and RLS comorbidity was also evaluated.
Two hundred and seventy-seven consecutive migraineurs (ICHD-II, 2004) were enrolled and compared with 200 controls; migraine was episodic in 175 and chronic in 102 patients. RLS (IRLSSG criteria, 2003) was present in 22.7% of the total sample of migraineurs and in 7.5% of the controls (p<0.0001). RLS occurred significantly more frequently in chronic compared with episodic migraineurs (34.3% vs 16%, respectively, p=0.0006); a significant association between RLS diagnosis and moderate-severe migraine-related disability was also documented (p=0.0003).
In conclusion, the results of the present study not only confirm the higher occurrence of RLS in migraine patients compared with the general population, but also suggest that RLS (the condition itself, or the disruption of sleep patterns often found in patients affected by RLS) might affect migraine clinical presentation, being associated with chronic and highly disabling migraine. These findings could have important therapeutic and prognostic implications in clinical practice.
PMCID: PMC3812772  PMID: 23158580
chronic migraine; migraine; migraine disability; restless legs syndrome; sleep
19.  The impact of depression and ghrelin on body weight in migraineurs 
Comorbidity of migraine with anxiety and depression may play a role in the link between migraine and obesity. We examined the moderating and mediating roles of ghrelin in the relationship between depression (and anxiety) and body weight in newly diagnosed migraineurs.
Participants were 63 newly diagnosed migraine patients (using the ICHD-II criteria) and 42 healthy volunteers. Body mass index (BMI) was calculated by measuring height and weight. Ghrelin was assessed at fasting. Depression was assessed with the Hamilton Depression scale, and anxiety with the Hamilton Anxiety scale.
The data did not support the mediating role of ghrelin in the relationship between depression (or anxiety) and BMI for either the migraine or the control group. The interaction between ghrelin and depression as well as anxiety was significant for the migraine group, but not for the control group. Depressed (or anxious) migraineurs had a positive association between ghrelin and BMI, whereas for the non-depressed (or non-anxious) migraineurs this association was negative.
Depression and anxiety moderated the effect of ghrelin on BMI for migraineurs. Management of anxiety and depression might be regarded as part of migraine treatment.
PMCID: PMC4016645  PMID: 24762133
Body weight; Ghrelin; Migraine; Psychiatric comorbidity; Depression; Anxiety
20.  Increase in self-reported migraine prevalence in the Danish adult population: a prospective longitudinal population-based study 
BMJ Open  2012;2(4):e000962.
It is uncertain whether migraine prevalence has increased in modern society. The aim of this study was to assess any change in migraine prevalence over an 8-year period among the adult population in Denmark.
Prospective longitudinal population-based study.
30 000 twin individuals were invited to participate in two cross-sectional questionnaire surveys containing validated questions to diagnose migraine in 1994 and 2002. The twins are representative of the Danish population with regard to migraine and other somatic diseases.
The 1994 cohort comprised 28 571 twin individuals aged 12–41 years and the 2002 cohort 31 865 twin individuals aged 20–71 years.
Outcome measures
Sex-, age- and subtype-specific incidence and lifetime prevalence as well as 1-year prevalence of migraine.
1-year prevalence in 2002 was 12.3% for migraine, 4.1% for migraine with aura and 8.2% for migraine without aura. Lifetime prevalence of migraine was 16.1% in 1994 (aged 12–41 years) and 25.2% in 2002 (aged 20–71 years). Lifetime prevalence of migraine for age 20–41 was increased from 1994 to 2002 (18.5% vs 24.5%) by 32.2% (95% CI 27.0% to 37.3%; p<0.001). The difference was primarily seen in the population older than 32 years. The increase was especially evident in migraine with aura (5.6% vs 9.4%, p<0.001) but also a significant increase in migraine without aura was found (13.0% vs 15.1%, p<0.001). Eight-year period incidence rate of migraine was 0.141 corresponding to an average annual incidence rate of 17.6 per 1000 person-years.
Lifetime prevalence of migraine in Denmark increased substantially from 1994 to 2002. Part of the increase may be due to increased medical consultation resulting in increased rate of physician diagnosis or awareness due to previously participation in the 1994 survey. It is pertinent to study the environmental causes of the increase and to implement preventive measures.
Article summary
Article focus
Has migraine prevalence increased in modern society?
Key messages
Self-reported migraine prevalence increased substantially in the Danish young adult population.
Sex- and age-specific prevalence and incidence of migraine and its subtypes were estimated in a large population-based sample.
Strengths and limitations of this study
Large sample size made it possible to differentiate between migraine with aura and migraine without aura using the validated diagnostic questions and furthermore subdivide between men and women and to distinguish between age groups.
The validation of the two questions used to identify migraine cases showed that self-reported migraine was only correct in 74.5% of cases, and furthermore, approximately 23.8% of the migraine patients were not identified. Thus, our estimates would tend to be conservative.
PMCID: PMC3391377  PMID: 22761284
21.  Determinants of physician empathy during medical education: hypothetical conclusions from an exploratory qualitative survey of practicing physicians 
BMC Medical Education  2014;14:122.
Empathy is an outcome-relevant physician characteristic and thus a crucial component of high-quality communication in health care. However, the factors that promote and inhibit the development of empathy during medical education have not been extensively researched. Also, currently there is no explicit research on the perspective of practicing physicians on the subject. Therefore the aim of our study was to explore physicians’ views of the positive and negative influences on the development of empathy during their medical education, as well as in their everyday work as physicians.
We administered a written Qualitative Short Survey to 63 physicians in seven specialties. They were able to respond anonymously. Our open-ended question was: “What educational content in the course of your studies and/or your specialist training had a positive or negative effect on your empathy?” We analyzed the data using thematic content analysis following Mayring’s approach.
Forty-two physicians took part in our survey. All together, they mentioned 68 specific factors (37 positive, 29 negative, 2 neutral) from which six themes emerged: 1. In general, medical education does not promote the development of empathy. 2. Recognizing the psycho-social dimensions of care fosters empathy. 3. Interactions with patients in medical practice promote empathy. 4. Physicians’ active self-development through reflective practice helps the development of empathy. 5. Interactions with colleagues can both promote and inhibit empathy through their role modeling of empathic and non-empathic behavior. 6. Stress, time pressure, and adverse working conditions are detrimental to empathy development.
Our results provide an overview of what might influence the development of clinical empathy, as well as hypothetical conclusions about how to promote it. Reflective practice seems to be lacking in current medical curricula and could be incorporated. Raising physicians’ awareness of the psycho-social dimension of disease, and of the impact of peer influence and role modeling, seems promising in this regard, too. Stress and well-being seem to be closely related to physician empathy, and their modulation must take into account individual, social, and organizational factors. Further research should investigate whether or how these hypothetical conclusions can deepen our understanding of the determinants of physician empathy in order to help its promotion.
PMCID: PMC4080581  PMID: 24952736
Empathy; Medical education; Physician; Physician-patient relationship; Health communication; Promoting factors; Inhibiting factors
22.  Measurement and correlates of empathy among female Japanese physicians 
BMC Medical Education  2012;12:48.
The measurement of empathy is important in the assessment of physician competence and patient outcomes. The prevailing view is that female physicians have higher empathy scores compared with male physicians. In Japan, the number of female physicians has increased rapidly in the past ten years. In this study, we focused on female Japanese physicians and addressed factors that were associated with their empathic engagement in patient care.
The Jefferson Scale of Empathy (JSE) was translated into Japanese by using the back-translation procedure, and was administered to 285 female Japanese physicians. We designed this study to examine the psychometrics of the JSE and group differences among female Japanese physicians.
The item-total score correlations of the JSE were all positive and statistically significant, ranging from .20 to .54, with a median of .41. The Cronbach’s coefficient alpha was .81. Female physicians who were practicing in “people-oriented” specialties obtained a significantly higher mean empathy score than their counterparts in “procedure-” or “technology-oriented” specialties. In addition, physicians who reported living with their parents in an extended family or living close to their parents, scored higher on the JSE than those who were living alone or in a nuclear family.
Our results provide support for the measurement property and reliability of the JSE in a sample of female Japanese physicians. The observed group differences associated with specialties and living arrangement may have implications for sustaining empathy. In addition, recognizing these factors that reinforce physicians’ empathy may help physicians to avoid career burnout.
PMCID: PMC3493267  PMID: 22726449
Empathy; Female physicians; Career development
23.  The effects of a sensitisation campaign on unrecognised migraine: the Casilino study 
The Journal of Headache and Pain  2007;8(4):205-208.
A striking feature of migraine is the difference between the estimated migraine prevalence and the actual number of migraineurs consulting their general practitioners (GPs). We investigated the impact of a sensitisation campaign on migraine in a large cohort of patients, living in a district of Rome. The study involved 10 GPs and a population of about 12 000 people, contacted by mail and posters located in GP clinics. Both the letter and poster stressed the impact of headache on quality of life and included the Italian version of the three-item Identification of Migraine (ID Migraine) screening test, consisting of questions on disability, nausea and photophobia. If the subjects suffered from headaches, they were invited to contact their GPs for a visit and a free consultation with a headache expert. By means of this sensitisation campaign, 195 headache patients consulted their GPs. Ninety-two percent of them (n=179) were migraineurs; 73% of them had never consulted a physician for headache. The ID Migraine test had a sensitivity of 0.92 (95% CI 0.86–0.95), a specificity of 0.75 (95% CI 0.47–0.91) and a positive predictive value (PPV) of 0.97 (95% CI 0.93–0.99) for a clinical diagnosis of migraine, according to the International Headache Society (IHS) criteria. This study confirms that a large number of migraine patients never see a doctor for their headache. This awareness campaign is likely to identify the severest cases of undiagnosed migraineurs. However, mailing campaigns do not seem to be so effective in bringing undiagnosed migraine patients into the primary care setting, and more efficient strategies have to be planned.
PMCID: PMC3451666  PMID: 17901925
Migraine; ID Migraine; Sensitisation campaign
24.  Resident Physician Well-Being and Assessments of Their Knowledge and Clinical Performance 
Medical knowledge and clinical performance ratings are major criteria for assessing the competence of resident physicians. However, these assessments may be influenced by residents’ mental health. The relationship between residents’ well-being and empathy and assessments of their global performance remains unclear.
To determine whether resident well-being and empathy are associated with assessments of their medical knowledge and clinical performance.
We studied 730 clinical performance assessments completed by peers, supervising residents, and allied health professionals; 193 mini-clinical evaluation exercise (mini-CEX) evaluations; and 260 in-training examinations (ITE) of Mayo Clinic internal medicine residents between January 2009 and August 2010. Multivariate generalized estimating equations were used to evaluate associations between residents’ well-being and empathy and assessments of their knowledge and clinical performance.
Independent variables were empathy using the Interpersonal Reactivity Index (IRI), burnout using the Maslach Burnout Inventory, depression using a standardized two-question screening instrument, and quality of life using a Linear Analog Self-Assessment item and the Medical Outcomes Study Short Form (SF-8). Dependent variables were mini-CEX, ITE, and the validated six-item Mayo clinical performance assessment.
202 residents (64.7%) provided both well-being and at least one category of assessment data. In multivariate models, residents’ scores on the IRI empathy measure of “the tendency to adopt the psychological view of others” were associated with higher peer ratings on “desirability as a physician for a family member” (beta = 0.023, 95% CI = 0.007–0.039, p = 0.004). Additionally, burnout was associated with higher supervisor ratings of communication (beta = 0.309, 95% CI = 0.100–0.517, p = 0.004). There were no observed associations between ITE or mini-CEX scores and resident quality of life, burnout, fatigue, depression, or empathy.
Most dimensions of resident well-being were not associated with residents’ knowledge scores and assessments of their clinical performance by other members of the health care team, which supports the trustworthiness of these measures. Nonetheless, correlations of resident empathy and burnout with assessments completed by peers and supervising residents suggest that some ratings of residents may be influenced by interpersonal factors.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1891-6) contains supplementary material, which is available to authorized users.
PMCID: PMC3286555  PMID: 21948207
graduate medical education; well-being; empathy; assessment
25.  Empathy in Undergraduate Medical Students of Bangladesh: Psychometric Analysis and Differences by Gender, Academic Year, and Specialty Preferences 
ISRN Psychiatry  2014;2014:375439.
Empathy is considered to be associated with better patient compliance, satisfaction, and clinical outcomes. The aim of the study is to measure and examine empathy among a sample of undergraduate medical students of Bangladesh. It was a cross-sectional study and all the medical students of first through fifth year enrolled at Chattagram Maa-O-Shishu Hospital Medical College during the study period of 2014 were surveyed. Participants anonymously completed the Jefferson Scale of Empathy Medical Student version translated into Bengali language, a valid and reliable 20-item self-administered questionnaire. Principal component factor analysis with varimax rotation and Cronbach's alpha coefficient were calculated to check validity and reliability of the scale. ANOVA was used to examine the differences in empathy between gender, academic years, and specialty preferences. The mean empathy score was 110.41 ± 13.59. Cronbach's alpha coefficient was 0.88. There were significant associations between gender and empathy scores. The level of empathy in medical students gradually increases after clinical training in medical college. A nonsignificant difference was found between empathy scores and specialty preferences. It is suggested that the medical curriculum in Bangladesh should include more extensive program to promote empathy and other humanistic values among the medical students.
PMCID: PMC4004052  PMID: 25006522

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