Interoception refers to the ability to detect and interpret internal bodily signals, such as heartbeat or hunger.
In autism, differences in interoceptive awareness—either heightened or reduced—can contribute to difficulties in recognizing and regulating emotions.
Anxiety is particularly common among autistic individuals, partly because differences in interoceptive processing can trigger or worsen anxiety symptoms, and autistic individuals often experience additional sensory sensitivities and social stressors that further elevate anxiety risk.
Kiera, A., Jonahs, S., Mary, B., Geoffrey, B., & Polly, W. Experiences of interoception and anxiety in autistic adolescents: A reflexive thematic analysis. Autism. https://doi.org/10.1177_13623613251314595
Key Points
- Main focus: Exploring experiences of interoception (detection and interpretation of internal bodily signals) and its relationship with anxiety in autistic adolescents.
- Research aims: To qualitatively understand the role interoception plays in autistic adolescents’ anxiety experiences.
- Qualitative approach: Reflexive thematic analysis using semi-structured interviews.
- Key findings: Interoceptive experiences significantly impacted anxiety, with variations in hyperawareness, hypoawareness, and negative interpretations contributing to anxiety.
- Implications: The findings suggest targeted interventions could be developed to manage anxiety through addressing interoceptive awareness and evaluation, with careful consideration of individual variability.
Rationale
Autistic adolescents have heightened risk for anxiety disorders compared to neurotypical peers, with approximately 40% experiencing one or more anxiety disorders (van Steensel et al., 2011).
Existing interventions often fail to adequately support this population (van Steensel & Bögels, 2015), indicating a knowledge gap regarding anxiety phenomenology among autistic youths.
Interoception is theorized to influence anxiety but remains understudied within autistic populations, particularly adolescents.
Existing research provides inconsistent evidence about whether autistic individuals exhibit differences in interoceptive accuracy, attention, or evaluation, and how these differences influence anxiety (Garfinkel et al., 2016; Trevisan et al., 2021).
The study addresses these gaps by qualitatively exploring adolescents’ lived experiences to inform future research and interventions.
Method
Sample
13 autistic adolescents aged 14–17 from diverse UK backgrounds (varied ethnicity, gender, socioeconomic status).
Setting
UK-based participants, recruited via social media, including diverse socioeconomic and ethnic backgrounds.
Qualitative data collection
One-on-one semi-structured interviews.
Data analysis
Reflexive thematic analysis using inductive coding, thematic mapping, and NVivo 14 software.
Results
Three main themes emerged:
1. Interoceptive Awareness:
- Hyperawareness: Overly heightened focus on bodily signals led to overwhelm and anxiety. “I am almost constantly aware of my heart rate.” (Tealswan)
- Appropriate Awareness: Balanced awareness allowed participants to regulate without inducing anxiety.
- Hypoawareness: Limited ability to detect signals led to delayed anxiety management, intensifying distress.
2. Interoceptive Evaluation:
- Adaptive: Neutral or positive interpretations that did not trigger anxiety.
- Non-adaptive: Overly negative interpretations resulting in anxiety.
- Catastrophising: Perception of bodily signals as signs of severe health issues, intensifying anxiety.
3. Situational Interoception:
- Signal Domain: Different responses depending on bodily signal type (cardiac, respiratory, gastric).
- Arousal: Heightened anxiety and exercise increased awareness, forming bidirectional feedback loops.
- Cognitive Overload: Masking and cognitive overload affected ability to notice bodily signals.
Insight
The study’s novel findings highlight the complexity and variability in interoceptive experiences of autistic adolescents and their relationship to anxiety.
Hyper- and hypo-awareness as well as negative evaluations can each uniquely exacerbate anxiety. This extends prior research by demonstrating the variability and bidirectionality of interoceptive influences on anxiety.
Future research could explore targeted interventions focusing on improving adaptive interoceptive awareness and evaluation in autistic populations.
Clinical Implications
The findings suggest interoceptive-based interventions could improve anxiety management in autistic adolescents.
Recommendations include co-designed interventions focusing on neutral interoceptive evaluation and using wearable technology to manage hypo-awareness.
However, potential anxiogenic effects for those with hyper-awareness need careful consideration.
Strengths
This study had several methodological strengths, including:
- Explicit inclusion of autistic adolescents in PPI (Patient and Public Involvement) at design and analysis stages, enhancing ecological validity.
- Diverse sample, particularly concerning underrepresented groups (female, Black participants, varied socio-economic backgrounds, homeschooling and specialist schooling).
- Thorough reflexive thematic analysis approach with meticulous data familiarization and iterative theme refinement through participant validation.
- Comprehensive documentation of procedures and thematic processes, transparency via open data sharing (OSF repository).
Limitations
This study also had several limitation, including:
- Sample size (13 participants), though adequate for qualitative saturation, may limit generalizability.
- Despite intentional diversity efforts, representation gaps remained for Asian heritage, non-binary adolescents, and participants with severe intellectual disabilities.
- Possible self-selection bias given voluntary participation via social media recruitment, potentially skewing towards participants more comfortable with verbal communication or having heightened self-awareness of anxiety and interoception.
Socratic Questions
- How might the variability in interoceptive awareness within participants affect the design of interventions?
- Could interoceptive hyper-awareness be adaptive under certain circumstances? Provide examples.
- What alternative explanations might there be for the relationships found between anxiety and interoceptive evaluation?
- How might findings differ if the study included non-verbal or severely intellectually disabled autistic adolescents?
- Discuss the potential ethical implications of using wearable technology for managing anxiety in autistic adolescents with hyper-awareness.
