Compassionomics

by Stephen Trzeciak

  On the first post-operative day, the researchers found that patients randomly assigned to a compassion intervention had 50 percent lower scores on pain ratings compared to patients randomly assigned to usual care. Very similar results to what they found at Mass General way back in the 1960s.

  In these randomized trials of vulnerable patients about to undergo surgery, the health care providers themselves made a major difference in the patients’ care. The compassionate pre-operative visit reduced the need for drugs, both sedatives and pain medication. These were the effects observed with the experimental application of a “new” therapy…a compassionate human connection!

  Perhaps the results here should not be that surprising, because there is abundant data to support the physiology of the calming effect of compassion on patients. So the notion that compassion for patients could combat not only stress, but also stress-mediated disease, should not be that difficult to believe.

  Compassion Calms Physiological Response to Stress

  Compassion acts in a powerful way on the autonomic nervous system, which is responsible for all of the body functions that happen automatically, without you having to consciously think about it. For example, you do not have to consciously think about your heart beating, and you don’t have to remember to breathe. They just happen.

  The autonomic nervous system has two components: the sympathetic nervous system and the parasympathetic nervous system. Earlier in this chapter, we talked about activation of the sympathetic nervous system, i.e., the “fight or flight” response to threat, danger, and stress in general. Sustained activation of the fight or flight response due to prolonged stress and anxiety can cause all kinds of physical symptoms that aren’t conducive to healing.

  But the other side of the autonomic nervous system is the parasympathetic nervous system, i.e., the “rest and digest” response. It directly counterbalances the response of the sympathetic nervous system, like a yin and yang phenomenon.

  While the sympathetic nervous system involves a spike in circulating cortisol and adrenaline for the fight or flight response while you are under threat, activation of the parasympathetic nervous system is a response producing a feeling of peacefulness and calm.

  Activation of the parasympathetic nervous system can also be thought of as the “relaxation response.” And it is part of the scientific explanation of the positive emotion—the warm, calming effect that we feel—when someone cares deeply about us and shows us compassion. It not only lowers our stress, it quells our fears.101

  Along with parasympathetic nervous system activation, there is also a rise in a circulating hormone called oxytocin, a molecule that serves numerous functions in the body including an increase in feelings of nurturing, bonding, and affiliation (i.e., gravitating toward close relationships with others). That is why some people refer to oxytocin as the “trust hormone”, the “bonding hormone,” or even the “love hormone.”

  Scientific evidence supports that human connection is a powerful activator of not only positive emotion, but also the parasympathetic nervous system.102 This is especially true for compassion. For example, research from Wake Forest University shows that compassion can change the physiology of the receiver of compassion by harnessing the power of the parasympathetic nervous system.103, 104 In these experiments conducted in a health care clinic, the researchers found that treating another person with compassion not only improved the receiver’s subjective sense of well-being and lowered their stress, but it also improved the receivers’ physiological measures of autonomic nervous system activity.

  The receivers’ respiratory rate and heart rate decreased, while their heart rate variability increased. This is a good thing: it’s a sign of cardiovascular well-being when an individual’s heart rate varies based on changing conditions.

  The measurement of heart rate variability is a measure of variation within beat-to-beat intervals that is measured with a heart rhythm monitor. When heart rate variability is high, this indicates that the body’s natural “pacemaker”—the link between the nervous system and the cardiovascular system—is functioning properly.

  Although it is not something that is routinely measured in doctor’s offices (at least not yet), scientists are well aware that lack of heart rate variability can be a “canary in the coal mine” for nervous system and cardiovascular system dysfunction (i.e., indicator of physiologic instability). The important take-home point here is that compassion for others not only improves the receivers’ subjective experience (i.e., feeling of warmth), but it can actually have measurable effects on how the receivers’ nervous system and cardiovascular system function.

  This effect can cut both ways. While the beneficial physiological effects of compassion are mediated largely through activation of the parasympathetic nervous system, negative interpersonal interactions can cause the opposite reaction through activation of the sympathetic nervous system.

  Although it is intuitive that a negative interpersonal interaction can be upsetting and can exacerbate one’s stress, there is ample scientific evidence that it can also trigger a reduction in one’s heart rate variability.105

  Compassion Lowers Blood Pressure

  If the effect of compassion on one’s respiratory rate, heart rate, and heart rate variability isn’t compelling enough evidence for you that compassion can have meaningful physiological effects, what about blood pressure? While understanding the value of heart rate variability may be new to you, you probably already know that a rise in blood pressure over time is bad thing.

  Compassionate touch from a supportive other can lower the receiver’s blood pressure.

  Research from Brigham Young University shows that compassionate touch from a supportive other can lower the receiver’s blood pressure over time.106 The mechanism is thought to be buffering (i.e., reducing the effects of) stress-mediated rises in blood pressure.

  These data are corroborated by numerous other research studies that have shown a compassionate connection from a supportive other can buffer one’s cardiovascular stress responses, when compared to the presence of a non-supportive other or experiencing the stress alone.107, 108 This may be why that University of Chicago study mentioned earlier in this chapter found that loneliness was associated with developing high blood pressure.

  So the take-home message here is this: compassion is not just “in your head.” Rigorous research shows that compassion for others (or lack thereof) can affect people’s nervous system and cardiovascular system in measurable ways. (If you need a reminder of the most dramatic example, just look back at the section on Takotsubo cardiomyopathy, and how a person under severe emotional stress can die of a broken heart!)

  Perhaps this is part of the explanation why the compassionate “special care” visit from the anesthesiologist in the Mass General study described earlier was more effective than drugs for inducing calm in patients headed for the operating room.98

  We have already seen that a compassionate connection from a health care provider can have a profound effect on patients in an extreme health situation, like undergoing major surgery.99 A University of Colorado study supported by a research grant from the NIH had a similar finding after analyzing data from 34 controlled experimental studies of patients recovering from a medical crisis (specifically, heart attack or surgery).109

  In the vast majority (85 percent) of the outcome measures examined across these 34 studies, the researchers found a positive association between psychological and emotional support from health care providers and favorable clinical outcomes. Compared to “ordinary care,” they found that psychological and emotional support was associated with an improvement in the patients’ recovery. Again, compassion mattered in measurable ways.

  Compassion Promotes Healing from Trauma

  It appears that compassion also matters in patients who undergo major trauma.110 In a study of 136 trauma patients admitted to a Level 1 trauma center, researchers assessed Patient Reported Outcome Measures (PROMs)—which are the patie
nts’ subjective assessment of their own recovery—at six weeks and one year following discharge from the hospital.

  Using a validated compassionate care scale, they also measured the patients’ assessment of the compassion of the physicians caring for them at the trauma center. They analyzed the data with a mathematical model that adjusted for demographic, socioeconomic, and injury-related factors and found that high physician compassion was independently associated with a good outcome at the one year mark.

  In a study of trauma patients, the odds of a patient-reported good outcome were four times higher when the physician was rated as having high compassion.

  In fact, the odds of a patient-reported good outcome were four times higher. So if you were a trauma patient in this study, the odds of you reporting a good outcome one year later were four times higher if the physician that treated you was particularly compassionate in handling your care.

  Compassion Improves Quality of Life in Palliative Care

  Another extreme health situation is which compassion appears to make a measurable difference is end-of-life care. Palliative care is a specialty within medicine that focuses on relief of symptoms and quality of life among patients who have a terminal diagnosis. The goal of palliative care is not to cure the disease, but rather to improve the quality of life in the time that a patient has left.

  A cornerstone of palliative care is compassion for patients and their families.111 A study from Mass General (in collaboration with Columbia University and Yale University) published in The New England Journal of Medicine tested the effects of compassionate palliative care in terminally ill patients with lung cancer.112 They randomized the patients to receive standard cancer care versus standard care plus early palliative care and tested the effects on quality of life.

  The results confirmed the hypothesis; patients receiving palliative care had better quality of life. That was expected. What was unexpected was that there was also an effect on survival. Patients randomly assigned to receive compassionate palliative care actually survived, on average, 30 percent longer!

  Think about this: a study designed to show that compassion increases quality of life in people with limited time left to live actually found that it increased how long they lived. We wonder if the authors of the study even contemplated that was a possibility. In some sense, these patients were surviving on compassion.

  But what about less dire circumstances? Does compassion only matter in an emergency or major (life or death) crisis, or does it also matter in everyday health?

  We have seen how compassion can have a measurable effect on a patient’s physiological parameters (i.e., measures of nervous system and cardiovascular system homeostasis). But what about in the context of a routine visit to the doctor’s office?

  The answer is yes. Let’s walk through some of the most common reasons for visits to the doctor and see examples of how compassion can make a difference there as well.

  Compassion Reduces Perception of Pain

  What about the impact of compassion on a patient’s perception of pain? You will recall from the Harvard anesthesiology research that a compassionate connection from the anesthesiologist before surgery reduced the requirement of opiate pain medication after surgery.99 Is there evidence of this type of effect in other health care domains?

  First a disclaimer: there is no evidence that compassion for patients eliminates pain. It doesn’t. That’s not the question. The question is this: can compassion reduce pain? Can it buffer a patient’s experience of pain in a way that makes it more bearable?

  Another thing before we look at the data: The science of feeling and treating pain is extraordinarily complex. So much so that there is now an entire specialty in medicine devoted to the subject (i.e., pain management specialists).

  In fact, there are sub-specialists of specialists that now specialize in pain. All of these specialties—anesthesiologists, family medicine physicians, internal medicine physicians, neurologists, psychiatrists, emergency medicine physicians, physical medicine/rehabilitation physicians (and the list is growing)—now have pathways to advanced training in pain management.

  There are numerous physiological, pathophysiological, and psychological factors that influence one’s experience of pain and pain relief. The data to follow is not meant to be overly simplistic or minimize a very complex set of factors that culminate in a patient’s experience of pain.

  But, that said, there is a clear signal in the data. Human connection can in fact modulate the pain that people experience in measurable ways.

  Human connection can modulate the pain that people experience in measurable ways.

  But how? Although the physiological mechanisms are complex and incompletely understood at the present time, it is clear that endogenous opioids play a large role. Endogenous opioids are molecules produced naturally by the body in response to a number of potential triggers, one of which is receiving compassion from others.

  One example of endogenous opioids produced by the body are endorphins, the molecules responsible for what happens to runners when they experience a “runner’s high.” That’s when a runner becomes numb to the pain of extremely strenuous running and actually experiences a euphoric feeling.

  The biological effects of endogenous opioids are similar to the effects of exogenous opioids (e.g., giving powerful drugs like morphine); they bind to similar opioid receptors in the brain to give an analgesic (pain reducing) effect or reduce sensitivity to pain. For years, scientists have known from experimental studies that a compassionate connection with a supportive other can affect one’s experience of pain. An experimental study refers to experimentally-induced pain (i.e., deliberately inducing pain in a human subject).

  Of course, this has to be done in healthy volunteers because it would be unethical to expose a sick patient to more pain than they already have for the sake of an experiment! But there is abundant experimental data from laboratory studies conducted in healthy volunteers.

  Touch Matters

  In one study from the University of Haifa in Israel, researchers applied a painful heat stimulus to volunteers’ forearms and then tested their subjective pain scores when either a stranger or a trusted other (e.g., a spouse or life partner) held the subject’s hand.113 Pain wasn’t affected at all with hand holding from the stranger.

  But you know what? When it was a loved one doing the hand holding, there was statistically significant reduction in the rating of pain—by more than 50 percent. Trust is powerful. But so is the compassion of the trusted other providing support. The researchers found a statistically significant inverse correlation between the assessment of the hand holders’ compassion and the pain rating (i.e., higher compassion = lower pain). This study shows that the touch of trusted others can in fact reduce one’s perception of pain, and there is a synergistic effect of compassion and the magnitude of the effect.

  In another interesting and elegant study from the same group, the researchers found that during experimentally-induced pain, the compassionate touch of a trusted other results in physiological “coupling.”114 The cardiovascular system and respiratory system of the trusted other literally gets in sync with the cardiovascular system and the respiratory system of the one receiving the painful stimulus.

  The researchers found that there is coupling of both the heart rates and the respiratory rates of the two people, a synchronous harmony of the heartbeats and breathing that mirrors each other. Their autonomic nervous systems actually align.

  Even their brain waves mirror each other!115 Further, it is in this physiological coupling that the effect of compassionate touch on pain reduction occurs. In fact, the research showed that a compassionate response from a trusted other was only effective if touch occurred.

  Touch matters. Maybe you have felt the effects of that synchrony and connectedness before, when someone who cares deeply about you lends a hand. Compelling data on this phenomenon are also available from the laboratory of Dr. James Coan at the University of Virginia, b
ut this research relates to the threat (i.e., the expectation) of experimentally-induced pain, in the form of an electric shock.116, 117

  In this laboratory, volunteers gazed at a screen in front of them. Whenever they saw a red “X”, there was a one in five chance that they would receive an electric shock in the next few seconds. Whenever they saw an “O” on the screen, that meant they were safe. Coan and colleagues wanted to see how people’s brains reacted to the threat of pain and, in particular, whether the brain behaved differently whether a person was facing the threat alone, holding the hand of a stranger (one of the lab technicians), or that of someone they knew and trusted.

  The zaps of the electric shocks hurt…a lot. After the first jolt, the volunteers felt a sort of panicked dread every time they saw a red X. They were hugely relieved when the experiment ended.

  What Coan and colleagues found using brain imaging is that when a person was alone or holding a stranger’s hand as he or she anticipated the shock, the regions of the brain that process danger lit up like a Christmas tree. But when holding the hand of a trusted person, the brain grew quiet.

  The researchers believe that having a trusted other with you alters the perception of that threat. The volunteers can “take it” (i.e., do not perceive threat or danger) because they do not feel alone.118

  This research may not be surprising to you because, intuitively, having people walk with us through difficult times can lessen the pain. We know this clinically as well. A University of Toronto randomized controlled trial published in The New England Journal of Medicine found that, for patients with metastatic breast cancer, participating in supportive-expressive group therapy (i.e., a support group) significantly reduced patients’ reports of pain over time, especially if the baseline pain level was high at the time of study entry.119