Multidimensional assessment of anticipated and experienced interoceptive states

As the sense of the body's internal state, interoception represents the afferent component of the brain-body feedback loop essential for linking internal sensation with body regulation, thereby minimizing erroneous feedback and maintaining homeostasis. The anticipation of potential future interoceptive states enables organisms to take regulatory actions to meet demands before they arise, and alterations of anticipation have been implicated in the pathophysiology of medical and psychiatric conditions. However, laboratory approaches operationalizing the anticipation of interoceptive states are missing. Therefore, we developed two interoceptive awareness paradigms, the Accuracy of Interoceptive Anticipation paradigm, and the Interoceptive Discrepancy paradigm, which we tested in 52 healthy participants on two sensory modalities: nociception and respiroception. Ten participants took part in a retest. The Accuracy of Interoceptive Anticipation paradigm focused on assessing how individuals anticipate and experience interoceptive stimuli of varying strengths. The Interoceptive Discrepancy paradigm extended this measure by manipulating previously learned expectations to induce discrepancies between anticipated and experienced stimuli. We found that anticipation and experience ratings successfully related to stimulus strength in both paradigms and modalities and were stable between test-retest. Furthermore, the Interoceptive Discrepancy paradigm successfully induced the expected discrepancies between anticipation and experience conditions, and discrepancy values were correlated across sensory modalities. Thus, both paradigms are valid and reliable tools for assessing the anticipation of future interoceptive states, and the Interoceptive Discrepancy paradigm is additionally suited to evaluate discrepancy awareness.

Potential Explanatory Factors for the Concurrent Experience of Dyspnea and Pain in Patients with COPD

Previous research has identified unexpectedly strong associations between dyspnea and pain, but the reasons remain unclear. Ascertaining the underlying biological and psychological mechanisms might enhance the understanding of the experience of both conditions, and suggest novel treatments. We sought to elucidate whether demographic factors, disease severity, psychological symptoms and biomarkers might account for the association between pain and dyspnea in individuals with COPD. We analyzed data from 301 patients with COPD who were followed in a prospective longitudinal observational study over 2 years. Measures included self-reported dyspnea and pain, pulmonary function tests, serum levels of inflammatory cytokines, measures of physical deconditioning, and scales for depression and anxiety. Analyses involved cross-sectional and longitudinal linear regression models. Pain and dyspnea were strongly correlated cross-sectionally (r = 0.77, 95% CI 0.72-0.82) and simultaneously across time (r = 0.42, 95% CI 0.28-0.56). Accounting for any of the other health factors only slightly mitigated the associations. Symptoms of pain and dyspnea thus may be fundamentally linked in COPD, rather than being mediated by common biological, psychological, or functional factors. From the patient's perspective, pain and dyspnea may be part of the same essential experience. It is possible that treatments for one condition would improve the other.

Where is emotional feeling felt in the body? An integrative review

Contemporary research on "embodied emotion" emphasizes the role of the body in emotional feeling. The evidence base on interoception, arguably the most prominent strand of embodied emotion research, places emphasis on the cardiac, respiratory and gastrointestinal systems. In turn, interoception has evidence-based links with improved emotion regulation. Despite the focus on separate bodily systems, it is unclear whether particular interoceptive locations play a greater role in emotional feeling and emotion regulation. Further, according to Gross' "process model", the sooner that regulation of an emotion occurs, the better; hence, it is additionally important to identify the first body areas to activate. These issues are investigated in a two-stage integrative review. The first stage was preliminary, giving an overview of the evidence base to highlight the distribution of measured body areas. This indicated that 86% of publications (n = 88) measured cardiac activity, 26% measured the respiratory system, and six percent the gastrointestinal system. Given the emphasis placed on all three systems in interoception theory and research on emotion, this suggests a dearth of comprehensive findings pertaining to feeling locations. The second stage investigated the core issues of where emotional feelings are felt in the body and time-related implications for regulation. This was based on ten texts, which together suggested that the head, throat and chest are the most consistently detected locations across and within numerous emotional contexts. Caution is required, however, since-among other reasons discussed-measurement was not time-restricted in these latter publications, and direct physiological measurement was found in only a minority of cases.

Cross-modal relationships of neural gating with the subjective perception of respiratory and somatosensory sensations

Neural gating is a phenomenon whereby the response to a stimulus in the electroencephalogram (EEG) is attenuated when preceded by an identical stimulus. Attenuation of paired auditory clicks has repeatedly been shown to be affected in mental disorders, for example, schizophrenia. Neural gating has also been measured for respiratory and somatosensory sensations, however the attenuation of bodily relevant stimuli has not yet been systematically related to the subjective perception of bodily sensations. This research direction is potentially relevant to explaining disease trajectories in psychosomatic conditions characterized by chronic breathlessness and/or pain. In the present study, we recorded high-density EEG from 85 healthy young adults while they experienced brief paired respiratory occlusions and brief paired electrocutaneous stimulation of the wrist. The event-related potential N1 was measured centro-laterally in response to the second relative to the first stimulus to quantify neural gating in both sensory domains. Participants experienced resistive loaded breaths and electrocutaneous stimuli of various intensities, rated their perceived intensity and unpleasantness, and performed magnitude estimation. Relationships of respiratory and somatosensory neural gating to the subjective intensity and unpleasantness of sensations, as well as the ability to discriminate sensations of varying intensities, were investigated intra-modally and cross-modally. We report significant relationships of the somatosensory neural gating to perceived intensity and unpleasantness of respiratory and somatosensory sensations, with the stronger neural gating relating to a stronger subjective intensity and unpleasantness. We discuss these unexpected findings through the lens of individual differences and different theoretical accounts on the origins of cortical attenuation of repetitive stimuli.

Comfort and clinical events at the end of life of nursing home residents with and without dementia: The six-country epidemiological PACE study

OBJECTIVES

We aimed to investigate the occurrence rates of clinical events and their associations with comfort in dying nursing home residents with and without dementia.

METHODS

Epidemiological after-death survey was performed in nationwide representative samples of 322 nursing homes in Belgium, Finland, Italy, the Netherlands, Poland, and England. Nursing staff reported clinical events and assessed comfort. The nursing staff or physician assessed the presence of dementia; severity was determined using two highly discriminatory staff-reported instruments.

RESULTS

The sample comprised 401 residents with advanced dementia, 377 with other stages of dementia, and 419 without dementia (N = 1197). Across the three groups, pneumonia occurred in 24 to 27% of residents. Febrile episodes (unrelated to pneumonia) occurred in 39% of residents with advanced dementia, 34% in residents with other stages of dementia and 28% in residents without dementia (P = .03). Intake problems occurred in 74% of residents with advanced dementia, 55% in residents with other stages of dementia, and 48% in residents without dementia (P < .001). Overall, these three clinical events were inversely associated with comfort. Less comfort was observed in all resident groups who had pneumonia (advanced dementia, P = .04; other stages of dementia, P = .04; without dementia, P < .001). Among residents with intake problems, less comfort was observed only in those with other stages of dementia (P < .001) and without dementia (P = .003), while the presence and severity of dementia moderated this association (P = .03). Developing "other clinical events" was not associated with comfort.

CONCLUSIONS

Discomfort was observed in dying residents who developed major clinical events, especially pneumonia, which was not specific to advanced dementia. It is crucial to identify and address the clinical events potentially associated with discomfort in dying residents with and without dementia.

Experimental dyspnea as a stressor: differential cardiovegetative responses to inspiratory threshold loading in healthy men and women

Dyspnea is associated with an emotional reaction that involves limbic activation. The inspiratory threshold load (ITL) is known to elicit a dyspneic response in healthy subjects. Laboratory-induced stress conditions have been shown to elicit sex-related differences in cardiovascular responses. The aim of this study was to evaluate how healthy men ( n = 8) and women ( n = 9) react and adapt to 5-min periods of ITL at three levels (low, medium, and high) in terms of heart rate (HR), temporal (RMSSD) and spectral (LF, HF, LF/HF ratio) HRV indexes, and rating of breathing discomfort. HR increased with low, medium, and high ITL in men, whereas it increased only with high ITL in women. LF/HF ratio increased at low ITL in both men and women. Modifications appear to depend essentially on increased LF in men and on reduced HF in women. In addition, HRV modifications differ between men and women, following the order of presentation of ITLs. Our results show a continuous and sustained stress in men (increased HR, LF, and LF/HF ratio across ITL presentation) and a stress adaptation in women. Subjective responses of breathing discomfort were not correlated with sympatho-vagal balance modifications for a subgroup of subjects ( n = 10). Breathing against the ITL induced autonomic modifications that are different between men and women, i.e., driven by sympathetic mediated responses in men, whereas women showed a greater parasympathetic modulation of cardiovascular activity. These results highlight the role of the mechanical inspiratory load in the heart rate variability seen in chronic obstructive pulmonary disease.

NEW & NOTEWORTHY Breathing against the ITL induced autonomic modifications driven by sympathetic mediated responses in men, whereas women showed a greater parasympathetic modulation of cardiovascular activity, even for low load. A stress circuit could be at the origin of autonomic modifications induced by ITL. Our results would underline the role of the mechanic inspiratory load in the abnormalities in heart rate variability seen in COPD patients.

Sex differences in the neural processing of aversive interoceptive events: the benefit of relief

Do men and women process and experience unpleasant bodily states differently? We used fMRI to determine brain processing before, during and after an aversive respiratory stimulation. No sex difference emerged during anticipation or stimulation. However, after the offset of the stimulation, men but not women showed enhanced activation of brain regions that are important for interoception and reward processing. Moreover, this activation was highest in those males who rated the preceding stimulation as most unpleasant. These results indicate that men are particularly sensitive to reward associated with the termination of an aversive event, which may signal relief.

Evidence for cognitive-behavioral strategies improving dyspnea and related distress in COPD

BACKGROUND

Dyspnea is a complex, prevalent, and distressing symptom of chronic obstructive pulmonary disease (COPD) associated with decreased quality of life, significant disability, and increased mortality. It is a major reason for referral to pulmonary rehabilitation.

METHODS

We reviewed 23 COPD studies to examine the evidence for the effectiveness of cognitive-behavioral strategies for relieving dyspnea in COPD.

RESULTS

Preliminary evidence from randomized controlled trials exists to support cognitive- behavioral strategies, used with or without exercise, for relieving sensory and affective components of dyspnea in COPD. Small to moderate treatment effects for relieving dyspnea were noted for psychotherapy (effect size [ES] = 0.08-0.25 for intensity; 0.26-0.65 for mastery) and distractive auditory stimuli (ES = 0.08-0.33 for intensity; 0.09 to -0.61 for functional burden). Small to large dyspnea improvements resulted from yoga (ES = 0.2-1.21 for intensity; 0.67 for distress; 0.07 for mastery; and -8.37 for functional burden); dyspnea self-management education with exercise (ES = -0.14 to -1.15 for intensity; -0.62 to -0.69 for distress; 1.04 for mastery; 0.14-0.35 for self-efficacy); and slow-breathing exercises (ES = -0.34 to -0.83 for intensity; -0.61 to -0.80 for distress; and 0.62 for self-efficacy). Cognitive-behavioral interventions may relieve dyspnea in COPD by (1) decreasing sympathetic nerve activity, dynamic hyperinflation, and comorbid anxiety, and (2) promoting arterial oxygen saturation, myelinated vagus nerve activity, a greater exercise training effect, and neuroplasticity.

CONCLUSION

While evidence is increasing, additional randomized controlled trials are needed to evaluate the effectiveness of psychosocial and self-management interventions in relieving dyspnea, in order to make them more available to patients and to endorse them in official COPD, dyspnea, and pulmonary rehabilitation practice guidelines. By relieving dyspnea and related anxiety, such interventions may promote adherence to exercise programs and adaptive lifestyle change.

Tracheal occlusion conditioning causes stress, anxiety and neural state changes in conscious rats

Evidence from human and animal studies indicates that mechanical loads to breathing are stressful stimuli and evoke compensatory behaviours. Conditioning of stressful stimuli is known to cause changes in basal stress levels and behaviour. Individuals with respiratory obstructive diseases repeatedly experience bouts of airway obstruction, which may act as a form of conditioning, and often have affective disorders, such as anxiety and depression. It is unknown whether the development of affective disorders in these individuals results from the unexpected recurring respiratory perturbations. To investigate this possibility, we developed a model to elicit tracheal occlusion (TO) in conscious rats and exposed them to 10 days of TO conditioning. We hypothesized that healthy, conscious animals exposed to TO conditioning would develop stress and anxiety and would have modulated neural activity in respiratory, stress, discriminative and affective neural regions. Following TO conditioning, rats had increased basal corticosterone levels, greater adrenal weights and elevated anxiety levels compared with animals not receiving TO. Significant increases in cytochrome oxidase staining were found in brainstem respiratory nuclei, periaqueductal grey, dorsal raphe, thalamus and insular cortex. These results suggest that healthy animals develop stress and anxiety responses to respiratory load conditioning via inescapable tracheal occlusions, which may be mediated through state changes in specific brain nuclei.

Combining nitrous oxide with carbon dioxide decreases the time to loss of consciousness during euthanasia in mice--refinement of animal welfare?

Carbon dioxide (CO(2)) is the most commonly used euthanasia agent for rodents despite potentially causing pain and distress. Nitrous oxide is used in man to speed induction of anaesthesia with volatile anaesthetics, via a mechanism referred to as the "second gas" effect. We therefore evaluated the addition of Nitrous Oxide (N(2)O) to a rising CO(2) concentration could be used as a welfare refinement of the euthanasia process in mice, by shortening the duration of conscious exposure to CO2. Firstly, to assess the effect of N(2)O on the induction of anaesthesia in mice, 12 female C57Bl/6 mice were anaesthetized in a crossover protocol with the following combinations: Isoflurane (5%)+O(2) (95%); Isoflurane (5%)+N(2)O (75%)+O(2) (25%) and N(2)O (75%)+O(2) (25%) with a total flow rate of 3 l/min (into a 7 l induction chamber). The addition of N(2)O to isoflurane reduced the time to loss of the righting reflex by 17.6%. Secondly, 18 C57Bl/6 and 18 CD1 mice were individually euthanized by gradually filling the induction chamber with either: CO(2) (20% of the chamber volume.min-1); CO(2)+N(2)O (20 and 60% of the chamber volume.min(-1) respectively); or CO(2)+Nitrogen (N(2)) (20 and 60% of the chamber volume.min-1). Arterial partial pressure (P(a)) of O(2) and CO(2) were measured as well as blood pH and lactate. When compared to the gradually rising CO(2) euthanasia, addition of a high concentration of N(2)O to CO(2) lowered the time to loss of righting reflex by 10.3% (P<0.001), lead to a lower P(a)O(2) (12.55 ± 3.67 mmHg, P<0.001), a higher lactataemia (4.64 ± 1.04 mmol.l(-1), P = 0.026), without any behaviour indicative of distress. Nitrous oxide reduces the time of conscious exposure to gradually rising CO(2) during euthanasia and hence may reduce the duration of any stress or distress to which mice are exposed during euthanasia.

Pain and quality of life with chronic obstructive pulmonary disease

BACKGROUND

Pain as a symptom may be underrecognized in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE

The aim of this study is to explore the prevalence and intensity of pain, its location, how demographic and clinical variables may be related to pain, and how pain is associated with quality of life (QOL).

METHODS

In this cross-sectional study, 154 patients with COPD answered the Brief Pain Inventory, Respiratory Quality of Life Questionnaire, and Quality of Life Scale, and performed spirometry.

RESULTS

Seventy-two percent of the patients indicated the location of pain on a body diagram. Lower lung function, higher score of pain intensity, and pain interference were associated with lower disease QOL. A higher score of pain interference was associated with lower global QOL. When controlling for disease QOL in the equation of global QOL, pain interference was no longer significant.

CONCLUSION

The experience of pain is related to disease QOL in patients with COPD.

Cold perception and cutaneous microvascular response to local cooling at different cooling temperatures

The aim of the present study was to investigate the effect of quantitatively measured cold perception (CP) thresholds on microcirculatory response to local cooling as measured by direct and indirect response of laser-Doppler (LD) flux during local cooling at different temperatures. The CP thresholds were measured in 18 healthy males using the Marstock method (thermode placed on the thenar). The direct (at the cooling site) and indirect (on contralateral hand) LD flux responses were recorded during immersion of the hand in a water bath at 20°C, 15°C, and 10°C. The cold perception threshold correlated (linear regression analysis, Pearson correlation) with the indirect LD flux response at cooling temperatures 20°C (r=0.782, p<0.01) and 15°C (r=0.605, p<0.01). In contrast, there was no correlation between the CP threshold and the indirect LD flux response during cooling in water at 10°C. The results demonstrate that during local cooling, depending on the cooling temperature used, cold perception threshold influences indirect LD flux response.

Perception of multiple-breath inspiratory resistive loads in males and females

Resistive load magnitude estimation (ME) was measured over multiple breaths in male and female subjects. It was hypothesized that multiple breaths against a range of resistive loads would result in a change in the perceived load magnitude as a function of load magnitude and the number of inspiratory efforts. It was further hypothesized that males and females would differ in their perceptual response to sustained breathing against inspiratory resistive loads. The subjects were tested in a sound isolated room and respired through a non-rebreathing valve, the inspiratory port connected to the loading manifold. The subject inspired to a peak airflow target for each breath. Each R load was presented for 10 continuous breaths. The load was estimated at breath 1, 5, and 10 using a modified Borg scale. Each 10-breath load presentation was presented in a randomized block. There was no significant group difference between the ME for breath 1 and 10 for small R loads, but a significant group difference for large R loads. The ME for males did not change between breath 1 and 10 for the small load magnitudes, but decreased with large loads. The ME for the 10th breath of the large R load was greater than the 1st breath for females. Males estimated the large R load on the 1st breath the same as females but the ME on the 10th breath was significantly less for males compared to females. These results demonstrate that magnitude estimation of large resistive loads with a sustained 10-breath trial elicits significant increases in females, but significantly decreased in males. The increase in ME may represent increased respiratory discomfort for females and the decrease habituation in males.

Down-regulation of insular cortex responses to dyspnea and pain in asthma

RATIONALE

Dyspnea is the impairing cardinal symptom of asthma but its accurate perception is also crucial for timely initiation of treatment. However, the underlying brain mechanisms of perceived dyspnea in patients with asthma are unknown.

OBJECTIVES

To study brain mechanisms of dyspnea in asthma.

METHODS

By using functional magnetic resonance imaging we compared the neuronal responses to experimentally induced dyspnea in patients with asthma and healthy controls. These brain activations were compared with neuronal responses evoked by pain to study neuronal generalization processes to another, similarly unpleasant, physiological sensation.

MEASUREMENTS AND MAIN RESULTS

While lying in the scanner, fourteen patients with mild-to-moderate asthma and fourteen matched healthy controls repeatedly underwent conditions of mild dyspnea, severe dyspnea, mild pain and severe pain. Dyspnea was induced by resistive loaded breathing. Heat pain of similar intensity was induced by a contact thermode. Whereas the sensory intensity of both sensations was rated similar by patients and controls, ratings of the affective unpleasantness of dyspnea and pain were reduced in patients. This perceptual difference was mirrored by reduced insular cortex activity, but increased activity in the periaqueductal gray (PAG) in patients during both increased dyspnea and pain. Connectivity analyses showed that asthma-specific down-regulation of the insular cortex during dyspnea and pain was moderated by increased PAG activity.

CONCLUSIONS

The results suggest a down-regulation of affect-related insular cortex activity by the PAG during perceived dyspnea and pain in patients with asthma. This might represent a neuronal habituation mechanism reducing the affective unpleasantness of dyspnea in asthma, which generalizes to other unpleasant physiological sensations such as pain.

The Relationship Between Pain Perception and Interoception

The question of whether the perception of externally applied pain stimuli and the perception of interoceptive stimuli are based upon similar neuronal or behavioral processes is still open to debate. If such a similarity exists, one would expect that persons who are highly sensitive to visceral stimuli would also exhibit a higher sensitivity to pain stimuli. The present study investigated the sensitivity to heat pain of individuals with high vs. low cardiac interoceptive sensitivity. Pain threshold and pain tolerance were assessed using a testing-the-limits procedure. Furthermore, participants rated the subjective intensity and unpleasantness of tonic heat stimuli on visual analog scales and in a questionnaire. The results show that pain experience did not differ between participants with high and low interoceptive sensitivity, nor did correlation analyses reveal significant relationships between pain experience and cardiac interoceptive sensitivity. These findings suggest that the pathway of peripheral pain processing is at least partially independent of the pathway of interoceptive sensations.