Dr Emma Goodall is an autistic author, advocate and Adjunct Research Fellow at the University of Southern Queensland, Australia. Here, Emma explains interoception and its effect on mental wellbeing, and how professionals can support autistic people who experience interoception difficulties. 

Interoception is an internal sensory system in which the physical and emotional states of the person are consciously or unconsciously noticed, recognised and responded to. For example:

• a person notices their stomach is rumbling and they have a pulling sensation in their abdomen
• they recognise this as signaling hunger
• they respond by eating something.

Interoception skills are required for a range of basic and more advanced functions, such as knowing when to go to the toilet or being aware that you are becoming angry or upset. 

Regardless of age, the development of interoception can slow down or even stop for autistic people. It is not known why this happens, although it may be due to a self-protection mechanism associated with trauma. Many autistic people experience trauma, and this may halt or lower their interoceptive awareness.

Mental wellbeing

If a person’s interoception is not fully developed, they may find it difficult to manage their emotions and social interactions. If someone does not recognise the signals for an emotion, they are not able to respond to it. This can result in anger becoming rage, sadness becoming distress and so on. Other people can perceive this as dysregulation or a lack of emotional maturity. 

When people are experiencing mental health difficulties and/or overwhelm with life, their interoceptive accuracy decreases significantly or disappears completely.  This may affect their ability to self-regulate and self-manage. Self-regulating is the ability to express emotions and feelings, appropriate to context. Self-management is the ability to respond helpfully to biological needs such as hunger and thirst.

As an example, when I am overwhelmed I am much more easily distressed by small sensory things. I often have no idea what emotions I am experiencing. When in this state, I am less able to self-manage my eating or drinking as I do not notice nor recognise my body signals of hunger and thirst. I am also less able to self-regulate my emotions as I am not aware of the emotion that is developing and so cannot respond helpfully. This means anxiety may skyrocket before I realise I am anxious. At this point I have no idea what will help manage my anxiety, whereas normally I would do some interoception activities, such as belly breathing or toe curls, to self-calm and decrease my anxiety.

Survival instinct

Our survival instinct drives our actions and over-rides our emotions and feelings. It is the ultimate in self-managing. For example, if a large snake slithers out of the grass and into our path, we do not want to think ‘oh a snake’, then notice our heart rate quicken, then feel panic and then react. Instead, we want our survival instinct to take over.

However, in non-life-threatening situations, we do need to be able to notice our internal body signals, feelings and emotions, so that we respond or behave appropriately. Part of the difficulty for people with atypical interoception is that they can become overly reliant on their survival instinct, since they ‘misinterpret’ situations and events as life-threatening. 

Assessing interoception

When autistic people ask for support with chronic stress or mental health difficulties, it is important to assess their interoceptive abilities and address these, as well as supporting their mental wellbeing. You can evaluate an adult’s interoceptive awareness using the Interoception Sensory Questionnaire (ISQ) (Fiene, Ireland & Brownlow, 2018), or a shorter questionnaire, such as Goodall’s Interoception Evaluation and Support Plan (Goodall, 2022). 

These tools evaluate an individual’s interoceptive awareness over a number of areas. When attempting to evaluate our own or someone else’s interoceptive awareness, it is not appropriate to ask ‘do you know when you feel hot?’ as many people will say ‘yes’, regardless of their interoceptive awareness. Instead, they should be asked ‘how do you know when you feel hot?’ or ‘what signals does your body show you (or make) so that you know when you are getting hot?’ If someone does not yet have a basic level of interoceptive awareness, then this needs to be developed before they focus on their emotional awareness.

Support

We can use external or internal signals and supports to develop interoception awareness. One is not superior to the other, however external signals are not available for everything, so it is useful to continually improve our internal awareness.

External supports may include:

• smart watches – these can be used to measure heart rates 
• weather apps – this can guide a person’s awareness of temperature and support them to choose appropriate clothing. 
• hydration and Bristol stool charts to check pee and poo
• water bottles linked to apps that prompt you to drink
• verbal or visual prompts to eat, drink and/or go to the toilet.

Internal supports and activities improve interoceptive awareness through somatic therapy (body connection activities), and have been shown to improve wellbeing. These mindful body awareness activities need to be done 2-3 times a day for at least 8 weeks. It is useful to build these into a daily routine, such as first thing in the morning, just before leaving the house and just before going to bed. Examples of these activities might include hand breathing and shoulder shrugs.

Examples of internal supports and activities can be found at:

• Interoception kit
• Healthy Possibilities (YouTube)