PSYCHOBIOLOGY

OF COMMUNICATION
AND RELATIONSHIPS
Massimo Biondi, MD
Professor and Chair of Psychiatry
Departments of Neurology and
Psychiatry
University of Rome Sapienza
PoliclinicoUmberto I

PSYCHOBIOLOGY
OF COMMUNICATION

Psychosomatic and
neuroscience research
clearly show the central
neural circuits and
biological correlates of
emotions and cognitive
processes
Brain neurotransmitter
circuits (5HT, NA, GABA,
DA), psycho-neuroendocrine and autonomic
nervous systems
participate in providerpatient communication

COMMUNICATION WITH PATIENTS

IS NOT ONLY A MATTER OF WORDS

Communication with patients involves

intense positive and negative emotions
Emotions have specific brain circuits and
peripheral somatic correlates
Communication with a suffering person
elicits distress and repeated activation of
these brain circuits and can be monitored
by peripheral somatic effects (muscular,
autonomic nervous, psychoendocrine and
immune systems changes)

Emotions involve the Autonomic Nervous,

the Neuroendocrine, Immune and MuscularSkeletal systems

COMMUNICATION,
EMPATHY AND SUPPORT
ENGAGE
THE NEURAL CIRCUITS
OF THE SOCIAL BRAIN

THEORY OF MIND and EMPATHY

RELY on THE SOCIAL BRAIN

The social brain: a set of

specific neural and PNE
circuits involved in
emotion, action and
communication
the social brain is
involved in important
aspects of provider -patient communication
The molecular set of the
social brain, as any
biological system, has
limited resources for
confronting painful
affective stimuli and can
be exhausted

Viewing facial expressions of pain

engages cortical areas involved
in the direct expression of pain

Cingulate and
insula activation
following viewing
facial expressions
of pain with respect
to neutral visual
stimuli
Botvinick e al, 2005

Jackson e al, 2005

INSULAR CORTEX ACTIVATION WHILE

OBSERVING SOMEONE IN PAINFUL SITUATIONS

EMPATHY FOR PAIN ACTIVATES BRAIN

AFFECTIVE COMPONENTS FOR PAIN

The subject sees his own loved

one experiencing a painful
stimulus during an experiment
Brain activation of the viewer
shows the activation of his brain
components of pain (insular
cortex, anterior cingulate,
cerebellum, somatosensory
cortex)
Seeing pain of another person
activates the affective but
not the sensory brain
components of pain
Empathy as the ability to have
an experience of another s pain

Singer e al, 2004

In the same study,

while viewing the
loved one suffering,
high empathy is
correlated to higher
insular cortex and
anterior cingular
cortex activation
(ACC)

Singer et al, 2004

MORE EMPATHY, MORE PAIN

SOME ASPECTS OF THE

SOMATIC STRESS
OF COMMUNICATION

Some psychophysiological
parameters

Electrodermal activity (GSR)

Heart rate and EKG
Blood pressure
Vasoconstriction and Skin temperature
Electromyography (EMG)
Electroencephalography (EEG)
Salivary cortisol

Steps toward a psychobiology

of provider-patient relationship

The registration of the providers

electrodermal activity (such as GSR) is a
simple non-invasive technique that gives
information about moment-to-moment
emotional-related autonomic arousal during
communication with the patient
Phases of distress while discussing bad
news, worrying about a cancer recurrence,
confronting issues of prognosis, presenting
complications of treatment and participating
in episodes of patient despair and crying elicit significant GSR changes in the
professional

Central correlates of Galvanic Skin Response:

PET shows activation of anterior, posterior cingulate
cortex and primary motor cortex

Frederikson e al, 1998

THE PATIENT

Electrodermal activity of a patient during psychiatric

interview about distressing personal issues
10

Fears for
failures at
university

attivazione elettrodermica

partner's

Anger at partner
pause

7
6
5

start

Series1

4
3
2
1
0
1

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
minuti

PATIENTS HEART RATE WHILE REPORTING

CONFLICTING PERSONAL ISSUES
95

Very angry
criticism

90

85

BPM

Series1
80

75

70
1

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

minutes

Patients Frontal EMG while discussing personal issues (1-20 min)

and during 10-min biofeedback guided relaxation
8

EMG microV

Series1

0
1

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Session - Minutes

The impact of effective

communication

Blood systolic pressure decreases in a patient after

communication with empathy and reassurance from
physician
(BLUE: not supported, RED: supported)
180
170

Patient A,
not supported)

160
150
140

Patient B,
Receives empathy,
supported

130
120
110
100
1

Blocchi di colloquio - 10 min

The therapist introduces cold, critical

comments about what the patient
reported i.e. No, no, you were wrong,
sure, your wife was right, better if you
told her Im sorry .
9

GSR score

7
6

GSR score

Series1

2
1
0
1

The therapist starts repeated empathic

comments I imagine how it was
difficult
for
you
to16deal
with
her
and that
10
11
12
13
14
15
17
18
19
20
situation she seems to easily lose
control and so critical of you, I
understand its not easy to live with her

GIVING
EMOTIONAL SUPPORT and
EMPATHIC COMMUNICATION
PREVENT
STRESS-INDUCED CORTISOL AND
BLOOD PRESSURE INCREASE

While the subject performs a

difficult computer task, the
screen gives back every 1 min
the performance.
Despite his increasing effort, the
resulting score is decreasing
Its not the actual score: the
machine gives back a low false
score.
There are several subsequent, frustrating, trials.
The experimenter gives the subject different comments:
neutral: I see, thats how you did
supportive: yes, I understand you, we made a mistake,
the task we selected is too hard, no one was able to do it

Biondi et al, 1986

Verbal social support given under failure and

frustration prevents stress-induced rise
of plasma cortisol and blood pressure

TYPE OF DOCTORS
COMMUNICATION
IS REFLECTED
IN THE NEURAL CIRCUITS
OF PATIENT
DURING
CHOICE OF TREATMENT

COMMUNICATION :
THE FRAMING EFFECT
Treatment choice can be also susceptible to the
way options are communicated (framing effect):
1. this treatment has a 20% mortality rate
2. this treatment has a 80% survival rate
Most people would refuse option 1 and choose
option 2 option even if the treatment is the same
It is possible that the language used to describe
options could activate different brain circuits, so
influencing decision

COMMUNICATION WITH FRAMING

EFFECT IS RELATED TO AMYGDALA
FEAR CIRCUITS
The framing effect is
specifically related to
amygdala activation;
Orbital and medial
prefrontal cortex
activation predict a
reduced susceptibility
to the framing effect

Inferred from De Martino e al, 2006

The provider

Stands suddenly
GSR stress of the psychiatrist during interview up and tries to
leave the room
8
with
a severe psychotic patient
while parents talk
to him
7

grado di disagio emozionale

0
1

I hate psychiatrists, they damaged my

mind - voices from the wall are of my
first psychiatrist, hes persecuting me who are you? I do not want to be in
treatment with you - I dont want
medicine; my mother brought me here ;
I3 want
home,
now
4 5 to
6 go
7 back
8 9 10
11 12 13
14 15 16 17 18 19

20 21 22 23 24 25 26 27 28 29

Min
minuti del colloquio

Heart rate and GSR changes (x10) of a psychiatrist during a 50min session with a 48 yr Major Depressed patient, fifth visit,
discussing profound personal issues of life

80
70

HR

60
50
40

Series1
Series2

30
20

GSR

10
0
1

10

A deeply calm session, softly speaking, hes doing better after medication,
things in his life are now going better; calmness satisfaction,
meaningful responses

Heart rate (red line) and GSR (blu) changes of

a therapist during a 50-min interview with an
Obsessive Compulsive patient, first visit
9

The doubious
patient persists and
refuses to leave the
office while other
patients are waiting
(feelings of being
75 bpm
hurried, irritation
of the therapist)

8
7
6
5
4
3
2

GSR1
0
1

10

Series1
Series2

The patient, a young man worried and troubled by his thouhghts,

repeats again and again his obsessions and rituals to the therapist to be sure
he Is exactly undestanding his problem (first part, declining GSR
line)(therapist a little bored)

Electrodermal activity of the therapist during interviews with a calm/collaborative/mild

patient (blue line, below) and an oppositive/provocative/irritable patient with Borderlineparanoid Personality Disorder (red line)
10

Patient MG 35 yr talks aloud, restless, express her hurts,

interrupts the doctor, openly criticizes doctors, asks for her rights

9
8

GSR activity score

7
6
Series3
5

Series4
Series1

Series2

3
2

Patient FR 65 yr, GAD and Hypochondriasis,

talks quietly, soft, waiting confident for the doctor
with some silences

1
0
1

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Patient
starts
to speak

Patient
starts
to cry

Patient shows
open despairr

Patients emotional
recovery

LEFT FOREARM MEAN EMG ACTIVITY OF THE PHYSICIAN DURING VISIT

8

Patient cries

while presenting

Wife comes

his history

in the visit room

Alone, waiting
for the patient

Serie1

Patient

Biondi, 1990

out
2

0
1

10

11

12

13

14

15

16

17

18

19

20

Visit minutes

Hulsman e al, 2010

Very high arousal and distress of young students in

communicating bad news (+15-20 HR/min with respect to BL)
days)

Heart rate in medical students peaks

giving bad news in a simulated session

Brown et al, 2009

Are there immune correlates

of communication?

High insecure
attachment, related to
avoidance of
communication with
patients and other
relationships in
healthy nurses, is
significantly
correlated to
decreased
lymphocyte NK cell
activity

NK cell cytotoxicity (LU 20/107 cells)

ATTACHMENT STYLE AND NK CELL ACTIVITY

Attachment-related avoidance was associated with lower NK cell cytotoxicity

Increase of heart rate and NK cell activity

In the same study,

while viewing the
loved one suffering,
high empathy is
correlated to higher
insular cortex and
anterior cingular
cortex activation
(ACC)

Singer et al, 2004

MORE EMPATHY, MORE PAIN

Some suggestions

As our brain pain centers are repeatedly

activated while we see patients suffering,
Given that our brain steadily consumes its
molecular resources of some actively
partecipates inthe effort of care giving
The mind and body periodically need ....

SUMMARY: PSYCHOBIOLOGY
OF COMMUNICATION
1.
2.

3.

4.

5.

Communication has central neural and somatic

peripheral correlates
Improving communication skills enhances the
quality of care and reduces distress for both
patient and professional, with better handling of
negative emotions
The psychobiology of communication implies a
biological impact on the patient. Communication
of support could reduce biological responses of
stress Further esearch is still needed.
The emotional costs of professional caring,
treating psychological pain and despair are high
and can exhaust the circuits of the social brain.
Self care is needed to replenish them