On the relation between interoceptive attention and health anxiety: Distinguishing adaptive and maladaptive bodily awareness

Abstract The objectives of this study were to (1) demonstrate differences in the most common measures of interoceptive attention based on correlations with theoretically relevant emotional constructs, and (2) explore the interoceptive mechanisms contributing to health anxiety. Participants were 327 adults from the general population who completed a series of questionnaires on an online survey tool called Qualtrics. Associations among variables were ana-lyzed using simple correlations and a hierarchical multiple regression. The two most common measures of interoceptive attention were statistically unrelated to each other and had opposite patterns of relationships with measures of worry, health anxiety, and alexithymia. Results from a regression analysis suggest that an interoceptive profile of “high interoceptive attention” and “low interoceptive accuracy” is most predictive of health anxiety. Results suggest that there are “adaptive” and “maladaptive” forms of interoceptive attention that are captured by different measures of interoceptive attention. Researchers should choose measures of interoceptive attention carefully based on their own unique research needs. Findings about the interoceptive correlates of health anxiety may have implications for treatment of illness anxiety disorder.

Interoception is a broad construct pertaining to conscious and non-conscious processing of internal bodily signals.Interoceptive signals, such as hormones and afferent neuronal firing, are transmitted from the body to the brain via diverse pathways, including the bloodstream, spinal columns, and vagus nerve (Barrett et al., 2016;Craig, 2002).In turn, this information is utilized by various brain systems to regulate an array of bodily processes.This bidirectional information exchange is critical for maintaining homeostatic regulation of the body and for mental functioning.Interdisciplinary interest in interoception has amplified in recent years based on findings of atypical interoception in a variety of disparate psychiatric conditions including autism spectrum disorder, schizophrenia, eating disorders, depression, and anxiety (Ardizzi et al., 2016;DuBois et al., 2016;Herbert & Pollatos, 2018;Murphy et al., 2017).For this reason, interoceptive processes represent a transdiagnostic mechanism of pervasive relevance and worthy of increased research focus (Khalsa et al., 2018).
Whereas many interoceptive processes operate beneath conscious awareness (e.g., circadian, respiratory, and cardiac systems), regulation of some interoceptive signals requires conscious attention to the signal.For example, regulation of anxiety is aided by first noticing and attending to physical symptoms of anxiety (e.g., increased heart rate, sweating) and accurately associating those bodily cues with the corresponding physiological state (i.e., anxiety) by discriminating other possibilities (e.g., illness, physical exertion).This example illustrates a useful framework of interoceptive awareness described by Murphy et al. (2019), which differentiates "interoceptive attention" and "interoceptive accuracy."In this model, interoceptive attention refers to the degree to which interoceptive signals are the object of attention throughout daily life, while interoceptive accuracy refers to one's ability to accurately perceive interoceptive signals by locating the signal within the body and associating that signal with specific physiological or emotional states (Murphy et al., 2019(Murphy et al., , 2020)).Thus, regulation of certain interoceptive processes that are available to conscious awareness, requires both attention to the relevant bodily signal, and accuracy in interpreting the meaning of that signal.

Present study
Research Question #1: In a recent commentary, we argued that there are both adaptive and maladaptive forms of interoceptive attention (Trevisan et al., 2020).Adaptive forms of interoceptive attention are based on principles of mindfulness, such that mindful attention to bodily signals can provide useful information about the state of one's body and guide subsequent actions (e.g., rest in response to feelings of fatigue, or eat in response to hunger (Mehling et al., 2012(Mehling et al., , 2018)).;In contrast, maladaptive forms of interoceptive attention may involve hypervigilant or repetitive searching for signs of illness or injury or misattributing benign bodily sensations as medical concerns (Trevisan et al., 2020).Unfortunately, this previously unrecognized distinction may have contributed to confusion in the literature; the two most commonly used measures of interoceptive attention, the Body Perception Questionnaire (BPQ (Porges, 1993); and the Multidimensional Assessment of Interoceptive Awareness [MAIA; (Mehling et al., 2012(Mehling et al., , 2018))] while yet to be validated in this regard, appear to differentially measure maladaptive interoceptive attention versus adaptive interoceptive attention, respectively.BPQ-BA items predominantly cover bodily signs of sympathetic activity and stress with negative biased towards internal body states (Köteles, 2021;Vig et al., 2022).One of the goals of the present study is to empirically examine the hypothesized distinction between adaptive and maladaptive forms of interoceptive attention described in our previous commentary.Specifically, we hypothesized that higher scores on the BPQ (higher maladaptive interoceptive attention) would associate with elevated anxiety (worry), illness anxiety, and alexithymia (i.e., difficulties understanding one's own emotions).In contrast, we predict elevated scores on the MAIA (higher adaptive interoceptive attention) to be associated with lower levels of worry, illness anxiety, and alexithymia.
Research Question #2: If our hypothesis that maladaptive interoceptive attention is associated with elevated illness anxiety is confirmed, we will examine the moderating influence of interoceptive accuracy as measured by Interoceptive Sensory Questionnaire (Fiene et al., 2018).The ISQ was originally designed in neurodivergent populations where it finds increasing utility as a measure for studying interoception (Suzman et al., 2021).While we await further validation of the ISQ, it has been found to correlate with other self report measures like the Interoceptive Accuracy Scale (Murphy et al., 2020).
Having poor interoceptive accuracy may make it difficult for individuals to distinguish benign bodily sensations from serious health concerns.Conversely, strong interoceptive accuracy might reduce the detrimental impact of even high levels of maladaptive interoceptive attention.Previous work by Garfinkel et al. (2015) has shown that high BPQ scores and low cardioperceptive accuracy predicts anxiety in autistic participants.Thus, we predict that high maladaptive interoception in combination with poor interoceptive accuracy will lead to elevated health anxiety.

Participants
Participants (N = 327) were recruited to this study using Amazon MTurk.Registered users viewed a description of this study online and voluntarily participated in the study if they met inclusion criteria.To be eligible for study participation, participants were required to be 18 years of age or older, speak English fluently, and live in the United States.Names of the participants were not collected, although participants were asked to indicate their biological sex, gender, race, ethnicity, and age.Participants were compensated $6 for completing the survey, which took an average of 25.7 minutes to complete.Age ranged from 22-72 years old with a mean of 42.2 years.Participants included 173 (52.9%) men and 154 women (47.1%).Twenty-one (6.4%) participants indicated that they were of Hispanic or Latino descent.In a separate question, 287 (87.8%) indicated they were White, 22 (6.7%) were Black or African American, 13 (4.0%)were Asian, and 5 (1.5%) were mixed.

Materials
Participants completed several questionnaires on Qualtrics, an online survey platform.Previously published self-report questionnaires were used to assess interoceptive attention, interoceptive accuracy, worry, health anxiety, and alexithymia.

Maladaptive interoceptive attention
Maladaptive interoceptive attention was assessed using the 26-item Body Awareness subscale of the Body Perception Questionnaire (Porges, 1993).This questionnaire asks participants to state how often they are aware of bodily sensations such as "Swallowing frequently," "My mouth being dry," or "Muscle tension in my face."The internal consistency of this measure within our sample was α = .98.

Adaptive interoceptive attention
Adaptive interoceptive attention was assessed using the Multidimensional Assessment of Interoceptive Awareness, version 2 (Mehling et al., 2018), which includes 37 items such as "I notice how my body changes when I am angry," or "I listen to my body to inform me about what to do."This measure has 8 separate subscales including Noticing, Not-Distracting, Not-Worrying, Attention Regulation, Emotional Awareness, Self-Regulation, Body Listening, and Trusting (α = .94).

Interoceptive accuracy
Interoceptive accuracy was assessed by a self report measure called the Interoceptive Sensory Questionnaire (Fiene et al., 2018), which includes 20 items such as "I am confused about my bodily sensations," and "Sometimes I don't know how to interpret sensations I feel within my body" (α = .97).As Fiene et al. (2018) conceptualized, higher scores on the ISQ indicate more interoceptive confusion.For the purposes of our study, we conceptualize higher scores on the ISQ as lower interoceptive accuracy, consistent with Murphy et al. (2018).
2.2.3.1.Worry.Worry was assessed using the Penn State Worry Questionnaire (Meyer et al., 1990), which includes 16 items such as "My worries overwhelm me," and "I know I should not worry about things, but I just cannot help it" (α = .97).

Health anxiety
Health anxiety was assessed using the Health Anxiety Inventory (Salkovskis et al., 2002), which has 18 items that require participants to choose between different statements that most closely apply to them.As an example, one item asks participants to choose between the following options: "As a rule I am not afraid that I have a serious illness," "I am sometimes afraid that I have a serious illness," "I am often afraid that I have a serious illness," and "I am always afraid that I have a serious illness" (α = .92).

Alexithymia
Alexithymia was assessed using the Toronto Alexithymia Scale −20 (Bagby et al., 1994(Bagby et al., , 1994)), that requires participants to rate their level of agreement with 20 items such as "I am often confused about what emotion I am feeling" or "When I am upset, I don't know if I am sad, frightened, or angry" (α = .86).

Procedure
Upon voluntarily viewing the study description and agreeing to participate, participants clicked on a link taking them to the Qualtrics survey outside of the Amazon MTurk interface.Participants first read an informed consent description detailing the purpose of the study, how the data is stored and kept confidential, and contact details for further study information.If they agreed to the terms of the study, participants then answered three questions confirming that they speak English fluently, are 18 years of age or older, and live within the United States.Location in the U.S. was also automatically verified by an IP address, and users could not have accessed the survey if their IP address was from a location outside of the United States.The survey logic was designed such that if participants indicated that they were younger than 18 years old or did not speak English fluently they were taken to a page stating that they were not eligible to participate and the survey was terminated.If they were eligible, they advanced to a page to complete demographic information followed by separate pages for each questionnaire.The questionnaires were designed to require a response from participants so they could not advance to the next page unless they completed all items.There were three "attention tests" randomly inserted into various questionnaires that stated, e.g., "This question is to verify that you are paying attention.Select answer C." Upon completion of the entire survey, participants were given a randomly generated code that they entered into Amazon MTurk to verify study completion and receive payment.

Results
Five participants did not pass one or more of the attention tests and were excluded from all following analyses.The first research question was to determine how different measures of interoceptive attention relate differently to theoretically relevant emotional constructs.Table 1 displays intercorrelations between the two measures of interoceptive attention, interoceptive accuracy, and theoretically related emotional constructs.As predicted, higher scores on the BPQ Body Awareness subscale, which we conceptualized as "maladaptive interoceptive attention," were associated with higher levels of worry, higher levels of health anxiety, and unrelated to alexithymia.In contrast, higher scores on the MAIA, which we conceptualized as "adaptive interoceptive attention" were negatively correlated with worry, health anxiety, and alexithymia.It is also worth emphasizing that the MAIA and BPQ were not correlated, r = .002,CI [−.11, .11],p = .977,offering further confirmation that these measures tap distinct constructs.
The second research question concerned the interoceptive mechanisms contributing to health anxiety.We predicted that higher levels of maladaptive interoceptive attention and lower levels of interoceptive accuracy would independently predict higher levels of health anxiety.To explore these relationships, we conducted a hierarchical multiple regression using maladaptive Table 1.Intercorrelations among study measures 1.

Maladaptive Interoceptive Attention (BPQ)
.00 [−.11, .11interoceptive attention, interoceptive accuracy, and their interaction term as independent variables in predicting variability in health anxiety.A key prediction was that maladaptive interoceptive attention and interoceptive accuracy would interact to explain additional variance in health anxiety, such that a combination of high maladaptive attention and low accuracy in interpreting bodily sensations would lead to highest levels of health anxiety.
The BPQ and ISQ were entered separately in the first two steps of a hierarchical regression to examine the independent contributions of maladaptive attention and interoceptive accuracy in explaining variance in health anxiety.As seen in Table 2, both variables independently explained a statistically significant portion of variance in the model.In step 3, the interaction term, calculated as the product of mean-centered ISQ and BPQ variables, was entered into the model.The interaction term explained an additional statistically significant portion of variance to the model.This finding suggests that interoceptive accuracy moderates the relationship between maladaptive interoceptive attention and health anxiety.
Figure 1 is a visual representation of the moderating effect of interoceptive accuracy on health anxiety.For this scatterplot, the sample was split into three groups based on levels of interoceptive accuracy.The correlation between maladaptive interoceptive attention and health anxiety for the high accuracy subgroup was statistically non-significant, r = .108,p = .069.For the medium and high accuracy subgroups, the correlations were r = .443,p < .001,and r = .513,p = .001,respectively.The pattern of findings suggests that for individuals with lower interoceptive accuracy, the relationship between maladaptive interoceptive attention and health anxiety is stronger.

Discussion
A key purpose of this study was to empirically examine the ideas presented in Trevisan et al. (2020).In that commentary, we suggested that there are both adaptive and maladaptive forms of interoceptive attention and that different existing measures of interoceptive attention may be differentially capturing these dimensions.Adaptive forms of interoceptive attention are based on perspectives consistent with the tenets of mindfulness and meditation practices (Kabat-Zinn, 2003).These perspectives suggest that mindful attention towards the state of one's internal bodily and emotional sensations can provide important information about one's physiological and mental state (Mehling et al., 2009(Mehling et al., , 2012)).That information can then be used to guide adaptive behavior necessary for meeting the body's needs, contributing to maintenance of homeostasis and healthy bodily and mental functioning.In contrast, maladaptive interoceptive attention may represent a hypervigilant state of searching for signs and symptoms of illness that both cause and are exacerbated by anxiety about one's health.
Findings from the present investigation support our hypothesis that two of the most common measures of interoceptive attention are capturing distinct valences of interoceptive attention based on opposite patterns of relationships with theoretically related emotional constructs.Higher scores on the MAIA, which we suggest measures an adaptive style of interoceptive attention, are associated with lower levels of worry, health anxiety, and alexithymia.The opposite pattern of findings was found for the BPQ, which we suggest measures a maladaptive style of interoceptive attention, such that higher scores on the BPQ were associated with higher levels of worry and health anxiety but were unrelated to alexithymia.These findings highlight (a) the importance of future research to untangle the respective clinical significance of adaptive and maladaptive forms interoceptive attention and (b) the importance of thoughtful selection of measures of interoceptive attention for specific research objectives.
The 2 × 2 model of interoception (Murphy et al., 2019(Murphy et al., , 2020) ) seeks to describe the interaction between interoceptive attention and interoceptive accuracy and how they are measured.Other than the apparent methodological differences, there are critical differences in self report versus sensory measures of interoceptive accuracy (Gabriele et al., 2022) with some evidence that the subjective process around perceiving internal states is more relevant to clinical states (Adams et al., 2022;Ferentzi et al., 2019).Top down processes such as biases in one's perception of internal states appear to have a more reliable relationship with clinical concerns like illness anxiety and functional disorders (Wolters et al., 2022).This study sought to explore the interoceptive mechanisms related to health anxiety.Higher levels of maladaptive interoceptive attention and lower levels of interoceptive accuracy both independently predicted health anxiety.The two constructs also interacted such that interoceptive accuracy moderated the relationship between maladaptive interoceptive attention and health anxiety.Subgrouping our sample based on levels of interoceptive accuracy revealed a pattern such that the relationship between maladaptive interoceptive attention and health anxiety was strongest in individuals with lower interoceptive accuracy.This makes intuitive sense; a person with high levels of interoceptive attention combined with high interoceptive accuracy may have continual awareness of bodily sensations but would also be able to easily distinguish benign bodily sensations from serious health conditions.In contrast individuals with an interoceptive profile featuring high attention and low accuracy would continually examine the body for interoceptive sensations but have difficulty accurately distinguishing benign bodily sensations from serious health concerns.This profile of constant body-scanning combined with interoceptive confusion was most predictive of excessive worry about one's health.

Limitations and future research directions
As this study was conducted entirely online, we necessarily assessed interoception using only selfreport measures.Future research should aim to verify these findings using objective measures of interoceptive accuracy, such as heartbeat tracking tasks (Schandry, 1981;Whitehead et al., 1977), and objective measures of interoceptive attention, such as experience sampling methods (Csikszentmihalyi & Larson, 2014;Murphy et al., 2019).Given limitations of self-report methods and criticisms of extant objective measures of interoceptive accuracy (Murphy et al., 2018), it is an urgent priority for this field of research to develop and validate new objective measures of various interoceptive constructs [e.g., see, Murphy et al. (2018)].
Another limitation is that this study examined health anxiety and all other variables of interest continuously in a convenience sample of adults from the general population.Future research should examine the findings in individuals with diagnoses of illness anxiety disorder to better understand the interoceptive profiles of individuals who meet diagnostic criteria.Illness anxiety disorder is a psychiatric condition defined by a preoccupation with having or acquiring serious illness, high levels of anxiety about personal health, or excessive focus on healthrelated behaviors [(e.g., repeatedly checking body for signs of illness; (American Psychiatric Association, 2013)].Future investigations could provide clinically relevant information regarding illness anxiety disorder treatment and the potential benefit of consideration of interoceptive processes.For example, individuals with significant health anxiety who have a maladaptive interoceptive attention style may benefit from interventions that focus on establishing adaptive interoceptive attention styles based on principles of mindfulness and meditation (Kabat-Zinn, 2003).For example, Bornemann and Singer (2017) observed that individuals from the general population who practiced mindfulness and meditation techniques over a 9-month period displayed marked improvements in alexithymia and interoceptive accuracy.In another investigation with autistic participants, Quadt et al. (2021) demonstrated that increasing interoceptive accuracy using a behavioral feedback intervention leads to a decrease in anxiety.Future research should examine whether such interventions targeting specific interoceptive processes may be effective in treating the core symptoms of health anxiety.