Transcutaneous vagus nerve stimulation improves interoceptive accuracy

A computationally informed distinction of interoception and exteroception

While interoception is of major neuroscientific interest, its precise definition and delineation from exteroception continue to be debated. Here, we propose a functional distinction between interoception and exteroception based on computational concepts of sensor-effector loops. Under this view, the classification of sensory inputs as serving interoception or exteroception depends on the sensor-effector loop they feed into, for the control of either bodily (physiological and biochemical) or environmental states. We explain the utility of this perspective by examining the perception of skin temperature, one of the most challenging cases for distinguishing between interoception and exteroception. Specifically, we propose conceptualising thermoception as inference about the thermal state of the body (including the skin), which is directly coupled to thermoregulatory processes. This functional view emphasises the coupling to regulation (control) as a defining property of perception (inference) and connects the definition of interoception to contemporary computational theories of brain-body interactions.

The vagus nerve in cardiovascular physiology and pathophysiology: From evolutionary insights to clinical medicine

The parasympathetic nervous system via the vagus nerve exerts profound influence over the heart. Together with the sympathetic nervous system, the parasympathetic nervous system is responsible for fine-tuned regulation of all aspects of cardiovascular function, including heart rate, rhythm, contractility, and blood pressure. In this review, we highlight vagal efferent and afferent innervation of the heart, with a focus on insights from comparative biology and advances in understanding the molecular and genetic diversity of vagal neurons, as well as interoception, parasympathetic dysfunction in heart disease, and the therapeutic potential of targeting the parasympathetic nervous system in cardiovascular disease.

Transcutaneous auricular vagus nerve stimulation modulates the processing of interoceptive prediction error signals and their role in allostatic regulation

It has recently been suggested that predictive processing principles may apply to interoception, defined as the processing of hormonal, autonomic, visceral, and immunological signals. In the current study, we aimed at providing empirical evidence for the role of cardiac interoceptive prediction errors signals on allostatic adjustments, using transcutaneous auricular vagus nerve stimulation (taVNS) as a tool to modulate the processing of interoceptive afferents. In a within-subject design, participants performed a cardiac-related interoceptive task (heartbeat counting task) under taVNS and sham stimulation, spaced 1-week apart. We observed that taVNS, in contrast to sham stimulation, facilitated the maintenance of interoceptive accuracy levels over time (from the initial, stimulation-free, baseline block to subsequent stimulation blocks), suggesting that vagus nerve stimulation may have helped to maintain engagement to cardiac afferent signals. During the interoceptive task, taVNS compared to sham, produced higher heart-evoked potentials (HEP) amplitudes, a potential readout measure of cardiac-related prediction error processing. Further analyses revealed that the positive relation between interoceptive accuracy and allostatic adjustments-as measured by heart rate variability (HRV)-was mediated by HEP amplitudes. Providing initial support for predictive processing accounts of interoception, our results suggest that the stimulation of the vagus nerve may increase the precision with which interoceptive signals are processed, favoring their influence on allostatic adjustments.

Effects of transcutaneous auricular vagus nerve stimulation and exploration of brain network mechanisms in children with high-functioning autism spectrum disorder: study protocol for a randomized controlled trial

Background

Autism Spectrum Disorders (ASD) are a collection of neurodevelopmental diseases characterized by poor social interaction and communication, a limited range of interests, and stereotyped behavior. High-functioning autism (HFA) indicates a subgroup of individuals with autism who possess cognitive and/or language skills that are within the average to above-normal range for their age. Transcutaneous auricular vagus nerve stimulation (taVNS) holds promise in children with HFA. However, few studies have used randomized controlled trials to validate the effectiveness of taVNS. Therefore, in this study, we intend to provide a study protocol to examine the therapeutic effects of taVNS in individuals diagnosed with HFA and to investigate the process of brain network remodeling in individuals with ASD using functional imaging techniques to observe alterations in large-scale neural networks.

Methods and design

We planned to employ a randomized, double-blind experimental design, including 40 children receiving sham stimulation and 40 children receiving real stimulation. We will assess clinical scales and perform functional imaging examinations before and after the stimulation. Additionally, we will include age- and gender-matched healthy children as controls and conduct functional imaging examinations. We plan first to observe the therapeutic effects of taVNS. Furthermore, we will observe the impact of taVNS stimulation on the brain network.

Discussion

taVNS was a low-risk, easy-to-administer, low-cost, and portable option to modulate the vagus system. taVNS may improve the social performance of HFA. Changes in the network properties of the large-scale brain network may be related to the efficacy of taVNS.

Clinical trial registration

http://www.chictr.org.cn, identifier ChiCTR2300074035.

Acute fasting modulates autonomic nervous system function and ambulatory cardiac interoception

Intermittent fasting has been associated with diverse physical and psychological health benefits. According to previous research, fasting-induced alterations in psychophysiological functioning should facilitate the accurate detection of an internal bodily signal (like the heart), which is referred to as interoceptive accuracy. In two within-subjects studies we aimed to examine whether an intermittent fasting protocol (i) evokes distinct autonomic nervous system changes in the laboratory and (ii) improves (objectifiable) interoceptive accuracy and sensibility (i.e., the subjective belief in perceiving bodily signals) in everyday life. Study 1 (N = 36) found increasing heart rate variability (precisely, the root mean square of successive differences; RMSSD) accompanied by a more vascular than myocardial response following a 16 h fast. Study 2 (N = 40) applied an ecological momentary assessment design including intermittent fasting (8 h normal eating followed by 16 h fasting) and normal eating (24 h normal eating) for three consecutive days each. Findings suggested a tendency toward higher interoceptive accuracy and sensibility during the fasting regimen, which was particularly pronounced in individuals exhibiting lower RMSSD. Together, findings suggest that (short-term) fasting seems to facilitate momentary attention to organismic cues due to alterations in autonomic nervous system function.

Dynamic heartbeat tracking beyond the laboratory: Introducing the novel Graz Ambulatory Interoception Task (GRAIT)

We present a novel ambulatory method, the Graz Ambulatory Interoception Task (GRAIT), to assess the accuracy of interoceptive beliefs (AccIB). This method captures both between- and within-person variations of AccIB by having participants counting perceived heartbeats in daily life. Reliability analyses showed high between-person (RkR = 0.99) and moderate within-person reliability (RCn = 0.62). Validity was supported by associations with an established laboratory task (r = 0.87). Within-person associations revealed that interoceptive sensibility, heart rate variability, and states of low arousal coupled with positive affect were linked to AccIB. Study 2 replicated these findings and showed a relationship between AccIB and self-control in everyday life, highlighting the importance of cardiac interoception and its relevance for health.

Cardiovascular effects of auricular stimulation -a systematic review and meta-analysis of randomized controlled clinical trials

Background

The number of randomized controlled trials using auricular stimulation (AS) such as transauricular vagus nerve stimulation, or other auricular electrostimulation or auricular acupuncture or acupressure, in experimental and clinical settings, has increased markedly over the last three decades. This systematic review focusses on cardiovascular effects of auricular stimulation.

Methods and analysis

The following databases were searched: MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, and Scopus Database. RCTs were reviewed that had been published in English and European languages. Data collection and analysis was conducted by two reviewers independently. Quality and risk assessment of included studies was performed and the meta-analysis of the effect of the most frequently assessed biomarkers.

Results

Altogether, 78 trials were included. 38 studies assessed heart rate (HR), 19 studies analyzed heart rate variability (HRV), 31 studies analyzed blood pressure (BP) and 7 studies were identified that measured oxygen saturation (O2), 2 studies on baroreflex sensitivity and 2 studies on skin conductance were evaluated in this review. 26 studies contained continuous data and were eligible for meta-analysis, 50 trials reported non continuous data and were evaluated descriptively. The overall quality of the studies was moderate to low. AS leads to a significant reduction of HR, the changes though were not considered an adverse reaction. Furthermore, when looking at HRV, AS was able to reduce the LF/HF ratio significantly compared to control procedures. No other cardiovascular parameters (blood pressure, oxygen saturation, baroreflex sensitivity) were changed significantly. AS produced only minor side effects in all trials.

Conclusion

AS can lead to clinically safe reduction of HR and changes in the LF/HF ratio of the HRV, which is presumably via an increase in vagal activity. More research is needed to clarify whether AS can be used to modulate tachycardia or indications with autonomic imbalance.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=231885 PROSPERO, ID CRD42021231885.

Development and validation of the Exteroceptive Body Awareness (EBA-q) questionnaire

The conscious processing of body signals influences higher-order psychological and cognitive functions, including self-awareness. Dysfunctions in the processing of these signals has been connected to neurological and psychiatric disorders characterized by altered states of self-consciousness. Studies indicate that perceiving the body through interoceptive signals (e.g., from internal organs such as heartbeat and breathing) is distinct from perceiving the body through exteroceptive signals (e.g., by relying on visual, tactile and olfactory cues). While questionnaires are available for assessing interoception, there are no validated self-report instruments for measuring bodily exterception. To fill this gap, we performed three studies to develop and validate a novel scale designed to assess bodily self-consciousness based on the processing of exteroceptive bodily signals. Exploratory factor analysis (Study 1, N = 302) led to an 18-item questionnaire comprised of four factors. We called this instrument Exteroceptive Body Awareness questionnaire (EBA-q). Confirmatory factor analysis (Study 2, N = 184) run on a second sample showed an acceptable fit for a bifactor model, suggesting researchers may use the questionnaire as a unidimensional scale reflecting exteroceptive bodily self-consciousness, or use each of its four sub-scales, reflecting "visuo-tactile body awareness", "spatial coordination", "awareness of body changes" and "awareness of clothing fit". Overall EBA-q showed good internal consistency. Convergent and divergent validity were assessed via cross-validation with existing body awareness questionnaires (Study 3, N = 366) and behavioral measures (Study 3, N = 64) of exteroceptive and interoceptive bodily self-consciousness. Research applications are discussed within a multi-faceted model of exteroception and interoception as distinct, but at the same time interconnected, dimensions of bodily self-consciousness.

Thinking versus feeling: How interoception and cognition influence emotion recognition in behavioural-variant frontotemporal dementia, Alzheimer's disease, and Parkinson's disease

Disease-specific mechanisms underlying emotion recognition difficulties in behavioural-variant frontotemporal dementia (bvFTD), Alzheimer's disease (AD), and Parkinson's disease (PD) are unknown. Interoceptive accuracy, accurately detecting internal cues (e.g., one's heart beating), and cognitive abilities are candidate mechanisms underlying emotion recognition. One hundred and sixty-eight participants (52 bvFTD; 41 AD; 24 PD; 51 controls) were recruited. Emotion recognition was measured via the Facial Affect Selection Task or the Mini-Social and Emotional Assessment Emotion Recognition Task. Interoception was assessed with a heartbeat detection task. Participants pressed a button each time they: 1) felt their heartbeat (Interoception); or 2) heard a recorded heartbeat (Exteroception-control). Cognition was measured via the Addenbrooke's Cognitive Examination-III or the Montreal Cognitive Assessment. Voxel-based morphometry analyses identified neural correlates associated with emotion recognition and interoceptive accuracy. All patient groups showed worse emotion recognition and cognition than controls (all P's ≤ .008). Only the bvFTD showed worse interoceptive accuracy than controls (P < .001). Regression analyses revealed that in bvFTD worse interoceptive accuracy predicted worse emotion recognition (P = .008). Whereas worse cognition predicted worse emotion recognition overall (P < .001). Neuroimaging analyses revealed that the insula, orbitofrontal cortex, and amygdala were involved in emotion recognition and interoceptive accuracy in bvFTD. Here, we provide evidence for disease-specific mechanisms for emotion recognition difficulties. In bvFTD, emotion recognition impairment is driven by inaccurate perception of the internal milieu. Whereas, in AD and PD, cognitive impairment likely underlies emotion recognition deficits. The current study furthers our theoretical understanding of emotion and highlights the need for targeted interventions.

The effect of cranial techniques on the heart rate variability response to psychological stress test in firefighter cadets

Heart rate variability (HRV) is a simple tool to monitor cardiovascular stress. The proper function of the cardiovascular system is a problem among firefighters. Physical activity has health benefits correlated with psychological stress. Physically active people should be more resilient to psychological stress, but this has not always been demonstrated. The aim of this study was to determine whether cranial techniques would have an effect on HRV parameters. Osteopathy in the cranium reduces stress and improves cardiovascular function. Fifty-seven firefighter cadets aged 18-24 years (21.63 ± 1.41) participated in the study. All subjects had their heart rate variability measured and were randomly assigned either to the cranial techniques (CS) group, with therapy performed once a week for 5 weeks), or to the control group (CO). After 5 weeks, heart rate variability was measured again in both groups. In the Friedman test, in the CS group there was a statistically significant effect of cranial techniques on Heart Rate (HR) and Low Frequency (LF), but not on High Frequency (HF); in the CO group, a statistically significant difference was observed for HR, HF and LF. In the Nemenyi test, in the CS group there was a statistically significant difference for HR and LF and in the CO group for HR, HF and LF. After applying hierarchical clustering with Euclidean measure and the complete method, dendrograms were drawn up showing similarities for HR, HF and LF values. The cranial techniques and touch might exert a beneficial effect on HRV. Both factors can be used in stressful situations to lower HRV.

A systematic review of the effects of transcutaneous auricular vagus nerve stimulation on baroreflex sensitivity and heart rate variability in healthy subjects

PURPOSE

This systematic review aimed to evaluate the effect of transcutaneous auricular vagus nerve stimulation on heart rate variability and baroreflex sensitivity in healthy populations.

METHOD

PubMed, Scopus, the Cochrane Library, Embase, and Web of Science were systematically searched for controlled trials that examined the effects of transcutaneous auricular vagus nerve stimulation on heart rate variability parameters and baroreflex sensitivity in apparently healthy individuals. Two independent researchers screened the search results, extracted the data, and evaluated the quality of the included studies.

RESULTS

From 2458 screened studies, 21 were included. Compared with baseline measures or the comparison group, significant changes in the standard deviation of NN intervals, the root mean square of successive RR intervals, the proportion of consecutive RR intervals that differ by more than 50 ms, high-frequency power, low-frequency to high-frequency ratio, and low-frequency power were found in 86%, 75%, 69%, 47%, 36%, and 25% of the studies evaluating the effects of transcutaneous auricular vagus nerve stimulation on these indices, respectively. Baroreflex sensitivity was evaluated in six studies, of which a significant change was detected in only one. Some studies have shown that the worse the basic autonomic function, the better the response to transcutaneous auricular vagus nerve stimulation.

CONCLUSION

The results were mixed, which may be mainly attributable to the heterogeneity of the study designs and stimulation delivery dosages. Thus, future studies with comparable designs are required to determine the optimal stimulation parameters and clarify the significance of autonomic indices as a reliable marker of neuromodulation responsiveness.

Impact of Cardiac Interoception on the Self-Prioritization Effect

Self-relevant information is processed faster and more accurately than non-self-relevant information. Such a bias is developed even for newly associated information with the self, which is also known as the self-prioritization effect (SPE). Interoception, which refers to the overall processing of information from within the body, is crucial for self-relevant processing; however, its role in SPE remains unexplored. In this study, we investigated the relationship between the magnitude of SPE and interoceptive accuracy (IAc), defined as one’s ability to accurately perceive one’s own interoceptive state. Additionally, to explore the causal relationship, we measured SPE by presenting self- or other-relevant stimuli based on the participant’s cardiac cycle in the shape-label matching task. We demonstrated that IAc was negatively correlated with the magnitude of SPE in terms of discrimination of the relevance of the stimuli. In addition, a correlation was observed only when the stimuli were presented during cardiac systole. Furthermore, IAc was negatively correlated with the processing of self-relevant stimuli but not with other-relevant stimuli. Collectively, our results show that individuals with higher IAc have relatively lower discriminative sensitivity to newly and temporary associated self-relevant stimuli presented during the accentuation of cardiac interoceptive information. Although SPE is a phenomenon in which newly self-associated stimuli are preferentially processed, our results suggest that individuals with higher IAc prioritized processing interoceptive information over temporarily associated self-relevant external information. Conversely, previous studies using paradigms other than the shape-label matching paradigm with familiar self-relevant stimuli, such as self-face, reported that interoceptive information enhances the processing of self-relevant stimuli. Whether interoceptive information enhances the processing of external self-relevant information may depend on the familiarity with the self-relevant stimuli and the experimental paradigm.

Event-related transcutaneous vagus nerve stimulation modulates behaviour and pupillary responses during an auditory oddball task

Transcutaneous auricular vagus nerve stimulation (taVNS) is a neuromodulatory technique that is thought to activate the Locus Coeruleus-Noradrenaline (LC-NA) system. Standard taVNS protocols consist of the administration of intermittent or continuous stimulation over long periods. However, there is currently a limited understanding of the temporal dynamics of taVNS modulation of cognitive processes, as well as its mechanisms of action. We argue that novel stimulation approaches, informed by established theories of the LC-NA system, are needed to further our understanding of the neurocognitive underpinnings of taVNS. In this pre-registered study, we tested whether an "event-related" taVNS protocol can modulate the LC-NA system. In a within-subject design (single session) we delivered brief trains of taVNS (3 s) during an auditory oddball paradigm. The taVNS was time-locked to the target stimuli presentation and randomly interleaved with sham stimulation. Response times (RT) and stimuli-driven pupillary diameter (PD) were used as indices of LC-NA activity. Results revealed that active taVNS increased RT to targets, as compared to sham trials. Notably, in line with current theories of LC-NA functioning, taVNS modulation of target-related pupil dilation depended on pre-stimulation PD, an index of baseline LC-NA activity. In particular, active (vs. sham) taVNS was associated with smaller pupil dilation in trials where the baseline PD was small. These results demonstrate, for the first time, the effectiveness of brief event-related taVNS in the modulation of cognitive processes and highlight the importance of using pupil size as an index of tonic and phasic LC-NA activity.

Transcutaneous auricular vagus nerve stimulation increases eye-gaze on salient facial features and oxytocin release

Non-invasive, transcutaneous electrical stimulation of the auricular branch of the vagus nerve (taVNS) via the ear is used therapeutically in epilepsy, pain, and depression, and may also have beneficial effects on social cognition. However, the underlying mechanisms of taVNS are unclear and evidence regarding its role in social cognition improvement is limited. To investigate the impact of taVNS on social cognition we have studied its effects on gaze toward emotional faces in combination with eye-tracking and on the release of the neuropeptide oxytocin which plays a key role in influencing social cognition and motivation. A total of 54 subjects were enrolled (49 were included in the final analysis) in a sham-controlled, participant-blind, crossover experiment, consisting of two treatment sessions 1 week apart. In one session participants received 30-min taVNS (tragus), and in the other, they received 30-min sham (earlobe) stimulation with the treatment order counterbalanced. The proportion of time spent viewing the faces and facial features (eyes, nose, and mouth) was measured together with resting pupil size. Additionally, saliva samples were taken for the measurement of oxytocin concentrations by enzyme-linked immunoassay. Saliva oxytocin concentrations increased significantly after taVNS compared to sham stimulation, while resting pupil size did not. In addition, taVNS increased time spent viewing the nose region irrespective of face emotion, and this was positively correlated with increased saliva oxytocin concentrations. Our findings suggest that taVNS biases visual attention toward socially salient facial features across different emotions and this is associated with its effects on increasing endogenous oxytocin release.

Exoskeletons for Mobility after Spinal Cord Injury: A Personalized Embodied Approach

Endowed with inherent flexibility, wearable robotic technologies are powerful devices that are known to extend bodily functionality to assist people with spinal cord injuries (SCIs). However, rather than considering the specific psychological and other physiological needs of their users, these devices are specifically designed to compensate for motor impairment. This could partially explain why they still cannot be adopted as an everyday solution, as only a small number of patients use lower-limb exoskeletons. It remains uncertain how these devices can be appropriately embedded in mental representations of the body. From this perspective, we aimed to highlight the homeostatic role of autonomic and interoceptive signals and their possible integration in a personalized experience of exoskeleton overground walking. To ensure personalized user-centered robotic technologies, optimal robotic devices should be designed and adjusted according to the patient's condition. We discuss how embodied approaches could emerge as a means of overcoming the hesitancy toward wearable robots.

The Interoceptive Sensitivity and Attention Questionnaire: Evaluating Aspects of Self-Reported Interoception in Patients With Persistent Somatic Symptoms, Stress-Related Syndromes, and Healthy Controls

OBJECTIVE

This study aimed to validate the Interoceptive Sensitivity and Attention Questionnaire (ISAQ), a 17-item self-report measure assessing sensitivity and attention to interoceptive signals.

METHODS

In study 1, exploratory and confirmatory factor analysis was performed in a student convenience sample (n = 1868). In study 2, ISAQ data of a healthy sample (n = 144) and various patient groups experiencing stress-related syndromes (overstrain, n = 63; burnout, n = 37; panic disorder [PD]. n = 60) and/or persistent somatic symptoms in daily life (irritable bowel syndrome, n = 38; fibromyalgia and/or chronic fatigue syndrome, n = 151; medically unexplained dyspnea [MUD], n = 29) were compared.

RESULTS

Three subscales were revealed: (F1) sensitivity to neutral bodily sensations, (F2) attention to unpleasant bodily sensations, and (F3) difficulty disengaging from unpleasant bodily sensations. Overall, patients with fibromyalgia and/or chronic fatigue syndrome and patients with MUD scored significantly higher on F1 (p = .009 and p = .027, respectively) and F2 (p = .002 and p < .001, respectively) than healthy controls. Patients with PD had higher scores on subscales F2 (p < .001) and F3 (p < .001) compared with healthy controls, as well as higher scores on F2 compared with all other patient groups (pPD versus MUD = .008; all other p values < .001).

CONCLUSIONS

Interoceptive sensibility-the self-reported aspect of interoception-is not a homogeneous or unitary construct. The subscales of the ISAQ differentiate healthy controls from patients with persistent somatic and/or stress-related complaints in daily life and distinguish different patient groups. The ISAQ can be used as a concise, reliable, and clinically relevant research tool to further disentangle adaptive and maladaptive aspects of interoceptive ability.

Therapeutic applications of transcutaneous auricular vagus nerve stimulation with potential for application in neurodevelopmental or other pediatric disorders

Non-invasive transcutaneous auricular vagus nerve stimulation (taVNS) as a newly developed technique involves stimulating the cutaneous receptive field formed by the auricular branch of the vagus nerve in the outer ear, with resulting activation of vagal connections to central and peripheral nervous systems. Increasing evidence indicates that maladaptive neural plasticity may underlie the pathology of several pediatric neurodevelopmental and psychiatric disorders, such as autism spectrum disorder, attention deficit hyperactivity disorder, disruptive behavioral disorder and stress-related disorder. Vagal stimulation may therefore provide a useful intervention for treating maladaptive neural plasticity. In the current review we summarize the current literature primarily on therapeutic use in adults and discuss the prospects of applying taVNS as a therapeutic intervention in specific pediatric neurodevelopmental and other psychiatric disorders. Furthermore, we also briefly discuss factors that would help optimize taVNS protocols in future clinical applications. We conclude from these initial findings that taVNS may be a promising alternative treatment for pediatric disorders which do not respond to other interventions.

Sex differences in interoceptive accuracy: A meta-analysis

Interoceptive accuracy, the ability to correctly perceive internal signals arising from the body, is thought to be disrupted in numerous mental and physical health conditions. Whilst evidence suggests poorer interoceptive accuracy in females compared to males, raising the possibility that interoceptive differences may relate to sex differences in mental and physical health, results concerning sex differences in interoceptive accuracy are mixed. Given such ambiguity, this meta-analysis aimed to establish the presence or absence of sex differences in interoceptive accuracy across cardiac, respiratory, and gastric domains. A review of 7956 abstracts resulted in 93 eligible studies. Results demonstrated superior accuracy in males across cardiac, but not gastric, tasks, while findings on respiratory tasks were mixed. Effect sizes were consistent across cardiac tasks, but instability and/or moderate heterogeneity was observed across other domains, likely due to the small number of eligible studies. Despite such limitations, results indicate the possibility of sex differences across interoception tasks and domains. Methodological limitations concerning the influence of physiological factors, and directions for future research are discussed.

How does yoga practice and therapy yield psychological benefits? A review and model of transdiagnostic processes

Interest in yoga as an intervention for psychological wellbeing has increased in recent years, with literature investigating beneficial effects in a variety of presentations and settings. The theoretical understanding of this benefit has previously focused on physiological changes involved in yoga practice, however interest has turned to the potential psychological mechanisms eliciting psychological wellbeing. The current paper builds on previous theory and argues that yoga practice targets transdiagnostic psychological processes; mechanisms that feature commonly across a wide range of presentations, thus reducing distress and increasing wellbeing across clinical and non-clinical populations. Features of yoga practice are discussed in relation to these transdiagnostic processes and the features of modern talking therapies. A new model is proposed positing specific aspects of yoga practice correlate with specific transdiagnostic processes to elicit psychological change and argues that the mechanisms by which change occurs are directly compared with the changes observed in talking therapies. The implications for future research and the potential for this to support the commissioning of holistic approaches in clinical practice are discussed.

Short-term fasting induced changes in HRV are associated with interoceptive accuracy: Evidence from two independent within-subjects studies

Previous research suggested increased cardiac interoceptive accuracy after 24-h food-deprivation by means of the heartbeat tracking task. The present study investigated if 16-h of voluntary fasting shows similar effects and whether changes in interoceptive accuracy are accompanied by changes in autonomic function. In two independent within-subjects studies two measures of interoceptive accuracy, the heartbeat tracking task and the heartbeat discrimination task were applied. In study 1 (n = 24) and study 2 (n = 72) vagally-mediated HRV increases and heart rate decreases were observed. Stronger effects of fasting on vagally-mediated HRV went along with a higher interoceptive accuracy increase in the heartbeat tracking task. Furthermore, the fasting associated changes in interoceptive accuracy in both tasks were significantly associated, suggesting that these tasks are suitable to track changes in cardiac interoception. Taken together, fasting of 16-h might be suitable to increase participants' parasympathetic efference, thereby facilitating interoception.

Does transcutaneous auricular vagus nerve stimulation affect vagally mediated heart rate variability? A living and interactive Bayesian meta-analysis

Non-invasive brain stimulation techniques, such as transcutaneous auricular vagus nerve stimulation (taVNS), have considerable potential for clinical use. Beneficial effects of taVNS have been demonstrated on symptoms in patients with mental or neurological disorders as well as transdiagnostic dimensions, including mood and motivation. However, since taVNS research is still an emerging field, the underlying neurophysiological processes are not yet fully understood, and the replicability of findings on biomarkers of taVNS effects has been questioned. The objective of this analysis was to synthesize the current evidence concerning the effects of taVNS on vagally mediated heart rate variability (vmHRV), a candidate biomarker that has, so far, received most attention in the field. We performed a living Bayesian random effects meta-analysis. To keep the synthesis of evidence transparent and up to date as new studies are being published, we developed a Shiny web app that regularly incorporates new results and enables users to modify study selection criteria to evaluate the robustness of the inference across potential confounds. Our analysis focuses on 16 single-blind studies comparing taVNS versus sham in healthy participants. The meta-analysis provides strong evidence for the null hypothesis (g = 0.014, CI_shortest = [-0.103, 0.132], BF₀₁ = 24.678), indicating that acute taVNS does not alter vmHRV compared to sham. To conclude, there is no support for the hypothesis that vmHRV is a robust biomarker for acute taVNS. By increasing transparency and timeliness, the concept of living meta-analyses can lead to transformational benefits in emerging fields such as non-invasive brain stimulation.

Nonsuicidal Self-Injury Is Associated With Attenuated Interoceptive Responses to Self-Critical Rumination

Nonsuicidal self-injury (NSSI) is a prevalent and dangerous behavior. Those with a history of NSSI often report high levels of self-critical rumination (SCR), a form of negatively valenced introspective self-referential processing. It is plausible that this overly analytical style of relating to the self might hinder the ability to process interoceptive signals, thereby increasing the capacity to engage in behaviors that cause bodily harm. Two studies investigated whether trait or state SCR influenced aspects of interoception in those with and without a history of NSSI. In Study 1 (N = 180), irrespective of NSSI history, trait SCR was associated with finding attending to the heartbeat unpleasant. However, no associations were observed for interoceptive confidence, or metacognitive insight into their interoceptive abilities (confidence-accuracy correspondence). Trait SCR was associated with having higher interoceptive accuracy, but only in those without a history of NSSI. In Study 2 (N = 98), irrespective of NSSI history, state self-criticism led to a more negative interoceptive valence, and reduced participants' metacognitive insight. In those without a history of NSSI, state self-criticism also increased interoceptive accuracy-an effect attenuated in those with NSSI. These findings suggest that those with NSSI are characterized by a blunted interoceptive response to negatively valenced self-focused attention.

Rebuilding Body-Brain Interaction from the Vagal Network in Spinal Cord Injuries

Spinal cord injuries (SCIs) exert devastating effects on body awareness, leading to the disruption of the transmission of sensory and motor inputs. Researchers have attempted to improve perceived body awareness post-SCI by intervening at the multisensory level, with the integration of somatic sensory and motor signals. However, the contributions of interoceptive-visceral inputs, particularly the potential interaction of motor and interoceptive signals, remain largely unaddressed. The present perspective aims to shed light on the use of interoceptive signals as a significant resource for patients with SCI to experience a complete sense of body awareness. First, we describe interoceptive signals as a significant obstacle preventing such patients from experiencing body awareness. Second, we discuss the multi-level mechanisms associated with the homeostatic stability of the body, which creates a unified, coherent experience of one's self and one's body, including real-time updates. Body awareness can be enhanced by targeting the vagus nerve function by, for example, applying transcutaneous vagus nerve stimulation. This perspective offers a potentially useful insight for researchers and healthcare professionals, allowing them to be better equipped in SCI therapy. This will lead to improved sensory motor and interoceptive signals, a decreased likelihood of developing deafferentation pain, and the successful implementation of modern robotic technologies.

Noradrenergic activation induced by yohimbine decreases interoceptive accuracy in healthy individuals with childhood adversity

Acute stress affects interoception, but it remains unclear if this is due to activation of the sympatho-adreno-medullary (SAM) or hypothalamic-pituitary-adrenocortical axis. This study aimed to investigate the effect of SAM axis activation on interoceptive accuracy (IAcc). Central alpha2-adrenergic receptors represent a negative feedback mechanism of the SAM axis. Major depressive disorder and adverse childhood experiences (ACE) are associated with alterations in the biological stress systems, including central alpha2-adrenergic receptors. Here, healthy individuals with and without ACE as well as depressive patients with and without ACE (n = 114; all without antidepressant medication) were tested after yohimbine (alpha2-adrenergic antagonist) and placebo. We assessed IAcc and sensibility in a heartbeat counting task. Increases in systolic and diastolic blood pressure after yohimbine confirmed successful SAM axis activation. IAcc decreased after yohimbine only in the healthy group with ACE, but remained unchanged in all other groups (Group × Drug interaction). This effect may be due to selective upregulation of alpha2-adrenergic receptors after childhood trauma, which reduces capacity for attention focus on heartbeats. The sympathetic neural pathway including alpha2-adrenergic circuitries may be essential for mediating interoceptive signal transmission. Suppressed processing of physical sensations in stressful situations may represent an adaptive response in healthy individuals who experienced ACE.

Behavioral and neurophysiological signatures of interoceptive enhancements following vagus nerve stimulation

An accruing body of research has shown that interoception (the sensing of signals from the body's internal milieu) relies on both a direct route (afforded by the vagus nerve) and a secondary route (supported by somatosensory mechanisms). However, no study has causally tested the differential role of these pathways, let alone via direct stimulation. To bridge this gap, we tested whether multidimensional signatures of interoception are modulated by noninvasive vagus nerve stimulation (nVNS). Sixty‐three participants were divided into an nVNS and a sham‐stimulation group. Before and after stimulation, both groups performed a validated heartbeat detection (HBD) task including a genuinely interoceptive condition (monitoring one's own heartbeat) and a control exteroceptive condition (tracking an aurally presented heartbeat). Electroencephalographic signals were obtained during both conditions to examine modulations of the heartbeat‐evoked potential (HEP). Moreover, before and after stimulation, participants were asked to complete a somatosensory heartbeat localization task. Results from the interoceptive condition revealed that, after treatment, only the nVNS group exhibited improved performance and greater HEP modulations. No behavioral differences were found for the exteroceptive control condition, which was nonetheless associated with significant HEP modulations. Finally, no between‐group differences were observed regarding the localization of the heartbeat sensations or relevant cardiodynamic variables (heart rate and or heart rate variability). Taken together, these results constitute unprecedented evidence that the vagus nerve plays a direct role in neurovisceral integration during interoception. This finding can constrain mechanistic models of the domain while informing a promising transdiagnostic agenda for interoceptive impairments across neuropsychiatric conditions.

Interoception, Stress, and Physical Symptoms in Stress-Associated Diseases

Abstract. The brain and peripheral bodily organs continuously exchange information. Exemplary, interoception refers to the processing and perception of ascending information from the body to the brain. Stress responses involve a neurobehavioral cascade, which includes the activation of peripheral organs via neural and endocrine pathways and can thus be seen as an example for descending information on the brain-body axis. Hence, the interaction of interoception and stress represents bi-directional communication on the brain-body axis. The main hypothesis underlying this review is that the dysregulation of brain-body communication represents an important mechanism for the generation of physical symptoms in stress-related disorders. The aims of this review are, therefore, (1) to summarize current knowledge on acute stress effects on different stages of interoceptive signal processing, (2) to discuss possible patterns of abnormal brain-body communication (i.e., alterations in interoception and physiological stress axes activation) in mental disorders and chronic physical conditions, and (3) to consider possible approaches to modify interoception. Due to the regulatory feedback loops underlying brain-body communication, the modification of interoceptive processes (ascending signals) may, in turn, affect physiological stress axes activity (descending signals), and, ultimately, also physical symptoms.

The relationship between heartbeat counting and heartbeat discrimination: A meta-analysis

Interoception concerns the perception of the body's internal state. Despite the importance of this ability for health and aspects of higher-order cognition, its measurement remains problematic. Most studies of interoception employ one of two tasks: the heartbeat counting or heartbeat discrimination task. These tasks are thought to index common abilities, an assertion often used to justify the use of a single measure of cardiac interoception. However, mixed findings regarding the relationship between performance on these tasks raises the question of whether they can be used interchangeably to assess interoceptive accuracy, confidence and awareness ('metacognition'). The present study employed a meta-analytical approach to assess the association between these tasks. Pooled findings from 22 studies revealed a small relationship between accuracy scores on the measures. Additional analyses demonstrated a moderate relationship between confidence ratings but no association between measures of interoceptive awareness. These findings question the interchangeable use of the two tasks.

Vagus Nerve Stimulation as a Gateway to Interoception

The last two decades have seen a growing interest in the study of interoception. Interoception can be understood as a hierarchical phenomenon, referring to the body-to-brain communication of internal signals, their sensing, encoding, and representation in the brain, influence on other cognitive and affective processes, and their conscious perception. Interoceptive signals have been notoriously challenging to manipulate in experimental settings. Here, we propose that this can be achieved through electrical stimulation of the vagus nerve (either in an invasive or non-invasive fashion). The vagus nerve is the main pathway for conveying information about the internal condition of the body to the brain. Despite its intrinsic involvement in interoception, surprisingly little research in the field has used Vagus Nerve Stimulation to explicitly modulate bodily signals. Here, we review a range of cognitive, affective and clinical research using Vagus Nerve Stimulation, showing that it can be applied to the study of interoception at each level of its hierarchy. This could have considerable implications for our understanding of the interoceptive dimension of cognition and affect in both health and disease, and lead to development of new therapeutic tools.

Brain Stimulation in Eating Disorders: State of the Art and Future Perspectives

The management of eating disorders (EDs) is still difficult and few treatments are effective. Recently, several studies have described the important contribution of non-invasive brain stimulation (repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and electroconvulsive therapy) and invasive brain stimulation (deep brain stimulation and vagal nerve stimulation) for ED management. This review summarizes the available evidence supporting the use of brain stimulation in ED. All published studies on brain stimulation in ED as well as ongoing trials registered at clinicaltrials.gov were examined. Articles on neuromodulation research and perspective articles were also included. This analysis indicates that brain stimulation in EDs is still in its infancy. Literature data consist mainly of case reports, cases series, open studies, and only a few randomized controlled trials. Consequently, the evidence supporting the use of brain stimulation in EDs remains weak. Finally, this review discusses future directions in this research domain (e.g., sites of modulation, how to enhance neuromodulation efficacy, personalized protocols).

Dynamic neurocognitive changes in interoception after heart transplant

Heart–brain integration dynamics are critical for interoception (i.e. the sensing of body signals). In this unprecedented longitudinal study, we assessed neurocognitive markers of interoception in patients who underwent orthotopic heart transplants and matched healthy controls. Patients were assessed longitudinally before surgery (T1), a few months later (T2) and a year after (T3). We assessed behavioural (heartbeat detection) and electrophysiological (heartbeat evoked potential) markers of interoception. Heartbeat detection task revealed that pre-surgery (T1) interoception was similar between patients and controls. However, patients were outperformed by controls after heart transplant (T2), but no such differences were observed in the follow-up analysis (T3). Neurophysiologically, although heartbeat evoked potential analyses revealed no differences between groups before the surgery (T1), reduced amplitudes of this event-related potential were found for the patients in the two post-transplant stages (T2, T3). All these significant effects persisted after covariation with different cardiological measures. In sum, this study brings new insights into the adaptive properties of brain–heart pathways.

The Effect of Transcutaneous Auricular Vagal Nerve Stimulation (taVNS) on P3 Event-Related Potentials during a Bayesian Oddball Task

Transcutaneous auricular Vagal Nerve Stimulation (taVNS) is a non-invasive brain stimulation technique associated with possible modulation of norepinephrinergic (NE) activity. NE is suspected to contribute to generation of the P3 event-related potential. Recent evidence has produced equivocal evidence whether taVNS influences the P3 in healthy individuals during oddball tasks. We examined the effect of taVNS on P3 amplitudes using a novel visual Bayesian oddball task, which presented 200 sequences of three stimuli. The three consecutive stimuli in each sequence are labelled Draw 1, Draw 2 and Draw 3. In total, 47 Subjects completed this visual Bayesian oddball task under randomised sham and active taVNS stimulation in parallel with an electroencephalographic (EEG) recording. We conducted exploratory analyses of the effect of taVNS on P3 amplitudes separately for Draws. We found typical oddball effects on P3 amplitudes at Draws 1 and 2, but not Draw 3. At Draw 2, the oddball effect was enhanced during active compared to sham taVNS stimulation. These data provide evidence that taVNS influences parietal P3 amplitudes under specific circumstances. Only P3 amplitudes at Draw 2 were affected, which may relate to closure of Bayesian inference after Draw 2. Our findings seemingly support previously reported links between taVNS and the NE system.