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Empathy Ability Is Impaired in Alcohol-Dependent PatientsGiovanni Martinotti a; Marco Di Nicola a; Daniela Tedeschi a; Sante Cundari a; Luigi Janiri a

a Department of Psychiatry, Catholic University Medical School, Rome, Italy

Online Publication Date: 01 March 2009

To cite this Article Martinotti, Giovanni, Nicola, Marco Di, Tedeschi, Daniela, Cundari, Sante and Janiri, Luigi(2009)'Empathy Ability IsImpaired in Alcohol-Dependent Patients',American Journal on Addictions,18:2,157 — 161

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The American Journal on Addictions, 18: 157–161, 2009Copyright C© American Academy of Addiction PsychiatryISSN: 1055-0496 print / 1521-0391 onlineDOI: 10.1080/10550490802544391

Empathy Ability Is Impaired in Alcohol-Dependent Patients

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

Empathy is a complex form of psychological inference inwhich observation, memory, knowledge and reasoning arecombined to yield insights into the thoughts and feelingsof others. The aim of this study was to evaluate the levelof empathy in a sample of alcohol-dependent patients incomparison to a control sample. One hundred and fifty alcohol-dependent subjects were consecutively recruited. All of thesubjects successfully detoxified have been evaluated with theEmpathy Quotient (EQ) and then compared with 107 controlsubjects. The level of empathy was significantly lower in thegroup of alcohol-dependent subjects than in the control sample(p < .001). Differences with respect to gender and psychiatriccomorbidity have also been observed. A low level of empathycould be a psychological trait typically observed in pre-morbidalcoholic personalities. Further, the lack of empathy could leadlatent abusers to find in the alcohol misuse something enablingthem to compensate for their intrinsic weakness. (Am J Addict2009;18:157–161)

INTRODUCTION

The word “empathy” is the translation of the German word“Einfuhlung,” a term from aesthetics meaning “to projectyourself into what you observe.” Only at the beginning ofthe twentieth century, following the important contributionof Theodor Lipps and Edith Stein, did the term “empathy”become incorporated within the field psychology with themeaning of “the way in which we perceive what the othersfeel.”1,2

According to Ickes,3 empathy is a complex form of psycho-logical inference in which observation, memory, knowledge,and reasoning are combined to yield insights into the thoughtsand feelings of others. Zahn-Waxler and Radke-Yarrow4

believed that empathy is central to what it means to be fullyhuman. It allows us to tune into how someone else is feeling,

Received April 13, 2008; revised May 22, 2008; accepted July 2,2008.

Address correspondence to Dr. Giovanni Martinotti, Clinica VillaMaria Pia, Via del Forte Trionfale 36, Rome 00135, Italy. E-mail:giovanni.martinotti@libero.it

or what they might be thinking. It allows us to understandthe intentions of others, predict their behavior, and experienceemotion triggered by their emotions. In other words, empathyallows us to interact effectively in the social world. It is alsothe “glue” of social relations, drawing us to help others andstopping us from hurting others.5

Humans can feel empathy for other people in a wide varietyof conditions: in response to basic emotions and sensationssuch as anger, fear, sadness, joy, pain, and lust, as well asto more complex emotions such as guilt, embarrassment, andlove.6

Over time, various definitions of empathy have beenproposed reflecting its multidimensional nature. Research inthis area follows two main trends: researchers that considerempathy basically as an affective response to another personor an understanding of another person’s feeling,7–11 and thosewho have taken a more cognitive approach, regarding empathyas a cognitive capacity to take the perspective of the otherperson while keeping self and other differentiated.12–19 Thislast conceptualization is actually developed using the conceptof theory of mind (ie, the ability to think about the contents ofother minds20,21) and the concept of mind reading.22,23

The “social” role of empathy has been largely emphasizedin literature. It has been related with sense of morality, altruism,pro-social behavior, and cooperation. Some authors believethat a deficit in this ability may invalidate the developmentand the formation of sustainable human social structures.24

As such, it is critical to moral development and to theimplementation of justice, thereby acting as a catalyst forsocietal cohesion and unity.25

Different dimensional traits are associated to empathy, suchas alexithymia,26 the inability to talk about feelings due to alack of emotional awareness, or impulsiveness.27 Individualswith empathy deficits are more likely to display aggressiveand antisocial behaviors toward others,28 while the absence ofempathy is what characterizes specific disorders such as autismand Asperger Syndrome.5,29,30 Furthermore, an impaired em-pathy ability can be found in schizophrenia31,32; in personalitydisorders such as antisocial personality disorder,33,34 whichcan be characterized by the tendency to hurt others withoutfeeling guilt or remorse35; and in narcissistic36 and borderline

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personality disorders, in which empathy is driven principallyby the desire to have needs satisfied.

The role of empathy in a psychotherapeutic relation is a keyfactor that needs to be assessed in order to plan the suitableapproach for the patient. The addiction service providersshould not ignore this dimension, considering that a goodtherapeutic relation is probably at the basis of the clinicalimprovement.

The aim of this study was to evaluate the level of empathyin a sample of alcohol-dependent patients in comparison to ahealthy control sample. The potential roles of sex, age, multiplesubstance abuse and Axis I and II diagnoses in relation toempathy represented the secondary endpoints.

METHODS

One hundred and fifty subjects meeting clinical criteriafor alcohol dependence (DSM-IV-TR) were consecutivelyrecruited from the Day-Hospital of Psychiatry and DrugDependence of the University General Hospital ‘A. Gemelli’in Rome. Enrollment started in July 2006 and was completedin September 2007.

Inclusion criteria were an age of 18–65 years, a diagnosisof Alcohol Dependence, and proficiency in spoken and writtenItalian language.

Comorbidity with schizophrenic disorder, cognitive impair-ment, and inability in the reality test resulted in exclusion fromthe study. Patients were evaluated by attending psychiatristsand psychologists using the Structured Clinical Interview forDSM-IV (SCID I, SCID II) in order to assess their comorbidpsychiatric disorders and personality. All subjects includedwere detoxified for a flexible period of 5–10 days with benzo-diazepines according to established and validated protocols.37

Forty-three subjects did not complete the detoxification periodand were excluded from the study.

Finally, all detoxified subjects were evaluated using theEmpathy Quotient (EQ) after a period of at least three weeksfrom last alcohol intake.

The EQ is a questionnaire that can be self-administered, hasa forced choice format, and is straightforward to score becauseit does not depend on any interpretation.5

It comprises 60 randomized questions, broken down intotwo types: 40 questions tapping empathy and 20 filler itemsincluded to distract the participant from a relentless focuson empathy.5 Each of the empathy items scores 1 pointif the respondent records the empathic behavior mildly, or2 points if the respondent records the behavior strongly.Approximately half of the items were worded to produce a“disagree” response and half to produce an “agree” responsefor the empathic behavior being examined. This was to avoida response bias either way. The EQ score can be dividedinto four ranges: 0–32, 33–52, 53–63, and 64–80, respectivelyindicating a below average, average, above average, and veryhigh ability to understand how other people feel and to respondappropriately.5

The EQ was also used to evaluate 107 healthy controlsubjects who were recruited in random modality from amongthe staff of Universita Cattolica del Sacro Cuore and the generalpublic. Control subjects were matched with the experimentalgroup for age, sex, and level of education.

Both study and control subjects gave written informedconsent to take part in the study, for which they voluntarilyparticipated without receiving any form of payment.

Anonymity was guaranteed to all the participants. Allstudy procedures were submitted and approved by InstitutionalReview Board of Universita Cattolica del Sacro Cuore inRome.

Students’ t-test and chi-square test were employed in orderto compare socio-demographic and clinical data. Differencesbetween group scores were analyzed using the t-test forindependent samples. The analysis of variance (ANOVA)was used to analyze the differences between subjects in thedifferent range of EQ scores. The Pearson Product MomentCorrelation was used in order to assess the relationshipbetween EQ scores and the age of subjects.

RESULTS

In Table 1, the socio-demographic and clinical characteris-tics of the alcohol-dependent and healthy control groups areshowed.

The level of empathy as measured by the Empathy Quotient(EQ) was significantly lower (p < .001) in the group ofalcohol-dependent subjects (40.27 ± 9.2) than in the controlsample (46.58 ± 10.0; see Figure 1). Figure 2 shows thedivision of subjects in both groups into the four differentranges of EQ scores. Significant differences were found (F =19.18; df = 3; p < .005), with a significantly larger number ofalcohol-dependent subjects scoring in range 1 (below averagelevel of empathy), and a significantly larger number of control

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

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TABLE 1. Socio-demographic and clinical characteristics of thetwo samples of alcohol-dependent and control subjects

Alcohol-dependent Controlsubjects subjects

N 107 107Sex (males) 58 (54.2%) 51 (47.7%)Age (mean ± SD) 43 ± 10.7 42 ± 14.2

<30 14 (13%) 20 (18.7%)30–50 71 (66.4%) 58 (54.2%)>50 22 (20.6%) 29 (27.1%)

Marital statusSingle 34 (31.8%) 40 (37.4%)Married 59 (55.1%) 58 (54.2%)Separated/divorced 14 (13%) 9 (8.4%)

Level of educationElementary school 12 (11.2%) 9 (8.4%)Lower secondary school 37 (34.5%) 31 (28.2%)High school education 53 (49.5%) 58 (54.2%)Degree 5 (4.7%) 9 (8.4%)

Employment conditionRegular job 46 (43%) 60 (56.1%)Occasionally employed 9 (8.4%) 3 (2.8%)Unemployed 24 (22.4%) 20 (18.7%)Student 28 (26.2%) 24 (22.4%)—

Duration of alcohol misuse(years) 10 ± 8.1 —

Duration of abstinence (days) 49.3 ± 12.5 —Multiple substance abuse 24 (22.5%) —

Dual diagnosis (axis I) 20 (18.7%) —Affective disorders 12 (11.3%) —Impulse-control disorder 4 (3.7%) —Anxiety disorders 4 (3.7%) —

Dual diagnosis (axis II) 19 (17.7%)Cluster A 3 (2.8%)Cluster B 13 (12.1%)Cluster C 2 (1.9%)NAS 1 (0.9%)

subjects scoring in ranges 3 and 4 (high and very high levelsof empathy).

Across the whole sample of both experimental subjects andhealthy controls, the average EQ score was significantly higher(p < .001) in females (45.96 ± 10.4) than in males (41.19 ±9.3). This difference was not observed in the sample of alcohol-dependent subjects, where the average EQ score was almost thesame in females (n = 39; EQ = 40.35 ± 8.7) and males (n = 68;EQ = 40.22 ± 9.6). The average EQ score was significantlyhigher (p < .001) in female controls (49.32 ± 9.9) than inalcohol-dependent females (40.35 ± 8.7), while the averageEQ scores of males were not significantly different betweengroups (alcoholics: 40.22 ± 9.6; controls: 43.02 ± 8.7).

The age of all the subjects evaluated did not significantlycorrelate (r = −12; p < .079) with levels of empathy asmeasured by the EQ.

In the sample of alcohol-dependent subjects, the subgroupswith a comorbid Axis I disorder (n = 15; EQ = 38.80 ± 9.1)had an average EQ score that was significantly lower (p < .05)than that of the subgroup without an Axis I disorder (EQ =43.05 ± 8.9). The Axis I psychiatric diagnoses reported wereMajor Depression (n = 3), Bipolar Disorder type II (n = 4),Impulse-Control Disorder (n = 3), General Anxiety Disorder(n = 2), Bipolar Disorder type I (n = 1), Cyclothymic Disorder(n = 1), and Panic Disorder (n = 1).

The average EQ score in the subgroup with a comorbid AxisII disorder (n = 19; EQ = 41.25 ± 9.4) was not significantlydifferent (p= .51) from that in the subgroup without an AxisII disorder (EQ = 39.92 ± 9.2). The Axis II psychiatricdiagnoses reported were Borderline Personality Disorder(n = 5), Narcissistic Personality Disorder (n = 3), AntisocialPersonality Disorder (n = 3), Histrionic Personality Disorder(n = 2), Paranoid Personality Disorder (n = 1), DependentPersonality Disorder (n = 1), Depressive Personality Disorder(n = 1), Schizotypal Personality Disorder (n = 1), SchizoidPersonality Disorder (n = 1), and Avoidant PersonalityDisorder (n = 1).

The average EQ score in the subgroup of alcohol-dependentpatients also reporting abuse of other substances (n = 24; EQ= 41.61 ± 9.9) did not differ significantly (p = .30) from

FIGURE 2. Percentage of alcohol-dependent and control subjects in the different ranges of EQ score. Abbreviations: EQ range: 0–32 = lowlevel of empathy; 33–52 = average empathic ability; 53–63 = high empathic ability; 64–80 = very high level of empathy. *significant differencesbetween groups (p < .005).

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the sample of alcoholics not using any other substances (EQ= 41.60 ± 8.9). Other reported substances of abuse werecocaine,7 benzodiazepine,6 cannabis,6 multiple substances,3

amphetamines,1 and MDMA.1

DISCUSSION

The present study was the first to examine the level ofempathy in abstinent alcohol-dependent patients. In this study,we employed a newly introduced scale for the assessment ofempathy, which is a controversial dimension that has provendifficult to evaluate. Several scales have been developed tomeasure empathy but each has significant weaknesses. Ofthese, the Empathy Quotient (EQ)5 is the most recent addition,and unlike previous scales, it was specifically designed forclinical application and to be sensitive to a lack of empathy asa feature of psychopathology.

A strength of this study is that all the patients evaluatedwere abstinent at the time of the assessment and thereforenot influenced by alcohol in terms of their performance.Furthermore, as stipulated by the inclusion criteria, the timesince the last alcohol intake was longer than three weeks inorder to eliminate any possible bias caused by withdrawalsymptoms.

In this study, subjects with alcohol dependence demon-strated reduced empathy, as measured by the EQ. Thehypothesis that this data may be influenced by the largenumber of abusers with a cluster B Personality Disorder, acluster usually characterized by a low level of empathy, isnot in line with our data, given the finding that there were nosignificant differences between the subgroups of alcoholicswith and without an Axis II disorder. The presence of adual diagnosis of an Axis I disorder is a factor that shouldnonetheless be taken into account, as it can be considered astate condition capable of lowering the ability to feel empathy.However, despite the potential influence of comorbidity asa confounding factor in the observed reduction in empathylevels, we do not believe that the lower EQ scores in theexperimental group can be explained by comorbidity alone,and hypothesize that a diagnosis of alcohol dependence is in-trinsically characterized by an impaired capacity for empathy.This characteristic may be a psychological trait of the varietytypically observed in pre-morbid alcoholic personalities.38,39

An impairment in the ability to understand the mental andaffective state of others could be at the root of the highlevels of impulsivity, aggression, and antisocial behavior,which represent key characteristics of some typologies ofalcoholics.19,40

It is also possible that a lack of empathy could leadlatent abusers to seek something that could compensate fortheir intrinsic weakness; intriguingly, some substances ofabuse are called empathogenic drugs (generating a state ofempathy).41 By these, we mean those psychoactive compoundsthat cause a transient rise in lucidity, a higher sensibility forthe environment’s aesthetic properties, and a better ability

to communicate and to understand others (for instance,ecstasy—that is, MDMA—was, at the beginning, called“empathy”).42

The role of alexithymia is another factor to take intoaccount. Because the awareness of one’s emotional states is aprerequisite to recognizing such states in others, alexithymia,or the difficulty in identifying and expressing one’s own emo-tional states, presumably involves impairment in the ability tofeel empathy.26,43 Different studies have shown the associationof alcohol and substance misuse with alexithymic traits,44–47

and, based on our findings, we extend this hypothesis toalso include an association of substance misuse with reducedcapacity for empathy.

Another issue that emerges from this study is that thedifferences in EQ scores between alcoholics and controlsis mostly determined by the female subgroup. This findingis difficult to interpret, but we hypothesize that femalesare typically more empathic than males,48–51 and, whenimpaired in this trait, they may search for something capableof improving their ability to communicate and understandothers. From the psychosocial point of view, commonlyheld stereotypes and popular culture suggest that womentend to show a greater capacity for understanding others’thoughts and feelings than do men.52 Therefore females areexpected to behave and act in an empathic way, and a lackof emotional awareness of others may be seen to representa maladaptive trait. Alcohol use could satisfy this need fora compensatory dynamic. However, it is also possible that along history of alcoholism could overcome the constitutionalpersonality features of patients and modify them in a waythat could give rise to homogeneous subpopulations ofalcoholics.

In fact, although impaired empathy could be a characteristicof a premorbid alcoholic personality and therefore representsa risk factor for the development of alcohol dependence, wecannot forget that the long-term misuse of alcohol might beitself responsible for the development of an impaired empathicability. This might be determined by a direct neurobiologicaleffect or by an acquired psychological habit.

With regard to treatment, because empathy and constructiveinterpersonal relations are contingent upon the willingnessto take another’s perspective,53 an impaired empathic abilitycould be at the root of a non-functional therapeutic alliance, alow adherence to pharmacological treatments, and a higherrelapse rate, given that the therapeutic relationship wasdescribed as one of the strongest predictors of drop-out.54,55

These findings may represent a basis for better understand-ing of the impaired ability of alcoholics to engage in social andinterpersonal interactions, such as problems between couplesand co-dependent dynamics, and highlight an opportunity forthe introduction of specific psychotherapeutic interpersonaltechniques capable of improving the expression of empathy inthese patients.

The authors wish to thank Lamia Nayeb and Jan Lewis forlanguage revision.

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