Association Between Interoception and Emotion Regulation in Individuals With Alcohol Use Disorder

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.

Emotion regulation in substance use disorders: a systematic review and meta-analysis

BACKGROUND AND AIMS

The ability to regulate emotions effectively has been associated with resilience to psychopathology. Individuals with substance use disorders (SUDs) have been shown to have higher levels of negative emotionality, with some evidence suggesting impairment in emotion regulation compared with individuals without SUDs. However, no previous attempt has been made to systematically review the literature to assess the magnitude of this difference. We aimed to assess the association between SUD diagnosis and emotion regulation as measured by the Difficulties in Emotion Regulation Scale (DERS) and Emotion Regulation Questionnaire (ERQ) through a systematic review and meta-analysis of existing findings.

METHODS

The systematic review was conducted using PubMed, PsycINFO and Embase. We examined cross-sectional studies that compared a SUD group with a control group and measured emotion regulation using the DERS or the ERQ. The primary analysis focused on papers using the DERS, as this was the predominant instrument in the literature.

RESULTS

Twenty-two studies met our primary analysis criteria, representing 1936 individuals with a SUD and 1567 controls. Individuals with SUDs relative to controls had significantly greater DERS scores, with a mean difference of 21.44 [95% confidence interval (CI) = 16.49-26.40, P < 0.001] and Hedges' g = 1.05 (95% CI = 0.86-1.24, P < 0.001). The difference was robust, remaining significant after removing outliers and studies with high risk of bias. Individuals with SUDs demonstrated poorer emotion regulation on each subscale of the DERS, with the largest deficits in the Strategies and Impulse subscales. The ERQ analysis revealed greater use of expressive suppression in those with SUDs relative to controls (Hedges' g = 0.76, 95% CI = 0.25-1.28, P = 0.004).

CONCLUSIONS

People with substance use disorders appear to have greater difficulties in emotion regulation than people without substance use disorders.

Spatial-topographic nestedness of interoceptive regions within the networks of decision making and emotion regulation: Combining ALE meta-analysis and MACM analysis

Prominent theories propose that interoception modulates our behavioral and emotional responses involving decision-making and emotion regulation. Are the regions implicated in interoception also spatially related to and possibly nested within the networks of decision making and emotion regulation? Addressing this question, we performed three meta-analyses of functional magnetic resonance imaging studies to identify the regions that are commonly activated by the three domains using activation likelihood estimation (ALE). Additionally, we assessed the coactivation pattern of identified common regions using meta-analytic connectivity modeling (MACM). The results showed major overlaps of interoception with both decision making and emotion regulation in specifically the right dorsal anterior insula. The pairwise contrast analyses confirmed this finding and revealed conjunction-based activities in decision making and emotion regulation in the dorsal anterior cingulate cortex (dACC). MACM based on the identified insula revealed a widespread convergent coactivation pattern with the left anterior insula, dACC, and bilateral thalamus which, together, constitute the salience network. Among these co-activated regions, bilateral insula and the dACC were shared among all three domains. These results suggest that the regions mediating interoception including intero-exteroceptive integration and salience attribution are contained and thus spatially nested within the more extensive networks recruited during decision making and emotion regulation.

Alexithymia mediates the association between childhood trauma and adolescent E-cigarette use

BACKGROUND

Adolescent electronic cigarette use (e-cigarette) is a public health concern and factors associated with vaping remain to be understood. Childhood emotional abuse/neglect is a risk factor for e-cigarettes. Yet, pathways by which trauma impacts use remain unclear. Alexithymia (i.e., difficulties identifying and describing feelings) is one possible link. Indeed, emotional abuse/neglect leads to difficulties identifying and verbalizing emotions. This impairment may lead to distress and promote e-cigarette use as a coping strategy.

METHODS

Using parallel mediation, this study examined the degree to which alexithymia, assessed using the Toronto Alexithymia Scale, mediates the link between emotional abuse/neglect, assessed using the Child and Adolescent Trauma Screen, and e-cigarette use. The sample (n = 166) consisted of adolescents from a larger multi-wave study.

RESULTS

Emotional abuse/neglect predicted difficulty describing feelings (effect = 0.23, p = 0.001), which in turn predicted e-cigarette use (effect = 0.30, p = 0.004). Moreover, difficulty describing feelings mediated the link between emotional abuse/neglect and e-cigarette use (sum of indirect 95% CI [1.68, 16.48]). Difficulty identifying feelings was not a significant mediator and the externally-oriented thinking subscale was excluded due to low reliability.

CONCLUSIONS

As e-cigarettes are often used in social contexts, teens who experience difficulty describing feelings may vape as a means of connecting emotionally with others. Moreover, nicotine, found in most e-cigarettes, releases dopamine and noradrenaline in the brain modulating action, learning, and memory processes; plausibly, improving verbalization of emotions. Programming which identifies nuances in alexithymia among adolescents with emotional abuse/neglect could mitigate e-cigarette use or delay initiation.

Interoception Dysfunction Contributes to the Negative Emotional Bias in Major Depressive Disorder

Background

Previous research studies have demonstrated that impaired interoception is involved in emotional information processing in major depressive disorder (MDD). Heartbeat-evoked potential (HEP) amplitudes, an index for interoception, could be manipulated by emotional faces in healthy people. Considering negative emotional bias is the core characteristic in MDD, we hypothesized that interoception dysfunction was associated with the negative emotional bias in MDD.

Methods

An electroencephalogram (EEG) study under an emotional faces task was applied to explore the relationship between interoception and emotional bias. HEPs before emotional faces stimuli were used to predict the late positive potential (LPP) amplitudes and it worked as an index of emotional bias. Twenty-seven patients with MDD and 27 healthy controls (HCs) participated in this study. Source analysis gave an auxiliary description for results in sensory level.

Results

Major depressive disorders (MDDs) had poor performance in the heartbeat count task (HCT) and attenuate HEP average amplitudes (455-550 ms). Compared with HCs, cluster-based permutation t-tests revealed that MDDs had attenuated LPP amplitudes (300-1,000 ms) over centroparietal regions and enhanced LPP amplitudes over frontocentral regions. Furthermore, abnormal attenuated HEPs could predict aberrant LPPs under sad face stimuli in MDDs, which could be associated with the dysfunction of the anterior cingulate cortex (ACC) and right insula.

Conclusion

Mediated by ACC and insula, interoception dysfunction contributes to the negative emotional bias of MDD, highlighting the importance of interoception in the disorder.

Mindfulness-Based Interventions for the Treatment of Aberrant Interoceptive Processing in Substance Use Disorders

Altered interoception, or the processing of bodily signals, has been argued to play a role in the development and maintenance of substance use disorders (SUD). Therefore, interoceptive interventions focusing on bodily awareness, such as mindfulness meditation, may improve treatment outcomes for individuals with SUD. Here we review: (1) subjective, behavioral and brain evidence for altered interoceptive processing in SUD, focusing on insular and anterior cingulate cortices (INS, ACC), key regions for interoceptive processing; (2) research highlighting links between mindfulness and brain function; and (3) extant brain research investigating mindfulness-based interventions in SUD. SUD tend to be characterized by heightened INS and ACC responses to drug cues but blunted interoceptive awareness and attenuated INS and ACC responses during tasks involving bodily attention and/or perturbations. In contrast, mindfulness interventions in healthy individuals are linked to enhanced INS and ACC responses and heightened interoceptive awareness. It is crucial for future research to identify: (1) whether mindfulness-based treatments are efficacious across substance classes; (2) what particular approaches and dosages show the largest effect sizes in enhancing INS and ACC function to non-drug stimuli and reducing responsivity to substance cues, thereby improving SUD treatment outcomes (reducing drug craving and relapse).

Emotion regulation and substance use: A meta-analysis

There has been exponential growth in research on emotion regulation and substance use in the past decade. The current meta-analysis evaluated variability in the magnitude of the relation between aspects of emotion regulation and substance use. A search of PsycINFO, Embase, PubMed, CINAHL Plus, and PILOTS in December 2020 resulted in 6642 initial studies, of which 95 met inclusion criteria (association between emotion regulation and substance use was reported, participants were > 18 years old, article was in English). A total of 445 effects were obtained (N = 156,025 participants; weighted M_age = 29.31; 59.5% female; 66.1% White; 76.6% non-clinical). Emotion regulation and substance use were significantly related (r = 0.19; p < 0.001; 95%CI [0.17, 0.20]). Emotion regulation abilities were generally more strongly related to substance use than emotion regulation strategies; this pattern was stronger for behavioral vs. cognitive abilities and extended to both negative and positive emotions. Relations were stronger for older and clinical samples; mixed effects were found for sex and no conclusive effects were found for race. Despite limitations of the existing literature (e.g., cross-sectional, self-reports), results indicated that the magnitude of the relation between emotion regulation and substance use varied considerably as a function of emotion regulation and substance use constructs and sample characteristics.

Alcohol use and interoception - A narrative review

Interoception, defined as the ability to perceive and interpret body signals, may play an important role in alcohol use disorder (AUD). Earlier studies suggested an association between interoception impairment and known risk factors for AUD (e.g., alexithymia, emotion dysregulation, impulsivity, pain). Neurobiological studies show that the neurotoxicity of alcohol affects various elements of the interoceptive system (especially the insula) at structural and functional levels, with differential short/long term impacts. Conversely, primary interoceptive impairments may promote alcohol consumption and foster the evolution towards addiction. Despite convincing evidence demonstrating that interoception impairment may be an important contributor to the development and course of AUD, only a few studies directly evaluated interoceptive abilities in AUD. The research shows that interoceptive accuracy, the objective component of interoception, is lower in AUD individuals, and is correlated with craving and emotion dysregulation. Interoceptive sensibility is in turn higher in AUD individuals compared to healthy controls. Moreover, there is evidence that therapy focused on improving the ability to sense signals from the body in addiction treatment is effective. However, important methodological limitations in interoceptive measures persist, and it is therefore necessary to further investigate the associations between interoception and AUD.

Associations between physiological and self-reported indices of emotion dysregulation across varying levels of alcohol use among individuals with and without borderline personality disorder

Emotional functioning can be assessed across multiple levels of analysis (e.g., subjective, physiological). The degree of concordance/discordance across such indices may mark psychopathology risk. The current study assessed associations between physiological and subjective indices of emotional responding among drinkers, with (n = 39) and without (n = 42) borderline personality disorder. Subjective changes in affect were assessed by calculating difference scores on the Positive and Negative Affective Schedule, administered before and following a lab-based stress task. Physiological dysregulation was indexed by respiratory sinus arrhythmia (RSA) reactivity. We created Discordance Index scores to examine the direction and magnitude of misalignment. More frequent alcohol use was associated with greater discordance between RSA and positive affect changes (β = -0.07, p-value = 0.009). Findings were confirmed with a response surface modeling analysis. Results highlight that individuals with greater discordance between indices of emotional responding may be at elevated risk for frequent alcohol use.

A real-world ten-week follow-up of the COVID outbreak in an outpatient drug clinic in Salamanca (Spain)

Objective

To compare over ten weeks the number of relapses, hospital admissions, calls made, admissions to therapeutic communities, face-to-face visits, treatment adjustment, number of injectables administered, and number of emergencies attended due to emotional and behavioral alterations and/or substance use disorder, and to describe and quantify social emergencies in an outpatient drug clinic (ODC) in Salamanca (Spain) from March 16, 2020, to May 22, 2020.

Methods

This is an ecological study of the COVID pandemic over ten weeks. The study examines the set of alcohol or other drug-dependent or dual disorder patients in the population of Salamanca, Spain. The measurements were: professionals; calls made; percentage of successful calls; face-to-face visits; first visits made; reviews made; techniques; injectable treatments; other treatments; evolution; relapses. The ODC includes about 375 new patients each year and another 650 other patients annually.

Results

The study found the number of relapses to be greater in the last five weeks of the 10-week study period. Patients' psychopathological instability also increased, and face-to-face visits were necessary. The most frequent psychopathology that required face-to-face intervention was depressive disorder. The number of interventions with patients increased. In parallel, social workers' efforts were greater after the seventh week. There was a decrease in response to calls. Throughout this time, the ODC attended to patients who needed to be treated for the first time.

Conclusions

Confinement due to the coronavirus pandemic generated maladaptive emotional responses and other behaviors, such as excessive alcohol consumption. The number of face-to-face consultations, admissions, and referrals to therapeutic communities increased. Patients under stress and in social isolation resorted more often to substance use. The ODC had to adopt a flexible approach to evaluate patients with more serious problems, by using face-to-face assessments.

The synergistic effect between interoceptive accuracy and alcohol use disorder status on pain sensitivity

BACKGROUND

Interoceptive accuracy and pain sensitivity are both risk factors in the development of alcohol use disorder (AUD). However, the synergistic association between these two factors has not been investigated in an AUD sample. Therefore, the aim of the current study was to investigate whether the association between interoceptive accuracy and sensitivity to pain differed across AUD status.

METHODS

The study group included 165 individuals diagnosed with AUD (88.1% men) and 110 healthy controls (HCs; 74.5% men). Interoceptive accuracy was assessed with the Schandry Task. The Pain Sensitivity Questionnaire was utilized to measure sensitivity to pain. Anxiety, biological sex, and age were included as covariates in a model examining the role of AUD status as a moderator in the association between interoceptive accuracy and pain sensitivity.

RESULTS

A significant interaction was found between interoceptive accuracy and AUD status (b = -4.580, 95% CI = [-8.137, -1.022], p = 0.012, ΔR² = 0.032). Findings indicate that interoceptive accuracy was negatively associated with pain sensitivity among individuals with AUD, while there was a trend for an opposite association among healthy controls.

CONCLUSION

We hypothesize that persistent alcohol drinking may contribute to disruption of the normative association between interoception and pain. Future studies should be conducted to develop knowledge on this association and to investigate its possible therapeutic significance and implications.

Emotion perception and theory of mind in obesity: a systematic review on the impact of social cognitive deficits on dysfunctional eating behaviors

The aim of this paper was to summarize our current understanding of emotion perception and Theory of Mind (ToM) in obesity and how they relate to dysfunctional eating behaviors (DEB), frequently found in candidates for bariatric surgery. The literature was searched using the electronic databases PsychInfo, Medline, and Web of Science databases, and by additional hand searches through reference lists and specialist eating disorders journals. Relevant studies were included if they were written in English, included participants suffering from obesity and evaluation with tasks assessing social cognition, such as emotion recognition and perception, as well as ToM. Twelve studies analyzed for this systematic review suggest that deficits in such social cognitive domains may lie behind many emotional and social difficulties present in people with obesity, be they bariatric or not, which usually favor DEB. Our review suggests that people with obesity of all ages score significantly less than controls on instruments assessing emotion recognition and ToM, justifying a possible relationship between social cognitive impairments and dysfunctional eating behaviors, such as binges, emotional eating, and addition to food, frequently seen in people with obesity. These findings have important implications for our understanding of the social cognitive foundations of eating behavior in individuals with obesity. They can help not only the presurgical behavioral assessment, but also guide postoperative follow-up of this population.