Interoception, Part 2

How to improve an often-overlooked mechanism that helps us calm and self-regulate

Sensory Processing

Part 2 of a 2-part series.

In last month’s issue, I discussed a little-known but important eighth sensory system termed interoception, which gives us information regarding the internal condition of our bodies.

Interoception enables us to feel states such as hunger, fullness, itch, pain, coldness, hotness, nausea, need for the bathroom, sleepiness, tickle, physical exertion and sexual arousal. Additionally, it allows us to feel our emotions. Interoception allows us to answer the question, “How do I feel?”^1-2

Individuals that have effective interoceptive systems can be described as having good interoceptive awareness (IA). IA is our ability to both notice internal sensations and give meaning to them.³

Strategies to Build IA

Can IA be improved? The good news is that it can be. Learning to attend to body signals in a specific way is a key feature of improving interoceptive awareness.⁴

A collection of new strategies called IA Builders are grounded in this philosophy. Many IA Builders employ techniques derived from mindfulness and other
forms of meditation, which are an evidence-based intervention to enhance IA.^5-8 Mindfulness involves “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.”⁹ As such, it promotes attention to internal body sensations such as breath, muscle tension and heartbeat.

There is a brain-based explanation for why mindfulness and similar strategies can improve IA. Studies reveal that the insula, the interoceptive center in the brain, is strongly activated during meditation.^10-11 Those who participate in regular meditation have superior insula function, both structurally (a thicker insula) and in activity levels.^10-14

Given the research as well as clinical reports, building IA can have a significant impact on occupational performance. However, it’s often not enough to use traditional meditation methods as they may not match the client’s learning style. Simply asking a client to call attention to internal signals is often too abstract.

Additionally, IA is twofold. It requires the ability to both notice the sensation and give it meaning. Therefore, with certain clients, strategies need to target both aspects.

The Body Check Chart

A body check chart (BCC) can be used for a wide range of ages, from preschool through adulthood. The BCC calls attention to internal sensations in a structured, visual format.

1. Start by directing the client’s attention to one body part (e.g., the hands or heart). Encourage the client to focus on that body part and think about how the area feels.

2. Direct the client to select the body part icon with the descriptor that matches the sensation (e.g., sweaty hands, fidgety hands, dry hands, clenched hands, loose hands). If the client feels something different than the descriptors provided, he may use the blank icon of the body part.

3. Guide the client to place the selected body icon at the appropriate space on the body outline (such as the hand region).

4. Continue the body check by moving through each remaining body part following steps 1-3. When first introducing the BCC, focus on a small number of body areas. Even one body part is OK. For younger or more basic learners, start with body parts that one can visually observe, such as the hands and fingers, or feet and toes. Gradually add areas that one cannot visually observe, such as the heart or stomach.

5. Repeated practice is mandatory for success. The BCC should be used many times throughout the day. When starting, it’s best to use it only during periods of calm or in positive situations. If a client is having difficulty noticing subtle sensations, body checks can be completed during times of more intense sensations but with positive emotions involved. For example, running at recess, stepping outside in hot or cold weather, during “tickle time” with a parent, during a warm bath or shower, before bedtime, while playing an active game or when carrying a heavy backpack.

6. First notice the sensations, then give sensations meaning. As the client grows proficient, give sensations meaning in a systematic format. Add a list of body states and emotions on the back of the BCC. After the client labels body signals, assist them in identifying matching body states. Start with a small list of choices and expand with the client’s growing ability. To further enhance their ability, establish body-emotion categories.

Building IA in Younger Learners

To increase IA in younger and more naïve learners, follow these strategies.

1. For a more concrete version of a BCC, trace the client’s body on a large piece of butcher or art paper. Emphasize that “this is your body.” Label the outline with the client’s name and include a picture if needed.

2. If the BCC is too abstract, use it to slowly build a foundation. For example, use the BCC to build awareness of body parts by playing the “point-and-wiggle” game, in which an adult points to an area on the BCC and the client wiggles the corresponding body part. Have the client name the body part if possible.

“Simon Says” is another fun way to build a foundation with the BCC. The adult can give directions while pointing at areas on the BCC. For example, “Simon says point to your stomach,” “Simon says squeeze your hand really tight,” “Simon says breathe three times really fast,” “Simon says do something that makes your heart beat really fast,” etc.

3. An adult can use the BCC to label observations of body areas. This should be performed in a kind and non-judgmental manner. The adult can say, “I see your feet pacing” and place the “pacing feet” icon on the client’s BCC. Or “I see your hands wiggling” and place the “wiggling hands” icon on the BCC. Or “I hear your voice getting loud” and move the “loud voice” icon on the BCC. As the client grows in skill, he can participate with assistance.

4. Focus areas can evoke sensations in a specific body area via structured and fun experiments.3 For example, experiments to evoke mouth-related sensations can include eating a strong mint, tasting a lemon, sipping a carbonated drink, three quick mouth breaths, brushing gums, teeth and tongue with a toothbrush, or eating an ice cube. After each experiment the client should describe how the mouth feels.

Ready for the Limelight

Could interoception be a missing link for many of our clients? The evidence suggests so. Difficulty with interoception underlies many challenges we see as occupational therapists.

Chloe, a 23-year-old with ASD, shared that “It has helped me to learn about interoception. It has given me a name for it and allowed me to think and realize that it was something I struggled with. After learning about interoception, I was encouraged and motivated to find an occupational therapist to work on ‘feeling’ my body better. Now that I am more aware of my body signals, I have far better control over my emotions.”

Interoception is ready for the limelight. Occupational therapists are the perfect advocates for spreading awareness of this important sensory system.

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References

1. Craig, A. D. (2002). How do you feel? Interoception: the sense of the physiological
   condition of the body. Nature Reviews Neuroscience, 3(8), 655-666.
2. Craig, A. D. (2003). Interoception: The sense of the physiological condition of the body. Current Opinion in Neurobiology, 13(4), 500-505.
3. Mahler, K. (2016). Interoception: The Eighth Sensory System: Practical Solutions for Improving Self-Regulation, Self-Awareness and Social Understanding of Individuals With Autism Spectrum and Related Disorders. Shawnee Mission, KS: AAPC Publishing
4. Mehling, W. E., Price, C., Daubenmier, J. J., Acree, M., Bartmess, E., & Stewart, A. (2012). The multidimensional assessment of interoceptive awareness (MAIA). PLoS One, 7(11), e48230. doi:10.1371/journal. pone.0048230
5. Daubenmier, J., Sze, J., Kerr, C. E., Kemeny, M. E., & Mehling, W. (2013). Follow your breath: Respiratory interoceptive accuracy in experienced meditators. Psychophysiology, 50(8), 777-789.
6. Farb, N. A., Anderson, A. K., Mayberg, H., Bean, J., McKeon, D., & Segal,
   Z. V. (2010). Minding one’s emotions: Mindfulness training alters the neural expression of sadness. Emotion, 10(1), 25.
7. Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-basedstressreductionandhealthbenefits: Ameta-analysis. Journal of Psychosomatic Research, 57(1), 35-43.
8. Khalsa, S. S., Rudrauf, D., Damasio, A. R., Davidson, R. J., Lutz, A., & Tranel, D. (2008). Interoceptive awareness in experienced meditators. Psychophysiology, 45(4), 671-677.
9. Kabat-Zinn, J. (1994). Wherever you go, there you are. New York, NY: Hyperion.
10. Farb, N. A., Segal, Z. V., Mayberg, H., Bean, J., McKeon, D., Fatima, Z., & Anderson, A. K. (2007). Attending to the present: mindfulness meditation reveals distinct neural modes of self-reference. Social cognitive and affective neuroscience, 2(4), 313-322.
11. Lutz, A., Slagter, H. A., Dunne, J. D., & Davidson, R. J. (2008). Attention reg- ulation and monitoring in meditation. Trends in Cognitive Sciences, 12(4), 163-169. doi:10.1016/j.tics.2008.01.005
12. Hölzel, B. K., Ott, U., Gard, T., Hempel, H., Weygandt, M., Morgen, K., & Vaitl, D. (2008). Investigation of mindfulness meditation practitioners with voxel-based morphometry. Social Cognitive and Affective Neurosci- ence, 3(1), 55-61.
13. 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: Neuroimaging, 191(1), 36-43.
14. Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J. R., Greve, D. N., Tread- way, M. T., . Fischl, B. (2005). Meditation experience is associated with increased cortical thickness. Neuroreport, 16(17), 1893-1897.