ORIGINAL ARTICLE

Affective, sensory and empathic sharing of another’s pain: The

Empathy for Pain Scale
M.J. Giummarra1,2, B.M. Fitzgibbon3, N. Georgiou-Karistianis1, M. Beukelman1, A. Verdejo-Garcia1,
Z. Blumberg4, M. Chou4,5, S.J. Gibson2,6,7
1 School of Psychological Science, Monash University, Melbourne, Australia
2 Caulfield Pain Management and Research Centre, Caulfield Hospital, Australia
3 Monash Alfred Psychiatry Research Centre, Central Clinical School, The Alfred Hospital, Monash University, Melbourne, Australia
4 Rehabilitation Services, Caulfield Hospital, Australia
5 Amputee Unit, Caulfield Hospital, Australia
6 National Ageing Research Institute, Parkville, Australia
7 Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia

Correspondence
Melita Joy Giummarra
E-mail: melita.giummarra@monash.edu
Funding sources
This project was supported by a small project
grant from Caulfield Hospital, and bridging
fellowships awarded to MJG and BMF from
the Faculty of Medicine, Nursing and Health
Sciences, Monash University. MJG and BMF
are supported by NHMRC early career
fellowships (APP1036124, APP1070073).
Conflicts of interest
None declared.
Accepted for publication
22 September 2014
doi:10.1002/ejp.607
Abstract
Background: Through two studies, we introduce and validate the
Empathy for Pain Scale (EPS), which characterizes the phenomenology of
empathy for pain, including the vicarious experience of pain when seeing
others in pain.
Methods: In study 1, 406 individuals completed the EPS and
Interpersonal Reactivity Index (IRI). In the EPS, four painful scenarios
(witnessing surgery, patient recovering from surgery, assault and
accidental injury) were rated for 12 emotional, empathic and sensory
responses. In study 2, 59 participants completed the same questionnaires
and then watched and rated videos of sporting injuries.
Results: In study 1, we identified three factors of the EPS with principal
component analysis, which were validated with confirmatory factor
analysis: affective distress; vicarious pain; and empathic concern. The EPS
demonstrated good psychometric properties, re-test reliability (n = 105)
and concurrent validity. In study 2, we validated the EPS against empathic
reactions to the pain of others as displayed in video clips depicting sporting
injuries and showed that the scale has unique utility to characterize
empathic reactions to pain above general trait empathy measures. Both
studies showed that the affective distress and empathic concern subscales
of the EPS correlated with measures of cognitive and affective empathy
from the IRI, whereas the vicarious pain subscale was only correlated with
the personal distress IRI subscale.
Conclusions: The EPS is a psychometrically sound new scale that
characterizes empathy for pain and vicarious pain. The EPS offers valuable
insight to the phenomenological profile of the affective, empathic and
sensory dimensions of empathy for pain.

others involves cognitive appraisal, in which we seek to

1. Introduction
Empathy is interpersonal social experience that
involves affective resonance, cognitive appraisal and
emotion regulation, which together enhance pro-
social interactions (Decety, 2010). Empathizing with
represent the internal mental states of others, also
referred to as theory of mind (Blair, 2005), and emo-
tional or affective appraisal in which we resonate with
the emotional state of others through empathic
concern or vicarious emotional responses (Reniers

© 2014 European Pain Federation - EFIC® Eur J Pain •• (2014) ••–•• 1

The Empathy for Pain Scale
What’s already known about this topic?
• The neural correlates of ‘empathy for pain’ are
well established.
• Individual differences are associated with
increased (e.g., trait empathy, in-/out-group
biases) and reduced (e.g., autism spectrum disor-
ders) affective or sensory resonance for others’
pain.
What does this study add?
• Validation of a new scale that characterizes the
dispositional profile of empathic, sensory and
affective responses to pain in others.
et al., 2011). Further, sensorimotor dimensions of
empathy involve evaluating the experiences and
behaviours of others through shared or ‘mirrored’
neurophysiological pathways in order to understand
their internal and motivational states (Keysers et al.,
2010). When witnessing others in pain, most of us
experience embodied empathic reactions to the other
person’s distress. Most research in this field has
focused on characterizing the neural networks
involved empathizing with others in pain. These
studies have found that thinking about another in pain
arouses cognitive and affective empathic appraisals,
with increased activation throughout the
motivational-affective brain networks (e.g., anterior
insula, frontal operculum and cingulate cortices;
Singer et al., 2004). Seeing another in pain also brings
about sensorimotor empathic appraisals, with
increased activation in neural regions underpinning
sensory processing and perspective taking (e.g., soma-
tosensory and inferior parietal cortices; see meta-
analysis: Lamm et al., 2011). Furthermore, while
seeing others in pain elicits sensorimotor empathic
resonance, 16–30% of the population also report
vicarious sensory experiences of pain (Fitzgibbon
et al., 2010; Osborn and Derbyshire, 2010). In this
context, vicarious (Latin origin: ‘vicãrius’ meaning
‘substituted’) pain is defined as a spontaneous experi-
ence or exacerbation of pain when seeing another in
pain. Numerous studies have found that seeing others
in pain increases pain intensity, unpleasantness (Craig
and Weiss, 1971), and nociceptive reflexes
(Vachon-Presseau et al., 2011), and reduces pain tol-
erance (de Wied and Verbaten, 2001) and threshold
(Morrison et al., 2012). Although vicarious pain
appears to be related to heightened pain-related
anxiety and attention to pain, it is not known how it
relates to the key dimensions of empathy (i.e., cogni-
tive, affective, sensorimotor).
2 Eur J Pain •• (2014) ••–••
M.J. Giummarra et al.
While the neural correlates of empathy for anoth-
er’s pain are well characterized (Lamm et al., 2011;
Bernhardt and Singer, 2012), the need to better
understand the phenomenology of how we empathize
with others in pain remains. Many studies have failed
to find an association between trait measures of
empathy and objective neurophysiological assessment
of empathic reactions to others’ pain (Jackson et al.,
2005). This implies that dispositional empathic reac-
tions to others in pain only partially overlap with
empathic traits in general, and that there is something
unique to the context of pain that modulates empathic
responses. In order to better understand the multidi-
mensional nature of how we empathize with others in
pain, there is a clear need for tailored psychometric
tools specific to empathy for pain, which are currently
lacking. Moreover, considering vicarious pain and dis-
tress are thought to lead to avoidance rather than
empathic pro-social responses (Bernhardt and Singer,
2012), being able to characterize these specific dispo-
sitional traits is of major importance for future
research.
In two studies, we introduce and validate a new
questionnaire: the Empathy for Pain Scale (EPS). We
aimed to identify the subscales of the EPS and
examine their validity and reliability. Study 1 admin-
istered the EPS to over 400 individuals to identify the
subscales, test their convergent validity with existing
trait empathy measures and evaluate re-test reliability.
Study 2 examined the convergent validity of the EPS
subscales, compared with alternative measures of trait
empathy, against ratings of pain intensity and emotion
in short video clips of sporting injuries.
2. Methods and results
2.1 Study 1: EPS subscales identification
and validation
2.1.1 Participants
Four hundred and six individuals participated in study 1. A
wide cross-section of people were recruited, including 152
individuals with idiopathic chronic pain conditions (106
with chronic pain, 62% female, age: 21–82 years, M = 50,
SD = 15; 46 with chronic-intermittent pain, 41% female,
age: 21.6–91, M = 51, SD = 14), 68 with post-amputation
pain (37% female age: 21–91 years, M = 55, SD = 12) and
245 pain-free controls (69% female; age: 18–83, M = 34,
SD = 14). Chronic pain was defined in accordance with the
International Association for the Study of Pain taxonomy
(Merskey et al., 2011) as pain that has persisted for more
than 3 months and/or the expected time to recover from
injury. Participants were recruited from Monash University
© 2014 European Pain Federation - EFIC®
M.J. Giummarra et al. The Empathy for Pain Scale

students and staff (N = 165), community advertisements
(N = 126), amputee support groups (N = 8), and the
Amputee Unit (N = 59) and Pain Management & Research
Centre (N = 47) at Caulfield Hospital in Australia (see Sup-
porting Information Table S1 for further details on recruit-
ment and participant demographics).
Of the initial 406 participants, 253 were invited to com-
plete the EPS a second time via email in order to determine
the test–retest reliability. One hundred and five responded
(42% response rate; M = 5.70 months later; SD = 3.6
months), including 64 (61%) pain-free individuals, 15
amputees and 41 individuals with chronic or chronic-
intermittent pain.
2.1.2 Materials and procedure
ous painful sensations; see Supporting Information Appen-
dix S1 for further details), which will be reported elsewhere.
The Interpersonal Reactivity Index (IRI) (Davis, 1980) is a
28-item measure of trait empathy that comprises four sub-
scales: perspective taking (predisposition to assume the psy-
chological outlook of another person; Cronbach’s alpha =
0.54), fantasy scale (tendency to project oneself in the persona
of a fictional character; Cronbach’s alpha = 0.77), empathic
concern (ability to feel sympathy and compassion for another;
Cronbach’s alpha = 0.69) and personal distress (the extent to
which an individual feels anxiety as a result of witnessing
another’s emotional distress; Cronbach’s alpha = 0.50). Cron-
bach’s alphas reported above are for the present sample. The
IRI has previously been reported to have high internal con-
sistency and good test–retest reliability and convergent valid-
ity (Davis, 1983).

The study was approved by local hospital and university

human research ethics committees, and all participants pro- 2.1.3 Data analysis
vided informed consent. Participants completed a simple
The data were analysed with IBM SPSS version 20.0 and
demographics survey and measures of empathy and
AMOS version 20.0. Analyses included principal component
empathy for pain. The demographics survey included ques-
analysis (PCA), confirmatory factor analysis (CFA) and reli-
tions about whether participants were experiencing acute or
ability testing. Prior to PCA, a mean (‘aggregate’) of each
chronic pain and, where relevant, asked for further details
emotion and sensation rating was generated across the four
about the cause, frequency, duration, intensity and impact of
scenarios to reflect average empathic responses to pain in
pain with the brief pain inventory (Cleeland, 1989) and
others. PCA with varimax rotation was performed with the
graded chronic pain scale (Von Korff et al., 1992).
12 aggregated items to identify the probable subscales of the
The EPS was developed for this study (see Supporting
EPS. Component loadings were retained if they were ≥±0.40
Information Appendix S1). The items in the EPS were based
(Hair et al., 1998), and eigenvalues greater than 1.0 were
on examination of the vast empathy for pain literature to
retained as component factors. The fit of the factor structure
identify the key types of phenomena investigated in relation
identified in the PCA was examined for goodness of fit using
to empathy for pain, and focus group discussion with people
CFA, with a maximum likelihood extraction. Modification
who experience vicarious pain, who were identified from
indices were examined to account for cross-loadings and
our previous studies (Giummarra and Bradshaw, 2008;
correlations between items. Model fit was based on exami-
Fitzgibbon et al., 2010). In this scale, empathy for pain was
nation of the root mean square residual (RMR: <0.05),
measured across 4 scenarios using 12 identical items rated on
goodness-of-fit index (GFI: >0.95), comparative fit index
a 5-point scale (1 = strongly disagree; 5 = strongly agree). The
(CFI: >0.95) and root mean square error of approximation
scenarios were: (1) a person undergoing a surgical procedure
(RMSEA: <0.05) (Byrne, 2009). To ensure the applicability of
(e.g., as part of a television hospital drama); (2) a person who
the subscales in both the chronic pain and the pain-free
has recently had a surgical procedure (e.g., they have stitches or
groups, CFA was conducted first in the whole sample, and
bandaged amputation stump); (3) a person being accidentally
then in the chronic pain and pain-free samples. Subscale
injured (e.g., in a car accident); and (4) a person being physi-
scores were the average of the items belonging to each
cally assaulted. The four scenarios were selected so that the
subscale.
EPS could be used to examine both ‘general’ empathy for
Psychometric properties (internal consistency and re-test
pain (average response to others in pain), as well as context-
reliability) for the subscales were examined. Re-test reliabil-
specific scenarios. The 12 response items were distress, dis-
ity of the subscales was tested using within-subjects
comfort, disgust, fear, restlessness, sense of compassion,
repeated-measures analysis of variance (ANOVA) and
sense of what it feels like, a need to get help, a desire to look
Pearson correlations. Finally, we examined the concurrent
away, non-painful sensations, painful sensations and visceral
validity of the subscales against the subscales of the IRI using
sensations (e.g., nausea). Prior to the present study, a longer
correlation analysis.
version of the scale was piloted in 24 individuals, including
17 prone to vicarious pain (Giummarra et al., 2012). As the
scale aimed to characterize vicarious pain, three scenarios 2.1.4 Results
that did not elicit these experiences in people who were
normally prone to vicarious pain were removed.
2.1.4.1 Component structure of the EPS
When participants indicated experiences of vicarious pain
they were asked additional questions about the nature of PCA with varimax rotation of the aggregate ratings
that pain (e.g., onset, intensity, location and quality of vicari- explained 72% of the variance. All but one loading was

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The Empathy for Pain Scale M.J. Giummarra et al.

Table 1 Component loadingsa and communalities (h2) for principal com- all observed variables (see Table 2), except the ‘need to help’
ponent analysis with varimax rotation of aggregate data. variable (β = 0.42). Examination of the goodness-of-fit sta-
Component tistics (RMR = 0.03, GFI = 0.95; CFI = 0.98; RMSEA = 0.05)
showed that the model fit was supported in this sample. In
Construct 1 2 3 h2 both the chronic pain and pain-free samples, the uncon-
Distress 0.78 0.75 strained estimates of the regression weights were all signifi-
Discomfort 0.80 0.76 cant, and the latent constructs explained a moderate to large
Disgust 0.78 0.63 portion of the variance (except ‘need to help’ variable in the
Restless 0.70 0.77 pain-free sample; R2 = 0.28).
Fear 0.77 0.72
Avoidance 0.76 0.69
Visceral sensations 0.73 0.72 2.1.4.4 Reliability and psychometric properties of
State empathy 0.75 0.69
the EPS
Compassion 0.86 0.78
Need to help 0.59 0.52 The psychometric properties of the 12-item EPS were strong,
Vicarious sensations 0.86 0.83 with high internal consistency (Cronbach’s alpha of 0.91)
Vicarious pain 0.86 0.83 and good reliability (split-half reliability of 0.91). Each of the
Rotated eigenvalues 6.43 1.14 1.12 subscales of affective distress (Cronbach’s alpha: 0.93),
% Variance explained 53.55 9.50 9.36 vicarious pain (Cronbach’s alpha: 0.83) and empathic
a
Loadings ≤0.40 are suppressed. concern (Cronbach’s alpha: 0.70) also showed moderate to
high levels of internal consistency. A repeated-measures
ANOVA found that the affective distress (MT1 = 2.88;
≥0.70, and no item loaded on more than one factor, indicat- MT2 = 2.92), vicarious pain (MT1 = 1.97; MT2 = 2.04) and
ing that it is a robust model. A three-factor solution was empathic concern (MT1 = 3.39; MT2 = 3.50) EPS subscale
obtained on the basis of the scree test. See Table 1 for load- scores did not differ significantly between time 1 and time 2;
ings and communalities for the Varimax-rotated factors. The F(3,102) = 1.61, p = 0.19. Correlations between time 1 and 2 for
first component was labelled ‘affective distress’, the second the affective distress (r(105) = 0.79, p < 0.001), vicarious pain
‘empathic concern’ and the third ‘vicarious pain’. (r(105) = 0.65, p < 0.001) and empathic concern (r(105) = 0.62,
p < 0.001) subscales also demonstrated strong re-test
reliability.
2.1.4.2 EPS factor structure validation: CFA
CFA was conducted in the full sample (N = 406) to examine
the validity of the component structure indicated by the PCA. 2.1.4.5 EPS: Concurrent validity
Examination of the goodness-of-fit statistics showed good fit The concurrent validity of the EPS was examined against the
(RMR = 0.04; GFI = 0.91; CFI = 0.94; RMSEA = 0.09). Some IRI subscales. The affective distress EPS subscale was signifi-
cross-loadings were identified and once these were accom- cantly correlated with the perspective taking [r(390) = 0.13,
modated, the model fit improved further (RMR = 0.03; p < 0.05], fantasy scale [r(390) = 0.28, p < 0.001], empathic
GFI = 0.96; CFI = 0.98; RMSEA = 0.05). Over 80% of factor concern [r(390) = 0.20, p < 0.001] and personal distress
loadings were ≥0.70, all unconstrained estimates of the [r(390) = 0.31, p < 0.001] subscales of the IRI. Likewise, the
regression weights were significant, and the latent variables empathic concern subscale of the EPS was significantly cor-
explained a moderate to large portion of the variance in the related with perspective taking (rs = 0.27, p < 0.001), fantasy
respective observed variables. See Table 2 for all regression scale (rs = 0.15, p < 0.01), empathic concern (rs = 0.33,
statistics and coefficients, and cross-loading regression p < 0.001) and personal distress (rs = 0.11, p < 0.05) subscales
weights. of the IRI. Vicarious pain was correlated with personal dis-
tress (rs = 0.12, p < 0.05), but not with any of the other
subscales of the IRI.
2.1.4.3 Validation of the factor structure in chronic
pain and pain-free groups
In the chronic pain sample (N = 152), a CFA of the three- 2.2 Study 2: Validation of the EPS subscales
factor model was supported by standardized factor loadings against actual empathic reactions to
≥0.60 on 83% of the observed variables (see Table 2), except others’ pain
the distress (β = 0.54) and ‘need to help’ (β = 0.52) variables.
Examination of the goodness-of-fit statistics (RMR = 0.05,
2.2.1 Participants
GFI = 0.92; CFI = 0.97; RMSEA = 0.07) shows that the
model has a good fit to measure empathy for pain in people Fifty-nine individuals, aged 18–55 (median = 23), partici-
with chronic pain. In the pain-free sample (N = 245), a CFA pated in response to university and community advertise-
of the three-factor model resulted in factor loadings ≥0.60 on ments. The sample was predominantly female (n = 46; 78%)

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 M.J. Giummarra et al.

Table 2 Goodness-of-fit statistics, regression statistics (R2), standardized (β) and unstandardized (B) coefficients and scalar estimates (SE) for full model of confirmatory factor analysis, after post hoc
modifications in the full sample, and specific to the chronic pain and pain-free samples.

Full sample Chronic pain sample Pain-free sample

© 2014 European Pain Federation - EFIC®

N = 406 N = 152 N = 245

RMR = 0.03; GFI = 0.96; CFI = 0.98; RMSEA = 0.05 RMR = 0.05, GFI = 0.92; CFI = 0.97; RMSEA = 0.07 RMR = 0.03, GFI = 0.95; CFI = 0.98; RMSEA = 0.05
2 2
Observed variable Latent variable R β B SE R β B SE R2 β B SE

Fear Affective distress 0.64 0.80 1.21 0.09 0.77 0.88 1.32 0.18 0.53 0.73 1.12 0.10
Distress Affective distress 0.45 0.61 1.00 0.35 0.54 1.00 0.58 0.69 1.00
Discomfort Affective distress 0.73 0.79 1.24 0.09 0.70 0.79 1.28 0.18 0.76 0.80 1.21 0.09
Disgust Affective distress 0.48 0.69 0.93 0.08 0.54 0.74 0.98 0.14 0.45 0.67 0.92 0.09
Restless Affective distress 0.76 0.87 1.42 0.10 0.86 0.93 1.45 0.19 0.68 0.83 1.40 0.11
Avoidance Affective distress 0.65 0.84 1.33 0.10 0.75 0.90 1.37 0.18 0.57 0.78 1.28 0.11
Visceral sensations Affective distress 0.71 0.84 1.38 0.10 0.78 0.89 1.43 0.19 0.62 0.79 1.33 0.11
Vicarious sensations Vicarious Pain 0.76 0.87 1.00 0.82 0.91 1.00 0.75 0.86 1.00
Vicarious pain Vicarious Pain 0.69 0.83 0.83 0.06 0.73 0.85 0.88 0.08 0.64 0.80 0.76 0.07
State empathy Empathic concern 0.51 0.72 1.00 0.45 0.67 1.00 0.55 0.74 1.00
A need to help Empathic concern 0.37 0.50 0.57 0.06 0.45 0.55 0.56 0.10 0.28 0.42 0.54 0.09
Compassion Empathic concern 0.58 0.82 0.82 0.07 0.49 0.77 0.71 0.11 0.59 0.82 0.89 0.10
Cross-loadings
Help Fear 0.18 0.16 0.19 0.16 0.17 0.16
Distress A need to help 0.13 0.15 0.10 0.15 0.15 0.15
Discomfort Distress 0.10 0.09 0.10 0.09 0.09 0.09
Discomfort Vicarious pain −0.10 −0.10 −0.10 −0.10 −0.10 −0.10
Discomfort Compassion 0.10 0.13 0.09 0.13 0.11 0.13
Avoid A need to help −0.08 −0.09 −0.08 −0.09 −0.08 −0.09
Compassion Vicarious pain −0.12 −0.09 −0.12 −0.09 −0.12 −0.09

RMR, root mean square residual; GFI, goodness-of-fit index; CFI, comparative fit index; RMSEA, root mean square error. of approximation.

Eur J Pain •• (2014) ••–••

5
The Empathy for Pain Scale
The Empathy for Pain Scale
and were mostly students (n = 40; 68%), scientists (n = 7,
12%), or administrative assistants or professionals (n = 11;
19%).
2.2.2 Materials and procedure
The study was approved by the university human research
ethics committee, and all participants provided informed
consent. Participants completed a simple demographics
survey and the EPS and IRI, described in study 1. They were
then asked to watch 10 short clips of professional athletes
playing Australian Rules Football. In each of these clips, a
player sustained a painful injury (e.g., knee dislocation, head
clash, leg fracture). After each clip, participants were
prompted to rate the intensity of pain (R1; 0 = no pain;
10 = worst possible pain) and emotions (R2; 0 = very negative;
10 = very positive) in the player, and their own discomfort
(R3; 0 = no discomfort; 10 = extreme discomfort), arousal (R4;
0 = calm; 10 = excited) and vicarious pain (R5; 0 = no pain;
10 = strong pain) on numerical rating scales (NRSs) with
semantic anchors at each extreme of the rating scale.
2.2.3 Data analysis
We first examined the psychometric properties (internal con-
sistency) of the subscales of the EPS and IRI in this sample, as
well as the consistency in ratings of the injury video clips. We
used correlation analyses to investigate whether we could
replicate the associations between the IRI and EPS subscales
reported in study 1. Next, correlation analyses examined
whether the EPS and IRI subscales corresponded to actual
empathic reactions to the pain of others (i.e., players’ pain
and emotions, and the participants’ own discomfort, arousal
and vicarious pain). Because the vicarious pain subscale is
novel, we undertook two final analyses to examine whether
it was a sensitive measure of vicarious pain. First, an inde-
pendent samples t-test was conducted to demonstrate
whether the vicarious pain subscales, completed before par-
ticipants observed the video clips, were higher in those who
then reported vicarious pain to the injury clips compared
with those who did not. A linear regression examined
whether the intensity of vicarious pain when viewing the
injury video clips was predicted by the vicarious pain
subscale.
2.2.4 Results
The ratings of the injury video clips were highly consistent,
whereby they were rated on average as moderately painful
(M = 6.14/10; Cronbach’s alpha = 0.83) with negative emo-
tions in the players (M = 1.34/10; Cronbach’s alpha = 0.73),
see Table 3. The clips elicited vicarious pain in 20 participants
(34%), consistent with prevalence rates reported in study 1
and previous studies (Osborn and Derbyshire, 2010). The
psychometric properties of the IRI subscales were low to
moderate, like in study 1. In study 2, the affective distress
6 Eur J Pain •• (2014) ••–••
M.J. Giummarra et al.
and vicarious pain subscales of the EPS correlated with the
perspective taking and personal distress subscales of the IRI,
whereas the empathic concern subscale of the EPS only
correlated with the IRI empathic concern subscales (see
Table 3).
The concurrence between the EPS subscales and ratings of
the injury video clips were examined using correlation
analyses. The affective distress subscale was correlated with
the participant’s ratings of their own distress (r(53) = 0.29,
p < 0.05), arousal (r(53) = 0.28, p < 0.05) and the intensity of
vicarious pain (r(53) = 0.41, p < 0.01). The vicarious pain sub-
scale was correlated with the participants’ arousal
(r(53) = 0.28, p < 0.05) and the intensity of vicarious pain
(rs = 0.52, p < 0.001), and the empathic concern subscale
correlated with evaluations of the players’ emotions
((53)r = 0.31, p < 0.05), and the participants’ experience of
discomfort ((53)r = 0.28, p < 0.05) and arousal ((53)r = 0.28,
p < 0.05) when viewing the injury videos. The IRI subscales,
on the other hand, showed slightly different associations
with the empathic reactions to others’ pain. The perspective
taking (r(59) = 0.29, p < 0.05) and empathic concern
(r(59) = 0.31, p < 0.05) subscales were significantly correlated
with ratings of the intensity of the players’ pain and the
personal distress subscale only correlated with the intensity
of vicarious pain (rs = 0.32, p < 0.05). The fantasy scale did
not correlate with any ratings, and no IRI subscales were
associated with ratings of the players’ emotions, or the par-
ticipants’ own discomfort or arousal.
An independent samples t-test demonstrated significant
differences in the vicarious pain subscale scores between
groups who then reported experiencing vicarious pain when
viewing the sporting injuries (M = 3.55, SD = 1.66) com-
pared with those who did not report vicarious pain
(M = 0.15, SD = 0.38); t(57) = −13.11, p < 0.0001. A linear
regression assessed the ability of the EPS subscales (empathic
concern, vicarious pain and affective distress) to predict the
intensity of vicarious pain. The model explained 38.6% of
the variance, F(3, 49) = 10.25, p < 0.001. Moreover, the
vicarious pain subscale significantly predicted vicarious pain
intensity (β = 66, p < 0.001), but the affective distress
(β = .−0.16, p = 0.31) and empathic concern (β = 0.12,
p = 0.34) subscales did not.
3. Discussion
These studies achieved our objective to identify and
validate the subscales of the EPS. The subscales were
psychometrically sound, replicable between samples
(i.e., chronic pain and pain free), reliable over time,
and concurred with empathic appraisals and
responses when witnessing others in pain. The EPS
measured three core components of empathy for
pain: affective distress (distress, discomfort, fear,
avoidance, restlessness, visceral sensations), vicarious
pain (both non-painful and painful vicarious sensa-
tions) and empathic concern (feelings of compassion,
© 2014 European Pain Federation - EFIC®
 M.J. Giummarra et al.

© 2014 European Pain Federation - EFIC®

Table 3 Correlation matrix of stimulus ratings and questionnaire subscales.

Injury stimuli ratings IRI EPS

R1 R2 R3 R4 R5
Player’s pain Player’s emotion Own discomfort Own arousal Vicarious paina PT FS PD EC AD VP EC

Injury stimuli R1: Player’s pain 1

ratings R2: Player’s emotion −0.57*** 1
R3: Own discomfort 0.42*** −0.41*** 1
R4: Own arousal 0.15 (ns) −0.06 (ns) 0.76*** 1
R5: Vicarious paina 0.09 (ns) −0.09 (ns) 0.33* 0.27* 1.000
IRI PT 0.29* −0.01 (ns) 0.19 (ns) 0.13 (ns) 0.23 (ns) 1
FS −0.11 (ns) 0.05 (ns) 0.05 (ns) 0.07 (ns) −0.06 (ns) 0.19 (ns) 1
PD 0.21 (ns) −0.02 (ns) 0.22 (ns) 0.26 (ns) 0.32* 0.36** 0.31* 1
EC 0.31* −0.17 (ns) 0.21 (ns) 0.14 (ns) −0.09 (ns) 0.58*** 0.23 (ns) 0.14 (ns) 1
EPS AD 0.14 (ns) −0.13 (ns) 0.29* 0.28* 0.41** 0.45*** −0.06 (ns) 0.34* 0.23 (ns) 1
VP −0.08 (ns) 0.14 (ns) 0.19 (ns) 0.28* 0.52*** 0.29* −0.05 (ns) 0.39** 0.05 (ns) 0.62*** 1
EC 0.22 (ns) −0.29* 0.28* 0.28* 0.25 (ns) 0.26 (ns) −0.03 (ns) 0.18 (ns) 0.37** 0.45*** 0.35* 1

R1: players pain intensity (0 = no pain; 10 = worst possible pain); R2: players emotions (0 = very negative; 10 = very positive); R3: Participants own discomfort (0 = no discomfort; 10 = extreme discomfort);
R4: Player’s own arousal (0 = calm; 10 = excited); R5: player’s vicarious pain (0 = no pain; 10 = strong pain).
*p < 0.05.
**p < 0.01.
***p < 0.001.
a
Non-parametric correlations with these ratings.

Eur J Pain •• (2014) ••–••

7
The Empathy for Pain Scale
The Empathy for Pain Scale
desire to help, state empathy). The affective distress
subscale comprised many more items than the latter
two subscales; however, we suggest that this indicates
that affective reactions to others’ pain are a complex
and multifaceted sub-dimension of empathy for pain.
While the affective distress and empathic concern
subscales concurred with cognitive and affective trait
empathy, they also demonstrated divergent validity
and showed better associations with actual appraisal
of others in pain compared with measures of trait
empathy. The EPS offers a novel way to evaluate
vicarious pain, which was only correlated with the
personal distress dimension of empathy in the IRI.
Ultimately, the EPS measures unique, although inter-
related, aspects of empathy for pain and makes a sig-
nificant contribution to how we measure and
understand this multidimensional interpersonal
process.
In study 1, we found that the affective distress and
empathic concern subscales of the EPS were correlated
with both cognitive (i.e., perspective taking and
empathic concern) and affective (i.e., fantasy scale and
personal distress) dimensions of empathy measured by
the IRI. However, in study 2, we found that the IRI
subscales were not associated with the intensity of
discomfort or arousal when witnessing others in pain,
while the EPS subscales were. The ‘need to help’ item
loaded poorly on the empathic concern subscale of the
EPS, implying that there is a distinction between
empathic feelings and compassionate motivations in
the context of pain. Taken together, empathy is a mul-
tidimensional construct comprising affective,
empathic and sensory dimensions, which are well
characterized by the EPS subscales.
The vicarious pain subscale measured proneness for
vicarious painful and non-painful sensations, and was
correlated with the tendency to experience personal
distress. This subscale, which participants completed
before observing any stimuli depicting pain or injury
in study 2, significantly predicted the intensity of
vicarious pain, highlighting that self-report for these
experiences concurs with actual experiences of vicari-
ous pain. Being able to characterize this phenomenon
is of major social importance considering it may
impact on behaviour when one is confronted with
emergency situations (e.g., horrific accidents) or when
a patient or loved one is in severe pain (Robins et al.,
2009), particularly considering the tendency to expe-
rience vicarious distress may motivate withdrawal to
avoid personal distress (Bernhardt and Singer, 2012).
In sum, personal distress and vicarious pain are
uniquely associated, and may not be beneficial for the
observer or the observed.
8 Eur J Pain •• (2014) ••–••
M.J. Giummarra et al.
3.1 Why are empathy and empathy for
pain different?
Trait empathy is a stable personality characteristic that
enables us to share and understand the emotional and
sensory experiences of others. However, pain is a
unique sensory and emotional experience that can
elicit different types of empathic or compassionate
responses compared with other social situations.
Whether we experience pain directly, or others are in
pain, we are evolutionarily programmed to allocate
attention to it, appraise this threat and respond adap-
tively (Van Damme et al., 2010). Cognitive-affective
appraisals of pain mobilize and regulate homeostatic
and physiological states in readiness for a behavioural
response (Bufalari and Ionta, 2013). Evaluations of
pain therefore correspond to the emotional and
sensory qualities of pain in that moment as well as
factors such as the future implications of the pain or
injury. Moreover, the way that we respond empathi-
cally to another’s pain appears to be influenced by
prior experience (Preis and Kroener-Herwig, 2012).
The unique characteristics of pain have key impli-
cations for how its empathic appraisal should be
studied should be studied. Some studies report that
the tendency to project oneself into the persona of a
fictional character (IRI fantasy scale) is related to
increased motivational-affective appraisal of another’s
pain (Costantini et al., 2008), and we found it to be
correlated with increased empathic concern and affec-
tive distress (EPS subscales; study 1). However, it was
not related to any empathic appraisals of actual
dynamic stimuli depicting athletes in pain in our study
2. Moreover, none of the general trait empathy mea-
sures were associated with appraisals of the injured
person’s emotional state, or the individual’s own dis-
comfort or arousal when actually viewing individuals
in pain, yet the EPS empathic concern subscale was
associated with each of these appraisals. The present
findings therefore concur with previous studies, such
that general measures of trait empathy may not be
sufficiently sensitive to all empathic reactions to
others’ pain (Avenanti et al., 2005; Jackson et al.,
2005).
3.2 Future directions
There appears to be a lack of applied research address-
ing the clinical and social issues pertinent to empathy
for pain. The majority of research on empathy for pain
to date has predominantly relied on assessments of
trait empathy in conjunction with neurophysiological
or neuroimaging protocols. Large representative
© 2014 European Pain Federation - EFIC®
M.J. Giummarra et al.
studies are lacking (Bufalari and Ionta, 2013). The
present study is a first step towards filling this gap by
validating the EPS, which provides a means of char-
acterizing the affective, sensory and empathic trait
profile unique to the context of pain. Moreover, while
laboratory experiments investigating the neural basis
of how we empathize with others in pain have pro-
vided important insight to the neurophysiological
mechanisms involved, the ecological validity of these
studies may be questionable. In particular, these
studies provide limited insight to how cognitive-
affective appraisals of another’s pain are influenced by
both personal trait characteristics unique to pain, and
with respect to broader socio-economic factors.
Studies are now required to bring this research out of
the laboratory, and to focus on the social context in
which it may be most important. For example, it is
pertinent to examine how certain traits, specific to
pain appraisal, relate to the ability to empathize with
loved ones in either acute or chronic pain, and how
these characteristics impact on their role in helping a
loved one to cope with their pain (Issner et al., 2012).
Similarly, although clinicians must regulate their
empathic resonance to protect themselves from
burnout or secondary trauma (Cheng et al., 2007;
Robins et al., 2009), patients must nonetheless expe-
rience that these interactions are empathic for
maximum benefit (Shaw, 2004). Patients who per-
ceive a lack of empathy have greater psychological
distress and poorer recovery (Murgatroyd et al.,
2011), whereas perceiving affective and cognitive
reassurance is associated with improved clinical out-
comes (Pincus et al., 2013). Evidently, how we empa-
thize with others in pain, and how they perceive that
empathy, have major implications when applied to
these contexts. Finally, it appears that empathizing
with others in pain has unique variance that is only
partly explained by trait empathy, but that is measured
by the EPS.
3.3 Limitations
Several limitations of this study must be addressed.
First, limited socio-economic participant characteristics
were collected in study 1. However, the majority (63%)
were recruited from outside the university community
ensuring that the findings reflect both the general
population and a highly educated cohort. Second,
while the IRI is commonly used to measure empathy in
many clinical and community populations, the internal
consistency for some of the subscales was low in our
studies. This may explain why the IRI correlated poorly
with the EPS subscales and ratings of pain in study 2.
© 2014 European Pain Federation - EFIC®
The Empathy for Pain Scale
Finally, we conducted our CFA in the same sample as
the PCA, which is generally not recommended. Our
purpose was to first explore which items may belong to
the subscales, and then apply rigorous structural equa-
tion modelling to confirm the variance that each latent
variable explained in the respective subscales. Only
with this method did we identify that the ‘need to help’
item, with moderate component loadings in the PCA,
actually loaded poorly on the empathic concern
subscale.
3.4 Conclusions
We demonstrate that empathy for pain is a multidi-
mensional phenomenon, and that the EPS character-
izes the empathic, affective and sensory responses to
pain in others, which are partially unique from
general trait empathy. The empathic concern and
affective distress subscales demonstrated both concur-
rent and divergent validity with trait empathy. The
vicarious pain subscale correlated with personal dis-
tress, making an important and novel contribution to
characterizing of this phenomenon. Although the EPS
subscales characterized the tendency to experience
affective distress, empathic concern or vicarious pain,
and not the intensity of these experiences, the vicari-
ous pain subscale was nonetheless a significant predic-
tor of the intensity of vicarious pain. Future research
should investigate whether these characteristics are
predictive of approach or avoidance tendencies, espe-
cially pro-social and altruistic responses towards
others who are suffering.
Author contributions
Each co-author contributed significantly to the work
described, discussed the results and commented on the
manuscript. M.J.G. planned and executed studies 1 and 2,
developed the questionnaire, recruited and gained consent
from participants, collected and analysed data, and wrote the
paper with guidance and feedback from the co-authors.
B.M.F. contributed to questionnaire development and
design, interpretation of analyses, and writing and editing
the manuscript. M.B. assisted in the design, stimulus editing,
data collection and analysis for study 2. N.G-K. contributed
to research design, interpretation of analyses and editing the
manuscript. A.V.G. contributed to interpretation of analyses,
and writing and editing the manuscript. Z.B. contributed to
research design, data collection, interpretation of the find-
ings and editing the manuscript. M.C. contributed to
research design, data collection, interpretation of the find-
ings and editing the manuscript. S.J.G. contributed to
research design, data analysis, interpretation of the findings
and editing the manuscript.
Eur J Pain •• (2014) ••–•• 9
The Empathy for Pain Scale
Acknowledgement
The authors acknowledge Katrina Simpson for assistance
and advice on statistical analysis.
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Supporting Information
Additional Supporting Information may be found in the
online version of this article at the publisher’s web-site:
Table S1. Participant demographics and recruitment.
Appendix S1. Empathy for Pain Scale.
© 2014 European Pain Federation - EFIC®