Interoception - The critical 6th sense damaged by trauma

WHAT IS INTEROCEPTION?

Interoception is the perception of sensations from inside the body (1). It's your brain's way of telling you that you are currently sitting in a chair (you feel the pressure against your legs) and that you wish you had a snack (a pang in your stomach). Not every physiological condition under observation by our interoceptive system reaches our consciousness (2). The fact that your brain has given you the heads up that you're hungry means that it considers increasing your blood sugars to be an important matter at this point in time. Before your brain assigned you the task of walking over to the fridge, your interceptive system noted a chemical drop in the sugar levels of your blood. Your brain might first have asked your liver or muscles for some sugar. In a perfect world you brain would have taken the energy from the fat stored on your hips - wouldn't that be the dream!

The point is that processes like regulating chemicals, heart rate, internal organs, hormones and temperature are all accomplished by interoception - but they often don't enter our conscious awareness (3).

In order for internal sensations to reach our awareness, our brain needs to process them and then let us know what's going on so that we can decide how to act - a process known as interoceptive awareness (1). 

A lack of interoceptive awareness is linked to emotion disorders including anxiety and depression (4) as well as PTSD (5). Following trauma, common adaptive responses include hypo and hyper arousal (6) or too little and too much interoception.

So what happens when we invite women with PTSD to practice interoception?

PTSD AND INTEROCEPTION

Traumatized people generally have trouble focusing on inner sensations and perceptions (interoception) (7). When they try to meditate they often report:

1. Feeling overwhelmed by physical sensations that are reminiscent of their trauma (7)

2. Feeling disgusted with themselves, helpless and panicked (7)

3. That they cannot feel their body or parts of their body. That they feel disconnected from their body (8)

"Trauma victims tend to have a negative body image— as far as they are concerned, the less attention they pay to their bodies, and thereby, their internal sensations, the better". (7) Or, to quote one of my clients "The idea of connecting to my body is terrifying".

In non-traumatized people meditation increases brain activity (9) and size (10) in the regions associated with interception (11).

Meditation is traumatic for trauma survivors. Trauma survivors need to increase their capacity for interoception. The research shows that interoception is improved by meditation.

 So how the hell do we help trauma survivors increase their capacity for interoception??

We need to make the body, not the mind, the focus of our clients' attention (12).

David Emerson and Bessel Van der Kalk found that the interoceptive aspect of yoga  was responsible for a reduction in PTSD symptomatology in a 10 week study involving 64 women with chronic treatment resistant PTSD (13).

INTEROCEPTION AT THE FIGHT BACK PROJECT

The key word that David Emerson recommends Trauma Sensitive Yoga facilitators use to encourage interoception is: notice (12)

I invite all women in the fight back project to repeatedly ask themselves what they can notice happening in their body. During the warm up they are invited to close their eyes and notice the parts of their body in contact with the chair. We experiment with stretches involving the muscles which will feature in the technique section of the session. The women are invited to notice sensations such as stretching and tensing. While practicing kickboxing techniques women are invited to recall the muscles they felt during the warm up and notice what they feel in those same areas. When we sample intensity women are invited to experiment with whatever feels like intensity for them for 10-15 seconds followed by 30 seconds of grounding. While grounding the women are invited to notice their feet on the floor, their breath or their pulse, they can choose. In the cool down we repeat the practice from the warm up.

References

1. Price, C. J., & Hooven, C. (2018). Interoceptive Awareness Skills for Emotion Regulation: Theory and Approach of Mindful Awareness in Body-Oriented Therapy (MABT). Frontiers in psychology, 9, 798. https://doi.org/10.3389/fpsyg.2018.00798

2. Cameron O. G. (2001). Interoception: the inside story--a model for psychosomatic processes. Psychosomatic medicine, 63(5), 697–710. https://doi.org/10.1097/00006842-200109000-00001

3. Craig A. D. (2003). Interoception: the sense of the physiological condition of the body. Current opinion in neurobiology, 13(4), 500–505. https://doi.org/10.1016/s0959-4388(03)00090-4

4. Paulus, M. P., & Stein, M. B. (2010). Interoception in anxiety and depression. Brain structure & function, 214(5-6), 451–463. https://doi.org/10.1007/s00429-010-0258-9

5. Farb, N., Daubenmier, J., Price, C. J., Gard, T., Kerr, C., Dunn, B. D., Klein, A. C., Paulus, M. P., & Mehling, W. E. (2015). Interoception, contemplative practice, and health. Frontiers in psychology, 6, 763. https://doi.org/10.3389/fpsyg.2015.00763

6. Taylor, A. G., Goehler, L. E., Galper, D. I., Innes, K. E., & Bourguignon, C. (2010). Top-down and bottom-up mechanisms in mind-body medicine: development of an integrative framework for psychophysiological research. Explore (New York, N.Y.), 6(1), 29–41. https://doi.org/10.1016/j.explore.2009.10.004

7. Van der Kolk B. A. (2006). Clinical implications of neuroscience research in PTSD. Annals of the New York Academy of Sciences, 1071, 277–293. https://doi.org/10.1196/annals.1364.022

8. Schäflein, E., Sattel, H. C., Pollatos, O., & Sack, M. (2018). Disconnected - Impaired Interoceptive Accuracy and Its Association With Self-Perception and Cardiac Vagal Tone in Patients With Dissociative Disorder. Frontiers in psychology, 9, 897. https://doi.org/10.3389/fpsyg.2018.00897

9. Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S. F., Urbanowski, F., Harrington, A., Bonus, K., & Sheridan, J. F. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic medicine, 65(4), 564–570. https://doi.org/10.1097/01.psy.0000077505.67574.e3

10. Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J. R., Greve, D. N., Treadway, M. T., McGarvey, M., Quinn, B. T., Dusek, J. A., Benson, H., Rauch, S. L., Moore, C. I., & Fischl, B. (2005). Meditation experience is associated with increased cortical thickness. Neuroreport, 16(17), 1893–1897. https://doi.org/10.1097/01.wnr.0000186598.66243.19

11. Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry research, 191(1), 36–43. https://doi.org/10.1016/j.pscychresns.2010.08.006

12. Emerson, D. (2015). Trauma-sensitive yoga in therapy: Bringing the body into treatment. W W Norton & Co.

13. Van der Kolk, B. A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M., & Spinazzola, J. (2014). Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. The Journal of clinical psychiatry, 75(6), e559–e565. https://doi.org/10.4088/JCP.13m08561