Alexithymia mediates the relationship between interoceptive sensibility and anxiety

Interoception in anxiety, depression, and psychosis: a review

Research has examined the relationship between interoception and anxiety, depression, and psychosis; however, it is unclear which aspects of interoception have been systematically examined, what the combined findings are, and which areas require further research. To answer these questions, we systematically searched and narratively synthesised relevant reviews, meta-analyses, and theory papers (total n = 34). Existing systematic reviews and meta-analyses (anxiety n = 2; depression n = 2; psychosis n = 0), focus on cardiac interoceptive accuracy (heartbeat perception), and indicate that heartbeat perception is not systematically impaired in anxiety or depression. Heartbeat perception might be poorer in people with psychosis, but further evidence is needed. Other aspects of interoception, such as different body systems and processing levels, have been studied but not systematically reviewed. We highlight studies examining these alternative bodily domains and levels, review the efficacy of interoception-based psychological interventions, and make suggestions for future research.

Funding

Wellcome Trust UK.

Case report: Short-term psychotherapy for alexithymia in a patient with generalized anxiety disorder

Alexithymia is common among patients with generalized anxiety disorder (GAD) and may negatively affect the efficacy of treatment. This case report described a sole short-term psychotherapy focusing on alexithymia for a GAD patient. The intervention extends over 3 weekly 50-minute sessions and incorporates components of: (a) understanding the basic categories of emotions and the importance of processing them consciously and building one's own vocabulary of emotions; (b) developing skills in identifying and labeling emotions and learning to register both positive and negative emotions in daily life; (c) observing and interpreting emotion-related body sensations and learning to get in touch with, be empathetic to, and take care of one's own inner feelings in daily life. The Hamilton Rating Scale for Depression (HRSD), Hamilton Anxiety Rating Scale (HAMA), and Toronto Alexithymia Scale (TAS) were used to evaluate depression, anxiety, and alexithymia before and after the sessions. The results suggested that the treatment was not only effective in reducing alexithymia helping the patient to clarify, identify and describe her feelings, but also effective in reducing anxiety and depression.

Examining a model of anxiety in autistic adults

ABSTRACT

Anxiety disorders commonly occur in autism. Existing studies implicate intolerance of uncertainty, alexithymia, sensory processing differences and emotion regulation difficulties as influencing factors of anxiety in autism. To date, a few studies have considered the combination of these factors within the same sample. This study used structural equation modelling to test the prediction that intolerance of uncertainty and emotion regulation constitute more direct causes of anxiety in autism that mediate the influences of sensory processing difference and alexithymia as more sequential contributing factors. Autistic (n = 86) and non-autistic adults (n = 100) completed a battery of self-report questionnaires. Only when applied to each group separately, the broad predictions of the model were confirmed for the autistic group following data-driven additions of paths between sensory processing difference and anxiety and alexithymia implying that sensory processing difference contribute indirectly as well as directly to individual differences in anxiety. For the non-autistic group, model fit could only be achieved after removing autism-related traits and sensory processing differences as predictors of anxiety. These results suggest that aetiology and expression of anxiety in autism partially overlap with what is observed in the general population except that sensory processing differences appear to play a relatively unique role in the context of autism.

Interoceptive beliefs moderate the link between physiological and emotional arousal during an acute stressor

Growing work suggests that interoception, that is, representations of one's internal bodily changes, plays a role in shaping emotional experiences. Past studies primarily examine how behavioral accuracy in detecting interoceptive signals (interoceptive ability) relates to emotional states, with less work examining self-reported interoceptive facets such as the characterizations of one's interoceptive abilities (interoceptive sensibility) or evaluative beliefs about the value versus danger of interoceptive signals (interoceptive beliefs). However, existing studies rarely examine physiological reactivity, behavioral, and self-reported dimensions of interoception together in the same sample. As such, it remains unclear whether and how much individual differences in interoceptive facets uniquely and in interaction with physiological reactivity may matter for emotional experience. Herein, 250 healthy young adults completed a heartbeat detection task assessing interoceptive ability and questionnaire measures of interoceptive sensibility and beliefs during an initial laboratory visit. At a follow-up session, 227 participants returned to undergo an acute psychosocial stressor. Measures of physiological arousal such as preejection period (PEP) and heart rate variability were acquired throughout the stressor with self-reported emotions acquired immediately after. Linear regressions revealed that greater sympathetic nervous system reactivity (i.e., PEP), poorer interoceptive ability (i.e., accuracy), and less positive interoceptive beliefs were related to more intense high arousal emotions during the stressor. Importantly, across models, interoceptive beliefs was the only interoceptive facet to moderate the concordance between physiological and emotional arousal. Implications for psychological theories of emotion, stress, and interoception are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Interoceptive difficulties in children and adolescents with severe form of somatic symptom disorder: A pilot study with nineteen participants]

INTRODUCTION

Despite the high rate of somatic symptom disorder (TSS) in the pediatric population, etiological mechanisms remain poorly understood. Previous studies conducted in youths with anxiety, eating disorder, or autistic disorder support a relation between difficulties in the perception of sensory signals (i.e., interoception) and difficulties in identifying emotions.

METHOD

A cross-sectional study was carried out at the University Hospital of Amiens-Picardie in 19 young people aged 9 to 17 hospitalized in the pediatric ward for TSS. A mental heartbeat tracking task was used to assess interoceptive accuracy, awareness and sensibility. The Porges Body Perception Questionnaire (PBPQ) was used to assess interoceptive attention. Other questionnaires were used to assess associated clinical dimensions such as depression, anxiety, emotional dysregulation and alexithymia.

RESULTS

The mean interoceptive accuracy score was lower in TSS subjects compared to expected scores in the general population (33% error vs. 20%). A statistically significant correlation was found between, on the one hand, interoceptive sensibility and the "avoidance" subscore of the ECAP (r=0.51) and, on the other hand, between interoceptive awareness and the total score of the Child Depression Inventory (r=0.51). A significant relationship was found between the PBPQ scale total score and the Children-Toronto Alexithymia Scale total score (r=0.42), in particular with the "difficulty expressing emotions" subscore (r=0.62).

CONCLUSION

This study confirms that interoceptive difficulties occur in young patients with severe TSS. Our finding adds empirical evidence supporting the relations between interoceptive difficulties, alexithymia and somatic symptoms in children and adolescents.

Interoception, alexithymia, and anxiety among individuals with alcohol use disorder

Background

Interoception (i.e., the ability to recognize bodily signals), alexithymia (i.e., the inability to recognize emotional states) and negative affect (i.e., unpleasant feelings such as anxiety) have been associated with alcohol use disorder (AUD). Previous research suggests that interoception may underlie alexithymia, which in turn may be associated with negative affectivity. However, this remains to be empirically tested. This study investigates whether alexithymia mediates the association between interoception and anxiety and whether this association differs across individuals with AUD and a healthy control (HC) comparison group.

Methods

The AUD group consisted of 99 participants enrolled in an 8-week abstinence-based inpatient treatment program. The HC group included 103 healthy individuals. The heartbeat counting task (HCT) was used to assess interoception (cardiac interoceptive accuracy). The Toronto Alexithymia Scale (TAS-20) was used to assess alexithymia. The Brief Symptom Inventory (BSI) was used to assess anxiety.

Results

The moderated mediation model with interoception as the predictor, alexithymia as the mediator, and negative affect (i.e., state anxiety) as the dependent variable was tested. The analysis showed that the conditional indirect effect of interoception on anxiety via alexithymia was significant for individuals with AUD [ab = -0.300, bootstrap 95% CI = (-0.618, -0.088)], as well as for HCs [ab = -0.088, bootstrap 95% CI = (-0.195, -0.014)]; however, the conditional indirect effect significantly differed across HCs and individuals with AUD. Namely, the mediated effect was greater among individuals with AUD compared to the HC group.

Conclusion

The results suggests that interoceptive impairment contributes to greater negative affect (i.e., state anxiety) via alexithymia especially for individuals with AUD. Improving emotion recognition via therapeutic methods focused on strengthening interoceptive abilities could improve outcomes for individuals receiving treatment for AUD.

Self-disgust in patients with borderline personality disorder. The associations with alexithymia, emotion dysregulation, and comorbid psychopathology

BACKGROUND

Self-disgust is a negative self-conscious emotion, which has been linked with borderline personality disorder (BPD). However, it has not yet been investigated in relation to both emotion dysregulation and alexithymia, which are recognized as crucial to BPD. Therefore, the aim of our study was to measure these variables and examine the possible mediational role of emotional alterations and comorbid anxiety and depression symptoms in shaping self-disgust in patients with BPD and healthy controls (HCs).

METHODS

In total, the study included 100 inpatients with BPD and 104 HCs. Participants completed: the Self-Disgust Scale (SDS), Disgust Scale - Revised (DS-R), Toronto Alexithymia Scale (TAS-20), Emotion Dysregulation Scale short version (EDS-short), Borderline Personality Disorder Checklist (BPD Checklist), State-Trait Anxiety Inventory (STAI), and Center for Epidemiologic Studies Depression Scale (CESD-R).

RESULTS

Inpatients with BPD showed higher self-disgust, alexithymia, emotion dysregulation, core and comorbid symptoms levels, and lower disgust sensitivity. Alexithymia, emotion dysregulation, and trait anxiety partially mediated between BPD diagnosis and self-disgust. The relationship between the severity of BPD symptoms and self-disgust was fully mediated by alexithymia, emotion dysregulation, depressive symptoms, and trait anxiety.

CONCLUSIONS

The results of our study may imply the contribution of emotion dysregulation, alexithymia, and comorbid psychopathology to self-referenced disgust in BPD.

[Metacognitions and interoceptive sensibility in the perception of premonitory urges in tic disorders across the lifespan]

Metacognitions and interoceptive sensibility in the perception of premonitory urges in tic disorders across the lifespan Abstract. Objective: Depending on contextual factors, the prevalence of premonitory urges (PU) in patients with tic disorders (TD) increases with age and varies both intra- and interindividually. In youth, PUs correlate with metacognitions. In both youth and adults, interoceptive sensibility is altered compared to healthy controls. We examined the relationship between PUs, tics, metacognitions, and interoceptive sensibility across the lifespan regarding tic severity. Method: In an online survey, 53 participants reported their PUs on the Premonitory Urge for Tics Scale (PUTS) and tic severity on the Symptom Checklist for Tic Disorders (SBB-TIC). We assessed interoceptive sensibility via the Body Perception Questionnaire (BPQ-A) and metacognitions regarding tics with the Belief About Tics Scale (BATS). Results: Adults scored higher on the PUTS than youth. In youth, interoceptive sensibility increased with age; interoceptive sensibility correlated with PUTS. Metacognitions and interoceptive sensibility explained a significant amount of variance in premonitory urges, even after controlling for tic severity and age. Conclusions: The presumed cause of age-dependent development of PUs in youth lies in their neurophysiological maturing processes. However, negative metacognitions and interoceptive abilities also play an important role in the development and maintenance of PU and might be of therapeutic use in the treatment of TD.

Cardiac interoception in patients accessing secondary mental health services: A transdiagnostic study

BACKGROUND

Abnormalities in the regulation of physiological arousal and interoceptive processing are implicated in the expression and maintenance of specific psychiatric conditions and symptoms. We undertook a cross-sectional characterisation of patients accessing secondary mental health services, recording measures relating to cardiac physiology and interoception, to understand how physiological state and interoceptive ability relate transdiagnostically to affective symptoms.

METHODS

Participants were patients (n = 258) and a non-clinical comparison group (n = 67). Clinical diagnoses spanned affective disorders, complex personality presentations and psychoses. We first tested for differences between patient and non-clinical participants in terms of cardiac physiology and interoceptive ability, considering interoceptive tasks and a self-report measure. We then tested for correlations between cardiac and interoceptive measures and affective symptoms. Lastly, we explored group differences across recorded clinical diagnoses.

RESULTS

Patients exhibited lower performance accuracy and confidence in heartbeat discrimination and lower heartbeat tracking confidence relative to comparisons. In patients, greater anxiety and depression predicted greater self-reported interoceptive sensibility and a greater mismatch between performance accuracy and sensibility. This effect was not observed in comparison participants. Significant differences between patient groups were observed for heart rate variability (HRV) although post hoc differences were not significant after correction for multiple comparisons. Finally, accuracy in heartbeat tracking was significantly lower in schizophrenia compared to other diagnostic groups.

CONCLUSIONS

The multilevel characterisation presented here identified certain physiological and interoceptive differences associated with psychiatric symptoms and diagnoses. The clinical stratification and therapeutic targeting of interoceptive mechanisms is therefore of potential value in treating certain psychiatric conditions.

Predicting depression and anxiety of Chinese population during COVID-19 in psychological evaluation data by XGBoost

BACKGROUND

Due to the onset of sudden stress, COVID-19 has greatly impacted the incidence of depression and anxiety. However, challenges still exist in identifying high-risk groups for depression and anxiety during COVID-19. Studies have identified how resilience and social support can be employed as effective predictors of depression and anxiety. This study aims to select the best combination of variables from measures of resilience, social support, and alexithymia for predicting depression and anxiety.

METHODS

The eXtreme Gradient Boosting (XGBoost¹) model was applied to a dataset including data on 29,841 participants that was collected during the COVID-19 pandemic. Discriminant analyses on groups of participants with depression (DE²), anxiety (AN³), comorbid depression and anxiety (DA⁴), and healthy controls (HC⁵), were performed. All variables were selected according to their importance for classification. Further, analyses were performed with selected features to determine the best variable combination.

RESULTS

The mean accuracies achieved by three classification tasks, DE vs HC, AN vs HC, and DA vs HC, were 0.78, 0.77, and 0.89. Further, the combination of 19 selected features almost exhibited the same performance as all 56 variables (accuracies = 0.75, 0.75, and 0.86).

CONCLUSIONS

Resilience, social support, and some demographic data can accurately distinguish DE, AN, and DA from HC. The results can be used to inform screening practices for depression and anxiety. Additionally, the model performance of a limited scale including only 19 features indicates that using a simplified scale is feasible.

Interoceptive attention facilitates emotion regulation strategy use

Background

Method

Results

Conclusions

Emotional regulation deficits in autism spectrum disorder: The role of alexithymia and interoception

The aim of this study was to analyze emotional regulation, alexithymia and interoception in a group of people diagnosed with ASD (n = 27), a normative population with a technical academic training (n = 30), and another group with a humanities/health training (n = 20). Results showed significantly higher scores in alexithymia and emotional regulation problems, and lower scores in interoception in the ASD group. Also, alexithymia was found to correlate with emotional regulation, which was found to be significant in all three groups. In addition, interoception correlated negatively with alexithymia in the ASD group. Finally, the scores of the group with the technical training were closer to those of the ASD group compared to the humanities/health group.

Validation of the Japanese version of the Interoception Sensory Questionnaire for individuals with autism spectrum disorder

The Interoception Sensory Questionnaire (ISQ) is a self-report instrument used to assess the characteristics of interoceptive processing in individuals with autism spectrum disorder (ASD). Previous studies have shown that scores of the ISQ are more appropriate than other subjective measures for evaluating difficulties in interoceptive processing in individuals with ASD. Yet, no prior research has demonstrated the validation of the ISQ in Japanese samples. This study attempted to validate the Japanese version of the ISQ (ISQ-J) by examining its psychometric properties. We confirmed the score distribution, internal consistency, and factor structure in Japanese samples. We also examined the relationships with other interoceptive questionnaires. In addition, we compared the scores of the ISQ-J between adolescents and adults with ASD participants and control participants. Results of confirmatory factor analyses showed that the reliability of the ISQ-J in adults with ASD reached an acceptable level of a one-factor structure with excellent internal consistency (α = 0.963). The result of the ISQ-J showed a significant positive correlation with the measure of awareness of interoceptive sensitivity for localized bodily states; on the other hand, a significant negative correlation was found with those integrated bodily states. In addition, the ISQ-J scores were significantly higher in the ASD group than in the control group. The current findings depend on self-report data (including a diagnosis of ASD) to measure validity constructs. Additionally, since the ISQ-J was surveyed in adults with ASD, it is unclear whether similar the results would be obtained if the ISQ-J were conducted with children. These results indicate the validity and reliability of the ISQ-J and provide a tool for assessing confusion of interoceptive information in Japanese adults with ASD.

The relationship between alexithymia, reading the mind in the eyes and cognition in patients with multiple sclerosis

AIM

The purpose of this study was to determine the frequency of alexithymia, difficulty in recognizing one's own and others' emotions, to determine the ability to read the mind in the eyes that evaluates the emotions of others, and to assess the relationship between these parameters and demographic characteristics, cognition, anxiety and depression in people with multiple sclerosis (PwMS).

MATERIAL AND METHOD

Seventy patients presenting to the neurology clinic and diagnosed with MS and 70 healthy volunteers with similar demographic characteristics were included in the study. The California Verbal Learning Test II (CVLT II), Symbol Digit Modalities Test (SDMT), Revised Brief Visuospatial Memory Test (BVMT-R), and Trail-Making Test (TMT) were applied to determine all participants' cognitive status. All participants were also administered Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Toronto Alexithymia Scale-20 (TAS-20), Reading the Mind in the Eyes Test (RMET), Fatigue Impact Scale (FIS) and Short Form 36 Health Survey (SF-36) for quality of life.

RESULTS

Alexithymia levels were higher in the PwMS than in the control group, 24.2% of the PwMS and 4.2% of the control group being alexithymic. The PwMS group exhibited poorer performance on all cognitive tests and in BDI, BAI, FIS and SF-36 scale scores than the control group. No difference was determined between the groups' RMET scores. Depression and anxiety levels increased in line with alexithymia levels in the PwMS group, while RMET scores decreased. No association was determined between alexithymia levels and age, sex, duration of disease, degree of disability, cognition, or fatigue. RMET scores were not affected by age, sex, duration of disease, degree of disability, anxiety, or fatigue, but were lower among individuals with poor cognition and in depressive patients.

CONCLUSION

Neuropsychiatric symptoms have been the subject of considerable research in MS in recent years and these clinical characteristics in patients have begun being closely monitored. PwMS are capable of experiencing difficulty in identifying emotions in themselves and others, and their social lives can be affected. In addition, the fact that this exhibits an association with cognition based on RMET is particularly noteworthy.

On the Embodiment of Social Cognition Skills: The Inner and Outer Body Processing Differently Contributes to the Affective and Cognitive Theory of Mind

A specific interpretation of embodiment assigns a central role to the body representations (BR) in cognition. In the social cognition domain, BR could be pivotal in representing others’ actions and states. However, empirical evidence on the relationship between different BR and social cognition, in terms of Theory of Mind (ToM), in the same sample of participants is missing. Here, this relationship was explored considering individual differences in the action-oriented BR (aBR), nonaction-oriented BR (NaBR), and subjective predisposition toward internal bodily sensations (interoceptive sensibility, ISe). Eighty-two healthy adults were given behavioral measures probing aBR, NaBR, ISe, and affective/cognitive ToM. The results suggest that NaBR, which mainly relies on exteroceptive signals, predicts individual differences in cognitive ToM, possibly because it can allow differentiating between the self and others. Instead, the negative association between affective ToM and ISe suggests that an alteration of the internal body state representation (i.e., over-reporting interoceptive sensations) can affect emotional processing in social contexts. The finding that distinct aspects of the body processing from within (ISe) and from the outside (NaBR) differently contribute to ToM provides empirical support to the BR role in social cognition and can be relevant for developing interventions in clinical settings.

Shared and unique interoceptive deficits in high alexithymia and neuroticism

Interoception is the perception of internal bodily signals. It is considered fundamental to developing emotional awareness. For this reason, interoceptive deficits are often associated with alexithymia, a condition characterized by difficulty identifying feelings (DIF), difficulty describing feelings (DDF), and an externally-oriented style of thinking (EOT). Yet, the atypical interoception found in alexithymia might be of a similar type and/or more serious than those found in other partially overlapping constructs that entail emotional difficulties and behavioural patterns associated with specific emotional styles. Our study explores this issue by examining the relationship between the interoceptive deficits associated with alexithymia and the Big Five personality traits. A non-clinical sample (N = 504) completed the Toronto Alexithymia Scale, the Big Five Inventory and the Multidimensional Assessment of Interoceptive Awareness. Data were analysed using a network analytic approach that conceives psychological traits as networks of interacting symptoms. The estimated network highlighted that EOT is the alexithymia component least associated with interoception and most associated with lower Openness to Experience. Conversely, DIF and Neuroticism are, respectively, the dimensions of alexithymia and the Big Five most highly associated with interoception. We also compared interoceptive abilities in the four groups of participants whose scores were a) high for both alexithymia and neuroticism, b) high only for alexithymia c), high only for neuroticism, and d) low for both. High alexithymia was especially associated with the tendency to ignore sensations of pain or discomfort, while neuroticism was more indicative of the tendency to worry about these sensations. These results suggest that while high alexithymia and neuroticism share some interoceptive deficits, others are unique to alexithymia and contribute to overall lower interoceptive ability in this condition. Our findings suggest that interventions to enhance awareness of bodily sensations can be beneficial especially for profiles who present high neuroticism and alexithymia.

Acute stress affects peripersonal space representation in cortisol stress responders

Peripersonal space is the representation of the space near the body. It is implemented by a dedicated multisensory-motor network, whose purpose is to predict and plan interactions with the environment, and which can vary depending on environmental circumstances. Here, we investigated the effect on the PPS representation of an experimentally induced stress response and compared it to a control, non-stressful, manipulation. We assessed PPS representation in healthy humans, before and after a stressful manipulation, by quantifying visuotactile interactions as a function of the distance from the body, while monitoring salivary cortisol concentration. While PPS representation was not significantly different between the control and experimental group, a relation between cortisol response and changes in PPS emerged within the experimental group. Participants who showed a cortisol stress response presented enhanced visuotactile integration for stimuli close to the body and reduced for far stimuli. Conversely, individuals with a less pronounced cortisol response showed a reduced difference in visuotactile integration between the near and the far space. In our interpretation, physiological stress resulted in a freezing-like response, where multisensory-motor resources are allocated only to the area immediately surrounding the body.

What do measures of self-report interoception measure? Insights from a systematic review, latent factor analysis, and network approach

Recent conceptualizations of interoception suggest several facets to this construct, including "interoceptive sensibility" and "self-report interoceptive scales", both of which are assessed with questionnaires. Although these conceptual efforts have helped move the field forward, uncertainty remains regarding whether current measures converge on their measurement of a common construct. To address this question, we first identified -via a systematic review- the most cited questionnaires of interoceptive sensibility. Then, we examined their correlations, their overall factorial structure, and their network structure in a large community sample (n = 1003). The results indicate that these questionnaires tap onto distinct constructs, with low overall convergence and interrelationships between questionnaire items. This observation mitigates the interpretation and replicability of findings in self-report interoception research. We call for a better match between constructs and measures.

A network analysis of interoception, self-awareness, empathy, alexithymia, and autistic traits

Altered interoception has been consistently found in people with autism spectrum disorder (ASD), and this impairment may contribute to social cognitive dysfunctions. However, little is known regarding the intercorrelations between interoceptive sensibility, autistic, alexithymic, empathic, and self-related traits. We recruited 1360 non-clinical college students and adults to investigate the complex inter-relationship between these variables using network analysis. The resultant network revealed patterns connecting autistic traits to interoceptive sensibility, empathy, alexithymia, and self-awareness, with reasonable stability and test-retest consistency. The node of alexithymia exhibited the highest centrality and expected influence. As revealed by the network comparison test, networks constructed in high- and low-autistic subgroups were comparable in global strength and structure. Our findings suggested that alexithymia serves as an important node, bridging interoceptive deficits, self-awareness, and empathic impairments of autism spectrum disorder. The co-morbidity of alexithymia should be considered carefully in future studies of interoceptive impairments and social deficits in ASD.

Maternal anxiety and previous anaphylaxis are associated with alexithymia in young patients with food allergy

BACKGROUND

Alexithymia is a multifaceted personality construct described as "a lack of words to express emotions" that includes difficulty identifying feelings, difficulty describing feelings and a concrete, externally oriented cognitive style. Among patients with food allergy (FA) alexithymia has been found higher than in general population and associated with dysfunctional coping strategies. Childhood traumatic experiences and/or dysfunctional parent-child relationship can contribute to alexithymia. The study aimed to explore possible associations between child alexithymia and mother alexithymia and anxiety, as well as previous anaphylaxis.

METHODS

Sixty-five mother-child pairs have been recruited. Children had a medical diagnosis of FA. The Toronto Alexithymia Scale-20 was used to assess alexithymia in participants. The State-Trait Anxiety Inventory was used to assess trait anxiety in mothers. Statistical analysis was performed to investigate the influence of variables sex, previous anaphylaxis, and adrenaline auto-injector prescription on child and mother's alexithymia and to explore possible association between maternal and child alexithymia.

RESULTS

A substantial percentage of children were alexithymic (21.5%) or borderline (33.8%), while mothers' frequencies were lower and in line with prevalence in general population. Child alexithymia was positively associated with previous anaphylaxis and mothers' trait anxiety (p < .05). Mother trait anxiety was also associated with maternal alexithymia. Furthermore, a positive association between child and mother alexithymia has been found.

CONCLUSIONS

Clinicians must be aware of the role of alexithymia and its association with maternal anxiety and previous anaphylaxis in children with FA, encouraging seeking psychological support when needed. A multidisciplinary patient-centered approach should be put in place for the effective care of FA.

Prefrontal contributions to the stability and variability of thought and conscious experience

The human prefrontal cortex is a structurally and functionally heterogenous brain region, including multiple subregions that have been linked to different large-scale brain networks. It contributes to a broad range of mental phenomena, from goal-directed thought and executive functions to mind-wandering and psychedelic experience. Here we review what is known about the functions of different prefrontal subregions and their affiliations with large-scale brain networks to examine how they may differentially contribute to the diversity of mental phenomena associated with prefrontal function. An important dimension that distinguishes across different kinds of conscious experience is the stability or variability of mental states across time. This dimension is a central feature of two recently introduced theoretical frameworks-the dynamic framework of thought (DFT) and the relaxed beliefs under psychedelics (REBUS) model-that treat neurocognitive dynamics as central to understanding and distinguishing between different mental phenomena. Here, we bring these two frameworks together to provide a synthesis of how prefrontal subregions may differentially contribute to the stability and variability of thought and conscious experience. We close by considering future directions for this work.

Alexithymia is a mediating factor in the relationship between adult attachment and severity of depression and social anxiety

BACKGROUND

Major depressive disorder (MDD) and social anxiety disorder (SAD) are commonly occurring conditions, either alone or together (MDD-SAD). Recent research linked insecure attachment and alexithymia to MDD and/or SAD, indicating that the way affected individuals relate interpersonally and their ability to identify and communicate emotions are pertinent issues. The current study investigated the mediating role of alexithymia in the relationship between insecure attachment and severity of MDD and SAD symptoms.

METHOD

Using the SCID-I, participants (N=159) were identified as MDD-only (n=43), MDD-SAD (n=56), or a healthy control (n=60). Participants completed measures of adult attachment, depression, social anxiety and alexithymia (defined as difficulty identifying and describing feelings). A two-step mediation analysis approach recommended by Shrout and Bolger determined if alexithymia mediates the relationship between attachment-depression and attachment-social anxiety.

RESULTS

While alexithymia was high in MDD-only and MDD-SAD groups, individuals with MDD-SAD had significantly greater difficulty describing feelings. Alexithymia was a full mediator between attachment avoidance and depression, but only a partial mediator between attachment anxiety and depression. Meanwhile, alexithymia was a partial mediator for both attachment dimensions and social anxiety.

LIMITATIONS

Causal inferences regarding insecure attachment, alexithymia, and MDD and SAD cannot be assumed given the cross-sectional data. The 'externally oriented thinking' component in alexithymia was also excluded from analyses due to low reliability.

CONCLUSION

The results suggest emotional awareness and expression play a role in the illness severity for MDD and SAD-particularly in those with high attachment avoidance, offering a possible target for treatment and prevention strategies.

Interactions between interoception and perspective-taking: Current state of research and future directions

Interoception, the sense of the physiological state of the body, and perspective-taking, the ability to take another's point of view, are two fundamental components contributing to our perception and interaction with the external world. However, whether the perception of our inner body influences how we perceive the external world and other people remains poorly understood. Here, we review recent behavioural and neuroimaging evidence investigating the links between dimensions of interoception (i.e., accuracy, sensibility and awareness) and perspective-taking (i.e., affective, cognitive and visual). So far, only a limited subset of these dimensions has been investigated together and the results suggest that interoceptive abilities may only interact with perspective-taking when embodied mental transformations are required. Furthermore, mainly the emotional aspects of perspective-taking are related to interoception, influencing the ability to empathise with others. Future research should systematically investigate the links between all dimensions of interoception and perspective-taking to provide full understanding of the specific role interoception has on how we perceive the world and take another's point of view.

Emotional representations of space vary as a function of peoples' affect and interoceptive sensibility

Most research on people's representation of space has focused on spatial appraisal and navigation. But there is more to space besides navigation and assessment: people have different emotional experiences at different places, which create emotionally tinged representations of space. Little is known about the emotional representation of space and the factors that shape it. The purpose of this study was to develop a graphic methodology to study the emotional representation of space and some of the environmental features (non-natural vs. natural) and personal features (affective state and interoceptive sensibility) that modulate it. We gave participants blank maps of the region where they lived and asked them to apply shade where they had happy/sad memories, and where they wanted to go after Covid-19 lockdown. Participants also completed self-reports on affective state and interoceptive sensibility. By adapting methods for analyzing neuroimaging data, we examined shaded pixels to quantify where and how strong emotions are represented in space. The results revealed that happy memories were consistently associated with similar spatial locations. Yet, this mapping response varied as a function of participants' affective state and interoceptive sensibility. Certain regions were associated with happier memories in participants whose affective state was more positive and interoceptive sensibility was higher. The maps of happy memories, desired locations to visit after lockdown, and regions where participants recalled happier memories as a function of positive affect and interoceptive sensibility overlayed significantly with natural environments. These results suggest that people's emotional representations of their environment are shaped by the naturalness of places, and by their affective state and interoceptive sensibility.

Individuals with Autistic Traits Exhibit Heightened Alexithymia But Intact Interoceptive-Exteroceptive Sensory Integration

Interoceptive accuracy has been widely measured using the Heartbeat Tracking Test (HTT). We devised the novel paradigm of Interoception-Exteroception Synchronicity Judgement (IESJ) task to assess participants' interoceptive accuracy, exteroceptive accuracy, and the balancing score which reflected the ability to allocate attentions between interoceptive and exteroceptive signals. This study administered the behavioural paradigms of the HTT and the IESJ as well as other self-report scales to 119 typically-developing youths. Individuals with lower autistic traits (n = 30) showed comparable interoceptive accuracy, exteroceptive accuracy, and balancing scores as their higher autistic traits counterparts (n = 33). Taken together, the high autistic traits subgroup exhibited higher levels of alexithymia but not empathy or interoception than the low autistic traits subgroup.

Multidimensional Interoception and Autistic Traits Across life Stages: Evidence From a Novel Eye-tracking Task

Interoception is believed to underlie socio-cognitive functions which are often impaired in individuals with autism spectrum disorders (ASD). In this study, Experiment 1 examined in a sample of 114 neurotypical college students the associations among autistic traits, alexithymia, and interoceptive accuracy (IA), which was assessed by a novel paradigm "Eye-tracking Interoceptive Accuracy Task (EIAT). In Experiment 2, EIAT and the Autism Spectrum Quotient were administered to 52 preschool children, 50 adolescents, and 50 adults. Experiment 1 supported the association between autistic traits and alexithymia, but failed to support their association with multidimensional interoception. Experiment 2 strongly supported the association between age and IA. We conclude that cardiac IA differs between neurotypical age groups, but shows limited relationship with autistic traits.

Technology-Based Assessments and Treatments of Anxiety in Autistic Individuals: Systematic Review and Narrative Synthesis

This systematic review (Prospero Registration Number: CRD42019142910) aimed to narratively synthesise technology-aided assessments and treatments of anxiety in individuals with autism spectrum disorder (ASD) for the first time. Sixteen studies were identified: 5 assessment studies and 11 treatment studies. Assessment studies targeted state anxiety using ecological momentary assessment, wearables, or computerised tasks. Treatment studies targeted specific fears/phobias using electronic screen media or transdiagnostic anxiety using telemedicine. Broadly, results indicated technology-aided assessments and treatments may be feasible and effective at targeting anxiety in ASD, except treatments involving social scripts or peer modelling. Assessment results further indicated that state anxiety in ASD has a distinct psychophysiological signature and is evoked by idiosyncratic triggers. However, larger scale studies with representative samples are needed.

Disentangling interoceptive abilities in alexithymia

In recent years, research on interoceptive abilities (i.e., sensibility, accuracy, and awareness) and their associations with emotional experience has flourished. Yet interoceptive abilities in alexithymia—a personality trait characterized by a difficulty in the cognitive interpretation of emotional arousal, which impacts emotional experience—remain under-investigated, thereby limiting a full understanding of subjective emotional experience processing. Research has proposed two contrasting explanations thus far: in one model, the dimensions of interoceptive sensibility and accuracy in alexithymia would increase; in the other model, they would decrease. Surprisingly, the contribution of interoceptive awareness has been minimally researched. In this study (N = 182), the relationship between participants’ level of alexithymia and the three interoceptive dimensions was tested. Our results show that the higher the level of alexithymia is, the higher interoceptive accuracy and sensibility (R² = 0.29 and R² = 0.14); conversely, the higher the level of alexithymia is, the lower interoceptive awareness (R² = 0.36). Moreover, an ROC analysis reveals that interoceptive awareness is the most accurate predictor of alexithymia, yielding over 92% accuracy. Collectively, these results support a coherent understanding of interoceptive abilities in alexithymia, whereby the dissociation of interoceptive accuracy and awareness may explain the underlying psycho-physiological mechanisms of alexithymia. A possible neurocognitive mechanism is discussed which suggests insurgence of psychosomatic disorders in alexithymia and related psychotherapeutic approaches.

No Evidence of Perceptual Pseudoneglect in Alexithymia

Neuroscience research links alexithymia, the difficulty in identifying and describing feelings and emotions, with left hemisphere dominance and/or right hemisphere deficit. To provide behavioral evidence for this neuroscientific hypothesis, we explored the relationship between alexithymia and performance in a line bisection task, a standard method for evaluating visuospatial processing in relation to right hemisphere functioning. We enrolled 222 healthy participants who completed a version of the 20-item Toronto Alexithymia Scale (TAS-20), which measures alexithymia, and were asked to mark (bisect) the center of a 10-cm horizontal segment. The results document a significant rightward shift in the center of the line in participants with borderline and manifest alexithymia compared with non-alexithymic individuals. The higher the TAS-20 score, the greater the rightward shift in the line bisection task. This finding supports the right hemisphere deficit hypothesis in alexithymia and suggests that visuospatial abnormalities may be an important component of this mental condition.

Interoception moderates the relation between alexithymia and risky-choices in a framing task: A proposal of two-stage model of decision-making

Decision-making depends on the context (frame) in which questions and alternatives are presented. Moreover, research has showed that the ability to detect bodily sensations (interoception) and being able to attribute these changes to emotions correctly (alexithymia) influence how we make decisions. The aim of the present research was to study how interoception and alexithymia might affect the Framing effect (FE), a cognitive bias closely related to emotional system. 42 healthy participants completed the Risky-choice Framing task and their interoception and alexithymia levels were measured. Results showed that the participants were more risk-taking under the negative frames in comparison to the positive ones. In addition, we found that alexithymia and interoception were negatively and positively correlated with the FE, respectively. Finally, the moderation analyses revealed that alexithymia predicted a lower FE only when the interoception was high. Based on previous literature and in our results, we propose a two-stage model of intuitive decision-making.

Reduced differentiation of emotion-associated bodily sensations in autism

LAY ABSTRACT

More research has been conducted on how autistic people understand and interpret other people's emotions, than on how autistic people experience their own emotions. The experience of emotion is important however, because it can relate to difficulties like anxiety and depression, which are common in autism. In neurotypical adults and children, different emotions have been associated with unique maps of activity patterns in the body. Whether these maps of emotion are comparable in autism is currently unknown. Here, we asked 100 children and adolescents, 45 of whom were autistic, to color in outlines of the body to indicate how they experienced seven emotions. Autistic adults and children sometimes report differences in how they experience their internal bodily states, termed interoception, and so we also investigated how this related to the bodily maps of emotion. In this study, the autistic children and adolescents had comparable interoception to the non-autistic children and adolescents, but there was less variability in their maps of emotion. In other words, they showed more similar patterns of activity across the different emotions. This was not related to interoception, however. This work suggests that there are differences in how autistic people experience emotion that are not explained by differences in interoception. In neurotypical people, less variability in emotional experiences is linked to anxiety and depression, and future work should seek to understand if this is a contributing factor to the increased prevalence of these difficulties in autism.

Emotional self-awareness in autism: A meta-analysis of group differences and developmental effects

LAY ABSTRACT

Autistic people are thought to have difficulties with identifying and understanding their own emotions. This is referred to as emotional self-awareness. It is important to study emotional self-awareness as people who are more able to understand their own emotions, whether they are autistic or not, are more able to respond to them appropriately, as well as to identify them in other people. It has not yet been confirmed whether autistic people have difficulties with emotional self-awareness, or if any reported difficulties are actually due to the way in which emotional self-awareness is measured in autistic people. If these difficulties do exist, it is also not known when these difficulties emerge. In this research, we reviewed 47 existing studies that measured emotional self-awareness in autistic and non-autistic adults and children. We also compared studies that measured emotional self-awareness in different ways. We found that autistic adults did seem to have poorer emotional self-awareness compared to their neurotypical peers. However, this was not the case with autistic children of age 12 years and below. Instead, differences in emotional self-awareness only seemed to emerge during adolescence. Moreover, these difficulties seemed to increase with age. These results suggest that difficulties with emotional self-awareness may not be inherent in autism. Instead, they may emerge alongside the greater social and mental health difficulties that are experienced by many autistic people during adolescence. We therefore suggest that it is important to find out more about, and subsequently support, the emotional self-awareness difficulties that autistic adolescents may encounter.

Moderating Role of Health Literacy on the Association between Alexithymia and Depressive Symptoms in Middle School Students

Depression is a common psychological problem in adolescents. At present, few studies have described the moderating role of health literacy on the association between alexithymia and depressive symptoms among adolescents. The purpose of this study was to explore the relation among health literacy, alexithymia, and depressive symptoms and the moderating role of health literacy in middle school students. In December 2017, data were collected from a school in Shenyang by the convenient sampling method using a questionnaire including demographic information, health literacy, alexithymia, and depressive symptoms. A total of 1068 junior and senior high school students were selected as subjects, and 1062 valid questionnaires were retained for analysis. Logistic regression models were used to examine the association between health literacy and alexithymia with depressive symptoms. The prevalence of depressive symptoms was 48.2%, and the prevalence of alexithymia was 17.9%. Low health literacy was significantly associated with depressive symptoms (odds ratio (OR) (95% confidence interval (CI)) = 3.648 (2.493–5.338)). Alexithymia was significantly correlated with depressive symptoms (OR (95% CI) = 3.091 (2.156–4.429)). Low health literacy was related to a greater increase in the risk of depressive symptoms for students with alexithymia (OR (95% CI) = 10.566 (5.175–21.570)). The findings suggest that alexithymia and health literacy are important factors influencing depressive symptoms and health literacy has a moderating role on the association between alexithymia and depressive symptoms. Enhancing health literacy of middle school students with alexithymia may improve their mental health.

Emotions, Alexithymia, and Emotion Regulation in Patients With Psoriasis

Psoriasis is a chronic dermatological condition that is frequently associated with problematic patterns of emotional reactivity (the way in which patients react to stimuli), alexithymia (their ability to recognize and label the emotional reaction), and emotion regulation (the ability to enhance or reduce their own emotional reaction). A research in the peer-reviewed scientific literature was conducted in order to identify articles describing the association of psoriasis and affective problems. In particular, we first evaluate studies that have investigated abnormal emotional reactivity (in terms of duration, frequency, or type of the experienced emotions) and its impact on patients' quality of life; next, we review the role of alexithymia and emotion regulation in modulating the relationship between emotional reactivity and quality of life in this population. From a critical analysis of the reviewed studies, we highlight that altered emotional processing might be particularly important in the characterization of this condition. In particular, we show that this condition is related to an emotional reactivity characterized by negative emotions that have a stronger impact on patients' quality of life when emotion regulation abilities are weak, especially if patients have alexithymia. Finally, we present suggestions for future directions in both clinical and research fields.

Dissociation in How Core Autism Features Relate to Interoceptive Dimensions: Evidence from Cardiac Awareness in Children

Interoception in autism is receiving increasing research attention. Previously, differences were identified in autism on both objective and subjective measures of interoception, and an association with anxiety. Yet, it is currently unknown how interoception relates to core autism features. Here, in 49 autistic children, we consider how interoceptive accuracy (measured with heartbeat detection tasks) and sensibility (subjective judgements of awareness) relate to overall severity on the Autism Diagnostic Observation Schedule, and symptom domains of social-affective and repetitive, restricted behaviors. Socio-affective features were related to interoceptive sensibility, while repetitive restricted behaviors were related to interoceptive accuracy. This dissociation suggests disparate interoceptive mechanisms for the formation and/or maintenance of autistic features.

Self-guided mindfulness and cognitive behavioural practices reduce anxiety in autistic adults: A pilot 8-month waitlist-controlled trial of widely available online tools

LAY ABSTRACT

Anxiety in autism is an important target for psychological therapies because it is very common and because it significantly impacts upon quality of life and well-being. Growing evidence suggests that cognitive behaviour therapies and mindfulness-based therapies can help autistic individuals learn to manage feelings of anxiety but access to such therapies remains problematic. In the current pilot study, we examined whether existing online cognitive behaviour therapy and mindfulness-based therapy self-help tools can help reduce anxiety in autistic adults. Specifically, 35 autistic adults were asked to try either an existing online cognitive behaviour therapy (n = 16) or mindfulness-based therapy (n = 19) programme while a further 19 autistic adults served as a waitlist comparison group. A first important finding was that 23 of the 35 (66%) participants who tried the online tools completed them, suggesting that such tools are, in principle, acceptable to many autistic adults. In addition, adults in the cognitive behaviour therapy and mindfulness-based therapy conditions reported significant decreases in anxiety over 3 and to some extent also 6 months that were less apparent in the waitlist group of participants. On broader measures of mental health and well-being, the benefits of the online tools were less apparent. Overall, the results suggest that online self-help cognitive behaviour therapy and mindfulness-based therapy tools should be explored further as a means of providing cost-effective mental health support to at least those autistic individuals who can engage effectively with such online tools.

Auditory Mismatch Negativity Under Predictive Coding Framework and Its Role in Psychotic Disorders

Traditional neuroscience sees sensory perception as a simple feedforward process. This view is challenged by the predictive coding model in recent years due to the robust evidence researchers had found on how our prediction could influence perception. In the first half of this article, we reviewed the concept of predictive brain and some empirical evidence of sensory prediction in visual and auditory processing. The predictive function along the auditory pathway was mainly studied by mismatch negativity (MMN)-a brain response to an unexpected disruption of regularity. We summarized a range of MMN paradigms and discussed how they could contribute to the theoretical development of the predictive coding neural network by the mechanism of adaptation and deviance detection. Such methodological and conceptual evolution sharpen MMN as a tool to better understand the structural and functional brain abnormality for neuropsychiatric disorder such as schizophrenia.

Atypical bodily self-awareness in vicarious pain responders

Vicarious perception refers to the ability to co-represent the experiences of others. Prior research has shown considerable inter-individual variability in vicarious perception of pain, with some experiencing conscious sensations of pain on their own body when viewing another person in pain (conscious vicarious perception/mirror-pain synaesthesia). Self-Other Theory proposes that this conscious vicarious perception may result from impairments in self-other distinction and maintaining a coherent sense of bodily self. In support of this, individuals who experience conscious vicarious perception are more susceptible to illusions of body ownership and agency. However, little work has assessed whether trait differences in bodily self-awareness are associated with conscious vicarious pain. Here we addressed this gap by examining individual difference factors related to awareness of the body, in conscious vicarious pain responders. Increased self-reported depersonalization and interoceptive sensibility was found for conscious vicarious pain responders compared with non-responders, in addition to more internally oriented thinking (associated with lower alexithymia). There were no significant differences in trait anxiety. Results indicate that maintaining a stable sense of the bodily self may be important for vicarious perception of pain, and that vicarious perception might also be enhanced by attention towards internal bodily states. This article is part of a discussion meeting issue 'Bridging senses: novel insights from synaesthesia'.

Interoceptive sensibility tunes risk-taking behaviour when body-related stimuli come into play

In everyday life, we continuously make decisions, assuming the risk by making choices on material possessions or our body. Bodily signals may support the decision-making process, informing us about possible outcomes. Sensibility for such internal bodily changes influences the way we perceive the environment, and it can boost the body-related stimuli processing. Thus, the question arises of whether the individual sensibility to interoceptive signals modulates decision-making in the presence of biological stimuli. To test this hypothesis, we administered 50 healthy subjects with the Balloon Analogue Risk Task, in which participants were required to inflate a virtual balloon, and a modified version of it, in which they inflated a virtual body. We found that interoceptive sensibility predicted risk-taking behaviour only in the presence of body-related stimuli. Our results provided new evidence on the role of interoceptive sensibility in complex cognitive functions, such as risk-taking behaviour, which impacts the way we act within our society.

Altered Interoceptive Processing in Generalized Anxiety Disorder-A Heartbeat-Evoked Potential Research

Generalized anxiety disorder (GAD) is one of the most common anxiety disorders. The brain's dysfunctional processing of interoceptive information is increasingly recognized as an important component of anxiety disorders. However, the neural mechanisms remain insufficiently understood. In the present study, patients with GAD and healthy control participants underwent an eyes-closed (EC) resting state (interoception) and eyes-open (EO) resting state (exteroception) without paying conscious attention to heartbeat. Electrocardiography (ECG) and electroencephalography (EEG) signals were recorded at the same time. The results show that in healthy controls, the heartbeat-evoked brain potential (HEP) was modulated by the conditions, with a significantly higher amplitude under EC than EO, while this was not the case in GAD patients. Further analysis revealed that the dysfunction of HEP modulation in GAD patients may be attributed to excessive interoceptive processing under EO, with a marginally higher HEP in GAD than in the healthy controls. Finally, the right prefrontal HEP amplitude during EC condition was significantly correlated with the severity of the patients' anxiety symptoms. Our results suggest that altered cortical processing of interoceptive signals may play an important role in the pathophysiology of generalized anxiety disorder.