“I Feel Your Pain..Not”
I was battling my fourth week of coughing repeatedly. I followed the standard protocol for treating my cold symptoms; one week of zinc tablets for a presumed viral infection, followed by 10 days of antibiotics after my symptoms clued a secondary bacterial infection. My upper respiratory infection seemed to settle in my chest, as I developed laryngitis. I started self-treatment with a steam vaporizer and even used a muscle thumper to clear my lungs. But for some reason, my deep cough was continued without any resolution in sight. I decided to pay the clinic a visit to have my primary physician provide other strategies for treatment.
He agreed with my diagnostic impression of post-infection bronchitis and he prescribed an expectorant and cortisone along with two kinds of antitussives (cough suppressant medicines). I had used Dextromethorphan in past years without any problems. The other antitussive, Benzonatate was a medicine that I had never tried before. I started the treatment right away, hoping for a speedy recovery.
After nearly a week of treatment, I became increasingly aware that my normal level of energy and emotional posture had shifted. On one level I was a quiet observer of the change I was experiencing. But on a different level, I was feeling numb and apathetic, and oddly, depressed. Clearly, I had anhedonia (no pleasure in activities ) and psychomotor retardation (sluggish) with a decreased appetite and increased need for sleep. Yet beyond this, I seemed to have lost interest in feelings and appreciation of others, especially with those closest to me. I knew if I had the energy to gaze at my experience, it would have shocked me just how much I could ‘care-less” with anything or anyone. Knowing this was a clear departure from who I am, I reasoned that this dysphoria had to be related to the medicine I was taking for my cough. I stopped the Benzonatate and reduced my routine dose of Dextromethorphan (I had already finished my Hydrocortisone regimen )
Now on the other side of my illness, almost completely recovered, I had to revisit this dysphoria in order to unravel the mystery behind my mood experience. I mean, if such a profound emotional shift could occur from routine medication of a physical illness, then how many times have I missed treating a patient for refractory depression without considering iatrogenic bilateral treatment influence? Since I was familiar with Dextromethorphan and I knew I tolerated it well before, the culprit had to be the Benzonatate.
So what is unique to Benzonatate that it would diminish my sense of connection with others? What would interfere with my level of empathy and the Will to care? I explored this matter further.
What I found on Benzonatate:
“It is an ester local anesthetic derived from tetracaine."
After absorption and circulation to the respiratory tract, it distributes into the mucosa, anesthetizing vagal afferent fibers that contribute to both cough and hiccups.”
Benzonatate behaves as a painkiller of sorts for vagal afferent fibers. I continued to explore this further and came across an article that surprised me and seemed to explain what I had experienced. Apparently, this has been a recent issue related to a very common pain medicine, Tylenol.
“..acetaminophen has a general blunting effect on individuals’ evaluative and emotional processing,
irrespective of negative or positive valence..”
“..It is thus conceivable that acetaminophen may also reduce willingness to help others in physical or emotional distress”
What is EMPATHY
According to Webster “Empathy” is:
“the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also : the capacity for this ” ("empathy").
Empathy plays an important part in our lives as social beings. That part of our internal monitor which appeals to fairness and justice in the world helps us to wear in someone else's shoes and ponder the question, “What if that person was me?”. Modifying our behavior is important for survival and remain safe with each other. In return, we depend on this emotion to assure our well-being as well. This is not only related to safety from harm, but also to the regard of others in our social circle for the security we require in our relationships.
As one author shared, “..empathy regulates prosocial and antisocial behavior”.
Components of Empathy
In order to empathize with others, there has to exist something within us to register “what if that person was me?”. This requires both the Will [W] to take a template of another person (like us) [T] and recreate a similar scenario [S] of ourselves in such a situation. Then we would need to employ some sort of a “personalized assessment” [A] where our resulting emotions [E(r)] are compared to our baseline emotional function [E(b)]. If the disturbance of comfortable baseline is exceeded, we are motivated [M] toward action to restore the balance.
[W] * [M] = [E(b)] - [E(r)], where A (S* ( [T] ) ) = [E(r)]
Given the equation here, we can see if a baseline Emotional state E(b) is not significantly altered by the imagined self in the represented scenario E(r), there will be no motivation (M) to alter the situation. This can occur for example, when one who is actively suffering a loss, observes another experiencing a loss. However, if the number of losses of the other person (E(r)) is exceeded by personal loss(E(b)), one might be motivated to give comfort.
What would increase the likelihood for deciding action by empathy? First, there would have to be a willingness (W) to look beyond ourselves. Then there would have to be a high degree of similarity of the observed person (T) to ourselves (e.g. age, gender, traits, etc) and the assessment (A) of imagined distress (E(r)) would have to be significantly different from our baseline emotional comfort (E(b)).
The Biology of Empathy
"Simulation theories of empathy hypothesize that empathizing with others’ pain shares some common psychological computations with the processing of one’s own pain. Support for this perspective has largely relied on functional neuroimaging evidence of an overlap between activations during the experience of physical pain and empathy for other people’s pain"
A substantial body of functional magnetic resonance imaging (fMRI) research suggests that observing others experiencing pain (e.g. observing a person receiving a hot probe placed on the hand), activates brain regions that are also activated during one’s own experience of pain—the anterior cingulate cortex (ACC) and the anterior insula (AI) cortex
It is not the purpose of my present writing to discuss the detailed aspect with the neurology of empathy. But it suffices at this point to say we have the brain structures which are clearly identified with a role for Empathy. This seems to support the importance of “being wired” for this function for our lives and how we relate to each other as social creatures.
But what is important here is that when we observe others who suffer specific injuries, our brains appear to have a similar pattern of activity related to experiencing the observed injury. In fact, if you consider the brain pattern activity, it is much like we experience the very same injury by observing the one in pain.
Pain is a subjective experience of discomfort but from a physiological perspective, there are some common characteristics of the experience.
“...pain can result from increased activity in excitatory pathways involving, for example, substance P, glutamate, etc. decreased activity in inhibitory pathways involving, for example, noradrenaline or serotonin (5-HT) or both mechanisms..”(3)
Given that we seem to experience a similar injury pattern from observation, questions were raised on how this ‘perceived pain ‘ would be impacted after an observer is administered a painkiller. Given, it is unclear exactly how acetaminophen works, but it clearly has analgesic and fever-reducing qualities. It is believed to regulate serotonin pathways.
Paracetamol has a central analgesic effect that is mediated through activation of descending serotonergic pathways.
Empathy and Painkillers
To examine the impact of painkillers on empathy, a study was conducted where randomized subjects were given direct irritation by air puffs and tested for estimating pain when others were observed in a painful situation after an oral administration of 1000mg of acetaminophen in a double-blind study.
You can review this study here.
Surprisingly, what was discovered is that acetaminophen (aka paracetamol or Tylenol) had a profound effect not only on direct painful stimuli but also in the pain attributed to others experiencing pain. In other words, empathy was directly diminished by taking 1000mg of Tylenol.
As hypothesized, acetaminophen reduced empathy in response to others’ pain. Acetaminophen also reduced the unpleasantness of noise blasts delivered to the participant, which mediated acetaminophen's effects on empathy. Together, these findings suggest that the physical painkiller acetaminophen reduces empathy for pain and provide a new perspective on the neurochemical basis of empathy (2)
This raises some concern for those involved in mental Healthcare.
“Because empathy regulates prosocial and antisocial behavior, these drug-induced reductions in empathy raise concerns about the broader social side effects of acetaminophen, which is taken by almost a quarter of adults in the United States each week”. (2)
“As hypothesized, acetaminophen reduced empathy in response to others’ pain. .. these findings suggest that the physical painkiller acetaminophen reduces empathy for pain and provide a new perspective on the neurochemical bases of empathy”.
What this implies is that most people taking Tylenol for chronic pain, are likely experiencing an ongoing emotional shift just as I experienced. Tylenol (acetaminophen) is frequently taken to manage chronic pain, as it does not have the same risk concerns of other pain medications. Medications like ibuprofen and Aspirin commonly produce gastric ulcers and increase bleeding problems. Yet it seems very important to expose the impact that medicines have on our emotional tone. Let’s face it, we are often clueless about how common medicines can dampen our empathy and fuel our depression. How often do we hear people say, "it is just how I feel’ or “something is wrong with me for not caring for others in my life”? Counseling is always important in addressing the maladaptive way we approach relationships. But it is vital that people are ‘equipped emotionally’ to make necessary changes in the way they think about their relationships. I wonder how often we work with those who have adopted hopelessness following failed therapy, when the answer may be as simple as changing their pain medication strategy. The missing piece of the puzzle may just require a change in pain management medicines.
I then consider people taking Tylenol for chronic pain whom I have met in social support groups or churches; many who likely struggle with feeling they just don't care and not knowing why. I wonder how often leaders, like our pastors managed by pain medicine, feel challenged because they may question their "called" role as a pastor, yet feel they are not able to have the love for their flock as they “ought”.
It really does give you something to consider, especially for those that are guilt-prone. If they knew their pain medication may be preventing them from improving their relationships, it might renew their hopes of healing.
"Based on the drug-induced reductions in empathy seen here, acetaminophen, and potentially other analgesics, might interfere with social processes that are critical for the promotion of social bonds and social order." (2).
My study here did not provide clear answers with the exact mechanisms of my prescription medicine. There was no direct evidence for the impact it had on my emotional state. But this review did provide a wake-up call for reviewing medications when treating patients with depression. We ought to consider the medication a patient is taking when we notice signs of disinterest or lack of empathy. Sometimes problems of relating may have more to deal with their medication and not their lack of motivation or resistance to conflict resolution.
If you my reader are dealing with the distress of emotional challenges, consider taking two Tylenol and call me in the morning. (ok, not really).
Thanks for reading.
1).“empathy. ” Empathy | Definition of Empathy by Merriam-Webster. n.p., n.d. Web. 23 April 2017. https://www.merriam-webster.com/dictionary/empathy
2). Dominik Mischkowski, Jennifer Crocker, Baldwin M. Way; From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain. Soc Cogn Affect Neurosci 2016; 11 (9): 1345-1353. doi: 10.1093/scan/nsw057
n.d.: n. pag. Print. 23 April 2017
3) What do we (not) know about how paracetamol (acetaminophen) works?
K Toussaint, XC Yang, MA Zielinski… - Journal of clinical …, 2010 - Wiley Online Library