This exercise reveals marked generalized muscle tension, sweating, and a brief period of going “blank” in her mind when she recalled one of her impulsive, aggressive episodes. You explain that these physical reactions are part of the normal biologic fear response. Apart from these symptoms, Ms. N denies any prototypical manic symptoms and does not meet bipolar disorder criteria.
Using interoceptive cues
To frame an interoceptive inquiry, discuss with patients how the brain’s fear system is connected to the body, and explain that investigating these physical symptoms can assist diagnosis and treatment. For example, you might ask, “Could we look into your physical responses in these situations to help us better understand your difficulties?”
To actively explore somatic markers of anxiety (anxious feelings), encourage the patient to describe a specific stressful or avoided situation in detail. While he or she does this, direct the patient’s attention to objective physiologic markers of anxiety, such as strained breathing or increased heart rate. Use body-directed questions (interoceptive cues) to foreground these sensory experiences in the patient’s mind. For example:
- “As we are discussing this issue, I notice your breathing becomes more strained. Do you notice it?”
- “As you picture this incident in your mind, are you aware of what happens in your body?”
- “When you perceive her in that way, what do you notice about your physical response?”
You can further inquire into these somatic symptoms and their effect on the patient by asking, “How long have you been having these particular symptoms?” “How frequently do they occur?” or “How distressing are these symptoms?” These questions can separate transient physiologic arousal (normal) from pathologic (recurrent, disabling) responses that may respond to treatment. These cues and their responses can be used as person-specific biomarkers to assay a patient’s:
- ability to attend to his or her somatic state
- baseline level of autonomic arousal
- internal state before problematic behaviors (such as impulsive or self-harming behaviors, substance use)
- tendency toward anxiety-related perceptual disturbances (such as dissociation).
When the patient actively attends to and carefully describes his or her somatic sensations, the immediate outcome typically is anxiolytic. A shared awareness of the anxiolytic nature of this exercise—“It’s interesting that paying attention to these feelings actually reduces anxiety”—creates a positive first step toward further exploration. Patients can feel the power of the mind to regulate distress.
Overcoming barriers to interoception
Many patients—including those with dissociative disorders, impulse control disorders, or disorders with significant obsessive features—have difficulty using their attention to bring physical symptoms to mind. Some develop automatic, phobic patterns of disattention to contemporaneous somatic feelings of anxiety. This experiential avoidance is the fear of fear itself—fear of the conscious experience of fearful feelings. Their typical responses to interoceptive cues include:
- lack of awareness (“I don’t know,” “I wasn’t aware of anything”)
- perceptions, phrased as feelings (“I feel as if he doesn’t like me”)
- action tendencies or impulses, phrased as feelings (“I feel like I want to get out of there”)
- a verbal explanation of why they are anxious (“I’m worried about what might happen”).
Depending on the context of your inquiry, if the patient does not respond to an interoceptive cue with actual body-centered feelings, you can:
- reframe the question: “OK, but when you perceive him in that way, if you focus your mind on your physical reactions, what do you notice?”
- point out observable symptoms: “Did you notice as we were talking about this issue that your breathing got very shallow, and your hands got tense?”
Some patients may look transiently “spacey” or report “checking out” during the exercise. Inquire specifically about this because they may be demonstrating dissociative symptoms: “Does this sometimes happen when you are stressed, that you lose touch with your sense of your body, you go numb or your mind goes blank?” These symptoms warrant attention, as they may preclude effective retention of the exercise.
Explaining occult anxiety
Regardless of how far you choose to pursue an interoceptive inquiry, uncovering an interoceptive deficit—an inability to describe one’s somatic experience—may be diagnostically helpful. Doing so identifies a potentially modifiable component of self-awareness. So-called mindfulness-based and emotion-focused therapies assist patients in developing a more robust awareness and understanding of their emotions, including the somatic sensations of emotion (see Related Resources).
With appropriate psychoeducation, an interoceptive exploration makes anxiety a real, physical event anchored in brain-body function, and facilitates a nonshaming, organ-based explanation of anxiety. Psychoeducation about fear grounds physical symptoms of anxiety in a brain-based, evolutionarily selected neural system whose activity has a variety of inputs and outputs (Table 2).