Saturday, September 28, 2013

What If the Best Remedy for a Broken Family Is No Family at All?

This excellent article from Pacific Standard Magazine looks at the San Pasqual Academy, a non-profit group home that can serve about 180 kids, located in the San Diego area of Southern California. This facility exists because families fail - and when teenagers are involved, families tend to fail in violence, neglect, and suffering, especially for the kids.
The academy believes teenagers should bond with a community of their peers and a group of adults rather than be folded into a series of potentially dysfunctional families. The concept can be reduced to a simple truth: There is no time. There are more than 60,000 foster children in California alone, and it can take years even to try to rehabilitate troubled biological parents or family members, or find stable adoptive parents.
On average, foster children will have three family placements, but for teenagers it's not uncommon for teenagers to end up living in 10 to 12 different homes. By the time a kid is 12, if s/he is still living in foster care you have a single-digit chance of being adopted (if you want to be - and not all kids do).
In fact, a teenage girl in foster care is more likely to get pregnant than to get adopted. Somewhere near 25 percent of foster care kids become homeless.
The way they have structured San Pasqual is highly unique and represents a new model with traditional values.
[Situated on] 238-acre parcel of land, San Pasqual Academy’s $14 million campus includes a small public high school, an organic farm, a fire station, a colony of subsidized housing for seniors (who serve as surrogate grandparents), a swimming pool, a technology center, and a manicured football field. Up to eight students live in each cottage with one or two adults, who cook meals, help with homework, and enforce bedtime. The adults are there to offer an approximation of parental support when needed, but the main focus of San Pasqual is to establish a structure whereby the kids can create their own community—and bond with it.
They have a graduation rate twice that of foster kids in California. Their students are required to participate in extracurricular activities, in job training, get summer internships, and apply for college (the Friends of San Pasqual non-profit helps raise money for tuition).

Granted, this program does not accept kids with a background in violence or serious chemical addiction. And the kids have to show some desire to be there and to get an education. Still, we need more schools set up on this kind of model.

What If the Best Remedy for a Broken Family Is No Family at All?

The San Pasqual Academy argues we should let foster teenagers create their own tribe.

September 16, 2013 • By Natasha Vargas-Cooper


Between the ages of eight and 16, Nora lived in 32 foster-care settings. She lived in emergency shelters for children, in the homes of well-intentioned short-stay foster parents, and at home during her mother’s brief bouts of sobriety. One of her foster families would not allow Nora (not her real name) to bring her belongings inside; she had to change her clothes in the garage. She was in her last placement for four months when her foster family decided to move—and leave her behind.

Foster children have a median number of three family placements, but many teenagers end up living in 10 to 12 different homes. If you’re still in foster care by the time you’re 12, you have a single-digit chance of being adopted if you want to be. In fact, a teenage girl in foster care is more likely to get pregnant than to get adopted. Somewhere near 25 percent of foster care kids become homeless. So, even though Nora was non-violent, sober, and free of physical and emotional disorders, her prospects were grim. The surest way for Nora to have had a fixed address, attend the same school, and establish some routine would have been placement in a group home, a highly restrictive setting usually reserved for teenagers with behavioral problems—and one of the lowest rungs on the ladder of foster-care placements.

What was unusual about Nora was her ambition. “I wanted two things more than anything,” Nora says. “I wanted to make sure my mom took better care of my younger sister than she did of me, and I wanted to go to college.” And Nora had great grades. So her social worker recommended she enroll in San Pasqual Academy, an unorthodox—some would say controversial—group home and boarding school for foster kids near San Diego, California.

What happened after that wasn’t what society has come to expect from kids who’ve lived in group homes. Nora graduated from high school, then college, and is now in her final year of graduate school. Census data reveals that about three percent of foster children earn college degrees, a tenth of the national average, but Nora’s story isn’t uncommon for San Pasqual.

TODAY, FOSTER-CARE POLICY tends to be leveraged on the assumption that a family structure best serves a child’s interests. Ideally, that would mean biological parents or relatives. But even a substitute family is considered preferable to (and more cost effective than) a group home. To be sure, research shows this is true for very young children.

San Pasqual, a non-profit that can serve about 180 kids, exists because families fail. And when teenagers are involved, families tend to fail most spectacularly. The academy believes teenagers should bond with a community of their peers and a group of adults rather than be folded into a series of potentially dysfunctional families. The concept can be reduced to a simple truth: There is no time. There are more than 60,000 foster children in California alone, and it can take years even to try to rehabilitate troubled biological parents or family members, or find stable adoptive parents.

For kids stuck in the churn of the national foster-care system through their teens, prospects for adulthood are bleak. Almost 60 percent of those who age out of the national foster-care system wind up unemployed, and more than 20 percent of young people who arrive at homeless shelters come directly from foster care. According to the Brookings Institution, 80 percent of males who have been in long-term foster care, and 57 percent of females, have been arrested at some point (compare that to 17 and four percent in the general population).

“The foster-care system is pernicious,” says retired family court judge Jim Milliken, one of the founders of San Pasqual Academy. “It’s damaging for the kids that stay too long. The vast majority of them end up with bonding disorders. They get psychological damage from never having a secure, permanent place.”

Milliken, at almost 70, is a pink-faced man with a white mop and glassy blue eyes who served for eight years as the presiding judge over San Diego County’s juvenile court. When he began his tenure in 1996, he was appalled that the average time between a child’s removal from home and landing a long-term placement was 34 months (22 more months than it’s supposed to take). Milliken instituted reforms, and family reunification rates tripled under his watch. But for all that he accomplished, he was acutely aware of the courts’ continuing failures.

“I looked around and we had all these kids who were turning 13 and 14 years old and have been in the system for years. They were being sent off to group homes because they didn’t want to go to another stranger’s house,” Milliken says. “They want to go to the same school and claim some independence.”

San Pasqual’s public school boasts a graduation rate twice that of foster kids statewide. (PHOTO: COURTESY OF SAN PASQUAL ACADEMY)

NESTLED IN ONE OF San Diego’s lush coastal canyons, on a 238-acre parcel of land, San Pasqual Academy’s $14 million campus includes a small public high school, an organic farm, a fire station, a colony of subsidized housing for seniors (who serve as surrogate grandparents), a swimming pool, a technology center, and a manicured football field. Up to eight students live in each cottage with one or two adults, who cook meals, help with homework, and enforce bedtime. The adults are there to offer an approximation of parental support when needed, but the main focus of San Pasqual is to establish a structure whereby the kids can create their own community—and bond with it.

San Pasqual, modeled after a similar academy in Israel, is the only home of its kind in the United States. And Milliken says its graduation rate is near 90 percent, as compared to 45 percent for foster youth statewide.

“I only believed half the things I read about the school,” Nora tells me over the phone from her apartment in Northern California. She was accepted into one of the school’s first graduating classes. Her San Pasqual college counselors helped her apply for grants, scholarships, and loans for her undergraduate and graduate education. Any gaps in Nora’s university funding, San Pasqual filled. “I mean, that’s more than a lot of families can do, so I’m pretty grateful,” Nora says. She has a polite lilt to her voice and adds, “I also got here because of me.”

To be accepted at San Pasqual, for the most part, students can’t have a bad history of violence or substance addiction (the state licenses schools to house various “classifications” of foster kids, but San Pasqual has some discretion and flexibility). They don’t have to be strong academically, but they do have to demonstrate that they want to be there, which means they have to request admission, even if a court recommends them. Students are required to take on extracurricular activities, undergo job training, get summer internships, and apply for college (the Friends of San Pasqual non-profit helps raise money for tuition).

RIGHT OUTSIDE HAIFA, ISRAEL, surrounded by the Mount Carmel forest, is the Yemin Orde Youth Village, a school for at-risk youth. Originally built in 1953 to shelter adult immigrants and orphans rendered homeless by the Holocaust, it now shelters mostly abandoned immigrant teens ages 12 to 19.

In 1998, Milliken took a research trip to see Israel’s extensive network of youth villages, modeled partly on the European boarding school and partly on the Israeli kibbutz. At Yemin Orde, Milliken met Chaim Peri, the philosophical father of the Israeli group-home model.

“You have a painfully short period of time to heal adolescents,” Peri says in an interview during a recent visit to the United States. “If you want to heal a family, with its own long-staying pathologies, then forget about healing the child.” Peri is in his 70s and has a thick silver mustache and a baldpate covered by a yarmulke. At Yemin Orde, he says, they tell “neglected, abused, and parentless children, half of them immigrants and half from abusive homes, ‘What your family cannot do for you, your community will.’”

Peri’s thinking is inspired in part, he says, by the pioneering writings of the British psychoanalyst John Bowlby. Bowlby’s work is, in a way, a surprising source for Peri. In his book Attachment and Loss, Bowlby argues that infants and young children need to have one secure primary caregiver, usually a biological mother, in their lives in order to form secure attachment to the outside world. This primary caregiver becomes a base from which the child can then explore the world. The thinking is, if children perceive this attachment figure to be nearby, accessible, and attentive, they will feel loved, secure, and confident. If they don’t, Bowlby posited, the child will be wracked with insecurity and emotional disorders that persist past infancy. Peri, though, understands that it’s not enough to simply place blind faith in the family unit. So he has adapted the idea of secure attachment for the realities of adolescent foster care.

“You can’t just leave a child in a pathological environment and expect them to be a part of a culture that is value laden and reveres life. The time slot is too short,” Peri says. For those who’ve had a destructive childhood, adolescence, Peri holds, is a time to recover—and find bonding and security elsewhere. “I sometimes refer to our village as a garden of late bloomers,” Peri writes in his book The Village Way, “because so many of our teenagers—like teenagers the world over—are wrapped in cocoons, dealing with traumatic childhood experiences and healing from them during the early years of adolescence. Only later are they capable of devoting themselves to building their futures. The trick is to be there for these teenagers when they are ready to bloom.” And not to leave them. No one is expelled from Yemin Orde: Everyone is told that they’ll always belong. Like a family.

The most direct inspiration for Peri’s model was the counseling work he did starting in the early ’60s, organizing schools for waves of immigrant children from countries like Ethiopia and Yemen. Given that Israel was a young nation with few people and few developed institutions, and with citizens steeped in the European boarding-school and Kibbutz models—and that many orphans were adrift in the world, with no expectation of reunifying with their families—the “village” model was a natural fit. By circumstance, the best option available, Peri says, was to create mutually collaborative and supportive communities among the children themselves, with adult supervision.

Peri’s approach was prescient. According to Cambridge researcher Michael Lamb’s review of hundreds of psychology studies, whether or not a child is related to a guardian has no impact on that child’s social and mental adjustment. More importantly, the social science and medical establishments now widely agree that the composition of a kid’s family is secondary to the family unit’s style of parenting. Peri’s model prioritizes that idea, and that approach let Milliken liberate San Pasqual from the conventional wisdom that continues to dominate foster-care policy: that family reunification always comes first.

Yemin Orde, in Israel, gives abandoned immigrant teenagers a stable place to create family. (PHOTO: COURTESY OF YEMIN ORDE)

STUDENTS AROUND SAN PASQUAL affectionately refer to Milliken as the Judge. Boys in dark baggy denim and loose white T-shirts high-five him as we enter the lunchroom. The Judge proudly talks about the record of relative success that San Pasqual has racked up during the decade it has existed. San Pasqual is no utopia and there are still plenty of shortcomings, but its statistics are much better than the national average for foster kids: None of the kids become homeless when they age out of the system since the academy provides them housing; there’s that 90 percent graduation rate from high school, with one-fourth entering college; and they have the best football team in their public-school division. That last point is not a minor one. The team has proven to be a key factor of the community. “The kids have a mascot, a silver-and-blue fire-breathing dragon—an identity, and a sense of pride,” Milliken says.

THE RESEARCH ON SAN PASQUAL is promising enough that it has renewed debate among researchers as to whether certain group home models can outperform other types of foster care. But the program is still too young and small to have a large body of data behind it. Building more campuses is an uphill slog. While San Pasqual is in part supported with public money, a number of the school’s programs depend on private fundraising; and the academy is legally classified as a group home, the least desirable form of foster care in the eyes of academia, the public, and the legislature—a technicality that makes mustering funding difficult.

And despite its impressive track record with graduation rates and retention, San Pasqual is also struggling to keep enrollment up. At times there are as many as 50 unfilled slots. Again, legal and structural problems are partly to blame: The state discourages the use of group homes as they are more expensive than private foster homes, and California puts a financial cap on the length of time a child can stay in a group home—sometimes making it hard to keep a kid at San Pasqual for all his or her high-school years.

But some of the hindrances have to do with how much San Pasqual asks of its students, and how radical its basic idea really is. On a recent afternoon, Milliken is watching students give a tour to a prospective enrollee. “We want the kids to be honest about their experience here. Potential students don’t need one more adult making them empty promises,” he says as the tour approaches.

Today’s potential student is a 14-year-old African American girl, apparently unenthusiastic. Milliken introduces himself with a hearty smile and gives some well-wishes.

“She’s not going to come here,” Milliken tells me with quiet despondency. “She doesn’t believe what we’re telling her.”

Americans often have a deep-seated suspicion of institutions, especially ones that play roles traditionally reserved for the family. And San Pasqual is a particularly pointed challenge to that sense of the family’s sanctity. Not long ago, the academy built a cluster of spacious apartments for recent alumni who have nowhere to spend holidays and breaks during college or to live after graduation. If home, as the saying goes, is the place that will always take you back, San Pasqual is an approximation of just that.

Synesthesia, At and Near its Borders

In this new opinion article from Frontiers in Psychology: Cognitive Science, Marks and Mulvenna examine the definition of synesthesia and six types of cross-modal experiences that may fit the definition. The six they examine are cross-modal correspondence, cross-modal imagery, sensory (cross-modal) autobiographical memory, empathic perception, hallucination, and the Doppler illusion.

They ask if any or all of the six constitute forms of synesthesia? According to their analysis, he answer depends on the framework for characterizing synesthesia. From there they identify three frameworks that differ in how they characterize these phenomena relative to prototypical forms of synesthesia

Full Citation: 
Marks LE and Mulvenna CM. (2013, Sep 26). Synesthesia, at and near its borders. Frontiers in Psychology: Cognitive Science; 4:651. doi: 10.3389/fpsyg.2013.00651

Synesthesia, at and near its borders

Lawrence E. Marks [1,2] and Catherine M. Mulvenna [3]
1. John B. Pierce Laboratory, Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
2. Department of Psychology, Yale University, New Haven, CT, USA
3. Child Study Center, Yale University School of Medicine, New Haven, CT, USA


In synesthesia, experiences in one domain evoke additional experiences in another, as when musical notes or letters of the alphabet evoke colors. Both the domains and their pairings are diverse. Indeed, Day's (2013) recently tabulated 60 types of synesthesia, each referring to a different combination of inducing and induced domains. The domains conjoined through synesthesia may belong to different sense modalities, as in music-color synesthesia, but may also belong to the same modality: In grapheme-color synesthesia, seeing printed letters or numbers evokes color experiences.

In music-color and grapheme-color synesthesia, the inducing stimuli are perceptual, reflecting culture-specific categories (notes of the Western musical scale, letters of the alphabet) learned by synesthetes and non-synesthetes alike. Synesthesia may be triggered not only by sounds, tastes, smells, and pains, but also by more complex signals: words(e.g., Simner, 2007), emotional states (e.g., Ward, 2004), and even personalities (e.g., Novich et al., 2011). Analogously, the domains of synesthetic responses too can range widely. The composer Rimsky-Korsakoff “saw” the key of D-major as golden (Myers, 1914), while a grapheme-personification synesthete reported, “Ts are generally crabbed, ungenerous creatures” (Calkins, 1893; p. 454). Other phenomena, however, such as cross-modally evoked images or memories, are not typically considered examples of synesthesia.

In this article, we briefly describe half a dozen illustrative cases that border on traditional forms of synesthesia: cross-modal correspondence, cross-modal imagery, sensory (cross-modal) autobiographical memory, empathic perception, hallucination, and the Doppler illusion. Do any or all of the six constitute forms of synesthesia? The answer depends, we suggest, on the framework for characterizing synesthesia. Consequently, after describing the six phenomena, we sketch three frameworks that differ in how they characterize these phenomena relative to prototypical forms of synesthesia. Several investigators, taking different perspectives and coming to different conclusions, have already considered possible relations to synesthesia in three of the six: cross-modal correspondence (Martino and Marks, 2001; Deroy and Spence, 2013); cross-modal imagery (Craver-Lemley and Reeves, 2013; Spence and Deroy, 2013); and empathic perception (Fitzgibbon et al., 2010; Rothen and Meier, 2013).

Six at the Borders: Synesthesia's Far and Near Kin?

Cross-Modal Correspondence

Cross-modal correspondences pervade not only several forms of traditional synesthesia but also, importantly, the experiences of individuals typically deemed non-synesthetic (Marks, 1975, 1978; Spence, 2011). Even non-synesthetes perceive high-pitched vs. low-pitched sounds to resemble bright vs. dark colors—the resemblances evident in various tasks of cross-modal comparison (Marks, 1975; Ward et al., 2006). Where music-color synesthetes see brighter colors in high-pitched notes (e.g., “gold, yellow and white moving … like a rippling stream”: Mulvenna and Walsh, 2005; p. 399), people lacking the induced qualia of synesthesia nevertheless recognize cross-modal similarities.

Cross-modal correspondences often reflect alignments between bipolar dimensions, such as higher pitch being associated with greater lightness, greater brightness, higher vertical location, and smaller size (e.g., Karwoski et al., 1942; Wicker, 1968; Marks, 1974, 1989; Ward et al., 2006). Several auditory-visual correspondences reveal themselves in young children (Marks et al., 1987; Mondloch and Maurer, 2004) and infants (Lewkowicz and Turkewitz, 1980; Walker et al., 2010; Haryu and Kajikawa, 2012), as well as in denizens of disparate cultures: Members of a remote, semi-nomadic, preliterate desert-tribe in southern Africa, having virtually no contact with Western culture, nevertheless overwhelmingly matched lighter gray colors to higher-pitched tones—thereby revealing pitch-lightness correspondence (Mulvenna, 2012).

The tendency for non-synesthetes to perceive similarities between experiences in different domains, despite the absence of secondary qualia, has been called “synesthetic thinking” (Karwoski et al., 1942) and “weak synesthesia” (Martino and Marks, 2001), consistent with the notion that cross-modal correspondence reflects general perceptual and cognitive processes. Further, by capitalizing on cross-modal correspondences, synesthesia too presumably capitalizes on these general processes of perception and cognition (e.g., Karwoski et al., 1942; Marks, 1978; Ward et al., 2006).

Cross-Modal Imagery

Compared to cross-modal correspondence, which can lack induced qualia, cross-modal imagery is nearer, phenomenologicaly, to prototypical synesthesia. In cross-modal imagery, as in synesthesia, stimulation in one modality may arouse mental images in another, although cross-modal imagery exhibits greater voluntary control (e.g., Karwoski and Odbert, 1938). Synesthetic responses commonly arise automatically, without requiring effort and being under relatively little control (e.g., Mattingley et al., 2001). By comparison, some non-synesthetes can voluntarily conjure up images, for example, imagining colors while listening to music (Karwoski et al., 1942). In some instances, there may be an especially intimate connection between visual imagery and prototypical sound-color synesthesia. Karwoski and Odbert (1938) inferred that a small subset of their subjects experienced visual imagery that could be modulated by music—a phenomenon that seems more automatic (less voluntary) than typical visual imagery, albeit less automatic (more voluntary) than synesthesia. Perhaps music-modulated imagery bears an especially close connection to traditional music-color synesthesia.

Sensory Autobiographical Memory (Proust Phenomenon)

(Marcel Proust 1922) famously described the floods of detailed, sensory memories from childhood evoked by tasting a tea-soaked madeleine. Sensory, autobiographical memory of this sort has been dubbed the “Proust phenomenon” in honor of the eponymous author. In the Proust phenomenon, odors or flavors in particular evoke strong sensory-based memories of associated events experienced in childhood (Chu and Downes, 2000). Proustian memory resembles traditional synesthesia, but also differs from it—resembling synesthesia in the automatic manner in which sensory experiences evoke memory images, but differing in the episodic character of the memories. In this regard, the sensory qualia of traditional synesthesia seem more “semantic” than “episodic.”

Empathic Perception: Pain, Touch, Couvade Syndrome

In several respects, empathetic perception strongly resembles synesthesia. In empathic pain, seeing or hearing evidence of another person's pain or discomfort produces analogous pain or discomfort (e.g., Jackson et al., 2005). Similarly, seeing another person being touched may produce an analogous tactile sensation—often called “mirror touch” (e.g., Banissy and Ward, 2007). Although the inducing stimuli come from another modality—typically, vision or hearing—the mechanisms underlying empathic perception presumably rely on an underlying within-domain equivalence: where implicitly-recognized sensations evoke sensory experiences of the same or similar kind, perhaps through merging constructs of “self” and “other.”

Possibly related to empathic pain is the couvade syndrome, which refers to a set of empathic symptoms (such as nausea, vomiting, and abdominal pain) reported by the partners of pregnant women. The couvade syndrome appears to be fairly common, having a reported prevalence of about 22% (Lipkin and Lamb, 1982), roughly five times that of traditional synesthesia (Simner et al., 2006).

A feature that distinguishes empathic perception from traditional forms of synesthesia is the very characteristic that makes empathy empathic—the intrinsic equivalence between the emotional qualities of the inducing and induced experiences. In traditional forms of synesthesia, however, as when sound evokes visual color or shape, the inducing and induced sensations not only reflect different domains but are also usually related more abstractly, even “metaphorically” (Rothen and Meier, 2013).


A hallucination is a “percept-like experience which (a) occurs in the absence of appropriate stimulus, (b) has the full force or impact of the corresponding (real) perception, and (c) is not amenable to direct and voluntary control by the experiencer” (Slade and Bentall, 1988; p. 23). Several of these attributes also characterize synesthesia. Hallucinations may involve any of the senses (Ohayon, 2000) and are easily distinguished as “perceptions not confirmed by others” (Ohayon, 2000; p. 154). Some types of hallucinations, though not all, may fall near the borders of synesthesia. Thus, synesthetic experiences commonly include colors and shapes (Day, 2013). Analogously, “simple hallucinations,” often triggered by migraines or hallucinogens (Ermentrout and Cowan, 1979), commonly include simple recurring shapes and patterns, or ‘form constants (Klüver, 1966), which apparently reflect patterns of neural activation in visual cortex (Ermentrout and Cowan, 1979).

No longer considered explicitly pathological, hallucinations are now generally treated as independent perceptual phenomena (Romme and Escher, 1989; see Strauss, 1969). Auditory verbal hallucinations (hearing voices), for instance, occur in about 13% of adults in the general population (Beavan et al., 2011), and their presence does not correlate significantly with psychopathology (Johns et al., 2002; Sommer et al., 2010). Although the strongest predictor of psychopathology in hallucinations is distress over their content or possible basis (Romme and Escher, 1989; Chadwick and Birchwood, 1994; Beavan et al., 2011), distress is rarely associated with synesthetic experience.

The Doppler Illusion

Day's (2013) table listing 60 types of synesthesia includes only one type that is explicitly intra-modal, namely, grapheme-color synesthesia. We note here another phenomenon in which sensory experiences in one domain induce experiences in the same modality, the “Doppler illusion,” reported by Neuhoff and McBeath (1996): When a tone increases continuously in intensity over time (as though a sound-emitting source were approaching at constant velocity) but maintains a constant sound frequency, observers nevertheless report hearing the tone's pitch to increase as loudness increases. Neuhoff and McBeath dubbed the illusory increase in pitch the “Doppler illusion” because a sound source approaching at constant velocity will produce, at the observer's location, an elevated, albeit constant, sound frequency (the physical Doppler effect). But might we not also call the Doppler illusion a case of intra-modal (loudness-pitch) synesthesia?

Synesthesia: Continuous, Discrete, Pluralistic?

If, as the term implies, synesthesia is first and foremost a “conjoining of experiences,” then one might construe several or perhaps all six of our cases as examples of synesthesia. If, on the other hand, synesthesia is defined more narrowly, for example, by requiring it to include qualia and to arise automatically and consistently, then fewer cases would make the cut. Recently, the first author outlined three theoretical frameworks—monism, dualism, and pluralism—that, in different ways, characterize how synesthesia could relate to borderline perceptual and conceptual phenomena like the six just described (Marks, 2011, 2012).

Synesthetic monism refers to the notion that synesthesia may appropriately be considered a spectrum or continuum. Using this framework, traditional forms of synesthesia, such as music-color and grapheme-color, serve as prototypes, residing at the high end of the continuum, with weaker forms, such as cross-modal correspondence, residing toward the low end. In the present examples, music-modulated imagery, hallucinations, empathic perceptions, Proustian evoked memories, and the Doppler illusion might lie at various loci between the ends of the synesthetic spectrum—although the differences amongst them suggest that the hypothesized spectrum is multidimensional.

The other two frameworks both distinguish sharply between synesthesia and non-synesthetic forms of perception and conception. Dualism posits a simple dichotomy between the two categories, with synesthesia incorporating both traditional forms (e.g., sound-color, grapheme-color, word-flavor, taste-shape) and others (e.g., grapheme-personification, ordinal sequence-spatial sequence), and non-synesthesia incorporating cross-modal correspondence, cross-modal imagery, and hallucination. How to categorize other borderline examples, such as empathic perception, Proustian memory, and the Doppler illusion, however, is less clear.

Like dualism, the third framework, pluralism, explicitly distinguishes synesthetic from non-synesthetic experiences, but rests on the additional assumption that synesthesia is well characterized as (appropriating James's, 1890; p. 224, expression) “a teeming multiplicity.” Like monism, synesthetic pluralism recognizes that some forms of synesthesia, such as music-color, are better exemplars than are others, such as empathic perception and the Doppler illusion. In the pluralistic view, however, the broad category of synesthesia itself contains a cornucopia of distinct sub-categories, lacking common denominators but perhaps linked one to another along the lines suggested by (Wittgenstein's 1953) notion of family resemblance.

Critical, in our view, to choosing amongst frameworks is characterizing the role of phenomenal experience in defining synesthesia; many investigators judge this role to be significant (see, e.g., the exchange among Cohen Kadosh and Terhune, 2012; Eagleman, 2012; Simner, 2012a, b). Monism in particular relies substantially on the notion that phenomenal experience plays a central, and ineluctable, role in characterizing synesthesia. Alternatively, jettisoning phenomenology may be conducive to pluralistic frameworks that rely on mechanism-based distinctions amongst multiple forms of synesthesia. And jettisoning phenomenology may be especially conducive to dualistic frameworks that rely on a mechanism-based distinction between synesthesia and borderline phenomena—perhaps akin to distinguishing mechanistically between rhinovirus-induced sniffles and pollen-induced seasonal nasal allergies.

But we ask, Are phenomenal experiences (qualia) analogous to sneezes?

References available at the Frontiers site

Neurological Basis for Lack of Empathy in Psychopaths


In this new study from Jean Decety (one of the preeminent scholars of empathy), he and his research team examined the ability of psychopaths (or those who score highly on the PCL-R) to experience empathy for others' pain.

When the most highly psychopathic participants imagined pain to themselves, their brains showed a typical neural response within the regions involved in empathy for pain, including the anterior insula, the anterior midcingulate cortex, somatosensory cortex, and the right amygdala. The increase in brain activity in these regions was unusually pronounced, suggesting that psychopathic people are sensitive to the thought of of their own pain.

But when participants imagined pain to others, these regions failed to become active in highly psychopathic subjects. The psychopaths - this is important - showed an increased response in the ventral striatum, an area known to be involved in pleasure, when imagining others in pain.

Interesting paper.

First up is a summary of the paper from Science Daily, followed by the whole paper from Frontiers in Human Neuroscience.

Full Citation:
Decety, J, Chen, C, Harenski, C, and Kiehl, KA. (2013, Sep 24). An fMRI study of affective perspective taking in individuals with psychopathy: Imagining another in pain does not evoke empathy. Frontiers in Human Neuroscience,  DOI: 10.3389/fnhum.2013.00489

Neurological Basis for Lack of Empathy in Psychopaths

Sep. 24, 2013 — When individuals with psychopathy imagine others in pain, brain areas necessary for feeling empathy and concern for others fail to become active and be connected to other important regions involved in affective processing and decision-making, reports a study published in the open-access journal Frontiers in Human Neuroscience.

This is response in the right amygdala across groups of low (L), medium (M) and high (H) psychopathy participants, when they adopted an imagine-self and an imagine-other affective perspective while viewing bodily injuries. Groupwise effects (bars at the bottom of the figure) are expanded to show the contribution of continuous PCL-R subscores on factor 1, which encompasses the emotional/interpersonal features of psychopathy. (Credit: Decety. J, Chenyi. C, Harenski. C, and Kiehl. K, A. Frontiers in Human Neuroscience, 2013.)
Psychopathy is a personality disorder characterized by a lack of empathy and remorse, shallow affect, glibness, manipulation and callousness. Previous research indicates that the rate of psychopathy in prisons is around 23%, greater than the average population which is around 1%.

To better understand the neurological basis of empathy dysfunction in psychopaths, neuroscientists used functional magnetic resonance imaging (fMRI) on the brains of 121 inmates of a medium-security prison in the USA.

Participants were shown visual scenarios illustrating physical pain, such as a finger caught between a door, or a toe caught under a heavy object. They were by turns invited to imagine that this accident happened to themselves, or somebody else. They were also shown control images that did not depict any painful situation, for example a hand on a doorknob.

Participants were assessed with the widely used PCL-R, a diagnostic tool to identify their degree of psychopathic tendencies. Based on this assessment, the participants were then divided in three groups of approximately 40 individuals each: highly, moderately, and weakly psychopathic.

When highly psychopathic participants imagined pain to themselves, they showed a typical neural response within the brain regions involved in empathy for pain, including the anterior insula, the anterior midcingulate cortex, somatosensory cortex, and the right amygdala. The increase in brain activity in these regions was unusually pronounced, suggesting that psychopathic people are sensitive to the thought of pain.

But when participants imagined pain to others, these regions failed to become active in high psychopaths. Moreover, psychopaths showed an increased response in the ventral striatum, an area known to be involved in pleasure, when imagining others in pain.

This atypical activation combined with a negative functional connectivity between the insula and the ventromedial prefrontal cortex may suggest that individuals with high scores on psychopathy actually enjoyed imagining pain inflicted on others and did not care for them. The ventromedial prefrontal cortex is a region that plays a critical role in empathetic decision-making, such as caring for the wellbeing of others.

Taken together, this atypical pattern of activation and effective connectivity associated with perspective taking manipulations may inform intervention programs in a domain where therapeutic pessimism is more the rule than the exception. Altered connectivity may constitute novel targets for intervention. Imagining oneself in pain or in distress may trigger a stronger affective reaction than imagining what another person would feel, and this could be used with some psychopaths in cognitive-behavior therapies as a kick-starting technique, write the authors.

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An fMRI study of affective perspective taking in individuals with psychopathy: imagining another in pain does not evoke empathy

Jean Decety [1,2], Chenyi Chen [1], Carla Harenski [3,4] and Kent A. Kiehl [3,4]
1. Department of Psychology, University of Chicago, Chicago, IL, USA
2. Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
3. Departments of Psychology and Neuroscience, University of New Mexico, Albuquerque, NM, USA
4. Mind Research Network, Albuquerque, NM, USA
While it is well established that individuals with psychopathy have a marked deficit in affective arousal, emotional empathy, and caring for the well-being of others, the extent to which perspective taking can elicit an emotional response has not yet been studied despite its potential application in rehabilitation. In healthy individuals, affective perspective taking has proven to be an effective means to elicit empathy and concern for others. To examine neural responses in individuals who vary in psychopathy during affective perspective taking, 121 incarcerated males, classified as high (n = 37; Hare psychopathy checklist-revised, PCL-R ≥ 30), intermediate (n = 44; PCL-R between 21 and 29), and low (n = 40; PCL-R ≤ 20) psychopaths, were scanned while viewing stimuli depicting bodily injuries and adopting an imagine-self and an imagine-other perspective. During the imagine-self perspective, participants with high psychopathy showed a typical response within the network involved in empathy for pain, including the anterior insula (aINS), anterior midcingulate cortex (aMCC), supplementary motor area (SMA), inferior frontal gyrus (IFG), somatosensory cortex, and right amygdala. Conversely, during the imagine-other perspective, psychopaths exhibited an atypical pattern of brain activation and effective connectivity seeded in the anterior insula and amygdala with the orbitofrontal cortex (OFC) and ventromedial prefrontal cortex (vmPFC). The response in the amygdala and insula was inversely correlated with PCL-R Factor 1 (interpersonal/affective) during the imagine-other perspective. In high psychopaths, scores on PCL-R Factor 1 predicted the neural response in ventral striatum when imagining others in pain. These patterns of brain activation and effective connectivity associated with differential perspective-taking provide a better understanding of empathy dysfunction in psychopathy, and have the potential to inform intervention programs for this complex clinical problem.

Empathy, the social-emotional response that is induced by the perception of another person's affective state, is a fundamental component of emotional experience, and plays a vital role in social interaction (Szalavitz and Perry, 2010). It is thought to be a proxy for prosocial behavior, guiding our social preferences and providing the affective and motivational base for moral development. Empathy is a deeply fundamental component of healthy co-existence whose absence is the hallmark of serious social-cognitive dysfunctions. Among the various psychopathologies marked by such deficits, psychopaths are characterized by a general lack of empathy and attenuated responding to emotional stimuli (Blair et al., 1997; Herpertz and Sass, 2000; Hare, 2003; Mahmut et al., 2008).

Empathy includes both cognitive and affective components (Decety and Jackson, 2004; Shamay-Tsoory, 2009; Singer and Lamm, 2009; Decety, 2011a; Zaki and Ochsner, 2012). The empathic arousal component, or emotion contagion, develops earlier than the cognitive component, and seems to be hardwired in the brain with deep evolutionary roots (Decety and Svetlova, 2012). In addition developmental research has found that concern for others emerges prior to the second year of life. In these studies, young children are not only moved by others' emotional states, but they make distress and pain attribution in conjunction with their comforting behavior and recognize what the target is distressed about (Roth-Hanania et al., 2011). Empathic arousal plays a fundamental role in generating the motivation to care and help another person in distress and depends only minimally on mindreading and perspective-taking capacities. In naturalistic studies, young children with high empathy disposition are more readily aroused vicariously by other' sadness, pain or distress, but at the same time possess greater capacities for emotion regulation so that their own negative arousal motivates rather than overwhelms their desire to alleviate the other's distress (Miller and Jansen op de Haar, 1997; Nichols et al., 2009). Empathic arousal is a bottom-up process in which the amygdala, hypothalamus, anterior insula (aINS), and orbitofrontal cortex (OFC) underlie rapid and prioritized processing of emotion signals sent by others (Decety and Svetlova, 2012). The cognitive component of empathy overlaps with the construct of perspective taking (Ruby and Decety, 2003). Perspective taking describes the ability to consciously put oneself into the mind of another individual and imagine what that person is thinking or feeling. The ability to adopt the perspective of another has previously been linked to social competence and social reasoning (Underwood and Moore, 1982). A substantial body of behavioral studies has documented that affective perspective taking is a powerful way to elicit empathy and concern for others (Batson et al., 1997; Decety and Hodges, 2006; Van Lange, 2008). For instance, Oswald (1996) found that affective perspective taking is more effective that cognitive perspective taking to evoke empathy and altruistic helping. Functional neuroimaging studies have consistently identified a circumscribed neural network reliably involved in perspective taking, which links the medial prefrontal cortex (mPFC), posterior superior temporal sulcus (pSTS/TPJ), and temporal poles/amygdala (Ruby and Decety, 2003, 2004; Hynes et al., 2006; Lawrence et al., 2006; Vollm et al., 2006; Rameson et al., 2011). Lesion studies have shown that affective perspective taking depends on intact medial and ventromedial prefrontal cortex (vmPFC) as well as regions in the posterior temporo-parietal cortex (Rankin et al., 2006). Importantly, neurological patients with damage to the vmPFC are found to exhibit a specific impairment in affective theory of mind tasks, sparing their cognitive empathy ability (Shamay-Tsoory et al., 2006).

In the empathy literature, a number of behavioral studies have documented a distinction between an imagine-self perspective and an imagine-other perspective (Batson, 2011). When adopting the former perspective, the central figure is oneself and one's own thoughts and feelings, and increases the salience of self-attributes. The imagining-other perspective involves an empathic attentional set in which the individual opens himself or herself in a deeply responsive way to the other person (Barrett-Lennard, 1981; Batson, 2009; Halpern, 2012). This distinction between imagine-self and imagine-other perspectives is also supported by functional neuroimaging research. For instance, when participants are asked to imagine being in physical pain themselves, they report greater pain intensity ratings and have greater activation in the aINS, aMCC, thalamus, and somatosensory cortex compared to imagining the same pain happening to another person (Jackson et al., 2006). The reverse contrast, imagining-other in pain vs. imagining oneself in pain, was associated with increased activity in the right pSTS and mPFC. Another study reported that self-perspective compared to other-perspective, when watching videos depicting facial expression of pain, led to higher activity in brain areas involved in the affective response to threat or pain, such as the amygdala, the insula, and the aMCC, as well as higher subjective ratings of personal distress (Lamm et al., 2007).

It is well established that individuals with psychopathy have limited aversive arousal to the distress and sadness cues of others (Van Honk and Schutter, 2006; Blair, 2007; Anderson and Kiehl, 2011), but spared theory of mind and cognitive perspective taking capacities (Blair, 2005; but see Brook and Kosson, 2012). However, it is not known if, when they adopt the affective perspective taking of another person, the extent to which the active contemplation of another's affective experience modulates brain circuits involved in affective processing.

Building on past research on perspective taking and empathy with healthy participants (Jackson et al., 2006; Lamm et al., 2007; Decety and Porges, 2011) as well as a recent study of pain empathy in criminal psychopaths (Decety et al., 2013), incarcerated offenders with different levels of psychopathy on Factors 1 and 2 underwent fMRI scanning while watching visual stimuli depicting physical pain. To elicit first- or third-person perspective taking (or imagine-self and imagine-other perspectives respectively) we explicitly manipulated the task instructions given to the participants in the scanner before each block, by asking them to think of the situations as either occurring to them or to someone else. Factor 1 describes a constellation of affective and interpersonal traits considered to be fundamental to the construct of psychopathy, which includes shallow affect, callous and lack of empathy, while Factor 2 reflects an unstable and antisocial lifestyle (Hare, 2003). Based on fMRI studies that used similar instructions and stimuli with healthy participants, it was predicted that imagine-self perspective would be associated with stronger visceromotor response in the aINS, somatosensory cortex and ACC than imagine-other perspective taking in participants scoring low on the psychopathy checklist-revised (PCL-R), especially Factor 1, because these regions have been associated with activation of representations of pain and of other negative emotions (Benuzzi et al., 2008). However, due to altered responding to affective stimuli in psychopathy, the opposite effect was expected for individuals scoring high on psychopathy PCL-R Factor 1. When instructed to adopt the perspective of another individual in physical pain, we hypothesized that individuals scoring high on the PCL-R would show a pronounced deficit in aINS and vmPFC hemodynamic response. This prediction is based on the large body of evidence from lesion studies and neuroimaging studies with healthy individuals as well as with psychopaths that show the importance of these regions in affective perspective taking and empathic concern (Rankin et al., 2003; Shamay-Tsoory et al., 2003; Kiehl, 2006; Gleichgerrcht et al., 2011; Rameson et al., 2011; Decety et al., 2012; Young and Dungan, 2012). The distinction between imagine-self and imagine-other is critical, as most studies suggest that psychopaths have spared mentalizing (cognitive empathy) abilities, and that the key deficit appears to relate to their lack of concern about the impact of their behavior on potential victims, rather than the inability to adopt a victim-centered perspective (Dolan and Fullam, 2004).

Finally, analyses of functional segregation can be complemented by effective connectivity analyses. Whereas standard contrast analyses create a “snapshot” of regional brain activity in response to a task or condition, functional connectivity analyses can identify patterns of communication between regions that contrast analyses may not detect [see Decety and Porges, 2011; Zaki et al. (2007) for such methods in empathy for pain]. Given the role of the insula in mapping internal states of bodily and subjective feelings (Craig, 2002) and that of the amygdala in motivational salience (Cunningham and Brosch, 2012), these two regions were selected as seeds for the functional connectivity analyses.

Materials and Methods


One hundred twenty-four adult right-handed males between the ages of 18 and 50, incarcerated in a medium-security North American correctional facility, volunteered for the study and provided informed consent to the procedures described here, which were approved by the Institutional Review Boards of the University of New Mexico and the University of Chicago. Participants underwent the PCL-R assessment, including file review and interview, conducted by trained research assistants under the supervision of Dr. Kiehl. Three participants were excluded for excessive movement in the scanner. Participants scoring 30 and above on the PCL-R were assigned to the high-psychopathy group (n = 37; age 32.5 ± 7.8; IQ 103.3 ± 13). To create the medium- and low-psychopathy groups, two groups of volunteers were matched to high scorers on age, race and ethnicity, IQ (WAIS), comorbidity for DSM-IV Axis II disorders, and past drug abuse and dependence, from pools of incarcerated volunteers scoring between 21 and 29 (n = 44; age 34.1 ± 7; IQ 97.3 ± 12.7), and volunteers scoring below 20 on the PCL-R (n = 40; age 34.6 ± 6.9; IQ 99.3 ± 14), respectively. Participants were paid for their participation in the study.

Exclusion Criteria 
Additional participants who volunteered for the study but met exclusion criteria were not included. Exclusion criteria were age younger than 18 years or older than 55, non-fluency in English, reading level lower than 4th grade, IQ score lower than 80, history of seizures, prior head injury with loss of consciousness > 30 min, current Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) Axis I diagnosis, lifetime history of a psychotic disorder or psychotic disorder in a first degree relative, or current alcohol or drug use.

Task Design

Participants in the MRI scanner were instructed to adopt either a self-perspective or an other-perspective while viewing visual stimuli depicting right hands and right feet of individuals in painful and non-painful situations [stimuli and procedure similar to Jackson et al. (2006)]. All stimuli showed familiar events that can happen in everyday life to people (e.g., pinching one's finger in a door, or catching one's toe under a heavy object). Various types (mechanical, thermal and pressure) of pain inflicted to the limbs were depicted. Neutral pictures showed limbs in visually similar situations without pain component (e.g., a hand on the handle of a drawer as opposed to being caught in the same drawer). Participants viewed 120 stimuli of pain and no pain. Each trial lasted 1.4 s and consisted of one of the pain scenarios, and the inter-stimuli intervals were jittered between 2.5 and 5.4 s. Timing parameters were generated using a genetic optimization algorithm (Wager and Nichols, 2003). Eye-tracking was monitored in the scanner to ensure that participants were paying attention to the stimuli.

Perspective Instructions 
A mixed block-event related fMRI design [24 blocks (12 imagine-self and 12 imagine-other) with a total 120 trials] was employed, in which instructions were given to the subjects at the beginning of each block, i.e., for the imagine-self perspective blocks (“Imagine that these situations are happening to you”), and for the imaging-other perspective blocks (“Imagine that these situations are happening to someone else”). A colored border (blue or yellow) around the stimuli was used to further cue participants about which perspective to employ. Block order was pseudo-randomized across participants. Painful and non-painful scenarios were randomized within each block. Post-scan debriefings were conducted to make sure that subjects did follow the perspective-taking instructions.

MRI Acquisition
Scanning was conducted on a 1.5 Tesla Siemens Magnetom Avanto mobile unit equipped with advanced SQ gradients and a twelve element head coil. Functional images were collected using an EPI gradient-echo pulse sequence with TR/TE = 2000/39 ms, flip angle = 90°, field of view = 240 × 240 mm, matrix = 64 × 64 cm, in-plane resolution = 3.4 × 3.4 mm, slice thickness = 5 mm, and 30 slices, full-brain coverage. Task presentation was implemented using the commercial software package E-Prime (Psychology Software Tools, Inc., Pittsburgh PA).

High-resolution T1-weighted structural MRI scans were acquired using a multiecho MPRAGE pulse sequence (repetition time = 2530 ms, echo times = 1.64 ms, 3.50 ms, 5.36 ms, 7.22 ms, inversion time = 1100 ms, flip angle = 7°, slice thickness = 1.3 mm, matrix size = 256 × 256) yielding 128 sagittal slices with an in-plane resolution of 1.0 × 1.0 mm.

Image Processing and Analysis 
Functional images were processed with SPM8 (Wellcome Department of Imaging Neuroscience, London, UK) in Matlab (Mathworks Inc., Sherborn, MA, USA). For each participant, functional data were realigned to the first image acquisition of the series and re-sampled to a voxel size of 2 × 2 × 2 mm3. Structural T1 images were co-registered to the mean functional image and segmented using the “New Segment” routine. A group-level structural template and individual flow fields were created using DARTEL, and the flow fields were in turn were used to spatially normalize functional images to standard MNI space. Data were smoothed with an 8 mm full-width at half maximum (FWHM) isotropic Gaussian kernel. Three participants were eliminated from further analysis due to issues related to movement or image quality, leaving N = 121 (n = 40, 47, 37 for low, intermediate, and high psychopathy, respectively).

Statistics were calculated at the first level using the general linear model. The design matrix included three regressors for each stimulus category (detailed above), representing the event onsets and their time and dispersion derivatives. Movement parameters from the realignment output were included as regressors of no interest. All participants were entered into a second-level pooled analysis, and full brain activations were thresholded voxelwise at p < 0.001 and with an extent threshold based on Gaussian random fields set to control the whole-brain family-wise error rate (FWE) at p < 0.05.

Second-level analyses were conducted by comparing the extremes of the sample distribution of PCL-R scores, and then as a continuous regressor using the entire sample. Participants with PCL-R total score at or above 30 were selected for the psychopathy group, while participants scoring at 20 or below comprised the incarcerated control group. For these analyses, regions of interest (ROIs) were defined using the MarsBar ROI toolbox. We focused on brain regions that were of maximal importance to the hypotheses under investigation, informed by the existing literature on empathy for pain in particular from a meta-analysis of 32 fMRI studies of empathy for pain (Lamm et al., 2011). MNI coordinates were selected from a previous fMRI study of empathy for pain in 80 male incarcerated participants (Decety et al., 2013). That study employed the same 1.5 mobile MRI scanner, and exposed the participants (from a different North American prison) to visual stimuli depicting bodily physical pain and videos of facial expressions of pain. ROI data are reported for significant contrast image peaks within 10 mm of these a priori coordinates (FWE-corrected p < 0.05). Beyond existing literature on the processing of empathy-inducing stimuli in healthy populations, there may be additional cortical or subcortical brain regions that contribute to abnormal processing of these regions in psychopathy. For instance, the ventral striatum has been found to be over-reactive in adolescents with conduct disorder as well as sexual sadists (Decety et al., 2009; Harenski et al., 2012). Therefore, coordinates for the ventral striatum were selected from a recent meta-analysis of fMRI studies (Diekhof et al., 2012).

To explore the extent to which results found in the groupwise analysis are driven by PCL-R Factor 1, Factor 2, or both, the regions reported above were tested for significant correlation with PCL-R factor scores. Corresponding t-values for sub-factor covariates within 10 mm of the ROIs above, if significant, were reported for each factor and task.

Functional Connectivity 
Effective connectivity using psychophysiological interaction (PPI, Gitelman et al., 2003) was used to examine the effective connectivity from the anterior insula during imagine-first and imagine-third perspective taking conditions. The right anterior insula was selected because of its role in affective processing and attention. This polysensory region is considered as the integral hub of a salience network, which assists target brain regions in the generation of appropriate behavioral responses to salient stimuli (Menon and Uddin, 2010). Under the hypothesis that high psychopathy may result from a systemic brain deficit which is reflected in abnormal functional-connectivity patterns while imagining pain, we compared effective connectivity in imagine-self perspective and imagine-other perspective conditions between low- and high-psychopathy groups. Because of the importance of the amygdala reactivity (or the lack thereof) in psychopathy, we also ran a similar PPI analysis seeded in the right amygdala.

The time series of the first eigenvariates of the BOLD signal were temporally filtered, mean corrected, and deconvolved to generate the time series of the neuronal signal for the source region—the insula—as the physiological variable in the PPI. The psychological variable represented the time course of the contrast between painful and non-painful trials. An additional regressor represented the interaction of the psychological and physiological factors. These regressors were convolved with the canonical HRF and entered into the regression model. The interaction term in the resulting SPM showed areas with selective connectivity to the insula across the psychological contrast of pain vs. no pain. The PPI analysis was performed for each subject, and the resulting images of contrast estimates were entered into a random-effects group analysis. Second-level analysis results are reported at a voxelwise statistical cutoff of p < 0.001 and a spatial extent threshold of k > 10 voxels.


The entire sample of 121 participants (regardless of their psychopathy level) showed significant neuro-hemodynamic increase in the network of regions involved in the actual experience of physical pain under the imagine-self trials (k > 10, p < 0.05, FWE corrected). This network includes the anterior insula (aINS), anterior midcingulate cortex (aMCC), supplementary motor area (SMA), inferior frontal gyrus (IFG), dorsomedial prefrontal cortex (dmPFC), mPFC, and somatosensory cortex, in both hemispheres (Table 1). In addition, signal change was detected in the left striatum and right amygdala.

Table 1. Imagine-self perspective.
When participants adopted the imagine-other perspective, a similar network was implicated, except for the right amygdala (Table 2). The only additional regions activated were the pSTS and mPFC in the right hemisphere. When imagine-other perspective was contrasted with imagine-self perspective, bilateral activation was detected in the superior parietal cortex (−23, −52, 60 and 27, −44, 59), superior frontal gyrus (−21, −7, 52 and 26, −8, 52), and dorsal striatum (−6, 4, 12 and 9, 4, 11). No significant signal increase was detected for the reverse contrast.
Table 2. Imagine-other perspective.

Region of Interest Analyses

Results from the ROI analyses are presented in Table 3. When participants with low scores on the PCL-R were compared with individuals scoring high on the PCL-R, the mPFC (−12, 52, 8) was activated during imagine-self perspective. A cluster of significant hemodynamic increase was found in the OFC. The opposite contrast (high psychopathy > low psychopathy) showed increased signal in the aMCC, SMA, right aINS, IFG, and right pSTS/TPJ. All participants showed significant response in the right amygdala during imagine-self perspective (Figure 1).

Table 3. Groupwise results and factor sub-score covariates for imagine-self and imagine-other perspectives.
Figure 1. Response in the right amygdala across groups of low (L), medium (M), and high (H) psychopathy (on total PCL-R scores) participants, when they adopted an imagine-self and an imagine-other affective perspective while viewing bodily injuries. Groupwise effects (bars at the bottom of the figure) are expanded to show the contribution of continuous PCL-R subscores on Factor 1, which encompasses the emotional/interpersonal features of psychopathy.
During the imagine-other perspective, individuals with low scores on the PCL-R compared with individuals with high scores on the PCL-R, showed greater signal change in the SMA, right mPFC, intraparietal sulcus, precentral gyrus, and parahippocampal gyrus/amygdala, pSTS, dorsal aINS and dorsal ACC. In participants with high scores on the PCL-R, the imagine-other perspective was associated with greater activation in the dlPFC and ventral striatum (p < 0.001), when compared to low-scoring incarcerated controls.

Correlations Between PCL-R Scores and ROIs

The hemodynamic response in the aINS was significantly greater in individuals scoring high on psychopathy (total PCL-R score) during imagine-self perspective, and the reverse was found for imagine-other perspective (Figure 2). Factor 2 positively correlated with the activity in aINS during imagine-self perspective (r = 0.372, p = 0.016), whereas it negatively correlated with aINS activity during imagine-other perspective (r = −0.254, p = 0.01). Factor 1 was negatively correlated with response in aINS during third-person perspective (r = −0.272, p = 0.01). Activity in the dmPFC was negatively associated with both Factor 1 (r = −0.24, p < 0.01) and Factor 2 (r = −0.237, p = 0.01) during imagine-self perspective. The hemodynamic response in the dlPFC was positively correlated with both Factor 1 (r = 0.288, p < 0.01) and Factor 2 (r = 0.274, p < 0.01) during imagine-other perspective. The response in the ventral striatum during imagine-other perspective significantly correlated with scores on Factor 1 (r = 0.212, p < 0.02, see Figure 3). Finally, response in the right amygdala (26, 2, −18) showed a negative correlation with Factor 1 (r = −0.258, p = 0.04) during imagine-other perspective. No significant correlation was found in imagine-self perspective with either Factors 1 and 2. See Table 3 for a complete list of results.

Figure 2. Response in the right anterior insula across groups (L, low; M, medium; H, high on total PCL-R scores) during imagine-self and imagine-other perspectives in participants viewing bodily injuries. Groupwise effects seen in (bar graph) are expanded to show the contribution of Factors 1 and 2 from PCL-R subscores.

Figure 3. Response in the right ventral striatum in participants scoring high on the PCL-R (≥30) when they imagined another person in pain, and correlation with scores on Factor 1.

Effective Connectivity Analyses

Functional connectivity analyses seeded in the anterior insula revealed distinct patterns in functional coupling between the low- and high-psychopathy groups. During imagine-self perspective, individuals scoring low on the PCL-R showed a negative connectivity between the aINS and the hippocampus and the OFC (Figure 4). In the high psychopathy group, there was only significant functional connectivity between the aINS and the right pSTS. During imagine-other perspective, low-psychopathy participants had significant effective connectivity between the aINS and posterior cingulate cortex and dlPFC (Figure 5). In high-scoring participants, negative connectivity was found between aINS and the right OFC and posterior cingulate cortex.

Figure 4. Functional connectivity analyses, seeded in the anterior insula in participants with the lowest scores on the PCL-R (≤20) and participants with the highest scores on the PCL-R (≥30) during imagine-self perspective.
Figure 5. Functional connectivity analyses, seeded in the anterior insula in participants with the lowest scores on the PCL-R and participants with the highest scores on the PCL-R (>30) during imagine-other perspective.  
Functional connectivity analyses seeded in the right amygdala showed distinct patterns of co-variations depending on the perspective adopted in controls vs. psychopaths. During imagine-self perspective, controls exhibited a significant negative coupling between the amygdala and ventral and mPFC, while participants with high scores on the PCL-R showed a positive coupling with the pSTS/TPJ, ventral and mPFC, and dlPFC (Figure 6). During imagine-other perspective, the reverse pattern of functional connectivity was observed. Low psychopathy was associated with greater positive coupling with the OFC, whereas the high psychopathy showed a negative coupling with the OFC and dlPFC (Figure 7).
Figure 6. Functional connectivity analyses, seeded in the right amygdala in participants with the lowest scores on the PCL-R (≤20) and participants with the highest scores on the PCL-R (≥30) during imagine-self perspective.
Figure 7. Functional connectivity analyses, seeded in the right amygdala in participants with the lowest scores on the PCL-R and participants with the highest scores on the PCL-R (>30) during imagine-other perspective.


Perspective taking while observing or imagining other's feelings has been described as an empathic attentional set that facilitates other-oriented emotional and motivational responses congruent with the perceived welfare of that person (Van Lange, 2008; Batson, 2012). To examine the extent to which affective reactions can be evoked or modulated by perspective taking in individuals with psychopathy, incarcerated participants with different levels on the PCL-R were scanned while viewing stimuli depicting bodily injuries and instructed to imagine these situations as either happening to themselves or to someone else.

At the group level, collapsed across the PCL-R scores (n = 121), both conditions of imagine-self and imagine-other in pain were associated with signal increase in brain regions implicated in the perception of pain and distress, when viewing body parts suffering injuries or facial expressions of pain (Jackson et al., 2006; Lamm et al., 2007, 2011; Decety and Porges, 2011; Bruneau et al., 2012). In healthy participants, activity in this network, which includes the aINS, thalamus, aMCC, IFG, and somatosensory cortex, has been interpreted as a form of somatosensory resonance, or shared neural representations with the pain of others, providing an implicit intersubjective affective knowledge (Decety and Jackson, 2004; Singer and Decety, 2011; Zaki and Ochsner, 2012). However, these vicariously instigated activations of the so-called “pain matrix” are not specific to the sensory qualities of pain, but instead are associated with more general survival mechanisms such as aversion and withdrawal when exposed to danger and threat (Benuzzi et al., 2008; Decety, 2010). In fact, based on a systematic review of electroencephalographic and functional MRI studies that examined neural response triggered by nociceptive stimuli, activity of this cortical network seems to reflect a system involved in detecting, processing, and reacting to the occurrence of salient sensory events regardless of the sensory channel through which these events are conveyed (Legrain et al., 2011).

Interestingly and quite surprisingly, the hemodynamic response in aINS and aMCC, regions considered as pivotal in the affective component of empathy, was highest in high psychopaths during imagine-self perspective, replicating the results of a recent study of pain empathy in criminal psychopaths that reported greater activation in the insula, which was positively correlated with scores on both PCL-R factors 1 and 2 (Decety et al., 2013) (Figure 2). The aINS and aMCC are the two regions that have been most reliably activated in fMRI studies of pain empathy with healthy subjects (Valentini, 2010; Lamm et al., 2011). This finding does not support the view that psychopaths do not resonate when exposed aversive stimuli such as pain, or at least they are not totally blunted when they take a first-person perspective. This finding also raises an interesting question: whether or not sensorimotor resonance (underpinned by the mirror neuron system involved in perception-action coupling) is the mechanism that facilitates emotion contagion and empathic arousal. Psychopaths are characterized by a lack of affective empathy, but there is little evidence that they show a deficit in sensorimotor resonance (Blair, 2011; Decety, 2011b). For instance, a transcranial magnetic stimulation study demonstrated increased sensorimotor resonance to painful hand-pricking videos in college students scoring high on the psychopathic personality inventory (PPI), as compared to students who score low on the PPI (Fecteau et al., 2008). Juvenile incarcerated psychopaths showed greater sensorimotor resonance as measured by EEG and suppression of the mu rhythm when they viewed visual stimuli depicting people being physically injured, despite a lack of affective arousal to the same stimuli as measured by the N120 ERP component (Cheng et al., 2012). Children with aggressive conduct disorder and psychopathic tendencies and incarcerated psychopaths exhibit typical (Marsh et al., 2013) or even stronger activation in the somatosensory cortex than control participants when they watched scenarios depicting people in pain (Decety et al., 2009, 2013), all of which does not suggest an impairment in somatosensory responses to others' pain. Our finding that participants scoring high on psychopathy activate the pain network during imagine-self perspective fits well with studies showing that individuals with psychopathy may up-regulate emotional (at least for fear) processing when attention to salient stimuli is particularly engaged (Newman and Lorenz, 2003), and this may be the case for pain.

Furthermore, and as expected, the lower the participants scored on Factors 1 and 2 of the PCL-R, the higher the activity in the aINS during imaging-other perspective. This indicates that more vicarious experience was elicited in control participants when they imagined another in pain, and the opposite pattern (low activation in the aINS) was found in participants who scored high on psychopathy. In addition, functional connectivity analyses, seeded in the right aINS during imagine-self perspective negatively co-varied with activation in the hippocampal gyrus and OFC in control participants (low on psychopathy), and was positively coupled with the right pSTS region in psychopaths. During imagine-other perspective, the aINS positively covaried with activity in the right dlPFC and PCC in controls, and negatively with the OFC and PCC in high psychopaths. Altogether, the hemodynamic response in the aINS shows distinct profiles of activation depending on whether participants adopted an imagine-self or imagine-other perspective taking. These results from the imagine-other perspective condition support two recent functional neuroimaging studies in children with conduct disorder (Lockwood et al., 2013; Marsh et al., 2013). Both studies reported a reduced response in the aINS and ACC when the children viewed pictures of others in pain. Furthermore, a negative association between callous traits and the aINS/ACC was found. The fact that individuals with high scores on the PCL-R showed a reduced response when imagining the pain of another suggests a specific deficit in affective processing in a region considered as a critical hub to integrate salient stimuli and events with visceral and autonomic information (Menon and Uddin, 2010).

Signal change in the right amygdala was detected during imagine-self perspective in all participants, and during imagine-other perspective in controls. The hemodynamic response in the amygdala was inversely correlated with individual scores on PCL-R Factor 1 during imagine-other perspective. This is in line with most neuroimaging studies of psychopathy that documented reduced amygdala response to fearful and aversive stimuli (Marsh and Blair, 2008; Harenski et al., 2009). This finding is consistent with the notion that psychopaths lack the ability to be responsive to, or aroused by distress cues, and therefore are not sensitive to signs of vulnerability. A recent fMRI study in youths with psychopathic traits also reported reduction in the amygdala and insula when they imagined physical injuries to others, but not their own pain (Marsh et al., 2013).

It is very interesting to note that imagine-self perspective was associated with activity in the amygdala in psychopaths when they focus on their own affective reaction. While most studies report a reduced response in the amygdala in psychopaths, an fMRI study conducted on a small number psychopaths and controls found increased activation in the right amygdala in the psychopath group with respect to controls when viewing negative IAPS pictures (Müller et al., 2003), indicating that the role of the amygdala in psychopathy may not be straightforward, nor its lateralization. A meta-analysis of 67 neuroimaging studies reported that the lateralization of activation in the amygdala was explained by differences in temporal dynamics and/or habituation rates, namely a short-duration response in the right amygdala and a more sustained one in the left (Sergerie et al., 2008). It is however difficult to interpret the amygdala activation during imagine-self perspective further without a more fine-grain analysis of amygdala sub-nuclei and their anatomical connectivity, which helps determine their function (Saygin et al., 2011). With this caveat in mind, it is important to note that functional connectivity analyses, seeded in the right amygdala, demonstrated very different patterns of connectivity depending on the perspective taking strategy (imagine-self vs. imagine-other) and participants (low vs. high psychopaths). The response in the right amygdala was negatively coupled with activity in the OFC in controls and positively correlated with the OFC and dlPFC and pSTS in high psychopathy during imagine-self perspective (Figure 3). The exact reverse functional connectivity was detected during imagine-other perspective (Figure 4). This finding specifically points to amygdala–OFC interactions as being an important neural mechanism that underlies the outcome of perspective taking in psychopathy. It seems to indicate that during imagine-self perspective, individuals with psychopathy elicit amygdala-OFC coupling but fail to do so during imagine-other perspective. Such a failure to recruit the OFC during third-person perspective taking supports the dysfunction of this neural pathway in response to distress cues of others in psychopaths. It has been argued that the integrated functioning of this circuit enables the basics of care-based morality, and that dysfunction within these regions in psychopathy means that reinforcement-based decision making, including moral decision making, and care base morality is impaired (Blair, 2007; Shamay-Tsoory et al., 2010; Marsh et al., 2011). One theory of the origin of empathic deficits in psychopathy is the failure during development to form stimulus-reinforcement associations connecting harmful or aggressive actions with the pain and distress of others (Kiehl, 2006; Glenn and Raine, 2009). It is worth mentioning that psychopathic traits are not exclusively associated with amygdala hyporeactivity. A study that included 200 young adults with self-reported psychopathy assessment found that amygdala reactivity to fearful facial expressions is negatively associated with the interpersonal facet of psychopathy, whereas reactivity to angry expressions is positively associated with the lifestyle facet (Carré et al., 2013).

Finally, the increase of activity in the ventral striatum during imagine-other perspective in psychopaths, which was predicted by their scores on Factor 1 of the PCL-R, is an intriguing finding. This could suggest that psychopaths not only experience blunted vicariously arousal to others' pain and reduced feelings of concern when adopting their perspective, but they may in fact find the distress of others pleasurable or positively arousing. The ventral striatum is selectively recruited during reward anticipation in healthy participants (Diekhof et al., 2012 for a meta-analysis). In adolescents with conduct disorder and psychopathic tendencies, an fMRI study found activation of the ventral striatum during the perception of pain in others (Decety et al., 2009). In healthy subjects, the ventral striatum has been associated with experiencing pleasure at others' misfortune (e.g., Dvash et al., 2010; Cikara et al., 2011). It has been suggested that neurons in the ventral striatum have access to central representations of reward and thereby participate in the processing of information underlying the motivational control of goal-directed behavior (Schultz et al., 1992). Activation of the ventral striatum while imaging another in physical pain was correlated with PCL-R Factor 1, and not Factor 2. Abnormalities in the ventral and dorsal striatum are considered to play a key role in the etiology of psychopathic traits (Buckholtz et al., 2010; Carré et al., 2013).


There is general consensus among theorists that the ability to adopt and entertain the psychological perspective of others has a number of important consequences, including empathic concern (e.g., Blair, 2007; Batson, 2009; Decety and Svetlova, 2012). Adopting the perspective of another is a powerful way to place oneself in the situation or emotional state of that person (Batson, 2011). Our results demonstrate that while individuals with psychopathy exhibited a strong response in pain-affective brain regions when taking an imagine-self perspective, they failed to recruit the neural circuits that are were activated in controls during an imagine-other perspective, and that may contribute to lack of empathic concern. Finally, this atypical pattern of activation and effective connectivity associated with perspective taking manipulations may inform intervention programs in a domain where therapeutic pessimism is more the rule than the exception (Salekin, 2002). Altered connectivity may constitute novel therapeutic targets for interventions. Both cognitive and pharmacotherapy interventions may restore connectivity patterns (Crocker et al., 2013). Imagining oneself in pain or in distress may trigger a stronger affective reaction than imagining what another person would feel, and this could be used with some psychopaths in cognitive-behavior therapies as a kick-starting technique for eliciting emotional tagging of different outcomes of interpersonal situations.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This study was supported by NIMH R01 grant 1R01MH087525-01A2 (J. Decety, PI) and by NIMH R01 grant MH070539-01 and NIDA 1R01DA026505-01A1 (K. Kiehl, PI). Dr. J. Decety, Dr. C. Chen, Dr. C. Harenski, and Dr. K. Kiehl have no conflicts of interest to disclose. Dr. Decety takes full responsibility for the integrity of the data and the accuracy of the data analysis. All authors had full access to all the data in the study.