Emine Gurbuz, PhD student in the Psychology Department, Durham University, reviews the ‘Interoception: Sensation and Embodied Awareness’ workshop at the Institute for Medical Humanities, Durham University on 8th November 2018.
Interoception, defined as “the process by which the nervous system senses, interprets, and integrates signals originating from within the body, providing a moment-by-moment mapping of the body’s internal landscape across conscious and unconscious levels”  is a very crucial concept in understanding the link between the body and the brain.
In this workshop, the definitions of interoception, the ways to measure it and how to harness it to improve mental and physical health were discussed by researchers and practitioners across disciplines. As a psychology student working with autistic individuals who have impaired interoception , I left the workshop with a lot of new ideas, but also more questions. How we can objectively quantify interoception? Is it an innate ability or can it be trained? Are there people who have very good interoceptive awareness, and if there are, what are the predictors of this ability? In this blog post, I will reflect on different definitions and approaches, and the future challenges to apply interoception in therapeutic and educational contexts.
Following an introduction by Jane Macnaughton, Director of the Institute for Medical Humanities and also organizer of the workshop, the first panel included talks by from Sarah Garfinkel, neuroscientist at University of Sussex, and Andy Hamilton, a philosopher at Durham University. Sarah discussed different dimensions of interoception such as interoceptive accuracy, the ability to correctly guess the internal bodily states, and metacognitive awareness, the ability to know how good you are at interoception, in relation to different brain regions associated with each dimension. She gave examples from her research on autistic individuals who had reduced interoceptive accuracy, but heightened sensitivity to their internal bodily states, a combination which was associated with high levels of anxiety . She also made a very compelling point about how our bodily senses (e.g. heart beats) change the way we process emotions even though we cannot consciously report that. This is a very powerful example of body-mind interaction: do we feel it more when our heart beats faster? Can we unconsciously manipulate our emotions by changing our bodily responses?
On the other hand, Andy introduced an alternative explanation of interoception, in particular proprioception, the ability to know the position and movement of our body in space, by questioning whether it is a sense, like vision or hearing, or it is more like a direct, non-inferential knowledge that we just “know”. This led to a discussion about whether we can trick our brains to change our proprioception, and if we do, does it mean interoception is not a fully self-conscious process? I believe that these two somehow contradictory approaches to definitions of interoception is very important in operationalizing and testing it in the lab: if it is not self-conscious, can we rely on self-reports to measure it? If it is self-conscious, wouldn’t everyone be good at telling exactly what their bodies are doing? Do we really want to be overly-aware of our bodily sensations? I think these are very important questions in understanding interoception, particularly in individuals with anxiety and bodily manifestations of mental distress.
Kyle Pattinson, Clinical Research Fellow at University of Oxford, and George Dean, a PhD student at University of Edinburgh talked about the ways the brain processes and interprets the signals of the body and how the Bayesian models can help us to explain the body-mind interaction. According to Kyle, the mismatch between the disease markers and the reported symptoms of the asthma patients could be explained by the moderator role of expectancy and affect. Therefore, the breathlessness symptoms are the product of not only the input from the lungs, but also associations with past experience in the brain. For example, patients report more breathlessness symptoms when they do not have their inhalers with them. In addition, patients with higher anxiety levels make poorer predictions of their disease markers. Pulmonary rehabilitation, as suggested by Kyle, might reduce the symptoms and improve the quality of the patients with respiratory problems by reducing the mismatch between the objective and reported symptoms as a result of improved interoception. I found this idea fascinating as it suggests that you might improve a physical health problem just by changing the interoceptive abilities of the patients. This could also be applied to psychiatric disorders such as anxiety, where symptoms include inaccurate interpretation of the bodily signals or to use George’s term ‘predictive error’. According to George, “the perception is not veridical” as it is influenced by the current state of the person – his/her immediate needs – and their prior knowledge (e.g. childhood experiences). These might lead the brain to make predictive leaps, for example when a person with anxiety perceives his/her fast heartbeats as a symptom of heart attack while in reality, it is not the case . I think framing the brain as a predictive source in interoception leaves room for intervention. But how we can change the response to stimuli in the environment to improve health? First, we might need to go back and understand how these inaccurate predictions were built in the first place? So, the intervention might require information about childhood experiences, which need to be corrected to reduce predictive error.
Moving from the definitions of interoception towards therapeutic applications, Caroline Dower, clinical psychologist at Durham University, introduced her ‘Calm to the Core’ programme for university students with anxiety and depression. Upon observing the change in students’ body language with therapy, she started to examine non-verbal and relational patterns in her sessions. She believes that by using movement therapy, “the body becomes the conductor of the awareness of the body and also relations/feelings with others”. Accordingly, Rick Telford, participant in Dance City’s ‘Get Moving’ a dance programme for people with Parkinson’s Disease, was a very good example for the healing effect of movement in mental and physical health. Dance therapy is a very promising and motivating tool for patients to see their own improvement and to increase their quality of life socially and physically. Even 10 minutes of improvised movement without judging and being judged can boost our awareness of our bodies, which we were all fortunate to experience in the session led by Krzysztof Bierski!
Considering the importance of interoception in physical and mental health, it is surprising that there are very few interoception-based practices in educational and therapeutic contexts. I believe that collaboration between researchers, policy makers, teachers, and practitioners are urgently needed to do so. However, there are still many unanswered questions. How to objectively measure interoception? Which dimension should be targeted for intervention: accuracy or awareness? Whether individual differences in interoceptive ability might influence treatment efficacy? Could it be incorporated into the curriculum of younger children at schools? As a fundamental researcher, I am also curious about the neural correlates of interoception and whether interoception training could improve neural engagement of these regions. In case of autism, interoception could be related to deficits in social skills such as emotion recognition and social information processing. It would be very interesting to look at these associations in individuals with and without autism and develop interventions accordingly. The workshop was the first step not only to open up an incredibly stimulating platform to discuss interoception, but also for future collaborations across disciplines which should bring doctors, clinicians, practitioners, and teachers together with the aim of developing interventions for schools and primary care.
You can read a different perspective on this workshop in ‘Hope, expectation and interoception‘ by Lena Maria Lorenz (published Thu 13 Dec)
: Khalsa, S. S., Adolphs, R., Cameron, O. G., Critchley, H. D., Davenport, P. W., Feinstein, J. S., … & Meuret, A. E. “Interoception and mental health: a roadmap,” Biological Psychiatry: Cognitive Neuroscience and Neuroimaging (2017)
: DuBois, D., Ameis, S. H., Lai, M. C., Casanova, M. F., & Desarkar, P. “Interoception in autism spectrum disorder: A review” International Journal of Developmental Neuroscience, 52 (2016): 104-111.
: Garfinkel, S. N., Tiley, C., O’Keeffe, S., Harrison, N. A., Seth, A. K., & Critchley, H. D. “Discrepancies between dimensions of interoception in autism: Implications for emotion and anxiety”. Biological psychology, 114 (2016): 117-126.
: Paulus, M. P., & Stein, M. B. . “Interoception in anxiety and depression” Brain structure and Function, 214(5-6)(2010): 451-463.