ARFID and Interoception: A Balancing Act
Understanding ARFID
Avoidant/Restrictive Food Intake Disorder (ARFID) is an eating disorder characterized by a persistent failure to meet appropriate nutritional and energy needs, leading to significant health and psychosocial impairments. One key aspect often overlooked in ARFID is the role of interoception. Interoception refers to the sense that allows individuals to perceive and understand the internal state of their own bodies. It involves the ability to sense and interpret internal signals, such as hunger, thirst, heartbeat, breathing rate, body temperature, pain, emotions, and other bodily sensations. Essentially, interoception is the awareness of physiological and emotional processes happening within oneself (Craig, 2002). Individuals with ARFID frequently face challenges with interoception, either experiencing heightened or muted sensitivity to internal cues, which can exacerbate their condition.
ARFID is distinct from other eating disorders like anorexia nervosa or bulimia nervosa in that it does not involve body image disturbances. Instead, ARFID is driven by an aversion to certain foods, fear of negative consequences from eating (such as choking, vomiting, or allergic reactions), or a lack of interest in eating. These issues can lead to nutritional deficiencies, weight loss, and a range of physical and psychological problems (American Psychiatric Association, 2013).
Interoceptive Challenges in ARFID
Difficulty Recognizing Hunger and Fullness:
Individuals with ARFID often struggle to recognize and respond appropriately to hunger and fullness cues. This may be due to a disrupted interoceptive awareness, where internal signals are either not perceived correctly or are misinterpreted. Consequently, they might eat too little or avoid food altogether, even when their body requires nourishment. A person with ARFID might not feel or recognize hunger cues despite having not eaten for an extended period.
Heightened Sensitivity to Physical Sensations:
Many individuals with ARFID experience heightened sensitivity to physical sensations associated with eating and digestion. This can include an exaggerated response to the texture, smell, or taste of food, as well as discomfort or pain during digestion. The texture of certain foods might cause extreme discomfort or even a gag reflex, leading to avoidance of those foods. Similarly, normal digestive sensations, such as mild bloating, may be perceived as severe discomfort, further discouraging eating.
Fear of Physical Symptoms:
Fear of negative physical symptoms, such as nausea, fullness, vomiting, or choking, is common in ARFID. This fear can be so intense that it overrides normal interoceptive signals, leading to avoidance behaviors that exacerbate nutritional deficiencies and health problems. A person with ARFID might chew excessively or struggle to swallow foods out of fear that swallowing might hurt their throat or because feeling full is associated with pain. This fear tends to outweigh the need to eat.
Misinterpreting Interoceptive Signals:
Misinterpretation of interoceptive signals is another significant challenge. Individuals with ARFID might mistake emotion-induced stomach discomfort for hunger or fullness, leading to further avoidance of food. Anxiety-related nausea might be misinterpreted as a sign that eating will lead to vomiting, when in fact the internal cues are a reflection of an emotional state rather than a digestive state.
Neurodiversity and ARFID
Many individuals with ARFID may also experience neurodiversity. Neurodiverse individuals, such as those with autism or ADHD, often experience challenges with interoception due to varied sensory processing. Unique neurological wiring can affect the recognition and interpretation of internal cues, making it harder to sense hunger, fullness, and thirst (Quigley, Kanoski, & Grill, 2021).
Impact on Hunger and Thirst
Traditionally, hunger is taught to manifest as a grumbling stomach and thirst as a dry mouth. However, for many neurodiverse individuals struggling with interoception, these cues may not be apparent. This discrepancy can lead to dehydration, low blood sugar levels, nausea, and a dysregulated nervous system (Craig, 2009).
To assist individuals with low interoceptive awareness, gentle reminders and visual aids can be effective. These might include setting alarms, hanging pictures around the house, or keeping food and water visible and easily accessible (Mahler, 2017). It’s important to create space for individuals to process and understand their own experiences, rather than teaching them how to “feel in their bodies” or what hunger and thirst should feel like. Human perception of internal signals is highly individual (Garfinkel, Seth, Barrett, Suzuki, & Critchley, 2015).
For instance, while a grumbling stomach is a common sign of hunger, neurodiverse individuals might experience hunger differently. Be open to exploring various bodily signals that indicate hunger and avoid assuming that a grumbling stomach is the only valid cue. To increase interoceptive awareness, it’s important to pay attention to and begin to trust one’s body cues. Begin to ask what hunger, thirst, and fullness feel like in the body. You’ll begin to gain valuable insights into a person’s unique interoceptive experience.
Addressing Interoceptive Challenges in ARFID
Interventions to improve interoceptive awareness and reduce the impact of ARFID can include:
Mindfulness-Based Therapies: Mindfulness practices can help individuals become more attuned to their bodily sensations in a non-judgmental way, improving their ability to recognize and respond to hunger and fullness cues. Mindful eating exercises that focus on the sensory experience of eating can help individuals with ARFID become more comfortable with food.
Interoceptive Exposure: Gradual exposure to feared foods and the physical sensations associated with eating can help desensitize individuals to these experiences and reduce avoidance behaviors. Systematic desensitization techniques, where individuals are gradually exposed to increasingly challenging foods while practicing relaxation techniques, can help reduce fear and improve interoceptive awareness.
Cognitive-Behavioral Therapy (CBT): CBT can help individuals reframe negative thoughts about eating and physical sensations, reducing fear and avoidance behaviors. This can also involve educating individuals about normal digestive processes and sensations. For example, a therapist might work with a person with ARFID to challenge and reframe their fear of choking by providing accurate information about how the body manages swallowing and digestion.
Nutritional Rehabilitation: Working with a dietitian to develop a structured eating plan that gradually reintroduces a variety of foods can help individuals meet their nutritional needs and reduce anxiety around eating. A dietitian might create a meal plan that starts with small, manageable portions of safe foods and gradually increases the variety and quantity of foods as the individual's comfort level improves.
Interoceptive challenges are a significant component of ARFID, contributing to the difficulties individuals face in recognizing and responding to their body's needs. By addressing these interoceptive issues through mindfulness, therapy techniques, and building nutrition over time, individuals with ARFID can improve their relationship with food, enhance their interoceptive awareness, and achieve better health outcomes.
If you are seeking eating disorder treatment or mental health therapy for you or your adolescent, Cypress Wellness Collective can help. Cypress Wellness Collective is located in the San Francisco Bay Area where they specialize in Family Based Treatment (FBT), therapy, and nutrition counseling for teens, adults, and families going through eating disorder recovery. They offer in person and virtual appointments throughout all of California. Call today for your free consultation to see if Cypress Wellness Collective is right for you!
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.
Craig, A. D. (2002). How do you feel? Interoception: the sense of the physiological condition of the body. Nature Reviews Neuroscience, 3(8), 655-666. https://doi.org/10.1038/nrn894
Craig, A. D. (2009). How do you feel—now? The anterior insula and human awareness. Nature Reviews Neuroscience, 10(1), 59-70.
Garfinkel, S. N., Seth, A. K., Barrett, A. B., Suzuki, K., & Critchley, H. D. (2015). Knowing your own heart: Distinguishing interoceptive accuracy from interoceptive awareness. Biological Psychology, 104, 65-74.
Mahler, K. (2017). Interoception: The eighth sensory system. AAPC Publishing.
Murphy, J., Brewer, R., & Catmur, C. (2017). Interoception and psychopathology: A developmental neuroscience perspective. Developmental Cognitive Neuroscience, 23, 45-56. https://doi.org/10.1016/j.dcn.2016.12.006
Quigley, K. S., Kanoski, S. E., & Grill, H. J. (2021). Neurobiology of interoception: Emerging opportunities for research and translation. Psychophysiology, 58(10), e13879.
Schandry, R. (1981). Heart beat perception and emotional experience. Psychophysiology, 18(4), 483-488. https://doi.org/10.1111/j.1469-8986.1981.tb02486.x