PLOS Mental Health Conversations: Redefining how we understand empathy

The mental health field is constantly evolving. It needs to. Nothing stays the same and that includes the needs of individuals and communities. But with that evolution, comes gaps and barriers, which determine the direction of progress that is needed. In order for progress to be made, new ideas, theories and proposed frameworks need to be shared, discussed, tested and modified accordingly. At PLOS Mental Health we think it is important to provide a platform for mental health professionals, researchers, advocates and community members to explore together. Not only will this hopefully stimulate further ideas and discussions, but also potentially open the door to collaborations. This is why we are starting this new blog series ‘PLOS Mental Health Conversations’ and for the first blog of this series, we hear from Ayesha Qahash, who explains the need for, and details of, a new framework for empathy differences, namely, Empathy Spectrum Disorder.

What is Empathy Spectrum Disorder (ESD)?

[AQ] After graduating, I began to notice a troubling pattern: more and more people were using labels like “narcissist,” “autistic,” or “empath” to explain interpersonal struggles or pathologizing others, often without clinical context. These terms were being applied to everything from burnout to emotional flooding to manipulative behavior, but no shared framework existed for understanding how empathy itself might be distorted, dysregulated, or strategically used. That gap became the foundation for Empathy Spectrum Disorder (ESD): a dimensional, trauma-informed model of empathy dysregulation that aims to validate lived experiences while moving beyond oversimplified or stigmatizing labels.

ESD is a proposed transdiagnostic framework for understanding how empathy, rather than being universally good or static, is actually shaped, distorted, or dysregulated across development. The model identifies six subtypes of empathy dysregulation:

1. Hypoempathy – emotional blunting, detachment, or flat affect
2. Hyperempathy – emotional flooding, overidentification, and fatigue
3. Rational Empathy – perspective-taking without resonance or emotional attunement
4. Dysregulated Empathy – erratic switching between numbness and overwhelm
5. Shutdown Empathy – compartmentalization and emotional suppression
6. Dark Empathy – strategic use of empathic insight to manipulate or dominate

ESD treats empathy as a flexible, developmentally shaped capacity that varies in intensity, regulation, and intentionality. These variations are often adaptive responses to relational trauma, cultural conditioning, or neurobiological differences, but they can lead to distress when misunderstood or unsupported. Rather than pathologizing people for being “too sensitive,” “too cold,” or “emotionally unavailable,” ESD offers a compassionate map for how empathy functions, fragments, or evolves across life experience.

What are the current challenges faced for research in this area (given that it is not yet a recognized clinical diagnosis)?

One of the biggest challenges is definitional: empathy itself is inconsistently measured and poorly operationalized across psychological disciplines. Most tools focus only on cognitive or affective components, ignoring regulation and context. Without a shared language for what empathy is doing, whether it’s being suppressed, exaggerated, or split, research often misses the lived complexity of empathic dysfunction.

Another challenge is legitimacy. Because ESD isn’t a formal diagnosis, it lacks institutional support. That means no standard assessments, no dedicated funding streams, and limited clinical training. Meanwhile, people are turning to social media, peer forums, or self-diagnosis to try to understand what they’re feeling, often absorbing inaccurate or stigmatizing narratives in the process.

There’s also a cultural challenge: empathy is idealized in many settings, particularly for women, caregivers, and marginalized communities. This makes it difficult to talk openly about the costs of empathy, emotional burnout, blurred boundaries, or even strategic manipulation, without shame or judgment. ESD aims to hold that nuance: empathy can hurt, fail, or be misused, and we need frameworks that reflect that complexity.

What questions do you think we need to ask in order to better understand ESD?

To truly understand ESD, we need to ask questions that sit at the intersection of psychology, identity, and power:

●      How do gendered expectations shape how empathy is expressed, rewarded, or suppressed?

●      How does cultural context influence whether emotional restraint is seen as strength or pathology?

●      How do trauma histories, especially in marginalized communities, condition people to hyper-attune, emotionally disconnect, or strategically “read the room” for survival?

●      When is empathy an ethical impulse, and when is it a performance shaped by systemic demands (e.g., emotional labor in caregiving roles)?

●      How do we differentiate between genuine emotional detachment and socially sanctioned shutdown?

Intersectionality is essential. Empathy doesn’t operate in a vacuum, it’s filtered through nervous systems, relational histories, and sociocultural survival strategies. If we want to understand empathy’s distortions, we must also understand the world that distorts it.

About Ayesha

Ayesha Qahash is a bodyworker, educator, and researcher working at the intersection of trauma, neurodiversity, and emotional development. She currently teaches in the bodywork program at Montgomery County Community College and holds a Master’s degree from Goddard College, where she designed a self-directed graduate curriculum focused on empathy, successful psychopathy, and healing-centered psychology. Her thesis explored the concept of “Constructive Empathy” which specified how empathy can be consciously cultivated, regulated, and applied in ethical, relationally coherent ways.