I didn’t learn what interoception is until after I completed my doctoral training in clinical psychology. Once I learned what interoception is and its important role in emotional regulation, I was shocked that this was not a basic concept in my psychological training. Interoceptive awareness is the building block of emotional regulation, so how this is not incorporated into basic psychological training is beyond me!

To put it simply: a person can not consistently self-regulate when their interoception system is dysregulated. As a Psychologist, I learned so many “emotional regulation strategies” that often seem misattuned to my neurodivergent clients. It wasn’t until I learned what interoception is that I began to connect the dots. Many of the emotional regulation strategies that I had learned do not effectively work when there are underlying interoception issues. For this reason, it’s important to consider interoceptive awareness as part of any therapeutic work. I find the “interoception lens” can lead to some powerful breakthroughs, so let’s dive into what interoception awareness is and how to work with it. This article provides a lot of content; feel free to save and come back to it later or purchase the workbook, which breaks this content down into visual information. In today’s article, we’ll cover:

• What is interoception?

• The 8 sensory systems

• Interoception Defined

• The brain anatomy of interoception

• Neurodivergence and Interoception

• Three distinct interoceptive profiles

• How to Increase interoception awareness

What is Interoception?

Interoception is how we “feel” our internal experiences. It is one of the eight primary sensory systems, more specifically, one of the three “hidden” sensory systems. Before diving into interoception, let’s do a refresher on the 8 sensory systems.

The 8 Sensory Systems

Our experiences of our bodies and environment are intimately shaped by our sensory systems. How our minds and bodies integrate sensory information plays a big role in everyday tasks. It influences our ability to self-regulate, interact with others, and accomplish basic tasks in living.

For a long time, it was believed we have five primary sensory systems (touch, smell, taste, visual, and sound). Over the past several years, there has been increasing awareness of the three "hidden" sensory systems. These three hidden sensory systems include the vestibular, proprioception, and interoception systems. A person can be hypo or hypersensitive in any of these systems. Complicating matters, a person may be hypersensitive in one area and hyposensitive in another. To read about the signs of hypo and hyper sensitivities in these 8 systems, see this article posted here.

Tactile

Tactile receptors exist all over our skin and send signals to our brains letting us know when we’ve touched something and providing us with information about what we’ve touched. Our tactile receptors are responsible for our experience of touch, pressure, pain, vibration temperature, and texture. A person may be under-responsive (hypo-sensitive and sensory seeking) or over-responsive (hypersensitive and sensory avoidant).

Auditory

Auditory receptors located in the inner ear identify loud, soft, high, near, and far noises. These experiences help us to process the volume, tone, pitch, and rhythm of sound.

Visual

Visual stimuli are picked up by visual receptors in the eye and provide information about color contrast, shape, form, and movement. Our visual processing system helps us to determine what to pay attention to and directs actions and movements in the world.

Gustatory

Taste is picked up by gustatory receptors in our tongue and linked to our olfactory senses (smell). Experiences related to our gustatory system include our ability to taste sweet, sour, bitter, salty, and spicy flavors. A person with gustatory sensory processing differences may be an under-responder (sensory seeker) or an over-responder (sensory avoider).

Olfactory

Smell is processed through ‘Olfactory’ receptors located in the nose. Olfactory senses can distinguish between a range of smells. Strong memories can also be associated with smell. People with processing differences may be under-responsive or over-responsive to smell.

Vestibular

‘Vestibular’ receptors are located in our inner ear and process balance and movement. This system helps us to distinguish between speed and direction of movement. Posture depends on the signals from the vestibular system.

Proprioception

Proprioception receptors are located in muscles and joints of the body and provide information about where your body is in space. Our sense of body awareness and coordination is impacted by proprioceptive input. The system helps to create smooth movement. Responsible for applying the "right" amount of pressure. You can read more about how to support proprioception differences in children here.

Interoception

Receptors on our internal organs are responsible for interoception signals that provide information on our internal body and emotional states. Experiences: urge to urinate, hunger, temperature, pain, sadness, joy, anxiety.

What is Interoception?

The interoceptive system provides us with awareness of internal body states. The interoceptive system receives information from sensory neurons in our internal organs and communicates information about body states and emotions. It provides us with information such as:

• The urge to urinate or eliminate

• Fullness, Hunger, Cramps

• Thirst

• Pain

• Tension

• Emotions

• Heartbeat

Interoception awareness speaks to our ability to accurately perceive and identify our internal body states. Broadly speaking, interoceptive awareness provides us with information about our body states and our emotional states.

When a person has interoception awareness difficulties they may confuse these signals, over-feel these signals or simply have difficulty differentiating between body signals and emotion signals (for example, struggling to discern if it is it hunger or anxiety?).

How is Interoception Measured?

The most widely used way of measuring interoception is by heart-beat detection tests. People with good interoception awareness can detect their heartbeat with high accuracy. In contrast, people with poor interoception awareness struggle to detect their heartbeat accurately (Ponzo et al., 2021).

The Insular Cortex

The insular cortex plays a key role in how the body registers interoceptive awareness. 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).

Decreased functioning in the insula is associated with several psychological conditions and forms of neurodivergence, including:

• Autism

• ADHD

• OCD

• Schizophrenia

• Depression

• Anxiety

• Substance abuse

• Bipolar

• PTSD

• Eating Disorder

The Impact of Interoception Difficulties

Interoception is essential for several key psychological and physical health principles. Several implications of poor interoception awareness include:

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 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.

A system depends on feedback loops to be able to make adjustments and stay within the window of stability.

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 turns off. When it detects the temperature dipping below the set temperature, it turns the heat on to stay within the designated temperature window.

However, the thermostat process only requires one feedback loop, while our bodies depend on thousands of feedback loops to keep us alive. 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.

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. For example:

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

• 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.

Without accurate interoceptive signals we struggle to keep our bodies in a state of homeostasis. And this is directly connected to the next issue: self-regulation.

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 in 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. Interoception awareness is key for self-care and self-regulation.

Interoception provides information that helps us act in ways that create stability. When the body is in disequilibrium it communicates this through an interoception signal (hunger, cold, thirst), which activates the person to address the body's need so that it can return to equilibrium (homeostasis). So when our bodies miss this signal, it becomes more difficult to engage in activities that help us to self-regulate. This applies to both bodily needs (cold, thirst, hunger) and emotions. This connects directly to the next area of concern: emotional regulation.

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!

Imagine trying to control an emotion if you don't know you're feeling it until you're in the red zone!

If you haven't responded to typical "emotional regulation" skills, it may be due to underlying interoception issues.

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

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

Sense of Self and 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 gives us the sense that "this is me; this is my body; this is how I feel" -Kelly Mahler

Interoception provides us with a basic sense of self. 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).

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 make it 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.

Relationships

Poor interoception awareness can make relationships more difficult, particularly due to increased difficulty with accessing empathy and perspective-taking.

• 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. This often translates to having more difficulty empathizing with (and understanding) the emotions of others. This can result in misunderstanding and difficulty accessing empathy for others.

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.

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, and 3) Emotional Regulation. Additionally, it negatively affects our health and wellness, impacts our sense of self, and can contribute to relationship difficulties.

Interoception and Neurodivergence

Interoception issues are common among ADHD and Autistic people. Until recently, the connection between interoception, autism, and ADHD has been poorly understood. Many of the struggles of Autistic and ADHD people are related to interoception issues; however, we have lacked the appropriate lens for understanding this until recently.

Both Autistic and ADHD people commonly experience interoception difficulties. There is a range of interoception difficulties — from too many signals to too few signals to difficulty differentiating the signals. Research on the insula has shown mixed results, with some studies showing hypo-connectivity of the insula and others showing hyper-connectivity.

Autism and Interoception

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).

When it comes to autism and interoception, it's a complex and paradoxical picture. One study found that while Autistic people tend to have less interoceptive accuracy, we have more interoceptive sensitivity. This means that 1) We tend to perform less well when interoception awareness is objectively measured (for example, through heartbeat detection tests). And on the other hand, 2) tend to have an exaggerated interoceptive sensibility (subjective sensitivity to internal sensations). On questionnaires where Autistic people provide a self-report of their experiences, they report higher awareness of bodily sensations.

This suggests that on average Autistic person has difficulty objectively detecting bodily signals while simultaneously experiencing an over-inflated perception of bodily sensations (Garfinkel et al., 2016).

ADHD and Interoception

Several features specific to ADHD were connected to insular activity (therefore interoception).

• Oppositional behaviors were associated with the reduced gray matter of the left insula cortex.

• Reduction in gray matter in the right insula cortex was associated with both attention problems and inhibition.

• "Time blindness," a common feature of ADHD, is associated with interoception difficulties (Craig, 2009 and Vicario 2020).

Interoception Profiles

There are several ways a person's interoception awareness may be dysregulated. People who experience difficulty with interoception awareness fall into one of three main categories: interoceptive over-responsivity, interoceptive under-responsivity, and interoception differentiation difficulty (Maher, 2017).

The one most widely talked about within Autistic spaces is interoception under-responsivity (and so far, this workbook has primarily focused on under-responsivity). However, an Autistic or ADHD person can also have over-responsive interoception awareness (they pick up too many signals and feel things intensely!). Or a person may struggle with differentiating the signals. There are three common interoceptive profiles. It's important to note you may resonate with elements of more than one.

Interoceptive Under-Responsivity

With interoception under-responsivity the person has a muted experience of their internal signals. They struggle to discern thirst, hunger, and pain signals. They often experience alexithymia and difficulty registering emotion. Signs of under-responsivity include:

• May be seriously sick but delay seeking medical care

• Difficulties remembering to eat and drink

• Alexithymia-difficulties knowing what they are feeling and communicating about there feelings

Interoceptive Over-Responsivity

With interoception over-responsivity the person feels too much of their internal signals. They "over-feel" their internal sensations. Signs of over-responsivity include:

• Visits the nurse's office several times a week with aches, pains, and illness

• Requests frequent bathroom breaks

• Limps on an injured knee or ankle for longer than expected

Interoceptive Discrimination Difficulties

With interoceptive discrimination difficulty, the person has a vague feeling but has difficulty identifying specifically what the sensation means. Signs of discrimination difficulty include:

• Says they are hungry but then only eats a small amount

• Has big emotions but is confused by them

• Unsure if they need to use the bathroom

Increasing Interoception

There are two main ways of supporting interoception difficulties

1) Provide adaptations or environment supports

2) Increase interoception awareness through practices known as "interoception awareness builders"

Ideally, adaptations are used to support a person's wellness while also including interoception builders to help increase interoception awareness.

Interoception 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 Activities

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.

The following section provides several different practices and exercises that can be used to improve interoceptive awareness and accuracy. There are several practices provided, and I recommend you just try one at a time. Once you have mastered one feel free to try another one.

Following are several activities to help increase your body awareness. You may not resonate with all these; choose and practice the activities that most resonate.

Mindful Check-ins

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.

You can connect body sensations to emotional states as you get better.

Example of a Mindful Interoceptive 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.

1) Hold a hot or cold drink in your hand.

2) Focus on how the skin in your hands is perceiving it (you may notice the sensation in your palm or further up the arm).

3) Release the cup and notice the difference in sensation.

4) 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.

5) Now repeat.

Body Scans

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.

It's called a body scan because you will "scan" your body from your feet to head, much like a copying machine "scans" the original before printing. Visualizing a scanning light moving from feet to head is helpful for some people.

1) Start by getting into a comfortable position

2) Take a few slow breaths and mindfully bring your attention to your feet. Notice (without judgment or evaluation) any sensations you experience in your feet.

3) Move to your lower legs and continue upward until you've reached your head.

4) 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.

Interoception on the Go

Interoception on the go involves quick check-ins throughout the day that help to improve awareness of body sensations. It involves two steps:

Step One: Take a few moments once or twice a day 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. Some activities that can provide good interoception check-ins.

**The following activities provide some opportunities that can provide good interoception check-ins:

• When washing hands

• When washing dishes

• When showering

• After eating

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, introduced by Kelly Mahler, is fun, playful way to increase body awareness. This exercise provides a way of using biofeedback without fancy equipment. This activity 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 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).

2) draw attention to your heartbeat and try to estimate the rate of your heart rate.

3) Now measure it and see how close you were.

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

Credit: Exercise adapted from Interoception: The Eighth Sensory System (Kelly Mahler)

Summary

We covered a lot of information here: from an introduction to interoception, the impact of interoception, neurodivergence and interoception, different interoception profiles, and how to work with interoceptive difficulties. If you would like more of a deep-dive, or fillable worksheets to go along with these exercises then check out my fillable workbook on interoception (PDF) available here.

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