The Fear Factor Read online

  Could amygdala responses to others’ fear represent a similarly empathic response, one that could predict compassionate responses to others’ distress? Perhaps. My research on psychopathy is consistent with this possibility. As I (and others) have found, adolescents and adults who are psychopathic claim not to experience strong fear themselves. This deficit seems not only to leave them callous in the face of others’ fear but to impair their ability to even recognize others’ fear. Other studies of large samples of adults have yielded similar findings, namely, that people who report experiencing less fear in their own lives also have more trouble recognizing it in others. It is as though a meager personal experience of fear prevents someone from even understanding what fear is, much as people who are color-blind to red and green shades cannot really understand what “red” is. The fact that psychopaths have limited personal experiences of fear and have difficulty even labeling others’ fear strongly suggests that they are fundamentally impaired in their ability to empathize with fear—that they cannot encode and translate others’ internal fearful experience into something they can understand. That psychopaths’ amygdala responses to others’ fear are abnormal supplies further evidence that dysfunction in this structure—a core structure necessary both for recognizing others’ fear and for generating a fear response—underlies their deficits.

  I should note that amygdala-based deficits impair understanding of others’ fear across the board, not only when it is expressed via the face. The amygdala is essential for recognizing not only fearful facial expressions but fearful vocal expressions as well. One recent study investigating the acoustic properties of screams found that the amygdala is particularly attuned to their rough, ragged sound. Studies of patients with amygdala lesions have found these individuals to be similarly impaired in recognizing fearful vocalizations, as well as fearful body postures—even spooky music, of the kind that creates chills of fear in most people, leaves them unaffected. Quite recently, my student Elise Cardinale and I found that the amygdala is also important for identifying behaviors (threats, for example) that cause others fear. In a series of studies we conducted, high psychopathy scorers failed to recognize that a threatening utterance like “You better watch your back” is likely to frighten someone, and their impairments corresponded to reduced recruitment of the amygdala when considering the acceptability of uttering such a statement.

  These findings are, I think, a critical piece of the puzzle. They bolster the case that amygdala deficits in psychopathy don’t impair only responses to others’ fear expressed via the face. If that were true, it would imply that the problem is simply perceptual and that psychopaths’ problems could be solved just by giving them little strategies or clues to help them recognize others’ fear—like looking for wide eyes or raised and crinkled brows. If it were only that simple! Instead, it seems, the amygdala is the final common pathway for generating a coordinated understanding of others’ fear at a gut level, whether it is seen or heard or smelled or simply imagined. And even more importantly, the fact that psychopathic individuals struggle to understand others’ fear across all these modalities provides a concrete link between empathy for fear and the experience of concern and compassion—the traits that are quintessentially absent in psychopaths.

  It’s not clear that the same link exists for other forms of empathy. Psychopaths are not generally impaired in understanding various other internal states, such as beliefs and goals, or even most other emotions. This reinforces the idea that empathy is not a single broad construct. There are many forms of empathy, and it is possible to possess some in abundance but lack others. Psychopaths are not really impaired in understanding anger or disgust, for example. It’s not even clear whether psychopathy impairs empathy for pain. Although empathy for pain is an important social response, little evidence links a lack of empathy for pain to actual callousness. Behaviorally, there is not at this point a strong body of research showing that psychopaths have reduced experiences of pain, or that they have difficulty recognizing when others are in pain. Evidence from brain imaging studies is similarly mixed. One recent brain imaging study of psychopathic adolescents showed reduced activity in the pain matrix, but my own similar study with James Blair did not. And one study of adult psychopaths found more activity in the anterior insula in response to others’ pain. All signs, then, point to the idea that psychopathy may be more closely intertwined with deficits in empathy for fear than empathy for pain.

  Is it simply a coincidence that those individuals who are most marked by their lack of compassion and caring are also deficient in recognizing and responding to others’ fear? Or is this actually the heart of the matter? Is the ability to generate an amygdala-based empathic response to others’ distress—and fear in particular—somehow tied to the capacity for caring and compassion? If so, this might be a critical step toward understanding extraordinary altruism.

  If understanding others’ fear and emotional distress is essential to generating care and compassion in response to that distress, then it is clear what a peek inside the brains of extraordinary altruists should reveal. These individuals, whose attitudes toward others’ welfare are so unlike those of psychopaths, whose behavior indicates that they experience unusually enhanced feelings of care and compassion for others, should show responses in the lab that are the polar opposite of what has been found in psychopaths: they should be more sensitive to other people’s fear, and their amygdalas should be more responsive to fearful faces. Their amygdalas might even be larger than average as well.

  Extraordinary altruists should have, in short, anti-psychopathic brains.

  Another brain scan, another bunch of brain scanning subjects causing problems. This was not what I’d expected would happen on our first day of scanning altruistic kidney donors’ brains to see if they were, in fact, “anti-psychopaths.”

  Recruiting the altruists had been astonishingly easy. Not only were they enthusiastic about participating, but they often pitched in, unasked, to help me recruit—peppering their Facebook feeds and blog posts with messages about the study and encouraging others to take part. Not one of the altruists expressed hesitation when my students explained that, for the study, they would need to travel to Georgetown for a day or two and spend over five hours completing a long battery of brain imaging and behavioral testing for a fairly paltry $150 in compensation. All of them led busy lives, and many were professionals with well-paying jobs—software engineers and bankers and physicians and marketers—but they didn’t hesitate to arrange to take days off work and fly across the country to help us out. One young altruist from the Midwest told us that he was very interested in taking part but would need a few months to save up for the plane ticket. “No, no, no!” we hastened to tell him. “We’ll cover all your travel costs and pay you—you don’t have to pay anything to participate!” But think of it—he was perfectly willing to do so.

  Another altruist named George Taniwaki flew in to see us from the Pacific Northwest. I know how long it takes to travel from the Seattle area to Washington, DC, as I’ve done it many times myself. It’s a long day of travel on the best day. And this was not the best day. Sea-Tac Airport was socked in by fog and freezing rain, and his flight got canceled—twice. And then it got rescheduled twice. Many people would have given up after the first four hours of waiting. But George sat there in that airport all day, waiting, refusing to go home if there was any chance at all he might still be able to make it to Georgetown in time for his scheduled brain scan. (Most MRI scanners, including ours, are tightly scheduled, and it’s nearly impossible to reschedule a ninety-minute session at the last minute.) After sitting and waiting in an uncomfortable airport seat for most of a day, and then taking a five-hour flight to DC, he finally made it to Georgetown. Then, rather than rest after his testing wrapped up the next day, he invited us all out to have dinner with him. I had never before considered whether eating dinner with a study participant following the conclusion of testing entails an ethical or scientific dilemma.
Whoever heard of the question even coming up? In any case, I couldn’t come up with any reason not to go, so we went, and we had a lovely evening. (I of course wouldn’t let him pay for us.)

  It was not this altruist, however, who caused trouble on scanning day. The culprits were the first three altruistic donors we brought into the lab, all on the same day. They were three women who had flown in from all over the country and who knew each other through the living donor community. They were excited that we brought them in at the same time so that they could spend the evening enjoying the city together. They were equally excited about the opportunity to take part in the study. One of them, Angela Cuozzo, later blogged about how fortunate she had felt to be able to participate, adding that the anticipation leading up to the weekend had been nearly “killing” her.

  Perhaps all this excitement was the reason that these three fortyish women ended up on the verge of setting off shrieking, clanging alarms all over the section of the Georgetown School of Medicine campus where the MRI suite is housed, which not even our most behaviorally disordered teenager had ever accomplished. Why? Because they were so determined not to be late for their scans. The first scan was scheduled for 9:15 a.m., the next for 10:45 a.m., and the final one for 12:15 p.m. The three were staying in a hotel about a five-minute shuttle ride from campus. So naturally, all three of them departed for campus more than an hour before the first scan. Then they got a little mixed up trying to locate the MRI suite from the spot where the shuttle dropped them off (which is completely understandable, as the suite is notoriously difficult to find). So they raced down a series of unmarked corridors in the hospital until they got so lost that they attempted to break through a secure fire exit as a shortcut. Thank goodness that plan didn’t work.

  They ended up backtracking and eventually managed to find their way to us, still arriving well ahead of time, around 8:30 a.m. They then waited patiently on the little gray couches in the waiting area, amid back issues of Consumer Reports and Redbook, until it was their turn to be tested. That meant that the last of the three scheduled subjects had arrived over three hours early for her brain scan. And had been worried about being late! This is a degree of conscientiousness that I feel must be nearly unprecedented in the history of psychological research. It presented me with a “problem” I had never faced before: feeling sincerely unworthy in the face of the kindness and helpfulness of my research subjects.

  The scanning itself felt familiar, even if the project was anything but. Once again, my subjects watched from the dark bore of the MRI scanner as black-and-white pictures of Ekman and Friesen and all the others flashed before them one by one. Sometimes the faces wore faint smiles. Others glowered angrily. And of course, still others showed the wide eyes, oblique brows, and grimaces of fear. While they watched, the subjects held in each hand old-school black-plastic video game–looking controllers. Long wires sprouting from the controllers snaked through the MRI and across the floor of the scan room, then through holes carved into the wall of the adjoining control room, where we sat watching and where our computers recorded the subjects’ responses. To keep them focused on the faces, we had instructed them to push the red button atop one controller every time they saw a man’s face and to press the button on the other controller for a woman’s face. Simple. Man or woman? Man or woman? Over and over and over again—more than 300 times over the course of about twenty minutes.

  All the while, another roomful of nearby computers ran the scanner, manipulating the massive magnetic field surrounding the subjects’ heads. CLACK-CLACK-CLACK-CLACK-deedeedeedeedee-deedeedee, rumbled the scanner, its machinations causing tiny charged particles inside the altruists’ brains to tumble and spin on their axes. Inside the scanner, the birdcage-shaped coil encircling their heads collected the faint radio signals created by all this tumbling and spinning. I could picture the pink, two-centimeter ovals of the amygdalas pulsing deep within their brains, waiting for their cue. The subjects hadn’t been told to pay attention to the expressions on the flickering faces, but no matter. Flash! A bright, white sclera leapt from the screen. Did the amygdala blaze to life a few dozen milliseconds later, its cells pulsing out a Morse code message to the rest of the brain? Look sharp! Someone’s scared! If so, it would momentarily increase this structure’s fuel consumption by a tiny amount, no more than 1 percent or so. But that would change the way the protons within it danced and spun just enough for us to measure—enough to inform us how an extraordinary altruist responds to others’ fear.

  As friendly and helpful and generous as the altruists were, and as patiently as they lay in the scanner pushing the red buttons, many of them didn’t hesitate to tell me—tactfully—how wrongheaded the study was. Harold Mintz was perhaps the most vocal of them. Harold’s story is an unusual one, even in the world of altruistic kidney donors, because, like Sunyana Graef, he had never heard of anyone donating a kidney to a stranger before he came up with the idea on his own. He first had the idea around the time Graef did, in 1998 (what was in the air that year?), at which time he was living in Arlington, Virginia. Unlike Graef, he didn’t live near a transplant center willing to remove his kidney and give it to a stranger. He tried contacting the National Kidney Foundation, but all he got in return was a stack of pamphlets in the mail that explained how to donate his organs after he died. Hey, he thought, I’m not dead yet. So he called them back. He tried to clarify: “I’m just curious about donating now to somebody here in the DC area.”

  A long silence followed. Then:

  “You can’t do that. It’s illegal.”

  But they took down his name and number and said they would call him back if anything changed.

  Yeah, sure, Harold thought.

  But something did change. That same year, the Washington Regional Transplant Consortium was in the early stages of developing what would become the first community-based living organ donor registry. They got Harold’s contact information from the National Kidney Foundation and called him back two years later to say that they were launching the program. Did he still want to donate? He jumped at the chance. After a long bout of psychiatric and medical screening, Harold became the very first person the program approved to donate.

  Knowing Harold, this doesn’t surprise me at all. I find it hard to imagine meeting with him and denying him the chance to give away his kidney. He looks like a cigarette billboard cowboy, complete with a wild shock of graying hair and a fulsome grizzled mustache, and he has the charisma of a preacher. He’s one of those people who seems to make the air around him sparkle. I’ve shown clips of my interviews with him at conferences, and attendees will circle back to me years later to ask about the “mustache guy.”

  Harold describes his decision to give away a kidney as if it’s the most obvious, the most straightforward decision a person could make. When asked to explain why he donated, he responds with a question that most people find easy to answer, which is, “Would you give a kidney to your mother to save her life?”

  Essentially everyone answers yes.

  He’ll nod, then scribble down a few letters on a piece of paper. He’ll then ask, “Okay, why? Why would you donate to your mom?”

  Everyone, he says, replies exactly the same way. I did as well when he asked me: “Because she’s my mom.”

  Harold then flips the paper around to show the letters “BSMM” written on it: Because She’s My Mom. He already knew what they would say.

  And what people say is telling. The response “because she’s my mom” is not really an explanation at all. It’s hardly better than just saying, “Because.” It’s not a description of costs and benefits, or an exegesis on the details of what the surgery might entail and the likely long-term outcomes of kidney disease. The answer is much more primitive: she’s my mom, she’s going to die otherwise, so I’ll give her my kidney and worry about the details later. In this way, in this response, we are almost all the same.

  Then Harold will push further: “So we got that, you’d do it for your mom.
Okay, how about your sister or your brother? How about your best friend, who’s not related? How about your teacher, or your boss?” He extends the circle further and further out, challenging you to tell him when you would stop caring enough about another person’s life to give them your kidney. “What if,” he asks, “that person is going to die next week and you’re the only person who can save them? There is somebody dying right now while we’re having this conversation, where the doctors know exactly what to do to fix them. We can actually stop somebody from suffering—from losing what they might have.”

  These questions echo a conversation Harold had while being screened for his donation. He had asked the transplant team, “If I don’t give my kidney to somebody this week, will someone die waiting for it?”

  “Yes,” they told him.

  That sealed the deal. For him, Harold says, taking all of this into account, donating his kidney really wasn’t a choice. It was an opportunity. “Because someone is going to die” was for him just as obvious and simple an explanation for donating his kidney to a stranger as “because she’s my mom” is for everyone else.

  On December 12, 2000, in an operating suite at Georgetown University, steps away from where we would later scan his brain, a team of surgeons removed Harold’s left kidney and stitched it into the abdomen of a young woman named Gennet Belay, a wife, mother, and Ethiopian immigrant who at the time had only 6 percent of her kidney function remaining. In a short film called 1-800-Give-Us-Your-Kidney, Belay’s husband recalled that her doctor had told her at one point she had only three days left to live. Harold’s kidney started working to filter her blood almost immediately after the transplant and continues to do so to this day. Harold sends it a birthday card every year. Belay considers the day of the transplant her own “re-birthday”—the day Harold returned her to a life free of disease and medical complications.