Can we predict burnout severity from empathy-related brain activity?
Citation: Transl Psychiatry
Can we predict burnout severity from empathy-related brain activity?
Empathy cultivates deeper interpersonal relationships and is important for socialization. However, frequent exposure to emotionally-demanding situations may put people at risk for burnout. Burnout has become a pervasive problem among medical professionals because occupational burnout may be highly sensitive to empathy levels. To better understand empathy-induced burnout among medical professionals, exploring the relationship between burnout severity and strength of empathy-related brain activity may be key. However, to our knowledge, this relationship has not yet been explored. We studied the relationship between self-reported burnout severity scores and psychological measures of empathic disposition, emotional dissonance and alexithymia in medical professionals to test two contradictory hypotheses: Burnout is explained by (1) 'compassion fatigue'; that is, individuals become emotionally over involved; and (2) 'emotional dissonance'; that is, a gap between felt and expressed emotion, together with reduced emotional regulation. Then, we tested whether increased or decreased empathy-related brain activity measured by fMRI was associated with burnout severity scores and psychological measures. The results showed that burnout severity of medical professionals is explained by 'reduced' empathy-related brain activity. Moreover, this reduced brain activity is correlated with stronger emotional dissonance and alexithymia scores and also greater empathic disposition. We speculate that reduced emotion recognition (that is, alexithymia) might potentially link with stronger emotional dissonance and greater burnout severity alongside empathy-related brain activity. In this view, greater empathic disposition in individuals with higher burnout levels might be due to greater difficulty identifying their own emotional reactions. Our study sheds new light on the ability to predict empathy-induced burnout.
Occupational burnout has become a pervasive problem in human
services, particularly among medical professionals who are highly
vulnerable to burnout.1 Behavioral studies suggest a strong link
between burnout and empathy.2?6 Although empathic attitude
and approach impact every aspect of medical care for patients
and their families,7,8 as many as 76% of medical professionals
report symptoms of burnout that may lead to medical errors,
substance abuse and even suicide.9 Empathy often relates to a
pro-social behavior and is essential to human life.10 However,
excessive empathy might be problematic because frequent
exposure to emotionally-demanding situations may put
individuals at risk of burnout.2?6 Previous research has found that
burnout severity is related to both increases and decreases in
dispositional empathy scores.11,12 There are two contradictory
theories of burnout; while the conventional theory, ?compassion
fatigue theory?,13 suggests that burnout relates to excessive
empathy, the alternative theory, ?emotional dissonance theory?,14
suggests that burnout relates to reduced emotional regulation
that causes a gap between felt and expressed emotions.
?Compassion fatigue theory? refers to one?s exhaustion
associated with caring for individuals who are experiencing significant
emotional/physical pain and distress.13 This theory suggests that
more empathic medical professionals tend to be at greater risk of
compassion fatigue and subsequent burnout.15 Meanwhile, the
?emotional dissonance theory? denotes a conflict between
experienced emotions and emotions expressed to conform to
display rules.16 Emotional dissonance may emerge when one?s
efforts to express socially-required, and in some instances
occupationally-required, empathic emotions become too much
of a burden and emotional responses become poorly regulated.17
Related research has found that inexperienced nurses who hide
negative emotion showed greater burnout symptoms than those
who do not freely express their emotions.18
Also supporting the ?emotional dissonance theory?, research
suggests that burnout severity is related to difficulty in regulating
negative arousal and difficulty describing/identifying one?s own
emotions (that is, alexithymia: reduced emotional awareness).19
Indeed, emotional dissonance may be related to alexithymia
because individuals with relatively greater alexithymic tendencies
fail to match their experienced and expressed emotions. Despite
having cognitive empathic abilities within the normal range,
people with high levels of alexithymia may show reduced
emotional reactions when observing others in pain, due to their
limited emotional regulation abilities.20,21 Therefore, it is possible
that the ?emotional dissonance theory? could better explain
burnout severity in medical professionals, in addition to the
conventional ?compassion fatigue theory?.
Because occupational burnout in medical professionals may
greatly depend on empathy levels,2 the relationship between
burnout severity and strength of empathy-related brain activity
may be the key to understanding empathy-induced burnout.
However, to our knowledge, this relationship has not yet been
explored. Meanwhile, some studies have shown differences in
levels of empathy-related brain activity in medical professionals
compared with healthy, nonmedical individuals, further
speculating on the relationship between this brain activity and burnout.
However, these previous studies did not implement psychological
measures of burnout severity. Using functional magnetic
resonance imaging (fMRI) and electroencephalography, these studies
have revealed reduced empathy-related brain activity in
physicians, compared with healthy controls, when viewing photographs
of others experiencing physical pain.22,23 This included activity in
the anterior insula (AI), anterior cingulate cortex (ACC) and
somatosensory cortex. Although burnout level was not directly
examined, this reduced brain activity was speculated to reflect an
adaptive strategy for resisting burnout.23 Specifically, this reduced
brain activity may enable physicians to address their patients?
symptoms without becoming too emotionally involved.
Importantly, however, reduced empathy-related brain activity was
associated with greater empathic capabilities in physicians. Along
with some other reports (described below), these findings suggest
that empathy-related brain activity is not necessarily correlated
with empathic capabilities. Although fMRI studies have
demonstrated a positive correlation between strength of
empathyrelated brain activity during the experience of vicarious pain and
Interpersonal Reactivity Index (IRI) empathy scores, for
example,7,24,25 a negative correlation has also been shown among
individuals with psychopathy;26 and healthy participants.27?30
According to a recent review, observation of others in pain
induces an empathic response that mainly involves the AI, ACC,
inferior frontal gyrus (IFG) and anterior medial cingulate cortex.24
In addition, the temporoparietal junction (TPJ) may also have an
important role in empathy-processing, including perspective
taking,31 in the patient?clinician relationship. For instance, in
two fMRI experiments, physicians showed stronger TPJ activation
when viewing a patient receiving pain compared with a no-pain
condition.7,22 We thus hypothesized that AI, ACC, IFG and TPJ
activity would be correlated with self-reported burnout severity in
In this study, we explored the relationship between
selfreported burnout severity scores and psychological measures of
empathic disposition, emotional dissonance and alexithymia to
test two contradictory hypotheses in medical professionals
(?compassion fatigue theory? versus ?emotional dissonance
theory?). Then, we tested whether increased or decreased
empathyrelated brain activity measured by fMRI was associated with
burnout severity scores and psychological measures.
MATERIALS AND METHODS
Participants were 25 nurses in active service with less than 11 years of
experience (20 females, aged 22?34, mean = 26.0, s.d. = 3.14). All
participants had worked in nursing for at least 1 year. Participants were
righthanded, according to the Edinburgh handedness inventory. Exclusion
criteria included a history of neurological injury or disease, medical
diseases or substance abuse. None of the participants met the DSM-IV
criteria for any psychiatric disorders, as assessed by structured clinical
interviews. Further, all participants underwent MRI scanning to rule out
cerebral anatomic abnormalities. Participants were recruited via
advertising from hospitals in Kyoto. All participants provided informed written
consent and were paid for their participation. The institutional review
board of Kyoto University approved the study.
To avoid bias towards the concept of a relationship between burnout and
empathy, participants completed the following four self-report measures
after the fMRI scanning session. Burnout severity was assessed by the
Maslach Burnout Inventory (MBI),32 which includes two core dimensions:
) ?emotional exhaustion? and (
) ?depersonalization?.33 The ?emotional
exhaustion? dimension measures feelings of being emotionally
overextended and exhausted by one?s work. The ?depersonalization? dimension
measures emotional detachment toward the recipients of one?s care. In our
study, the MBI served as a standardized measure for burnout and
compassion fatigue because these two symptoms largely overlap.19,34
Empathetic disposition was assessed by the IRI,35 which is one of the
most widely used self-report measures of dispositional empathy. Following
previous studies, the ?fantasy? subscale was excluded;11 thus, three
subscales were used: (
) ?perspective taking? (the tendency to cognitively
adopt the perspective of another); (
) ?empathic concern? (the tendency to
feel emotional concern for others); and (
) ?personal distress? (the tendency
to experience negative feelings in response to the distress of others).
Emotional dissonance was assessed by the Emotion Work Requirements
Scale (EWRS).36 In this scale, higher scores imply a greater degree of
emotional dissonance. In the current study, emotional dissonance was
distinctly defined by EWRS scores. EWRS measures emotional deviance as a
conflict between one?s own emotional experience and the expression of
emotions that are socially desired.37 It is comprised of two subscales ?hide
negative emotion? and ?display positive emotion? that trigger the conflict.
Previous research suggests that burnout is related, in particular, to
difficulty regulating negative emotions.19 Thus, we only focused on
measuring negative emotions and used the subscale ?hide negative
An inability to identify and describe one?s own emotions (alexithymia)
was assessed by the Toronto Alexithymia Scale (TAS-20).38 This measure
includes the following subscales: (
) ?difficulty in identifying feelings?; (
?difficulty in describing feelings?; and (
) ?externally oriented thinking?. The
relationships between burnout severity (MBI) and other psychological
measures were examined by Pearson's r correlation analyses implemented
in SPSS 21.0 (Chicago, IL, USA).
fMRI & data analysis
Video clips showing a hand in painful (pain) or nonpainful (no-pain)
situations were presented to participants during the fMRI scanning.
Participants were asked to passively look at the stimuli. The video clips
consisted of images of other people?s hands being harmed by different
tools (that is, knife, hammer and icepick; 2.8 s duration each). For the
nopain condition, a similar setting to the pain condition was shown, but the
tool being used was a soft brush. Each scanning session consisted of pain
and no-pain conditions (six blocks each) presented in a randomized order.
Each block contained six video clips and lasted a total of 16.8 s. A fixation
cross was displayed for 14.4 s as a baseline condition and was inserted
between each stimuli block (pain and no-pain; please see a schematic of
the experimental paradigm in the Supplementary Information
(Supplementary Figure S1)).
All participants participated in MRI scans using a 3-T scanner equipped
with an eight-channel, phased array head coil (Trio, Siemens, Erlangen,
Germany). Functional images were obtained in a T2*-weighted gradient
echo-planar imaging sequence with the following parameters: TE/TR:
30/2,400 ms, flip angle = 90?, FOV = 192 ? 192 mm, matrix = 64 ? 64; 40
interleaved axial slices of 3-mm thickness without gaps; resolution = 3 mm
cubic voxels. Imaging data were preprocessed and analyzed using SPM 8
(Wellcome Department of Imaging Neuroscience, London, UK). All
functional brain volumes were realigned to the first volume, spatially
normalized to a standard echo-planar imaging template, and finally
smoothed using an 8-mm Gaussian kernel.
At the single subject level, we conducted a t-test for the contrast
pain>no-pain using a general linear model. This was thresholded at
P = 0.05 (two-tailed, family-wise error corrected: FWE). Then, at the
grouplevel, we conducted region-of-interest (ROI)-based random effects analyses
to investigate activity specifically recruited within pain-related empathy
regions. A pain localizer was not used during the study; however, we used
predefined ROIs informed by previous research, representing AI, IFG and
ACC. These regions have been discussed as major affective components of
the pain matrix, and commonly recruited during empathy-for-pain.24 ROI
analyses were performed using the PickAtlas toolbox within SPM 8, and
parameter estimates were extracted from group-level clusters within the
AI, IFG and ACC.39 AI and IFG clusters were included in a single ROI because
they are anatomically adjacent to each other and partly overlapped in the
functional ROI implemented in PickAtlas. We also included an ROI
representing the TPJ, which is crucially involved in physicians? brain
response for empathy-for-pain.7,22 As TPJ is not considered a part of the
pain matrix, we purposely applied a more conservative analysis when
investigating neural correlates of TPJ activity. That is, TPJ parameter
estimates were extracted from the cluster obtained in the whole brain
analysis. Furthermore, because it is still a matter of debate whether TPJ is a
precisely identifiable cortical region,40 we selected clusters that were
anatomically overlapped with the TPJ x-y-z Talairach coordinates from a
meta-analysis, centered at (?50 ? 55 25), specifically extending from the
superior temporal sulcus to the inferior parietal lobe.41,42 Following the
conventional threshold,43 clusters smaller than 10 voxels were not
considered significant in our analyses. Furthermore, because there is no
clear functional laterality regarding empathic processing, parameter
estimates of ROI activity in the right and left hemispheres were averaged
within each participant. Subsequently, correlation analyses were
conducted on the basis of this averaged result. Using Pearson?s r correlation
analyses implemented in SPSS, parameter estimates of the pain>no-pain
contrast were correlated with psychological measures.
After the scanning session, participants were asked to rate each of the
video clips on the following: (
) intensity of distress (how much distress
they felt from a first-person perspective); and (
) intensity of pain
(objective rating of pain from a third-person perspective). Distress and pain
were each rated on a 9-point Likert scale, ranging from no-distress/pain to
the most extremely imaginable distress/pain. Video clips were shown in
the same order as they had been seen during the fMRI scanning. The order
of the two ratings was counterbalanced among participants. Subsequently,
for each of the video stimuli, the difference between these two ratings
(that is, distress minus pain score) was calculated and combined to give a
sum score for all stimuli for each participant. This score was also used as a
representation of emotional dissonance.
There were statistically significant relationships between burnout
severity (MBI) and other psychological measures (Table 1). Burnout
severity (MBI) and dispositional empathy (IRI) showed a positive
correlation. In addition, burnout severity showed a positive
correlation with emotional dissonance (EWRS) and alexithymia
(TAS). Specifically, ?emotional exhaustion? on the MBI showed a
positive correlation with ?perspective taking (PT)? on IRI (r = 0.507,
P = 0.010), ?hide negative emotion (HNE)? on the EWRS (r = 0.430,
P = 0.032) and ?difficulty in identifying feelings (Dif)? on the TAS-20
(r = 0.637, P = 0.001).
Contrasting the strength of hemodynamic activity between pain
and no-pain conditions, there were statistically significant
differences within our defined ROIs. Table 2 shows the results of
one-sample t-tests within the defined ROIs (that is, AI/IFG and TPJ),
demonstrating higher activations in the pain condition relative to
the no-pain condition. ACC activity was not examined because it
did not meet our cluster threshold (only one voxel remained
Correlations between neural activity and behavioral measures
There were statistically significant correlations between
hemodynamic activity associated with the pain>no-pain contrast and
psychological scores. Neural activity in AI/IFG and TPJ showed
negative correlations with burnout severity. Namely, AI/IFG and
TPJ activity negatively correlated with ?emotional exhaustion? on
the MBI (r = ? 0.590, P = 0.002 and r = ? 0.550, P = 0.004,
respectively). Figures 1 and 2 show correlations between burnout
severity and hemodynamic activity in AI/IFG and TPJ across all
In addition, AI/IFG and TPJ activity showed significantly
negative correlations with other psychological measures (that is,
empathic disposition, emotional dissonance, alexithymia and the
difference between distress and pain ratings; Table 3). Namely, AI/
IFG and TPJ activity negatively correlated with ?perspective taking?
on the IRI (r = ? 0.524, P = 0.007 and r = ? 0.431, P = 0.031,
respectively); ?hide negative emotion? on the EWRS (r = ? 0.528,
P = 0.007 and r = ? 0.504, P = 0.010, respectively); ?difficulty in
identifying feelings? on the TAS-20 (r = ? 0.399, P = 0.048 and
r = ? 0.581, P = 0.002, respectively); and the difference between
post-ratings of distress and pain (r = ? 0.419, P = 0.037 and
r = ? 0.464, P = 0.020, respectively). Furthermore, AI/IFG activity
showed a negative correlation with ?empathic concern? on the IRI
(r = ? 0.432, P = 0.031), and TPJ activity showed a negative
correlation with ?difficulty in describing feelings? on the TAS-20
(r = ? 0.467, P = 0.019).
To our knowledge, this is the first study to investigate the neural
correlates of empathy in relation to burnout in medical
professionals. Burnout severity was associated with ?reduced?
empathyrelated brain activity. In the initial correlation analysis between
self-reported psychological measures, burnout severity showed a
positive correlation with empathic dispositional scores, supporting
the ?compassion fatigue theory?. However, burnout severity also
showed a positive correlation with trait emotional dissonance
scores and alexithymia scores, which might represent a link
between burnout and emotional dissonance. This positive
correlation between burnout severity and emotional dissonance
was no longer significant when alexithymia scores were covaried
out (that is, changed from r = 0.430, P = 0.032 to r = 0.261,
P = 0.219). This goes along with previous studies suggesting a
link between burnout, emotional dissonance and
alexithymia.19,44?46 Meanwhile, the positive correlation between
burnout severity and empathy remained significant when
alexithymia scores were covaried out (changed from r = 0.507,
P = 0.010 to r = 0.467, P = 0.022). Thus, the initial correlation
analysis between the psychological measures supported both
theories (?compassion fatigue? and ?emotional dissonance?).
The brain imaging results cannot determine whether the
?compassion fatigue hypothesis? is supported or not because the
relationship between empathy-related brain activity and empathic
capabilities is not well understood. However, at least, the
correlation between empathy-related brain activity and
psychological measures showed a modest sign of emotional dissonance.
Medical professionals with ?reduced? empathy-related brain
activity exhibited higher burnout severity scores and greater
dispositional empathy scores. This ?reduced? pain empathy-related
brain activity also correlated with higher trait scores of emotional
dissonance and alexithymia. We thus speculate that reduced
emotion recognition (that is, alexithymia) might potentially link
with stronger emotional dissonance and greater burnout severity
alongside reduced empathy-related brain activity. In this view,
greater empathic disposition in those with higher burnout levels
may be because they have more difficulty identifying their
emotional reactions. Moreover, a negative correlation between
empathy-related brain activity and difference scores between
post-scan ratings of the pain stimuli may also go along with higher
alexithymia and emotional dissonance tendencies. Differences
between distress and pain scores can be considered
representations of the state of emotional dissonance; that is, participants
with subjective distress scores greater than their objective ratings
of pain showed weaker brain activity and stronger burnout
Stronger activity in the defined ROIs (AI/IFG and TPJ) was
associated with reduced severity of burnout, as measured by the
MBI, emotional dissonance trait scores on the EWRS, alexithymia
scores on the TAS-20 and empathy disposition scores on the IRI.
IFG has been previously implicated in reducing negative arousal,
inhibiting distress, facilitating response selection, encouraging
optimistic thinking and supporting belief formation.47,48 Moreover,
greater activity in AI/IFG may reduce a sense of dissonance or
depersonalization by enhancing ongoing awareness and sense of
reality because AI/IFG contains von Economo neurons.49 Thus,
people with reduced AI/IFG activation may demonstrate relatively
incomplete suppression of negative arousal and emotional
conflict, thereby inducing stronger emotional dissonance,
emotional exhaustion and burnout. Moreover, TPJ is involved in
distinguishing between awareness of self and others during
empathic behavior,50 metalizing51 and alexithymia.52 Our results
could imply that participants with reduced TPJ activity make a
weaker distinction between one?s own emotion and that of
another person, thereby evoking stronger feeling of dissonance
and/or reduced emotional recognition.
The relationship between burnout and empathy appears to be a
more global construct than previously argued. One of the reasons
for the existence of the contradictory theory in burnout might be
because the relationship between dispositional empathy levels
and burnout severity is complex. For example, dispositional
empathy scores in medical interns both increased (according to
the ?personal distress? subscale of IRI) and decreased (according to
other subscales of the IRI) when compared from the beginning to
the end of their intern year, along with increased burnout
severity.12 Furthermore, the relationship between the strength of
empathy-related brain activity and dispositional empathy is
complex. Several studies have reported positive as well as
negative correlations between empathy disposition measures
and different brain regions.26?30 To further distinguish this
relationship, continued research is required.
Another point that warrants caution is generalizing the
burnout-empathy theory to other populations. The observed
relationship between burnout severity and empathy-related brain
activity might only apply to inexperienced nurses because
burnout can be triggered by various factors besides altered
emotional regulation, such as work-life balance, salary and
relationship with co-workers.53 Moreover, the emergence of
burnout symptoms may depend on occupational type.
Professionals within human services are expected to manage their
emotions according to occupational demands. For example,
medical professionals and police officers may boost or inhibit
their emotions depending on the situation, which might
contribute to triggering burnout (for example, empathizing to
raise a strategic smile or expressing detached reception to elicit a
matter-of-fact attitude).14,54 However, professionals from other
fields, such as military service members55 and athletes,56 may
experience burnout as a result of different psychological
processes. Therefore, oversimplifying the burnout phenomenon
In conclusion, burnout in medical professionals might be
explained by reduced empathy-related brain activity. This reduced
brain activity was also associated with greater difficulty in
recognizing one?s own emotional state, as well as with greater
self-reported empathic disposition. Our results support findings
from previous behavioral studies, arguing that burnout is related
to weakened emotional regulation. Further, our study sheds new
light on the potential to predict future burnout in medical
professionals by the application of brain imaging, which may
strongly complement existing psychological examinations. This
approach can provide remarkable clues for understanding
burnout, namely, which particular aspects of the empathic trait
and state and which neuronal processes might be associated with
It is argued that individuals who are most vulnerable to burnout
in human service work are those who are highly motivated,
dedicated and emotionally involved in their work.57 Early risk
assessment of burnout in these individuals is very important
because they are indispensable for providing high-quality human
service.58 Because burnout in human service has become such a
critical issue,1 further clarification of the neural mechanisms of
occupational burnout is essential.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
This work was supported by grants-in-aid for scientific research A (24243061), and on
Innovative Areas (23120009), from the Ministry of Education, Culture, Sports, Science
and Technology of Japan (MEXT); Grants-in-Aid for Young Scientists A (23680045)
from the Japan Society for the Promotion of Science (JSPS), and a Health and Labour
Science Research Grant for Research on Applying Health Technology
(H25-seishinjitsuyouka-ippan-001) from the Ministry of Health, Labour and Welfare. A part of this
study is the result of Development of BMI Technologies for Clinical Application
carried out under the Strategic Research Program for Brain Sciences by the MEXT. KFJ
was supported by a Japanese Society for the Promotion of Science International
Research Fellowship and a National Science Foundation Graduate Research
Opportunities Worldwide (GROW) Fellowship?a component of a National Science
Foundation Graduate Research Fellowship (2011122786). We would like to thank
Dr. Toshihiko Aso, Dr. Nobukatsu Sawamoto and Dr. Hidenao Fukuyama for their
support with data collection.
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Supplementary Information accompanies the paper on the Translational Psychiatry website (http://www.nature.com/tp)
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