Emotional and Cognitive Empathy in Caregivers of People With Neurodegenerative Disease: Relationships With Caregiver Mental Health

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                               Empirical Article                                                                                 PSYCHOLOGICAL SCIENCE
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                               Emotional and Cognitive Empathy                                                                   1­–18
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                                                                                                                                  DOI: 10.1177/2167702620974368
                                                                                                                                  https://doi.org/10.1177/2167702620974368

                               Neurodegenerative Disease: Relationships                                                           www.psychologicalscience.org/CPS

                               With Caregiver Mental Health

                               Alice Y. Hua , Jenna L. Wells, Casey L. Brown, and
                               Robert W. Levenson
                               Department of Psychology, University of California, Berkeley

                               Abstract
                               Caregiving for a person with dementia or neurodegenerative disease is associated with increased rates of depression
                               and anxiety. As the population ages and dementia prevalence increases worldwide, mental health problems related
                               to dementia caregiving will become an even more pressing public health concern. In the present study, we assessed
                               emotional empathy (physiological, behavioral, and self-reported emotional responses to a film depicting others
                               suffering) and two measures of cognitive empathy (identifying the primary emotion experienced by another person
                               and providing continuous ratings of the valence of another person’s changing emotions) in relation to mental health
                               (standard questionnaires) in 78 caregivers of people with dementia or neurodegenerative disease. Greater emotional
                               empathy (self-reported emotional responses) was associated with worse mental health even after accounting for known
                               risk factors. Neither measure of cognitive empathy was associated with mental health. A relationship between high
                               levels of emotional empathy and poor mental health in caregivers suggests possible risk indicators and intervention
                               targets.

                               Keywords
                               depression, anxiety, mental health, caregiving, emotional empathy, cognitive empathy, dementia, neurodegenerative
                               disease

                               Received 5/18/20; Revision accepted 9/9/20

                               Older adults generally have lower levels of mental             individuals between the ages of 75 and 84 have
                               health problems, such as depression and anxiety, com-          Alzheimer’s disease, the most common form of demen-
                               pared with younger adults (Fiske et al., 2009; Schuurmans      tia; Herbert et al., 2013), mental health problems associ-
                               & van Balkom, 2011). One exception to this pattern is          ated with caregiving will be a growing major public
                               found in individuals providing care for a person with          health issue with increasing implications for clinical
                               dementia or neurodegenerative disease (hereafter               psychology.
                               referred to as person or people with dementia). Familial           Although, as a group, familial caregivers of people
                               caregivers of people with dementia manifest up to four-        with dementia are highly vulnerable to declining mental
                               fold increases in rates of depression and threefold            health, individual caregivers differ considerably.
                               increases in seeking treatment for anxiety compared with       Whereas some find caregiving to be a highly rewarding
                               same-aged noncaregiving adults (Brodaty & Donkin,              experience, including feeling enhanced spirituality and
                               2009; Coope et al., 1995; Cuijpers, 2005; Kolanowski
                               et al., 2004). With the worldwide “graying” of the popu-
                                                                                              Corresponding Author:
                               lation (by 2050, 11.4% of the U.S. population will be          Robert W. Levenson, Department of Psychology, University of
                               older than 75; Kawas & Brookmeyer, 2001) and the               California, Berkeley
                               increasing prevalence of dementia with age (44% of             E-mail: boblev@berkeley.edu
2                                                                                                                Hua et al.

a greater sense of fulfillment and purpose (­Abdollahpour      However, familial caregivers’ emotional experiences or
et al., 2018), others struggle with the increased burden       emotional functioning (which we conceptualize as
and strain of caregiving, including being exposed to the       emotional reactivity, emotion regulation, and empathy;
suffering of a loved one (Monin & Schulz, 2009;                Levenson et al., 2008) have largely not been investi-
Richardson et al., 2013). This variation among caregivers      gated as a basis for predicting adverse caregiver mental
underscores the importance of identifying factors that are     health outcomes. Because of the importance of one’s
associated with declining mental health in caregivers.         own emotional functioning in relation to one’s mental
Such factors can help identify caregivers who are at           health (Gross et al., 2019), we sought to examine this
heightened risk for developing mental health problems          relationship in familial caregivers.
and suggest potential intervention targets to prevent new         Studies that have examined the relationship between
mental health problems and reduce the severity of exist-       caregiver emotional functioning and their mental health
ing ones.                                                      suggest that negative emotional reactivity and poor
                                                               emotion regulation relate to negative caregiver out-
                                                               comes. For example, caregiver propensity to experience
Vulnerabilities to Poor Mental Health
                                                               negative emotions or a negative attitude toward caregiv-
in Caregivers                                                  ing relates to worse psychological outcomes (Safavi
Studies on individual differences in the negative effects      et al., 2017; Shim et al., 2012). We have found that
of familial caregiving have identified specific character-     caregivers who have the short-short variant in the sero-
istics belonging to people with dementia. An emerging          tonin transporter gene, which is thought to be related
consensus suggests that greater severity of the behavioral     to greater emotional reactivity (Belsky & Pluess, 2009;
and psychological symptoms (including emotion-related          Gyurak et al., 2013; Haase et al., 2015), show a relation-
behaviors such as agitation and apathy) of people with         ship between low empathy in the person with dementia
dementia are worse for caregiver health than cognitive         and low psychological well-being in the caregiver,
(e.g., memory loss) or functional (e.g., loss of mobility)     whereas others who do not have this variant do not
symptoms (Ornstein & Gaugler, 2012; Schulz et al., 1995).      show such an association (Wells et al., 2019). Moreover,
In our research, for example, we have found that declines      work from our laboratory has shown that poor emotion-
in emotional functioning in people with dementia, includ-      regulation ability in caregivers relates to their having
ing reduced empathy (Brown et al., 2018; Brown, Wells,         higher levels of anxiety (Wells et al., 2020). In the present
et al., 2020), altered emotional reactivity (Chen et al.,      study, we focused on empathy; despite the strong evi-
2017; Lwi et al., 2018), and diminished emotion regula-        dence for the important role played by low empathy in
tion (Otero & Levenson, 2017), are associated with             the person with dementia in poor caregiver mental
poorer caregiver health and well-being. Together, these        health (Brown et al., 2018; Hsieh et al., 2013), empathy
findings suggest that declining emotional functioning in       in familial caregivers in relation to their own mental
people with dementia is an important risk factor for poor      health has not been well studied.
mental health outcomes in caregivers.
    In addition to these risk factors related to people with   Empathy as a Risk Factor for Poor
dementia, a number of demographic, financial, and social
variables have also been linked to poor health in familial
                                                               Caregiver Mental Health
caregivers. Meta-analyses suggest that being (a) the           The ability to know, feel, and respond appropriately to
spouse of a person with dementia, (b) a woman (i.e.,           what others are feeling (Levenson & Ruef, 1992) is often
experiencing sexism), (c) a member of a systemically           referred to as empathy. Empathy can be broken down
oppressed race (i.e., experiencing racism), (d) low in         into emotional and cognitive facets. Emotional empathy
socioeconomic status (i.e., having fewer resources, expe-      refers to the ability to feel or share others’ emotional
riencing classism), and (e) more socially isolated are all     states, whereas cognitive empathy refers to the ability
associated with negative outcomes in caregivers (Brodaty       to know or understand another person’s emotions
& Donkin, 2009; Schulz et al., 1995; Young et al., 2020).      (Decety & Jackson, 2006; Preston & de Waal, 2002;
    Many studies have robustly characterized the nega-         Singer & Lamm, 2009; Zaki et al., 2009).
tive psychological effects of caregiving experienced by           Emotional and cognitive empathy are both beneficial
health care providers and family members of people             in many contexts (Morelli et al., 2017; Wei et al., 2011).
with dementia (e.g., Kokkonen et al., 2014; Schulz             However, in the context of providing care for a loved
et al., 2020) and characterized familial caregivers’           one undergoing a distressing life experience, these fac-
­emotion-related experiences during caregiving (e.g.,          ets of empathy may have quite different relationships
 compassion fatigue, coping strategies to reduce stress;       with caregiver mental health (Lee et al., 2001). When a
 Day & Anderson, 2011; van Knippenberg et al., 2018).          person with dementia experiences distress, a caregiver
Cognitive Empathy                                                                                                   3

with high emotional empathy may feel or share the            behavior, self-reported emotional experience) to view-
person’s distress, which can lead to the caregiver being     ing others who are experiencing powerful negative
overwhelmed by the caregiver’s own sense of distress,        emotions, such as emotional pain or distress (Hein &
making high emotional empathy problematic for care-          Singer, 2008; Lamm et al., 2011; Marsh, 2018). Labora-
givers by increasing their distress vicariously. In con-     tory assessments of cognitive empathy typically ask
trast, a caregiver with high cognitive empathy may           participants to label or track others’ emotions, and
accurately know or understand that the person with           accuracy is judged against an external criterion, such
dementia has a higher need for care, which can lead          as ratings by the target person or a panel of experts
to more effective ways of helping the person in their        (Goodkind et al., 2012; Ickes, 1997; Levenson & Ruef,
care and to reduced burden for caregivers.                   1992; Ruef & Levenson, 2007; Zaki et al., 2009). Whereas
   In line with these ideas, professional health care        these laboratory assessments use forms of self-report
providers with greater emotional empathy are espe-           responses (e.g., ratings of emotional experience in
cially prone to share others’ distress. When exposed to      response to viewing others suffering or reporting on
high levels of negative emotions in stressful environ-       what they think someone else feels), these self-report
ments, providers can develop empathy burnout and             empathy measures capture a more immediate feeling
emotional exhaustion (Decety & Fotopoulou, 2014;             or understanding of others’ emotional states. Such
Figley, 2011). On the other hand, greater cognitive          responses may be less susceptible to variation in meta-
empathy (operationalized as perspective-taking or            cognitive insight about empathic abilities compared
understanding others’ emotions using trait empathy           with traditional trait empathy measures (Murphy &
measures, such as the Interpersonal Reactivity Index or      Lilienfeld, 2019). Furthermore, because heightened
Jefferson Scale of Empathy; Davis, 1983; Hojat et al.,       negative emotional reactivity has been independently
2001) in professional health care providers (e.g., physi-    associated with poor caregiver mental health (Safavi
cians, nurses) has been associated with beneficial           et al., 2017) and because greater emotional reactivity
patient outcomes (patient satisfaction, control of hemo-     may help individuals feel or understand others’ emo-
globin A1C in diabetic patients; Blatt et al., 2010; Hojat   tional states (Rueckert et al., 2011), accounting for the
et al., 2011) and provider outcomes (compassion satis-       potential influence of caregivers’ emotional reactivity
faction; Gleichgerrcht & Decety, 2013). These tensions       to a negative or aversive stimulus will help determine
between different kinds of empathy are also found in         whether findings are specific to empathy. Applying
early psychotherapy theory and research (Rogers, 1951,       these approaches could greatly increase understanding
1957), in which effective psychotherapists were thought      of the role that caregiver empathy plays in accounting
to be able to understand clients’ emotional states accu-     for individual differences in caregiver mental health.
rately without becoming enmeshed and emotionally
overinvolved.
                                                             The Present Study
   Despite these provocative insights from previous
work, researchers have rarely examined familial care-        In the present study, we aimed to understand the rela-
givers’ emotional and cognitive empathy in relation to       tionships between laboratory-based measures of care-
their own mental health. One study found that higher         giver emotional and cognitive empathy and caregiver
emotional empathy in caregivers was associated with          mental health measured using standard questionnaires.
lower life satisfaction and that higher cognitive empathy    We measured caregivers’ general ability to feel or share
was associated with greater life satisfaction (Lee et al.,   others’ emotion states (emotional empathy) and to
2001). In another study ( Jüttenet al., 2019), higher emo-   know or understand others’ emotional states (cognitive
tional empathy in caregivers was associated with greater     empathy). Emotional empathy was assessed by measur-
anxiety; cognitive empathy was associated with depres-       ing physiological, behavioral, and self-reported emo-
sion in a curvilinear fashion, such that highest levels      tional responses to a film depicting others suffering.
of cognitive empathy predicted the lowest levels of          Cognitive empathy was assessed both by having par-
depression.                                                  ticipants identify the primary emotion experienced by
   In these two prior studies of the relationship between    a target character in a film and by having them provide
caregiver empathy and mental health, empathy was             continuous ratings of the valence of a person’s chang-
measured using self-report inventories, which can be         ing emotions. To control for individual differences in
susceptible to several forms of bias (Levenson & Ruef,       emotional reactivity, we measured caregivers’ self-
1992; Murphy & Lilienfeld, 2019). To our knowledge,          reported emotional response to an aversive emotional
no prior studies of caregiver empathy and mental health      stimulus (a sudden, unexpected loud noise) and used
have used laboratory-based measures of caregiver             it as a covariate in our analyses. By examining labora-
empathy. Laboratory assessments of emotional empathy         tory measures of emotional and cognitive empathy in
typically measure participant responses (physiology,         relation to caregiver mental health, our study has the
4                                                                                                             Hua et al.

potential to further caregiving research by identifying      educated (71.7% with at least 16 years of education).
a specific aspect of caregiver emotional functioning that    At UCSF, people with dementia were diagnosed accord-
may place caregivers at greater risk for developing poor     ing to consensus criteria (Armstrong et al., 2013; Budka
mental health.                                               et al., 1995; Gorno-Tempini et al., 2011; Klockgether,
   Our primary hypothesis was that greater emotional         2010; Litvan et al., 1996; McKeith, 2004; McKhann et al.,
empathy in caregivers would be associated with worse         2011; Rascovsky et al., 2011). The sample of 78 people
caregiver mental health. We reasoned that caregivers         with dementia included (a) 33 with frontotemporal
with greater emotional responses to the suffering of         dementia (FTD), which includes three clinical syn-
others in our laboratory task would also have greater        dromes that affect socioemotional and language func-
emotional responses to the declines and suffering of         tioning (16 behavioral variant FTD, nine nonfluent
the person with dementia who is in their care. We rea-       variant primary progressive aphasia, eight semantic vari-
soned that greater sensitivity to the suffering of others,   ant primary progressive aphasia); (b) 11 with Alzheimer’s
combined with the other stressors and burdens involved       disease (AD), which predominantly affects memory
in caregiving, would create a fertile breeding ground        functioning; (c) 25 with diagnoses that were character-
for symptoms of anxiety and depression. Because cog-         ized by motor symptoms, including nine with cortico-
nitive empathy does not engender this kind of addi-          basal syndrome, two with dementia with Lewy body
tional suffering, we did not expect greater cognitive        disease, one with Parkinson’s disease, one with prion
empathy in our laboratory tasks to be related to worse       disease, 11 with progressive supranuclear palsy, and
caregiver mental health.                                     one with spinocerebellar ataxia; and (d) nine at risk for
   We did not have a priori hypotheses as to which           developing dementia, including five with mild cognitive
aspect of emotional empathy would be most strongly           impairment (MCI) and four relatives of a person with
associated with caregiver mental health. Because we          FTD. For more details on demographics of caregivers
conceptualize emotional responses as having physiologi-      and people with dementia, see Table 1.
cal, behavioral, and self-report components (Levenson
et al., 2008) and because laboratory measures of emo-
tional empathy have not yet been examined in relation
                                                             Procedure
to caregiver mental health, we wanted to determine           Upon arrival at UCB, all participants (people with
which aspect of emotional empathy would be most              dementia and caregivers) reviewed the procedures for
strongly related to caregiver mental health.                 the day and completed the consent forms. People with
                                                             dementia and caregivers were then seated in separate
                                                             rooms, and noninvasive physiological sensors (see more
Method                                                       details below) were attached to participants to monitor
                                                             their physiological responses. Participants sat in a chair
Participants                                                 facing a 21-in. color monitor. Video recordings of par-
Seventy-eight people with dementia and their familial        ticipants’ heads and torsos were obtained using a
or close caregivers participated in a study of emotional     remote-controlled camera that was partially hidden from
functioning at the Berkeley Psychophysiology Labora-         view. Participants completed a daylong laboratory ses-
tory at the University of California, Berkeley (UCB).        sion designed to provide a comprehensive assessment
Participants were recruited at the Memory and Aging          of multiple aspects of emotional functioning, including
Center at the University of California, San Francisco        emotion recognition, emotional reactivity, and emotion
(UCSF), where individuals with dementia or neurode-          regulation (Levenson et al., 2008).
generative disease underwent a full diagnostic evalua-          In the present study, we focused on caregiver data
tion, including neurological, neuropsychological, and        from four specific tasks (described below), including
neuroimaging assessment. At the UCSF assessment, care-       assessments of cognitive empathy (two tasks), emo-
givers were told about the Berkeley study and, if they       tional empathy, and emotional reactivity.
expressed interest, were subsequently contacted to
schedule a laboratory session. All participants, or their
                                                             Apparatus and measures
legal guardians when appropriate, provided consent for
their participation. All procedures for obtaining consent    Rating dial. The rating dial (Ruef & Levenson, 2007)
and all study procedures were approved by the Com-           consisted of a small metal box with a knob and attached
mittee for the Protection of Human Subjects at UCB.          pointer that rotated through a 180° semicircle. The semi-
   Caregivers were 64.5 years old on average, predomi-       circle was divided into nine equal divisions labeled with
nantly spouses of people with dementia seen at UCSF          descriptors of “very bad” (shown with a schematic frown-
(92.3%), women (60.3%), White (83.3%), and highly            ing face) at the far left, “neutral” (shown with a schematic
Cognitive Empathy                                                                                                                 5

             Table 1. Sociodemographic Characteristics and Clinical Variables

             Statistic                                                          PWDs                        Caregivers
             Age (years)                                                M = 62.60 (SD = 8.69)         M = 64.52 (SD = 9.26)
             Gender (% women)                                                   43.3                          60.3
             Race/ethnicity (n)
               Native American/Alaska Native                                        2                             0
               East or Southeast Asian/Asian American                               4                             5
               Black/African American/Afro-Caribbean                                1                             1
               Latine/Chicane/Hispanic                                              4                             3
               Multiracial                                                          3                             4
               Native Hawaiian/Pacific Islander                                     1                             0
               White                                                               63                            65
             Caregiver education (n)
               High school                                                         —                              7
               2-year college                                                      —                             15
               4-year college                                                      —                             29
               Master’s degree                                                     —                             15
               PhD, MD, or other professional degree                               —                             12
             Caregivers
               Relationship to the PWD (% spouse)                                  —                         92.3%
               Severity of anxiety symptoms (BAI)                                  —                  M = 7.06 (SD = 7.60)
               Severity of depression symptoms (CES-D)                             —                  M = 12.12 (SD = 9.24)
             PWD
               Diagnosis
               FTD                                                               33                              —
               AD                                                                11                              —
               Motor disease                                                     25                              —
                MCI or family member of person with FTD                           9                              —
               Disease severity (CDR)                                   M = 3.96 (SD = 2.71)                     —
               Cognitive functioning (MMSE)                             M = 24.82 (SD = 4.81)                    —

             Note: N = 78. Values are ns unless otherwise noted. PWD = person with neurodegenerative disease or dementia;
             BAI = Beck Anxiety Inventory (Steer & Beck, 1997); CES-D = Center for Epidemiological Studies Depression Scale
             (Radloff, 1977); FTD = frontotemporal dementia; AD = Alzheimer’s disease; MCI = mild cognitive impairment;
             CDR = Clinical Dementia Rating Scale (Morris, 1993); MMSE = Mini-Mental State Examination (Folstein et al., 1975).

neutral face) in the middle, and “very good” (shown with                electrodes with Redux paste that were placed on oppo-
a schematic smiling face) at the far right. The dial gener-             site sides of the participants’ chest; (b) finger pulse
ated a voltage that reflected the dial position; a computer             amplitude—a photoplethysmograph (UFI, Morro Bay,
sampled the voltage every 3 ms and calculated the aver-                 CA) recorded the amplitude of blood volume in the fin-
age dial position every second. The rating dial was                     ger using a photocell taped to the distal phalanx of the
located near the participant’s dominant hand.                           index finger of the nondominant hand; (c) finger pulse-
                                                                        transmission time—the time interval in milliseconds was
Physiology. In line with psychophysiology standard                      calculated between the R wave of the electrocardiogram
practices (Mendes, 2009), physiological measures were                   and the upstroke of the peripheral pulse at the finger site,
monitored continuously to capture reactivity (e.g., differ-             recorded from the distal phalanx of the index finger of
ences in physiological activity during resting baseline                 the nondominant hand; (d) ear pulse-transmission time—
periods and trial periods) for various tasks. We used a                 a photoplethysmograph (UFI) recorded the volume of
system consisting of Biopac amplifier modules, a com-                   blood in the ear to measure transmission time between
puter with analog-to-digital capability, and an online data             the R waves of the electrocardiogram signal and the
acquisition and analysis software package (written by R.                upstroke of pulse at the ear; (e) systolic and diastolic
W. Levenson). The program computed second-by-second                     blood pressure—a cuff placed on the ring finger of the
averages for the following measures: (a) heart rate—                    participant’s nondominant hand calculated blood pres-
interbeat interval was the time interval in milliseconds                sure on every heartbeat using a finger blood pressure
between successive R waves, using Beckman miniature                     monitor (Ohmeda 2300 Finapres; Finapres, Englewood,
6                                                                                                               Hua et al.

CO); (f) skin conductance level—the electrical conduc-         Cognitive empathy: dynamic-tracking task. Partici-
tance of the skin was computed using a constant voltage        pants watched videos of two different heterosexual mar-
device to pass voltage between Beckman regular elec-           ried couples having conversations. These conversations
trodes on the ring and index fingers of the nondominant        were selected from a study that followed couples longi-
hand to calculate the sweat response; (g) somatic activity—    tudinally (Levenson et al., 1993; Verstaen et al., 2018) and
the amount of overall movement was computed using an           had been used previously to study empathy in young,
electromechanical transducer attached to the platform of       middle-aged, and older adults (Sze, Goodkind, et al.,
the participant’s chair; and (h) respiration rate—the inter-   2012). For each video, participants were asked to focus
cycle interval was the time interval in milliseconds between   on rating the emotions of a target spouse (i.e., the wife or
breaths calculated using a pneumatic bellows stretched         husband) who was highlighted with a green dot above
around the thoracic region.                                    the head. Using the rating dial, participants rated the
   These nine measures were selected to sample the             valence of the emotion being experienced by the target
major autonomic (cardiovascular, electrodermal, respi-         person by moving the rating dial continuously to indicate
ratory) and somatic systems associated with emotional          how positive or negative they believed the target person
responding. For each measure, the average of the rest-         was feeling. Each video lasted approximately 3 min.
ing baseline period was subtracted from the average               Accuracy on this task was calculated using time-
obtained during the task period to create a difference         lagged cross-correlations to determine the agreement
score for physiological reactivity (length of baseline         between a caregiver’s moment-to-moment ratings of the
and task period detailed below). Averages for each             target person’s emotions and the averaged ratings from
physiological reactivity score were normalized, reverse-       an expert panel of graduate students trained in the
scored if necessary (so that larger values reflected           Facial Action Coding, Emotional Expressive Behavioral
greater physiological arousal), and then averaged. The         Coding, and Specific Affect Coding systems (Coan &
use of this kind of composite measure, which helps             Gottman, 2007; P. Ekman & Friesen, 1978; Gross &
control for Type I error, has been described in detail         Levenson, 1993). To allow for differences in processing
in several of our other publications (Sturm et al., 2006;      speed, we followed methods previously used with this
Verstaen et al., 2016).                                        task (Brown et al., 2018) in which the maximum correla-
                                                               tion coefficient was selected for lags between −10 s
Facial behavior. Trained coders rated recordings of            and +10 s. Because performances for both videos on
participants’ facial behavior using the Emotional Expres-      the dynamic-tracking task were correlated, r = .59, t(76) =
sive Behavior coding system (Gross & Levenson, 1993).          6.37, p < .001, 95% confidence interval (CI) = [.42, .72],
Facial behavior was coded second by second for nine            a composite accuracy score was calculated by averag-
emotional facial behaviors (anger, disgust, happiness/         ing the maximum cross-correlation coefficient for the
amusement, contempt, sadness, embarrassment, fear, sur-        two videos. Higher averaged cross-correlation coeffi-
prise, and confusion) on an intensity scale ranging from       cients indicated greater accuracy on this task.
0 to 3.
                                                               Emotional-empathy task: film depicting suffering. Par-
                                                               ticipants watched a film clip that has been found to
Laboratory tasks
                                                               induce concern and distress in young, middle-aged, and
Cognitive empathy: emotion-recognition task. Par-              older adults (Sze, Gyurak, et al., 2012). The film consists
ticipants watched a series of 11 film clips that were devel-   of images of people in Darfur suffering from starvation
oped to assess ability to recognize specific emotions          and disease. The film lasted 120 s and was preceded by
(Goodkind et al., 2015). Each film clip (approximately 35      a 60-s baseline period during which an “X” was displayed
s in length) showed a character experiencing a positive        on the monitor. After the film, participants rated (on a
(affection, amusement, calmness, enthusiasm), negative         scale from 0 to 2) how much they felt 10 positive and
(anger, disgust, fear, sadness), or self-conscious emotion     negative emotions (affection, fear, amusement, anger,
(embarrassment, pride, shame) and was preceded by a            shame, disgust, embarrassment, enthusiasm, pride, sur-
30-s baseline period during which an “X” was displayed         prise) as well as concern and distress.
on the monitor. After watching each film clip, partici-            Physiological responses to the film were computed
pants were shown a picture of the target character dis-        by subtracting the average level of each measure during
playing a neutral expression and were asked to identify        the prefilm baseline from the average level during
the emotion the target character felt most strongly from a     the last 80 s of the film, which had previously been
list of the 11 emotions.                                       found to produce the most intense emotional facial
    Accuracy on this task was calculated by summing            responses (Sze, Gyurak, et al., 2012). The responses
correct answers across film clips, for a minimum score         were combined into a composite score as described
of 0 and a maximum score of 11.                                above. Facial behavior was also coded during the final
Cognitive Empathy                                                                                                         7

          Table 2. Correlation Coefficients Between Measures of Caregiver Mental Health, Cognitive Empathy
          Emotional Empathy, and Emotional Reactivity

          Measure                                        1     2       3        4        5         6          7
          1.   Depression and anxiety                    —     .10    −.01     −.20     .29*     −.07        .15
          2.   Cognitive empathy (emotion recognition)          —      .09      .10    −.20       .03        .03
          3.   Cognitive empathy (dynamic tracking)                    —        .10    −.10       .13        .16
          4.   Emotional empathy (physiological)                                —      −.10       .09        .01
          5.   Emotional empathy (self-reported)                                        —        0.0         .22
          6.   Emotional empathy (facial behavior)                                                 —        −.01
          7.   Emotional reactivity (self-reported)                                                         —

          *p < .05.

80 s of the film. A composite measure of negative facial       Correlations between laboratory tasks. Table 2 dis-
behavior was obtained by summing the intensity scores          plays correlations between laboratory measures. Figure
for seven negative emotion codes (sadness, confusion,          S1 in the Supplemental Material available online displays
anger, fear, surprise, contempt, and disgust). Intercoder      the distributions of these laboratory measures.
reliability was high (intraclass correlation coefficient =
.83). Self-reported emotional experience was calculated        Validity for laboratory tasks. The emotion-recogni-
by summing the total reported intensity for seven nega-        tion task has criterion validity because it is correlated
tive and two caring emotions (fear, anger, surprise,           with performance on standardized emotion-recognition
sadness, disgust, shame, distress, affection, concern).        tasks using standardized photographs of emotional facial
                                                               expressions (Goodkind et al., 2015). Whereas the emotion-
Emotional reactivity: acoustic-startle task. Partici-          recognition film task captures recognition of discrete
pants were told to relax and watch the computer screen.        emotion states, the dynamic-tracking task captures recog-
An “X” was displayed on the screen when the pretrial           nition of emotional valence over time. We expect these
baseline began and remained in view for 60 s. A loud           two different cognitive empathy tasks to capture different
startle stimulus (115-dB, 100-ms burst of white noise)         aspects of recognizing emotion. The dynamic-tracking
was then presented without warning using speakers              task shows discriminant validity because it is not corre-
located behind the participant. Participants sat through a     lated with performance on the emotion-recognition task
60-s poststartle period during which an “X” was pre-           (as noted above). This discriminant validity was also dem-
sented on the screen. After the poststartle period, partici-   onstrated in a previous study in which performance on
pants rated on a scale from 0 to 2 how much they felt 10       the dynamic-tracking task is not correlated with perfor-
positive and negative emotions (affection, fear, amuse-        mance on recognizing emotion from standardized photo-
ment, anger, shame, disgust, embarrassment, enthusiasm,        graphs of emotional facial expressions (Sze, Gyurak,
pride, surprise). We used this task, which has been used       et al., 2012). The emotional-empathy task has content
previously with participants of all ages (Levenson et al.,     validity because the film was selected to induce negative
2008; Soto et al., 2005; Sturm et al., 2006), to provide a     and caring emotions for others, emotional experiences
measure of emotional reactivity to an aversive stimulus        this film has been shown to effectively induce (Lwi et al.,
that is experienced directly rather than vicariously (as       2019; Sze, Gyurak, et al., 2012). Furthermore, the emo-
with the film depicting suffering).                            tional-reactivity task has content validity because responses
   Self-reported emotional experience was calculated           to the acoustic startle have well-characterized and well-
by summing the total intensity for the seven emotions          documented emotional responses (P. Ekman et al., 1985;
that are typical responses to the startle task (Sturm          Roberts et al., 2004; Sturm et al., 2006).1
et al., 2006): surprise, sadness, anger, fear, disgust,
embarrassment, and amusement. Because laboratory
sessions ended early as a result of participant fatigue
                                                               Other measures
or caregivers declining to participate in all tasks, data      Disease severity in people with dementia. At UCSF,
on this task were obtained from only 68 participants.          the Clinical Dementia Rating Scale (CDR) was completed
Physiology and facial behavior were also recorded dur-         using a semistructured interview conducted by clinicians
ing this task; however, these data were not used in            with caregivers (Morris, 1993). The CDR assesses functional
analyses (see below).                                          performance in six domains: (a) memory, (b) orientation,
8                                                                                                               Hua et al.

(c) judgment and problem-solving, (d) community affairs,         Higher scores on the composite of mental health indi-
(e) home and hobbies, and (f) personal care. Scores in           cate greater severity of averaged depression and anxiety
each domain range from 0 (none) to 3 (severe) and are            symptoms.
summed to create a composite score, ranging from 0 to
18; higher scores indicate greater disease severity. This
                                                                 Sensitivity power analyses
measure is often used to stage disease severity in indi-
viduals with dementia (Morris, 1997; M. M. Williams              Because we recruited a convenience sample to maxi-
et al., 2013). The CDR has been validated against neuro-         mize our sample size, we could not conduct a priori
pathology data (Berg et al., 1993) and demonstrates good         power analyses. To determine whether our study had
reliability (Burke et al., 1988).                                adequate power to detect effects, we conducted two
                                                                 sensitivity power analyses. For analyses with our full
Cognitive impairment in people with dementia. At                 sample size of 78, a maximum of five predictors, an α
UCSF, the Mini-Mental State Examination (MMSE) was               level of .05, and 80% power, we computed a medium
administered to assess the severity and progression of           effect size (f 2) of 0.18 (Cohen, 1988). Only 68 partici-
cognitive impairment (Folstein et al., 1975). This exam          pants completed the acoustic-startle task (see above).
evaluates several domains of cognitive functioning: (a)          For analyses with a sample size of 68, a maximum of
orientation, (b) visuospatial construction, (c) language,        five predictors, α level of .05, and 80% power, we com-
(d) concentration or attention, (e) working memory, and          puted a medium effect size (f 2) of 0.21. Thus, our study
(f) memory recall. A total score is calculated, ranging          was adequately powered to detect medium effect sizes.
from 0 to 30; lower scores indicate greater cognitive
impairment. This measure is often used to detect demen-
tia and stage disease course (O’Bryant, Humphreys, et al.,
                                                                 Analytic approach
2008; O’Bryant, Waring, et al., 2008). The MMSE has dem-         Bivariate correlations were conducted to examine (a)
onstrated good reliability and validity for grading cogni-       the relationship between caregiver cognitive empathy
tive impairment (Tombaugh & McIntyre, 1992).                     and caregiver mental health and (b) the relationship
                                                                 between caregiver emotional empathy and caregiver
Caregiver mental health. Within a month after the                mental health. Then, if significant associations were
laboratory session at UCB, caregivers completed two              found, linear regression analyses were conducted with
online questionnaires to assess their mental health.             inclusion of covariates, including relevant demographic
Depression was measured using the Center for Epidemi-            or clinical variables (identified below) and caregiver
ological Studies Depression Scale (CES-D; Radloff, 1977),        emotional reactivity. We focused on independent sig-
which asks respondents to rate themselves over the past          nificant associations from correlations to avoid potential
week on a scale from 0 (rarely or none of the time) to 3         suppressor effects in multivariate linear regression
(most or all of the time) for 20 items (e.g., “I felt sad,” “I   (Beckstead, 2012). Physiology, facial behavior, or self-
felt lonely”). Four items were reverse-scored, and then all      reported emotional responses to the emotional-­
items were summed; higher scores indicate greater levels of      reactivity task were used as a covariate, depending on
depression symptoms. The CES-D has been previously vali-         the type of empathy response (i.e., physiological,
dated for measuring depression in older adults (Beekman          behavioral, or self-report) that emerged as being sig-
et al., 1997; Haringsma et al., 2004). Anxiety was mea-          nificantly associated with caregiver mental health.
sured using the Beck Anxiety Inventory (BAI; Steer &
Beck, 1997), which asks respondents to rate themselves
                                                                 Identifying covariates
over the past month on a scale from 0 (not at all) to 3 (a
lot) for 21 items (e.g., “Unable to relax”). Scores were         We calculated correlations between caregiver demo-
summed; higher scores indicate greater levels of anxiety         graphic variables or the person with dementia’s clinical
symptoms. The BAI has demonstrated reasonable test-              variables and caregiver mental health to identify covari-
retest reliability and validity when used with individuals       ates to include in our primary analyses of the relation-
with anxiety disorders (Beck et al., 1988; Fydrich et al.,       ship between caregiver emotional functioning (cognitive
1992).                                                           empathy, emotional empathy, emotional reactivity) and
    Because the CES-D and BAI were significantly cor-            caregiver mental health. Potential covariates included
related in our sample, r = .68, t(76) = 8.14, p < .001,          caregiver age; caregiver gender (0 = man, 1 = woman);
95% CI = [.54, .79], and to reduce the risk of Type I            caregiver race, as a crude index for systemic oppression
errors from multiple comparisons, a composite of care-           on the basis of race (given the small number of people
giver mental health symptoms was computed by z-­                 of color, this variable was coded as 0 = White, 1 =
scoring the CES-D and BAI and averaging these z-scores.          people of color); caregiver education (0 = high school,
Cognitive Empathy                                                                                                                                       9

                  Self-Reported Emotional-Empathy Response
                                                             15

                                                                                                                        Diagnosis in Person
                                                             10                                                         With Dementia
                                                                                                                           AD
                                                                                                                           At Risk
                                                                                                                           FTD
                                                                                                                           Motor
                                                              5

                                                              0
                                                                  −1   0           1           2           3
                                                                       Caregiver Mental Health Composite
                     Fig. 1. Scatterplot of the sum of intensity for self-reported emotional empathy (in response to
                     the film depicting suffering) and caregiver mental health (composite of caregiver depression and
                     anxiety symptoms). Greater self-reported emotional empathy was associated with worse caregiver
                     mental health. This relationship was significant in a bivariate correlation and in linear regressions
                     accounting for caregiver race, disease severity of the person with dementia, cognitive functioning
                     of the person with dementia, and caregiver self-reported emotional reactivity (in response to the
                     acoustic-startle task). Note that one caregiver had a depression and anxiety composite score > 3 SD
                     above the mean (z = 4.03). All findings remained the same without this outlier. FTD = frontotemporal
                     dementia; AD = Alzheimer’s disease; Motor = motor disease.

1 = 2-year college, 2 = 4-year college, 3 = master’s                                           diagnosis: r = −.02, t = −0.15, p = .88, 95% CI = [−.24,
degree, 4 = MD, PhD, or other professional degree);                                            .21]; AD diagnosis: r = −.07, t = −0.62, p = .54, 95% CI =
caregiver relationship to the person with dementia (1 =                                        [−.29, .15]; motor-disease diagnosis: r = .10, t = 0.91,
spouse, 0 = nonspouse); diagnosis of the person with                                           p = .37, 95% CI = [−.12, .32].
dementia (FTD, AD, or motor diseases; three variables
coded as 1 = yes, 0 = no); disease severity in the person
                                                                                               Results
with dementia; and cognitive functioning in the person
with dementia.                                                                                 Caregiver cognitive empathy
   Caregiver race (non-White), greater disease severity                                        and caregiver mental health
in the person with dementia, and lower cognitive func-
tioning in the person with dementia were correlated                                            Caregiver accuracy was not related to caregiver mental
with worse caregiver mental health in our sample; thus,                                        health on either the emotion-recognition task, r = .13,
they were included as covariates in analyses—race: r =                                         t(76) = 1.12, p = .27, 95% CI = [−.10, .34], or the
.23, t(76) = 2.05, p = .04, 95% CI = [.007, .43]; disease                                      dynamic-tracking task, r = −.01, t = −0.10, p = .91, 95%
severity: r = .37, t(76) = 3.57, p < .001, 95% CI [.17, .55];                                  CI = [−.23, .21], was related to caregiver mental health.
cognitive functioning: r = −.28, t(76) = −2.50, p = .01,
95% CI = [−.47, −.06]).                                                                        Caregiver emotional empathy
   Caregiver age, gender, education, relationship to the
person with dementia, and diagnosis variables were not
                                                                                               and caregiver mental health
correlated with caregiver mental health in our sample;                                         Caregiver self-reported emotional experience to the
thus, they were not included as covariates in analyses—                                        film depicting suffering was associated with caregiver
caregiver age: r = −.19, t(76) = −1.60, p = .11, 95% CI =                                      mental health such that greater experience of negative
[−.41, .05]; caregiver gender: r = .18, t(76) = 1.48, p =                                      and caring emotions was related to lower mental health,
.14, 95% CI = [−.06, .40]; caregiver education: r = .02, t =                                   r = .29, t(76) = 2.66, p = .009, 95% CI = [.07, .48] (see
0.17, p = .87, 95% CI = [−.20, .24]; caregiver relationship:                                   Fig. 1). In contrast, caregiver physiological responses,
r = −.10, t = −0.85, p = .40, 95% CI = [−.31, .13]; FTD                                        r = −.14, t(76) = −1.24, p = .22, 95% CI = [−.35, .09], and
10                                                                                                                Hua et al.

facial behavior responses, r = −.07, t = −0.61, p = .55,          Discussion
95% CI = [−.29, .16], to the film depicting suffering were
not related to caregiver mental health. 2                         In the present study, we examined the relationship that
   We evaluated the robustness of the relationship                laboratory measures of emotional and cognitive empa-
between greater emotional empathy (i.e., self-reported            thy have with mental health in a sample of caregivers
emotional experience to film depicting suffering) and             of people with dementia. Results were partially consis-
lower caregiver mental health in two ways: (a) account-           tent with our hypothesis that laboratory measures of
ing for covariates and (b) accounting for covariates and          emotional empathy would be associated with poor
for caregiver emotional reactivity (i.e., self-reported           caregiver mental health. Using a composite measure of
emotional experience to the acoustic-startle task).               depression and anxiety symptoms, we found an asso-
                                                                  ciation between one of the three emotional empathy
Accounting for covariates. We conducted a linear                  measures (self-reported emotional experience to the
regression accounting for caregiver race, disease severity        emotional-empathy task) and caregiver mental health.
in the person with dementia, and cognitive functioning in         Given the heightened depression and anxiety found in
the person with dementia (the variables found to be inde-         caregivers of people with dementia (Brodaty & Donkin,
pendently predictive of caregiver mental health above).           2009; Coope et al., 1995; Cuijpers, 2005; Kolanowski
When these variables were entered as covariates, greater          et al., 2004) and the increasing prevalence of caregiv-
emotional empathy (self-reported emotional experience)            ing for people with dementia as a result of the aging
was still related to worse caregiver mental health, t(73) =       population (Schulz et al., 2020), this finding suggests
2.62, β = 0.25, p = .01.                                          an important risk factor and possible intervention tar-
                                                                  get for clinical psychologists and other health profes-
Accounting for covariates and caregiver emotional                 sionals who are concerned with late-life mental health
reactivity. We conducted a linear regression accounting           issues.
for self-reported emotional experience to the acoustic-
startle task as well as caregiver race, disease severity in       Emotional empathy and caregiver
the person with dementia, and cognitive functioning in
the person with dementia. In this analysis, caregiver emo-
                                                                  mental health
tional reactivity was not associated with caregiver mental        Historically, clinical psychologists have considered
health, t = 0.59, β = 0.06, p = .55. However, greater emotional   empathy to be a highly desirable quality that is associ-
empathy (self-reported emotional experience) remained             ated with desirable outcomes (Elliott et al., 2018; Rogers,
associated with worse caregiver mental health, t(62) =            1957). However, in the present study, we found the
2.74, β = 0.30, p = .008.                                         opposite: High levels of a particular aspect of empathy
                                                                  (i.e., emotional empathy, as measured by self-reported
                                                                  negative and caring emotions in response to viewing
Caregiver emotional empathy and                                   the suffering of others) were associated with an
mental health: depression and anxiety                             undesirable outcome (i.e., greater severity of mental
                                                                  health symptoms) in caregivers of people with demen-
considered separately
                                                                  tia. Of course, these findings are not without precedent;
Although measures of caregiver depression and anxiety             rather, they are consistent with prior research indicating
were highly correlated in our sample, for transparency,           that high levels of emotional empathy are associated
we examined relationships between caregiver emo-                  with poorer mental health in the context of others’ suf-
tional empathy (self-reported emotional experience)               fering. For example, prior research has found that too
and depression and anxiety considered separately. Lin-            much empathy leads to empathy burnout and emo-
ear regressions accounting for caregiver emotional                tional distress in nurses, doctors, and other health care
reactivity, caregiver race, disease severity in people            providers who regularly interact with distressed or suf-
with dementia, and cognitive functioning in people                fering individuals (Decety & Fotopoulou, 2014; Figley,
with dementia revealed that greater emotional empathy             2011). Likewise, an optimal level of empathy (i.e., not
was associated with greater depression symptoms,                  too much or too little) is thought to be critical for hav-
t(62) = 2.97, β = 0.33, p = .004, and with greater anxiety        ing a better psychological distinction between oneself
symptoms at trend level, t(62) = 1.94, β = 0.23,                  and another’s distress (E. Ekman & Halpern, 2015).
p = .057. In contrast, caregiver emotional reactivity was         Having too much emotional empathy runs the risk of
not associated with either depression, t = −0.28, β =             reducing this psychological distinction (Lee et al., 2001)
−0.03, p = .78, or anxiety, t(62) = 1.26, β = 0.14, p =           and is considered an important cause of overidentifica-
.21, symptoms.                                                    tion with patients in health care professionals (Decety
Cognitive Empathy                                                                                                    11

& Fotopoulou, 2014). Our findings similarly exemplify         high in emotional empathy. Future research should
the adages that “it depends on the context” and that          examine whether helping caregivers who are high in
one can have “too much of a good thing.” In the context       emotional empathy learn to regulate their emotions to
of caring for a person with dementia, caregivers high         others’ suffering and maintain distinction between self
in emotional empathy may become overly enmeshed,              and other has preventive and/or therapeutic value for
taking on the added burden of feeling the distress and        protecting mental health.
suffering experienced by a loved one who is dealing
with the ravages of a cruel, progressive, and ultimately      Robustness of findings
terminal illness. For these caregivers, chronically expe-
riencing a combination of their own distress and that         Our findings were robust to a number of covariates
of the person in their care could greatly heighten risk       found to be related to caregiver mental health (care-
for developing symptoms of depression and anxiety.            giver race, disease severity in people with dementia,
   Previous psychological and neuroscience research           and cognitive functioning in people with dementia) and
suggests that individuals who can regulate their own          a measure of caregiver emotional reactivity (self-
emotional responses to others’ suffering (and thus have       reported emotional experience to an acoustic-startle
optimal levels of emotional responses) can express            stimulus). There is a wealth of research on caregivers’
greater concern for others instead of feeling over-           demographic variables and people with dementia’s
whelming emotional distress (Decety & Meyer, 2008;            clinical variables that are associated with poor caregiver
Ho et al., 2014; A. Williams et al., 2014). Caregivers may    mental health (Cooper et al., 2007; Schulz et al., 2020).
similarly benefit from evidence-based interventions that      However, even after accounting for these potential
help them manage their negative emotional responses           influences in our sample, the relationship between
to the suffering of others to help maintain the distinc-      caregiver emotional empathy and mental health
tion between self and other. Emotional responses,             remained. Moreover, several prior studies have found
including those elicited as a function of empathy, are        that caregivers who experience more negative emotions
amenable to influence by emotion-regulation processes         are more vulnerable to negative mental health out-
(Thompson et al., 2019; Zaki, 2014; Zaki et al., 2008).       comes (Brodaty & Donkin, 2009; Safavi et al., 2017).
One well-studied regulation strategy is to engage in          However, in our study, even after controlling for care-
self-distancing, a form of adaptive self-reflection in        givers’ emotional responses to an aversive stimulus, the
which a fly-on-the-wall approach is taken to process          relationship between caregiver emotional empathy and
one’s emotional experiences (Kross et al., 2012; Verduyn      mental health remained. We conclude from these find-
et al., 2012). This approach has been demonstrated to         ings that in our study sample, emotional empathy plays
be helpful in the context of relationships (Ayduk &           an important role in caregivers’ mental health above
Kross, 2010) in which high self-distancers respond to         and beyond the role of other well-established factors
negative emotions from partners with less reciprocation       related to patient functioning, caregiver demographics,
of negative emotions, thus allowing for reconstrual of        and caregiver emotional reactivity.
difficult situations. Therapists who use a similar distanc-
ing approach (e.g., imagining greater psychological           Limited to self-report aspect
distance from overwhelming client distress and the cli-
ent themselves) reported greater psychological well-
                                                              of emotional empathy
being (Weilenmann et al., 2018).                              Note that among the multiple aspects of caregivers’
   In the context of a familial caregiver and person with     emotional empathy (physiological, behavioral, self-
dementia, a caregiver may be advised to observe men-          reported emotional experience) that we assessed, only
tally their own emotional responses “from afar” in            greater self-reported emotional experience in response
response to the person with dementia’s distress. Slow-        to a film depicting suffering was associated with worse
ing down the pace and reducing the magnitude of the           caregiver mental health. This specificity in findings may
immediate negative emotional responses may reduce             have implications for identifying caregivers most at risk
distress levels and allow for greater psychological dis-      for poor mental health. Because emotional empathy
tinction between caregivers and people with dementia.         behavior was not associated with caregiver mental
Of course, compared with health care professionals and        health, it may be difficult for clinicians and outside
their patients, familial caregivers and people with           observers to recognize if caregivers are not faring well.3
dementia are likely to share a much longer, more inti-        Clinicians and outside observers may ask caregivers
mate, and more personal history. This can make sepa-          directly about their emotional experiences (particularly
rating oneself from the person with dementia’s suffering      those that are relevant to another person’s suffering) to
particularly difficult, especially for caregivers who are     identify those who may be at greater risk.
12                                                                                                            Hua et al.

   Although physiological, behavioral, and self-report        our data whether caregiver emotional empathy influ-
aspects of emotional responding can cohere in certain         ences caregiver mental health or vice versa. Indeed,
situations (Brown, Van Doren, et al., 2020; Mauss et al.,     similar associations between emotional empathy and
2005), this is certainly not always the case (Evers et al.,   mental health have been found in research for individu-
2014; Reisenzein et al., 2013). We have argued previ-         als with depression, anxiety, and other forms of psy-
ously that self-reported emotional experience is much         chopathology. For example, individuals with more
more malleable to contextual influences than physio-          severe psychopathology symptoms have been shown
logical and expressive aspects of emotion (e.g., culture;     to have greater emotional empathy (O’Connor et al.,
Levenson et al., 2007; Soto et al., 2005). Self-reported      2002; Thoma et al., 2015; Tibi-Elhanany & Shamay-
emotional experience arises from complex appraisals           Tsoory, 2011) and have trouble effectively regulating
that include both contextual and interoceptive pro-           their emotional states (Sheppes et al., 2015; Thompson
cesses (Levenson, 1999, 2003; Levenson et al., 2017)          et al., 2019). Future research using longitudinal and
and thus may tap into some of the same processes that         experimental designs would be critical for understand-
contribute to symptoms of anxiety and depression. Con-        ing the directional influences between caregiver emo-
sequently, although some caregivers of people with            tional empathy and caregiver mental health.
dementia may respond to a film depicting suffering with
heightened facial expressions of negative emotions and
autonomic nervous system activation, it may be those
                                                              Strengths and limitations
caregivers who report actually “feeling” high levels of       Strengths of this study include using laboratory-based
negative emotions and concern for whom the worries,           measures of emotional and cognitive empathy; measur-
loneliness, burdens, and grief associated with caregiv-       ing physiological, behavioral, and self-reported aspects
ing are most profound and developing symptoms of              of emotional empathy; including two measures of cogni-
depression and anxiety is most likely. Conversely, care-      tive empathy (emotion-recognition and dynamic-track-
givers who have more severe depression and anxiety            ing tasks); examining and accounting for demographic
symptoms may be more likely to report “feeling” high          factors, characteristics of the people with dementia,
levels of negative emotions and concerns for others.          and caregiver emotional reactivity, all of which could
                                                              influence caregiver mental health; and including
                                                              caregivers who were providing care for people with
Cognitive empathy and caregiver                               dementia with heterogeneous diagnoses to increase
mental health                                                 generalizability.
In contrast to the robust relationship we found between          Limitations of the study include using self-report
greater emotional empathy and worse mental health in          measures of caregiver anxiety and depression rather
caregivers of people with dementia, we found no rela-         than structured clinical diagnostic interviews; using
tionship between either of the two measures of cognitive      stimuli that activated different emotions across cognitive-
empathy and caregiver mental health. Prior research sug-      empathy and emotional-empathy tasks rather than con-
gests that professional health care providers (e.g., physi-   sistently using stimuli showing others’ suffering, which
cians, nurses) with greater cognitive empathy experience      limits our ability to compare across facets of empathy;
better psychological outcomes by increasing emotional         difficulty ruling out spontaneous emotion regulation
distance and focusing on how the distressed person feels      used by caregivers, which may have affected their emo-
rather than sharing that distress (Cusi et al., 2011; E.      tional responses to our laboratory tasks; using a cross-
Ekman & Halpern, 2015; Halpern, 2003). Although a             sectional design that limits ability to determine causal
similar association could be expected for familial caregiv-   and directional influences; lack of comparison groups
ers who are high in cognitive empathy, we found no            (e.g., caregivers of people with other illnesses, control
evidence supporting this in our sample of caregivers and      participants); and lack of diversity in race, socioeco-
people with dementia. Nonetheless, additional research        nomic status, and type of relationship to the people
with caregivers for individuals with other disorders, at      with dementia in our sample, which limit the generaliz-
other stages of caregiving, and with yet other measures       ability of our findings.
of cognitive empathy would be worthwhile.
                                                              Conclusions
Causality                                                     We examined the relationships between two facets of
Because in the present study we used a cross-sectional        empathy and mental health in a sample of familial care-
design, findings raise important questions regarding the      givers of people with a number of different kinds of
direction of influence. It is impossible to know from         dementia and neurodegenerative diseases. Our findings
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