3/26 Interoception in Neurodivergent Patients: Part 1

Last year, DNA introduced interoception: our ability to sense and interpret signals coming from inside the body. But after a semester spent discussing sleep, chronic illness, fatigue, and neuroimmune health, we want to come back to it with fresh context. What happens when the body is speaking but the brain interprets the signal differently?

Interoception shapes far more than hunger and thirst. It's involved in emotion, fatigue, stress, attention, pain, temperature, and knowing when you need rest before you hit a wall. This week we're revisiting it through a biological lens and asking whether differences in internal body sensing help explain things a lot of neurodivergent students experience but struggle to put words to.

Our discussion questions:

• Can you trust your sense of how well you know your body? Garfinkel et al. found that autistic participants had lower interoceptive accuracy but higher interoceptive sensibility than controls. That means they objectively detected body signals less accurately while simultaneously believing they were more attuned to them. The gap between those two measures predicted both anxiety levels and emotion deficits. So the question isn't just "do you notice your body" but whether your confidence in that noticing is calibrated to reality. (Garfinkel et al., 2016)

• What does the brain actually do with a body signal once it arrives? Quadt et al. describe interoception through a predictive processing framework: the brain doesn't passively receive signals, it generates predictions about what the body should be feeling and updates them when something doesn't match. Interoceptive disorders, on this model, aren't about broken sensors but about miscalibrated predictions. This reframes a lot of neurodivergent experience as a prediction problem rather than a sensitivity problem. (Quadt et al., 2018)

• Why do interoceptive differences show up differently across conditions? Quadt et al. map how the same interoceptive system breaks down differently in depression, eating disorders, fatigue, autism, and anxiety. Each condition involves a different level of the process going wrong. We'll ask what that specificity means for neurodivergent people who often carry multiple diagnoses and whether treating them as separate issues misses something about the underlying system. (Quadt et al., 2018)

• Is interoception a sensory issue or a self-regulation issue? Mahler frames interoception as the foundational sensory system underlying self-regulation, social understanding, and emotional awareness, not just a body signal detector. She argues that for autistic people, difficulties with hunger, pain, temperature, and emotion regulation may all trace back to the same root. That's a different claim than the neuroscience papers make and we'll ask where they agree and where they don't. (Mahler, 2016)

• Does alexithymia explain interoceptive differences, or is it the other way around? A critique of Mahler's book raised by peer reviewers at the time was that the interoceptive differences she describes in autism might actually be driven by co-occurring alexithymia rather than autism itself. Garfinkel et al.'s three-dimensional model complicates this further: if accuracy and sensibility can dissociate, what does that mean for how we understand alexithymia's role? This is a live debate in the field. (Garfinkel et al., 2016; Mahler, 2016)

• If you could design an intervention, what would it target? Quadt et al. close by pointing to interoceptive predictive processing as a potential treatment target, suggesting that recalibrating the brain's body predictions could have downstream effects on fatigue, anxiety, and emotion regulation. Mahler offers practical strategies from an OT perspective. We'll close by asking what a real intervention would need to look like to actually shift interoceptive processing and what outcome you'd even measure.

Papers we're reading

• Garfinkel, S. N., Tiley, C., O'Keeffe, S., Harrison, N. A., Seth, A. K., & Critchley, H. D. (2016). Discrepancies between dimensions of interoception in autism: Implications for emotion and anxiety. Biological Psychology, 114, 117–126.

• Quadt, L., Critchley, H. D., & Garfinkel, S. N. (2018). The neurobiology of interoception in health and disease. Annals of the New York Academy of Sciences, 1428(1), 112–128.

• Mahler, K. (2016). Interoception: The eighth sensory system.