The felt sense of the body: an empirical evaluation of a mindful-interoceptive approach to post-traumatic stress disorder

  • Kelly Leech

Student thesis: Doctoral Thesis


Traumatic events, from personal tragedies to national and global crises, occur on an everyday basis and people may be repeatedly exposed directly or indirectly to these events. A prominent traumatic event, the coronavirus disease (COVID-19), a global pandemic, is suggested to pose the greatest test to humans since World War II with the impact spanning worldwide to over 200 countries. The depth and breadth of the impact COVID-19 has on individuals’ mental health is yet to be fully realised, with vulnerable populations including those with pre-existing mental health disorders, those placed in quarantine, the unemployed and casualised workforce, as well as healthcare workers and first responders (Black Dog Institute, 2020). The demands placed on first responders have significant consequences and they are particularly vulnerable to developing post-traumatic stress disorder (PTSD) from elevated exposure to such traumatic incidents (Karam et al., 2014).

Repeated exposure to traumatic incidents alters the functioning of the brain and autonomic nervous system. Individuals experiencing PTSD oscillate between dysregulated responses of hyper- and hypo- arousal and additionally experience a range of cognitive impairments which are disruptive to psychological and social functioning. An important feature of affect regulation is interoceptive awareness. Interoceptive awareness is the ability to observe feelings arising from the body that allows for a sense of emotional status and physical condition (Craig, 2003). Having an enhanced ability to mindfully notice and attend to body sensations is suggested to improve an individual’s ability to respond effectively and appropriately to physiological dysregulation observed in PTSD. This in turn is suggested to reduce symptoms of PTSD. How interoceptive awareness may contribute to and maintain PTSD symptoms and the mechanism behind its influence is relatively unexplored in the research. Conceptual frameworks and theories have proposed connections between interoceptive awareness and emotion regulation (Price & Hooven, 2018) and the generation of physiological symptoms and stress response based on an altered interoceptive awareness (Schulz & Vögele, 2015); however, no theory has tested a model of the relationship that exists. Furthermore, limited or no research has investigated interoceptive awareness between different trauma populations (e.g., first responders and frontline healthcare workers) and identified factors which pose as a risk or protection to interoceptive awareness.

At present, the literature varies on the way interoceptive awareness is termed, defined, and conceptualised. It has previously been linked to increasing anxiety symptoms as it was understood through the lens of a ruminative focus on bodily sensations which likely exacerbate catastrophising cognitions thought to be associated with heightening anxiety. With this understanding, interoceptive awareness has received little attention in regard to the aetiopathogenesis and treatment of PTSD. More recent and contemporary definitions have incorporated a mindfulness element which appears to account for the adaptive characteristics of increasing one’s awareness and attention of the physiological state of the body. Interoceptive awareness is suggested to integrate the mind and body and be a key ingredient in this important interplay. Cognitive models of PTSD have historically largely focused largely on the role of distorted cognitions, information processing, and memory in the development and maintenance of PTSD (Ehlers & Clark, 2000; Foa & Kozak, 1986). Additionally, heightened arousal and hypervigilance are thought to stem from those cognitive approaches (Foa & Kozak, 1986; Ehlers & Clark, 2000). This has led to a treatment focus centering on top-down, cognitive approaches. Interoceptive awareness extends the understanding of these models through the incorporation of beliefs, attributions, and biases resulting in a somatic bottom-up focus. This is particularly important, as with trauma, ‘the body keeps the score’ (Van der Kolk, 2014).

The overall objective of this thesis was to evaluate a mindful-interoceptive approach to PTSD. It aimed to do this by firstly reviewing the current literature on interoceptive awareness and PTSD to identify the current understanding. A scoping review was conducted to answer four main questions relating to interoceptive awareness and PTSD: how is interoceptive awareness defined, how is it measured, what is the function of interoceptive awareness, and what is the relationship between interoceptive awareness and PTSD. The scoping review identified this as a rapidly growing area of research with very little being conducted prior to 2015. Largely the definition and method of assessment has varied across disciplines, but the incorporation of an adaptive mindful component to the definition, and the use of the self-report measure, Multidimensional Assessment of Interoceptive Awareness, was more dominant throughout the literature reviewed. The most compelling function of interoceptive awareness was the influence it appeared to have on affect and emotion regulation with clinical trials indicating an indirect association with PTSD. However, none directly assessed the relationship.

Secondly, this thesis aimed to develop and test the mindful-interoceptive model of PTSD to understand the relationship between interoceptive awareness, emotion regulation, and PTSD symptomology. A path analysis was conducted with the final model demonstrating three elements of interoceptive awareness to have a direct negative relationship with difficulties in emotion regulation which in turn had a direct positive relationship with PTSD symptomology. This confirmed the presence of a negative relationship between interoceptive awareness and difficulties in emotion regulation, supporting the relationship previously theorised by Price and Hooven (2018), and the model further established this in turn influenced PTSD symptomology. The model accounted for 34% of variance in PTSD symptomology. It expanded current theory by determining three specific elements of interoceptive awareness, non-distracting, not-worrying, and body trusting, to directly influence PTSD symptomology.

Thirdly, this thesis aimed to explore the presence of a feedback loop theorised by Schulz and Vögele (2015) to be occurring between interoceptive awareness and autonomic reactivity, that explains the maintenance of a dysregulated nervous system in individuals with PTSD. Regression analyses were conducted revealing a largely bidirectional relationship between the elements of interoceptive awareness and supradiaphragmatic autonomic reactivity, suggesting possible sympathetic nervous system arousal. Furthermore, this study further validated the significant impact adverse childhood experiences have on an individual’s autonomic reactivity which through the feedback loop would continue to affect interoceptive awareness.

Lastly, it examined the variables which may serve as risk and protective factors for interoceptive awareness in individuals with PTSD and compared differences between first responders, frontline healthcare workers, and other trauma survivors. It utilised regression analyses to understand which traumatic event characteristics predict more impaired interoceptive awareness and MANOVAs to examine between trauma group differences. Results of this study confirmed the association between interoceptive awareness and PTSD, validating the mindful-interoceptive approach to PTSD. Other trauma survivors were found to have more impaired elements of interoceptive awareness, greater difficulties with emotion regulation, and consequently higher PTSD symptomology compared to the other two trauma groups. Characteristics such as experiencing physical and sexual abuse, higher severity events, and being younger at the time of the trauma all pose risks for impacting an individual’s element of interoceptive awareness, body trusting, the ability to trust and find a sense of safety in the body. Lastly, this study identified a possible protective factor for first responders and frontline healthcare. The element of interoceptive awareness, not-worrying (the tendency to experience distress and worry pertaining to uncomfortable somatic sensations) was not only higher in this population compared to other trauma survivors but was comparable to the general population without PTSD.

This thesis proposes the incorporation of a mindful-interoceptive approach to the aetiopathogenesis and treatment of PTSD which is theoretically and empirically supported. The implications of interoceptive awareness on PTSD underscore the intricate relationship between mind and body in the context of trauma and mental health. Recognising the impact of impaired interoceptive awareness in individuals with PTSD offers promising avenues for early detection, prevention, and treatment. Incorporating interoceptive awareness techniques into therapeutic approaches and tailoring it for the risk and protective factors presented in each trauma population, may help individuals with PTSD regain control over their emotions. This would ultimately contribute to their overall well-being and quality of life. As innovative therapeutic strategies continue to be explored, the mindful-interoceptive approach offers a holistic path towards recovery, recognising that healing from PTSD is not solely a matter of the mind or body but an integrated journey towards resilience.
Date of Award6 Jun 2024
Original languageEnglish
SupervisorPeta Stapleton (Supervisor) & Alan Patching (Supervisor)

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