Interoception

Validação portuguesa do multidimensional assessment of interoceptive awareness (maia)

Objectivo

Consciência interoceptiva refere-se à percepção consciente dos estados internos do organismo. O presente trabalho pretendeu a validação do Multidimensional Assessment of Interoceptive Awareness (MAIA) recolhida a partir de uma amostra não probabilística de 755 indivíduos.

Método

O MAIA é originalmente constituído por 32 itens (divididos em oito dimensões) que assumem como possibilidade de resposta uma escala de Likert de 6 pontos. O estudo das qualidades métricas deste instrumento realizou-se com recurso a análise factorial exploratória (N = 376) e, numa amostra diferente, a análise factorial confirmatória (N = 379).

Resultados

Verificou-se uma estrutura diferente da original, mantendo-se o seu significado psicológico e características de validade, sensibilidade e fiabilidade adequadas.

Conclusão

Obtiveram-se quatro dimensões (Regulação Atencional; Consciência Emocional; Escuta Corporal e Confiança), as quais correspondem a dimensões da medida original.

Respiratory modulation of intensity ratings and psychomotor response times to acoustic startle stimuli

Respiratory interoception may play an important role in the perception of respiratory symptoms in pulmonary diseases. As the respiratory cycle affects startle eye blink responses, startle modulation may be used to assess visceral-afferent signals from the respiratory system. To ascertain the potential impact of brainstem-relayed signals on cortical processes, we investigated whether this pre-attentive respiratory modulation of startle (RMS) effect is also reflected in the modulation of higher cognitive, evaluative processing of the startle stimulus. Twenty-nine healthy volunteers received 80 acoustic startle stimuli (100 or 105 dB(A); 50 ms), which were presented at end and mid inspiration and expiration, while performing a paced breathing task (0.25 Hz). Participants first responded to the startle probes by 'as fast as possible' button pushes and then rated the perceived intensity of the stimuli. Psychomotor response time was divided into 'reaction time' (RT; from stimulus onset to home button release; represents stimulus evaluation) and 'movement time' time (MT; from home button release to target button press). Intensity judgments were higher and RTs accelerated during mid expiration. No effect of respiratory cycle phase was found on eye blink responses and MTs. We conclude that respiratory cycle phase affects higher cognitive, attentional processing of startle stimuli.

Applying the Theory of Constructed Emotion to Police Decision Making

Law enforcement personnel commonly make decisions in stressful circumstances, where the costs associated with errors are high and sometimes fatal. In this paper, we apply a powerful theoretical approach, the theory of constructed emotion (TCE), to understand decision making under evocative circumstances. This theory posits that the primary purpose of a brain is to predictively regulate physiological resources to coordinate the body's motor activity and learning in the short term, and to meet the body's needs for growth, survival, and reproduction in the long term. This process of managing the brain and body's energy needs, called allostasis, is based on the premise that a brain anticipates bodily needs and attempts to meet those needs before they arise (e.g., vestibular activity that raises sympathetic nervous system activity before standing), because this is more efficient than responding to energetic needs after the fact. In this view, all mental events-cognition, emotion, perception, and action-are shaped by allostasis, and thus all decision making is embodied, predictive, and concerned with balancing energy needs. We also posit a key role for the autonomic nervous system (ANS) in regulating short-term energy expenditures, such that the ANS influences experience and behavior under stressful circumstances, including police decision making. In this paper, we first explain the core features of the TCE, and then offer insights for understanding police decision making in complex, real-world situations. In so doing, we describe how the TCE can be used to guide future studies of realistic decision making in occupations in which people commonly make decisions in evocative situations or under time pressure, such as in law enforcement.

No Relationships Between the Within-Subjects' Variability of Pain Intensity Reports and Variability of Other Bodily Sensations Reports

Purpose

The subjective nature of pain assessment and its large variance negatively affect patient–health care provider communication and reduce the assay sensitivity of pain clinical trials. Given the lack of an objective gold standard measure, identifying the source (true or error) of the within-subject variability of pain reports is a challenge. By assessing the within-subjects variability of pain and taste reports, alongside with interoceptive measures, the current study is aimed to investigate if the ability to reliably report bodily sensations is a cross-modal characteristic.

Patients and Methods

This prospective study enrolled healthy volunteers from local universities. After consenting, subjects underwent the Focus Analgesia Selection Task (FAST), to assess within-subjects variability of pain reports in response to experimental noxious stimuli; a taste task, which similarly assesses within-subjects variability of tastes (salty and sweet) intensity reports; and the heartbeat perception task, an interoceptive task aimed to assess how accurate subjects are in monitoring and reporting their own heartbeat. In addition, all subjects completed the Multidimensional Assessment of Interoceptive Awareness (MAIA), the Perceived Stress Scale (PSS), and Hospital Anxiety and Depression Scale (HADS). Spearman’s correlations were used to assess relations between all measures.

Results

Sixty healthy volunteers were recruited. Variability of intensity reports of different modalities were independent of each other (P > 0.05 for all correlations). The only correlation found was within modality, between variability of intensity reports of salt and sweet tastes (Spearman’s r = 0.477, P < 0.001). No correlations were found between any of the task results and questionnaire results.

Conclusion

Within-subjects variability of pain reports do not relate to variability of reports of other modalities or to interoceptive awareness. Further research is ongoing to investigate the clinical relevance of within-subjects’ variability of pain reports.

Level-2 visuo-spatial perspective-taking and interoception - More evidence for the embodiment of perspective-taking

Level-2 visuo-spatial perspective-taking is an embodied process during which the perspective-taker mentally simulates a movement of his or her body into the location of the target. Evidence for the embodiment of this process so far exclusively stems from congruency effects in visuo-spatial perspective-taking experiments. Here, additional triangulation for the embodiment of this process is provided from an interindividual differences perspective. In a cross-sectional observational study, participants completed a behavioral level-2 visuo-spatial perspective-taking task and the heartbeat tracking task, which measures interoceptive accuracy and sensibility. Interoceptive accuracy is the objective ability to accurately perceive signals from within the body. In the present study, interoceptive accuracy was quantified by comparing the number of actual heartbeats observed via electrocardiographic recording to subjectively perceived heartbeats during that time. This measure was related to faster perspective-taking and better overall perspective-taking performance. Interoceptive sensibility refers to subjective beliefs about interoceptive abilities. Here, confidence in the estimated number of heartbeats served as a measure if interoceptive sensibility. Finally, the correspondence between interoceptive accuracy and sensibility is referred to as interoceptive awareness. Interoceptive sensibility and awareness were unrelated to perspective-taking. The study is a demonstration of the role interindividual differences in different facets of interoception play for embodied cognition. Implications for future research on links between embodied cognition and interoception are outlined and critically discussed.

Longitudinal effects of interoceptive awareness training through mindful awareness in body-oriented therapy (MABT) as an adjunct to women's substance use disorder treatment: A randomized controlled trial

BACKGROUND

Training in interoceptive awareness is a promising behavioral approach for improving substance use disorder (SUD) treatment. This study examined the longitudinal effects of Mindful Awareness in Body-oriented Therapy (MABT) as an adjunct to women's SUD treatment. MABT teaches interoceptive awareness skills to promote self-care and emotion regulation.

METHODS

Women in intensive outpatient treatment for SUD at three community clinics were recruited and randomly assigned to one of three study conditions Treatment as Usual (TAU) + MABT, TAU + Women's Health Education (WHE), and TAU only. Four assessments were delivered over one year (N = 187) baseline, 3, 6 and 12 months to examine primary outcome of percent days abstinent from substance use, and secondary outcomes of emotion dysregulation, craving, psychological distress, mindfulness and interoceptive awareness. Changes in outcomes across time were assessed using multilevel mixed effects linear regression.

RESULTS

Substance use improved significantly for MABT vs. TAU at 6 months and 12 months. Positive longitudinal effects on secondary outcomes for MABT were evident on respiratory sinus arrhythmia (RSA), a physiological index of emotion regulation; on craving; and on interoceptive awareness skills. Analyses based on participants who completed >75% of the intervention sessions revealed additional immediate significant improvements for MABT vs. TAU and WHE on depressive symptoms and emotion regulation difficulties and longitudinal improvement on mindfulness skills.

CONCLUSIONS

Results show MABT to be efficacious for longitudinal health outcomes to support women's recovery as an adjunct to community-based SUD treatment.

Interoception and Mental Health: A Roadmap

Interoception refers to 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. Interoceptive signaling has been considered a component process of reflexes, urges, feelings, drives, adaptive responses, and cognitive and emotional experiences, highlighting its contributions to the maintenance of homeostatic functioning, body regulation, and survival. Dysfunction of interoception is increasingly recognized as an important component of different mental health conditions, including anxiety disorders, mood disorders, eating disorders, addictive disorders, and somatic symptom disorders. However, a number of conceptual and methodological challenges have made it difficult for interoceptive constructs to be broadly applied in mental health research and treatment settings. In November 2016, the Laureate Institute for Brain Research organized the first Interoception Summit, a gathering of interoception experts from around the world, with the goal of accelerating progress in understanding the role of interoception in mental health. The discussions at the meeting were organized around four themes: interoceptive assessment, interoceptive integration, interoceptive psychopathology, and the generation of a roadmap that could serve as a guide for future endeavors. This review article presents an overview of the emerging consensus generated by the meeting.

Multichannel Investigation of Interoception: Sensitivity Is Not a Generalizable Feature

Objective: The term interoception refers to the perception of bodily cues. In empirical studies, it is assessed using heartbeat detection or tracking tasks, often with the implicit assumption that cardioception reflects general interoceptive ability. Studies that applied a multichannel approach measured only a limited number of modalities. In the current study, six modalities were assessed to gain a deeper understanding of the relationship between the different sensory channels of interoception. Methods: For 118 university students (53% male) gastric perception (water load test), heartbeat perception (Schandry task), proprioception (elbow joint), ischemic pain (tourniquet technique), balancing ability (one leg stand), and perception of bitter taste were measured. Pair-wise correlation analysis and exploratory factor analyses (principal component analysis (PCA) and maximum likelihood (ML) extraction with oblimin rotation) were then carried out with a three-factor solution to investigate the underlying associations. Results: Correlation analysis only revealed significant associations between variables belonging to the same sensory modality (gastric perception, pain, bitter taste). Similarly, the three factors that consistently emerged in the factor analyses represented the three aforementioned modalities. Discussion: Interoceptive sensitivity assessed by using one channel only cannot be generalized. Interoceptive modalities carrying crucial information for survival are not integrated with other channels.

Interoceptive Awareness Skills for Emotion Regulation: Theory and Approach of Mindful Awareness in Body-Oriented Therapy (MABT)

Emotion regulation involves a coherent relationship with the self, specifically effective communication between body, mind, and feelings. Effective emotion regulation involves the ability to accurately detect and evaluate cues related to physiological reactions to stressful events, accompanied by appropriate regulation strategies that temper and influence the emotional response. There is compelling evidence demonstrating links between poor or disrupted awareness of sensory information, or interoceptive awareness, and difficulties with emotion regulation. This paper presents a framework, based on psychological and neurobiological research, for understanding how interoceptive awareness facilitates regulation and an integrated sense of self, and thus contributes to health and well-being. A mind-body therapeutic approach called mindful awareness in body-oriented therapy (MABT), uniquely designed to teach fundamental skills of interoceptive awareness, is described. MABT develops the distinct interoceptive awareness capacities of identifying, accessing, and appraising internal bodily signals that are identified in physiological models as the critical components of interoception for emotion regulation. The explanatory model is that the development of these key interoceptive capacities improves sensory (physical and emotional) awareness, reduces distress, and improves regulation. Strategies for teaching and learning interoceptive awareness are not well-developed in mindfulness or psychotherapeutic approaches, particularly important for people who may have difficulty attending to interoceptive awareness due to stress, chronic pain or trauma. To address this issue, MABT provides an individualized protocol for scaffolding interoceptive awareness through a combination of psychoeducation and somatic approaches explicitly addressing difficulties with interoceptive processing. Clinical vignettes are included to provide exemplars of this approach and to highlight key components of the therapeutic process. Results from research are also included to highlight the acceptability, safety, health outcomes, and possible mechanisms underlying the MABT approach.

Non-linear Heart Rate Variability as a Discriminator of Internalizing Psychopathology and Negative Affect in Children With Internalizing Problems and Healthy Controls

Background: Internalizing psychopathology and dysregulated negative affect are characterized by dysregulation in the autonomic nervous system and reduced heart rate variability (HRV) due to increases in sympathetic activity alongside reduced vagal tone. The neurovisceral system is however, a complex nonlinear system, and nonlinear indices related to psychopathology are so far less studied in children. Essential nonlinear properties of a system can be found in two main domains: the informational domain and the invariant domain. sample entropy (SampEn) is a much-used method from the informational domain, while detrended fluctuation analysis (DFA) represents a widely-used method from the invariant domain. To see if nonlinear HRV can provide information beyond linear indices of autonomic activation, this study investigated SampEn and DFA as discriminators of internalizing psychopathology and negative affect alongside measures of vagally-mediated HRV and sympathetic activation. Material and Methods: Thirty-Two children with internalizing difficulties and 25 healthy controls (aged 9-13) were assessed with the Child Behavior Checklist and the Early Adolescent Temperament Questionnaire, Revised, giving an estimate of internalizing psychopathology, negative affect and effortful control, a protective factor against psychopathology. Five minute electrocardiogram and impedance cardiography recordings were collected during a resting baseline, giving estimates of SampEn, DFA short-term scaling exponent α1, root mean square of successive differences (RMSSD), and pre-ejection period (PEP). Between-group differences and correlations were assessed with parametric and non-parametric tests, and the relationships between cardiac variables, psychopathology and negative affect were assessed using generalized linear modeling. Results: SampEn and DFA were not significantly different between the groups. SampEn was weakly negatively related to heart rate (HR) in the controls, while DFA was moderately negatively related to RMSSD in both groups, and moderately positively related to HR in the clinical sample. SampEn was significantly associated with internalizing psychopathology and negative affect. DFA was significantly related to internalizing psychopathology. Conclusions: Higher invariant self-similarity was linked to less psychopathology. Higher informational entropy was related to less psychopathology and less negative affect, and may provide an index of the organizational flexibility of the neurovisceral system.

Hippocampal dependent neuropsychological tests and their relationship to measures of cardiac and self-report interoception

The hippocampus is involved in interoceptive processing (i.e., perceiving internal bodily states), with much of this evidence relating to hunger and fullness. Here we examine whether cardiac and self-report measures of interoception are related to two measures of hippocampal dependent learning and memory (HDLM) - the Rey Auditory Verbal Learning Test (RAVLT) and Logical Memory. Healthy adults completed a neuropsychological test battery including all of these measures, along with assessments of intelligence and executive function. Biographical, medical and psychological-related data that might confound detecting an HDLM-interoception relationship was also collected. Both measures of HDLM were associated with cardiac interoception after controlling for confounding variables. More accurate cardiac interoception was linked to better HDLM performance. On the self-report measure of interoception, better performance on the RAVLT was associated with better-reported attention regulation, consistent with the hippocampus's known role in mindfulness. Overall, these findings suggest hippocampal involvement in cardiac and self-report interoceptive capacity. The broader functional role of the hippocampus in interoception is discussed.

Tulsa 1000: a naturalistic study protocol for multilevel assessment and outcome prediction in a large psychiatric sample

INTRODUCTION

Although neuroscience has made tremendous progress towards understanding the basic neural circuitry underlying important processes such as attention, memory and emotion, little progress has been made in applying these insights to psychiatric populations to make clinically meaningful treatment predictions. The overall aim of the Tulsa 1000 (T-1000) study is to use the NIMH Research Domain Criteria framework in order to establish a robust and reliable dimensional set of variables that quantifies the positive and negative valence, cognition and arousal domains, including interoception, to generate clinically useful treatment predictions.

METHODS AND ANALYSIS

The T-1000 is a naturalistic study that will recruit, assess and longitudinally follow 1000 participants, including healthy controls and treatment-seeking individuals with mood, anxiety, substance use and eating disorders. Each participant will undergo interview, behavioural, biomarker and neuroimaging assessments over the course of 1 year. The study goal is to determine how disorders of affect, substance use and eating behaviour organise across different levels of analysis (molecules, genes, cells, neural circuits, physiology, behaviour and self-report) to predict symptom severity, treatment outcome and long-term prognosis. The data will be used to generate computational models based on Bayesian statistics. The final end point of this multilevel latent variable analysis will be standardised assessments that can be developed into clinical tools to help clinicians predict outcomes and select the best intervention for each individual, thereby reducing the burden of mental disorders, and taking psychiatry a step closer towards personalised medicine.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Western Institutional Review Board screening protocol #20101611. The dissemination plan includes informing health professionals of results for clinical practice, submitting results to journals for peer-reviewed publication, presenting results at national and international conferences and making the dataset available to researchers and mental health professionals.

TRIAL REGISTRATION NUMBER

NCT02450240; Pre-results.

Interoception in Psychiatric Disorders: A Review of Randomized, Controlled Trials with Interoception-Based Interventions

Interoception, or the process of sensing, interpreting, and integrating internal bodily signals, has increasingly been the subject of scientific research over the past decade but is still not well known in clinical practice. The aim of this article is to review clinical treatment interventions that use interoception, to synthesize the current research knowledge, and to identify the gaps where future research is needed. We conducted a comprehensive literature search on randomized, controlled trials that both include interoception in treatment interventions for individuals with psychiatric disorders and measure aspects of interoception using self-report measures. Out of 14 randomized, controlled trials identified, 7 found that interventions with interoception were effective in ameliorating symptoms. These studies included individuals with anxiety disorders, eating disorders, psychosomatic disorders, and addictive disorders. All of the intervention studies with positive clinical outcomes also demonstrated changes on interoceptive measures; however, these measures were often related to specific illness symptoms. Interoception may be a mechanism of action in improving clinical symptomatology, though studies incorporating general, symptom-independent interoceptive measures remain scarce. To further our understanding of the role interoception has in psychiatric disorders and their treatment, more studies integrating interoceptive measures are needed, along with a clearer definition of interoceptive terms used.

Scale of Body Connection: A multi-sample construct validation study

The Scale of Body Connection (SBC) was created to address the need for a self-report measure to examine body awareness and bodily dissociation in mind-body research. Developed in the U.S.A., it has been translated into many languages and tested for validity of scale translation. The burgeoning of mind-body research and the widespread use of the SBC scale underscored the need for critical assessment of the instrument’s measurement properties. Thus, a broader evaluation of the SBC was designed using large samples from eight international, cross-sectional studies drawn from community (i.e., non-clinical) populations. Specifically, we assessed scale distribution properties and internal consistency reliabity, and using confirmatory factory analysis we evaluated scale contruct validity and compared male/female measurement models. The results indicated acceptable reliability for both the body awareness and bodily dissociation scales, and a good fit between the proposed theoretic model and the data, providing evidence of construct validity across all samples. Mean differences in body awareness were observed for males vs. females in most samples, with females generally showing higher body awareness compared to males. Multi-group structural equation modeling demonstrated a stable latent factor structure and factor loadings, indicating equivalent measurement models for males and females. In summary, this multi-sample study demonstrated SBC construct validity that supports its use in clinical research as a brief, readily translated, easy to administer measure of body awareness and bodily dissociation.

Improvement of Interoceptive Processes after an 8-Week Body Scan Intervention

Objective: Interoceptive processes are defined as ability to detect sensations arising within the body. There is a growing body of research investigating ways of improving interoceptive processes. One promising approach increasing the attention to bodily sensations is the body scan (BS), a method stemming from mindfulness-based stress reduction. Research so far revealed only heterogenous findings of meditational practice and mindfulness-based stress reduction on interoceptive processes. Even more importantly, there is no study considering the effect of an 8-week BS intervention on interoceptive processes and the distinguishable subdomains of interoception. Therefore, the main objective of this research is to examine the effects of a BS intervention on different interoceptive subdomains over 8 weeks of training in two different samples.

Methods: In study 1, healthy participants executed a 20 min standardized audiotaped BS in the BS intervention group (n = 25) each day over 8 weeks. The control group (n = 24) listened to an audio book for the same amount of time. In study 2, the BS group (n = 18) was compared to an inactive control group (n = 18). In both studies, three measurement points were realized and interoceptive accuracy (IAc) – using a heartbeat perception task – as well as interoceptive sensibility (IS) – using confidence ratings for the heartbeat perception task and the subscale ‘interoceptive awareness’ of the Eating Disorder Inventory-2 (EDI-2) – were assessed.

Results: In study 1, we found, as a descriptive trend, IAc and confidence ratings to be increased irrespective of the condition. However, post hoc analysis revealed a significant improvement of IAc between T1 and T3 in the BS intervention only. IS revealed to be unaffected by the interventions. In study 2, we observed a significant positive effect of the BS intervention on IAc and confidence ratings compared to the inactive controls. As in study 1, IS (EDI-2) was unaffected by the intervention.

Discussion: The results highlight the fact that interoception can be improved by long-term interventions focusing on bodily signals. Further studies might focus on clinical samples showing deficits in interoceptive processes and could use other bodily systems for measurement (e.g., respiratory signals) as well methods manipulating body ownership.

Sleep and the heart: Interoceptive differences linked to poor experiential sleep quality in anxiety and depression

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Poor sleep quality differentially impacts interoception across diagnoses.

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For all diagnoses, poor sleep quality was linked with poor interoceptive accuracy.

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For all diagnoses, poor sleep was linked with enhanced interoceptive sensibility.

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For depression and mixed diagnoses, poor sleep impaired metacognitive awareness.

Interoception is the sense through which internal bodily changes are signalled and perceived. Individual differences in interoception are linked to emotional style and vulnerability to affective disorders. Here we test how experiential sleep quality relates to dimensions of interoceptive ability. 180 adults (42 ‘non-clinical’ individuals, 138 patients accessing mental health services) rated their quality of sleep before performing tests of cardiac interoception. Poor sleep quality was associated with lower measures of interoceptive performance accuracy, and higher self-report measures of interoceptive sensibility in individuals with diagnoses of depression and/or anxiety. Additionally, poor sleep quality was associated with impaired metacognitive interoceptive awareness in patients with diagnoses of depression (alone or with anxiety). Thus, poor sleep quality, a common early expression of psychological disorder, impacts cardiac interoceptive ability and experience across diagnoses. Sleep disruption can contribute to the expression of affective psychopathology through effects on perceptual and interpretative dimensions of bodily awareness.

Feedback from the heart: Emotional learning and memory is controlled by cardiac cycle, interoceptive accuracy and personality

Feedback processing is critical to trial-and-error learning. Here, we examined whether interoceptive signals concerning the state of cardiovascular arousal influence the processing of reinforcing feedback during the learning of 'emotional' face-name pairs, with subsequent effects on retrieval. Participants (N=29) engaged in a learning task of face-name pairs (fearful, neutral, happy faces). Correct and incorrect learning decisions were reinforced by auditory feedback, which was delivered either at cardiac systole (on the heartbeat, when baroreceptors signal the contraction of the heart to the brain), or at diastole (between heartbeats during baroreceptor quiescence). We discovered a cardiac influence on feedback processing that enhanced the learning of fearful faces in people with heightened interoceptive ability. Individuals with enhanced accuracy on a heartbeat counting task learned fearful face-name pairs better when feedback was given at systole than at diastole. This effect was not present for neutral and happy faces. At retrieval, we also observed related effects of personality: First, individuals scoring higher for extraversion showed poorer retrieval accuracy. These individuals additionally manifested lower resting heart rate and lower state anxiety, suggesting that attenuated levels of cardiovascular arousal in extraverts underlies poorer performance. Second, higher extraversion scores predicted higher emotional intensity ratings of fearful faces reinforced at systole. Third, individuals scoring higher for neuroticism showed higher retrieval confidence for fearful faces reinforced at diastole. Our results show that cardiac signals shape feedback processing to influence learning of fearful faces, an effect underpinned by personality differences linked to psychophysiological arousal.

Neural correlates of heart-focused interoception: a functional magnetic resonance imaging meta-analysis

Interoception is the ability to perceive one's internal body state including visceral sensations. Heart-focused interoception has received particular attention, in part due to a readily available task for behavioural assessment, but also due to accumulating evidence for a significant role in emotional experience, decision-making and clinical disorders such as anxiety and depression. Improved understanding of the underlying neural correlates is important to promote development of anatomical-functional models and suitable intervention strategies. In the present meta-analysis, nine studies reporting neural activity associated with interoceptive attentiveness (i.e. focused attention to a particular interoceptive signal for a given time interval) to one's heartbeat were submitted to a multilevel kernel density analysis. The findings corroborated an extended network associated with heart-focused interoceptive attentiveness including the posterior right and left insula, right claustrum, precentral gyrus and medial frontal gyrus. Right-hemispheric dominance emphasizes non-verbal information processing with the posterior insula presumably serving as the major gateway for cardioception. Prefrontal neural activity may reflect both top-down attention deployment and processing of feed-forward cardioceptive information, possibly orchestrated via the claustrum.This article is part of the themed issue 'Interoception beyond homeostasis: affect, cognition and mental health'.

Respiratory modulation of startle eye blink: a new approach to assess afferent signals from the respiratory system

Current approaches to assess interoception of respiratory functions cannot differentiate between the physiological basis of interoception, i.e. visceral-afferent signal processing, and the psychological process of attention focusing. Furthermore, they typically involve invasive procedures, e.g. induction of respiratory occlusions or the inhalation of CO₂-enriched air. The aim of this study was to test the capacity of startle methodology to reflect respiratory-related afferent signal processing, independent of invasive procedures. Forty-two healthy participants were tested in a spontaneous breathing and in a 0.25 Hz paced breathing condition. Acoustic startle noises of 105 dB(A) intensity (50 ms white noise) were presented with identical trial frequency at peak and on-going inspiration and expiration, based on a new pattern detection method, involving the online processing of the respiratory belt signal. The results show the highest startle magnitudes during on-going expiration compared with any other measurement points during the respiratory cycle, independent of whether breathing was spontaneous or paced. Afferent signals from slow adapting phasic pulmonary stretch receptors may be responsible for this effect. This study is the first to demonstrate startle modulation by respiration. These results offer the potential to apply startle methodology in the non-invasive testing of interoception-related aspects in respiratory psychophysiology.This article is part of the themed issue 'Interoception beyond homeostasis: affect, cognition and mental health'.

How the heart speaks to the brain: neural activity during cardiorespiratory interoceptive stimulation

Prominent theories emphasize key roles for the insular cortex in the central representation of interoceptive sensations, but how this brain region responds dynamically to changes in interoceptive state remains incompletely understood. Here, we systematically modulated cardiorespiratory sensations in humans using bolus infusions of isoproterenol, a rapidly acting peripheral beta-adrenergic agonist similar to adrenaline. To identify central neural processes underlying these parametrically modulated interoceptive states, we used pharmacological functional magnetic resonance imaging (phMRI) to simultaneously measure blood-oxygenation-level dependent (BOLD) and arterial spin labelling (ASL) signals in healthy participants. Isoproterenol infusions induced dose-dependent increases in heart rate and cardiorespiratory interoception, with all participants endorsing increased sensations at the highest dose. These reports were accompanied by increased BOLD and ASL activation of the right insular cortex at the highest dose. Different responses across insula subregions were also observed. During anticipation, insula activation increased in more anterior regions. During stimulation, activation increased in the mid-dorsal and posterior insula on the right, but decreased in the same regions on the left. This study demonstrates the feasibility of phMRI for assessing brain activation during adrenergic interoceptive stimulation, and provides further evidence supporting a dynamic role for the insula in representing changes in cardiorespiratory states.This article is part of the themed issue 'Interoception beyond homeostasis: affect, cognition and mental health'.

Interoceptive dimensions across cardiac and respiratory axes

Interoception refers to the sensing of signals concerning the internal state of the body. Individual differences in interoceptive sensitivity are proposed to account for differences in affective processing, including the expression of anxiety. The majority of investigations of interoceptive accuracy focus on cardiac signals, typically using heartbeat detection tests and self-report measures. Consequently, little is known about how different organ-specific axes of interoception relate to each other or to symptoms of anxiety. Here, we compare interoception for cardiac and respiratory signals. We demonstrate a dissociation between cardiac and respiratory measures of interoceptive accuracy (i.e. task performance), yet a positive relationship between cardiac and respiratory measures of interoceptive awareness (i.e. metacognitive insight into own interoceptive ability). Neither interoceptive accuracy nor metacognitive awareness for cardiac and respiratory measures was related to touch acuity, an exteroceptive sense. Specific measures of interoception were found to be predictive of anxiety symptoms. Poor respiratory accuracy was associated with heightened anxiety score, while good metacognitive awareness for cardiac interoception was associated with reduced anxiety. These findings highlight that detection accuracies across different sensory modalities are dissociable and future work can better delineate their relationship to affective and cognitive constructs.This article is part of the themed issue 'Interoception beyond homeostasis: affect, cognition and mental health'.

The Water Load Test As a Measure of Gastric Interoception: Development of a Two-Stage Protocol and Application to a Healthy Female Population

The sensitivity for one’s own internal body signals (i.e., interoception) has been demonstrated to play an important role in the pathogenesis of eating and weight disorders. Most previous measures assessing interoceptive processing have not, or only partly, captured perception of hunger and satiety cues, which is a core aspect of interoceptive deficits in eating disorders. In addition, methods used to measure sensitivity to gastric signals are heterogeneous and findings inconsistent. The primary aim of the present study was to establish a standardised test to measure gastric interoception, and to provide normative data using a non-clinical adult sample. The two-step Water Load Test (WLT-II) involves ingestion of non-caloric water until perceived satiation (step 1) and until maximum fullness (step 2). The WLT-II consists of several variables: Besides volumes of water ingested until satiation and maximum fullness expressed in ml, percentage of satiation to maximum fullness is calculated as an individual index of gastric interoception that is not confounded with stomach capacity. Ninety-nine healthy women participated in the study. Measures included the WLT-II, the heartbeat tracking test, a self-report questionnaire assessing subjective sensations, and the Eating Disorder Inventory-2. Twenty-eight participants underwent test-retest of the WLT-II. Results suggest that the WLT-II is a valid and reliable measure of gastric interoception. Importantly, satiation volume and percentage of satiation to maximum fullness were strongly positively related to self-reported bulimic symptoms, indicating that the WLT-II could emerge as a useful clinical tool to measure interoceptive processing in the field of eating disorders.

Interoceptive awareness and its relationship to hippocampal dependent processes

Many neuropsychological and animal lesion studies point to the hippocampus as being critical for mediating interoceptive awareness, while neuroimaging studies have been used to argue for the importance of the insula and anterior cingulate cortex. Here, using healthy young adults - as with the neuroimaging data - we tested for an association between performance on a hippocampal dependent learning and memory (HDLM) measure (logical memory percent retention) and interoceptive awareness assessed on three tasks - heart rate tracking, water loading and the Multidimensional Assessment of Interoceptive Awareness questionnaire (MAIA). After controlling for other relevant potentially confounding variables, we found significant associations between both the water loading and MAIA measures (which were both correlated) and HDLM performance. These findings imply that hippocampal dependent processes are involved in interoceptive awareness in healthy young adults. More tentatively, they suggest that medial temporal lobe structures may mediate interoceptive tasks that involve ingestion and/or integration of past and current state-based information.

Design and Application of a New Automated Fluidic Visceral Stimulation Device for Human fMRI Studies of Interoception

Mapping the brain centers that mediate the sensory-perceptual processing of visceral afferent signals arising from the body (i.e., interoception) is useful both for characterizing normal brain activity and for understanding clinical disorders related to abnormal processing of visceral sensation. Here, we report a novel closed-system, electrohydrostatically driven master–slave device that was designed and constructed for delivering controlled fluidic stimulations of visceral organs and inner cavities of the human body within the confines of a 3T magnetic resonance imaging (MRI) scanner. The design concept and performance of the device in the MRI environment are described. In addition, the device was applied during a functional MRI (fMRI) investigation of visceral stimulation related to detrusor distention in two representative subjects to verify its feasibility in humans. System evaluation tests demonstrate that the device is MR-compatible with negligible impact on imaging quality [static signal-to-noise ratio (SNR) loss <2.5% and temporal SNR loss <3.5%], and has an accuracy of 99.68% for flow rate and 99.27% for volume delivery. A precise synchronization of the stimulus delivery with fMRI slice acquisition was achieved by programming the proposed device to detect the 5 V transistor–transistor logic (TTL) trigger signals generated by the MRI scanner. The fMRI data analysis using the general linear model analysis with the standard hemodynamic response function showed increased activations in the network of brain regions that included the insula, anterior and mid-cingulate and lateral prefrontal cortices, and thalamus in response to increased distension pressure on viscera. The translation from manually operated devices to an MR-compatible and MR-synchronized device under automatic control represents a useful innovation for clinical neuroimaging studies of human interoception.

Cardiac cycle time effects on selection efficiency in vision

The effect of cardiac cycle time on attentional selection was investigated in an experiment in which participants classified target letters in a visual selection task. Stimulus onsets were aligned to the R wave of the electrocardiogram and stimuli presented either during the ventricular systole or diastole. Selection efficiency was operationalized as difference in target selection performance under conditions of homogeneous and heterogeneous distractors. Differences in performance (i.e., the impact selection difficulty had on the ability to select the target) were attenuated for stimuli presented during the ventricular systole compared to the diastole. Increased baroafferent signal transmission during the systole appears to reduce interference of highly distracting stimuli on visual selection efficiency.

The Relationship Between Interoception and Metacognition

Abstract. Recently, Garfinkel and Critchley (2013) proposed to distinguish between three facets of interoception: interoceptive sensibility, interoceptive accuracy, and interoceptive awareness. This pilot study investigated how these facets interrelate to each other and whether interoceptive awareness is related to the metacognitive awareness of memory performance. A sample of 24 healthy students completed a heartbeat perception task (HPT) and a memory task. Judgments of confidence were requested for each task. Participants filled in questionnaires assessing interoceptive sensibility, depression, anxiety, and socio-demographic characteristics. The three facets of interoception were found to be uncorrelated and interoceptive awareness was not related to metacognitive awareness of memory performance. Whereas memory performance was significantly related to metamemory awareness, interoceptive accuracy (HPT) and interoceptive awareness were not correlated. Results suggest that future research on interoception should assess all facets of interoception in order to capture the multifaceted quality of the construct.

Touching the Lived Body in Patients with Medically Unexplained Symptoms. How an Integration of Hands-on Bodywork and Body Awareness in Psychotherapy may Help People with Alexithymia

Medically unexplained symptoms (MUS) are a considerable presenting problem in general practice. Alexithymia and difficulties with mental elaboration of bodily arousal are hypothesized as a key mechanism in MUS. In turn, this inability influences the embodied being and participating of these patients in the world, which is coined as 'the lived body' and underlies what is mostly referred to as body awareness (BA). The present article explores a more innovative hypothesis how hands-on bodywork can influence BA and serve as a rationale for a body integrated psychotherapeutic approach of MUS. Research not only shows that BA is a bottom-up 'bodily' affair but is anchored in a interoceptive-insular pathway (IIP) which in turn is deeply connected with autonomic and emotional brain areas as well as verbal and non-verbal memory. Moreover, it is emphasized how skin and myofascial tissues should be seen as an interoceptive generator, if approached in the proper manual way. This article offers supportive evidence explaining why a 'haptic' touch activates this IIP, restores the myofascial armored body, helps patients rebalancing their window of tolerance and facilitates BA by contacting their bodily inner-world. From a trans-disciplinary angle this article reflects on how the integration of bodywork with non-directive verbal guidance can be deeply healing and resourcing for the lived body experience in MUS. In particular for alexithymic patients this approach can be of significance regarding their representational failure of bodily arousal.

Interoceptive Processes in Anorexia Nervosa in the Time Course of Cognitive-Behavioral Therapy: A Pilot Study

OBJECTIVE

Previous studies report reduced interoceptive abilities in anorexia nervosa (AN) using various methods. Recent research suggests that different levels of interoceptive processes aiming at different subdomains of interoceptive abilities must be further distinguished as these levels can be differentially affected. Two important levels refer to interoceptive accuracy (IA) derived from objective performance tasks such as the heartbeat detection task and interoceptive sensibility (IS) as assessed by self-report. There is a lack of studies investigating both IA and IS in AN and examining them in the time course of therapy. The aim of this pilot study was to evaluate the different interoceptive processes - especially IA and IS - in the time course of therapy.

METHODS

Fifteen patients with AN (restricting type) from the Psychosomatic Clinic in Windach were investigated three times (T1, T2, T3) during a standardized cognitive-behavioral therapy and compared with 15 matched healthy controls assessed at Ulm University in a comparable design. All participants performed the heartbeat detection task examining IA and completed standard psychological assessments including an assessment of IS.

RESULTS

Patients with AN showed a significantly decreased weight, higher levels of depression, and both reduced IA and IS compared to healthy controls at T1. Following therapy, patients recovered in terms of weight and depression symptomatology. A descriptive trend for recovering from IA and IS was observed.

DISCUSSION

Our findings suggest that interoceptive deficits are present in recovered patients. Therefore, further investigations are needed with more patients, differentiating between relapsed and recovered patients, and more specific training methods to improve interoceptive processes.

Can Interoception Improve the Pragmatic Search for Biomarkers in Psychiatry?

Disrupted interoception is a prominent feature of the diagnostic classification of several psychiatric disorders. However, progress in understanding the interoceptive basis of these disorders has been incremental, and the application of interoception in clinical treatment is currently limited to panic disorder. To examine the degree to which the scientific community has recognized interoception as a construct of interest, we identified and individually screened all articles published in the English language on interoception and associated root terms in Pubmed, Psychinfo, and ISI Web of Knowledge. This search revealed that interoception is a multifaceted process that is being increasingly studied within the fields of psychiatry, psychology, neuroscience, and biomedical science. To illustrate the multifaceted nature of interoception, we provide a focused review of one of the most commonly studied interoceptive channels, the cardiovascular system, and give a detailed comparison of the most popular methods used to study cardiac interoception. We subsequently review evidence of interoceptive dysfunction in panic disorder, depression, somatic symptom disorders, anorexia nervosa, and bulimia nervosa. For each disorder, we suggest how interoceptive predictions constructed by the brain may erroneously bias individuals to express key symptoms and behaviors, and outline questions that are suitable for the development of neuroscience-based mental health interventions. We conclude that interoception represents a viable avenue for clinical and translational research in psychiatry, with a well-established conceptual framework, a neural basis, measurable biomarkers, interdisciplinary appeal, and transdiagnostic targets for understanding and improving mental health outcomes.

When the brain does not adequately feel the body: Links between low resilience and interoception

This study examined neural processes of resilience during aversive interoceptive processing. Forty-six individuals were divided into three groups of resilience Low (LowRes), high (HighRes), and normal (NormRes), based on the Connor-Davidson Resilience Scale (2003). Participants then completed a task involving anticipation and experience of loaded breathing during functional magnetic resonance imaging (fMRI) recording. Compared to HighRes and NormRes groups, LowRes self-reported lower levels of interoceptive awareness and demonstrated higher insular and thalamic activation across anticipation and breathing load conditions. Thus, individuals with lower resilience show reduced attention to bodily signals but greater neural processing to aversive bodily perturbations. In low resilient individuals, this mismatch between attention to and processing of interoceptive afferents may result in poor adaptation in stressful situations.

Optimization of a motor learning attention-directing strategy based on an individual's motor imagery ability

Motor learning performance has been shown to be affected by various cognitive factors such as the focus of attention and motor imagery ability. Most previous studies on motor learning have shown that directing the attention of participants externally, such as on the outcome of an assigned body movement, can be more effective than directing their attention internally, such as on body movement itself. However, to the best of our knowledge, no findings have been reported on the effect of the focus of attention selected according to the motor imagery ability of an individual on motor learning performance. We measured individual motor imagery ability assessed by the Movement Imagery Questionnaire and classified the participants into kinesthetic-dominant (n = 12) and visual-dominant (n = 8) groups based on the questionnaire score. Subsequently, the participants performed a motor learning task such as tracing a trajectory using visuomotor rotation. When the participants were required to direct their attention internally, the after-effects of the learning task in the kinesthetic-dominant group were significantly greater than those in the visual-dominant group. Conversely, when the participants were required to direct their attention externally, the after-effects of the visual-dominant group were significantly greater than those of the kinesthetic-dominant group. Furthermore, we found a significant positive correlation between the size of after-effects and the modality-dominance of motor imagery. These results suggest that a suitable attention strategy based on the intrinsic motor imagery ability of an individual can improve performance during motor learning tasks.

Methodological recommendations for a heartbeat detection-based measure of interoceptive sensitivity

Heartbeat detection tasks are often used to measure cardiac interoceptive sensitivity-the ability to detect sensations from one's heart. However, there is little work to guide decisions on the optimum number of trials to use, which should balance reliability and power against task duration and participant burden. Here, 174 participants completed 100 trials of a widely used heartbeat detection task where participants attempt to detect whether presented tones occurred synchronously or asynchronously with their heartbeats. First, we quantified measurement reliability of the participant's accuracy derived from differing numbers of trials of the task using a correlation metric; we found that at least 40-60 trials were required to yield sufficient reliability. Next, we quantified power by simulating how the number of trials influenced the ability to detect a correlation between cardiac interoceptive sensitivity and other variables that differ across participants, including a variable measured from our sample (body mass index) as well as simulated variables of varying effect sizes. Using these simulations, we quantified the trade-offs between sample size, effect size, and number of trials in the heartbeat detection task such that a researcher can easily determine any one of these variables at given values of the other two variables. We conclude that using fewer than 40 trials is typically insufficient due to poor reliability and low power in estimating an effect size, although the optimal number of trials can differ by study.

Interoception and stress

Afferent neural signals are continuously transmitted from visceral organs to the brain. Interoception refers to the processing of visceral-afferent neural signals by the central nervous system, which can finally result in the conscious perception of bodily processes. Interoception can, therefore, be described as a prominent example of information processing on the ascending branch of the brain–body axis. Stress responses involve a complex neuro-behavioral cascade, which is elicited when the organism is confronted with a potentially harmful stimulus. As this stress cascade comprises a range of neural and endocrine pathways, stress can be conceptualized as a communication process on the descending branch of the brain–body axis. Interoception and stress are, therefore, associated via the bi-directional transmission of information on the brain–body axis. It could be argued that excessive and/or enduring activation (e.g., by acute or chronic stress) of neural circuits, which are responsible for successful communication on the brain–body axis, induces malfunction and dysregulation of these information processes. As a consequence, interoceptive signal processing may be altered, resulting in physical symptoms contributing to the development and/or maintenance of body-related mental disorders, which are associated with stress. In the current paper, we summarize findings on psychobiological processes underlying acute and chronic stress and their interaction with interoception. While focusing on the role of the physiological stress axes (hypothalamic-pituitary-adrenocortical axis and autonomic nervous system), psychological factors in acute and chronic stress are also discussed. We propose a positive feedback model involving stress (in particular early life or chronic stress, as well as major adverse events), the dysregulation of physiological stress axes, altered perception of bodily sensations, and the generation of physical symptoms, which may in turn facilitate stress.

Interoception, contemplative practice, and health

Interoception can be broadly defined as the sense of signals originating within the body. As such, interoception is critical for our sense of embodiment, motivation, and well-being. And yet, despite its importance, interoception remains poorly understood within modern science. This paper reviews interdisciplinary perspectives on interoception, with the goal of presenting a unified perspective from diverse fields such as neuroscience, clinical practice, and contemplative studies. It is hoped that this integrative effort will advance our understanding of how interoception determines well-being, and identify the central challenges to such understanding. To this end, we introduce an expanded taxonomy of interoceptive processes, arguing that many of these processes can be understood through an emerging predictive coding model for mind–body integration. The model, which describes the tension between expected and felt body sensation, parallels contemplative theories, and implicates interoception in a variety of affective and psychosomatic disorders. We conclude that maladaptive construal of bodily sensations may lie at the heart of many contemporary maladies, and that contemplative practices may attenuate these interpretative biases, restoring a person’s sense of presence and agency in the world.

Interaction of physical activity and interoception in children

Background: Physical activity (PA) is associated with positive health outcomes, whereas physical inactivity is related to an increased risk for various health issues including obesity and cardiovascular diseases. Previous research indicates that interindividual differences in the perception of bodily processes (interoceptive sensitivity, IS) interact with the degree of PA in adults. Whether there is a similar relationship between PA and IS in children has not been investigated yet. Therefore, the aim of this study was to investigate the interaction between IS and PA during physical performance tasks and in everyday situations. Methods: IS was assessed using a heartbeat perception task in a sample of 49 children within the health promotion program “Join the Healthy Boat” which is implemented in several primary schools in the southwest of Germany. PA was examined using a physical performance task, assessing the distance covered during a standardized 6-min run. In a subsample of 21 children, everyday PA was measured by a multi-sensor device (Actiheart, CamNtech, Cambridge, UK) during five consecutive days with more than 10 h of daily data collection. Results: Children with higher IS performed better in the physical performance task. Additionally, based on energy expenditure defined as metabolic equivalents, IS was positively correlated with the extent of light PA levels in the morning and afternoon. Conclusion: Our findings reveal that IS interacts positively with the degree of PA in children supporting the idea that interoception is important for the self-regulation of health-related behavior.

The preparatory set: a novel approach to understanding stress, trauma, and the bodymind therapies

Basic to all motile life is a differential approach/avoid response to perceived features of environment. The stages of response are initial reflexive noticing and orienting to the stimulus, preparation, and execution of response. Preparation involves a coordination of many aspects of the organism: muscle tone, posture, breathing, autonomic functions, motivational/emotional state, attentional orientation, and expectations. The organism organizes itself in relation to the challenge. We propose to call this the "preparatory set" (PS). We suggest that the concept of the PS can offer a more nuanced and flexible perspective on the stress response than do current theories. We also hypothesize that the mechanisms of body-mind therapeutic and educational systems (BTES) can be understood through the PS framework. We suggest that the BTES, including meditative movement, meditation, somatic education, and the body-oriented psychotherapies, are approaches that use interventions on the PS to remedy stress and trauma. We discuss how the PS can be adaptive or maladaptive, how BTES interventions may restore adaptive PS, and how these concepts offer a broader and more flexible view of the phenomena of stress and trauma. We offer supportive evidence for our hypotheses, and suggest directions for future research. We believe that the PS framework will point to ways of improving the management of stress and trauma, and that it will suggest directions of research into the mechanisms of action of BTES.

Cross-cultural differences in somatic awareness and interoceptive accuracy: a review of the literature and directions for future research

This review examines cross-cultural differences in interoception and the role of culturally bound epistemologies, historical traditions, and contemplative practices to assess four aspects of culture and interoception: (1) the extent to which members from Western and non-Western cultural groups exhibit differential levels of interoceptive accuracy and somatic awareness; (2) the mechanistic origins that can explain these cultural differences, (3) culturally bound behavioral practices that have been empirically shown to affect interoception, and (4) consequences for culturally bound psychopathologies. The following outlines the scope of the scientific review. Part 1 reviews studies on cultural variation in spontaneous somatic word use, linguistic expressions, traditional medical practices, and empirical laboratory studies to assess the evidence for cultural differences in somatic processes. Integration of these findings suggests a startling paradox: on the one hand, non-Western cultures consistently exhibit heightened somatic focus and awareness across a variety of contexts; on the other hand, non-Western cultures also exhibit less interoceptive accuracy in laboratory studies. Part 2 discusses the various mechanistic explanations that have been proposed to explain these cultural differences in somatic awareness and interoceptive accuracy, focusing on cultural schemas and epistemologies. Part 3 addresses the behavioral and contemplative practices that have been proposed as possible "interventions," or methods of cultivating bodily awareness and perceptual accuracy. Finally, Part 4 reviews the consequences of interoception for psychopathology, including somatization, body dysmorphia, eating disorders, and anxiety disorders.

Interoceptive sensitivity, body image dissatisfaction, and body awareness in healthy individuals

Relationships among interoceptive sensitivity (IS), body image dissatisfaction, body mass index (BMI), and self-reported body awareness were investigated in a cross-sectional study. Eighty-two Norwegian high school students and 70 Hungarian undergraduate university students participated in the study. Subjects completed two questionnaires (Body Image Ideals Questionnaire - BIQ; Body Awareness Questionnaire - BAQ) followed by the assessment of interoceptive sensitivity using the Mental Tracking Method (MTM). An inverse, medium-level relationship between body image dissatisfaction and IS was found in both the Norwegian and the Hungarian samples. The relationships between IS and self-reported body awareness, and between body image dissatisfaction and BMI were uniformly non-significant in both samples. Predictors of body image dissatisfaction were resting heart rate, gender, and IS in the regression analysis after controlling for BMI, age, and nationality. The negative relationship between IS and body image dissatisfaction described in patients with anorexia nervosa also exists in healthy individuals. There is no direct connection between IS and self-reported body awareness.

Interoceptive sensitivity, body weight and eating behavior in children: a prospective study

Previous research indicates that interindividual differences in the ability to perceive one's own bodily signals (interoceptive sensitivity, IS) are associated with disordered eating behavior and weight problems. But representative and prospective data in children are lacking and therefore, the exact nature of these observed associations remains unclear. Data on IS measured by heartbeat perception ability in 1657 children between 6 and 11 years of age were collected on the basis of two measurement points with a year distance in time. Stability of the construct and its prospective association with different food approach behaviors [assessed via parent questionnaires (Children's Eating Behavior Questionnaire and Dutch Eating Behavior Questionnaire)] as well as with weight status were analyzed via structural equation modeling. Main results were that only in overweight children external and emotional eating behavior were predictive for later IS, whereas no such relation was found in normal weight children. There was no direct relation between IS and body mass index. For the first time, we could show that eating behavior and IS in middle childhood are prospectively related to each other. But surprisingly, our data indicate that altered interoceptive processes rather follow than precede non-adaptive eating behavior patterns in overweight children. This suggests a possible crucial role of faulty learning mechanisms in eating behavior early in life, undermining the later confidence in one's body.