Interoception in autism

Summary

Interoception — the perception of the body’s internal states — is sometimes called the “eighth sense.” It encompasses awareness of heartbeat, hunger, thirst, pain, bladder fullness, breathing, temperature, and the bodily sensations that underpin emotions. While the five external senses and the vestibular and proprioceptive senses have long been studied in autism, interoception has only recently attracted sustained research attention. The evidence so far is mixed and methodologically challenging, but the clinical implications are significant: interoceptive differences may underlie a range of difficulties autistic people experience, from emotional regulation challenges to what can appear to be behavioural problems but are actually unrecognised bodily needs.

What interoception is

Interoception refers to the processes by which the nervous system senses, interprets, and integrates signals from within the body. These signals — originating from the heart, gut, lungs, bladder, muscles, and other organs — travel primarily via the vagus nerve and lamina I spinothalamic pathway to the brainstem, thalamus, and ultimately the insular cortex, which is considered a central hub for interoceptive processing.

Garfinkel, Seth, and Critchley (2015) proposed an influential three-dimensional model of interoception that distinguishes:

• Interoceptive accuracy (also called cardiac interoceptive accuracy, or cIA): the objective ability to detect internal signals, typically measured through heartbeat counting or heartbeat discrimination tasks.
• Interoceptive sensibility: a person’s subjective self-report of how well they perceive their internal states, measured through questionnaires such as the Multidimensional Assessment of Interoceptive Awareness (MAIA) or the Body Perception Questionnaire (BPQ).
• Interoceptive awareness: a metacognitive dimension — how well a person’s confidence in their interoceptive accuracy matches their actual performance.

This distinction matters because the three dimensions do not always align. A person may report being highly attuned to their body (high sensibility) while performing poorly on objective accuracy tasks. The gap between sensibility and accuracy — what Garfinkel et al. (2016) termed the “interoceptive trait prediction error” (ITPE) — may itself be clinically meaningful.

What the evidence shows

A picture of inconsistency — with emerging patterns

Research on interoception in autism is characterised by mixed findings. The most comprehensive meta-analysis to date (Williams et al., 2023, Journal of Autism and Developmental Disorders) systematically reviewed case-control studies and found:

• Interoceptive accuracy: Small to moderate reductions in autistic participants compared to non-autistic controls, though results varied considerably across studies. Some studies found clear differences (Garfinkel et al., 2016; Mul et al., 2018); others did not (Nicholson et al., 2018, 2019; Pickard et al., 2020).
• Interoceptive sensibility: Highly inconsistent. Some studies found autistic participants reported higher body awareness (Garfinkel et al., 2016, using the BPQ), others found lower awareness (Mul et al., 2018, using the MAIA), and others found no difference. Williams et al. (2023) suggest these discrepancies are partly explained by different questionnaires measuring subtly different constructs.
• Interoceptive trait prediction error: Several studies have found that autistic people show a larger gap between their self-reported interoceptive ability and their objective accuracy — in other words, they tend to overestimate their interoceptive abilities. This overestimation has been linked to anxiety (Garfinkel et al., 2016; Palser et al., 2018).

A more recent systematic review and meta-analysis (published in Frontiers in Psychiatry, 2025) confirmed the picture: across 31 studies, there was little evidence of consistent, large-scale differences in interoception between autistic and non-autistic groups, but this is likely because the research is heterogeneous, methodologically limited, and has not adequately controlled for confounds including alexithymia, anxiety, and intellectual ability.

The alexithymia connection

Perhaps the most important finding in this field is that many interoceptive differences attributed to autism may actually be driven by alexithymia — the difficulty identifying and describing one’s own emotions, which co-occurs with autism at high rates (~50%) but is not specific to it (see: alexithymia-and-autism). Bird and Cook (2013) and Brewer, Cook, and Bird (2016) have argued that alexithymia, not autism itself, is the key predictor of interoceptive difficulties. If this is correct, it means that not all autistic people have interoceptive difficulties — but those who do may have particularly pronounced ones, and the mechanism is the alexithymia-interoception connection rather than autism per se.

The predictive processing link

From a predictive processing perspective, interoceptive differences in autism can be understood as atypicalities in how the brain generates and updates predictions about the body’s internal state. If an autistic person’s brain generates overly precise predictions or fails to appropriately weight incoming interoceptive signals, this could produce the kind of mismatch that Garfinkel et al.’s ITPE captures — feeling certain about one’s internal state while being objectively inaccurate. This framework connects interoception to the broader theory of autism as involving differences in predictive coding (see: predictive-processing-and-autism).

Why interoception is often missed

Most widely-used sensory processing assessments — including the Sensory Profile 2, the Sensory Processing Measure, and the Sensory Experiences Questionnaire — were designed primarily around the external senses. Interoception is either absent from these instruments or addressed only tangentially. This means that a person can undergo a thorough sensory assessment and have their interoceptive differences go entirely unrecognised.

Kelly Mahler’s clinical work (2017, Interoception: The Eighth Sensory System) has been influential in raising practitioner awareness that interoception should be assessed and addressed alongside the other senses. The MAIA (Mehling et al., 2012) is the most commonly used research instrument for interoceptive sensibility, but it was not designed specifically for autistic populations, and its psychometric properties in this group are not fully established.

What interoceptive differences look like in practice

For practitioners and carers, interoceptive differences can present as:

• Not noticing hunger until the person is in a state of distress or meltdown. The connection between the meltdown and the missed meal may not be obvious to anyone, including the person themselves.
• Not recognising the need to use the toilet until it becomes urgent, leading to what may appear as “accidents” but is actually a processing delay.
• Difficulty identifying emotions. If emotions are, as many theories suggest, partially constituted by bodily states (the racing heart of anxiety, the gut-clench of fear), then difficulty detecting those bodily states may make it harder to know what one is feeling. This connects directly to alexithymia.
• Unusual pain responses. Some autistic people appear to have very high pain thresholds — not because they don’t experience pain, but because they don’t register or communicate it in expected ways. Others are highly sensitive to pain. Both patterns may reflect interoceptive processing differences.
• Difficulty with emotional regulation. If you can’t detect the early bodily signs of rising distress (increasing heart rate, muscle tension, changes in breathing), you have fewer opportunities to intervene before reaching overload.
• Difficulty distinguishing between internal states — for example, confusing hunger with anxiety, or nausea with emotional upset.

These presentations are often misinterpreted as behavioural problems, non-compliance, or “attention-seeking,” particularly in autistic people with intellectual disability who may have limited means of communicating their internal states.

Open questions

• Are interoceptive differences a core feature of autism, or are they primarily driven by co-occurring alexithymia?
• How do interoceptive processing patterns change across the lifespan? Almost all research has been conducted with adults; very little is known about interoception in autistic children, and even less in autistic people with intellectual disability.
• Can interoceptive awareness be improved through training or intervention, and if so, does this lead to better emotional regulation and wellbeing? Early evidence from Mahler’s interoception curriculum and other body-awareness approaches is promising but limited.
• How should interoception be incorporated into standard sensory processing assessments and frameworks like the prikkelprofiel?
• What would it mean to apply a predictive processing framework to interoceptive interventions?

Implications for practice

• Assess interoception explicitly. Do not assume that a standard sensory profile covers interoception adequately. Ask about hunger cues, thirst, toileting patterns, pain responses, emotional body awareness.
• Consider alexithymia. If a person has difficulty identifying emotions, explore whether interoceptive differences may be contributing.
• Build interoceptive vocabulary. Helping a person develop language (verbal or non-verbal) for their internal states — “my stomach feels tight,” “my heart is beating fast” — can be a foundation for better emotional regulation.
• Don’t assume pain absence means pain absence. An autistic person who doesn’t react to pain may still be in pain. Check, don’t assume.
• Include interoception in the prikkelprofiel. When building a sensory profile, interoception should be listed alongside the other senses — not as an afterthought.

Key sources

• DuBois, D., Ameis, S.H., Lai, M.-C., Casanova, M.F. & Desarkar, P. (2016). Interoception in autism spectrum disorder: a review. International Journal of Developmental Neuroscience, 52, 104–111. doi: 10.1016/j.ijdevneu.2016.05.001
• 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. doi: 10.1016/j.biopsycho.2014.11.004
• Garfinkel, S.N., Tiley, C., O’Keeffe, S., Harrison, N.A., Seth, A.K. & Critchley, H.D. (2016). Discrepancies between dimensions of interoception in autism: implications for emotion and anxiety. Biological Psychology, 114, 117–126. doi: 10.1016/j.biopsycho.2015.12.003
• Williams, Z.J. et al. (2023). Characterizing interoceptive differences in autism: a systematic review and meta-analysis of case-control studies. Journal of Autism and Developmental Disorders, 53, 947–962. doi: 10.1007/s10803-022-05656-2
• Mul, C.-L., Stagg, S.D., Herbelin, B. & Aspell, J.E. (2018). The feeling of me feeling for you: interoception, alexithymia and empathy in autism. Journal of Autism and Developmental Disorders, 48, 2953–2967. doi: 10.1007/s10803-018-3564-3
• Mahler, K. (2017). Interoception: The Eighth Sensory System. Shawnee, KS: AAPC Publishing.
• Bird, G. & Cook, R. (2013). Mixed emotions: the contribution of alexithymia to the emotional symptoms of autism. Translational Psychiatry, 3, e285. doi: 10.1038/tp.2013.61
• Brewer, R., Cook, R. & Bird, G. (2016). Alexithymia: a general deficit of interoception. Royal Society Open Science, 3(10), 150664. doi: 10.1098/rsos.150664
• Proff, I., Williams, G.L., Quadt, L. & Garfinkel, S.N. (2022). Sensory processing in autism across exteroceptive and interoceptive domains. Psychology & Neuroscience, 15, 105–130. doi: 10.1037/pne0000262
• Loureiro, F., Ringold, S.M. & Aziz-Zadeh, L. (2024). Interoception in autism: a narrative review of behavioral and neurobiological data. Psychology Research and Behavior Management, 17, 1841–1853. doi: 10.2147/PRBM.S410605

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