Peter R. Martin: Historical Vocabulary of Addiction

Empathy

        According to the current electronic version of the Oxford English Dictionary (OED), the noun empathy was formed within English by derivation and combination of the prefix em- (“Transitive verbs [often found only in verbal noun, past participle, or participial adjective]”) with -pathy (“Forming nouns denoting kinds of feeling or ways of being affected.”).  The combining form -pathy is a borrowing from ancient Greek -πάθεια.  The sense of -pathy employed here is according to OED “…attested from the late 16^th century” similarly to other nouns such as sympathy and antipathy.    

        The conceptual underpinnings of the word empathy were formulated in the German language at the turn of the 20^th century.  The first sense of the word was after the German Empathie as used in the psychological theory of Kurd Lasswitz (1848–1910), a German author, scientist and philosopher who has been called “the father of German science fiction.” This now obsolete meaning of empathy is defined in OED as: “In the psychological theory of K. Lasswitz: a physical property of the nervous system analogous to electrical capacitance, believed to be correlated with feeling.”  The second sense of empathy was as used by Theodor Lipps (1851–1914).  Lipps was a German philosopher who was known for his theory regarding aesthetics and laying the foundation for a new branch of interdisciplinary research between psychology and philosophy using the concept of Einfühlung (empathy) that he defined as “projecting oneself onto the object of perception.”  This now rarely used meaning of the word is defined in OED as: “The quality or power of projecting one's personality into or mentally identifying oneself with an object of contemplation, and so fully understanding or appreciating it.”

        The first use of the word empathy in the English language was pertaining to Psychology and Philosophy and was published in Philosophical Review in a translation of Ueber psychophysische Energie und ihre Factoren (Lasswitz 1895):  “For the capacity factor of psychophysical energy the name ‘empathy’ is proposed.  Empathy is then a physical quantity, a physiological brain-function, and is defined as the relation of the whole energy at any change of the central organ to the intensity.”  This perspective based in Physics presages and draws upon the then emerging understanding of the nervous system in terms of its electrophysiologic properties, contemporaneously studied by the English neurophysiologist Sir Charles Scott Sherington (1857–1952) who received the Nobel Prize in Physiology or Medicine together with Edgar Douglas Adrian (1889–1977) in 1932 for their discoveries regarding the functions of neurons. 

        An early example in the English language of the second sense of the word empathy relating to Psychology and Aesthetics is found in a quote from Edward Bradford Titchener (1867–1927) in his Lectures on the experimental psychology of the thought-processes (1909): “Not only do I see gravity and modesty and pride… but I feel or act them in the mind's muscles. This is, I suppose, a simple case of empathy, if we may coin that term as a rendering of em>Einfühlung<//em>.”  Titchener, an English experimental psychologist, is best known for creating his version of Psychology describing the structure of the mind (Structuralism).  In the same volume, Titchener also wrote: “All such ‘feelings’… normally take the form, in my experience, of motor empathy.”  These quotes attempt to portray empathy as a tangible and measurable expression of brain functioning, namely motoric activity, thereby presaging subsequent recognition of the mirror neuron system (di Pellegrino, Fadiga, Fogassi et al. 1992).  However, this reification of empathy as muscular activity abjures the subtlety and ephemeral qualities of thoughts and feelings as suggested in a recent analysis (Ganczarek, Hünefeldt and Olivetti Belardinelli 2018) of the thinking of the German philosopher Robert Vischer (1847–1933) who is credited with actually inventing the term Einfühlung as a predominantly aesthetic formulation (Vischer 1873).   

        While having less palpable manifestations than motoric activity, thoughts and feelings are essential for the second definition of empathy that has come to be used in Psychology and in everyday parlance: “The ability to understand and appreciate another person's feelings, experience, etc.”  An early example in the English language of this use of empathy appeared in an article describing a form of psychotherapy in The dynamics of non‐directive psychotherapy (Meister and Miller 1946):  “A ‘man-to-man’ regard for the client, characterized (ideally) by the understanding of empathy without the erratic quality of identification or the supportiveness of sympathy.”  Perhaps a less technical and more easily understood example is found in a quotation of Sir Cecil Beaton (1904–1980), the British fashion, portrait and war photographer noted for his depictions of the British Royal Family (Beaton and Buckle 1979): “It is her [sc. the Queen Mother's] empathy and her understanding of human nature that endears her to everyone she talks to.”  This last perspective of empathy is now recognized as fundamental to the practice of medicine, especially to psychiatry and the field of addiction.

        Empathy must be distinguished from the commonly used word sympathy. While these words are often confused in common vernacular, their different etymologies reveal that they are conceptually distinct.  Sympathy is derived from late Latin sympathia, which, in turn, originated from the Greek συμπάθεια, comprised of συμπαθής (“having a fellow feeling”), a combining of the prefix σύν (Latinized sym, meaning “having the same or a like form”) and παθ-, which is the root of πάθος (“suffering, feeling”) from πάσχειν (“to suffer”).  The original meaning of sympathy is: “A (real or supposed) affinity between certain things, by virtue of which they are similarly or correspondingly affected by the same influence, affect or influence one another (especially in some occult way), or attract or tend towards each other.”  An example of the first use of this meaning in the English language can be found in The arte and science of preseruing bodie and soule, a volume written by the Welsh physician John Jones (1644 or 1645—1709) on the care of infants and small children that he dedicated to Queen Elizabeth I  (1579): “Plato also testifieth suche a Sympathia to be betweene the bodye and the soule, that if either exceede the meane, the one suffereth with the other.” Accordingly, the appearance of sympathy in the English language predates empathy by more than three centuries, suggesting that the conceptual basis of empathy was relatively late in the development of European languages and that sympathy may embody a more primal emotion.  All the same, there are overlapping elements in the emotions these words represent (and in their neurobiological underpinnings discussed below) as suggested by a quote from Robert L. Katz (1933–2010), an American social and organizational psychologist who created the concept of managerial skills (1963): “It is true that in both sympathy and empathy we permit our feelings for others to become involved.”  

        Humans are highly social and tend to live in groups that rely on each other for survival throughout life.  Collaborative human interactions require experimentally distinguishable emotional and cognitive brain functions that have become neurobiologically intertwined through evolution (Preston and de Waal 2002; Chen 2018; Heyes 2018).  Shared goals and behavioral responses to environmental challenges necessitate that individuals in a group draw upon cohesive responses, based on complex behavioral phenomena, to the feelings, cognitions and expressed behavior of other members of one’s “tribe” (Batson 2011).  The capacity to be able to experience the world through another’s perceptions and motivations appears to be a survival mechanism with primal roots (de Waal and Preston 2017). 

        Probably the first manifestion of this interconnectedness in humans is the mother-child bond (Bowlby 1966).  The capacity to understand and appreciate another person's emotions and motivations further develops through collaborative relationships with family members.  Continued involvement of the individual with their social group allows full maturation of empathy to the mutual benefit of the individual and the other members. 

        While it is controversial whether the foundations of empathy are inherited or learned (Heyes 2018), there is an expanding body of research on the neurobiological mechanisms involved (Engen and Singer 2013; Chen 2018; Lamm, Rütgen and Wagner 2019; Oscar-Berman, Ruiz, Marinkovic et al. 2021).  A mechanistic linkage to addiction research has recently emerged from findings of opioid modulation of human social learning, bonding and empathy in relation to affiliative and protective tendencies (Meier, van Honk, Bos and Terburg 2021).  This mu-opioid feedback model of social behavior extends the role of the endogenous mu-opioid system beyond the hedonic value of pain and pleasure so as to have implications for stress, anxiety, depression and attachment behaviors.   

        Currently accepted neurobiologically-based models of empathy include the perception-action model and mirror-neuron theories (de Waal and Preston 2017).  Emotional states of others may be understood by personal, embodied representations that progress to empathy based on the observer's past experiences.  Affect mirroring in offspring and emotional contagion in adults are related phenomena that have been observed in many mammalian species.  Mirror neurons that respond similarly to performed and observed actions were first identified in macaque monkeys, providing evidence for brain activation based on perception–action encoding in the brain (di Pellegrino, Fadiga, Fogassi et al. 1992).  This finding was extended to humans using positron emission tomography by demonstrating that premotor brain activation occurs on observing pictures of tools (e.g., hammers) or silently naming the use of the tool (Grafton, Fadiga , Arbib and Rizzolatti 1997). 

        The foundations of empathy in the brain were further supported by the finding that somatosensory damage resulted in impaired decoding of facial expressions of emotion (Adolphs, Damasio, Tranel et al. 2000).  Overlapping neural circuits for experiencing and observing affective states, including happiness, anger, fear, disgust, sadness and pain have been delineated using neuroimaging techniques (de Waal and Preston 2017).  While learning and conditioning are mechanistically important in the neurobiology of empathy, there is also evidence supporting  the role of genetic determinants of attachment based on allelic variation of the oxytocin receptor gene (Insel and Young 2001; Smith, Porges, Norman et al. 2014). 

        Various interacting biopsychosocial risk and resilience factors have been associated with the likelihood that an individual develops addiction and the tempo at which the disorder progresses (Martin, Weinberg and Bealer 2007).  While many of these determinants can be observed well before addiction is clinically manifested, others emerge subsequently as complications of the disorder per se.  Cognitive and emotional processing that contribute to empathy can rightly be considered as developmental precursors of executive functions, externalizing personality traits and related biopsychosocial determinants of addictive disorders (Le Berre 2019; Cristofani, Sesso, Cristofani et al. 2020; Rabin, Parvaz, Alia-Klein and Goldstein 2021).  For example, empathy has been conceptualized as the converse of aggression (Blair 2018) which has been found to be related to callous and unemotional behaviors (Waller and Hyde 2018) as well as the inability to verbalize one’s own emotions (Psederska, Savov, Atanassov and Vassileva 2019).  Thereby, empathy may be understood as inversely associated with antisocial traits, psychopathy and alexithymia which have all been implicated in etiopathogenesis of addiction.  These ideas are supported by the suggested role of empathy in the capacity of adolescents to resist peer pressure for binge drinking (Laghi, Bianchi, Pompili et al. 2019).  Of note, an analogous  role for empathy may pertain to development of behavioral addictions such as out-of-control and self-destructive internet use (Jiao, Wang, Peng and Cui 2017). 

        The multifaceted biopsychosocial trait of empathy can have an even wider role in development and course of addiction.  As an individual progresses in addiction, neuroadaptive brain changes accumulate so that the salience of alcohol/drugs and related behaviors overwhelms the behavioral repertoire, diminishing the capacity of the individual to stem their engagement in the self-destructive behaviors with which they struggle.  Additionally, the capacity of the addicted individual for empathy is progressively diminished with less ability to consider complex behavioral phenomena as the feelings, cognitions and expressed behavior of other members of their social group.  Such diminuition of empathy has been associated in neuroimaging studies with disturbed neural circuit connectivities among relevant brain regions (Wei, Wu, Bi and Baeken 2021; Baez, Fittipaldi, de la Fuente et al. 2021).  Accordingly, human relationships of the addicted individual suffer to a considerable extent as obtaining, using and recovering from the effects of the drug take precedence over everything else. 

        Re-acquiring empathy via interactions with a social network seems to be an important component of recovery from addictive disorders (Preller, Hulka, Vonmoos et al. 2014; Rupp, Junker, Kemmler et al. 2021).  Among those in whom there is a primary lack of this trait, acquiring empathy may be a part of recovery from addiction as suggested by the finding that sociocognitive deficits and cluster B personality traits of chronic cocaine users correlated with cocaine use as reflected by concentrations of cocaine in hair (Vonmoos, Eisenegger, Bosch et al. 2019).  Hence, abstinence orientation and training of social cognition and interaction might improve social functioning and should be considered an important therapeutic element in treatment of addictive disorders.  This focus on social functioning and empathy for others who are also on the road to recovery from addiction is clearly demonstrated by the processes involved in participation in mutual support self-help programs (Galanter 2014; Preller, Hulka, Vonmoos et al. 2014).  Those who suffer from addictive disorders may also experience empathy through healing relationships that promote recovery through physicians and other healthcare providers (Miller and Moyers 2015).  Reduced empathy as focus for treatment is not limited to drug use disorders but extends to behavioral addictions as gambling (Tomei, Besson and Grivel 2017). 

        In summary, empathy is essentially a biopsychosocial resilience factor in development and progression of drug use disorders and behavioral addictive disorders.  Due to the increasing salience of out-of-control and self-destructive behaviors that are incompatible with and supplant empathy, addiction is a disorder characterized by disruption of collaborative human interactions.  This capacity to be meaningfully engaged in human relationships must be acquired or restored if recovery is to be achieved.

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September 2, 2021