The Interoceptive Attentiveness fMRI Task is a functional magnetic resonance imaging assay of the ability to deploy attention toward information that is internal (i.e., inside the body) versus external (e.g., outside the body). In this task brain activation is measured while the participant is asked to alternate between turning their attention inward (‘Interoception’ condition) and outward (‘Exteroception’ condition). The interoceptive target can be any internal body organ, such as the heart, bladder, stomach, or lungs, although a focus on the heart and the sensations of heartbeats is most commonly used. The exteroceptive target is typically a standard external attention task, such as monitoring for changes in visual stimuli that appear on the screen, as in the widely used Continuous Performance Test. The dependent measure for the Interoceptive Attentiveness fMRI Task is BOLD activation in the Interoception > Exteroception contrast in one specific region of interest, namely the insula. The exteroceptive attention condition is designed to engage visual attention as “purely” as possible, without working memory or emotional components (which may activate the insula and therefore confound the contrast between this condition and the interoceptive condition).
The Interoceptive Attentiveness fMRI Task aims to provide a brain-based, objective marker of interoception. Interoception is the body-to-brain axis of sensation concerning the state of the internal body and its visceral organs, as opposed to exteroception, which is perceiving stimuli of the external environment (and proprioception, which is perceiving posture and position of one’s own body parts) (Sherrington, 1948; Cameron, 2001). Interoception has been proposed as a target for behavior change. Classically, research had linked interoception with maladaptive mental states including exaggerated focus on physical sensations, rumination and catastrophizing associated with negative health outcomes, including increased anxiety and pain disorders. However, with the advent of third-wave cognitive behavioral therapies and increased interest in mindfulness-based interventions, more adaptive conceptualizations of interoception have been proposed and interoceptive ability has been associated with more positive health outcomes (reviewed in Loucks, Schuman-Olivier, Britton, Fresco, Desbordes, Brewer, & Fulwiler, 2015; Tang, Hölzel, & Posner, 2015; Hölzel, Lazar, Gard, Schuman-Olivier, Vago, & Ott, 2011). It has been proposed that interoception consists of 3 distinct and dissociable dimensions: (1) interoceptive accuracy (correct, precise, and reliable detection of internal events such as heartbeats or gastric contractions using objective behavioral tests), (2) interoceptive awareness (metacognitive awareness of interoceptive accuracy indicated by a strong correspondence between subjective confidence ratings and objective interoceptive accuracy), and (3) interoceptive sensibility (the extent to which individuals attend to their internal states, usually assessed using interviews/questionnaires) (Garfinkel, Seth, Barrett, Suzuki, & Critchley, 2015). The Interoceptive Attentiveness fMRI task is an objective, quantitative measure of brain activation during an interoceptive task. It is well known that the insular cortex (or insula) plays a central role in interoception; accordingly, the interoceptive attentiveness fMRI task has been found to reliably activate the insula in a recent meta-analysis (Schulz, 2016). Importantly, this fMRI task does not include a performance measure and therefore provides complementary data to those provided by performance measures of ‘interoceptive accuracy’ and ‘interoceptive awareness’. As such, it is most closely related to the ‘interoceptive sensibility’ dimension of interoception. The choice of the term ‘interoceptive attentiveness’ to describe this task was proposed by Schulz (2016) “as a suitable descriptor for focused attention to a particular interoceptive signal for a given time interval that is … unambiguous with regards to the existing literature on interoception” (p. 6). Interoceptive sensibility is a potential mechanism of behavior change because, among others, it is associated with depressive mood. Unmedicated Major Depressive Disorder patients exhibited decreased activity bilaterally in the dorsal midinsula cortex during interoception (focusing on either heart, bladder, or stomach), compared to healthy subjects. In addition, activity within the insula during the heart-focused condition was negatively correlated with both depression severity and somatic symptom severity in depressed subjects (Avery, Drevets, Moseman, Bodurka, Barcalow, & Simmons, 2014). In another study using this task (with heart-focused interoception), currently depressed participants showed lower activation in the anterior insula, compared to both healthy controls and patients in remission from major depression (Wiebking, de Greck, Duncan, Tempelmann, Bajbouj, Northoff, 2015). These results suggest that successful treatment of depression may normalize the insula response to this task, indicating that this fMRI assay could be influenced by successful interventions.
[+] PMCID, PUBMED ID, or CITATION
PubMed ID: 25451381
PubMed ID: 26482755
PubMed ID: 25783612
PubMed ID: 26168376
|Garfinkel-et-al.-2015-Knowing-your-own-heart-Distinguishing-interoceptive-accuracy-from-interoceptive-awareness.pdf Schulz-2016-Neural-correlates-of-heart-focused-interoception-a-functional-magnetic-resonance-imaging-meta-analysis.pdf Loucks-Curr-Cardiol-Rep-2015.pdf Tang-Hölzel-Posner-2015-The-neuroscience-of-mindfulness-meditation.pdf Hölzel-et-al.-2011-How-does-mindfulness-meditation-work-Proposing-mechanisms-of-action-from-a-conceptual-and-neural-perspective.pdf Avery-et-al.-2014-Major-depressive-disorder-is-associated-with-abnormal-interoceptive-activity-and-functional-connectivity-in-the-in.pdf Wiebking-et-al.-2015-Interoception-in-insula-subregions-as-a-possible-state-marker-for-depression-an-exploratory-fMRI-study-investig.pdf|
The heart-focused interoceptive attentiveness fMRI task has been used in multiple studies, recently summarized in a meta-analysis (Schulz, Phil. Trans. R. Soc. B. 2016). Overall, this task was found to reliably activate an extended brain network including the posterior right and left insula (a known major gateway for relaying interoceptive information), right claustrum, precentral gyrus and medial frontal gyrus (part of prefrontal cortex, possibly reflecting both top-down attention deployment and processing of bottom-up interoceptive signals from the heart). However, the 9 studies included in this meta-analysis used healthy adult participants under the age of 43; more studies are needed to validate the task in other populations (i.e., older adults, children, clinical populations).
Healthy adults, adults with major depression.
This task has been used in depression research, since major depression often features interoceptive dysfunction. When performing this fMRI task, unmedicated Major Depressive Disorder patients exhibited decreased activity bilaterally in the dorsal midinsula cortex during interoception (focusing on either heart, bladder, or stomach), compared to healthy subjects. In addition, activity within the insula during the heart-focused condition was negatively correlated with both depression severity and somatic symptom severity in depressed subjects (Avery et al., Biol. Psychiatry 2014). Another study used this task (with heart-focused interoception) to investigate differences between patients with current major depression, patients in remission from major depression, and healthy controls (Wiebking et al., Front Behav Neurosci. 2015). Depressed participants showed lower activation in the anterior insula, compared to both healthy and remitted participants. These results suggest that successful treatment of depression may normalize the insula response to this task, indicating that this fMRI assay could be influenced by successful interventions.
Mindfulness-based interventions are especially of interest given their explicit focus on interoceptive training. Using a breath-focused interoceptive attentiveness task, a cross-sectional fMRI study found different engagement of the insula and the dorsomedial prefrontal cortex (DMPFC) in recent graduates of a Mindfulness-Based Stress Reduction 8-week course, compared to waitlist controls; mindfulness training predicted greater activation in the anterior dysgranular insula, consistent with greater integration of interoceptive sensation with external context, and reduced activation in the DMPFC (part of the brain’s default mode network) (Farb et al., Soc. Cogn. Affect. Neurosci. 2013).
Healthy adults, adults with major depression.
This measure has not been validated yet.
This fMRI task is used in several ongoing trials by investigators from the SOBC Research Network. The Mindfulness in Primary Care (Mindful-PC) clinical trial includes a pilot fMRI study which uses this Interoceptive Attentiveness fMRI task at pre and post 8-week mindfulness training, with preliminary results expected by April 2018 (ClinicalTrials.gov Identifiers: NCT03265600, NCT02972853; PI: Schuman-Olivier). This task is also used in a randomized controlled trial of Mindfulness-Based Cognitive Therapy (ClinicalTrials.gov Identifier: NCT02200341; PI: Desbordes).
The Science of Behavior Change (SOBC) program seeks to promote basic research on the initiation, personalization and maintenance of behavior change. By integrating work across disciplines, this effort will lead to an improved understanding of the underlying principles of behavior change. The SOBC program aims to implement a mechanisms-focused, experimental medicine approach to behavior change research and to develop the tools required to implement such an approach. The experimental medicine approach involves: identifying an intervention target, developing measures to permit verification of the target, engaging the target through experimentation or intervention, and testing the degree to which target engagement produces the desired behavior change.
Within the SOBC Measures Repository, researchers have access to measures of mechanistic targets that have been (or are in the processing of being) validated by SOBC Research Network Members and other experts in the field. The SOBC Validation Process includes three important stages of evaluation for each proposed measure: Identification, Measurement, and Influence.
The first stage of validation requires a measure to be Identified within the field; there must be theoretical support for the specific measure of the proposed mechanistic target or potential mechanism of behavior change. This evidence may include references for the proposed measure, or theoretical support for the construct that the proposed measure is intended to assess. The second stage of validation requires demonstration that the level and change in level of the chosen mechanistic target can be Measured with the proposed measure (assay). For example, if the proposed measure is a questionnaire, the score on the measure should indicate the activity of the target process, and it must have strong psychometric properties. The third stage of validation requires demonstration that the measure can be Influenced; there must be evidence that the measured target is malleable and responsive to manipulation. Evidence relating to each stage includes at least one peer-reviewed publication or original data presentation (if no peer-reviewed research is available to support the claim) and is evaluated by SOBC Research Network Members and experts in the field.
Once a measure has gone through these three stages, it will then either be Validated or Not validated according to SOBC Research Network standards. If a measure is Validated, then change in the measured target was reliably associated with Behavior Change. If a measure is Not validated, then change in the measured target was not reliably associated with Behavior Change. Why would we share measures that are not validated? The SOBC Research Network values open, rigorous, and transparent research. Our goal is to make meaningful progress and develop replicable and effective interventions in behavior change science. Therefore, the SOBC sees value in providing other researchers in the field with information regarding measures that work and measures that fall short for specific targets. Further, a measure that is not validated for one target in one population may be validated in another target or population.
Want to learn more? For any questions regarding the SOBC Validation Process or Measures Repository, please email firstname.lastname@example.org.
Has the mechanism been identified as a potential target for behavior change? This section summarizes theoretical support for the mechanism.
Have the psychometric properties of this measure been assessed? This section includes information such as content validity, internal consistency, and test-retest reliability.
Has a study manipulation led to change in the mechanism? This section addresses evidence that this measure is modifiable by experimental manipulation or clinical intervention.
Has a change in this mechanism been associated with behavior change? This section addresses empirical evidence that causing change in the measure reliably produces subsequent behavior change.