Interoception in Autistic Burnout

Interoception is the sense that tells us about the state of our bodies so that we can take action to meet our basic needs.  

Many people struggle with interoception. however research suggests that Autistic people are more likely to have increased difficulty in noticing, interpreting and responding to interoceptive cues.

Not noticing, or being able to interpret, or act on interoceptive cues is likely to cause increased stress on our bodies and minds and contribute to, or exacerbate, Autistic Burnout. 

In this article I will explain:

1. What Interoception is
2. Why Interoception is often different in Autistic People
3. How Interoception is an issue in Autistic Burnout
4. Ways you can improve your interoceptive awareness
5. Interoceptive supports to ensure your basic needs are met in the absence of reliable interoceptive cues

What Interoception is

Interoception is a sense that tells us about how our bodies feel.

We have receptors all over our bodies, including, but not limited to our hearts, lungs, muscles, stomachs and skin

These receptors gather information about the state of that body part, if it is sore, full, tight. we get information about how fast our hearts are beating, whether we are hot or cold and how full our bladder is.

The receptors deliver this information to our brains which then have to interpret the signals for example a heavy feeling in the bladder might mean we need the loo, a gnawing feeling in the stomach might mean we are hungry.

This is also how we experience emotions, so if our heart is racing and our palms are sweaty our brain might interpret that we are anxious.

Interoception is the basis for all emotions, including homeostatic emotions and affective emotions.

Homeostatic emotions are emotions about the state of our bodies in order for us to do something our bodies need (and maintain homeostasis). For example being tired compels us to rest, being hungry compels us to eat.

Affective emotions, are what we normally talk about when we talk about emotions, so joy, excitement, sadness etc.

I won’t cover Alexithymia in this article, but I just wanted to point out that alexithymia is a difficulty in identifying affective emotions which a large proportion of the Autistic community experience. If this is you, then working on your interoception is an important first step to getting a better understanding of your affective emotions.

In order for us to have interoceptive awareness we need to notice our bodily signals AND connect those bodily signals to our homeostatic emotions.

Why Interoception is often different in Autistic people

We already know that Autistic people are highly likely to have difficulties with sensory processing, with around 80% having sensory processing differences that impact on their daily lives.

Autistic people report lower interoceptive awareness than non autistic people (Fiene & Brownlow, 2015)

The insular is the brain’s interoception centre. Lots of studies have looked at how this brain structure is different in Autistic people.

Autistic children seem to have hyper-connectivity in their insulars, so they have significantly more connections inside the insular and between the insular and other brain structures (Uddin, Supekar & Lynch et.al., 2013).

In contrast, studies have shown that Autistic Adults seem to have hypo-connectivity, so low connectivity, in their insulars (Di Martino et al.,2014)

Our insulars also have less activity (Di Martino et al., 2009) and reduced grey matter volume (Radeloff et al., 2014) when compared with neurotypical insulars.

Under responders don’t notice their signals or only notice them when they are extreme. They may also have a sense that something isn’t right but that sense is vague or muted.

Over responders experience signals as overpowering and distracting. They may be experiencing multiple signals at the same time and find this very overwhelming and difficult to process.

For people with discrimination difficulties, they may be getting feedback from their bodies but find it difficult to work out what exactly their bodies are telling them, it might be that the feedback they are getting is vague or general, they struggle to differentiate between different feelings and might mislabel emotions and body states.

We know that Autistic people are more likely to experience extremes of interoceptive awareness.

We have often been brought up, or looked after, by people who haven’t understood this.

We may have felt extreme hunger and been told we are wrong, that we can’t possibly be hungry.

We might have felt a need to move our bodies in order to regulate them and been told to sit still.

more subtly, We might have noticed other people not expressing discomfort and seen them being more accepted by others

All of these experiences undermine and invalidate our internal experience and often cause us to disregard the signals we are getting in order to fit in.

How Interoception is an issue in Autistic Burnout

Not meeting our basic needs and either not noticing or feeling that our interoceptive signals are wrong is a massive cause of stress for Autistic people and this stress contributes to Autistic Burnout.

In order for interoception to result in regulation there are a number of steps:

1. First you need to notice and feel the sensation in your body.
2. Then you need to interpret this emotion.
3. You need to feel the urge to act on this emotion
4. And then you need to select and execute the appropriate action.
5. All of these steps result in the outcome, whether you are regulated or not.

Each step in this chain can present a problem for an Autistic person, particularly in Autistic Burnout.

1. You might not feel the sensation to begin with.
2. You might not know how to interpret it.
3. You might not feel the urge to act (particularly if you are in hyper focus or experiencing inertia).
4. Then you need to select and execute the right action, so if executive functioning is not working well for you this is another potential barrier.
5. Problems at any of these stages are likely to result in your basic needs going unmet.

Even if you are not aware of your basic needs, not meeting them is likely to cause you stress and health problems which may contribute to your Autistic Burnout. 

Ways you can improve your Interoceptive Awareness

1  Make time and space to notice any existing cues.

Body Scan

(nb.  If the thought of this fills you with dread then you might need support from a therapist or friend before you do this,  or you might prefer to focus on one ‘low risk’ area of your body)

Sometimes taking a moment to focus on each area of your body in turn can help you to notice cues your body is already giving you:

1. Take a moment to focus on each part of your body in turn and see if you are getting any feedback at all from that body part.It’s okay if you don’t feel anything, just move on to the next body part.
2. It’s also okay if you feel something but don’t know how to describe it.
3. Finding a word that best describes any sensation, however vague or nonsensical it might sound is a good starting place.
4. Please don’t be afraid to make up words or use unusual words to describe your experience.
5. What ever you feel is correct, you can’t get this wrong.

You may also find that this exercise makes you feel anxious, particularly if you usually shut off your bodily sensations. If this is the case I would suggest you start with the body part that feels the safest, perhaps your hands or your feet and give yourself permission to leave it there for now.

2  Make a plan for responding to interoceptive cues

Using any existing interoceptive feedback you are getting, either naturally or by ‘checking in ‘ with your body at regular intervals you can start to apply reactive strategies.

If you aren’t sure what your cues are telling you then this may be a case of trial and error. For example I might decide that if my mouth feels dry I will try drinking, if that makes me feel better then next time my mouth feels dry I will drink. In this example I am testing a hypothesis that dry mouth means I am thirsty.

If this is all new to you then I would suggest you start by just adding in one cue to pay more attention and respond to.  

If you are adding in a new cue or strategy for regulation, try to practice this when you are already feeling relatively regulated. 

3  Increase Interoceptive Awareness

You can increase your interoceptive awareness by drawing attention to your body parts at times when they are more likely to be experiencing a sensation.

For example:

• Drawing your attention to your hands before and after squeezing, shaking or washing them or doing a messy activity with them.
• Drawing your attention to your mouth when sucking an ice cube, crunching a carrot, chewing a toffee.
• Drawing attention to your stomach before and after a large meal or drink.

It is much easier to do this when you are already feeling regulated.

Focus on improving your interoceptive awareness at times of low stress rather than trying to learn new skills when you’re already stressed.

Practicing noticing sensations at these times can help you to be more aware of sensations at other times.

4 Use Interoceptive Supports

Without clear interoceptive awareness it is worth building in some interoceptive supports into your daily life.

Interoceptive supports allow you to meet your basic needs without relying on your body to give you information.

It’s important that you don’t use these techniques to over ride bodily sensations, but rather, use them in the absence of any signals from your body.

You can experiment with different schedules or rules and monitor your level of Autistic burnout.

For example:

• Eating: If you don’t eat until you are ravenous, or are very sensitive to feelings of hunger you could try experimenting with scheduling in times to eat, or routines around food.  You could try adding in snacks, eating more frequently, eating at set times of the day. If you are sensitive to changes in your blood sugar levels you might try to eat foods that help to regulate them such as fibre, fats and proteins.
• Drinking: If you don’t notice feeling thirsty or struggle to differentiate between thirst and other sensations, consider increasing your fluid intake.  There is rough guidance in the UK for two litres per day. the right amount for you will depend on lots of factors, including your activity levels, the temperature, etc.
• Toileting: If you don’t notice needing the loo or struggle to differentiate between needing the loo and other sensations, consider scheduling your toileting.  There is rough guidance in the UK for urinating 6-8 times per day and opening bowels anywhere between 3 times a week to 3 times a day.  If you are going a lot more or a lot less than that you might need to check this out with your GP.  You are more likely to open your bowels about 20 minutes after eating so this is a good time to use the loo, but other wise consider setting reminders, using set times of the day and adding it into your existing routines.
• Sleeping If you don’t notice needing to sleep or struggle to differentiate between needing to sleep and other sensations, consider scheduling your bedtime.  There is rough guidance in the UK for getting 8 hours of sleep per night, some people need more than this and some people need less.  If you don’t have any difficulty getting to sleep I would suggest you try experimenting with giving yourself longer to sleep.  If you find you lay awake for along time when you go to bed this can be counter productive so try getting up and doing something that isn’t too exciting or anxiety provoking for an hour or so, then try again.  Having a consistent time that you get out of bed can help you to regulate your sleep but you might need to experiment in order to ascertain what an ideal time to wake up is for you.  If sleep is a problem for you then there are lots of good sleep hygiene resources it might be worth having a look at online. Or if it’s a long term issue it might be worth speaking to your GP.

Summary

• Interoception is a sense that tells us about our emotions
• Emotions include affective (feelings) and homeostatic (maintaining bodily systems)
• Autistic people are more likely to have significant issues with noticing, differentiating, interpreting and responding to interoceptive cues
• You can increase your interoceptive awareness by paying attention to parts of your body during times when they are likely to be giving you more feedback
• You can hypothesise about what any feedback you are getting means
• In the absence of interoceptive cues it is worth scheduling in eating, drinking, toileting and sleeping and monitoring the impact on your level of burnout.

Further Reading

• Kelly Mahler has excellent resources on improving Interoceptive awareness.
• I have created a short standalone course that guides you through meeting your basic needs with and without interoceptive awareness

References

Fiene L, Brownlow C. Investigating interoception and body awareness in adults with and without autism spectrum disorder. Autism Res. 2015 Dec;8(6):709-16. doi: 10.1002/aur.1486. Epub 2015 Mar 25. PMID: 25808391.

Radeloff D, Ciaramidaro A, Siniatchkin M, Hainz D, Schlitt S, et al. (2014) Structural Alterations of the Social Brain: A Comparison between Schizophrenia and Autism. PLOS ONE 9(9): e106539. 

Uddin LQ, Supekar K, Lynch CJ, et al. Salience Network–Based Classification and Prediction of Symptom Severity in Children With Autism. JAMA Psychiatry. 2013;70(8):869–879. doi:10.1001/jamapsychiatry.2013.104