Motivation and emotion/Book/2019/Empathogens and empathy

Overview
Rebecca is a 14 year old girl who has a primary diagnosis of autism. With her diagnosis she has reduced social skills and has impaired ability to feel empathy. She has trouble in perceiving and understanding others' emotions. She often comes off to other people has cold or non-caring and she often does not participate or contribute in social situations. This then has caused a disruption and barrier in her everyday life. Rebecca then participates in a trial in which she takes MDMA in a controlled environment to increase her oxytocin levels to increase her cognitive and emotional empathy.
 * Case study

Have you ever felt as if you could feel or sense the emotions of others around you in a particular situation? If you do, you could be feeling empathy. Empathy is an emotional component where one has the ability to understand and feel others emotions or state of mind. Empathy is a complex emotion and some individuals may be less empathetic than others.

To increase empathy in individuals, there has been a question surrounding empathogens and how empathogens affect empathy. Different types of empathogens include Methyl​enedioxy​methamphetamine (MDMA), Ethylone, Methylone, and Methylenedioxy-N-ethylamphetamine (MDEA).The term entactogen comes from the Greek meaning "to touch within" and was coined by Nichols (1986) to help describe the psychoactive effects of stimulant drugs. Empathogens or entactogens combine the serotonergenic effects of psychedelics which are derived with the catecholaminergic effects of methamphethamine. These combined, produce a unique profile of prosocial and interpersonal effects.

The purpose of this chapter is to explain how empathogens affect empathy and in what way. First, this chapter will explain empathogens. Second, this chapter will summarise what empathy is and the different theories surrounding empathy. Lastly, this chapter will discuss the effects that empathogens have on empathy.

To get a good understanding of the effects of empathogens on empathy, MDMA will be the primary empathogen that will be discussed.


 * What are empathogens?
 * What is empathy?
 * How do empathogens affect empathy?

Empathogens
Empathogens or entactogens are a form of psychoactive drugs that alter perception, mood, consciousness and behaviour. Empathogens give the user a sense of oneness, closeness, union, relatedness, and emotional openness. In other words, increases the emotional experience of empathy (Kirkpatrick, Lee, Wardle, Jacob & de Wit, 2014; Schmid et al., 2014). Empathogens have effects on different hormones and neurotransmitters such as serotonin, dopamine and oxytocin. Each type of empathogen may produce more or less of an effect on these hormones and neurotransmitters.

MDMA and effects on brain regions and receptors
MDMA (also known as ecstasy) is a form of empathogen that is a psychostimulant drug (de la Torre, Yubero-Lahoz, Pardo-Lozano & Farré, 2012). It is seen to be the most widely studied drug and the drug that is used recreationally the most. MDMA is primarily used as a recreational drug and when taken orally, the effects can start from as soon as 30 minutes and can last anywhere between 3-6 hours. MDMA is known to have effects on monamines, such as serotonin, dopamine and norepinephrine. MDMA first binds to and inhibits the serotonin, dopamine and norepinephrine transporters, which leads to the inhibition of monoamine re-uptake and therefore, further leading to increased extracellular levels of these amines (Lüscher & Ungless, 2006). The chemical structure of MDMA can be seen in Figure 1.



The administration of MDMA causes an increase in prosocial feelings, leading from effects MDMA has on multiple hormones previously said and also including oxytocin. Oxytocin is both a hormone and neurotransmitter that is released from the hypothalamus. Oxytocin is involved with emotions and prosocial feelings and it is seen in humans to be released in the action of touching and hugging. Oxytocin also plays a central part in human trust and recognition of social cues and also has been seen to influence empathy (Domes, Heinrichs, Michel, Berger & Herpertz, 2007; Rodrigues, Saslow, Garcia, John & Keltner, 2009).

What is empathy?
In a broad sense, the phenomenon of empathy entails the ability for one to share the affective experiences of another, without losing sight of whose feelings belong to whom. Empathy occurs naturally and at different levels of processing, which will be explained later in the chapter. Empathy does not only occur when an individual is perceiving a situation directly. The phenomenon can also be activated from reading about a particular situation in book or even from simply perceiving a photograph (Decety & Jackson, 2004). There are both cognitive and emotional components regarding empathy. The cognitive component involves the observers cognitive capacity to understand the perspective of the other person, and the emotion component involves emotion regulation of that of the observer. Depending on the situation and how empathy is triggered, empathy could either involve top-down processing (the imaginative transposing of oneself into the feeling and/or thinking of another) or bottom-up processing (the automatic imitation of the expressions of others). Not every person shares the ability to empathise on a high level. Some people may have reduced empathy due to conduct disorder, autism spectrum disorder, or post traumatic stress disorder.



Measuring empathy
The widely used ways of measuring empathy include using a Likert-type self-report measure, for example, the Interpersonal Reactivity Index (Davis,1980). The Interpersonal Reactivity Index measures four aspects of empathy which include; social functioning, self-esteem, emotionality, and sensitivity to others. A second way of measuring empathy is through observational methods, for example, Bylund and Makoul (2005) conducted a study to measure empathy and medical encounters as an observational study. Lastly, a current measure for empathy that researchers are using is the Multifaceted Empathy Test (MET). The MET has the ability to measure both cognitive and emotional empathy. The MET uses a series of photographs in which to assess cognitive empathy, individuals are asked to infer the mental states of the people in the photographs. The MET then assesses emotional empathy by asking the individuals to rate their emotional reactions to the pictures (Dziobek et al., 2007).

Hoffman's theory of moral development
Martin L. Hoffman is a developmental psychologist who has, through his work, developed a comprehensive theory that describes empathy. Hoffman focuses on empathetic distress and his theory includes five mechanisms that explain how an observer becomes distressed when observing another individuals distress. These five mechanisms are; mimicry, classical conditioning, direct association, mediated association and role-taking. In the first three mechanisms, the observer perceives an individuals emotional distress directly and for the fourth and fifth mechanisms, the observer does not perceive the individuals distress directly and is therefore considered to involve more complex cognitive abilities. Descriptions and examples of the mechanisms of moral development are shown below in table 1.

Perception-action model of empathy
The perception-action model of empathy is a theory for empathy discovered by Preston and de Waal (2002). This theory describes that an observer may feel empathy by directly focusing attention on the distressed individual, much like Hoffman's (2000) direct association. Preston and de Waal explain that there are three levels of processing that occurs and depending on the level of processing, an individuals capacity of empathy can be determined. The first level of processing is a superficial level, where, if processing by the observer is not deep enough, there will be little to no action in response to the distressed individual and helping is unlikely to occur. The second level of processing explains that if processing is a little deeper, then the relevant limbic and cortical areas will be more strongly activated and therefore, the observer will experience empathy and will be likely to help the distressed individual. The third and final level of processing is described as the deepest level. If the observer reaches this level of processing then they will emotionally take on and feel the distress of the other individual. Preston and de Waal (2002) also mention that one's inhibition plays a role in determining the depth of processing one can reach. People normally inhibit imitation in one of two ways, centrally (prefrontal inhibition) or peripherally (spinal cord inhibition blocking the motoneurons from performing the action). Individuals with prefrontal lesions are effected in their ability to imitate due to inhibition, thus, showing that inhibition can effect the level of processing and therefore the level of empathy.

Choose the correct answer and click "Submit": The observer automatically imitates the emotional expression of an individual. The imitated expression then causes an emotional state in the observer. This is what mechanism in Hoffman's (2000) moral development?} - Classical conditioning - Mediated association - Role-taking + Mimicry - Direct association

{Oxytocin is...} - A hormone and is released from the hypothalamus + Both a hormone and neurotransmitter released from the hypothalamus - A hormone released from the thalamus - Both a hormone and neurotransmitter released from the thalamus - None of the above

Mirror neurons and brain regions responsible for empathy
Mirror neurons are a distinctive class of neurons where discharge occurs when an individual performs a motor act, and when the individual observes another performing the same or similar act. Significant scores have been found on the Empathic Concern sub-scale of the Interpersonal Reactivity Index, indicating that mirror neurons in the right inferior frontal mirror neuron area are activated during imitation and empathy (Kaplan & Iacoboni, 2006).

The main region that is involved in emotional processing is the temporal lobe including the amygdala. The anterior insula (AI) and the anterior cingulate cortex (ACC) are also highly involved in emotion processing and empathy. The ACC is not only involved in emotional empathy but also involved in the process of cognitive empathy; as the ACC lies in a unique part of the brain where there are connections to both the limbic system (emotional) and the prefrontal cortex (cognitive). A study on empathy conducted by Decety and Jackson (2006) showed activation of these three areas when participants were shown a picture of people who were in pain.

Cognitive and emotional empathy
Remembering that oxytocin plays an important role on empathy, the changes that occur in the levels of oxytocin after administration of MDMA then causes an increase in the levels of empathy (Dumont et al., 2009). These changes in oxytocin blood concentrations increase after administration of MDMA, which is followed by an increase in both cognitive and emotional empathy. Under the influence of MDMA, cognitive empathy is increased in the decoding of positive emotions and stimuli however, in contrast, decoding of negative stimuli is impaired (Hysek, Domes and Liechti, 2012). To explain further, Hysek et al., (2013), described in their study that under the influence of MDMA, their participants had an increased awareness in positive facial emotions, with a decreased recognition when presented with pictures of negative facial emotions. With emotional empathy, the increase includes a higher accuracy of positive emotions in individuals compared to negative emotions. In other words, Morelli, Lieberman and Zaki, (2015) explain that individuals experience 'positive empathy' after administration of MDMA, a state where one has the ability to share and enjoy others' positive emotions, which correlates with prosocial behaviour and a feeling of closeness.

Treatment potential
Like Rebecca in the case study at the start of this chapter, administration of MDMA may be beneficial and have treatment potential to increase empathy in individuals who struggle to produce the emotion. Individuals who struggle with issues like autism, conduct disorder and post-traumatic stress disorder (PTSD) have impaired social cognition and empathy. MDMA taken in a controlled environment may give these individuals an opportunity to increase their empathy and overall prosocial skills (Young & Barrett, 2015). MDMA could have treatment potential for PTSD as, as discussed earlier, MDMA reduces the amount of fear that individuals feel and decreases avoidance behaviour. Therefore in a therapeutic setting, therapeutic alliance can be strengthened and the individual has the ability to recall painful memories whilst still being in an alert and clear state of consciousness (Sessa, 2017).

Choose the correct answer and click "Submit": {What part of the brain is involved in both cognitive and emotional empathy?} - Amygdala - Anterior insula + Anterior cingulate cortex
 * Test your knowledge

{Hysek et al., (2013) explained in their study that under the influence of MDMA, individuals had an increased awareness in positive emotions and a decreased recognition to negative facial expressions.} + True - False

Conclusion
Empathogens are a class of psychoactive drugs that produce a sense of oneness, closeness and contribute the experience of empathy. Empathy is the ability to feel and understand the cognitive and emotional state of others while still being able to distinguish own feelings from feelings of another. The main hormone and neurotransmitter that heavily influences empathy is oxytocin. Oxytocin influences prosocial behaviour and the ability to feel empathy. As discussed, there are both cognitive and emotional components to empathy and MDMA has been seen to have an influence on both aspects of empathy. In a positive way, MDMA causes an increase in the oxytocin blood concentrations, which then produces an increase in prosocial behaviour and the ability to feel and understand others' emotions. Due to the positive increase, MDMA could have treatment potential for individuals who have impaired ability to feel empathy. The research of MDMA and treatment potential is still young and more studies need to be conducted within a controlled environment to explain how MDMA increases empathy, and what exactly in MDMA produces the positive affect on empathy.