During my deep dive into autism interoception, I was shocked to learn that some people are actually able to feel their own heartbeat! Heart beat detection is a common way that interoception is measured. Apparently, I don’t have the best interoceptive awareness! Before learning about interoception, I would have considered myself to have good bodily awareness. However, I have learned that my interoception awareness is a mix of under-responsive in some areas, over-responsive in other areas, and an overarching inability to differentiate or understand many of my body signals. Once I learned about the connection between interoception and autism, I gained a better understanding of why my body has often felt confusing to occupy.

As an Autistic psychologist working primarily with Autistic individuals, I understand how important interoception is for our daily well-being and our ability to regulate emotions. Interoception is the foundation of emotional regulation and helps us know how to orient to our body (and thus to our environment). That's why it's important to consider interoceptive awareness in any therapeutic work. By understanding interoception, we can make powerful breakthroughs in our ability to self-regulate. In this blog post, we'll explore the connection between autism interoception, how it relates to self-regulation, and how to improve our interoceptive awareness.

If you would like a full deep dive into all things interoception, see my in-depth article on interoception over here.

What is Interoception?

Interoception is the ability to sense what's going on inside your body. It's kind of like your body's internal GPS – it helps you to know how you're feeling physically and emotionally.

Interoception is important because it helps you to tune into your body's signals and respond to them in proactive and compassionate ways. Broadly speaking, interoceptive awareness provides information about two different states: body states and emotion states (see the image for details).

When you have good interoception skills, you're better able to tune into your body's needs and take care of yourself. When you have poor interoception awareness, you might find it harder to recognize and respond to your body's signals, which can lead to problems like stress, anxiety, or difficulty regulating your emotions. So if you want to be in tune with your body and take better care of yourself, it's worth working on your interoception awareness.

Interoception is an important ability for everyone, but it can be particularly challenging for Autistic people. Autistic people often struggle with interoceptive awareness. This can make it harder for us to recognize and respond to our body's signals, which can lead to problems like stress, anxiety, or difficulty regulating our emotions.

Autism and Interoception

When it comes to autism and interoception, it's a complex and paradoxical picture. One study on Autism Interoception found that while Autistic people tend to have less interoceptive accuracy, we have more interoceptive sensibility and sensitivity. This means that

1) We tend to perform less well when interoception awareness is objectively measured (for example, through heartbeat detection tests)

2) And paradoxically, we tend to have an exaggerated interoceptive sensibility (subjective sensitivity to internal sensations)

On self-report measures, Autistic people report higher awareness of bodily sensations while doing more poorly on objective measures. This suggests that, on average, the Autistic person has difficulty objectively detecting bodily signals while simultaneously experiencing an over-inflated perception of bodily sensations (Garfinkel et al., 2016). This means that an Autistic person may experience (subjective) heightened signals while being less accurate in their ability to objectively measure and interpret these signals.

Autism Interoception and The Insula

The insula is the "interoception center of the brain" (Mahler, 2017). The insular cortex plays a vital role in several activities:

• The perception of pain

• The primary emotions from happiness, joy, anger, and disgust

• Awareness of bodily states happens because of the insula (the experience of your heart beating, temperature such as being hot or cold)

• Insula is also existential in nature. It is through the insular cortex that we can perceive being a self

Brain studies have found that people with high interoception awareness tend to have thicker insulas. While poor interoception awareness is linked with less gray matter in the insula and less activity in the insula (Critchley et al., 2004).

Several studies looking at brain scans of Autistic people have found hypo-connectivity (less connectivity) of the insula and less gray matter volume in the insula (Martino et al., 2014 and Radeloff et al., 2014). While most studies found hypo-connection in the insula, emergent research shows more mixed results. While some Autistic people have hypo-connectivity, others have hyper-connectivity in the insula (Xu et al., 2018). Hyper-connectivity of the insula may be associated with a heightened awareness of interoceptive signals (over-responding to interoception signals).

These brain scans point to contradictory findings. This is why it is so important to remember that Autism can present in diverse ways! One Autistic person may have reduced interoceptive awareness, while another Autistic person will experience heightened interoceptive signaling!

Impacts of Autism and Interoception Difficulties

Autistic people struggle with interoception at higher rates than the general population. This can make it harder for us to recognize and respond to our body's signals, which can lead to problems like stress, anxiety, or difficulty regulating our emotions. Several features typically associated with autism itself are actually a byproduct of interoception difficulties. Some of these include:

• Emotional processing difficulties (which is connected to increased anxiety)

• Alexithymia (difficulty with identifying and describing emotions)

• Empathy and perspective taking (it is difficult to understand another person's perspective when we struggle to understand our own embodied experience)

In sum, interoception difficulties affect how Autistic people experience and express our emotions (many of us find it harder to identify and label our emotions, which can make it more challenging to communicate our feelings to others). This can lead to misunderstandings and difficulties in relationships and social situations. And interoception difficulties can also impact our physical health. We may have more difficulty identifying and responding to pain, hunger, thirst, and other physical sensations. This can lead to problems like poor nutrition, dehydration, and untreated physical conditions. Interoception is essential for several key psychological and physical health principles.

The following paragraphs will go into more detail about how these interoception difficulties can impact our emotional and physical health. We’ll review several implications of poor interoception awareness, including:

1) Difficulty with maintaining homeostasis

2) Self-Regulation

3) Emotional Regulation Challenges

4) Health and Wellness

5) A Diffuse Sense of Self and Other

6) Relationship Struggles

Maintaining Homeostasis

To understand the connection between interoception and self-regulation, we first have to understand the concept of homeostasis.

Homeostasis is a big word that means a system likes to stay in a state of equilibrium. Whether a social institution or a small micro-organism, the system seeks to maintain a condition of equilibrium – a stable internal environment.

Homeostasis is maintained through feedback loops. A helpful metaphor is to think about a thermostat. A thermostat regulates room temperature through feedback loops.

A bimetallic strip is at the center of a thermostat and responds to temperature changes. When it detects that the ideal temperature has been reached, the heater will turn off. When it detects the temperature dipping below the set temperature, it turns the heat on to stay within the designated temperature window.

The body works hard to stay in a state of homeostasis. however, unlike a thermostat that requires a single feedback loop, our bodies depend on thousands of feedback loops to keep us alive! Homeostasis helps the body to maintain a stable internal condition (examples include blood pressure, blood glucose, and temperature).

Our bodies need to stay in a state of relative equilibrium to survive. Our bodies work very hard to maintain a balanced equilibrium (homeostasis). For example:

Glucose Homeostasis: After eating a large meal, your pancreas releases insulin blood to keep glucose levels within a very narrow range.

Thermoregulation: This is the process of how we stay within an ideal window of temperature. For example, when overheating, your body will begin to sweat, which cools the skin as it evaporates, lowering the internal temperature.

Staying in a state of homeostasis, or balance is crucial for our survival. Our bodies have automatic processes that help us do this, like sweating when we're hot or releasing insulin after a big meal. But the body also depends on non-automatic processes. For example, our body will send signals such as hunger or thirst to communicate it needs water and food to stay in balance.

Responding to these signals and ensuring our body gets what it needs is where interoceptive awareness comes in. Interoception is the awareness of internal bodily sensations like hunger, thirst, and temperature. By paying attention to these sensations and acting on them, we help our body stay in a state of homeostasis.

So, it's not just automatic processes that keep us balanced; it's also our ability to listen to our body and respond to its needs. So when we struggle with interoceptive awareness, it is harder to provide our body with what it needs and to stay in a state of homeostasis.

So How Does Interoception Relate to Homeostasis?

Interoception signals help a person respond to their body signals which helps them stay in a place of homeostasis. This helps them to act in ways that help their bodies to regulate.

Interoceptive signals mobilize us for action. For example, in the following examples, the interoceptive signal mobilizes the person to act in such a way that their body stays in homeostasis:

• The experience of thirst mobilizes a person to drink, which keeps the person in the ideal hydration/electrolytes balance.

• The experience of hunger mobilizes a person to eat, which helps keep blood sugar levels in equilibrium.

• The experience of being cold will mobilize the person to put on a coat (which will help them stay in the ideal temperature window).

Self-Regulation

Difficulty with maintaining homeostasis ties in directly to the next issue — difficulty with self-regulation.

Without interoception awareness, it's like hiking in the mountains without a map and compass. Without good interoception awareness, we struggle to know what our body needs from moment to moment, making it hard to care for and comfort our bodies in ways that help us self-regulate and self-soothe.

Difficulties in interoception make it difficult to self-regulate our emotions, attention, and behavior. It can cause eating, toileting, and other physical difficulties.

Understanding these bodily signals is the foundation of self-care and self-advocacy. Body signals help us interpret what is happening inside our body, which helps us identify what we need at any given moment.

When we struggle with interoception awareness, the true source of discomfort can’t be pinpointed, which means we can't act in ways to address our unmet needs and regulate our bodies.

The following two diagrams provide examples of how interoception awareness is key for self-care and self-regulation.

In this example, the ability to perceive hunger mobilizes the person to engage in behavior that helps them regulate their body needs. In the next example, the interoception signals help cue the person into their anxiety. From here, they have the agency to act in a way that helps bring the body back to equilibrium.

Emotional-Regulation

A subset of self-regulation is emotional regulation. Emotional regulation is the ability to perceive our emotions and intervene in ways that help our body self-soothe. Any activity we engage in that helps to reduce the intensity of the emotion we are experiencing is a form of emotional regulation.

Emotions become more challenging to down-regulate or de-escalate the hotter they get. For example, when our stress level is at a 5 or 6 (1 to 10 scale), it's much easier to take a walk, do some breathwork, reframe our stress thoughts, and reduce our stress. But when our stress is at a 9 or 10, it is much harder to bring it back down.

Interoception plays a significant role in emotional regulation. If you don't know you are stressed or angry until you are yelling, crying, or punching something, then it isn't easy to control that emotion! It's hard to try and control your anger if you don't know you are angry until you have hit something!

Typically emotion regulation is taught at the skill level (how to decrease an intense emotion); however, these skills won't be as impactful if the person can't perceive when they are starting to get dysregulated. If you haven't responded to typical "emotional regulation" skills, it may be due to underlying interoception issues.

"Emotion regulation involves a coherent relationship with the self, specifically effective communication between body, mind, and feelings." -Price and Hooven, 2018

For people with interoceptive issues, communication with the body must first be addressed before emotional regulation skills will be impactful.

Health and Wellness

Interoceptive awareness is also vital for maintaining health and well-being. When we struggle with interoception, it can have implications for our physical health and wellness.

Achieving optimal health relies on the ability to tune into our bodies and assess what is working well and what isn't. When we cannot do this, it can impact our health in several ways. People with poor interoception often struggle with:

• Hydration: With a lack of thirst awareness, many forget to drink water resulting in dehydration. This can contribute to headaches, digestive issues, and more.

• Temperature regulation: People who have trouble adjusting to or perceiving their body temperature struggle to respond to body cues of coldness or overheating. This increases the risks of frostbite and heat stroke.

• Nutrition: People with weak hunger cues will often miss meals. A person may not realize they are hungry until their blood sugar crashes or until the evening, and they may over-respond through binge eating. This can result in an imbalanced diet and malnutrition.

• Pain and injury awareness: Weakened pain signals that result in reduced pain can lead to a delay in seeking medical treatment for an injury.

  Risks associated with this include chronic illness going undetected, appendix pain (about to burst), broken bones, and cuts that aren't attended to.

Sense of Self Versus Other

Interoceptive awareness also has existential dimensions. It creates awareness of our self as a body and provides us with an integrated sense of self. Interoception provides us with a basic sense of self.

Interoception gives us the sense that "this is me; this is my body; this is how I feel" -Kelly Mahler

The insula (the interoception center of the brain) is active during self-reflection, seeing yourself in the mirror, looking at pictures of yourself, and other forms of self-reflection. People who experience brain damage in this area of their brain may lack awareness of their body or cannot recognize themselves in the mirror. The insula (and thus interoception) play a crucial role in experiencing ourselves as a self (Mahler, 2017).

Relationships

Poor interoceptive awareness also impacts our ability to perceive and understand others. Being able to experience and feel our own emotions helps us better understand other people's emotions and experiences. When we struggle to understand our emotional experiences, it can be more difficult to understand other people's sadness, fear, excitement, and so on.

When our awareness of self (our feelings, thoughts, body, and desires) are solid, it builds a foundation from which we can understand the feelings, intentions, thoughts, and behaviors of others.

Furthermore, research looking at people who have experienced damage to the insula has observed that it is associated with a decreased ability to see the perspective of others and perceive and respond to social norms.

Interoception and Empathy

When we experience difficulty understanding and picking up our emotions and body states, we have less personal experience to draw from to help us understand other people. The tendency to draw on similar neural networks for self and other-empathy is sometimes referred to as the shared brain network of empathy. Interoception, therefore, can lead to having more difficulty empathizing with (and understanding) the emotions of others. This can result in misunderstanding and difficulty accessing empathy for others.

Interoception and Perspective-Taking

When we struggle to understand and differentiate our own emotions, it results in more difficulty in understanding other people's emotions (Cook, Brewer, Shah and Bird ,2013). This can make it more difficult to understand other people's perspectives, leading to more social confusion and misunderstandings.

Interoception and Autism Summary

To summarize, when we experience interoception awareness difficulty, it impacts us on nearly every level. It makes it more difficult to:

1) Stay in a state of homeostasis

2) Self-Regulate

3) Emotionally Regulate

4) Take care of our health and wellness

5) Have a centered experience of self and other

6) Connect interpersonally

How to Improve Interoception

While interoception struggles can certainly lead to difficulty for Autistic people, interoception awareness can be improved with practice and support. Improving interoception skills is a process that involves regular practice and patience. Here are a few ways to improve your interoception skills:

1. Practice interoception awareness activities: These can include things like body scans, deep breathing, progressive muscle relaxation, sensory awareness, and mindful check-ins. By regularly practicing these activities, you can become more attuned to your body's signals and better understand and manage your emotions.

2. Create accommodations and adaptations to support your body needs and that accommodations for your interoception difficulties.

3. Seek out neurodivergence-affirming support: If you're struggling with interoception skills, it can be helpful to seek out support from professionals or others who understand and affirm neurodiversity. They can offer guidance and strategies for improving your interoception skills.

4. Be patient and compassionate with yourself: Improving your interoception skills takes time and practice, and it's important to be patient and kind to yourself as you work on it. Remember that everyone's experience with interoception is unique, and it's okay to take your time and go at your own pace.

The following sections will take a closer look at how to specifically 1) Support interoception differences and 2) Improve interoception awareness.

Interoceptive Awareness Accommodations and Adaptations

One way of supporting poor interoception awareness is by building adaptations and accommodations into the environment. This works well for body-based needs such as hydration and nutrition.

• Timers (set timers for reminders to eat, drink, hydrate or use the bathroom).

• Timers that go off to remind the person to take a sensory break when they are in an intense sensory place for a prolonged period (helpful for managing sensory overload and overwhelming emotions).

Interoception Awareness Activities

Interoception awareness activities are exercises that help you to improve your interoception awareness. Interoception awareness activities include body scans, mindful sensory awareness, and mindful check-ins.

A growing body of research shows that people can build better interoceptive awareness. Mahler et al., 2022 found that Autistic children who practiced identifying body signals and linking them to their emotions were better able to regulate their emotions afterward. While it takes intentionality and work, interceptive awareness and accuracy can be improved with practice and repetition.

These activities can help you to tune into your body's signals and become more attuned to your physical and emotional experiences. By regularly practicing interoception awareness activities, you can strengthen your interoceptive awareness and improve your ability to understand and manage your emotions, and better take care of your physical and emotional health. It's important to be patient and compassionate with yourself as you improve your interoception skills, as it may take some time to become more attuned to your body's signals.

Next, I will walk you through several different practices and exercises that can be used to improve interoceptive awareness. There are several practices provided, and I recommend you just try one at a time. Once you have mastered that, feel free to try another one.

Mindful Check-ins

Mindful check-ins are a simple and effective way to improve your interoception skills. Mindful check-ins can be brief (a 10-second check-in) or can be a longer exercise. Mindful check-ins are characterized by checking in without judgment or evaluation to identify, label, and notice any of the sensations you experience.

Mindful check-ins involve taking a few moments throughout the day to focus on your physical and emotional experiences and to tune into any signals your body is sending.

Here's how to do a mindful check-in:

For this exercise, you will apply an outside sensation and do two interoception changes, bringing attention to any shifts in sensations you notice.

• Hold a hot or cold drink in your hand. Hold the drink in your palm and focus on how the skin in your hand is perceiving it (you may notice the sensation in your palm or further up the arm).

• Now release the cup and notice the difference in sensation. Mindfully turn your attention to that part of the body and observe how it feels different now that you've let go of the mug/cup.

• Now repeat. Grab a hot/cold drink and repeat the first step and then repeat the second step.

You can do a similar interoceptive mindfulness exercise by creating physical sensations with your body.

1) You can create sensations with your body by doing stretches, wall squats, cardio, or weight lifting.

2) Notice any changes to temperature, breathing, or other sensations.

3) Now stop the movement/stretch and observe how it feels different now that you've stopped the exercise/movement.

4) Now repeat the movement/stretch and notice the changes to sensations.

Body Scans

Body scans are another effective way of improving your interoceptive awareness. Body scans involve an intentional way of checking in with your body and observing different sensations and feelings. You can do a whole body scan or start with one or two parts and build up to a full body scan.

1) Find a comfortable and quiet place to lie down or sit.

2) Take a few slow breaths and mindfully bring your attention to your feet. focus on each part of your body in turn, moving slowly down to your toes. Notice (without judgment or evaluation) any sensations you experience in your feet.

3) Focus on each part of your body in turn, moving slowly up to your head.

4) As you focus on each part of your body, take a deep breath and try to tune into any physical sensations you're experiencing. You might notice things like tension, relaxation, warmth, or coolness.

5) If you find your mind wandering, gently bring your attention back to the sensations of your body.

6) When you reach your head, take a few more deep breaths and then slowly open your eyes.

7) When doing a body scan, it is important to use specific words (over global) and to use descriptive words rather than evaluative words (see below)

Descriptive Words Examples: Squishy, tense, hot, buzzy, relaxed, sharp, heavy

Evaluative Words Examples: Bad, good, hurt

Try to avoid global words like "anxious" and "pain" as you want to focus on describing the sensations. For example, instead of "anxious," you may say "tight," "heavy," and "springy." Instead of "pain," break it down with words like "sharp," "ache," etc.

By regularly practicing body scans, you can improve your ability to tune into your body’s signals. It's important to be patient and gentle with yourself as you work on improving your interoception skills, as it may take some time to become more attuned to your body's signals.

Interoception On-the-Go

If you want to improve your interoception skills but don't have a lot of time, there are plenty of on-the-go exercises you can try. Interoception on the go is where you do a quick check-in throughout the day, and this helps to build awareness muscles.

Interoception on the go involves quick check-ins throughout the day that help to improve awareness of body sensations. It involves two steps: first, master steps one before moving on to step two.

Step One: Take a few moments once or twice daily to do a quick interoception check-in. You can do this through either:

1) Set 2 timers to go off throughout the day as your "interoception check-in moments."

2) You can pick an activity that you do multiple times. If you pick an activity, try to use an activity that creates sensations. The following activities provide some opportunities that can provide good brief interoception check-ins:

• When washing hands

• When washing dishes

• When showering

• After eating

During this brief check-in, simply notice the sensation you are experiencing while engaged in this activity.

Step Two — Interoception Connectors: After you become more proficient, start working toward connecting these sensations to specific body and emotional states. Over time you'll begin to map out which sensations map onto hunger, irritability, contentment, and so on.

How Low Can You Go?

The "How low can you go" exercise helps to increase body awareness and also helps teach down-regulation skills (down-regulation means helping to quiet the nervous system). (Credit: This exercise comes from Kelly Mahler’s book the 8th Sensory system).

This exercise can be broken up into several mini-exercises that get more advanced as you progress.

These exercises provide a way of using informal biofeedback without fancy equipment. These practices with help you to 1) increase your awareness of heartbeat and 2) practice strategies to help you down-regulate your nervous system (decrease your nervous system activity).

For this game, you can use any device that captures your heart rate (a smartwatch, Fitbit, or finger oxidizer) to measure your heartbeat with your finger and a watch.

Exercise

1) Do an activity for 30-50 seconds that increases your heart rate (jumping jacks, push-ups, running in place).

First, draw attention to your heartbeat and try to estimate the rate of your heart rate. Now measure it and see how close you were. Track this over time so you can track your interoception awareness improvement.

Second step: After you've practiced step one several times, it's time to add step two. Here you do engage in any form of movement or exercise (30 seconds of movement to get your heart beat up). Take your heart rate measurement with a finger oxidizer or smartphone, and then try to see how low you can get your heart in 60 seconds.

The goal is to decrease your heart rate as much as you can in 60 seconds (this is where the name "how low can you go" comes from).

Experiment with different things (slowing down your breathing, focusing on something calming, etc.). Track how much you can lower your heart rate in one minute. Again, keep recording this so you can watch yourself improve over time.

For Autistic people, strategies that are designed to down-regulate our nervous systems don't always work as well for us. It may take a bit of experimenting to figure out what will work for your body which is one of the reasons this exercise can be so effective for us.

Why Practice Lowering Your Heart Rate?

When you play this game, you are teaching your body how to down-regulate (which is a valuable tool during stress and sensory overload).

For neurodivergent people, strategies that are designed to down-regulate our nervous systems don't always work as well for us. It may take a bit of experimenting to figure out what will work for your body.

As a bonus, in addition to building interoception awareness, this exercise helps build awareness of how to down-regulate your nervous system.

Many neurodivergent people find it more motivating when they can turn something into a competition. You can either compete against yourself (your past self) or find a family member or friend to compete with when doing this exercise.

Summary of Interoception Awareness Exercises

We reviewed several exercises to help build interoception awareness (Interoception MIndfulness, Body Scans, Mindfulness on the Go, and How Low can you Go). It can be overwhelming when we're introduced to several practices at once; remember, just pick one. I recommend picking the one that feels the most accessible to you and starting there.

Keep in mind interoception awareness builders don't have to be fancy! If you follow these two simple steps 1) Create a sensation (or catch a sensation!) and 2) Pay attention, then you will be on your way toward building more interoceptive awareness.

Summary: Autism and Interoception

Interoception is the ability to sense what's going on inside your body. It helps us to know how you're feeling physically and emotionally. Interoception is important because it helps you to tune into your body's signals and respond to them in proactive and compassionate ways. Autistic people struggle with interoception awareness at higher rates which can make it difficult for us to self-regulate. When we struggle with interoception, we may experience more difficulty regulating our physical or bodily needs as well as our emotions.

Interoception awareness can be accommodated by building in supports, and it can be improved. Interoception skills can be improved with practice and support. By being patient and compassionate with ourselves while incorporating interoceptive awareness builders, we can work on improving our interoception skills and better understanding and managing our emotions.

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