Evidence-Based Reviews

Interoceptive cues: When ‘gut feelings’ point to anxiety

Current Psychiatry. 2007 November;6(11):49-62

References

1. Katon W, Lin EH, Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry 2007;29(2):147-55.

2. Niedenthal PM. Embodying emotion. Science 2007;316(5827):1002-5.

3. McClure EB, Monk CS, Nelson EE, et al. Abnormal attention modulation of fear circuit function in pediatric generalized anxiety disorder. Arch Gen Psychiatry 2007;64(1):97-106.

4. Panksepp J. Affective neuroscience. New York: Oxford University Press; 1998:31.

5. Stein DJ. Advances in understanding the anxiety disorders: the cognitive-affective neuroscience of ‘false alarms’. Ann Clin Psychiatry 2006;18(3):173-82.

6. Kroenke K, Spitzer RL, Williams JBW, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146(5):317-25.

7. Damasio A. The feeling of what happens: body and emotion in the making of consciousness. New York: Harcourt; 1999.

8. Wiens S. Interoception in emotional experience. Curr Opin Neurol 2005;18(4):442-7.

9. Cameron OG. Interoception: the inside story—a model for psychosomatic processes. Psychosom Med 2001;63(5):697-710.

10. Wald J, Taylor S. Interoceptive exposure therapy combined with trauma-related exposure therapy for post-traumatic stress disorder: a case report. Cognit Behav Ther 2005;34(1):34-40.

11. Wells A, Papageorgiou C. Social phobic interoception: effects of bodily information on anxiety, beliefs and self-processing. Behav Res Ther 2001;39(1):1-11.

12. Davidson RJ. Anxiety and affective style: role of prefrontal cortex and amygdala. Biol Psychiatry 2002;51(1):68-80.

13. Kandel ER, Squire LR. Memory: from mind to molecules. New York: Henry Holt and Company, 1999.

14. Fokkema DS. The psychobiology of strained breathing and its cardiovascular implications: a functional system review. Psychophysiology 1999;36(2):164-75.

15. Arnsten AF. Fundamentals of attention-deficit/hyperactivity disorder: circuits and pathways. J Clin Psychiatry 2006;67 (suppl 8):7-12.

16. Keay KA, Bandler R. Parallel circuits mediating distinct emotional coping reactions to different types of stress. Neurosci Biobehav Rev 2001;25(7-8):669-78.

17. Garakani A, Mathew SJ, Charney DS. Neurobiology of anxiety disorders and implications for treatment. Mt Sinai J Med 2006;73(7):941-9.

18. Phelps EA. Emotion and cognition: insights from studies of the human amygdala. Annu Rev Psychol 2006;57:27-53.

19. LeDoux JE, Gorman JM. A call to action: overcoming anxiety through active coping. Am J Psychiatry 2001;158(12):1953-5.

20. LeDoux JE. The emotional brain. New York: Simon and Schuster, 1996.

21. Liddell BJ, Brown KJ, Kemp AH, et al. A direct brainstemamygdala-cortical ‘alarm’ system for subliminal signals of fear. Neuroimage 2005;24(1):235-43.

22. Harmer CJ, Mackay CE, Reid CB, et al. Antidepressant drug treatment modifies the neural processing of nonconscious threat cues. Biol Psychiatry 2006;59(9):816-20.

23. Hariri AR, Mattay VS, Tessitore A, et al. Neocortical modulation of the amygdala response to fearful stimuli. Biol Psychiatry 2003;53(6):494-501.

24. Paulus MP, Stein MB. An insular view of anxiety. Biol Psychiatry 2006;60(4):383-7.

25. Simmons A, Strigo I, Matthews SC, et al. Anticipation of aversive visual stimuli is associated with increased insula activation in anxiety-prone subjects. Biol Psychiatry 2006;60(4):402-9.

26. Stein MB, Simmons AN, Feinstein JS, et al. Increased amygdala and insula activation during emotion processing in anxiety-prone subjects. Am J Psychiatry 2007;164(2):318-27.

27. Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport 2005;16(17):1893-7.

An organ-based, body-centered discussion also may reduce defensiveness in patients who feel (or have been told) that anxiety is “not real” or signals personality weakness. This model may help trainees and medical colleagues avoid outdated distinctions between real/organic problems and functional/emotional problems and find a more conciliatory construct based in emotional neuroscience.

Serotonergic medications and psychotherapy—both of which work on the brain—have demonstrated broad efficacy for anxiety disorders.⁵ Several national organizations offer information about evidence-based psychotherapeutic treatments grounded in emotional awareness and neuroscience (see Related Resources).

Table 2

Activity of the fear system

Inputs
Contemporary situations
Memories (visual and sensory)
Anticipated future situations
Other nonconscious body and brain processes (including the physiologic symptoms of emotions and anxiety—a ‘fear of fear’ or ‘fear of feelings’)
Outputs
Physical symptoms
Thoughts
Perceptions
Behaviors
States of attention

CASE CONTINUED: Putting interoception to work

Your psychotherapeutic work with Ms. N focuses on attending to and consciously modulating her newly labeled anxiety For example, after an inquiry into a “stressful” situation, you help her use careful interoceptive attention—and when necessary, mindful relaxation and breathing—to regulate her fear symptoms.

She finds that these simple “exposure/regulation” exercises are enough to rapidly resolve her impulsive behaviors. In distressing situations, she can now be aware of her reactions and make a conscious choice of how to react. Your psychotherapeutic work now proceeds toward more effective interpersonal expression of other emotions.

Related Resources

Barrett LF, Mesquita B, Ochsner K, Gross JJ. The experience of emotion. Annu Rev Psychol 2007;58:373-403.
Damasio A. The feeling of what happens: body and emotion in the making of consciousness. New York: Harcourt; 1999.
International Experiential Dynamic Therapy Association. www.iedta.net.
International Center for Excellence in Emotionally Focused Therapy. www.eft.ca.

Disclosure

Dr. MacDonald reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.