by Michael D. Anestis, M.S.
It's been a bit of a slow week on PBB as I have attended to research projects while juggling a tricky schedule, but I have a little bit of time today to discuss an article sent to me by a colleague, Scott Braithwaite. The article, written by Jean Decety, Chia-Yan Yang, and Yawei Cheng (2010), is from a journal called NeuroImage and examines the response to images of pain in physicians relative to individuals with no medical training. At first glance, this might seem a bit off topic for this site, but bear with me as I try to tie it together with one of our most frequently discussed topics: suicide.
The authors of this study noted that research using functional neuroimaging strategies has shown that, when people see others experiencing pain or even simply imagine this happening, they experience an activation in a neural curcuit related to pain processing. This response, which is fairly aversive, readies the person to respond to a potentially threatening environment. At the same time, this sensation can elicit empathy and concern for the individual in pain. All of these responses are relatively adaptive as long as they are experienced in moderation. If, on the other hand, an individual chronically witnesses or imagines such imagery, he or she could ultimately experience a number of problematic outcomes, ranging from burnout to compassion fatigue to a deficit of cognitive resources that diminishes the individual's ability to effective attend to the individual in need (Decety & Lamm, 2009).
For physicians, this represents a bit of a tricky situation. On the one hand, empathy is a healthy feeling and an aversive response to pain in other that motivates decisive action could be professionally beneficial. On the other hand, if the job entails constant interactions with pain, physicians might use up emotional and cognitive resources and become unable to effectively manage their job. In this sense, it seems imperative that physicians be able to control their response to the sight of pain in other individuals in order to ensure that they can remain effective at their job over an extended period of time. Along these lines, previous research by Cheng and colleagues (2007) demonstrated that, when shown images of hands and feet either being pricked by a needle or rubbed by a Q-tip, non-medical personnel experienced activation of the pain matrix in their brain whereas physicians experienced activation of the cortical regions involved in executive functions, self-regulation, and executive attention. In other words, physicians responded in a completely different manner that enabled them to focus on the job at hand without using up cognitive resources on a more typical response to pain.
To investigate this phenomenon further, Decety and colleagues (2010) designed a study that utilized data from 30 participants, 15 of whom were physicians and 15 of whom had no medical training. My limited medical knowledge will prevent me from providing you with a detailed description of the methods; however, the actual article describes them quite well and I encourage you to consult that resource. Essentially what happened is that the participants were shown 120 images of various body parts either being pricked with a needle or rubbed with a Q-tip. Additionally, each participant filled out a number of questionnaires and, as they viewed the images, an EEG was used to detect brain activity.
The authors found a number of interesting results. First, control participants demonstrated substantial pain empathy in their EEG results (frontal N110 and late centro-parietal P3 activation) when viewing painful images relative to the Q-tip images. Physicians, on the other hand, did not respond differently to the two types of images and also provided lower subjective ratings of pain intensity and unpleasantness than the controls did. In other words, the painful images did not cause the physicians to react any differently than the Q-tip images did and they believed the experience of pain in the needle images to be less severe than the controls did. Additionally, physiological response to painful images was coupled with subjective pain intensity ratings in controls, but not in physicians. In other words, whereas control participants responded physically to a greater extent when they believed the image involved more pain, physicians' physical responses were not impacted by how painful they believed the image to be.
So what does this all mean and why am I writing about it on PBB? Perhaps even more importantly, why did I mention suicide in the title of this post? Think back to our article describing Joiner's interpersonal-psychological theory of suicidal behavior (2005). You'll remember that Joiner differentiates between those who desire suicide and those who are capable of it. In order to acquire the capability for suicide - which entails an elevated tolerance for physical pain and a diminished fear of death - an individual must encounter a substantial number of painful and provocative events (e.g., Van Orden et al., 2008). Doing this enables the individual to habituate to stimuli in their environment that previously would have been frightening or overwhelming. For instance, some research has demonstrated that individuals who have engaged in non-suicidal self-injury over an extended period of time no longer feel pain while self-injuring (e.g., Nock & Prinstein, 2005). Similarly, Orbach and colleagues (1997) found that individuals with multiple suicide attempts were able to tolerate more physical pain that were individuals with zero or one attempt. Put simply, the more an individual encounters and/or experiences pain, the less frightened they become of it and the more able they become to lethally harm themselves. The experience of doing so becomes less daunting (keep in mind, however, the majority of individuals capable of lethal self-injury have no desire to end their own lives).
As it turns out, physicians have one of the highest suicide rates of any occupation. They also regularly encounter substantial amounts of pain in their patients. In order to protect themselves from burnout, emotional distress, and limited cognitive capacity in emergent situations, physicians need to develop the ability to push through such situations and remained focused on the task at hand. In doing so, it appears that they might change their relationship with and response to pain, which in turn would elevate their acquired capability for suicide. This is an untested hypothesis with physicians; however, the situation is not unlike that of the military and, in a study I was fortunate to work on with PBB guest authors Craig Bryan and Chad Morrow as well as Thomas Joiner (2010), we found that US Air Force personnel who had recently completed basic training had higher levels of the acquired capability than did an outpatient community clinic sample. In both professions, there is a need to habituate to pain and fear in order to accomplish a task that is innately frightening and dangerous. There is nothing inherently wrong with becoming able to accomplish such noble tasks; however, it is important to keep in mind that, along with the benefits of such a shift, there comes the cost of increased risk. In this case, the risk takes the form of an increased acquired capability for suicide, meaning that these individuals immediately fall into the severe risk category any time they experience thoughts of suicide.
There are a couple of issues that were not relevant to the authors' goals, but which need to be considered when thinking about these results within the context of the interpersonal-psychological theory (keep in mind that these authors were not even looking at suicide risk - that is simply an issue I am bringing to the table). First, because this was not a longitudinal design, we cannot be certain that a selection bias was not in place. In other words, it remains possible that people who already respond to pain this way are more likely to become physicians and that these results do not actually represent change on the part of the participants. Second, another important variable to keep in mind here would be psychopathy. You might remember from previous discussions we've had about psychopathy that individuals who fit within that category have very low emotional reactivity and almost no risk of suicide. That being said, if a psychopath develops the acquired capability for suicide, and the behavioral tendencies characteristic of psychopathy render that possibility almost certain, he or she would still not be a great risk for suicide, as thoughts of suicide are unlikely to ever occur.
So, what is the take home point here? These data indicate that physicians do not respond to images of pain in others like non-medical personnel do. Instead, their response is dampened and their pain empathy is diminished, which allows them to avoid becoming emotionally overwhelmed and using all of their cognitive resources on processing emotions rather than planning and administering the appropriate medical intervention. This is a reasonable response for individuals in their position; however, it is also likely to result in an increased acquired capability for suicide, which places them at greater risk should they ever experience suicidal ideation. The point here is not that physicians should avoid this shifting view of and response to pain, but rather that mental health practitioners should be aware of its impact on suicide risk and carefully assess these variables when determining the safety of the client.
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If you would like to learn more about this and other topics discussed on PBB, we hope you will consult our online store for scientifically-based psychological resources.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident at the University of Mississippi Medical Center
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