Interoceptive Awareness and the Neurodivergent Client by Mel Wakeman

Interoceptive awareness (IA) enables us to know how we're feeling physically and emotionally. It’s how we know we are thirsty or hungry, or anxious through connecting with and interpreting the signals and sensations that arise from within our own body.

Interoception is important because it helps us tune into our body's needs, ideally responding to them in a timely manner thereby supporting our health and well-being.

Embracing or developing IA is more complicated than saying ‘just listen to your body’. How do you do that when you have no idea what you are supposed to be listening for? And what do you do when the volume has been turned down or off when it comes to feeling for those signals?

This means some folk will feel disconnected from their physical and emotional needs; they may find it exceedingly difficult to take care of themselves and navigate difficult emotions.

Many folk will experience temporarily low IA. This can happen because of stress, trauma and burnout as the body disconnects from the signals as part of a protective response. Suppression of IA can be a coping strategy for dealing with chronic pain. It’s also seen in chronic dieters and eating disorders.

Neurodivergent folk are highly likely to experience prolonged low IA, and research has revealed this is due to structural and functional differences of a region in the brain called the insula cortex. (Wiersema, J. R. 2018)

Brain studies have found the thickness of the insula can determine the level of IA; folk with higher interoception awareness tend to have thicker insulas. While poor interoception awareness is linked with less gray matter and less activity in the insula (Critchley et al., 2004).

Higher IA has been shown to play a key role in the processing and regulation of emotions, with higher IA being associated with more effective emotional regulation, through greater emotional intelligence (Price & Hooven, 2018).

Whilst some neurodivergent individuals may experience mixed interoceptive awareness; being under-responsive in some areas (commonly associated with ADHD) and hyper-responsive in others (Xu et al., 2018), seen in ASD. This can result in real confusion about what the body is trying to communicate to self and in interpreting others too.

The Interoceptive Processing Pathway

The insula cortex is the head office of IA, located deep in a groove of the cerebral cortex.

It plays vital roles in the perception of pain, the primary emotions from happiness and joy to anger and disgust. It enables awareness of bodily states (the experience of your heart beating, feeling hot or cold)

And it’s through the insular cortex that we develop self-perception.

Signals carrying sensory and movement information will come from all over the body to the insula, via a satellite hub; the thalamus, that is located in the middle of the brain, at the top of the spinal cord.

It’s the job of the thalamus to distribute the information it receives to other parts of the brain.

The cerebral cortex can then help process attention, perception and awareness.

The hypothalamus can then play its role in controlling temperature, hunger and thirst.

And finally, the insula cortex which has two halves: the posterior at the back and anterior at the front. As information from the thalamus reaches the posterior insula cortex (PIC), it’s combined with signals from the outside world, helping us form external senses such as sight, sound and touch.

It’s then passed to the anterior insula cortex (AIC), which is believed to be strongly linked to empathy and decision-making. It’s here we make our minds up how to act on our inner sensations, before sending these instructions back down to the body.

IA and Executive Function.

Lower IA can lead to greater difficulty identifying and responding to hunger, thirst, pain and other physical sensations, potentially resulting in poor nutrition, dehydration and untreated physical conditions.

Then factor in executive function challenges and we can start to understand why establishing adequate / good nutrition, (especially in the treatment of eating disorders), requires an accommodating, adapted approach with higher levels of support for the neurodivergent client.

Executive function is the cognitive processes that help us regulate, control and manage our thoughts and actions; attention, planning, working memory, task initiation, problem solving, verbal reasoning, inhibition, adaptation, and monitoring of actions.

Regarding eating behaviours, low IA combined with poor executive function can show up as erratic eating (missing or skipping meals and snacks), deprivation driven and / or emotionally driven binge eating, rigid and restrictive eating behaviours, all of which can further increase anxiety, which will exacerbate low IA even more.

How can we become better practitioners?

IA may be improved with practice and support.

Here are a few ways to help your client develop their interoception skills:

• Practice interoception awareness activities to build interoceptive accuracy and confidence: These can include embodied movement, breath work (if appropriate)*, body scans (if appropriate)*, and mindful check-ins (taking a few moments throughout the day to check in with their body to notice breathing, heartbeat, body temperature, body tension etc.)

• Use accommodations and adaptations: Set reminders for eating, drinking, going to bed and for taking breaks. Create meal & snack plans in ways that help reduce overwhelm & decision paralysis. Use gentle strategies that help to combat impulsiveness and raise emotional vocabulary and intelligence.

• Consider adapting intuitive eating (IE): The IE framework was created for neurotypical folk so many of the characteristics ND possess cannot be shoehorned in. However, its weight and food neutral focus can be helpful in supporting the ND client who struggles with food preoccupation and obsession. And IE also can help cultivate ways to challenge a critical internal dialogue; something ND people can find difficult due to emotional dysregulation, a low frustration tolerance and low self-esteem.

· Be patient and compassionate: Everyone's experience with interoception is unique. Safety should be at the forefront of the client’s needs, to avoid further anxiety and triggers.

*Trauma may contraindicate breath work and body scans