Interoceptive Awareness and Suicidal Ideation in a Clinical Eating Disorder Sample: The Role of Body Trust

Evaluating the predictions of an interoceptive inference model of bulimia nervosa

OBJECTIVE

Bulimia nervosa (BN) is associated with loss-of-control (LOC) eating episodes that frequently occur in response to negative emotions. According to recent neurocomputational models, this link could be explained by a failure to accurately update beliefs about the body in states of high arousal. Specifically, these interoceptive inference models suggest that under-relying on signals from one's body about sensory experience ("low sensory precision") and/or over-relying on previously held beliefs ("excessively precise priors") lead to inaccurate perception and maladaptive behaviors. We conducted an initial test of these core predictions of the interoceptive inference model in BN using self-report measures.

METHODS

We compared women with BN (n = 30) and age-, BMI-, and full-scale IQ-matched controls (n = 31) on trust in sensory information from the body and two types of beliefs about what can be done to regulate high negative affect. Within the BN group, we tested interrelations among these measures and explored their associations with LOC eating frequency.

RESULTS

Compared with healthy controls, the BN group reported lower levels of trust in sensory information and stronger beliefs that once upset, there is little one can do, apart from eating, to self-regulate. These beliefs were associated with each other and with lower body trust. Beliefs about the uncontrollability of emotion were associated with more frequent subjective binge-eating episodes.

CONCLUSIONS

Findings provide initial support for the core predictions of an interoceptive inference account of BN: low trust in sensory information ("sensory precision") may promote an overreliance on maladaptive "prior beliefs" about the effects of eating on negative emotions, ultimately interfering with accurate updating of beliefs about other strategies that could regulate emotions and maintain LOC eating. Low body trust, strong expectations about emotions, and their neurocomputational underpinnings could be promising combined treatment targets for BN.

The Neurophysiology of Interoceptive Disruptions in Trauma-Exposed Populations

In the aftermath of psychological trauma, many individuals experience perturbations in interoception, a term that broadly references the ability to accurately detect body signals and integrate these signals with emotional states. These interoceptive disruptions can manifest in different ways, including blunting or amplification of sensitivity to internal physiological signals. In this chapter we review extant neurophysiological research on interoception in trauma-exposed populations, with a particular focus on the effects of chronic interpersonal trauma, such as childhood maltreatment and racial discrimination. We explore research that used different types of interoceptive assays, from self-report measures to electrophysiological and neuroimaging tools to characterize the disruptions in pain perception, interoceptive acuity, and physiological responses that may arise after a traumatic event. Finally, we discuss interventions that are designed to target interoceptive mechanisms, from exposure-based therapies to mindfulness-based practices, as well as future directions in trauma interoception research.

Body Awareness as a Protective Factor against Suicidal Orientations in College Students

In this study, binary logistic regression and linear regression analyses were used to examine the relationship between interoceptive body awareness and suicidal orientation among Colombian university students. Additionally, the bootstrap technique was employed to resample and estimate the distribution of the data. The results support the idea that greater interoceptive awareness may protect against suicidal orientation by improving emotional regulation. An inverse relationship was found between interoceptive awareness and suicidal ideation. These findings align with previous literature emphasizing the importance of body awareness for emotional well-being. Further longitudinal research is needed to explore this relationship more deeply.

Sensory processing across eating disorders: A systematic review and meta-analysis of self-report inventories

OBJECTIVE

This review investigated the extant literature regarding the relationship between eating disorder diagnoses and sensory processing as measured by validated and reliable self-report inventories. Increasing evidence highlights the role of sensory processing in cognitive functions. Sensory processing is implicated in mental-ill health, including eating disorders (ED) and body image disturbances. However, the pathophysiological underpinnings of sensory processing, encompassing exteroception and interoception, in relation to ED remain underexplored.

METHOD

We included studies involving participants aged 15 years or older with an eating disorder diagnosis confirmed by semi-structured or structured interviews. We further limited inclusion to articles using validated and reliable self-report instruments to measure sensory processing. Our meta-analysis focused on studies using the interoceptive awareness subscale from the second version of the Eating Disorder Inventory. We used the Critical Appraisal checklist for quasi-experimental studies to assess the quality of included articles.

RESULTS

There were 19 studies that met our inclusion criteria. Most studies showed moderate-to-high quality. Anorexia nervosa (AN) and bulimia nervosa (BN) were associated with heightened exteroception. Moreover, people with AN reported a heightened sense of taste compared to those with BN. Our meta-analysis comprising 10 studies, 19 samples, and 6382 participants revealed that AN (binge-purge subtype) and BN were associated with increased interoceptive difficulties compared to AN (restrictive subtype) or binge-eating disorder.

DISCUSSION

Overall, this review emphasizes the need for a deeper investigation into sensory processing, spanning both exteroception and interoception, in relation to ED. This may prove important for individualizing person-centered care.

PUBLIC SIGNIFICANCE

How people process internal, for example, hunger, and external, for example, taste and sensations is known to influence cognition and mental-ill health, including ED and body image disturbances. However, the ways in which sensory processing may contribute to ED are incompletely understood. We found that individuals with AN or BN experienced heightened exteroception, while people with an eating disorder characterized by purging reported increased interoceptive difficulties. These patterns could inform the development of more personalized treatments.

Development and Psychometric Validation of the Body Trust Scale

Interoception (e.g., abilities to recognize/attend to internal sensations) is robustly associated with psychopathology. One form of interoception, body trust, is relevant for the development of disordered eating and suicidal thoughts/behaviors. However, measures of body trust are narrow, despite research suggesting body trust is multifaceted. The aim of this study was to develop a comprehensive measure of body trust: The Body Trust Scale (BTS). 479 U.S. adults completed self-report surveys containing the BTS and psychopathology measures. Exploratory and confirmatory factor analyses revealed a three-factor structure: Comfort with One's Body, Physical Attractiveness, and Comfort with Internal Sensations. Factors showed strong construct, convergent, and divergent validity, as well as moderate predictive validity for suicidal thoughts/non-suicidal self-injury. Furthermore, factors showed strong internal consistency, test-retest reliability, and were invariant across the gender binary. The BTS can be used in research and clinical settings to understand how specific facets of body trust relate to psychopathology.

Elevated interoceptive deficits in individuals with eating disorders and self-injurious thoughts and behaviors: A replication and extension

INTRODUCTION

People with eating disorders (EDs) frequently report self-injurious thoughts and behaviors (SITBs). We aimed to replicate and extend findings demonstrating greater interoceptive deficits according to SITB severity. We predicted that interoceptive deficits would be greater among people with versus without lifetime SITBs and among those with multiple suicide attempts compared with single attempts or nonsuicidal self-injury. We also predicted that interoception would be increasingly impaired with greater current suicidality severity.

METHOD

Adults (N = 118) seeking ED treatment reported current and lifetime SITBs upon admission to treatment. We used planned contrasts to compare interoceptive deficits (self-reported using the Eating Disorders Inventory) by SITB and current suicidality groups (assessed by self-report and clinical interview).

RESULTS

Interoceptive deficits were greater among people with any SITB history compared to those without. People with multiple suicide attempts did not differ in interoceptive deficits from those with single attempts or only nonsuicidal self-injury. Interoceptive deficits were elevated among those with any current suicidality compared to those with no suicidal symptoms; interoceptive deficits did not differ according to severity of suicidality.

CONCLUSION

Among those with EDs, interoceptive deficits are elevated among those with concurrent SITBs. Interventions aimed at improving interoception may reduce the risk for SITBs.

Exploring the Link between Interoceptive Body Awareness and Suicidal Orientation in University Students: A Cross-Sectional Study

INTRODUCTION

The transition to college life can impact the mental health of students. There are mental health care strategies that promote connection with the body's internal signals, which can help to improve mental well-being, manage emotions, and reduce the risk of suicide in university students.

AIM

This study aimed to examine the association between interoceptive body awareness variables and suicidal orientation in a sample of 169 undergraduate students in Colombia.

METHODS

An observational, cross-sectional study was conducted in 2023 with Colombian students as the participants.

RESULTS

The findings revealed a significant and moderately negative correlation between the Multidimensional Assessment of Interoceptive Awareness (MAIA) total score and the Inventory of Suicide Orientation (ISO-30) total score (r = -0.54, p < 0.001). Confidence and self-regulation were identified as the most influential factors in the relationship between MAIA and ISO-30. Significant correlations were observed (p < 0.001), indicating moderate correlation values ranging from -0.43 to -0.57.

DISCUSSION

Our findings support the existence of a negative correlation between interoceptive body awareness and suicidal orientation. Further research is needed to better understand this relationship and to develop specific interventions based on body awareness to prevent suicide orientation.

CONCLUSION

There are practical implications associated with recognizing the importance of body awareness in relation to decreasing suicidal orientation, and multidisciplinary teams addressing mental health can incorporate this knowledge.

Assessment of the mind-body connection: preliminary psychometric evidence for a new self-report questionnaire

OBJECTIVES

While interoceptive self-report scales provide a foundation for measuring the mind-body connection, they variably consider other important factors that could influence interpretations of internal bodily sensations and perceptions related to mind-body integration. The proposed Body-Mind Connection Questionnaire (BMCQ) aimed to operationalise the notion that this construct involves three major components: (a) Interoceptive Attention, (b) Sensation-Emotion Articulation, and (c) Body-Mind Values.

METHODS

Following panel review and piloting with the target population, the developed BMCQ was evaluated in 316 participants (189 identifying as female) aged 18-50 (MAge=30.78), alongside established self-report measures of interoceptive sensibility, body awareness, sensory processing sensitivity, and alexithymia. We examined the BMCQ factor structure through exploratory factor analysis and analysed convergent and discriminant validity.

RESULTS

Exploratory factor analysis supported three scales of the BMCQ, which explained 54.03% of variance. Factor loadings (>0.44) and reliability indices (0.74 to 0.85) were acceptable. Inter-scale correlations suggested that the scales are distinct but related (rs=0.38 to 0.59). BMCQ scales were supported by convergent (r=0.33 to 0.67) and discriminant evidence (rs=0.01 to 0.39, p range n.s. to <.05).

CONCLUSIONS

Preliminary psychometric properties indicate that the BMCQ is multidimensional and consists of three constructs that differentially relate to theoretically associated measures. Interoceptive Attention, Sensation-Emotion Articulation, and Body-Mind Values may serve as a basis for efficiently assessing the mind-body connection more holistically, which could be useful for developing interventions aimed at enhancing mind-body integration.

Predictors of current suicidal ideation in a multi-diagnostic sample of individuals with eating disorders

BACKGROUND

Individuals with eating disorders (EDs) have high rates of suicidal ideation (SI) and attempts (SA). Fasting, body dissatisfaction, binge eating and purging have been associated with SI in non-clinical samples, individuals with anorexia nervosa or low-weight EDs, and a multi-diagnostic sample. However, few studies have examined how ED symptoms contribute to risk for SI in conjunction with other well-established risk factors, such as nonsuicidal self-injury (NSSI) and past SA. The aim of this study was to examine which ED symptoms contribute unique risk for current SI in a multi-diagnostic, clinical sample when statistically adjusting for gender, NSSI, past SA, and past SI.

METHODS

We conducted a chart review of 166 individuals who presented for ED treatment at an outpatient facility and signed informed consent. Initial intake interviews were coded for the presence versus absence of fasting, fear of weight gain, binge eating, purging, excessive exercise, restriction, body checking, self-weighing, and body dissatisfaction, as well as NSSI, past SA, past SI, and current SI.

RESULTS

A total of 26.5% of the sample endorsed current SI. In a logistic regression analysis, identifying as male (n = 17) or having a non-binary gender identity (n = 1), the presence of fasting, and past SI were all significantly associated with increased odds of current SI, whereas excessive exercise significantly decreased odds of current SI. Fasting was equally common across all diagnostic groups.

CONCLUSIONS

Future research should establish the temporal relationship between fasting and SI to better inform intervention.

Confirmatory factor analysis of Acute Suicidal Affective Disturbance in a sample of treatment-seeking eating disorder patients

INTRODUCTION

We examined the factor structure of Acute Suicidal Affective Disturbance (ASAD) in individuals with eating disorders. ASAD is a proposed diagnosis with four symptoms: rapidly increasing suicidal intent, social or self-alienation, hopelessness regarding the previous symptoms, and overarousal.

METHODS

Patients with eating disorders (N = 378) completed self-report symptom questionnaires at admission to a partial hospitalization program for eating disorders. Using proxy measures, we conducted a confirmatory factor analysis (CFA) of the one-factor model of ASAD.

RESULTS

Initial model fit was poor. We iteratively revised the model to include theoretically-justified correlated residuals (i.e., those between items intended to measure the same ASAD symptom). After these modifications, model fit remained mediocre. We next conducted a multiple-group CFA to compare ASAD between individuals with the restricting subtype of anorexia nervosa (the "ANR" model, n = 145) and individuals with binge/purge disorders (i.e., bulimia nervosa and the binge-purge subtype of anorexia nervosa; the "BP" model, n = 234). The final model had mediocre fit with partial invariance between subgroups; the ASAD factor mean was higher in the BP model. We additionally tested a bifactor model, with similar findings.

LIMITATIONS

Our use of proxy measures of ASAD items may have resulted in imprecise measurement of ASAD symptoms, pointing to the importance of future research using validated measures of ASAD.

CONCLUSIONS

We found moderate support for ASAD in an eating disorder sample, with invariance between eating disorder phenotypes. Our findings suggest that the ASAD diagnosis may not fully generalize to eating disorder samples.

Disrupted interoception in Military Service Members and Veterans with a history of suicidality

INTRODUCTION

This project tested whether Service Members (SM) and Veterans with current suicidal ideation or a history of suicide attempt had greater interoceptive dysfunction than SM and Veterans with past or no suicidal ideation.

METHOD

Participants (N = 195; 69% male) were SM (62%) and Veterans (38%) who completed measures of suicidal thoughts and behaviors and subjective and objective interoceptive dysfunction. Participants were split into the following suicide groups: no suicidality, lifetime ideation, current ideation, and past attempt. Planned orthogonal contrasts tested for differences.

RESULTS

The combined suicidality group (lifetime ideation, current ideation, or past attempt) had worse body trust relative to the no suicidality group, and the current ideation group had worse body trust relative to those with lifetime ideation. Those with a history of suicide attempt had worse body appreciation than the combined group of ideators, and those with current ideation had worse body appreciation relative to those with lifetime ideation. The groups did not differ on objective interoception.

CONCLUSION

Interoception is disrupted among individuals with suicidality histories within a predominantly male-identified military sample. Individuals with current suicidal ideation had both worse body trust and appreciation relative to those with past ideation. Suicide risk assessments may benefit from including questions related to body trust.

Diminished body trust uniquely predicts suicidal ideation and nonsuicidal self-injury among people with recent self-injurious thoughts and behaviors

INTRODUCTION

Self-injurious thoughts and behaviors (SITBs) are difficult to predict, and novel risk factors must be identified. While diminished interoception is associated with SITBs cross-sectionally, the current study assesses whether multiple measures of interoception predict future SITBs.

METHODS

Adults (N = 43) with recent SITBs completed assessments of interoception during a baseline visit. Participants then completed biweekly assessments for 6 months in which they reported the presence and severity/frequency of suicidal ideation and nonsuicidal self-injury (NSSI).

RESULTS

Multilevel models were performed, where baseline interoceptive measures predicted presence and severity/frequency of suicidal ideation and NSSI at follow-up. The Multidimensional Assessment of Interoceptive Awareness (MAIA) Trusting subscale was the only significant predictor of the presence/severity of suicidal ideation. The MAIA Trusting, Emotional Awareness, and Body Listening subscales significantly predicted the presence of NSSI. The MAIA Emotional Awareness subscale and the Body Perception Questionnaire significantly predicted NSSI frequency.

DISCUSSION

Diminished body trust predicted both suicidal ideation and NSSI, indicating a potential shared risk pathway. However, two interoception measures (Body Listening subscale and Body Perception Questionnaire) were associated with NSSI only, indicating potentially unique risk pathways. Given the differential associations between interoception measures and SITBs, results highlight the importance of clearly defining how interoception is measured.

Associations of suicide risk with emotional reactivity, dysregulation, and eating disorder treatment outcomes

INTRODUCTION

Emotional processes play a role in both suicide risk and eating disorders (EDs), which are often comorbid. However, limited research has explored how emotional processes relate to suicide risk in EDs and the prognostic value of suicide risk for ED treatment. Thus, the current study examined associations between emotion dysregulation and reactivity with suicide risk in patients with EDs, and determined if suicide risk predicts ED treatment outcomes.

METHODS

Participants (n = 201) were adults in an ED partial hospitalization program who completed measures at admission, 1-month post-admission, and discharge.

RESULTS

When controlling for depressive symptoms, limited access to adaptive emotion regulation strategies, difficulties engaging in goal-oriented behaviors, and engaging in impulsive behavior when experiencing negative emotions (i.e., emotion dysregulation) were associated with suicide attempt frequency. Depressive symptoms were associated with suicide risk severity, while emotion dysregulation and reactivity were not. Importantly, patients with elevated suicide risk at admission improved comparably to other risk categories across treatment, despite presenting with greater ED symptoms at admission.

CONCLUSION

Emotion dysregulation and depression are salient factors when examining suicide risk in patients with EDs. Suicide risk and attempt history may not negatively impact ED treatment outcomes when using emotion-focused treatment.

Intra and inter: Alterations in functional brain resting-state networks in patients with functional constipation

Background

Functional constipation (FCon), is a symptom-based functional gastrointestinal disorder without an organic etiology and altering brain structure and function. However, previous studies mainly focused on isolated brain regions involved in brain plasticity. Therefore, little is known about the altered large-scale interaction of brain networks in FCon.

Methods

For this study, we recruited 20 patients with FCon and 20 healthy controls. We used group independent component analysis to identify resting-state networks (RSNs) and documented intra- and inter-network alterations in the RSNs of the patients with FCon.

Results

We found 14 independent RSNs. Differences in the intra-networks included decreased activities in the bilateral caudate of RSN 3 (strongly related to emotional and autonomic processes) and decreased activities in the left precuneus of RSN 10 (default mode network). Notably, the patients with FCon exhibited significantly decreased interactive connectivity between RSNs, mostly involving the connections to the visual perception network (RSN 7–9).

Conclusion

Compared with healthy controls, patients with FCon had extensive brain plastic changes within and across related RSNs. Furthermore, the macroscopic brain alterations in FCon were associated with interoceptive abilities, emotion processing, and sensorimotor control. These insights could therefore lead to the development of new treatment strategies for FCon.

Experiences of mimicry in eating disorders

BACKGROUND

People unknowingly mimic the behaviors of others, a process that results in feelings of affiliation. However, some individuals with eating disorders describe feeling "triggered" when mimicked. This study explores the effects of implicit non-verbal mimicry on individuals with a history of an eating disorder (ED-His) compared to healthy controls (HCs).

METHOD

Women (N = 118, n_ED-His = 31; M_age = 21 years) participated in a laboratory task with a confederate trained to either discreetly mimic (Mimicry condition) or not mimic (No-Mimicry condition) the mannerisms of the participant. Participants rated the likability of the confederate and the smoothness of the interaction.

RESULTS

Participants in the No-Mimicry condition rated the confederate as significantly more likable than in the Mimicry condition, and ED-His rated the confederate as more likable than HCs. ED-His in the Mimicry condition rated the interaction as less smooth than HCs, whereas this pattern was not found in the No-Mimicry condition. Among ED-His, longer disorder duration (≥ 3.87 years) was associated with less liking of a confederate who mimicked and more liking of a confederate who did not mimic.

CONCLUSIONS

We discuss the implications of these findings for interpersonal therapeutic processes and group treatment settings for eating disorders. Our study on subtle, nonverbal mimicry revealed differences in social behavior for women with a history of an eating disorder compared to healthy women. For participants with an eating disorder history, a longer duration of illness was associated with a worse pattern of affiliation, reflected in lower liking of a mimicker. Further research on how diverging processes of affiliation may function to perpetuate the chronicity of eating disorders and implications for treatment is needed.

Introduction to the Special Issue on Interoception and Suicidality

Empirically informed theories of suicide highlight the importance of identifying factors that lead from suicide ideation to suicidal behavior. Interoceptive dysfunction may be one such differentiating factor. Interoceptive dysfunction refers to a disconnection from the internal sensations of the body, which can cause difficulty in truly understanding and knowing one's own body. Specifically, interoceptive dysfunction may lead to such disconnection from the self that the body comes to be seen as "other" and potentially even "nonhuman." A burgeoning body of research supports these theoretical links and also highlights the need for methodologically rigorous studies that employ careful measurement of these constructs. Thus, this special section is devoted to articles that advance the understanding of the relationship between interoception and suicidality. A more nuanced understanding of the relationship between interoceptive dysfunction and suicidality is critical for improving suicide prevention and treatment efforts.