Journal of Psychiatric Research 148 (2022) 84–87

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Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/jpsychires

Interoceptive awareness in anorexia nervosa

Andrea Phillipou a, b, c, *, Susan L. Rossell a, b, David J. Castle d, e, Caroline Gurvich f
a
Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria, Australia
b
Department of Mental Health, St Vincent’s Hospital, Melbourne, Victoria, Australia
c
Department of Mental Health, Austin Health, Melbourne, Victoria, Australia
d
Centre for Complex Interventions, Centre for Addictions and Mental Health, Toronto, Ontario, Canada
e
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
f
Monash Alfred Psychiatry Research Centre, Monash University & the Alfred Hospital, Melbourne, Victoria, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Interoceptive awareness – the sense and awareness of the internal state of our bodies – has been of increasing
Interoception interest in anorexia nervosa (AN) given the observation that people with AN do not respond appropriately to
Eating disorder hunger cues. Despite the interest in the area, very little research has been undertaken to specifically assess
Recovery
interoceptive awareness in AN. The aim of this study was to explore levels of interoceptive awareness in in­
Sisters
dividuals at different stages of AN, as well as first-degree relatives. Eighty participants were compared on self-
Biological
Trait reported interoceptive awareness using the Multidimensional Assessment of Interoceptive Awareness (MAIA),
including participants with a current diagnosis of AN (c-AN), individuals who were weight-restored from AN (wr-
AN), biological sisters of individuals with AN (AN-sis), and healthy controls (HC). Significant group differences
were found for the noticing, not-distracting, self-regulation and trusting subscales of the MAIA; but not for the
not-worrying, attention regulation, emotional awareness or body listening subscales. Specifically, wr-AN and AN-
sis scored higher on the noticing subscale than HC; c-AN and wr-AN scored lower on the not-distracting subscale
than HC; and the c-AN group showed lower scores on the self-regulation and trusting subscales than other
groups. The results suggest that specific aspects of interoceptive awareness such as increased awareness of body
sensations and reduced trusting of one’s body, may relate to AN symptomatology such as ignoring hunger cues,
and may represent trait factors that increase the risk of developing AN.

Anorexia nervosa (AN) is a psychiatric illness characterised by dis­
turbances in body image that drive significant reductions in body weight
(American Psychiatric Association, 2013; Phillipou et al., 2018). The
apparent ability to ignore hunger signals, despite being severely
malnourished, has led many to theorise that deficits in recognising the
body’s sensations may be present in individuals with AN, and act as a
maintenance factor for the illness (Khalsa et al., 2015). Deficits in
interoceptive awareness – the term used to describe the sense and
awareness of one’s internal state of the body (Mehling et al., 2012) – has
been proposed to be involved in AN pathophysiology, and while it is an
area of significant clinical interest (e.g. it is specifically probed in older
eating disorder measures (Garner et al., 1983)), it has remained
understudied.
Research utilising objective measures of interoceptive awareness
such as heartbeat perception tasks have found that people with AN have
a reduced capacity to accurately perceive bodily signals (Pollatos et al.,
2008), while studies using subjective assessments have found poorer
self-reported interoceptive awareness in individuals with acute AN
(Monteleone et al., 2020). Specifically, Monteleone et al. (2020) re­
ported that interoceptive awareness on particular subscales of the
Multidimensional Assessment of Interoceptive Awareness (MAIA) –
including the body listening, self-regulation and trusting subscales –
were associated with AN symptomatology; though, no comparisons with
healthy controls were made. Deficits in interoceptive awareness have
also been specifically implicated in maintaining AN, and interoceptive
awareness scores have been found to improve in recovery (Matsumoto
et al., 2006). Furthermore, some evidence suggests that deficits in
interoceptive awareness may represent genetic susceptibility in AN, as
brain-derived neurotrophic factor blood levels (BDNF; responsible for
feeding behaviour and controlled by the BDNF gene) have been found to
correlate with interoceptive awareness in AN (Mercader et al., 2010).
Given the paucity of research undertaken in this area, specific

* Corresponding author. Centre for Mental Health, Swinburne University of Technology, PO Box 218, Hawthorn, VIC, 3122, Australia.
E-mail address: andreaphillipou@swin.edu.au (A. Phillipou).

https://doi.org/10.1016/j.jpsychires.2022.01.051
Received 6 August 2021; Received in revised form 16 January 2022; Accepted 26 January 2022
Available online 30 January 2022
0022-3956/© 2022 Elsevier Ltd. All rights reserved.
A. Phillipou et al.
hypotheses were not formulated for this study and we aimed to explore
how self-reported interoceptive awareness in individuals with a current
diagnosis of AN (c-AN) differs compared to healthy controls (HC). A
further aim was to explore whether interoceptive awareness deficits are
present in different illness stages, by investigating a weight-restored AN
group (wr-AN). Finally, we explored the potential genetic susceptibility
of interoceptive awareness deficits by examining biological siblings of
individuals with AN (sisters; AN-sis).
1. Methods
The study was granted ethics approval by the Human Research Ethics
Committee (HREC) at The Melbourne Clinic (TMC REC 263), and
expedited ethics approval from Swinburne’s Human Research Ethics
Committee (SUHREC, 2016/152). Written informed consent was ob­
tained from all participants.
1.1. Participants
Eighty participants in total took part in the study, with 20 in each
group: c-AN, wr-AN, AN-sis and HC. All four groups were matched on
age and premorbid intelligence using the Wechsler Test of Adult Reading
(WTAR) (Wechsler, 2001).
All participants were required to be female, English-speaking and
over 18 years of age. Participants were screened for neurological illness,
traumatic brain injury, and current psychotic illness prior to participa­
tion. HC were required to have no history of an eating disorder or other
diagnosed mental illness. wr-AN were required to have a previous
diagnosis of AN by a health professional (psychologist or psychiatrist),
and to have maintained a body mass index (BMI) of 18.5 or over for the
previous 12 months. c-AN participants were required to have a current
diagnosis of AN according to DSM-5 criteria. AN-sis participants were
required to have a biological sibling with a current or past diagnosis of
AN.
1.2. Measures
The Mini International Neuropsychiatric Interview, 5.0.0 (MINI;
Sheehan et al., 1998) was used to determine psychiatric disorders in all
participants. The MINI was also used to confirm diagnoses of AN, with
the exception of the amenorrhea criterion which is not included in
DSM-5. Eating disorder symptomatology was assessed with the Eating
Disorder Examination Questionnaire (EDE-Q) (Fairburn, 2008), with
increased scores being indicative of increased eating disorder symp­
tomatology (ranging from 0 to 6). Interoceptive awareness was assessed
with the Multidimensional Assessment of Interoceptive Awareness
(MAIA) (Mehling et al., 2012), consisting of eight subscales rated on a
6-point Likert scale (ranging from 0 to 5), with lower scores indicating
poorer interoceptive awareness. Subscales of the MAIA include: Noticing
(being aware of uncomfortable, comfortable, and neutral body sensa­
tions), Not-Distracting (tending not to ignore or distract oneself from
sensations of pain or discomfort), Not-Worrying (tending not to worry or
experience emotional distress with sensations of pain or discomfort),
Attention Regulation (ability to sustain and control attention to body
sensations), Emotional Awareness (being aware of the connection be­
tween body sensations and emotional states), Self-Regulation (being able
to regulate distress by attention to body sensations), Body Listening
(actively listening to the body for insight), and Trusting (experiencing
one’s body as safe and trustworthy).
1.3. Statistical analysis
Statistical analyses were performed with SPSS V27. Group compar­
isons were undertaken with a multivariate analysis of variance (MAN­
OVA), followed by between-groups analyses of variance (ANOVAs);
post-hoc comparisons were completed as appropriate. A Bonferroni
85
Journal of Psychiatric Research 148 (2022) 84–87
correction was applied to account for multiple comparisons for the post-
hoc analyses (i.e. six comparisons per subscale: .05/6 = 0.008). Given
the strict multiple comparison correction, trends were identified as
alpha <.05. Pearson’s correlations were also completed for each group
between the MAIA and the EDE-Q, BMI, illness duration and age of
onset, with alpha at <.001 to account for multiple comparisons.
2. Results
Basic demographic information and clinical characteristics are pre­
sented in Table 1.
The MANOVA revealed a significant group difference on the MAIA (F
(24, 226.83) = 4.845, p < .001). Univariate ANOVAs indicated that
groups differed significantly on four subscales of the MAIA (see Table 2
& Supplementary Table 1), namely: the noticing subscale, with increased
scores for wr-AN and AN-sis, compared to HC – and a trend for c-AN to
show increased scores compared to HC; the not-distracting subscale, with
c-AN scoring lower than AN-sis and HC, but not differing to wr-AN, and
the wr-AN group also showing lower scores relative to HC, though this
was only at a trend level; the self-regulation subscale, with the c-AN
group demonstrating lower scores than any other group, though dif­
ferences between c-AN and wr-AN were at a trend level; and the trusting
subscale, with the c-AN group showing lower scores than each of the
other groups and the wr-AN and AN-sis groups scoring lower than HC
(trend for AN-sis vs HC). There were no significant differences across
groups on the other subscales (i.e. not-worrying, attention regulation,
emotional awareness and body listening). The only significant correla­
tion identified was between the MAIA trusting subscale & EDE-Q shape
concern subscale, for the AN-sis group only (r = − .667, p < .001).
3. Discussion
The aim of this study was to explore levels of self-reported intero­
ceptive awareness in c-AN, wr-AN, AN-sis and HC. Groups were not
found to differ significantly on the subscales related to not-worrying,
attention regulation, emotional awareness or body listening. Signifi­
cant group differences were, however, found for the noticing, not-
distracting, self-regulation and trusting subscales of the MAIA.
In relation to the noticing subscale – which relates to awareness of
body sensations – the wr-AN and AN-sis groups showed increased
interoceptive awareness compared with HC (and there was a trend for
the c-AN group to also show increased scores on the noticing subscale,
relative to HC), but c-AN, wr-AN and AN-sis did not differ from one
another. This suggest that increased awareness of body sensations may
be a trait factor in AN that exists irrespective of illness stage, and may
also be related to genetic susceptibility as it was also present in first-
degree biological relatives of people with AN. As there was only a
trend for the c-AN group to show higher noticing to HC following
multiple comparison correction, a larger sample size is needed to in­
crease power to determine whether this relationship exists in c-AN.
Trusting one’s body was significantly poorer in the c-AN, wr-AN and
AN-sis groups, relative to HC; however, the c-AN group showed lower
scores than both wr-AN and AN-sis, suggesting that although perfor­
mance on this subscale may also represent a biological trait factor,
current illness state may exacerbate the inability to trust their body. Self-
regulating one’s distress by attention to body sensations was, however,
found to be poorer only in the c-AN group compared to all other groups
(though, only at a trend level compared to wr-AN), indicating that self-
regulation may be disrupted only in the active illness state when the
individual is underweight. Furthermore, the tendency to distract oneself
from discomfort or pain was poorer in the c-AN group relative to AN-sis
and HC. There was also a trend for the wr-AN group to show poorer
scores compared to HCs, but they did not significantly differ from either
c-AN or AN-sis; ANs-sis also did not differ in comparison with HC. This
pattern of results suggests similarities between c-AN and wr-AN in
poorer ability to distract, but that wr-AN are also similar to AN-sis who
A. Phillipou et al. Journal of Psychiatric Research 148 (2022) 84–87

Table 1
Basic demographic information and clinical characteristics.
c-AN wr-AN AN-sis HC F p
a a a a
Age 22.55(3.10) 22.45(2.79) 22.81(2.90) 24.05(4.39) 0.951 0.421
WTAR 109.15(10.00)a 111.15(9.28)a 108.89(6.85)a 109.63(6.93)a 0.281 0.839
BMI 16.72(1.48) 21.69(1.96)a 23.27(4.00)a 23.38(3.20)a 45.589^ <0.001
AN Age of Onset 15.47(2.12)a 14.45(2.42)a . . 1.971 0.169
AN Illness Duration 5.74(3.94)a 4.34(2.98)a . . 1.52 0.226
AN Weight-Restoration Duration . 3.36(2.72) . . . .
EDE-Q
Restraint 4.04(1.52) 2.28(1.78)a 1.53(1.66)a,b 0.50(0.47)b 36.537^ <0.001
Eating Concern 3.25(1.40)a 1.93(1.88)a 0.53(0.61)b 0.24(0.31)b 32.686^ <0.001
Shape Concern 4.22(1.36)a 3.25(2.01)a,b 1.92(1.48)b,c 1.34(1.17)c 18.603^ <0.001
Weight Concern 4.03(1.50)a 2.91(1.92)a,b 1.66(1.30)b,c 0.98(1.06)c 19.699^ <0.001
Global 3.89(1.25)a 2.60(1.82)a,b 1.51(1.22)b,c 0.81(0.71)c 31.364^ <0.001

Note: c-AN = current anorexia nervosa; wr-AN = weight-restored anorexia nervosa; AN-sis = sisters of people with anorexia nervosa; HC = healthy controls;
WTAR=Wechsler Test of Adult Reading; BMI = body mass index; illness duration and recovery duration reported in years; n = 20/group; ^Welch’s F; values not sharing
the same superscript letters are significantly different.

Table 2
Group differences in interoceptive awareness.
c-AN wr-AN AN-sis HC F p Post-Hoc

MAIA
Noticing 3.05 3.14 3.35 2.38 4.770 0.004 c-AN > HC#, wr-AN > HC, AN-sis > HC, c-AN = wr-AN = AN-sis
(0.82) (0.80) (0.67) (1.10)
Not-Distracting 1.47 1.97 2.23 2.62 6.032 0.001 c-AN = wr-AN, c-AN < AN-sis = HC, wr-AN = AN-sis, wr-AN < HC#
(0.99) (0.76) (0.77) (0.97)
Not-Worrying 2.78 2.79 2.68 3.27 1.317 0.275 .
(1.17) (0.80) (1.05) (1.03)
Attention 2.69 2.92 2.84 2.75 0.305 0.822 .
Regulation (0.99) (0.67) (0.79) (0.84)
Emotional 3.09 3.57 3.38 3.07 1.370^ 0.265 .
Awareness (1.00) (1.05) (0.76) (0.67)
Self-Regulation 1.79 2.45 2.79 2.75 4.160 0.009 c-AN < wr-AN#, c-AN < AN-sis, c-AN < HC, wr-AN = AN-sis = HC
(1.03) (0.95) (0.93) (1.14)
Body Listening 1.60 2.03 2.47 2.12 1.757 0.163 .
(1.20) (1.09) (1.30) (1.22)
Trusting 1.04 2.43 3.05 3.80 24.326 <.001 c-AN < wr-AN, c-AN < AN-sis, c-AN < HC, wr-AN = AN-sis, wr-AN < HC, AN-
(0.91) (1.17) (1.20) (0.87) sis < HC#

Note: c-AN = current anorexia nervosa; wr-AN = weight-restored anorexia nervosa; AN-sis = sisters of people with anorexia nervosa; HC = healthy controls; MAIA =
Multidimensional Assessment of Interoceptive Awareness; lower scores indicate poorer interoceptive awareness; ^Welch’s F; p < .008; #indicates trends at p < .05.

show higher scores on this subscale similarly to healthy individuals.
The findings are consistent with Monteleone et al. (2020) who
identified self-regulation and trusting as subscales of interest to AN.
Unlike Monteleone et al. (2020), however, body listening was not
identified to be related to AN in the present research. The lack of sig­
nificant findings on the several MAIA subscales in the current study is of
interest, and suggests that individuals with AN do not differ from
healthy individuals in terms of worrying about sensations of pain or
discomfort, being able to sustain and control attention to sensations,
being aware of the connection between body sensations and emotional
states, or actively listening to the body for insight.
Although the results reflect preliminary findings in a modestly sized
cross-sectional sample and require replication in a larger sample (to
improve the limited power of this study) with a longitudinal design, they
provide a basis for further work to elucidate the potential role of
interoceptive awareness in the aetiology and maintenance of AN.
Further research using both self-reported and objective measures of
interoceptive awareness would be beneficial, as would assessing the role
of psychiatric comorbidities and different illness stages, including long-
term full recovery from AN. While psychiatric comorbidities were
recorded in this study, they were not controlled for in analyses given the
small sample size and variability in comorbidities.
Overall, the findings suggest that specific aspects of interoceptive
awareness, such as increased awareness of body sensations and reduced
trusting of one’s body, may relate to AN symptomatology such as dis­
regarding hunger cues and may be beneficial to specifically target in
treatment. The findings also suggest that these differences in intero­
ceptive awareness may represent trait factors that increase the risk of
developing AN.
Author statement
AP designed the study, collected the data, performed the statistical
analyses and wrote the first draft of the manuscript. All authors
contributed to the final manuscript.
Data availability statement
Data are available upon reasonable request from the corresponding
author.
Declaration of competing interest
The authors report no conflict of interest in relation to this work.
Acknowledgements
This research was supported by the St Vincent’s Hospital Research
Endowment Fund and the Barbara Dicker Brain Sciences Foundation. AP
is supported by a National Health and Medical Research Council
(NHMRC) Project Grant (CIA: GNT1159953). SR holds an NHMRC Se­
nior Research Fellowship (GNT1154651). The authors would like to

86
A. Phillipou et al.
thank all of the participants who took the time to participate in the
study.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jpsychires.2022.01.051.
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