Altered insula activation during pain anticipation in individuals recovered from anorexia nervosa: Evidence of interocetive dysregulation

Research Service, VA San Diego Healthcare System, San Diego, California
International Journal of Eating Disorders (Impact Factor: 3.13). 01/2013; 46(1). DOI: 10.1002/eat.22045
Source: PubMed


Recent evidence raises the possibility that symptoms of anorexia nervosa (AN) could be related to impaired interoception. Pain is an interoceptive process with well-characterized neuroanatomical pathways that may overlap to a large degree with neural systems that may be dysregulated in individuals with AN, such as the insula.

Functional magnetic resonance imaging (fMRI) was used to assess neural substrates of pain anticipation and processing in 10 healthy control women (CW) and 12 individuals recovered from AN (REC AN) in order to avoid the confounding effects of malnutrition. Painful heat stimuli were applied while different colors signaled the intensity of the upcoming stimuli.

REC AN compared with CW showed greater activation within right anterior insula (rAI), dorsolateral prefrontal cortex (dlPFC) and cingulate during pain anticipation, and greater activation within dlPFC and decreased activation within posterior insula during painful stimulation. Greater anticipatory rAI activation correlated positively with alexithymic feelings in REC AN participants.

REC AN showed a mismatch between anticipation and objective responses, suggesting altered integration and, possibly, disconnection between reported and actual interoceptive state. Alexithymia assessment provided additional evidence of an altered ability to accurately perceive bodily signals in women recovered from AN.

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    • "Specifically, one factor primarily represents uncertainty regarding somatic (e.g., hunger, satiety, heart rate) and affective states (e.g., anxiety, sadness, anger), and another primarily represents the experience of heightened fear or guilt (or disgust) in relation to such somatic and affective states. Disordered eating behaviors , such as dietary restraint or binge eating, may be associated with either or both of these elements when considering hunger and satiety cues, and this has received attention in both eating disorder (Fassino et al., 2004; Pollatos et al., 2008; Strigo et al., 2013) and noneating disorder normal weight and obese samples (Kanoski, Walls, & Davidson, 2007). Similar to what has been found in affective disorders (Mennin, Holaway, Fresco, Moore, & Heimberg, 2007), deficits in the ability to identify or accurately interpret internal physical cues are posited to be associated with eating disorder symptomatology (Herbert & Pollatos, 2012), as individuals diagnosed with AN and BN frequently evidence lower levels of interoceptive awareness compared to noneating disordered controls (Fassino et al., 2004; Lilenfeld, Wonderlich, Riso, Crosby, & Mitchell, 2006; Pollatos et al., 2008). "
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    ABSTRACT: Interoceptive exposure (IE) was originally developed for the treatment of panic disorder. The scope of IE has recently expanded, as the transdiagnostic relevance of interoceptive constructs has become increasingly recognized in diverse problem areas. Despite high comorbidity rates with anxiety and recent attention to interoceptive constructs, IE has received minimal explicit attention in eating disorders. The conceptual and empirical literature supports IE as a transdiagnostic intervention strategy that can be integrated into cognitive‐behavioral therapy (CBT) for eating disorders. In this article, we (a) summarize the relevant literature on interoceptive constructs in eating disorders, (b) review common approaches to exposure in eating disorder treatment, and (c) provide a rationale and concrete suggestions for beginning to integrate IE more explicitly in eating disorder treatment.
    Clinical Psychology Science and Practice 06/2015; 22(2). DOI:10.1111/cpsp.12103 · 2.92 Impact Factor
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    • "While most of the aforementioned functional studies have not differentiated between anterior and posterior insular cortex or not targeted an insular subregion, pain stimuli can be used to specifically probe the posterior insula, which is thought to function as the primary interoceptive cortex [Craig, 2002, 2011]. Two studies have used heat pain in patients with AN and found decreased posterior insula responses during stimulation [Bar et al., 2013; Strigo et al., 2013]. Since the insular cortex is well-connected to the thalamus , amygdalae and basal ganglia [Augustine, 1996; Craig, 2011] reduced posterior insular responses are well in line with our own connectivity results and might lead to a relative insensitivity to pain, an established phenomenon in AN [de Zwaan et al., 1996; Lautenbacher et al., 1991; Raymond et al., 1999]. "
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    ABSTRACT: The neural underpinnings of anorexia nervosa (AN) are poorly understood. Results from existing functional brain imaging studies using disorder-relevant food- or body-stimuli have been heterogeneous and may be biased due to varying compliance or strategies of the participants. In this study, resting state functional connectivity imaging was used. To explore the distributed nature and complexity of brain function we characterized network patterns in patients with acute AN. Thirty-five unmedicated female acute AN patients and 35 closely matched healthy female participants underwent resting state functional magnetic resonance imaging. We used a network-based statistic (NBS) approach [Zalesky et al., 2010a] to identify differences between groups by isolating a network of interconnected nodes with a deviant connectivity pattern. Group comparison revealed a subnetwork of connections with decreased connectivity including the amygdala, thalamus, fusiform gyrus, putamen and the posterior insula as the central hub in the patient group. Results were not driven by changes in intranodal or global connectivity. No network could be identified where AN patients had increased coupling. Given the known involvement of the identified thalamo-insular subnetwork in interoception, decreased connectivity in AN patients in these nodes might reflect changes in the propagation of sensations that alert the organism to urgent homeostatic imbalances and pain-processes that are known to be severely disturbed in AN and might explain the striking discrepancy between patient's actual and perceived internal body state. Hum Brain Mapp, 2015. © 2014 Wiley Periodicals, Inc.
    Human Brain Mapping 01/2015; 36(5). DOI:10.1002/hbm.22736 · 5.97 Impact Factor
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    • "Craig, 2002, 2009) and it has been suggested that insular functioning is altered in AN patients compared to healthy individuals (see e.g. Nunn, Frampton, Fuglset, Torzsok-Sonnevend, & Lask, 2011; Strigo et al., 2013). The insula has also been implicated to be involved in bodily awareness (see e.g. "
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    ABSTRACT: Anorexia nervosa (AN) patients show disturbances in body size experience. Here, malleability of body representation was assessed by inducing the Rubber Hand Illusion (RHI). Specifically the impact of the illusion on body size estimation was investigated. Thirty AN patients and thirty healthy females participated. The RHI was induced synchronously (experimental condition) and asynchronously (control condition) Both before and after induction of the RHI participants were asked to estimate the size of their own and the rubber hand. The results showed that AN patients had a stronger experience of ownership over the rubber hand than healthy females in the experimental, but not the control condition. AN patients and HC did not differ on proprioceptive drift. Before induction of the illusion AN patients overestimated hand width. After induction of the illusion (experimental as well as control condition) AN patients no longer overestimated the width of their hand. Healthy females correctly estimated hand size both before and after induction of the RHI. In conclusion, stronger experience of ownership over the rubber hand in the AN group implies a more malleable body representation in AN patients compared to healthy females. Changed hand size estimation in the AN group appears to be unrelated to the RHI, as it occurred in both the experimental and control condition of the illusion. Alternative interpretations are discussed.
    Neuropsychologia 07/2014; 62(1). DOI:10.1016/j.neuropsychologia.2014.07.003 · 3.30 Impact Factor
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