Interoceptive accuracy and bias in somatic symptom disorder, illness anxiety disorder, and functional syndromes: A systematic review and meta-analysis

Somatic symptom distress is not related to cardioceptive accuracy

OBJECTIVE

(Cardiac) interoception was long considered a key mechanism behind symptom perception in persistent somatic symptoms (PSS). In this study, we aimed to extend earlier findings to clarify this potential interoceptive mechanisms of PSS.

METHODS

A cross-sectional sample of 251 participants (23.1% with self-reported functional somatic syndrome) completed a laboratory study with two cardioceptive accuracy tasks (Schandry task and a new cardiac signal detection task) and multiple questionnaires. Somatic symptom distress and associated constructs were assessed with the PHQ-15, as well as with a novel multidimensional questionnaire measure (HiTOP-SF1) derived from the somatoform spectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). Correlations (frequentist and Bayesian) and structural equation modelling (SEM) helped further investigate the interplay between these variables.

RESULTS

There were no significant correlations between measures of interoception and somatic symptom distress. Self-report and behavioral cardioceptive accuracy measures did not correlate significantly. No significant covariances emerged between diagnostic tools and cardioceptive accuracy; Bayesian analyses supported the lack of association between interoception and symptom perception.

CONCLUSIONS

Cardiac interoception (specifically cardioceptive accuracy) unlikely represents a key mechanism in PSS etiology. We recommend investigating other factors in PSS.

"And how did that make you feel?" - Repeated symptom queries enhance symptom reports elicited by negative affect

OBJECTIVE

Negative affect, alexithymia, and other predisposing traits (such as health anxiety) can influence an individual's symptom perception. In this study, we used the affective picture paradigm (APP, Bogaerts et al., 2010) to induce symptoms using affective picture stimuli. We aimed to cross-sectionally test the effect of high vs low-frequency symptom queries and analyze the time course of the APP, including interactions with health anxiety and somatic symptom distress.

METHODS

Participants (N = 124) completed a modified APP and filled out various questionnaires. In the APP, participants were randomized to either a highly-frequent-query condition (18 symptom checklists) or a less-frequent-query condition (6 checklists). Data were analyzed using ANOVAs, cross-lagged panel models, moderation models, and multilevel models.

RESULTS

Both groups had comparable symptom baseline values, but people in the highly frequent as opposed to less frequent condition reported significantly higher symptom levels once the experiment started (F (1,120) = 14.319, p < .001, η2=.107). Symptom levels stayed stable over the course of the experiment and were best predicted by symptom levels at earlier timepoints in the experiment (β = 0.43 and β = 0.68, both p < .001). Health anxiety levels significantly predicted symptom levels (F(1,121) = 10.054, p = .002, η2=.077) and moderated the relation between condition and symptom levels (F(2,121) = 16.253, p < .001, η2=.212).

CONCLUSION

In terms of the predictive processing model (e.g.,[1]), repeated symptom queries following negative affective cues may activate prior beliefs about symptoms, resulting in elevated levels of symptom reports in interaction with health anxiety.

The Relationship Between Interoceptive Awareness, Emotion Regulation and Clinical Symptoms Severity of Depression, Anxiety and Somatization

OBJECTIVE

The primary objective of this study was to examine the associations among emotion regulation strategies, interoceptive awareness, and psychological distress measures-namely, depression, anxiety, and somatization. Additionally, we aimed to explore the predictive power of various facets of interoceptive awareness in determining the severity of symptoms for each mental disorder.

METHODS

A cohort of 130 outpatients diagnosed with depression/anxiety disorder were recruited, and 20 subjects exhibiting incomplete responses were excluded from the dataset, leading to a final sample size of 110 outpatients. The clinical symptoms were measured by Patient Health Questionnaire-9, State-Trait Anxiety Inventory Form Y, and Symptom Checklist-90-Revised, and the usage of emotion-regulation strategies and interoceptive awareness was assessed with Emotion Regulation Questionnaire and Multidimensional Assessment of Interoceptive Awareness (MAIA), respectively. A hierarchical regression analysis was performed to examine whether emotion-regulation strategies and interoceptive awareness explain the statistically significant variance in each of the symptoms.

RESULTS

In the depression model, cognitive reappraisal, accept, and attention regulation showed significant associations, while in the anxiety model, cognitive reappraisal, attention regulation, trust, and notice emerged as significant factors. Lastly, cognitive reappraisal and attention regulation were found to be significant contributors to the final model for somatization.

CONCLUSION

The inclusion of MAIA subscales improved the predictive ability of the regression model, highlighting the independent association between interoceptive awareness-particularly attention regulation-and clinical symptoms of anxiety and depression. Additionally, the study underscores the relevance of considering the specific pathological context when implementing interventions, as evidenced by the positive associations between the accept subscale and depression and between the notice subscale and anxiety, respectively.

Vague sensations. About the background and consequences of discordance between actual and perceived physiological changes

Empirical evidence consistently shows that discordance, also called dissociation or discrepancy, between actual physiological (mainly visceral) events and their perceived counterparts is substantial. On the one hand, we typically do not perceive actual visceral events occurring in our bodies; on the other hand, sometimes we do perceive bodily changes that do not really take place. This narrative review presents the available empirical findings on the discordance, and summarizes possible explanations that approach the phenomenon from the viewpoint of evolution, cognitive development, and predictive processing. Also, the role of top-down factors, such as expectations and experiences is discussed. Finally, practically relevant consequences of the discordance are presented using the examples of mind-body practices, the placebo and nocebo phenomenon, and medically unexplained symptoms. It is concluded that the discordance between actual and perceived body changes can have a negative impact on health, mainly through issues with adherence and other behavioral factors. The existence of actual-perceived discordance should be taught and demonstrated in the elementary and high school, as well as in many areas of higher education.

"Brain-breath" interactions: respiration-timing-dependent impact on functional brain networks and beyond

Breathing is a natural daily action that one cannot do without, and it sensitively and intensely changes under various situations. What if this essential act of breathing can impact our overall well-being? Recent studies have demonstrated that breathing oscillations couple with higher brain functions, i.e., perception, motor actions, and cognition. Moreover, the timing of breathing, a phase transition from exhalation to inhalation, modulates specific cortical activity and accuracy in cognitive tasks. To determine possible respiratory roles in attentional and memory processes and functional neural networks, we discussed how breathing interacts with the brain that are measured by electrophysiology and functional neuroimaging: (i) respiration-dependent modulation of mental health and cognition; (ii) respiratory rhythm generation and respiratory pontomedullary networks in the brainstem; (iii) respiration-dependent effects on specific brainstem regions and functional neural networks (e.g., glutamatergic PreBötzinger complex neurons, GABAergic parafacial neurons, adrenergic C1 neurons, parabrachial nucleus, locus coeruleus, temporoparietal junction, default-mode network, ventral attention network, and cingulo-opercular salience network); and (iv) a potential application of breathing manipulation in mental health care. These outlines and considerations of "brain-breath" interactions lead to a better understanding of the interoceptive and cognitive mechanisms that underlie brain-body interactions in health conditions and in stress-related and neuropsychiatric disorders.

Soreness Reminds Me of Grief: Patients With Chronic Pain Show Less Differentiated Representations of Emotional Feelings and Bodily States

People experience similarities between emotional feelings and bodily states on a daily basis, but both the magnitude and pervasiveness of this experiential similarity vary across individuals. Inspired by previous findings that chronic pain (CP) is characterized by strengthened pain-affect coupling and reduced interoceptive accuracy, we conducted 2 cross-sectional studies to examine whether patients with CP would exhibit less differentiated perception and mental representation of emotional feelings and bodily states. In study 1 (N = 500), patients with CP and healthy controls (HCs) completed a self-report questionnaire that asked explicitly about the perceived similarity between 5 basic emotion categories and a series of bodily states. In study 2 (N = 73), a specially designed false memory test was administered to examine whether patients with CP would have reduced differentiation of concepts of negative emotion and somatic distress. We found that patients with CP perceived greater and more pervasive similarities between emotional feelings and bodily states, as indicated by higher questionnaire scores and denser, less specialized bipartite emotion-body networks, both associated with lower subjective interoceptive accuracy. Furthermore, patients with CP formed false memories of negative emotion words (eg, grief) more readily than HCs after memorizing somatic distress words (eg, soreness), as if they represented negative emotion and somatic distress as a single, enmeshed semantic category. Our findings extend previous literature by demonstrating reduced discrimination between emotional and bodily experiences in CP that is not restricted to pain-related emotional and sensory experiences and may be related to a fundamentally less differentiated interoception. PERSPECTIVES: This study shows that patients with chronic pain have a profoundly less differentiated perception and implicit conceptualization of emotional feelings and bodily states, which appears to be associated with altered interoception. These findings may provide new perspectives on why they often experience a stronger pain-affect coupling.

Respiratory Interoception and Pathological Illness Anxiety: Disentangling Bias

OBJECTIVE

Biased interoception decoupled from physiology might be relevant in the etiology of pathological illness anxiety (PIA). Empirical evidence for interoceptive deviations in illness anxiety is scarce but potentially informative to optimize treatments. We hypothesized that persons with PIA differ fundamentally in the classification of bodily sensations from those without PIA.

METHODS

In a respiratory categorization task, participants breathed into a pulmonary training device. Inspiration effort was varied by eight resistive loads. The lower/higher four loads were introduced as belonging to arbitrary categories "A"/"B," respectively. Participants memorized respiratory sensations in a first experimental block and were asked to label the resistances in a second block. We calculated the sensitivity of resistance classification according to category and response bias in terms of categorical misclassification. Data of 39 participants with PIA and 35 controls were compared with regard to sensitivity and response bias by group, resistive load, and their interaction in a multiple regression.

RESULTS

With similar sensitivity, patients more often labeled loads above the categorical border erroneously as belonging to category A, thus underestimating their resistance ( β = -0.06, p = .001; η2 = 0.02).

CONCLUSIONS

Individuals with PIA showed a systematic "wait and see" approach. Altered respiroception in PIA might stem from biased perception during training phase, the recognition phase, biased memory, or a combination of these. Its exact characteristics remain unknown, and future research must address the challenge of developing reliable and valid paradigms accounting for the variability of interoceptive biases.

REGISTRATION

This work was preregistered on OSF ( https://osf.io/9shcw ).

Perioperative Anxiety and Depression in Older Adults: Epidemiology and Treatment

The intervals before and after major surgery is a high-risk period for older adults; in this setting, anxiety and depression are common and serious problems. We comprehensively reviewed current evidence on perioperative anxiety and depression in older adults, focusing on epidemiology, impact, correlates, medication risks, and treatment. Principles of perioperative mental healthcare are proposed based on the findings. Prevalence estimates of clinically significant anxiety and depression range from 5% to 45% for anxiety and 6% to 52% for depression, depending on surgical populations and measurement tools. Anxiety and depression may increase risk for surgical complications and reduce patient participation during rehabilitation. Medical comorbidities, pain, insomnia, cognitive impairment, and delirium are common co-occurring problems. Concomitant uses of central nervous system acting medications (benzodiazepines, anticholinergics, and opioids) amplify the risks of delirium and falls. Based on these findings, we propose that anxiety and depression care should be part of perioperative management in older adults; components include education, psychological support, opioid-sparing pain management, sleep management, deprescribing central nervous system active medications, and continuation and optimization of existing antidepressants. More research is needed to test and improve these care strategies.

Emotion dynamics and somatic symptoms in everyday life: Ecological momentary assessment in somatic symptom disorder and healthy controls

OBJECTIVE

Negative affectivity (NA) is associated with the emergence and persistence of physical symptoms with unclear organic pathology. This study investigated the temporal dynamics of NA and somatic symptom burden using ecological momentary assessment (EMA) in adults with somatic symptom disorder (SSD) and healthy control participants (HC).

METHODS

Participants underwent a seven-day, smartphone-based EMA, with 6 randomly-stratified time points per day. NA was assessed using a five-item short form of the Positive and Negative Affectivity Scale (PANAS) and somatic symptom burden with two self-constructed items. 22 persons with SSD and 20 HCs were included in multilevel analyses.

RESULTS

Within-person analyses showed a significantly stronger (positive) association of concurrent NA with somatic symptom burden in participants with SSD than in HCs, β = 0.15, SE = 0.04, p = .001. Time-lagged analyses demonstrated that, across groups, NA at a previous time point t-1 significantly predicted somatic symptom burden at the subsequent timepoint t, β = 0.09, SE = 0.03, p = .005, but not in the other direction (somatic symptom burdent-1→ NAt, β = 0.01, SE = 0.04, p = .79). Between-person analyses showed that both inertia (i.e., persistence of negative affective states), d = 0.74, and instability (i.e., magnitude of moment-to-moment fluctuations), d = 0.76 of NA were significantly higher in participants with SSD than in HCs.

CONCLUSIONS

Our findings sustain the idea of (negative) affect-driven modulation in somatic signal processing and suggest that interoceptive and emotional differentiation training can advance the psychotherapeutic treatment of SSD.

Long COVID as a functional somatic symptom disorder caused by abnormally precise prior expectations during Bayesian perceptual processing: A new hypothesis and implications for pandemic response

This review proposes a model of Long-COVID where the constellation of symptoms are in fact genuinely experienced persistent physical symptoms that are usually functional in nature and therefore potentially reversible, that is, Long-COVID is a somatic symptom disorder. First, we describe what is currently known about Long-COVID in children and adults. Second, we examine reported "Long-Pandemic" effects that create a risk for similar somatic symptoms to develop in non-COVID-19 patients. Third, we describe what was known about somatization and somatic symptom disorder before the COVID-19 pandemic, and suggest that by analogy, Long-COVID may best be conceptualized as one of these disorders, with similar symptoms and predisposing, precipitating, and perpetuating factors. Fourth, we review the phenomenon of mass sociogenic (functional) illness, and the concept of nocebo effects, and suggest that by analogy, Long-COVID is compatible with these descriptions. Fifth, we describe the current theoretical model of the mechanism underlying functional disorders, the Bayesian predictive coding model for perception. This model accounts for moderators that can make symptom inferences functionally inaccurate and therefore can explain how to understand common predisposing, precipitating, and perpetuating factors. Finally, we discuss the implications of this framework for improved public health messaging during a pandemic, with recommendations for the management of Long-COVID symptoms in healthcare systems. We argue that the current public health approach has induced fear of Long-COVID in the population, including from constant messaging about disabling symptoms of Long-COVID and theorizing irreversible tissue damage as the cause of Long-COVID. This has created a self-fulfilling prophecy by inducing the very predisposing, precipitating, and perpetuating factors for the syndrome. Finally, we introduce the term "Pandemic-Response Syndrome" to describe what previously was labeled Long-COVID. This alternative perspective aims to stimulate research and serve as a lesson learned to avoid a repeat performance in the future.

Do we need to accurately perceive our heartbeats? Cardioceptive accuracy and sensibility are independent from indicators of negative affectivity, body awareness, body image dissatisfaction, and alexithymia

Assessment of the acuity of heartbeat perception, dubbed cardioceptive accuracy, as well as its association with various psychological characteristics are hot topics of interoception research. In this study, we aimed (1) to replicate previously reported findings on the association between the mental tracking task and a novel motor tracking task that eliminates disturbing tactile sensations; and (2) to explore associations between performance in the latter task and indicators of negative affectivity (anxiety, depression, anxiety sensitivity, somatic symptom distress), alexithymia, body focus, and dissatisfaction with body image. 102 young people (age = 20.8±5.08 yrs) participated in the study. Mental tracking score was significantly higher than motor tracking scores, although they were strongly associated. Frequentist correlation analysis showed no significant associations between indicators of cardioceptive accuracy and questionnaire scores; Bayesian analysis indicated the lack of association for the majority of the cases. Similarly, detectors and non-detectors showed no differences in any of the assessed characteristics and Bayesian results typically supported the lack of associations. In conclusion, cardioceptive accuracy, as assessed with different tracking methods, is not associated with the aforementioned self-reported characteristics in young individuals.

Symptom Perception in Pathological Illness Anxiety: Tactile Sensitivity and Bias

OBJECTIVE

Symptom perception in pathological illness anxiety (PIA) might be biased so that somatic signals are overreported. In the somatic signal detection task (SSDT), performance in detecting weak tactile stimuli gives information on overreporting or underreporting of stimuli. This task has not yet been applied in PIA.

METHODS

Participants with PIA (n = 44) and healthy controls (n = 40) underwent two versions of the SSDT in randomized order. In the original version, tactile and auxiliary light-emitting diode (LED) stimuli were each presented in half of the trials. In the adapted version, illness or neutral words were presented alongside tactile stimuli. Participants also conducted a heartbeat mental tracking task.

RESULTS

We found significantly higher sensitivity and a more liberal response bias in LED versus no-LED trials, but no significant differences between word types. An interaction effect showed a more pronounced increase of sensitivity from no LED to LED trials in participants with PIA when compared with the adapted SSDT and control group (F(1,76) = 5.34, p = .024, η2 = 0.066). Heartbeat perception scores did not differ between groups (BF01 of 3.63).

CONCLUSIONS

The increase in sensitivity from no LED to LED trials in participants with PIA suggests stronger multisensory integration. Low sensitivity in the adapted SSDT indicates that attentional resources were exhausted by processing word stimuli. Word effects on response bias might have carried over to the original SSDT when the word version was presented first, compromising group effects regarding bias.

TRIAL REGISTRATION

The study was preregistered on OSF (https://osf.io/sna5v/).

The Differential Relationship Between Self-Reported Interoceptive Accuracy and Attention With Psychopathology

Abstract. Background: Only recently has interoception been discussed as a common risk factor for psychopathology. Recent approaches distinguish between the ability to accurately perceive ( interoceptive accuracy) and the propensity to attend ( interoceptive attention) to internal signals. Objective: To examine the latent structure of self-reported interoceptive accuracy and attention and their relationships to psychopathology. Methods: We used a confirmatory factor analysis to clarify the latent structure of interoceptive accuracy and attention. Structural equation modeling was utilized to determine relationships between both abilities with internalizing and somatoform symptomatology according to the HiTOP model ( Kotov et al., 2017 ). Data from N = 619 persons from the German general population were analyzed. Results: Interoceptive attention showed significant positive relationships with all psychopathological traits ( r = .221 to r = .377), whereas interoceptive accuracy was negatively associated with internalizing symptomatology ( r = -.106). Conclusion: The present findings indicate that personal beliefs about interoceptive abilities have different influences on psychopathological developments.