People with traumatic brain injury, who often lose empathy, can regain it with treatment

Most people can easily determine when a loved one is feeling sad or anxious. This recognition will often trigger the person to offer a comforting gesture or even have a contagious emotional reaction, causing them to also feel sad or anxious, too.

These important actions are referred to as emotion recognition and empathy, and they are fundamental to establishing human emotional connections and relationships.

But imagine waking up one morning and your loved one lost the ability to recognize and empathize with your feelings. For the last couple of decades, researchers have been showing this to be a common outcome for people who have suffered a traumatic brain injury. The inability to recognize and empathize with others’ emotions after brain injury has a resounding impact on family and friends and has sparked research leading to promising treatments.

I started studying emotion recognition and empathy in 2005, and this is exactly how the wife of my first research participant described it happened for her husband who was in a car accident and suffered a traumatic brain injury, or TBI. Once a very affectionate partner who responded to all of her emotional needs, he now failed to recognize her sadness or comfort her when she lost her father. Conversely, he was unable to feel the emotional contagion of her joy when she received recognition at work. This once very strong couple later divorced.

Crashes, blasts and falls that affect millions

Falls are a common cause of traumatic brain injury, but car and motorcycle crashes also are major causes. Andre Marcelo Santa Maria/

A TBI is when an external physical force leads to a disruption in brain function. Falls and motor vehicle accidents are the most common causes, but damage also results from many other injuries, including blast injuries that are frequently experienced by active duty military.

In 2014, almost 3 million Americans received some type of medical care or died from a TBI-related incident. Problems with attention, memory, planning, reasoning or problem solving are common. But often more troublesome are the frequent emotional and behavioral changes, such as increased anger and aggression. Emotional and behavioral changes have been linked with problems recognizing others’ emotions and an inability to share another’s feelings.

Prevalence rates of problems with emotion recognition and decreased empathy after brain injury are 39% and 60%, respectively.

This is quite concerning for people with TBI and their family members, as this impairment has been related to worse social relations after TBI.

The first step of empathy

A boy responds to a girl’s look of pain. fizkes/

It has been a longstanding theory that a person must recognize others’ emotions in order to empathize with them.

However, despite the strong theoretical rationale, scientific experiments have had trouble finding strong support for this belief, in people with and without brain injury.

When I looked at how the past studies were conducted, I saw clear design flaws. Many of the former studies assessed emotion recognition and empathy in isolation of one another. Empathy was typically measured with unrelated subjective questionnaires. So it is not too surprising little relationship was found between two unrelated tests.

For example, researchers would administer an emotion recognition test, such as pictures of facial expressions. The researchers would then give participants a questionnaire about their general empathic tendencies. But the researchers did not test how the person with TBI felt in response to the facial expressions they had to identify. For example, did they feel sad when looking at a sad person? By not gauging a person’s feelings in response to the emotional expression in the picture, researchers were not measuring a direct empathic response to another’s feelings.

A second step to empathy

Due to the limitations of previous studies, my colleague, Dr. Barbra Zupan, and I decided to take a different approach. In our recent publication, we showed subjects with and without TBI emotional film clips and had them identify how the character in the clip felt and how they felt while watching the clip.

Since a shared emotional response is an element of empathy, when participants felt the same emotion they identified the character to be feeling, we defined that as an empathic response. We did not require them to recognize the character’s emotion accurately to be classified as an empathic response. Using this approach allowed us to measure the direct relationship between recognizing another’s emotion and having a shared empathic response. If we made accurate emotion recognition a requirement to be considered an empathic response, we would not have been able to measure this relationship.

We had several interesting findings. Based on past research showing impaired empathy after TBI, we expected the percent of empathic responses to be pretty low in our participants with TBI. While participants with TBI did not have as many empathic responses as their uninjured age and gender matched peers (79%), they did respond empathically 67% of the time.

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Further, we found that accurate recognition of characters’ emotions was associated with a greater number of empathic responses. The empathic responses of participants with TBI more than doubled when they accurately identified the character’s emotion, compared to a misrecognized emotion (71% vs. 32%, respectively).

We think it is important to note that correct emotion recognition was not sufficient for an empathic response to occur in either group. That is, participants did not always respond empathically when they correctly recognized the emotion.

Our findings also suggest that participants with TBI had a harder time recognizing and empathizing with sad and fearful emotions, compared to happy emotions. This was indicated by their lower recognition and empathic responses when characters were acting sad and afraid. This means that when loved ones need comforting the most – when feeling fearful or sad – they are unlikely to get it from a partner with TBI.

Helping those with TBI

We think these findings have important clinical implications.

First, clinicians treating people with TBI should plan to evaluate emotion recognition and empathy in their patients and learn how to treat these impairments. Interviewing patients with TBI and their family members can help paint a picture of how a person has changed compared to his or her pre-injury self and lead to goals for rehabilitation. There are evidence-based approaches and free treatment tools, designed by our group, that have now been deemed practice standards for improving emotion recognition skills.

When training emotion recognition after TBI, clinicians should also discuss with the patient ways they can respond empathically to loved ones. Newer research from another group in the Netherlands shows that this combination – both recognition and responding empathically – is effective and should involve the family member as part of treatment.

Also, clinicians should consider educating survivors of TBI and their families about these common changes after TBI, why it happens, what they might expect in terms of changes in behavior, and notifying them that it could improve with treatment.

Finally, family members could be directed to be more explicit about their emotions and what they would like from their loved one with a brain injury. Together, these efforts could improve outcomes after TBI and minimize the common relationship strains experienced after a brain injury.

— Update: 31-12-2022 — found an additional article Loss of Empathy After a Stroke from the website for the keyword loss of empathy after stroke.

After surviving a stroke, a stroke survivor may become less empathetic towards others. Empathy is the ability to see things from another person’s perspective. Empathy is especially important when it comes to understanding how another person is feeling. When someone lacks empathy, he often behaves insensitively towards others, and this makes others upset.

So a lack of empathy can have really serious repercussions when it comes to interpersonal relationships. Since much of our interactions with others depend on maintaining adequate relationships, a lack of empathy is a serious thing. When a stroke makes a person lose this important skill of empathy, it affects the stroke survivor and everyone she interacts with, especially close family members.

Sam Edwards / Getty Images

Types of Stroke That Can Cause Loss of Empathy

Not all strokes cause a loss of empathy. A stroke can be a devastating event, and sometimes it can make a stroke survivor more focused on himself and less focused on others for a while. But, after an adjustment period following a stroke, a stroke survivor will typically go back to being as sensitive and empathetic as he was prior to the stroke – unless he had a stroke on the area of the brain that controls empathy.

Overall, injuries to the right side of the brain are more likely to affect empathy than injuries to the left side of the brain. In right-handed people, the left side of the brain controls language and in left-handed people, the right side of the brain or the left side of the brain may control language. So whether a stroke survivor will have a deficit in language depends on whether he is left-handed or right-handed. But it is not clear whether handedness determines the side of the brain that controls empathy.

The areas of the brain that are most likely to cause a deficit in empathy are the right prefrontal cortex, the right insula, and the right temporal gyrus. These areas are typically associated with emotions, memory, and control of behavior. Relatively new technology has made it possible to locate and identify these areas as under-active in stroke survivors who lack empathy. All of this new information gained from studying stroke survivors may be helpful in the future in terms of gaining a better understanding of conditions such as autism, which is characterized, in part, by a lack of empathy.

Read more  Understanding Lack of Empathy After Brain Injury and How to Cope

What to Do

People who don't have empathy typically come across as oblivious to others’ feelings, socially awkward or rude. Ironically, people who display such off-putting behavior due to a neurological empathy handicap are often rejected by the people around them because even 'normal' individuals are usually not empathetic to the lack of empathy. This leads to further social isolation and trouble reaching out to others for support. The caregiver (usually a spouse or grown child) may feel saddened and rejected by the inconsiderateness of a stroke survivor who lacks empathy. The caregivers and loved ones may struggle to cope with the confusing behavior without understanding why the stroke survivor is being so mean.

Overcoming a lack of empathy is difficult. Many people have low levels of empathy, to begin with, and it is a handicap that is very hard to overcome, but not impossible to improve. One of the challenges when it comes to an injury of the 'empathy area' after a stroke is that the same area of the right frontal lobe that controls empathy is also located near the area of the brain that controls a person's ability to understand her stroke. So a stroke survivor who lacks empathy often cannot fully comprehend that she had a stroke, and therefore is less likely to make an effort to improve the problem.

Counseling may provide a degree of insight for caregivers and for some stroke survivors. Professional therapy can provide useful guidelines for patients and caregivers. For example, simpler ways to communicate feelings clearly and directly can prevent misunderstandings.

Straightforward methods for routinely asking about people's feelings can facilitate better relationships than completely ignoring the subject altogether. Exercises designed to name peoples' feelings and the appropriate responses to those feelings can help rebuild some of the skills lost when a stroke affects the right prefrontal cortex. This can help relieve some of the social, relationship and work-related consequences that result from having low levels of empathy.

— Update: 03-01-2023 — found an additional article Understanding Lack of Empathy After Brain Injury and How to Cope from the website for the keyword loss of empathy after stroke.

Lack of empathy after brain injury can cause TBI patients to appear more self-centered than they used to.

However, this behavior does not mean your loved one is actually selfish. Their injury has just made it harder for them to identify the emotions of others.

Today you will learn why a brain injury can lead to a lack of empathy, plus what therapies can help people regain their empathy skills.

Causes of Lack of Empathy After Brain Injury

Loss of empathy after stroke

Empathy is the ability to see things from another person’s perspective and feel what they feel.

Multiple areas of the frontal lobe play a role in empathy skills. For example, the right supramarginal gyrus helps people overcome egocentric bias (self-centeredness) when making decisions.

The orbitofrontal cortex is another area of the brain that helps us react to another person’s feelings. Therefore, if any of these brain regions become damaged, a lack of empathy can occur.

Other cognitive and behavioral problems that can accompany a lack of empathy after a brain injury include:

  • Childish behavior
  • Apathy or low motivation
  • Disinhibition
  • Aggressive behavior

It’s important to note that even though the person may display these behaviors, they are not fully responsible for them. Family members and friends should try not to take anything their loved one says or does personally during this time.

Alexithymia and Lack of Empathy

Sometimes TBI patients can still empathize with others, but they have trouble processing their emotions. This condition, called alexithymia, is also common in individuals with autism.

Alexithymia causes difficulties in identifying, describing, and processing one’s own emotions and those of others. It also makes it hard to distinguish bodily sensations from emotional feelings.

This can lead people to seem insensitive and non-empathetic when in fact they do experience the emotions of other persons. They just do not know how to react.

It can be difficult to distinguish alexithymia from a true lack of empathy. A neuropsychologist can help you get a proper diagnosis and teach you ways to process emotions again.

Is Lack of Empathy After Brain Injury Permanent?

Some brain injury side effects, such as a lack of empathy, can go away on their own. As their frontal lobe injury heals, you may notice your loved one becoming more responsive to others again.

Even if this does not occur naturally, it may still be possible to relearn empathy. Empathy is a skill, and like all skills, it can be improved through deliberate practice.

This is what the field of positive psychology is based on. Positive psychology, like the name suggests, is a method used to help train the brain to rest in more positive states.

For instance, by writing in a gratitude journal daily, you can help train the brain to notice more things to be grateful for. The repetitive practice of searching for gratitude helps the brain become more efficient at the skill of noticing things to be grateful for.

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Some research suggests that empathy can be learned, too. But this research is broad. There are no studies specifically within the TBI field proving that practicing empathy helps improve empathy.

However, the principle of deliberate practice is clear: the brain becomes more efficient at the tasks that you repetitively practice, including emotion.

If your loved one is receptive to it, practicing empathy as a skill could be worth trying.

What If Empathy Never Returns?

Loss of empathy after stroke

It is possible that your loved one’s empathy skills never return. However, that does not mean that they can never be compassionate again.

To understand how this can be true, we will need to discuss how empathy works. Most psychologists believe there are three different types of empathy:

  • Cognitive empathy. The ability to understand the positions and feelings of others.
  • Emotional empathy. The ability to share and experience the emotions of others.
  • Compassionate empathy. The ability to respond to others and help them when they are in need.

Even if patients lack cognitive or emotional empathy, they can still practice compassionate empathy. That’s because compassionate empathy involves actions and behavior, something most TBI survivors can more easily grasp.

While cognitive and emotional empathy can make it much easier to practice compassionate empathy, it is possible to be compassionate without them.

Depending on how severe the person’s cognitive deficits are, it may require a lot of work to help them learn how to respond compassionately again. It can be especially difficult if the person suffers from a lack of insight since that can make it hard for them to understand their own behavior.

But with help from a behavioral therapist, patients can learn how to control their behavior and recognize when to help others.

Dealing with Lack of Empathy After Brain Injury

Even though it is possible for TBI survivors to regain empathy, it will take time.

In the meantime, here are some steps that family members can take to help their loved ones improve their empathy skills.

Provide Feedback

Loss of empathy after stroke

It’s important to give feedback to your loved one about their behavior, otherwise, they will never improve.

For example, if they do something rude or inappropriate, gently but firmly let them know. Try your best not to embarrass them, but make sure they understand they can’t do that anymore. It’s very likely they didn’t even realize they were acting selfishly.

In the same way, if they show empathy and compassion, give them praise. Direct their attention to specific instances when they were considerate of another person, and congratulate them. This helps them learn which behaviors are positive and which are negative.

Develop Awareness

Second, try to direct the person’s attention to the feelings of others. This can help them develop a better awareness of another person’s emotions.

One thing you can do is ask them questions about the people they see throughout the day and how they might feel.

For instance, if they saw a mother at a store with three little ones, try asking them what they think the mother was feeling. Was she stressed, tired, or anxious? Then, ask how they might feel if they had to take a child out shopping.

This exercise can help them practice putting themselves in another’s shoes.

Nurture Social Skills

Loss of empathy after stroke

Lack of empathy after brain injury can make it hard for patients to maintain relationships. Therefore, it is helpful to remind them how to keep their friendships alive, especially if they struggle with social skills.

Some things you can remind them to do include:

  • Make phone calls, write letters, and text friends to keep in touch.
  • Remember and acknowledge birthdays and special occasions.
  • Initiate contact and suggest activities with family and friends.
  • Say please and thank you, and take turns.
  • Ask someone what they would like to do.

Again, the more the person can practice these skills, the more they will improve.

Don’t Take Things Personal

Patients with low empathy can sometimes appear aggressive, dismissive, and demanding.

If your loved one acts this way to you, don’t take it personally. Remember they are not in complete control. They just have a lot more emotions and fewer inhibitions now, and they are struggling to cope.

Understanding Lack of Empathy After Brain Injury

A person who suffers a brain injury may experience a lack of empathy, especially if they damaged their frontal lobe.

Fortunately, the brain can be rewired to learn empathy again with the right therapy.

Even if empathy never returns, your loved one can still relearn how to practice compassion to others. While it might take a lot of patience and dedication, they can eventually improve.  


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About the Author: Tung Chi