Working With the Predictable Life of Patients: The Importance of "Mentalizing Interoception" to Meaningful Change in Psychotherapy

Psychometric properties of an Arabic translation of the multidimensional assessment of interoceptive awareness (MAIA-2) questionnaire in a non-clinical sample of Arabic-speaking adults

BACKGROUND

Interoception refers to processes through which the nervous system identifies, analyzes, and integrates the information generated by the physiological state of the body (e.g., from internal organs such as the stomach, heart, or lungs). Despite its potential interest for clinical research and its wide use globally, no Arabic adaptation and validation of the Multidimensional Assessment of Interoceptive Awareness (MAIA-2) questionnaire exists to date. The goal of this study was to examine the psychometric properties of an Arabic translation of the MAIA-2 in a sample of Arabic-speaking community adults from Lebanon. We hypothesized that the Arabic version of the MAIA-2 would yield adequate internal consistency coefficients; the 8-factor structure model would show a good fit to our data, with measurement invariance and good convergent validity.

METHOD

The Arabic adaptation of the MAIA-2 was developed using the forward-backward translation method. A non-clinical sample of Arabic-speaking adults (n = 359, 59.9% females, mean age = 22.75 years (SD = 7.04)) took part of this validation study. To check if the model was adequate, several fit indices were calculated: the normed model chi-square (χ²/df), the Steiger-Lind root mean square error of approximation (RMSEA), the Tucker-Lewis Index (TLI) and the comparative fit index (CFI). Values ≤ 3 for χ²/df, and ≤ 0.08 for RMSEA, and 0.90 for CFI and TLI indicate good fit of the model to the data.

RESULTS

Confirmatory Factor Analyses corroborated the validity of the original 8-factor structure of the MAIA-2 [χ2/df = 1603.86/601 = 2.67, RMSEA = 0.068 (90% CI 0.064, 0.072), SRMR = 0.058, CFI = 0.903, TLI = 0.892]. Reliability estimates in our sample revealed good internal consistency, with McDonald's ω coefficients for the subscales ranging from 0.86 to 0.93. Our analyses also revealed measurement invariance of the Arabic MAIA-2 for gender. No statistically significant difference between men and women in all dimensions, except for the not worrying and attention regulation subscales where men scored significantly higher than women. Finally, the Arabic MAIA-2 dimensions showed positive correlations with the intuitive eating dimension "Reliance on Hunger and Satiety Cues", thus providing support for convergent validity.

CONCLUSION

We contribute the literature by providing the first Arabic adaptation and validation of a measure assessing the multidimensional construct of self-reported interoception. The Arabic MAIA-2 demonstrated good psychometric properties. We thus preliminarily recommend its use to measure the interoceptive awareness construct among Arabic-speaking communities worldwide.

Divergent Conceptualization of Embodied Emotions in the English and Chinese Languages

Traditional cognitive linguistic theories acknowledge that human emotions are embodied, yet they fail to distinguish the dimensions that reflect the direction of neural signaling between the brain and body. Differences exist across languages and cultures in whether embodied emotions are conceptualized as afferent (feelings from the body) or efferent (enacted through the body). This important distinction has been neglected in academic discourse, arguably as a consequence of the ‘lexical approach’, and the dominance within the affective psychology of the cognitive and semantic models that overlook the role of interoception as an essential component of affective experience. Empirical and theoretical advances in human neuroscience are driving a reappraisal of the relationships between the mind, brain and body, with particular relevance to emotions. Allostatic (predictive) control of the internal bodily states is considered fundamental to the experience of emotions enacted through interoceptive sensory feelings and through the evoked physiological and physical actions mediated through efferent neural pathways. Embodied emotion concepts encompass these categorized outcomes of bidirectional brain–body interactions yet can be differentiated further into afferent or interoceptive and efferent or autonomic processes. Between languages, a comparison of emotion words indicates the dominance of afferent or interoceptive processes in how embodied emotions are conceptualized in Chinese, while efferent or autonomic processes feature more commonly in English. Correspondingly, in linguistic expressions of emotion, Chinese-speaking people are biased toward being more receptive, reflective, and adaptive, whereas native English speakers may tend to be more reactive, proactive, and interactive. Arguably, these distinct conceptual models of emotions may shape the perceived divergent values and ‘national character’ of Chinese- and English-speaking cultures.

Piloting the Update: The Use of Therapeutic Relationship for Change - A Free Energy Account

We apply the Free Energy Principle (FEP) to cognitive behavioral therapy (CBT). FEP describes the basic functioning of the brain as a predictive organ and states that any self-organizing system that is in equilibrium with its environment must minimize its free energy. Based on an internal model of the world and the self, predictions-so-called priors-are created, which are matched with the information input. The sum of prediction errors corresponds to the Free Energy, which must be minimized. Internal models can be identified with the cognitive-affective schemas of the individual that has become dysfunctional in patients. The role of CBT in this picture is to help the patient update her/his priors. They have evolved in learning history and no longer provide adaptive predictions. We discuss the process of updating in terms of the exploration-exploitation dilemma. This consists of the extent to which one relies on what one already has, i.e., whether one continues to maintain and "exploit" one's previous priors ("better safe than sorry") or whether one does explore new data that lead to an update of priors. Questioning previous priors triggers stress, which is associated with increases in Free Energy in short term. The role of therapeutic relationship is to buffer this increase in Free Energy, thereby increasing the level of perceived safety. The therapeutic relationship is represented in a dual model of affective alliance and goal attainment alliance and is aligned with FEP. Both forms of alliance support exploration and updating of priors. All aspects are illustrated with the help of a clinical case example.

How Psychedelic-Assisted Treatment Works in the Bayesian Brain

Psychedelics are experiencing a renaissance in clinical research. In recent years, an increasing number of studies on psychedelic-assisted treatment have been conducted. So far, the results are promising, suggesting that this new (or rather, rediscovered) form of therapy has great potential. One particular reason for that appears to be the synergistic combination of the pharmacological and psychotherapeutic interventions in psychedelic-assisted treatment. But how exactly do these two interventions complement each other? This paper provides the first account of the interaction between pharmacological and psychological effects in psychedelic-assisted treatment. Building on the relaxed beliefs under psychedelics (REBUS) hypothesis of Carhart-Harris and Friston and the contextual model of Wampold, it argues that psychedelics amplify the common factors and thereby the remedial effects of psychotherapy. More precisely, psychedelics are assumed to attenuate the precision of high-level predictions, making them more revisable by bottom-up input. Psychotherapy constitutes an important source of such input. At best, it signalizes a safe and supportive environment (cf. setting) and induces remedial expectations (cf. set). During treatment, these signals should become incorporated when high-level predictions are revised: a process that is hypothesized to occur as a matter of course in psychotherapy but to get reinforced and accelerated under psychedelics. Ultimately, these revisions should lead to a relief of symptoms.

Rebooting in sport training and competitions: Athletes' perceived stress levels and the role of interoceptive awareness

The psychological consequences of the lockdown in the sport context have been well studied. However, few studies investigated athletes' perceived stress during the rebooting in sport training and competitions; moreover, no investigations examined the relationship between perceived stress and interoceptive awareness. To mind this gap and support the enactment of appropriate behaviours for practising sports in a unique situation, we compared athletes' perceived stress data collected during the rebooting in sport activities with normative data and with those collected during the first Italian lockdown. Furthermore, we examined the impact of interoceptive awareness towards positive and negative stress by means of regression analyses. The IPSS-10 and the MAIA questionnaire were administered to 220 athletes. Findings suggest that athletes were experiencing a detrimental situation despite the resumption of sport activities but when comparing rebooting phase with the lockdown, female athletes began to feel greater financial security thereby reducing their perceived stress. Athletes who scored high especially for body trusting - the experience of one's body as safe and trustworthy - could regulate their perceived stress levels by increasing positive and reducing negative stress. Athletes could engage in mindful activities related to the body to reduce their perceived stress levels and better deal with an unprecedented situation.

Validation of the Multidimensional Assessment of Interoceptive Awareness (MAIA-2) questionnaire in hospitalized patients with major depressive disorder

OBJECTIVES

Interoception refers to the sensation, interpretation, and integration of internal somatic signals. Abnormalities in self-reported interoception are prevalent features of major depressive disorder (MDD) and may affect treatment outcomes. In the present study, we investigated the psychometric properties of the revised eight-dimensional and 37-item Multidimensional Assessment of Interoceptive Awareness questionnaire (the MAIA-2) in a severely depressed sample, after translating two updated scales (Not-Distracting, Not-Worrying) into German. Specifically, we examined the measure's internal consistency reliability, sensitivity to change, and minimal important differences (MID) with a focus on patient's antidepressive responses to treatment.

METHODS

The study enrolled 110 participants (age: M = 46.85, SD = 11.23; female: 55.45%) undergoing hospital treatment, of whom 87 were included in the pre-post analysis. Participants completed a German translation of MAIA-2 and the Beck Depression Inventory-II (pre-/post-treatment). Internal consistency reliability was determined by Cronbach's α/McDonalds's ω, sensitivity to change was determined by effect sizes, and MIDs were determined by distribution- (0.5*SD) and anchor-based approaches (mean change method; ROC curve cut-points).

RESULTS

Depression severity reduced over the course of treatment (Median = -65.22%), and 34.48% of patients achieved remission. Reliability was appropriate for post-treatment (range of ω: .70-.90), but questionable for two pre-treatment scales (Noticing: ω = .64; Not-Distracting: ω = .66). The eight dimensions of MAIA-2 were sensitive to change (standardized response mean: .32-.81; Cohen's effect size: .30-.92). Distribution-based MIDs (.38-.61) and anchor-based mean change MIDs (remission vs. partial response: .00-.85; partial response vs. nonresponse: .08-.88) were established on the group level. For six scales, ROC cut-points (remission: .00-1.33; response: -.20-1.00) demonstrated accurate classification to treatment response groups on the individual level.

CONCLUSIONS

This study demonstrated the applicability of the MAIA-2 questionnaire in MDD. The updated version may have led to reliability improvements regarding the revised scales, but subthreshold reliability was evident prior to treatment. The measure's dimensions were sensitive to change. MIDs were established that corresponded with antidepressive treatment outcomes. Our findings are consistent with a growing area of research which considers somatic feelings as key contributors to mental health.

Dimensions of interoception in obsessive-compulsive disorder

Interoceptive sensibility (IS) refers to the subjective experience of perceiving and being aware of one's internal body sensations, and is typically evaluated using self-report questionnaires or confidence ratings. Here we evaluated IS in 81 patients with OCD and 76 controls using the Multidimensional Scale of Interoceptive Awareness (MAIA), which contains 8 subscales assessing adaptive and maladaptive responses to sensation. Compared to controls, OCD patients showed hyperawareness of body sensations. Patients also demonstrated a more maladaptive profile of IS characterized by greater distraction from and worry about unpleasant sensations, and reduced tendency to experience the body as safe and trustworthy. These findings were independent of medication status and comorbidities in the patient group. Correlational analyses showed that subscales of the MAIA were differentially associated with OCD symptom dimensions. These findings indicate that patients with OCD show abnormality of IS that is independent of confounding factors related to medication and comorbidities and associated with different OCD symptom dimensions. Future work would benefit from examining neural correlates of these effects and evaluating whether dimensions of IS are impacted by treatments for the disorder.

More Than Words Can Say: A Multi-Disciplinary Consideration of the Psychotherapeutic Evaluation and Treatment of Alexithymia

Alexithymia is a disorder that stands at the border of mind and body, with psychological/affective and physiological/experiential disturbances. The purpose of this article is to propose a new clinical access point for the evaluation and treatment of the deficits in emotional awareness demonstrated in alexithymia. This will be based on insights from recent neuroscientific research, which is adding to the psychodynamic understanding of alexithymia, regarding clinical presentation and etiology. Following a brief review of definitions, forms of measurement, and potential etiologic elements of alexithymia, current neuroscientific theory and research into "predictive processing" approaches to brain function will be outlined, including how "interoception" and "interoceptive inference" underpins emotion and emotional awareness. From this synergistic perspective, I will outline how interoceptive inference provides a key to the link between: problems in early life relational experiences and the patient's long held, but suboptimal models of their inner and outer world. This is reflected in the deficits in affective experiencing and emotional awareness described in alexithymia. Three clinical cases will be presented to illustrate this nuanced consideration of alexithymic etiology and treatment. The implications of the historical, psychological, and somatic aspects of experience will be considered, regarding the patients' diminished ability to: experience and represent emotional experience as distinct feeling states; signify the relevant meaning of affective experience; and incorporate such with cognitions to adaptively guide behavior. These will be addressed using psychometric, psychological, neuro-cognitive, and neurocomputational approaches. Elements from current theory, research, and treatment of alexithymia, will be highlighted that are salient to the clinician, in order to support their understanding of patients against the backdrop of current psychodynamic and neuroscientific research, which will thereby increase treatment options and benefits. The focus, and conclusion, of this article is the role that attention to interoception can play (within the safety of the therapeutic relationship and within any therapeutic process) in allowing updating of the patient's strongly held but dysfunctional beliefs.