Racial bias in empathy: Do we process dark- and fair-colored hands in pain differently? An EEG study

Understanding Links between Pandemic-Related Racial Attitudes and Out-Group Prosocial Behaviors

The current study examined COVID-19 pandemic racial attitudes in out-group empathy and out-group prosocial behaviors. Participants included 467 young adults who completed measures of their racial attitudes during the pandemic, out-group perspective taking and empathic concern, and out-group prosocial behaviors. Results demonstrated that pandemic-related racial attitudes were significantly, positively associated with out-group perspective taking and out-group empathic concern, which both positively predicted multiple forms of out-group prosocial behaviors, including emotional, dire, compliant, and anonymous prosocial behaviors. These findings highlight the important role of perspective taking and empathic concern toward individuals outside one's own ethnic group in explaining how racial attitudes during the pandemic were associated with helping behaviors. Discussion focuses on how color-conscious attitudes during an unprecedented U.S. pandemic crisis might be one avenue for promoting prosociality and harmony.

Intracranial EEG signals disentangle multi-areal neural dynamics of vicarious pain perception

Empathy enables understanding and sharing of others' feelings. Human neuroimaging studies have identified critical brain regions supporting empathy for pain, including the anterior insula (AI), anterior cingulate (ACC), amygdala, and inferior frontal gyrus (IFG). However, to date, the precise spatio-temporal profiles of empathic neural responses and inter-regional communications remain elusive. Here, using intracranial electroencephalography, we investigated electrophysiological signatures of vicarious pain perception. Others' pain perception induced early increases in high-gamma activity in IFG, beta power increases in ACC, but decreased beta power in AI and amygdala. Vicarious pain perception also altered the beta-band-coordinated coupling between ACC, AI, and amygdala, as well as increased modulation of IFG high-gamma amplitudes by beta phases of amygdala/AI/ACC. We identified a necessary combination of neural features for decoding vicarious pain perception. These spatio-temporally specific regional activities and inter-regional interactions within the empathy network suggest a neurodynamic model of human pain empathy.

Temporal Unfolding of Racial Ingroup Bias in Neural Responses to Perceived Dynamic Pain in Others

In this study, we investigated how empathic neural responses unfold over time in different empathy networks when viewing same-race and other-race individuals in dynamic painful conditions. We recorded magnetoencephalography signals from Chinese adults when viewing video clips showing a dynamic painful (or non-painful) stimulation to Asian and White models' faces to trigger painful (or neutral) expressions. We found that perceived dynamic pain in Asian models modulated neural activities in the visual cortex at 100 ms-200 ms, in the orbitofrontal and subgenual anterior cingulate cortices at 150 ms-200 ms, in the anterior cingulate cortex around 250 ms-350 ms, and in the temporoparietal junction and middle temporal gyrus around 600 ms after video onset. Perceived dynamic pain in White models modulated activities in the visual, anterior cingulate, and primary sensory cortices after 500 ms. Our findings unraveled earlier dynamic activities in multiple neural circuits in response to same-race (vs other-race) individuals in dynamic painful situations.

The Empathy for Pain Stimuli System (EPSS): Development and preliminary validation

We present the Empathy for Pain Stimuli System (EPSS): a large-scale database of stimuli for studying people's empathy for pain. The EPSS comprises five sub-databases. First, the Empathy for Limb Pain Picture Database (EPSS-Limb) provides 68 painful and 68 non-painful limb pictures, exhibiting people's limbs in painful and non-painful situations, respectively. Second, the Empathy for Face Pain Picture Database (EPSS-Face) provides 80 painful and 80 non-painful pictures of people's faces being penetrated by a syringe or touched by a Q-tip. Third, the Empathy for Voice Pain Database (EPSS-Voice) provides 30 painful and 30 non-painful voices exhibiting either short vocal cries of pain or neutral interjections. Fourth, the Empathy for Action Pain Video Database (EPSS-Action_Video) provides 239 painful and 239 non-painful videos of whole-body actions. Finally, the Empathy for Action Pain Picture Database (EPSS-Action_Picture) provides 239 painful and 239 non-painful pictures of whole-body actions. To validate the stimuli in the EPSS, participants evaluated the stimuli using four different scales, rating pain intensity, affective valence, arousal, and dominance. The EPSS is available to download for free at https://osf.io/muyah/?view_only=33ecf6c574cc4e2bbbaee775b299c6c1 .

The role of external factors in affect-sharing and their neural bases

Affect-sharing, the ability to vicariously feel another person's emotions, is the primary component of empathy that is typically thought to rely on the observer's capacity to feel the emotions of others. However, external signals, such as the target's physical characteristics, have been demonstrated to influence affect-sharing in the neuroscientific literature that speaks to the underappreciated role of external factors in eliciting affect-sharing. We consider factors that influence affect-sharing, including physical cues, emotional cues, situational factors, and observer-target relationships, as well as the neural circuits involved in these processes. Our review reveals that, while neural network activation is primarily responsible for processing affect-sharing, external factors also co-activate a top-down cognitive processing network to modulate the conscious process of affect-sharing. From this knowledge, an integrative framework of external factor interactions with affect-sharing are explained in detail. Finally, we identify critical areas for future research in social and affective neuroscience, including research gaps and incorporation of ecologically valid paradigms.

Neural dynamics of vicarious physical pain processing reflect impaired empathy toward sexually objectified versus non-sexually objectified women

Sexually objectified women are perceived as dehumanized. This may affect the behavioral and neural responses underlying the observer's empathic reactions for their physical pain, although this hypothesis still lacks empirical support. In the present study, we measured the electrophysiological activity of 30 participants (14 females and 16 males), in an empathy for physical pain paradigm in which pictures of sexualized and non-sexualized women were presented in painful and non-painful situations. The behavioral results revealed that sexualized women were evaluated as experiencing less pain than non-sexualized women. Neural evidence corroborated this finding showing that the perception of vicarious physical pain is lacking for sexualized women in both event-related potentials (ERPs) and brain oscillation domains. Specifically, the P2 component and the event-related synchronization/desynchronization (ERS/ERD) on the mu frequency band differed between painful and non-painful stimulation exclusively when women were not sexualized. Our results provide the first evidence that the neurophysiological responses to the vicarious experience of physical pain are dampened or even absent for sexualized women. These findings expand our understanding of the neurophysiological signatures of empathic processes and highlight the detrimental effect of a sexual-objectification bias in everyday contexts.

Event-related modulation of alpha rhythm explains the auditory P300-evoked response in EEG

Evoked responses and oscillations represent two major electrophysiological phenomena in the human brain yet the link between them remains rather obscure. Here we show how most frequently studied EEG signals: the P300-evoked response and alpha oscillations (8-12 Hz) can be linked with the baseline-shift mechanism. This mechanism states that oscillations generate evoked responses if oscillations have a non-zero mean and their amplitude is modulated by the stimulus. Therefore, the following predictions should hold: (1) the temporal evolution of P300 and alpha amplitude is similar, (2) spatial localisations of the P300 and alpha amplitude modulation overlap, (3) oscillations are non-zero mean, (4) P300 and alpha amplitude correlate with cognitive scores in a similar fashion. To validate these predictions, we analysed the data set of elderly participants (N=2230, 60-82 years old), using (a) resting-state EEG recordings to quantify the mean of oscillations, (b) the event-related data, to extract parameters of P300 and alpha rhythm amplitude envelope. We showed that P300 is indeed linked to alpha rhythm, according to all four predictions. Our results provide an unifying view on the interdependency of evoked responses and neuronal oscillations and suggest that P300, at least partly, is generated by the modulation of alpha oscillations.

Relationships between the race implicit association test and other measures of implicit and explicit social cognition

Background

The race-based Implicit Association Test (IAT) was proposed to measure individual differences in implicit racial bias subsumed within social cognition. In recent years, researchers have debated the theoretical tenets underpinning the IAT, questioning whether performance on this task: (1) measures implicit attitudes that operate automatically outside of conscious awareness; (2) reflects individual differences in social cognition; and (3) can predict social behavior. One way to better address these research questions is to assess whether the race-IAT correlates with other implicit processes that are subsumed within social cognition.

Aims

The current study assessed whether the race-IAT was related to other commonly used individual difference measures of implicit (and explicit) social cognition. Experiment 1 assessed whether dissociable patterns of performance on the race-IAT were related to measures of implicit imitative tendencies, emotion recognition and perspective taking toward White task actors, as well as explicit measures of trait and state affective empathy and racial bias. Overcoming limitations of task conceptual correspondence, Experiment 2 assessed whether these latter tasks were sensitive in detecting racial biases by using both White and Black task actors and again examined their relationships with the race-IAT.

Method

In two lab-based experiments, 226 and 237 participants completed the race-IAT followed by an extensive battery of social cognition measures.

Results

Across both experiments, pro-White/anti-Black bias on the race-IAT was positively related to a pro-White bias on explicit measures of positive affective empathy. However, relationships between the race-IAT and implicit imitative tendencies, perspective taking, emotion recognition, and explicit trait and negative state affective empathy were statistically equivalent.

Conclusion

The race-IAT was consistently related to explicit measures of positive state affective empathy but not to other individual difference measures of implicit social cognition. These findings are discussed with regards to the theoretical underpinnings of the race-IAT as an individual difference measure of implicit social cognition, as well as alternative explanations relating to the reliability of social cognition measures and the various combinations of general-purpose (social and non-social) executive processes that underpin performance on these tasks.

Empathic pain observation does not influence automatic imitation in an online setting

Previous research has shown that empathic pain observation can lead to motor facilitation in the form of faster reaction times. However, it is unclear whether participants are focusing on the others' pain or simply focusing on their own discomfort/distress (from watching the videos) during the task. This is an important issue as self- vs other-oriented focusing plays a key role in empathic processing. To address this issue, we combined empathic pain observation with the automatic imitation task (AIT). Previous work has shown that AIT effects are smaller after experiencing pain, which has been interpreted as the result of the experience of pain leading to a self-oriented focus. If empathic pain observation similarly leads to a self-oriented focus, then we should expect similar AIT results after pain observation (smaller AIT effects); however, if it instead leads to an other-oriented focus, then we should see the opposite (larger AIT effects). Although we found initial evidence for the latter hypothesis (Experiment 1), subsequent failed replications suggests that we do not have sufficient evidence to claim that pain observation influences automatic imitation one way or the other (Experiment 2 and 3). We discuss some possible reasons for finding null results in these experiments and suggest future avenues of research to better elucidate this topic.

Effect of doctor-patient news-induced moral judgments on pain empathy for doctors and patients in China

Objective

Pain empathy's preferential nature tends to trigger prejudice and intergroup conflicts. Given the current degree of proliferation of doctor-patient conflict news in China, this study aims to determine whether readers of doctor-patient news-initiated moral judgments prefer pain empathy for doctors or patients.

Materials and methods

This study utilized localized doctor-patient news with high or low moral performance (based on morality ratings of patients' behaviors) as moral-judgment-eliciting materials, and painful pictures as pain empathy-eliciting materials. The event-related potential (ERP) technique was utilized to assess moral judgment's effect on the cognitive empathy component and to investigate electroencephalogram signals' accuracy in classifying four brain response patterns when facing doctor or patient is experiencing or not experiencing pain.

Results

Under low moral text material, participants exhibited smaller mean wave amplitude of positive 300 (P3) and late positive potential (LPP) to painful pictures than non-painful pictures when facing patients; under high moral text material, participants exhibited larger mean wave amplitude of P3 and LPP to painful pictures than non-painful pictures when facing doctors. Electroencephalogram (EEG) signals' classification accuracy was significant in 0-1,000 ms in both high and low moral judgments, but the classification accuracy was higher in low moral judgments in some cognitive empathy stages (0.51, 0.53-0.55, 0.66-0.79, and 0.88-1 s).

Conclusion

Under low moral judgment, individuals pay less attention to the patient's (perpetrator's) pain; under high moral judgment, individuals empathize with the doctor (the person praised), showing that news-induced moral judgment can sway readers' empathy for different social groups. In cognitive empathy, individuals' brain representations are more discriminatory under low than high moral judgments when confronted with pain by doctors and patients, which provides insight into objectively recognizing group bias.

The Effect of Cognitive Strategies and Facial Attractiveness on Empathic Neural Responses

Empathy is a phenomenon that brings together both emotions and an understanding of another person. Recent studies have disentangled the mechanisms of empathy into emotional and cognitive aspects. Event-related potential (ERP) studies suggest that emotional empathy is related to the modulation of the amplitude of early ERPs, and cognitive empathy is linked to later ERPs. In the current study, we examined the influences of facial attractiveness on empathic response and the effect of cognitive strategies with setting the participants' attention to attractiveness or pain. Participants (N= 19) viewed photos of physically attractive and unattractive men and women receiving painful stimulation. The amplitude of the N2 component measured at the frontal regions was more negative in painful stimulation compared to the non-painful, but only for attractive faces. There were no differences between painful and non-painful stimulation for unattractive faces. The amplitude of the P3 measured at the central-parietal region component was more positive in the painful condition compared to the non-painful one, but only when participants performed a pain judgment task. There were no differences in the attractiveness judgment task. This study showed that the attractiveness of a model and drawing the participants' attention to pain constitute an essential modulator of pain empathy.

Skin Color and Attractiveness Modulate Empathy for Pain: An Event-Related Potential Study

Although racial in-group bias in empathy for pain has been reported, empathic responses to others’ pain may be influenced by other characteristics besides race. To explore whether skin color and attractiveness modulate empathy for pain, we recorded 24 participants’ reactions to painful faces from racial in-group members with different skin color (fair, wheatish, or dark) and attractiveness (more or less attractive) using event-related potentials (ERPs). Results showed that, for more attractive painful faces, dark skin faces were judged as less painful and elicited smaller N2 amplitudes than fair- and wheatish-skinned faces. However, for less attractive faces, there were no significant differences among the three skin colors. Our findings suggest that empathy for pain toward racial in-group members may be influenced by skin color and attractiveness.

Neuroscience and climate change: How brain recordings can help us understand human responses to climate change

There is little published neuroscience research on the psychology of climate change. This review outlines how carefully designed experiments that measure key neural processes, linked to specific cognitive processes, can provide powerful tools to answer research questions in climate change psychology. We review relevant literature from social neuroscience that can be applicable to environmental research-the neural correlates of fairness and cooperation, altruistic behaviour and personal values-and discuss important factors when translating environmental psychology constructs to neuroscientific measurement. We provide a practical overview of how to implement environmental neuroscience using electroencephalography, summarising important event-related potential components and how they can be used to answer questions in climate change psychology. Challenges for the field include accurate attribution of findings, both within and between studies, the need for interdisciplinary collaboration, peer review and reporting processes.

Increasing self-other bodily overlap increases sensorimotor resonance to others' pain

Empathy for another person’s pain and feeling pain oneself seem to be accompanied by similar or shared neural responses. Such shared responses could be achieved by mapping the bodily states of others onto our own bodily representations. We investigated whether sensorimotor neural responses to the pain of others are increased when experimentally reducing perceived bodily distinction between the self and the other. Healthy adult participants watched video clips of the hands of ethnic ingroup or outgroup members being painfully penetrated by a needle syringe or touched by a cotton swab. Manipulating the video presentation to create a visuospatial overlap between the observer’s and the target’s hand increased the perceived bodily self-attribution of the target’s hand. For both ingroup and outgroup targets, this resulted in increased neural responses to the painful injections (compared with nonpainful contacts), as indexed by desynchronizations of central mu and beta scalp rhythms recorded using electroencephalography. Furthermore, these empathy-related neural activations were stronger in participants who reported stronger bodily self-attribution of the other person’s hand. Our findings provide further evidence that empathy for pain engages sensorimotor resonance mechanisms. They also indicate that reducing bodily self-other distinction may increase such resonance for ingroup as well as outgroup targets.

Doctors inhibit social threat empathy in the later stage of cognitive processing: Electrophysiological evidence

Previous studies have found that repeatedly exposed to a threatening situation may reduce doctors' level of empathy, reducing psychological stress and avoiding burnout and compassion fatigue. However, many essential studies found that it does not seem universal but rather modulated by group membership. In this study, we recorded event-related potentials (ERP) when doctors and controls watched visual stimuli describing patients attacking doctors (Threat events) or shaking hands with doctors (Neutral events). The present study showed an early N190 and a later centro-parietal P3 differential amplitude between threat stimuli and neutral stimuli were observed in the controls. For the doctors, there was such ERP differentiation in early N190. However, later stage P3 differential amplitude was not observed. The current research suggests that doctors could regulate empathy and avoid allocating more attention resources when processing social threats to ensure treatment efficiency and avoid burnout.

Investigating the effects of pain observation on approach and withdrawal actions

Previous research has shown that observing another individual receiving a painful stimulus leads to motor facilitation as indexed by faster reaction times. The current study explores whether the type of action that is executed modulates this facilitation effect. Specifically, we examined whether approach-like and withdraw-like movements are differentially influenced by pain observation. In experiment 1, participants performed key presses (approach) and releases (withdraw) after observing another person in pain (vs. no pain). In experiment 2, participants used a joystick to make forward (approach) and backward (withdraw) movements after observing another person in pain (vs. no pain). Across both experiments, we did not find evidence for differential effects of pain observation on approach-like and withdraw-like movements. We do, however, report a robust response-general effect of pain observation on motor behaviour (i.e., faster reaction times after pain observation vs. no pain, regardless of movement type). We discuss these results in relation to the wider emotion, attention, and social neuroscience of empathy literatures.

Neural dynamics of pain expression processing: Alpha-band synchronization to same-race pain but desynchronization to other-race pain

Both electroencephalography and functional magnetic resonance imaging studies have revealed enhanced neural responses to perceived pain in same-race than other-race individuals. However, it remains unclear how neural responses in the sensorimotor, cognitive, and affective subsystems vary dynamically in the first few hundreds of milliseconds to generate racial ingroup favoritism in empathy for pain. We recorded magnetoencephalography signals to pain and neutral expressions of Asian and white faces from Chinese adults during judgments of racial identity of each face. We found that pain compared to neutral expressions of same-race faces induced early increased alpha oscillations in the precuneus/parietal cortices followed by increased alpha-band oscillations in the left anterior insula and temporoparietal junction. Pain compared to neutral expressions of other-race faces, however, induced early suppression of alpha-band oscillations in the bilateral sensorimotor cortices and left insular cortex. Moreover, decreased functional connectivity between the left sensorimotor cortex and left anterior insula predicted reduced subjective feelings of other-race suffering. Our results unraveled distinct patterns of modulations of neural dynamics of sensorimotor, affective, and cognitive components of empathy by interracial relationships between an observer and a target person, which provide possible brain mechanisms for understanding racial ingroup favoritism in social behavior.

Differences between empathy for face and body pain: Cognitive and neural responses

Empathy for pain is a hotspot in the field of empathy research because of its specific cognitive and neural mechanism. Currently, studies of empathy for pain can be classified into two categories based on the body regions receiving the painful stimulus, i.e., empathy for face pain and empathy for body pain, which conveys painful information based on individuals’ faces or body parts, respectively. Although the existing evidence revealed differences between these two kinds of pain empathy regarding the underlying cognitive and neural mechanisms, the current studies tend to confuse these findings. Therefore, we summarized the differences between empathy for face and body pain, mainly regarding the behavioral reactivity tendency, brain activations, and electrophysiological (EEG) signals. These differences probably stem from the fact that the human face contains more emotional information, while other body parts contain more perceptual information. Thus, future studies should identify the distinctions between empathy for face and body pain, to explore further how empathy for face pain is affected by the facial information of others and focus on empathy for face pain in individuals with psychopathological disorders. Furthermore, the specific reasons for these distinctions and their underlying neuromechanisms deserve to be further reviewed.

Empathic concern and personal distress depend on situational but not dispositional factors

Empathic concern and personal distress are empathic responses that may result when observing someone in discomfort. Even though these empathic responses have received much attention in past research, it is still unclear which conditions contribute to their respective experience. Hence, the main goal of this study was to examine if dispositional empathic traits or rather situational variables are more likely to evoke empathic concern and personal distress and how the two empathic responses influence motor responses. We presented pictures of persons in psychological, physical, or no pain with matched descriptions of situations that promoted an other-focused state. Approach-avoidance movements were demanded by a subsequently presented tone. While psychological pain led to more empathic concern, physical pain led to higher ratings of personal distress. Linear mixed-effects modelling analysis further revealed that situational factors, such as the type of pain but also the affect experienced by the participants before the experiment predicted the two empathic responses, whereas dispositional empathic traits had no significant influence. In addition, the more intensely the empathic responses were experienced, the faster were movements initiated, presumably reflecting an effect of arousal. Overall, the present study advances our understanding of empathic responses to people in need and provides novel methodological tools to effectively manipulate and analyze empathic concern and personal distress in future research.

Your Performance Is My Concern: A Perspective-Taking Competition Task Affects ERPs to Opponent's Outcomes

Previous research has shown that people have more empathic responses to in-group members and more schadenfreude to out-group members. As a dimension of cognitive empathy, perspective-taking has been considered to be related to the enhancement of empathy. We tried to combine these effects through manipulation of a competitive task with opponents and an in-group partner and investigated the potential effect of in-group bias or the perspective-taking effect on outcome evaluation. We hypothesized that the neural activities would provide evidence of in-group bias. We tested it with a simple gambling observation task and recorded subjects' electroencephalographic (EEG) signals. Our results showed that the opponent's loss evoked larger feedback-related negativity (FRN) and smaller P300 activity than the partner's loss condition, and there was a win vs. loss differential effect in P300 for the opponent only. The principal component analysis (PCA) replicated the loss vs. win P300 effect to opponent's performance. Moreover, the correlation between the inclusion of the other in the self (IOS) scores and FRN suggests perspective-taking may induce greater monitoring to opponent's performance, which increases the win vs. loss differentiation brain response to the out-group agent. Our results thus provide evidence for the enhanced attention toward out-group individuals after competition manipulation, as well as the motivation significance account of FRN.

Processing of Painful Pictures in Individuals With High and Low Rejection Sensitivity: Evidence From Event-Related Potentials

An increasing number of studies have investigated the relation between the processing of painful stimuli and rejection. Little was known, however, about the impact of the rejection sensitivity (RS) on the processing of painful pictures. This study addressed this issue using high temporal resolution event-related potential techniques. Thirty high RS (20 women and 10 men who scored in the top 20th percentile of the Rejection Sensitivity Questionnaire scores) and 30 low RS (20 women and 10 men who scored in the bottom 20th percentile) volunteers participated in the experiment. All volunteers performed a discrimination task of painful pictures in which they were asked to judge whether target pictures were painful or not. Behaviorally, participants exhibited shorter reaction times for painful than nonpainful pictures. For the P100 component, low RS participants showed stronger brain activities for painful than nonpainful pictures, suggesting vigilance toward painful pictures. High RS participants, however, exhibited no P100 amplitude differences between painful and nonpainful pictures, indicating an analgesia phenomenon. Furthermore, we found that there were larger amplitudes in the late late positive complex component for painful compared with nonpainful pictures, regardless of participants' RS. This suggested a person's further assessment for painful pictures. In short, our findings demonstrated that the level of RS influenced the pain processing at a very early stage of processing.

Meta-analysis of ERP investigations of pain empathy underlines methodological issues in ERP research

Empathy has received considerable attention from the field of cognitive and social neuroscience. A significant portion of these studies used the event-related potential (ERP) technique to study the mechanisms of empathy for pain in others in different conditions and clinical populations. These show that specific ERP components measured during the observation of pain in others are modulated by several factors and altered in clinical populations. However, issues present in this literature such as analytical flexibility and lack of type 1 error control raise doubts regarding the validity and reliability of these conclusions. The current study compiled the results and methodological characteristics of 40 studies using ERP to study empathy of pain in others. The results of the meta-analysis suggest that the centro-parietal P3 and late positive potential component are sensitive to the observation of pain in others, while the early N1 and N2 components are not reliably associated with vicarious pain observation. The review of the methodological characteristics shows that the presence of selective reporting, analytical flexibility and lack of type 1 error control compromise the interpretation of these results. The implication of these results for the study of empathy and potential solutions to improve future investigations are discussed.

Changing characteristics of the empathic communication network after empathy-enhancement program for medical students

The Empathy-Enhancement Program for Medical Students (EEPMS) comprises five consecutive weekly sessions and aims to improve medical students' empathic ability, an essential component of humanistic medical professionalism. Using a graph theory approach for the Ising network (based on l1-regularized logistic regression) comprising emotional regulation, empathic understanding of others' emotion, and emotional expressivity, this study aimed to identify the central components or hubs of empathic communication and the changed profile of integration among these hubs after the EEPMS. Forty medical students participated in the EEPMS and completed the Depression Anxiety Stress Scale-21, the Empathy Quotient-Short Form, the Jefferson Scale of Empathy, and the Emotional Expressiveness Scale at baseline and after the EEPMS. The Ising model-based network of empathic communication was retrieved separately at two time points. Agitation, self-efficacy for predicting others' feelings, emotional concealment, active emotional expression, and emotional leakage ranked in the top 20% in terms of nodal strength and betweenness and closeness centralities, and they became hubs. After the EEPMS, the 'intentional emotional expressivity' component became less locally segregated (P = 0.014) and more directly integrated into those five hubs. This study shows how to quantitatively describe the qualitative item-level effects of the EEPMS. The key role of agitation in the network highlights the importance of stress management in preserving the capacity for empathic communication. The training effect of EEPMS, shown by the reduced local segregation and enhanced integration of 'intentional emotional expressivity' with hubs, suggests that the EEPMS could enable medical students to develop competency in emotional expression, which is an essential component of empathic communication.