I do not feel your pain: Exploring the impact of state empathy on placebo and nocebo effects evoked by observational learning

Observational learning (OBL) can elicit placebo hypoalgesia or nocebo hyperalgesia if pain relief or exacerbation is observed after placebo administration. While dispositional empathy has occasionally been associated with increased placebo and nocebo responding, the contribution of situational empathy remains elusive. This study addresses this gap using a validated experimental paradigm. Healthy individuals (n=180, 60% females) were randomized to four experimental (placebo-OBL, high-empathy placebo-OBL, nocebo-OBL, high-empathy nocebo-OBL) or two control groups (random-ratings OBL, no-observation). Medium pain was evoked at baseline and post-OBL with heat stimuli to both arms. Before OBL, a placebo ointment was applied to one arm. In the experimental groups, participants observed a model expressing hypoalgesia or hyperalgesia in reaction to the ointment. In the empathy groups, participants were instructed to empathize with the model. OBL did not alter pain intensity (F(3,176)=1.02, p=.39, η_p²=.02), although pain expectations changed in the expected direction (F(5.76,337.84)=5.81, p<.001, η_p²=.09). There were no between-group differences in situational empathy (indicating a failed empathy manipulation), and the magnitude of placebo hypoalgesia, or nocebo hyperalgesia (all p's≥.19). The current study is one of only a few highlighting the limits of OBL-induced placebo and nocebo effects. It suggests that changing expectations alone may not always be sufficient to produce changes in pain perception. Potential factors explaining these findings, including attention and cognitive load, are discussed. Increasing our understanding of OBL-induced pain changes can support the development of interventions for (chronic) pain. Studying the contribution of empathic processes may be particularly relevant given their vital role in human interactions. PERSPECTIVE: This article presents the results of an experimental mixed-model study on state empathy and placebo hypoalgesia and nocebo hyperalgesia, induced by observational learning (OBL). Although expectations changed, empathy and OBL did not elicit any changes in the experience of pain. The findings highlight the limits of OBL for altering pain.