On the generalised embodiment of pain: how interoceptive sensitivity modulates cutaneous pain perception.
ABSTRACT Individual differences in interoceptive sensitivity are associated with differences in reported intensity of emotional experience, vulnerability to anxiety and mood disorder and capacity for emotional self-regulation. Enhanced sensitivity to autonomic state is often accompanied by increased autonomic reactivity. Here we tested the hypothesis that healthy people classified as more interoceptively sensitive, by their performance of a heartbeat monitoring task, will demonstrate enhanced perception of pain. We further explored whether this effect is associated with a greater physiological reactivity to the pain stimuli. Using an algometer, cutaneous pressure pain was applied to the thenar eminence in 60 healthy participants. Heart rate variability and respiratory activity were recorded concurrently. We observed significant relationships between heightened interoceptive sensitivity and both enhanced sensitivity and decreased tolerance to pain. These effects were accompanied by a more pronounced parasympathetic decrease and a change in sympathovagal balance during pain assessment in the high, compared to the low, interoceptively sensitive group. Our study provides novel evidence that interoceptive sensitivity is associated with the experience and tolerability of pain in conjunction with reactive changes in autonomic balance.
- SourceAvailable from: Piotr Winkielman[show abstract] [hide abstract]
ABSTRACT: Findings in the social psychology literatures on attitudes, social perception, and emotion demonstrate that social information processing involves embodiment, where embodiment refers both to actual bodily states and to simulations of experience in the brain's modality-specific systems for perception, action, and introspection. We show that embodiment underlies social information processing when the perceiver interacts with actual social objects (online cognition) and when the perceiver represents social objects in their absence (offline cognition). Although many empirical demonstrations of social embodiment exist, no particularly compelling account of them has been offered. We propose that theories of embodied cognition, such as the Perceptual Symbol Systems (PSS) account (Barsalou, 1999), explain and integrate these findings, and that they also suggest exciting new directions for research. We compare the PSS account to a variety of related proposals and show how it addresses criticisms that have previously posed problems for the general embodiment approach.Personality and Social Psychology Review 02/2005; 9(3):184-211. · 6.07 Impact Factor
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On the generalised embodiment of pain: How interoceptive sensitivity
modulates cutaneous pain perception
Olga Pollatosa,⇑, Jürgen Füstösa, Hugo D. Critchleyb,c
aDepartment of Psychology, University of Potsdam, Germany
bBrighton and Sussex Medical School, University of Sussex, UK
cSackler Centre for Consciousness Science, University of Sussex, UK
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
a r t i c l e i n f o
Received 13 October 2011
Received in revised form 28 March 2012
Accepted 30 April 2012
Cutaneous pain perception
a b s t r a c t
Individual differences in interoceptive sensitivity are associated with differences in reported intensity of
emotional experience, vulnerability to anxiety and mood disorder and capacity for emotional self-regu-
lation. Enhanced sensitivity to autonomic state is often accompanied by increased autonomic reactivity.
Here we tested the hypothesis that healthy people classified as more interoceptively sensitive, by their
performance of a heartbeat monitoring task, will demonstrate enhanced perception of pain. We further
explored whether this effect is associated with a greater physiological reactivity to the pain stimuli. Using
an algometer, cutaneous pressure pain was applied to the thenar eminence in 60 healthy participants.
Heart rate variability and respiratory activity were recorded concurrently. We observed significant rela-
tionships between heightened interoceptive sensitivity and both enhanced sensitivity and decreased tol-
erance to pain. These effects were accompanied by a more pronounced parasympathetic decrease and a
change in sympathovagal balance during pain assessment in the high, compared to the low, interocep-
tively sensitive group. Our study provides novel evidence that interoceptive sensitivity is associated with
the experience and tolerability of pain in conjunction with reactive changes in autonomic balance.
? 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
Pain is an unpleasant sensory and emotional experience associ-
ated with actual or potential tissue damage. Thus, pain is funda-
behaviour. This is reflected in the common classification of pain
into a sensory-discriminative and a negative affective component,
the currency of punishment as primary reinforcement. Pain is
modulated on a cognitive level depending on attention, anticipa-
tion, emotion and memory of previous pain experience .
Empirical studies demonstrate that measures of pain perception
are associated with changes of internal bodily reactions, such as
heart rate (HR), skin conductance response, baroreflex sensitivity
and HR variability (HRV) [4,35,52]. HRV measures are commonly
used to estimate the sympathovagal balance .
The generation and perception (interoception) of internal states
of bodily arousal are central to many theoretical accounts of
emotion [18,19,31,57]. James  presented an influential psycho-
logical theory linking somatic and visceroafferent feedback to sub-
jective emotional experience (feelings). This model argues that an
emotive stimulus automatically initiates visceral, vascular or so-
matic reactions such as changes in blood pressure or HR; and it
is the perception of these bodily reactions that crucially constitutes
the emotional component of experience. Refinements of this model
include the notion of somatic markers, which represent involun-
tary changes in internal bodily state signaling stimulus significance
to guide both emotional and cognitive behaviour (eg, decision
Such peripheral models of emotion led to an interest in individ-
ual differences in the perception and sensitivity to changes in
internal bodily state. Individuals differ substantially in measures
of interoceptive sensitivity, the ability to perceive consciously sig-
nals arising from the body. Interoceptive sensitivity is commonly
quantified by measuring a person’s ability to perceive and accu-
rately report one’s heartbeats at rest [7,17,20,47,49,58]. Differences
in interoceptive sensitivity are related with both reported emo-
tional experience, and corresponding psychophysiological markers
of emotion processing [21,29,44,46,48,64]. Moreover the strength
of correspondence between cognitive–affective processing and
0304-3959/$36.00 ? 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
⇑Corresponding author. Address: Department of Psychology, Faculty of Human
Sciences, Karl-Liebknecht-Str. 24/25, 14476 Potsdam, Germany. Tel.: +49 331 799
2895; fax: +49 331 799 2793.
E-mail address: firstname.lastname@example.org (O. Pollatos).
?153 (2012) 1680–1686
Author's personal copy
bodily reactions depends on whether individuals can perceive bod-
ily changes well—or not .
Experimental studies of pain demonstrate the importance of
bodily changes for the experience of pain, such as changes in HR
. It is hypothesized that interoceptive sensitivity interacts with
pain in part by facilitated detection of bodily changes accompany-
ated with the self-regulation of behaviour in situations that are
accompanied by somatic and/or physiological changes. These
sion making [21,62], can be usefully formulated in terms of somatic
markers. Nevertheless, the interaction of pain with interoceptive
sensitivity remains poorly understood. To address this shortfall,
we conducted a study on healthy participants who differed in levels
of interoceptive sensitivity determined from accuracy of heartbeat
ity would be associated with measures of pain threshold, tolerance
and pain experience. Moreover, we hypothesized that this effect
would also be associated with underlying differences in physiolog-
ical reactivity as measured by HRV to pain stimuli.
Sixty participants (mean ± SD age 24.4 ± 3.2, 30 men and 30 wo-
men) were recruited from an introductory psychology course and
by advertising announcements at the university. All participants
were screened for health status via a questionnaire. Participants
were excluded if they had a history of chronic pain, any common
psychiatric disorder, in particular anxiety disorders or depression
(or any other axis 1 disorders) according to the Diagnostic and Sta-
tistical Manual of Mental Disorders . Drug use (except of contra-
ceptives) was also an exclusion criterion. Experiments were
conducted in accordance with the Declaration of Helsinki. Ethical
approval from a local ethics board was obtained. All participants
provided written informed consent.
2.2. Procedure outline
Upon arrival at the laboratory room in the Department of Psy-
chology, each participant completed a set of questionnaires. After-
wards, they were fitted with physiological recording equipment for
HR (electrocardiography) and respiration (respiratory belts), using
a portable Biopac system (Biopac MP150, version 2.7.2.). The room
was air-conditioned with an average room temperature of 23 ?C.
All experiments were conducted between 9 and 12 o’clock in the
morning. The experiment started with a 10-min rest period in
which the baseline measures were assessed. This period was fol-
lowed by the interoceptive sensitivity task. First, interoceptive sen-
sitivity was assessed using 4 heartbeat counting phases (varying in
length) in accordance with the Mental Tracking Method suggested
by Schandry . Participants were asked to count their own
heartbeats silently and to verbally report the number of counted
heartbeats at the end of the counting phase. The beginning and
the end of the counting intervals were signaled acoustically. Inter-
oceptive sensitivity was estimated as the mean heartbeat percep-
tion score according to the following transformation:
? counted heartbeatsÞ=recorded heartbeats?
Score ¼ 1=4
½1 ? ðrecorded heartbeats
The mean ± SD obtained heartbeat perception score was 0.66 ±
0.15. We used a median split procedure to contrast participants
with higher interoceptive sensitivity (mean 0.79, high IS) to partic-
ipants with lower interoceptive sensitivity (mean 0.54, low IS). The
distribution of the heartbeat perception scores for both groups is
depicted as box-and-whisker plot in Fig. 1.
Then pain thresholds were assessed (twice on each hand side,
alternating between the left- and right-hand side, 60-s break after
one assessment on right- and left-hand side), which took an aver-
age of 4 min. Afterwards, pain tolerance measures were taken
(twice on each hand, alternating between left and right hands,
60-s break in between, mean duration 3 min). The average dura-
tion of the pain assessment block was 10 min (range 9–11 min).
Autonomic measures were recorded during the whole duration of
both pain threshold and tolerance measurements. Subsequent
analysis of autonomic responses was performed over an average
length of 10 min. Subjective pain intensity and unpleasantness
was assessed immediately at the end of each pain trial with a 9-
point self-rating scale.
2.3. Pain assessment
Pain thresholds and tolerance were measured with a pressure
algometer (FDN200; Wagner Instruments, Greenwich, CT) that ex-
erts forces up to 20 kg/cm2(corresponding to ?2000 kPa). This de-
vice is used to identify the pressure and/or force eliciting a
pressure–pain threshold and tolerance level. This validated meth-
od has a high interrater reliability in the rate of force application
[3,8,33]. Before testing, all involved investigators were familiar
with the algometer after practice sessions. The handheld algometer
had a 1 cm2round rubber application surface, which was placed
over the thenar eminence of the hand [53,54]. The pressure pain
threshold was determined with 3 series of ascending stimulus
intensities, each applied as a slowly increasing ramp of 50 kPa/s
(?0.5 kg/cm2per second). This procedure leads to high reliability
of the algometer assessment, in accordance to previous studies
[8,43]. Each trial was stopped when the participant experienced
the pressure applied by the algometer as painful. Pain tolerance
levels were then assessed; again, each trial was aborted as soon
as participants experienced the pressure as unbearable. We had
previously established the reliability of this assessment in a group
of 34 healthy participants in a pilot study at the University of Pots-
dam (Supplementary Material). Test–retest reliability scores
(Cronbach’s alphas) between both assessments were sufficiently
high (threshold: a = .90, P < .001; tolerance: a = .84, P < .001).
2.4. Autonomic measures
Mean HR and respiration rate during baseline and pain assess-
ment were recorded with a Biopac system (Biopac MP150, version
2.7.2.) and the corresponding software AcqKnowledge (Biopac Sys-
tems, Santa Barbara, CA). Signals were sampled at 500 Hz and ana-
lysed by a computer-based data acquisition system. HRV was
analysed stepwise as described by Herbert et al. . The details
are described in the Supplementary Material.
In short, R-R intervals were imported into a HR analysis pro-
gramme (HRV Analysis Software, version 1.1., SP1, The Biomedical
Signal Analysis Group, Department of Applied Physics, University
R-R interval data in order to obtain power spectrum density values
for high-frequency (HF; 0.15–0.40 Hz), low-frequency (LF; 0.04–
0.15 Hz), and very low-frequency (VLF; <0.04 Hz) spectra. These
ranges were based on previously established standards defined by
the Task Force of the European Society of Cardiology and North
American Society of Pacing and Electrophysiology . Because
the power in these frequency bands can vary widely within and be-
tween individuals, to generate more exact measures of the specific
O. Pollatos et al./PAIN
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by dividing the powerin eachband by the total power minusthe DC
LF component seems to be influenced by both parasympathetic and
sympathetic outflow [6,37]. Sympathetic influences on the LF com-
ponent seem to become more explicit if LF power is expressed in
normalised units(LF n.u.) , while the LF/HF ratiois oftenconsid-
ered to be an estimate of sympathovagal balance .
2.5. Pain unpleasantness and pain intensity
Perceived pain unpleasantness and pain intensity were assessed
after each pain trial (both threshold and tolerance) with a 9-point
rating scale. Participants were asked to rate their feelings concern-
ing pain unpleasantness (1: not unpleasant at all; 9: maximum
unpleasantness) and pain intensity (1: barely perceivable; 9: max-
imum intensity) while exposed to pain stimuli.
2.6. Data analyses
We calculated Pearson’s correlation coefficient between intero-
ceptive sensitivity and mean pressure pain thresholds as well as
tolerance levels. Pressure pain thresholds as well as tolerance lev-
els were analysed by a repeated measures analysis of variance (AN-
OVA) with the factors Measurement (threshold, tolerance) and
Group (high/low IS).
HR, respiration and HRV measures (HF, LF, LF/HF ratio) were
analysed by repeated measures ANOVA with the factors Experimen-
tal Condition (baseline, pain assessment) and Group (high/low IS).
Where appropriate, degrees of freedom were adjusted according
to the Greenhouse–Geisser correction . Correlation analyses
were assessed between interoceptive sensitivity and HRV mea-
sures, referring to the whole sample. All results are presented with
focus on the factor Group.
In a last step, we focused in more detail on the relationship be-
tween pain measures, interoceptive sensitivity and autonomic
changes. Two hierarchical regression analyses (criteria: pain
threshold, pain tolerance) were carried out. Sex, age, change in
sympathovagal balance (HF/LF ratio), interoceptive sensitivity
score and computed interaction terms between interoceptive sen-
sitivity and change in sympathovagal balance were included as
3.1. Pain assessment
Mean pain threshold was 4.6 kg/cm2, and mean pain tolerance
score was 6.7 kg/cm2. We observed a significant effect of Group
(F(1,58) = 6.02, P < .05, g2= .10, e = .68) indicating lower threshold
and tolerance scores in participants with high IS (mean 5.1 kg/cm2)
as compared to low IS (6.2 kg/cm2) (Fig. 2). We observed significant
inverse correlations between interoceptive sensitivity and pain
threshold (r = ?.42, P < .01), as well as pain tolerance (r = ?.33,
P < .05). Scatter plots depict these correlation coefficients (Fig. 3).
Fig. 1. Distribution of the heartbeat perception scores contrasting participants with high vs low IS.
Fig. 2. Pain threshold and tolerance scores contrasting participants with high vs
low IS (⁄P < .05).
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3.2. Pain unpleasantness and intensity
We observed a significant Group (F(1,58) = 4.19, P < .05,g2= .07,
e = .53)and
Group ? Measurement
P < .05, g2= .09, e = .64) indicating that the high IS group evaluated
stimuli at threshold pain level as significantly more unpleasant
(mean 7.0) when compared to the low IS group (mean 6.3, Fig. 4).
Referring to perceived pain intensity (1: lowest intensity, 9: highest
intensity), no significant main or interaction effect with regard to
interaction(F(1,58) = 5.49,
3.3. HR, respiration, and HRV
HR (F(1,58) = 57.31, P < .001, g2= .50, e = 1.00) and respiration
rate (F(1,58) = 4.67, P < .05, g2= .11, e = .64) were significantly in-
creased during pain perception (mean 82.5 beats/min and mean
16.6 breaths/min) as compared to baseline (mean 7.1 beats/min
and 14.1 breaths/min). Additionally, a significant Experimental Con-
dition ? Group interaction (F(1,58) = 8.74, P < .01, g2= .13, e = .83)
was observed indicating that the increase in HR was more pro-
nounced in the high IS group (baseline 69.1 bpm, pain assessment
86.4 bpm) as compared to the low IS group (baseline 71.5 bpm,
pain assessment 8.2, Tukey tests, P < .05).
For HRV, mean HF n.u. was significantly decreased during pain
assessment (mean 28.3) compared to baseline (mean 46.6,
F(1,58) = 4.06, P < .001, g2= .41, e = 1.00) (Fig. 4). Additionally, a
significant Experimental Condition ? Group interaction (F(1,58) =
8.74, P < .01, g2= .13, e = .83) was found. This interaction suggests
that the decrease in HF n.u. was more distinct in the high IS group
in comparison with the low IS group (Tukey test, P < .05). In other
words, the parasympathetic decrease was more pronounced in the
high IS group. The opposite pattern was observed for LF n.u.
LF/HF ratio significantly increased during pain assessment
(mean 3.27, F(1,58) = 64.11, P < .001, g2= .52, e = 1.00) as com-
pared to baseline (mean 1.47) indicating an increase in sympa-
thetic influence on sympathovagal balance (Fig. 5). Additionally,
a significant Experimental Condition ? Group interaction (F(1,58) =
8.74, P < .01, g2= .13, e = .83) occurred: The change in sympath-
ovagal balance was more pronounced in the high IS group as
compared to the low IS group, and both groups differed signifi-
cantly in LF/HF ratio during pain assessment (Tukey post hoc tests,
P < .05).
3.4. Interactions between change in sympathovagal balance,
interoceptive sensitivity and pain assessment
Because the change in sympathovagal balance and its interac-
tion to interoceptive sensitivity was one key finding, we performed
a correlation analysis between the interoceptive sensitivity score
and the change in LF/HF ratio. Interestingly, the correlation analy-
ses yielded a significant positive correlation of r = .41 (P < .01)
Fig. 3. Scatter plots between heartbeat perception scores (a) pain threshold and (b) pain tolerance scores.
Fig. 4. Perceived pain unpleasantness for threshold and tolerance levels stimuli
contrasting participants with high vs low IS (⁄P < .05).
Fig. 5. HRV measures (HF n.u. indicates high frequency normalised units; LF/HF
ratio, low frequency/high frequency ratio) contrasting participants with high vs low
IS (⁄P < .05).
O. Pollatos et al./PAIN
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which denotes a more substantial change in sympathovagal bal-
ance in relationship to interoceptive sensitivity. We depicted a
scatterplot of this relationship in Fig. 6. However, we did not ob-
serve any significant correlation between the change in LF/HF ratio
and pain threshold (r = ?.10, P < NS) as well as pain tolerance
(r = .02, P = NS).
In a last step, 2 hierarchical regression analyses (forward step-
ping) were performed using either pain threshold or pain tolerance
as criterion and sex, age, change in sympathovagal balance (HF/LF
ratio), interoceptive sensitivity and interaction terms between
interoceptive sensitivity and change in sympathovagal balance as
Pain threshold was explained by differences in interoceptive
sensitivity (T = ?3.81, b = .43, P < .001) and age (T = 2.71, b = .31,
P < .01, F(2,57) = 1.70, P < .001, R = .52, R2= .27). All other predic-
tors were not included. Concerning pain tolerance, the only predic-
tor included was interoceptive sensitivity (T = 2.97, b = .33, P < .05,
F(1,58) = 6.97, P < .05, R = .31, R2= .11).
In accordance with our hypotheses, we found evidence for a po-
sitive relationship between interoceptive sensitivity and the per-
ception of pain stimuli, both on a threshold as well as on a
tolerance level. These differences were accompanied by a larger
decrease in parasympathetic activity and a more pronounced
change in sympathovagal balance during pain assessment in the
high IS group as compared to the low IS group. When introducing
experimentally induced mechanical pain, the ‘normal’ reactivity
pattern involves both an increase in sympathetic as well as a de-
crease in parasympathetic activity. In conclusion, the present re-
sults demonstrate interaction of interoceptive sensitivity with
changes in sympathovagal balance, pain threshold and pain toler-
ance. However, pain measures per se as used in the paradigm were
not predicted by sympathovagal changes.
It is important to note that humans also differ in their sensitiv-
ity to other interoceptive conditions, such as esophageal or rectal
distension or thermal discomfort [27,40]. There is sparse evidence
that pain perception is associated with interoception of inputs
from different organ systems like the cardiovascular system or
the gastrointestinal system , suggesting that interoceptive sen-
sitivity may covary across different modalities. It is nevertheless an
open question whether cardiac sensitivity is also correlated to
other interoceptive conditions and other pain qualities such as vis-
ceral pain , as induced by rectal balloon distension or stomach
distension. In this study, pain led to a clear increase in sympathetic
activation known to be associated with activation of the right ante-
rior insula [12,14], a key structure for interoceptive sensitivity as
measured by heartbeat detection [17,51]. If the interoceptive con-
dition is associated with another autonomic pattern, such as a
parasympathetic increase, the observed interaction between car-
diac sensitivity and pain sensitivity may be undetectable.
When we interpret pain both as a distinct sensation and as a
motivation reflecting homeostatic behavioural drive (a homeo-
static emotion), such as suggested by Craig , we would expect
that interoceptive sensitivity covaries with particular emotional
conditions. We thereby extend findings of Dunn et al. , who
stress the notion that interoceptive sensitivity determines the
strength of the relationship between bodily reactions and cogni-
tive–affective processes as demonstrated by emotional and deci-
sion-making paradigms. Our data further demonstrate that both
pain threshold and tolerability are fundamentally associated with
interoceptive processes. We interpret our findings as indicating
that better detection of internal signals and evoked bodily changes
seems to increase pain perception for pressure pain. This was re-
flected in negative relationships between interoceptive sensitivity
and pain measures, which remained significant in regression anal-
yses that accounted for multiple interrelations between observed
We again observed, as have others, that autonomic reactivity
was positively correlated to interoceptive sensitivity, suggesting
that autonomic reactivity might be enhanced in participants with
high interoceptive sensitivity [28,45,50]. Thus, the enhanced abil-
ity of high IS individuals to perceive their bodily changes might
be further augmented by the more pronounced nature of such
changes. Thus, such a mechanism would facilitate the establish-
ment and short-term consolidation of somatic markers that could
be used to guide individual motivational behaviours in parallel
with the sensory signaling of pain. Our findings suggest a contex-
tual embellishment of the somatic marker hypothesis by Damasio
[18,19]. Furthermore, our regression analyses demonstrated that
interoceptive sensitivity (rather than differences in autonomic
reactivity) explained variance of the pain measures obtained. For
this reason, we suggest that future studies should focus on investi-
gating subgroups of participants selected priori with respect to dif-
ferential autonomic reactivity and interoceptive sensitivity.
Internal signals like one’s heartbeats are centrally processed via
dedicated pathways and both their neural representations as well
as their conscious perception provide key information accessible
to many cognitive and emotional processes [9,44]. Here, the insular
cortex plays a major role as a cortical projection area of viscerosen-
sory input . Craig  suggests 3 sequential processing steps
involving different portions of the insula consistent with the view
for a posterior-to-anterior progression in the insula. Raw intero-
ceptive signals such as those coming from visceral changes and,
importantly, pain, first project to the posterior insula and become
progressively integrated with contextual motivational and hedonic
information as they progress towards the anterior insula. There is
ample evidence that the activation of the insula is positively corre-
lated with interoceptive sensitivity [17,47,51]. What is more, the
cortical potential reflecting the processing of heartbeats (heart-
beat-evoked potential) was found to be associated with activation
in the right insula [25,47]. It is therefore likely that this structure
serves as an interface between interoception, interoceptive sensi-
tivity and pain processing.
The insular cortex and the anterior cingulate play crucial roles
connecting interoceptive processes and emotions [9,15,16]. Their
activation was found to be modulated by cognitive [5,56] and
Fig. 6. Scatter plots between heartbeat perception score and change in sympath-
O. Pollatos et al./PAIN
?153 (2012) 1680–1686
Author's personal copy
emotional factors in several studies [5,14,34,41]. We used HRV as
one approach to assess sympathovagal balance and associated
changes during pain assessment, but there are other methods
using the cardiac vagal tone, cardiac output measures derived from
impedance cardiography or baroreceptor sensitivity. Interestingly,
recent research highlights that HRV measures might be differen-
tially associated with activation of the insula  suggesting a lat-
eralization within the insula with the right insula strongly
associated with measures of sympathetic influence. One might
speculate whether the observed shift in sympathovagal balance
as assessed with the LF/HF ratio is also reflected in a similar activa-
tion change within the right and left insula.
Interoceptive sensitivity is also associated with more intense
negative and positive feelings, as in response to emotional pictures
[29,44,46]. Differences in the affective evaluation of pain stimuli
highlight the impact of interoceptive processes on cognitive–affec-
tive aspects of pain [23,32,55,60,65]. Theories of embodied cogni-
tion hold that higher cognitive processes operate on perceptual
symbols. Perceptual symbols involve the reactivation of previous
sensory-motor states occurring during experience with the world
[2,22,38]. It is stated that mental representations in bodily formats
including motoric, somatosensory, affective and interoceptive
information have an important role in cognition and emotion.
Our results support this notion by demonstrating that interocep-
tive processes and sensitivity to interoceptive signals are crucial
variables for explaining interindividual differences in respect
to the perception of pain and its cognitive–affective evaluation
Our study provides the first empirical evidence that interocep-
tive sensitivity and associated activation of interoceptive represen-
tations and metarepresentations of bodily signals profoundly
interact with the processing and the subjective experience of pain-
ful stimuli. Interoceptive processes and sensitivity to these pro-
cesses (as assessed by a heartbeat detection task) is associated
with our painexperience, extending theoreticalconceptsof embod-
ied cognition and embodied emotion to the field of pain perception.
For this reason, assessing interoceptive sensitivity in clinical sam-
ples—for example, in somatoform patients or in depression—might
be a powerful approach to explain different observations with re-
spect to autonomic reactivity and might provide ideas for novel
therapeutic interventions, as based on interoceptive sensitivity
Conflict of interest statement
The authors report no conflict of interest.
We thank Jennifer Meyer, Kevin Görsch, Alexander Dreyer, and
Sarah Wankner for their support in data assessment and data pro-
cessing, and Julia Schneider for her editorial support.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.pain.2012.04.030.
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