Developmental importance of interoception in eating disorders
The severe food aversion displayed by individuals with AN often develops during peripubertal periods, which suggests that a complex interplay between hormonal changes and stressful environments contributes to the expression of psychopathology. This has been characterized as a process of abnormal learning involving fear extinction neurocircuitry, one that is driven by reduced or markedly fluctuating levels of estrogen.13 Even less is known about the role of interoceptive dysfunction in this process. From that standpoint, patient observations can sometimes shine a spotlight on areas worth investigating. A recent comment from a patient with an eating disorder during a diagnostic evaluation seems particularly informative.
A 20-year-old female reported the onset of AN at age 13, characterized by a 30-lb weight loss over the course of a year and a resulting body mass index of 14.0. Moreover, she was plagued by fears of weight gain, active food avoidance behaviors, and body image disturbance (ie, feeling fat) despite her weight loss. When recalling her initial experience of symptoms, she stated, “I would lie in bed feeling like I was suffocating. I could feel the weight on my ribs and I felt like it was suffocating me. I was sure it was anxiety, but I just felt like I was going to die from the weight I was gaining.”
Beyond food-associated discomfort, the fact that anxiety and suffocation fears were distinctly remembered as a key to the onset of her disorder emphasizes the importance of comorbid anxiety and leads to speculation whether signals from associated organ systems, such as the respiratory system, might have played a role in the development of her illness.
Assessing interoceptive awareness in eating disorders
In research settings the accuracy of interoceptive sensing is routinely tested; for example, by comparing a person’s actual heartbeat signals against a subjective report of them. Unfortunately, there are currently no clinically validated tests of interoceptive accuracy for gastrointestinal or any other interoceptive sensations. Clinicians can still assess interoceptive awareness in patients with eating disorders during diagnostic assessments by focusing on the constituent elements.
Dr Khalsa is Director of Clinical Studies, Laureate Institute for Brain Research, University of Tulsa, Tulsa, OK. Dr Khalsa reports no conflicts of interest concerning the subject matter of this article.
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