HHS Public Access: Interoception and Mental Health: A Roadmap

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Biol Psychiatry Cogn Neurosci Neuroimaging. Author manuscript; available in PMC 2018
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July 20.
Published in final edited form as:
Biol Psychiatry Cogn Neurosci Neuroimaging. 2018 June ; 3(6): 501–513. doi:10.1016/j.bpsc.
2017.12.004.
Interoception and Mental Health: A Roadmap
Sahib S. Khalsa, Ralph Adolphs, Oliver G. Cameron, Hugo D. Critchley, Paul W. Davenport,
Justin S. Feinstein, Jamie D. Feusner, Sarah N. Garfinkel, Richard D. Lane, Wolf E. Mehling,
Alicia E. Meuret, Charles B. Nemeroff, Stephen Oppenheimer, Frederike H. Petzschner,
Olga Pollatos, Jamie L. Rhudy, Lawrence P. Schramm, W. Kyle Simmons, Murray B. Stein,
Klaas E. Stephan, Omer Van den Bergh, Ilse Van Diest, Andreas von Leupoldt, Martin P.
Paulus, and the Interoception Summit 2016 participants
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Laureate Institute for Brain Research (SSK, JSF, WKS, MPP) and Oxley College of Health
Sciences (SSK, JSF, WKS) and Department of Psychology (JLR), University of Tulsa, Tulsa,
Oklahoma; California Institute of Technology (RA), Pasadena, Department of Psychiatry and
Biobehavioral Sciences (JDF), Semel Institute for Neuroscience and Human Behavior, University
of California, Los Angeles, Los Angeles, Department of Family and Community Medicine (WEM),
University of California, San Francisco, San Francisco, and Department of Psychiatry (MBS),
University of California, San Diego, San Diego, California; Department of Psychiatry (OGC),
University of Michigan, Ann Arbor, Michigan; Department of Physiology (PWD), University of
Florida, Gainesville, and Department of Psychiatry and Behavioral Sciences (CBN), University of
Miami, Miami, Florida; Department of Psychiatry (RDL), University of Arizona, Tucson, Arizona;
Department of Psychology (AEM), Southern Methodist University, Dallas, Texas; Department of
Neurology (SO), Department of Biomedical Engineering (LPS), and Department of Neuroscience
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(LPS), Johns Hopkins University, Baltimore, Maryland; Sackler Centre for Consciousness Science
(HDC, SNG), University of Sussex, Brighton, United Kingdom; Translational Neuromodeling Unit
(FHP, KES), Institute for Biomedical Engineering, University of Zurich, Zurich, Switzerland;
Department of Clinical and Health Psychology (OP), Institute of Psychology and Education, Ulm
University, Ulm, Germany; Department of Health Psychology (OVdB, IVD, AvL), University of
Leuven, Leuven, Belgium
Abstract
Interoception refers to the process by which the nervous system senses, interprets, and integrates
signals originating from within the body, providing a moment-by-moment mapping of the body’s
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This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Address correspondence to: Sahib S. Khalsa, M.D., Ph.D., Laureate Institute for Brain Research, Oxley College of Health Sciences,
University of Tulsa, 6655 S. Yale Ave., Tulsa, OK 74136; skhalsa@laureateinstitute.org.
For the Interoception Summit 2016 participants, see below and Supplement.
Interoception Summit 2016 participant coauthors: Vivien Ainley, Obada Al Zoubi, Robin Aupperle, Jason Avery, Leslie Baxter,
Christoph Benke, Laura Berner, Jerzy Bodurka, Eric Breese, Tiffany Brown, Kaiping Burrows, Yoon-Hee Cha, Ashley Clausen, Kelly
Cosgrove, Danielle Deville, Laramie Duncan, Patrice Duquette, Hamed Ekhtiari, Thomas Fine, Bart Ford, Indira Garcia Cordero,
Diamond Gleghorn, Yvette Guereca, Neil A. Harrison, Mahlega Hassanpour, Tanja Hechler, Aaron Heller, Natalie Hellman, Beate
Herbert, Behnaz Jarrahi, Kara Kerr, Namik Kirlic, Megan Klabunde, Thomas Kraynak, Michael Kriegsman, Juliet Kroll, Rayus
Kuplicki, Rachel Lapidus, Trang Le, Kyle Logie Hagen, Ahmad Mayeli, Amanda Morris, Nasir Naqvi, Kristina Oldroyd, Christiane
Pané-Farré, Raquel Phillips, Tasha Poppa, Willliam Potter, Maria Puhl, Adam Safron, Margaret Sala, Jonathan Savitz, Heather Saxon,
Will Schoenhals, Colin Stanwell-Smith, Adam Teed, Yuri Terasawa, Katie Thompson, Marisa Toups, Satoshi Umeda, Valerie Upshaw,
Teresa Victor, Christina Wierenga, Colleen Wohlrab, Hung-wen Yeh, Adrian Yoris, Fadel Zeidan, Vadim Zotev, and Nancy Zucker.
Supplementary material cited in this article is available online at https://doi.org/10.1016/j.bpsc.2017.12.004.
Khalsa et al. Page 2
internal landscape across conscious and unconscious levels. Interoceptive signaling has been
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considered a component process of reflexes, urges, feelings, drives, adaptive responses, and
cognitive and emotional experiences, highlighting its contributions to the maintenance of
homeostatic functioning, body regulation, and survival. Dysfunction of interoception is
increasingly recognized as an important component of different mental health conditions,
including anxiety disorders, mood disorders, eating disorders, addictive disorders, and somatic
symptom disorders. However, a number of conceptual and methodological challenges have made it
difficult for interoceptive constructs to be broadly applied in mental health research and treatment
settings. In November 2016, the Laureate Institute for Brain Research organized the first
Interoception Summit, a gathering of interoception experts from around the world, with the goal of
accelerating progress in understanding the role of interoception in mental health. The discussions
at the meeting were organized around four themes: interoceptive assessment, interoceptive
integration, interoceptive psychopathology, and the generation of a roadmap that could serve as a
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guide for future endeavors. This review article presents an overview of the emerging consensus
generated by the meeting.
Keywords
Biomarker; Computational psychiatry; Interoception; Mental health; Research Domain Criteria;
Treatment
Interoception refers collectively to the processing of internal bodily stimuli by the nervous
system. Parcellation of the nervous system’s processing of sensory signals into
interoception, proprioception, and exteroception began more than 100 years ago (1),
although it was predated by interest in linking body–brain interactions with conscious
experience (2,3). Scientific interest in interoception has fluctuated (Figure 1A). During the
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1980s, biological psychiatry was inundated with observations of interoceptive disturbances

in panic disorder (4–7), although the trend receded after it became clear that the etiological
mechanism was broader than a single molecular receptor target (8). Recent years have
witnessed a surge of interest on the topic of interoception due in part to findings highlighting
its integral role in emotional experience, self-regulation, decision making, and
consciousness. Importantly, interoception is not limited to conscious perception or even
unique to the human species. From this perspective, interdisciplinary efforts to understand
different features of interoception have been essential for advancing progress in cognitive
and clinical neuroscience (Figure 1B).
ASSESSMENT
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Body Systems of Interoception

Interoceptive processing occurs across all major biological systems involved in maintaining
bodily homeostasis, including the cardiovascular (9,10), pulmonary (11), gastrointestinal
(12,13), genitourinary (14), nociceptive (15), chemosensory (16), osmotic (17),
thermoregulatory (18), visceral1 (19), immune (20,21), and autonomic systems (22,23)
(Table 1). There has been relatively little focus overall on the integration across bodily
systems; thus, it is not surprising that most investigations of the topic have been siloed
Biol Psychiatry Cogn Neurosci Neuroimaging. Author manuscript; available in PMC 2018 July 20.
within distinct research areas or scientific disciplines [see (24,25) for noteworthy
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exceptions].
Features of Interoception
Interoception is not a simple process but rather has several facets (26). The act of sensing,
interpreting, and integrating information about the state of inner body systems can be related
to different elements such as interoceptive attention, detection, discrimination, accuracy,
insight, sensibility, and self-report (Table 2). However, most interoceptive processes occur
outside the realm of conscious awareness. Consciously experienced elements are measured
clinically via subjective report, and there are few observable interoceptive signs (e.g., heart
rate, respiration rate, pupillary dilation, flushing, perspiration, piloerection, nociceptive
reflexes) (Table 3). Experimental approaches can quantify different body systems and
features of interoceptive processing. Nevertheless, these measures are only partially
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overlapping and likely reflect somewhat distinct neural processes (27). Access to the full
range of interoceptive signals often involves invasive approaches, which tend to elicit
physiological perturbations and index more objectively measurable features (28). However,
many insights have been gained by the application of noninvasive approaches within
neuroscience and psychological assessment contexts (29) (see “Eavesdropping on Brain–
Body Communication” section below).
Importance of an Interoceptive Taxonomy

There is no generally agreed-on taxonomy for interoception science. Variable definitions
have made it difficult to identify the features under investigation, let alone evaluate the
quality of the findings. Based on the number of physiological systems involved, it could be
questioned whether the terms “interoception” and “interoceptive awareness” are too broad.
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Interoceptive awareness is an umbrella term that was first used to describe a self-report
subscale (30), but it has subsequently been used to encompass any (or all) of the different
interoception features accessible to conscious self-report. Researchers from different fields
developed definitions that only partially overlapped, reflecting the need for
operationalization in neuroscience (31,32) and clinical practice (33,34). Here we develop a
more coherent nomenclature for its various components (Table 2), mirroring developments
in other fields, especially pain (35). One key aspect is the importance of distinguishing
sensation (i.e., the raw signals conveyed by bodily sensors) from perception (36,37). We
return to this theme below.
Multilevel Investigations
While interoception research to date has typically focused on single organ systems, an
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expanded approach that assesses multiple interoceptive organ systems and/or elements is
needed. Examples include targeting numerous interoceptive features simultaneously and
employing different tasks that converge on the same feature (e.g., combining top-down
1Visceroception has classically referred to the perception of bodily signals arising specifically from visceral organs, such as the heart,
lungs, stomach, intestines, and bladder, along with other internal organs in the trunk of the body (19). It did not include organs such as
the skin and skeletal muscle, in contrast to contemporary definitions of interoception that typically encompasses signals from both the
viscera and all other tissues that relay a signal to the central nervous system about the current state of the body, including the skin and
skeletal/smooth muscle fibers, via lamina I spinothalamic afferents (41,138,139).
assessments of interoceptive attention with bottom-up perturbation approaches in the same

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individual) (Figure 2A).
Sensing Perturbations
The inner and outer worlds of the body constantly fluctuate. The nervous system monitors
these environmental changes and responds adaptively in order to maintain a homeostatic
balance and promote survival. Because psychiatric disorders often promote or reflect the
development of chronic homeostatic and allostatic disturbances (38), there is a need for
methods capable of eliciting homeostatic perturbations in controlled settings, especially
those assessing subjective and behavioral responses to valence and arousal deviations.
However, interoception is not simply about afferent processing. The brain’s constant
monitoring of the body occurs in service of optimizing homeostatic regulation. This efferent
limb is understudied (39), and paradigms that can effectively measure visceromotor outputs
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will be critical to establish sensitive assays of dysfunctional interoception and homeostatic

regulation (e.g., detection of visceromotor-efferent neural signals controlling baroreflex
sensitivity during modulation of visceral-afferent input by sympathetic drugs). The
reliability and validity of methods should be rigorously established.
INTEGRATION
Interoception and Domain Specificity Within the Brain
There are fundamentally differing ways to interpret the evolution of brain and body
signaling in humans. The processing of interoceptive input could be domain specific, with
modular processing occurring in specialized, encapsulated neural circuits [e.g., cardiac,
respiratory, urinary, genital, chemical, hormonal; see (40) for a review of domain specificity]
or functionally coupled (e.g., cardiorespiratory, genitourinary, chemohormonal) and
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integrated within a single neural circuit. Understanding the adaptive origins and functions of
interoceptive domain specidicity (if present) could tell us how the implementation and
deployment of interoceptive signals by the nervous system contributes to disordered mental
health. Because interoceptive signaling involves afferent and efferent inputs across multiple
hierarchies within the autonomic and central nervous systems, identifying where and how
information processing dysfunctions negatively affect mental health represents a challenging
problem.
Neural Pathways of Interoception

Several pathways have been implicated in the neural processing of interoceptive signals,
beginning with a rich interface between autonomic afferents and the central nervous system.
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Relay pathways involve primarily spinal, vagal, and glossopharyngeal afferents, with
multiple levels of processing and integration in autonomic ganglia and spinal cord
(10,19,22,41). Several brainstem (nucleus of the solitary tract, parabrachial nucleus, and
periaqueductal gray), subcortical (thalamus, hypothalamus, hippocampus, and amygdala),
and cortical regions (insula and somatosensory cortices) represent key afferent processing
regions (22,42,43). A complementary set of regions involved in visceromotor actions
represents key efferent processing regions, including the anterior insula, anterior cingulate,
subgenual cingulate, orbitofrontal, ventromedial prefrontal, supplementary motor, and
premotor areas (44–46). It is noteworthy that these neural regions coincide closely with
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other sensory processing systems, especially the nociceptive and affective systems. The
degree to which these represent distinct or overlapping systems is currently unclear.
Linking Paradigms Across Units of Analysis

A particular challenge when examining interoception is the fact that afferent sensory signals
are integrated on several levels (peripherally, within the spinal cord, and supraspinally) to
form sets of interoceptive maps across different body systems. The brain appears to integrate
information representing particular states of multiple systems simultaneously (cardiac,
respiratory, chemical, hormonal, nociceptive, etc.) (41), and it is imperative to be able to
model and comparatively evaluate such mappings (Figure 2B). This poses many challenges.
One approach might be to apply measures that assess multiple organ systems or
interoceptive features simultaneously [see (42,47,48)] or to record activity across the brain,
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spinal cord, and peripheral organs (49). However, it is also possible that multisystem
assessments may reduce specificity for certain disorders and therefore may be unnecessary.
For example, some patients with panic disorder may experience dyspnea but not
palpitations. Localizing and then targeting the dysfunctional interoceptive domain would
become more useful than broad multisystem interventions.
Timing and Rhythm in Interoceptive Circuits

The physiological timescales and amplitudes of interoceptive signaling vary dramatically
(e.g., heart rate [0.5–3.3 Hz], respiratory rate [0.08–1 Hz], gastric contractility [0.05–0.1
Hz], urinary frequency [0.000045–0.00012 Hz]), with even slower changes in humoral
mediators (50) (Figure 2C, D). They also vary across individuals, and over the life span
(e.g., increased heart rates in infants/children). Despite the variance, the brain tracks such
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changes in similar subregions, including the insula, somatosensory cortices, cingulate,

amygdala, thalamus, and brainstem (42,43,51–53). Temporal synchrony or dyssynchrony
between these systems may affect interoceptive experiences, affect, and behavior, although
the exact mechanisms require further study (54). Repetitive events are another important
element for learning, and while there are numerous classic studies on visceral learning at the
peripheral organ system level (55,56), we know little about the central mapping of learned
visceral memories, especially in psychiatric disorders (57).
How Can Animal Research Improve the Understanding of Human Interoceptive

Processing?
Although the inability to measure the subjective state of animals results in indirect
inferences, well-established tasks exist [e.g., conditioned interoceptive place preference (58)
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and odor aversion (59)]. The principal utility of animal models is the hypothesis testing of
mechanistic processes at the biological level independent of appraisal and cognition. These
include examining effects of peripheral or central nervous system lesions on physiology/
behavior, or mapping of peripheral/central interactions via stimulation of selective neurons/
circuits using optogenetic methods (60,61), and targeted gene expression manipulation to
test genetic hypotheses (62). Animal models are advantageous in that they allow for
identification of neural mechanisms that may be distinct from higher cognitive processes
(e.g., nonmammalian [reptiles/birds] vs. mammalian [mice/rats/monkeys/apes/chimpanzees],
invertebrate [octopus] vs. vertebrate [fish/monkeys]). The study of interoception in

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nonhuman primates offers intriguing opportunities. Investigations in this area have been
centered primarily on neural encoding of baroreceptor afferent stimulation (9) and
neuroanatomical circuit tracing (63). Fewer studies have examined relationships between
mechanistic manipulation of interoceptive experiences and neural representation in these
animals [see (64,65) for exceptions].
Eavesdropping on Brain–Body Communications

Interoception is manifested by the conversation between the body and brain via multiple
afferent and efferent feedback loops (41,66). Listening in on this process requires different
approaches. Peripheral perturbations are often used to stimulate the afferent bottom-up
transfer of information, usually of mechanical (28,47,52,53), chemical (67–69), or hormonal
(70) origin (Supplemental Table S1). Central perturbations to probe efferent top-down
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processes have most typically involved selective regulation of attentional focus (29,71) and,
less commonly, expectancy manipulations such as placebo/sham delivery (72). Functional
magnetic resonance imaging (73), positron emission tomography (74), and
electroencephalography (75,76) have provided the primary means of assessing neural
circuitry. However, a host of novel tools are capable of inhibiting, stimulating, or modulating
the activity of interoceptive brain networks. Noninvasive methods include the application of
transcranial magnetic stimulation (77), transcranial direct and alternating current stimulation
(78), low-intensity focused ultrasound (79), temporally interfering electric fields (80),
transcutaneous vagus nerve stimulation (81), presentation of information during different
phases of visceral rhythms (e.g., cardiac systole vs. diastole) (82), and assessment of
corticocardiac signaling (83). An important point is that many of the critical brain structures
are difficult to modulate noninvasively because they are located deep within the brain or near
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the midline. Invasive measures do not share this limitation, and while their implementation is
driven by clinical concerns, they can provide important insights. These include implanted
vagus nerve stimulation (84), direct brain stimulation (85), and intracranial electrode
recordings (86,87). Beyond these perturbation tools, the use of experimental methods to
modulate expectancies, such as placebo and sham interventions, is key. These methods will
help to determine how sensitive psychiatric and other clinical patients’ afferent/efferent
feedback loops are to processes requiring integrations of environmental context with body–
brain signals (illustrated in the next section). Finally, neurofeedback (e.g., functional
magnetic resonance imaging, electroencephalogram) represents an exciting opportunity to
participate in the brain–body conversation by simultaneously measuring and modulating
brain regions during treatment [for a noninteroceptive example, see (88)]. Equipped with
these tools, the future looks promising, but to advance progress they need to be paired with
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better models of brain function.
Computational Theories of Interoception

Identifying the state of the body represents a problem that cannot be solved by pure sensing
because afferent signals from body sensors (interosensations) are not only noisy but often
ambiguous (89). Recent computational theories suggest that interoception deploys Bayesian
inference to address this challenge (36,37,44,45,90,91) (Figures 3 and 4). Specifically, the
brain is assumed to construct a so-called generative model of interosensations that combines
a predictive mapping (from hidden bodily states to interosensations) with prior information
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(beliefs or expectations about bodily states represented as probability distributions). This

view is supported by findings that interoceptive perception is strongly shaped by
expectations (41,72,92,93) and by theoretical arguments that suggest Bayesian inference as a
unifying principle for interoception and exteroception (37,91).
Another argument supporting a Bayesian view on interoception is its relation to what

constitutes arguably the brain’s most fundamental task: the regulation (or control) of bodily
states. Put simply, if the brain were unable to resolve the ambiguity of interosensations, it
would face difficulties in choosing appropriate actions to protect homeostasis. In
information-theoretic terms, the challenge of keeping bodily states within narrow
homeostatic ranges corresponds to choosing actions that minimize the long-term average
Shannon surprise (entropy) of interosensations (36,91). Solving this control problem
requires knowledge or estimations of current and/or future bodily states and hence inference
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and predictions/forecasts—two natural domains of generative models.
Eliciting surprise-minimizing (homeostasis-restoring) actions changes the bodily state and

thus interosensations. This means that inference and control of bodily states form a closed
loop. Inference–control loops that minimize interoceptive surprise can be cast as hierarchical
Bayesian models (HBMs). Anatomically, HBMs are plausible candidates given that
interoceptive circuitry is structured hierarchically (45,94). Under general assumptions,
HBMs employ a small set of computational quantities—predictions, prediction errors, and
precisions (37,95). These quantities can support surprise minimization in two ways: by
adjusting beliefs (probability distributions) throughout the hierarchy [predictive coding (95)]
or engaging actions that fulfill beliefs about bodily states [active inference (96)].
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HBMs support both homeostatic (reactive) and allostatic (prospective) control.

Reconsidering classical homeostatic set points as beliefs (i.e., probabilistic representations
of expected/desired bodily states) enables reactive regulation at the bottom of the hierarchy
(36,91); here, prediction errors elicit reflex-like actions that minimize momentary
interoceptive surprise. Allostatic regulation at longer time scales is achieved through
modulation of homeostatic beliefs by inferred or forecast states signaled from higher
hierarchical levels (36). Importantly, belief precision determines the force/pace of corrective
actions—that is, the tighter the expected range of bodily state, the more vigorous the elicited
regulatory action. This offers a novel explanation for psychosomatic phenomena and placebo
effects (37).
In summary, a hierarchical Bayesian perspective unifies interoception and homeostatic/

allostatic control under the same computational principles. This provides a conceptual
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foundation for computational psychosomatics and supports a taxonomy of disease processes

(37). One caveat is that the empirical evidence for hierarchical Bayesian principles of
interoception and homeostatic/allostatic control is indirect so far. Studies designed to probe
hierarchical Bayesian processes under experimentally controlled homeostatic perturbations
will be crucial for finessing (or refuting) current computational concepts of interoception.
PSYCHOPATHOLOGY
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Interoceptive Psychopathology
Several conceptual and heuristic models have linked dysfunctions of interoception to mental
health conditions. Specifically, mood and anxiety disorders have been linked to failures to
appropriately anticipate changes in interoceptive states (97). Eating disorders show
behavioral and neural abnormalities in interoceptive processing, particularly in the context of
caloric anticipation (72,98–100), although it remains unclear whether this is due to altered
afferent signaling, altered central sensory processing, abnormal temperament, and/or
metacognition. Drug addiction, another condition marked by interoceptive disturbances, has
an overlapping neural circuitry and abnormal responses to interoceptive cues (101–104).
Interoceptive dysfunction also likely plays a role in conditions such as posttraumatic stress
disorder and somatic symptom disorders (33). Other disorders also have interoceptive
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symptom overlap; however, the specific feature involved may differ according to the
disorder or affected individual [e.g., chronic pain (105,106), Tourette’s syndrome and other
tic disorders, borderline personality disorder, obsessive-compulsive disorder, autism
spectrum disorder (107), functional developmental disorders (108)]. Table 3 lists diagnostic
symptoms and clinical signs indicative of interoceptive dysfunction in several psychiatric
disorders. Conditions that have a psychiatric component include fibromyalgia, chronic
fatigue syndrome, irritable bowel syndrome, and functional disorders within medicine (e.g.,
noncardiac chest pain, functional dysphagia) as well as certain medical disorders (e.g.,
gastroesophageal reflux, asthma).
Alternatively, one can use a dimensional psychopathology approach to link processes

underlying interoceptive dysfunction to psychiatric disorders. Transdiagnostic perspectives
such as those provided by the Research Domain Criteria (109) may be particularly helpful in
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identifying the potential role played by various interoceptive processes because several of
these might not be readily identified at the symptom report level relied on by clinicians and,
accordingly, might not have entered into the diagnostic specifications for DSM. This would
allow for identification of mechanistic dysfunctions across units of analyses and might
bridge the biological gap in current diagnostic classification frameworks by directly probing
the links between physiological and psychological dysfunctions. Interoceptive investigations
in mental health populations might reveal evidence of 1) attentional bias (e.g.,
hypervigilance), 2) distorted physiological sensitivity (e.g., blunted or heightened magnitude
estimation in response to a perturbation), 3) cognitive bias (e.g., catastrophizing in response
to an anticipated stimulus), 4) abnormal sensibility (e.g., tendency to label one’s experiences
in a particular way), and 5) impaired insight (e.g., poor confidence–accuracy correspondence
on a task).
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Determining whether interoceptive processes are a cause or consequence of developmental

psychopathology, and which factors might affect this development (such as early life stress
or pain), will be an important area for future research. Such studies may benefit from the
examination of younger (110,111) or older (112,113) samples and premorbid identification
and longitudinal tracking of individuals (114). Investigating the role of social cognition/
theory of mind in clinically relevant interoceptive inference generation represents another

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ripe opportunity (115).
Interoceptive Tests and/or Biomarkers

Because interoception is fundamentally a process linking body and brain, it is conceivable
that objective measures of this process could serve as biological indicators of disease states.
However, there is currently limited evidence for interoceptive predictors of diagnostic,
prognostic, or treatment status (33,116,117). Biomarkers, such as those derived from
neuroimaging or blood measurements, should be sensitive, specific, and unaffected by
cognitive and emotional influences. However, it seems conceivable that the most clinically
sensitive interoceptive measures might derive from probes that perturb physiological
functions to engage specific metacognitive beliefs and/or expectations about bodily states.
Such measures could facilitate differential diagnosis testing by revealing the presence of
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interoceptive dysfunction of biological (within a physiological system or systems),

psychological (e.g., overly precise expectations about bodily states), or metacognitive (e.g.,
discrepant self-efficacy beliefs with regard to homeostatic/allostatic regulation) origin (37).
This approach could be seen as analogous to a cardiac stress test, such that adequate
engagement of the system under ecologically valid conditions is required in order to
measure its dysfunction.
The most common application of interoceptive evaluation in current clinical practice occurs
during interoceptive exposure psychotherapy for panic disorder (118). During this
procedure, patients self-induce varieties of interoceptive symptoms via low-arousal
manipulations (e.g., hyperventilation, performing jumping jacks, spinning in a chair,
breathing through a straw) while the clinician monitors their subjective distress level.
Unfortunately these manipulations often fail to adequately reproduce the fear response,
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possibly because the patient retains full control over the stimulation (the patient can quit at
any time) and the perturbation remains predictable with minimal uncertainty, raising the
question of whether modulating both physiological homeostasis and the perception of
controllability might further improve the ecological validity and efficacy of interoceptive
exposures (119). A test to verify successful interoceptive exposure therapy for panic disorder
involves completion of a standardized behavioral avoidance paradigm (120). In this setting,
the degree of tolerance to being enclosed in a small dark chamber for 10 minutes might
provide behavioral evidence verifying tolerance to triggers of interoceptive dysregulation.
There is also experimental evidence that pharmacological interoceptive exposure therapy can
reduce anxiety disorder symptom severity either as monotherapy (7,121–123) or as an
augmentative approach (124). However, there are few studies of these procedures to date, the
impact of such interventions on longer term outcomes (e.g., 6 months or beyond) are
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unknown, and none of these approaches has translated into clinical practice.
Current Treatments Relevant to Interoception

Among the currently available therapies with an interoceptive basis are pharmacotherapies
directly modulating interoceptive physiology. Examples include adrenergic blockade (e.g.,
propranolol) or agonism (e.g., yohimbine), stimulants (e.g., methylphenidate),
benzodiazepines, muscle relaxants, and opioids. A second example is cognitive behavioral
therapy with exposure and response prevention to reverse or attenuate conditioned fears or
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form new learned associations. It is helpful in ameliorating cognitive biases in numerous

disorders, including depression, obsessive-compulsive disorder, posttraumatic stress disorder
(specifically prolonged exposure therapy), irritable bowel syndrome, and chronic pain.
Interoceptive exposure is a special example demonstrated to be effective in specific disorders
(especially panic disorder). Behavioral activation therapy for depression sometimes includes
exposure to experiences with positive interoceptive value. A third example is capnometry-
assisted respiratory training. Based on the assumption that sustained hypocapnia resulting
from hyperventilation is a key mechanism in the production and maintenance of panic,
carbon dioxide capnography-assisted therapy aims to help patients voluntarily increase end-
tidal partial pressure of carbon dioxide and tolerate physiological variability associated with
panic attacks (125,126). As a fourth example, mindfulness-based stress reduction, yoga, and
other meditation/movement-based treatments may be aimed at improving metacognitive
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awareness of mind–body connections by systematically attending to sensations of breathing,

cognitions, and/or other modulated body states (e.g., muscle stretching) (127).
Interoceptive Treatments on the Horizon

Several emerging technologies may have relevance for interoception and mental health,
including Floatation-REST (reduced environmental stimulation therapy) and perturbation
approaches.
Floatation-REST—This intervention, which systematically attenuates exteroceptive

sensory input to the nervous system, also appears to noninvasively enhance exposure to
interoceptive sensations such as the breath and heartbeat (128). Preliminary data suggest that
a single 1-hour session has a short-term anxiolytic and antidepressant effect in patients with
comorbid anxiety and depression (129), but further research is needed to evaluate the safety,
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feasibility, and potential for long-term efficacy in psychiatric populations.
Perturbation Approaches—Minimally invasive tools capable of systematically

modulating interoceptive processing, such as inspiratory breathing loads (130), core body
thermomodulation (131,132), and transcutaneous vagus nerve stimulation (133), are several
approaches awaiting further investigation. Given the hypothesis of noisy baseline afferent
signaling, these approaches may systematically enhance the signal-to-noise ratio and
facilitate interoceptive learning. A key aspect in discerning clinical efficacy of any
perturbation may be the extent to which the patient perceives controllability over the
intervention and is willing/able to surrender this parameter in treatment. Interventions in
which escape or active avoidance behaviors are directly measurable may provide especially
meaningful information (134).
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ROADMAP
The Road Ahead
Beyond the issues outlined previously, progress in determining the relevance of
interoception for mental health relies on emphasizing the features that distinguish it from
other sensory modalities. Interoception seemingly involves a high degree of connectivity
within the brain (135). It appears to be tightly linked to the self and survival through
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homeostatic maintenance of the body, and by helping us to represent how things are going in
the present with respect to the experienced past and the anticipated future. These
computations may depend on what has occurred to shape the body’s internal landscape, and
it is in this regard that learning, and malleability of representations over time, could play
important roles.
The conceptual framework for investigating interoception may overlap with other processes,
including emotion (136) and pain (137), because each is integral for maintaining bodily
homeostasis. An important endeavor may involve the identification of which neural systems
for interoception, emotion, cognition, and pain are overlapping, interdigitating, or even
possibly identical. Additional effort is needed to define the neurophysiological
nomenclature, core criteria, common features, developmental aspects, modulating factors,
functional consequences, and putative pathophysiologic mechanisms of interoception in
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mental health disorders.
The current work offers some conceptual distinctions and some mutually agreed-on
terminology, with many others still needed. Several low-hanging fruits, as well as promising
emerging technologies and tools, have been mentioned. Further empirical work will be
critical to delineate how interoception can be mapped to mental health measures, models,
and approaches, and benchmarks for success/failure need to be established. Models of
interoceptive processing that improve on the traditional stimulus, sensorimotor processing,
and response function concepts have been described, but these models remain theoretical
and await further testing. Therefore, the current document is best viewed as a work in
progress.
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Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments
ACKNOWLEDGMENTS AND DISCLOSURES
We express our sincere appreciation to the William K. Warren Foundation for supporting the Interoception Summit
2016 and to all of the Laureate Institute for Brain Research staff members for their assistance with facilitating the
meeting.
AEM reports the following disclosures: research/grant: National Institutes of Health (NIH) Grant No.
1U01EB021952-01; scientific advisory board: Anxiety and Depression Association of America. AvL reports the
following disclosures: research/grants: Research Fund KU Leuven, Belgium (Grant Nos. STRT/13/002 and DBOF/
14/021), an infrastructure grant from the Herculesstichting, Belgium (Grant No. AKUL/13/07), “Asthenes” long-
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term structural funding Methusalem grant (Grant No. METH/15/011) by the Flemish Government, Belgium. CBN
reports the following disclosures: research/grant: NIH, Stanley Medical Research Institute; consulting (last 3 years):
Xhale, Takeda, Taisho Pharmaceutical, Inc., Prismic Pharmaceuticals, Bracket (Clintara), Total Pain Solutions,
Gerson Lehrman Group Healthcare & Biomedical Council, Fortress Biotech, Sunovion Pharmaceuticals, Inc.,
Sumitomo Dainippon Pharma, Janssen Research & Development, LLC, Magstim, Inc., Navitor Pharmaceuticals,
Inc., TC MSO, Inc.; stockholder: Xhale, Celgene, Seattle Genetics, Abbvie, OPKO Health, Inc., Bracket
Intermediate Holding Corporation, Network Life Sciences, Inc., Antares; scientific advisory boards: American
Foundation for Suicide Prevention (AFSP), Brain and Behavior Research Foundation (formerly National Alliance
for Research on Schizophrenia and Depression [NARSAD]), Xhale, Anxiety and Depression Association of
America (ADAA), Skyland Trail, Bracket (Clintara), RiverMend Health, LLC, Laureate Institute for Brain
Research, Inc.; board of directors: AFSP, Gratitude America, ADAA; income sources or equity of $10,000 or more:
American Psychiatric Publishing, Xhale, Bracket (Clintara), CME Outfitters, Takeda; patents: method and devices
for transdermal delivery of lithium (Patent No. US 6,375,990B1), method of assessing antidepressant drug therapy
Author Manuscript
via transport inhibition of monoamine neurotransmitters by ex vivo assay (Patent No. US 7,148,027B2). HDC
reports the following disclosures: research/grants: European Research Council Horizon 2020 Proof of Concept
Grant “HeartRater: Tools for the systematic evaluation of interoceptive ability,” Medical Research Council (UK)
MRC Confidence in Concept Grant “Identifying neural, cognitive, and phenomenological markers of auditory
verbal hallucinations in borderline personality,” MQ (Mental Health) PsyImpact “Aligning Dimensions of
Interoceptive Experience (ADIE) to prevent development of anxiety disorders in autism,” Dr. Mortimer and Theresa
Sackler Foundation Sackler Centre for Consciousness Science, University of Sussex, BIAL Foundation Bursary
“Microneurography as a tool for consciousness science”; scientific advisory boards: Emteq, Ltd., unpaid governor
on board of charity “Reflecting nature in art & science”; board of directors: Codirector of Sackler Centre for
Consciousness Science, University of Sussex. KES reports the following disclosures: research/grants: Deutsche
Forschungsgemeinschaft, Transregional Collaborative Research Centre, “Ingestive Behaviour: Homeostasis and
Reward,” René and Susanne Braginsky Foundation. LPS reports the following disclosures: scientific advisory
board: Laureate Institute for Brain Research, Inc. JDF reports the following disclosures: research/grants: NIH Grant
Nos. R01MH105662, R21MH110865, and R01HD087712; scientific advisory boards: International Obsessive-
Compulsive Disorder Foundation Clinical and Scientific Advisory Board. JLR reports the following disclosures:
research/grants: NIH Grant No. R01MD007807 and Oklahoma Center for the Advancement of Science and
Technology Grant No. HR15-079. JSF reports the following disclosures: research/grants: NIH/National Institute of
General Medical Sciences (NIGMS) Grant No. P20GM121312, Brain and Behavior Research Foundation (formerly
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NARSAD) Young Investigator Award. MBS reports the following disclosures: scientific advisory board: Laureate
Institute for Brain Research, Inc.; editorial board: Depression and Anxiety, Biological Psychiatry. MPP reports the
following disclosures: research/grants: the William K. Warren Foundation and NIH Grant No. R01DA016663, NIH/
NIGMS Grant No. P20DA027834, and NIH Grant Nos. R01DA027797, R01DA018307, U01DA041089, and
1R01MH101453; consulting (last 3 years): has received royalties for an article about methamphetamine use
disorder from UpToDate. OVdB reports the following disclosures: scientific advisory boards: Research Training
Group 2271 of the Deutsche Forschungsgemeinschaft on “Expectation maintenance vs. change in the context of
expectation violations: Connecting different approaches,” University of Marburg. RDL reports the following
disclosures: research/grant: NIH. SSK reports the following disclosures: research/grants: NIH/National Institute of
Mental Health Grant No. K23MH112949, NIH/NIGMS Grant No. P20GM121312, William K. Warren Foundation,
Brain and Behavior Foundation (formerly NARSAD) Young Investigator Award. WEM reports the following
disclosures: research/grants: NCIRE (Veterans Health Research Institute, San Francisco, California), Alzheimer’s
Association, Mental Insight Foundation, the Pepper Foundation, University of California, San Francisco, Resource
Allocation Program. WKS reports the following disclosures: research/grants: NIH Grant No. P20GM121312, Brain
and Behavior Foundation (formerly NARSAD) Young Investigator Award. The remaining authors report no
biomedical financial interests or potential conflicts of interest.
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Figure 1.
(A) Number of English language publications per year on interoception from PubMed,
PsycINFO, and Institute for Science Information Web of Knowledge. The timeline starts in
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1905, one year before the publication of Charles Sherrington’s book, The Integrative Action
of the Nervous System, which first defined the concept of interoception. Key historical
events relevant to interoception science are superimposed. (B) Publications per year on
interoception vs. those investigating features of interoception that do not specifically refer to
the term. These latter publications are more numerous and arise mainly from basic
neuroscience, physiology, and subspecialty disciplines within the biomedical field. Note the
use of a logarithmic scale in the second panel. [Figure reproduced and modified with
permission from Khalsa and Lapidus (33).]
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Figure 2.
(A) Cardiac interoceptive processing measures and feature loading. This illustrates how the
most commonly used heartbeat perception tasks differentially measure interoceptive
features. [Figure reproduced and modified with permission from Khalsa and Lapidus (33).]
(B) Multisystem interoceptive processing measures and feature loadings: Example of
hypothetical approaches to measuring interoceptive processing across multiple systems.
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Approaches that perturb the state of the body are recommended, as are convergent
approaches such as combined assessments of interoceptive attention and perturbation. (C)
Central neural integration of interoceptive rhythms. Interoceptive rhythms vary considerably
across the different systems of the body. They exhibit complex characteristics and are
hierarchically integrated within discrete regions of the central nervous system. [Figure
modified, with permission, from Petzschner et al. (37).] (D) Interoceptive rhythms vary in
both amplitude and frequency. The top trace illustrates a hypothetical example of an
amplitude modulation signal superimposed on a static frequency. The middle trace illustrates
a hypothetical frequency modulation signal superimposed on a static amplitude. The bottom
trace illustrates a hypothetical signal change involving both amplitude and frequency
modulations that are temporally correlated. GI, gastrointestinal; GU, genitourinary.
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Figure 3.
(A) Example of one possible form of a general inference–control loop illustrated within a
hierarchical Bayesian model. (B) Highly schematic example of illustrating that both
interoceptive information and exteroceptive information are concurrently integrated to
inform perceptual representations and action selection with respect to internally directed
(e.g., visceromotor, autonomic) and externally directed (e.g., skeletomotor) actions. (C)
General nodes that comprise a peripheral and central neural circuit for hierarchically
integrating afferent interoceptive information into homeostatic reflexes, sensory and meta-
cognitive representations, and allostatic regulators (predictions). ACC, anterior cingulate
cortex; AIC, anterior insular cortex; MC, metacognitive layer; MIC, midinsular cortex; OFC,
orbitofrontal cortex; PE, prediction error; PIC, posterior insular cortex; SGC, subgenual
cortex. [Panels (A) and (B) reproduced, with permission, from Petzschner et al. (37). Panel
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(C) adapted, with permission, from Stephan et al. (36).]

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Figure 4.
(A) Active inference implementation according to the Embodied Predictive Interoception
Coding model. Agranular visceromotor cortices, including the cingulate cortex, posterior
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ventral medial prefrontal cortex, posterior orbitofrontal cortex, and ventral anterior insula,
estimate the balance among autonomic, metabolic, and immunological resources available to
the body and its predicted requirements. These agranular visceromotor cortices issue
allostatic predictions to hypothalamus, brainstem, and spinal cord nuclei to maintain a
homeostatic internal milieu and simultaneously to the primary interoceptive sensory cortex
in the mid and posterior insula. The interoceptive sensory cortex in the granular mid and
posterior insula sends reciprocal prediction error signals back to the agranular visceromotor
regions to modify the predictions. Under usual circumstances, these agranular regions are
relatively insensitive to such feedback, which explains why interoceptive predictions are
fairly stable in the face of body fluctuations. One hypothesis of the role of interoception in
mental illness is that interoceptive input (i.e., posteriors) becomes increasingly decoupled
from interoceptive predictions issued by the agranular visceromotor cortex (priors), leading
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to increased interoceptive prediction error signals. This decoupling may present in the brain
as “noisy afferent interoceptive inputs” (97). (B) Proposed intracortical architecture and
intercortical connectivity for interoceptive predictive coding. The granular cortex contains
six cell layers including granule cells, which are excitatory neurons that amplify and
distribute thalamocortical inputs throughout the column. The granular cortex is structurally
similar to the neocortex and therefore more recently evolved than the agranular and
dysgranular cortices. Within the insula, the granular cortex is present in the mid and
posterior sectors. AC, anterior cingulate; PL, prelimbic cortex. [Figures reproduced, with
permission, from Barrett and Simmons (45).]
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Table 1
Physiological Processes Often Ascribed to Interoception

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Nonpainful
Cardiovascular, respiratory, gastrointestinal (esophageal, gastric, intestinal, colorectal), bladder, hunger, thirst, blood/serum (pH, osmolality,
glucose), temperature, vasomotor flush, air hunger, muscle tension, shudder, itch, tickle, genital sensation, sensual touch, fatigue
Painful
Visceral: kidney stone, pleuritic, angina, pericardial, bowel ischemia, pelvic, sickle crisis
Somatic: abscess/boil, bruising, myalgia, inflammation (systemic/laceration), headache
Skeletal: fractured/bruised bone, stress fracture, inflammatory/mechanical joint pain
Several key distinctions are that interoceptive sensing 1) may be painful or nonpainful, 2) occurs across the spectra of high/low arousal and
negative/positive valence, 3) usually occurs outside of conscious awareness (with the exception of pain sensations), and 4) is often (but not always)
consciously experienced during instances of homeostatic perturbation.
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Table 2
Features of Interoceptive Awareness

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Feature Definition
Attention Observing internal body sensations
Detection Presence or absence of conscious report
Magnitude Perceived intensity
Discrimination Localize sensation to a specific channel or organ system and differentiate it from other sensations
Accuracy (Sensitivity) Correct and precise monitoring
Insight Metacognitive evaluation of experience/performance (e.g., confidence–accuracy correspondence)
Sensibility Self-perceived tendency to focus on interoceptive stimuli (trait measure)
Self-report Scales Psychometric assessment via questionnaire (state/trait measure)
For some examples of paradigms assessing each feature, see Supplemental Table S1.
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Table 3
Diagnostic Symptoms and Clinical Signs Indicating Interoceptive Dysfunction in Some Psychiatric Disorders
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Psychiatric Disorder Symptoms Signs Sample Studies

Panic Disorder Palpitations, chest pain, dyspnea, choking, nausea, Elevated heart rate and/or (5,140,141)
dizziness, flushing, depersonalization/derealization blood pressure, exaggerated
escape, startle, and flinching
Depression Increased or decreased appetite, fatigue, lethargy Weight gain, weight loss, (142,143)
psychomotor slowing
Eating Disorders Hunger insensitivity, food anxiety, gastrointestinal Severe food restriction, (72,98)
complaints severe weight loss, binging,
purging, compulsive exercise
Somatic Symptom Disorders Multiple current physical and nociceptive Symptoms Medical observations do not (144,145)
correspond with symptom
report
Substance Use Disorders Physical symptoms associated with craving, intoxication, Elevated/decreased: heart (101,146,147)
and/or withdrawal (drug specific) rate, respiratory rate, and/or
blood pressure, pupil dilation/
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constriction, others (drug

specific)
Posttraumatic Stress Disorder Autonomic hypervigilance, depersonalization/derealization Exaggerated startle, (148)

flinching, and/or escape
responses, elevated heart rate
and/or blood pressure
Generalized Anxiety Disorder Muscle tension, headaches, fatigue, Gastrointestinal Trembling, twitching, (149,150)
complaints, pain shaking, sweating, nausea,
exaggerated startle
Depersonalization/Derealization Disorder Detachment from one’s body, head fullness, tingling, Physiological hyporeactivity (151,152)
lightheadedness to emotional stimuli
Autism Spectrum Disorders Skin hypersensitivity Selective clothing preferences (107,153,154)

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1980s, biological psychiatry was inundated with observations of interoceptive disturbances

Body Systems of Interoception

Importance of an Interoceptive Taxonomy

assessments of interoceptive attention with bottom-up perturbation approaches in the same

individual) (Figure 2A).

will be critical to establish sensitive assays of dysfunctional interoception and homeostatic

Neural Pathways of Interoception

Linking Paradigms Across Units of Analysis

Timing and Rhythm in Interoceptive Circuits

changes in similar subregions, including the insula, somatosensory cortices, cingulate,

How Can Animal Research Improve the Understanding of Human Interoceptive

invertebrate [octopus] vs. vertebrate [fish/monkeys]). The study of interoception in

Eavesdropping on Brain–Body Communications

better models of brain function.

Computational Theories of Interoception

(beliefs or expectations about bodily states represented as probability distributions). This

Another argument supporting a Bayesian view on interoception is its relation to what

and predictions/forecasts—two natural domains of generative models.

Eliciting surprise-minimizing (homeostasis-restoring) actions changes the bodily state and

HBMs support both homeostatic (reactive) and allostatic (prospective) control.

In summary, a hierarchical Bayesian perspective unifies interoception and homeostatic/

foundation for computational psychosomatics and supports a taxonomy of disease processes

Alternatively, one can use a dimensional psychopathology approach to link processes

Determining whether interoceptive processes are a cause or consequence of developmental

theory of mind in clinically relevant interoceptive inference generation represents another

ripe opportunity (115).

Interoceptive Tests and/or Biomarkers

interoceptive dysfunction of biological (within a physiological system or systems),

Current Treatments Relevant to Interoception

form new learned associations. It is helpful in ameliorating cognitive biases in numerous

awareness of mind–body connections by systematically attending to sensations of breathing,

Interoceptive Treatments on the Horizon

Floatation-REST—This intervention, which systematically attenuates exteroceptive

feasibility, and potential for long-term efficacy in psychiatric populations.

Perturbation Approaches—Minimally invasive tools capable of systematically

mental health disorders.

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108Flack F, Pane-Farre CA, Zernikow B, Schaan L, Hechler T. Do interoceptive sensations provoke

interoceptive exposure by optimizing inhibitory learning: A randomized controlled trial. Behav

sensitivity. Biol Psychiatry Cogn Neurosci Neuroimaging. 2018; 3:555–562. [PubMed:

Psychiatry. 1994; 36:548–558. [PubMed: 7827218]

342–350. [PubMed: 23855999]

heartbeat-evoked potentials in depersonalization/derealization disorder: Neurophysiological

(C) adapted, with permission, from Stephan et al. (36).]

Physiological Processes Often Ascribed to Interoception

Somatic: abscess/boil, bruising, myalgia, inflammation (systemic/laceration), headache

Skeletal: fractured/bruised bone, stress fracture, inflammatory/mechanical joint pain

Features of Interoceptive Awareness

Detection Presence or absence of conscious report