How does interoception change as we move through the polyvagal states? That is the thread we follow here, from the receptors that quietly re-tune themselves depending on whether we feel safe, to the mismatch in the insula that turns a gut signal into oh, something is off. It is a deep one, full of everyday moments, a touch on the neck, a full bladder in a meeting that ran long, that make the neuroscience land.
We set out to understand interoception in the mix of polyvagal theory: how the body’s internal signals shift as we move between a regulated ventral state, sympathetic mobilisation, and dorsal shutdown, and what that means for the kids in front of us. Tracy takes us deep into the receptors, and the lovely, surprising idea that they are not fixed, they become more open or more bristly depending on whether we feel safe and connected.
We keep landing it in the everyday: Tracy’s daughter who only wants her neck touched in the right context, a little boy who no longer needs to touch to share his joy, and Michelle nearly wetting her pants in a meeting because the signal never got loud enough until it was urgent. Along the way we get into the posterior and anterior insula, the moment neuroception tips into awareness, and why we have to treat both the valence and the discrimination when we work on something like toileting. It is a meandering, generous conversation that, as ever, keeps finding its way back to the clinic.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Cory: Before you get stuck into today’s episode on interoception, I want to make sure you all know that Tracy’s SPIRIT model training is now widely available to those who are interested. If you enjoy these kinds of discussions, I can a thousand percent recommend the SPIRIT model training that Tracy and her team at DFX have so diligently put together, so that people all around the world who have been asking and asking for it can access it. If you want to deepen your practice and improve your ability to think holistically about treatment, and how best to come at the complex, dynamic situations we find ourselves in, hit the link in the description and check it out, because it will be so worthwhile. The other small note is that a little while ago Seed was asked by a local preschool to put together an online course on the basics of regulation: how it typically unfolds in development, how to integrate some of the newer theory around polyvagal states as occupational therapists, and some practical strategies to support it at home or in an educational setting. So that course is available. If you have a parent, or you are working with someone, who might benefit from a basic course on regulation, even newer therapists, reach out and we can point you in the right direction. But we will hold you up no longer. Enjoy.
Cory: We are wondering today about interoceptive processing, and how it relates to polyvagal theory, because we have been talking about that in terms of making sense of our arousal, and whether we are safe or not, and linking that to the states in our nervous system, and the different processing in those different states. We were curious about interoception in the mix of all of this, because we touched on it in the somatosensory processing episode as part of that processing. We wanted to flesh out how interoception changes as we move through the different states. So if we are in a ventral vagal state, in the social engagement system and regulated, but interoceptive processing is still weak, what should we be thinking about clinically, and what could we do? And if we get stressed and move into a sympathetic state, what is inherently disrupted in interoceptive processing? I know it is not as simple as pure sympathetic activation or pure ventral vagal, but we will try to keep it as simple as we can, though maybe not, because we like to go there. And then if we hit more of a dorsal vagal shutdown, an immobilisation state, what might be happening in interoceptive processing, what can we look out for clinically, and how might we adjust our treatment depending on where kids are at? So what do you think?
Michelle: That’s the next three episodes.
Tracy: Of questions. Next three episodes, right on, Michelle. It is really cool to think about each of these systems in such detail. What is interesting for me is that, because I have studied the brain a lot, I have disciplined myself to think about the pathways, the tracks, the receptors, where the information goes and for what purpose. What happens so often in our thinking about these sensory integrative processes is that it is easy to be either too general or too detailed. In the podcast forum we do not have visuals, though we can post a couple of articles in the show notes, so I am picturing the pathways in my own mind’s eye, or thinking about the insula. We do not often say to each other in normal conversation, I am thinking about the insula.
Cory: We should.
Michelle: Anterior, posterior.
Tracy: That’s right. So it brings up all those questions: where is interoception, what is it, how is it processed? And it is connected to our state, which we can think about in a rich and beautiful way through polyvagal theory. So that gives us a lot to talk about, and none of it is directly clinical, so as I meander through the what-is-the-receptor-doing parts, help me land it back in clinical cases, because that is what is so beautiful about this podcast, the way we dialogue about the clinical implications and bring it to life for us as occupational therapists.
Cory: That sounds good. Were you going to talk about the receptors in the interoceptive system today, Trace?
Tracy: I think we should touch on it, partly because it is interesting that when we say state of the nervous system, let’s say we are in a ventral state, the receptors function differently than they do when we are in a dysregulated state. We sometimes think of states as happening in the autonomic or central nervous systems, but it affects the receptor, so we have to think about the receptors too. If you think about your interoceptors, they are the deep somatosensory receptors of your body, but we also have interoceptors in our eyes and ears, throughout our oral-facial structures, our pharynx and larynx and oesophagus, our lungs, our heart, our guts, our vascular system, and in the pressure throughout our connective tissue. They are everywhere. So for us as occupational therapists, when we hear interoception, we need to keep broadening beyond the visceral organs, which is what so many people think of. And in that, we tie together vestibular, proprioceptive and tactile receptors, all into this category of interoception. We are crossing categories all the time, and we have to have that fluidity of thinking. It is not a rigid set of labels. Does that feel comfortable, to think about interoception that way?
Cory: Yeah. In my mind I have looped it into the somatosensory processing piece, but I am also always thinking about the vestibular piece in among that, because they all form that body concept. I mean, everything does, but they are the real receptors of the body, of ourselves. So I try to parcel them out when I can, and put them back together as often as I can.
Michelle: I do too, and I probably think about tissues, fascia is part of that as well, so I do not just think about it in terms of organs. Can I complicate things this early and wonder about emotions? Because my understanding is that your feelings and emotions, and a sense of that in the body, are part of interoception as well, not just the tissue within the body. Is that right?
Cory: How do you normally explain that to parents, Michelle?
Michelle: I talk about it as having two aspects, as a way to communicate it simply. I say it is the internal expression in the body that is being noticed in the brain, or may not be noticed in the brain. That includes the tissues and the organs, so I break it down: heart rate, blood pressure, thirst, bladder and bowels is an easy one to talk about. But it is also the feelings within the body. I tease that out because, for some of the kids and people we work with, it can be easily noticed that they do not perceive that they are hot, their temperature regulation might not be noticed, or bladder and bowel, so they might have some continence issues. But I see there is also emotional dysregulation that is part of it, they are not noticing that they are getting a bit frustrated or nervous. So noticing the internal landscape, and knowing what to do about it, is just as complicated and nuanced for the feelings as it is for the body systems. It is really a story about what is happening on the inside. Trace, am I right, I did not get the nod, are feelings and emotions part of interoception?
Tracy: A hundred percent. Sometimes you will hear OTs, or people thinking a lot about emotion regulation or affective regulation, get to the understanding that affect is the evaluation or coding of an experience, sort of pre-emotion, and that sensation and affect dually code for each other. It is actually through the interoceptive functions that carry that information to the amygdala and then into the insula that the dual coding happens. But interestingly, there is also coding in the periphery, that is both sensation and affective, more affective valence than just pure sensation.
Cory: So you mean negative or positive in the periphery? To take an extreme example, if I touch something sharp, it is negatively coded right then and there in the receptor at my fingertip. I know that is obvious, but is that what you mean?
Tracy: It is also that the context for sensation matters so much. Sharp is a threat. But let’s think about social touch, on different parts of your body. My daughter recently moved back to Colorado after living in New York City for ten years. She moved there as she was beginning university, in her late teens, so let’s have a hiatus and talk about my interoception of letting my daughter move to New York City when she was 18, that is a separate story. She spent her formative early adult years there and is now a fully grown adult. So this comes back to social touch in that, in our family, we are quite tactile, super cuddly, we like to spend that kind of time together. She was laughing that, if I am sitting in our family room and she sits on the couch next to me, on our L-shaped couch, she might sit a little away so we can have an easy conversation, but at some point she will migrate closer and closer, because she wants a shoulder rub, a tactile, connected moment. And she is quite aware that she does not really like people to touch her neck, unless it is in that context. We were actually talking about interoception the other day, because she asked, why is that, why is my neck so off limits, unless it is in this context where then I cannot get enough? And that is all based on this evaluative system, the coding happening in the affective system, in the attachment, the connection, the relationship system, and how that sets a different scene and tone for how the receptors actually function. What is interesting is that if you are not open to receive, the receptors themselves become more bristly, more rejecting, more likely to receive the information in a defensive, protective way. Not just over-response, but defensive protection. Versus when we feel the warmth of an interoceptive experience, that opens and creates a spaciousness in the receptors themselves to be open to being touched. So there is this powerful thing happening there.
Cory: Yeah, it is super cool.
Cory: I talk about this, it is not my example, I have read it in multiple places, but the last place I saw it was, I think, Affective Neuroscience by Jaak Panksepp. He was talking about context for the processing of affect, and the situation of the dark car park at night is the clearest example people resonate with, because we all feel a little more on edge when you are alone, walking to your car, and it is dark. Your whole nervous system has shifted into a more protective, defensive state so you can respond if you need to, because of the context of that environment. It makes so much sense, and it helps integrate this information around sensory processing and state. But I had never really fully included the receptors. In my thinking I was probably thinking more about state centrally, not that you would see it in the body, and I had never really thought it changes right down to the level of the receptor, the way it is going to positively or negatively receive the input, shifting that valence in a certain direction. That makes a lot of sense to me.
Michelle: And it sets the tone, doesn’t it. It is interesting that, in both of those examples, your daughter being touched on the neck, or feeling like she is touched on the neck, in the dark alleyway, is very different from her being with you and comfortable, having some personal space, looking at you in a way that is conducive to conversation, and approaching you. Her body then is, okay, I need some more proximity, touch, whatever. She has opened up to you in the family room, a known space, but she is coming back and there is some newness to that. Even then there is, I do not know, with some people you come right in.
Cory: I love that, Michelle, the approach part of it, because it comes back to control. In treatment, one of the big things for safety is giving control back. For your daughter, Tracy, her being in control of the approach around the input, and of course you are her mum, a whole different person in terms of the safety and everything you represent for her, but she is in the approach, and that changes the nervous system in itself.
Michelle: There is a request for it then. That is what she is reflecting, she said, how come I want you to touch my neck, and I come to you for it, but it does not work like that for other people at other times. So fascinating that she can talk that through, and that we as OTs talk about all the things we do, it is such a personal growth experience in our clinic, because we are observing each other to life, really. It is just interesting where our little kids, or people without the language and the knowing, no wonder it is really awkward. I think I told you about another little boy, but I saw him yesterday. He usually rounds at me like he is going to tackle me around the legs and give me a gorgeous hug, and last time he did it around my face, put his hands around my face. Yesterday he ran to me and pulled up short, and I bobbed down, crouched to be with him, and he stopped about a foot from me, and we just went, oh, I am so excited. There was such a mobilised approach and energy that he does not need the tactile component to be expressing, and probably receiving, warmth and joy and approach. For me it was just the running and the stopping. We are digressing a little from interoception, but I am not sure we are, because I think he knows, I do not need to touch you, Michelle, to get that juice from seeing you. It is so natural for me to have them come up and encircle my legs, and because I do love touch, it is hard, I have to think about it, to not touch him and follow his lead, where are you going, how far are your hands going to come up to my face but not touch me, and just tune to that.
Tracy: So our biases, our internal motivations around what feels right to us, are informed by our interoceptive processing across all the different interoceptors, whether visceral, tactile, proprioceptive, or vestibular, the vibration receptors that pick up on the jush of what is going on around us. All of those things tell us and reinforce our proclivities. And as we tune into them, even little ones tune into that and use it as a go signal, yes, go ahead and hug me, or a stop signal, maybe not so much. Right away, even in very little children, we pick up these cues from each other around social boundaries, social space, what feels comfortable and what does not. It is all based in this neuroceptive function of comfort and safety, versus the opposite, which feels threatening, uncomfortable, disruptive, something I need to protect myself from. That valence-based function that neuroception is picking up is really driven by the interoceptors in many ways. Of course it is through all the sensory systems, but they get processed through this low route and eventually into the insula, and that is where we pick up that cueing. For me, I am a hugger, but I will pick up pretty fast if somebody is not a hugger, and there is no qualitative judgment about whether the hugger or the non-hugger is the way to be. It is what works for you. There is a colleague of mine here in Denver who started a new podcast recently, kind of about this. It is not about interoception, it is about the social experience and all of our neurodiversity. I love the name, it is called You Don’t Wanna Hug, Right? Because her starting space is, no thank you very much, and mine is sort of, yes thank you very much. So both are awesome.
Michelle: Yeah, bring it in.
Cory: I would have to check it out.
Michelle: This is where the social piece and the cognitive piece and that tuning in come in, because if you are really focused internally, maybe you are tactile-defensive, or you have a strong sensation of fluctuations in temperature or bowel, you might be so focused internally that you do not even tune into the fact that someone is not a hugger, so I come on in because I am one, my focus on my internal story. Or the opposite, you are so focused on the story externally that you do not notice what is happening internally, and you get really tired and thirsty. I can see how things go wrong quickly if you are not able to shift the attentional system from internal to external landscapes really fast, and then read it, either picking it up quickly from neuroception, or from your social knowing of other people’s perspective. There is so much social skill required to make those nuances, because if you do a little sidestep, Trace, to avoid a cuddle coming in, somebody has to notice that and go, oh, that angling back means, that is the definite no hug. Versus, my need for a hug is so great that I am not even tuning into your needs, I am just fulfilling my own. So if there is any neurodiversity around our interoception, or social, or executive functioning, I can see how it just goes wrong.
Cory: My brain goes in many directions, but what you were talking about, Michelle, made me think about the relationship we have with a caregiver early on, that can help us tune in and code the experience for us, and that without that we might be a little wayward in our ability to make sense of those internal signals, not just interoception but the whole body, people helping us code that experience. But before someone helps me label and make sense of it more cognitively, Tracy, earlier we were talking about emotions or feelings, and these words get confusing, but I am curious about the pickup of that in the body. I guess it depends on the receptor. First of all, do we actually know what the receptors look like for interoceptive processing? I am weird, it helps me to know what the receptor physically looks like, because then I know how it gets activated, and that helps me understand the process. Do we know that well enough, what the receptor is, how it picks up, and whether it is a physical change or a chemical change? Or am I leading us astray?
Tracy: I want to try to answer it, it is a good thing to grapple with. Most interoceptive receptors are somatosensory receptors, but they change depending on the state, which is the part that gets complicated to trace out. Let’s stick with one receptor, say the stretch receptors in our viscera, around our heart or lungs, in our ears, mouths or throats. The relative tension, that is a stretch receptor, and those are proprioceptors. If you are in a state of blissful excitement, ready to have a dialogue with a friend, which describes us right now, we have a degree of tension being produced through the vagal circuitry, through the interoceptors, to bring our voices into a more connected, melodic quality, because we are feeling warm and engaged and working to be connected across space and time. So the stretch receptors are constraining, and the sensory processing tends to direct and constrain and enhance processing. The receptors themselves are changed based on the state, and the number and quality of receptors are also changed by the state. If instead I were in a dorsal shutdown state, the quality of my ability to even access my voice might be shut down, I might become selectively mute and not be able to mobilise the sensory-motor function of my vocal system, because I am in so much shutdown. That is a change in the receptors themselves. So they change constantly. The initial change, the valence-based change, is actually electrical, that is the first thing that changes in the sequential processing. Then it becomes chemical, a complicated chemical soup, a story of up- and down-regulation, inhibition, disinhibition, facilitation. But it initially is based on this neuroceptive signalling, the sensory-affective quality that tells us, is this a good thing, do I want more of it or less of it? And those are all interoceptive signals that come from the receptors.
Cory: Can I see if I can wrap my head around it? At the moment, in this conversation, we are in more of a ventral vagal space, we feel open and connected so we can have this fun conversation. And in that space, maybe it is chicken or egg, but let’s start with, we are in that space, and from it comes the signalling, so whenever I smile, I get the receptors in my face and I have more access to that function. I get more signal, and they feed back, I am in this state, I am doing these things, and the appropriate receptors are telling me this is a joyful experience, and I am getting the continued, sustained interaction between the information in my body and the state, checking in with that all the time. I assume they are at a match. So if a signal came in and I did not feel good, or I was unsure, or thinking really hard, maybe I have less access to my open engagement, it shuts off a little. And the body does the same thing, the appropriate receptors change in the way I am using them and in the way I can access them, even just for functions around talking. And it can drive the other direction too, can’t it, they drive each other, the receptor can drive the shift in the state, and the state can drive the shift in the receptor. It is chicken or egg again, but we have to look at the dynamic, don’t we?
Tracy: When we are in a trusting, safe relationship and do not give each other many signals of uncertainty, we can stay in a pretty continuous flow. But we have all experienced social interactions, pretty much daily, where the safety is not a hundred percent established and the trust and connection is not solid, and you say something and get that little pause where you are literally having a mismatch, and you think, did that land for that person? We might even say it out loud once we are aware, but our nervous system is asking the question right away, before we ever say it. This gets into the deeper part of interoceptive processing, the posterior and anterior parts of the insula, and how they connect back to the deeper circuitry that is lower than the insula, and the circuitry surrounding it that allows for social, executive, cognitive and language skills to help us with the storying of what is happening in the anterior insula. So the higher parts of the insula we think about as interoceptive awareness. We have an awareness there, but in the lower centres there is not a conscious awareness, it is the part where you get the signal that something does not feel comfortable, or feels like it is shifting. When neuroception signals a slight constraining or shifting off pure safety, we start to have a slightly different experience, and a lot of that is processed broadly through the brainstem, autonomic functions, the limbic system, but certainly the posterior insula. And then there is a mismatch between what is expected and what is happening, and it is the mismatch that signals us, oh, I am having an emotion, I am having uncertainty, I am having a trigger of wonder, a trigger of pause, I was in full approach but maybe now I need to pause, oops. As soon as that happens, it shifts us into a more awareness-based process, which is much more cognitively mediated than the lower parts, which are not at all based in awareness.
Cory: So you have an initial neuroception around safety or not, that valence of positive or negative, coming in through all the sensory receptors, which depending on the state receive it in certain ways. That information comes up into the brain, through the brainstem, the amygdala, the low-route processing, the lower components, and gets sent up into the insula, which is sort of low but central, would you say?
Tracy: It really does go from the more frontally oriented, anterior parts, but the posterior parts of the insula are technically in the lower limbic system. They are subconscious, and they interact more with autonomic and brainstem functions.
Cory: Right. So it hits that spot, and if we are in a place of, let’s imagine, a hundred percent safety, maybe that never happens, but imagine it, and then suddenly you get an interoceptive signal that, mm, maybe you need to not be in approach right now. That initially, subconsciously, hits those parts in the brain, and then there is a mismatch. What would we call it when the signal has changed and we need to shift out of approach? It is a mismatch in the insula, but how?
Tracy: Part of it is that, if our awareness is, I am safe and this feels good, we have that pre-perceptually. Most of neuroception is below the level of perception, but it tips into perception, because the processing is continual and temporal, a live feed all the time. So what is not perception becomes perception, and it becomes awareness. When you first have a sense of safety, then you know you are safe. Awareness comes as that intuitive, almost rapid feeling, oh, there is something that does not feel right anymore. That is critical, and it is a mismatch partly in the insula. The anterior insula’s awareness is telling us, this is what is happening to you, and then when it shifts, it is, something shifted. Because this is all based on valence, and we have an expectancy paradigm, if we are in safety the shift is away from safety. So the mismatch is, safe, but now I am not.
Cory: So this change in signal pulls the pre-perception, the subconscious processing, into the awareness processing, to go, hey, something changed, maybe we need to change behaviour, pulling in cognitive awareness of the experience, and it might be really rapid, but there is a blending of the two. What do you think, Michelle?
Michelle: I am thinking of us as an example again, Cory. You and I sometimes do not quite get each other, but because we are bathed in safety mostly, if I say something a bit sharper or blunt, and there is a, oh, what does she mean by that, I am still mostly bathed in safety. When it moves up to perception, it is a curiosity of, what did you mean, did I get that right, but it is dampened down, so I will not get so mobilised. I have picked up that there was a curiosity, a bump, and then from social executive functioning I pull in, hey, what happened there, I noticed that, and they go, ah, blah blah, and we keep going. But if you are not in such a consistently safe environment, that miscuing might escalate more rapidly to, whoa, something happened. And if it is a big cue, or you are not invested in the person, I might just walk away. If it is in the street, actually I am not exploring that, that was a mismatch, no worries mate, see you later, bye, I am out of there, and you do not check, did I get that right? I am giving a social example of how that cascade might happen: if you are in safety you might dampen it down, but in a context that is not cueing safety, back in the alley, you take the nuance of, oh, there is a mismatch, and you might be out of there with a much stronger, less inhibited reaction. And maybe that context is right, you were right to leg it out of the alley. But I wonder if that is what is happening in the clinic, that a little something, or a big something, a perception that something has gone wrong, and we see the kiddo have a bigger reaction and pull away, and then we have to uncover what bit happened. Was it a loud sound in my voice, the social stuff, not winning, and you bailed? It is not purely interoception, but maybe it is a sensation of, I have to do a wee, and it is coming fast, and I do not feel it until it is really ready, and I have a full bladder and I just have to go and I cannot stay in this interaction anymore.
Cory: Michelle, I just want to respond to that beautiful comment. Can we talk a little about the states now? Because Michelle is talking about moving into flight, that mobilisation, and I am thinking about the sympathetic nervous system pulling in to resource us to deal with a potential threat. I wonder how that interacts with interoceptive processing, probably on both fronts: our ability to be perceptually aware of our interoceptive processing, and the not-aware, subconscious processing, which I assume also gets altered. And then what we pay attention to in a mobilised state is different as well. Can we talk about that?
Tracy: Yes, and it is so interesting because it makes us move in our thinking and not silo it, oh, it is an interoceptive problem so I will treat it interoceptively, or it is a social engagement issue, because these things interact with each other across this neural circuitry. The polyvagal system is one part, interoceptive processing is a part, our social and problem-solving is a part, and they are all interactive. That is why we use a tool like the SPIRIT model, honestly, to sort it, so we can identify clinically where the strengths are, where there is robust resource available for this kiddo or family, or us ourselves, and what we are going to target in intervention. So our state, if we are in a ventral state, like we are here together, we feel safe and connected and can operate from that. If we get a mismatch in our social interaction, which happens, and it has happened in this recording a few times, partly the technology, but human interaction is funny that way, the mismatch is an interoceptive cue before we are aware of it, but we are not tipping out of safety. The neuroceptive function organises approach and avoidance, activation and deactivation, based on what the valence is doing. So in safety and engagement we stay in a steady state until the cues change. It could be that the cues from our body change, because in a robust, deep conversation we cannot sustain it forever, we run out of energy, we run out of air, we cannot sustain the ooo-iness for long, so we inevitably get an interoceptive cue that we need to shift something. And while we stay in ventral, that shift is available to us, we can make lots of choices. The thing about state-dependency is that as soon as you are not in ventral, and you could be in a blended state, partially ventral but starting to mobilise into sympathetic activation for whatever cue shot you there, you have a little less spacious choice available. As that becomes narrower and more constrained and more pushed by the state, the interoceptive cues follow. So regulation begets regulation, and dysregulation begets dysregulation. The kindling process is happening.
Michelle: This is what happened, Cory. We had a business meeting yesterday that we were very invested in, and I needed to go to the toilet by the end of it. The meeting finished and Cory zoomed me so we could finish our component, and she asked, how are you going, and I said, it is all really awesome, but I need to go to the toilet. And by the end I cared less, I was like, yep, no worries, I have to go, I am going to wet my pants, see you later. I had gone from this is a hundred percent, and I was probably in a blended state, ventral and sympathetic, I had been thinking about it a lot and was very excited. When I am like that I am less able to tune in, I hyperfocus, so I tune into my body less. I had had back-to-back sessions too, so I had not noticed, your bladder is 30 percent full, Michelle, maybe you should, 50 percent. I had no cues in the meeting. And then at the end, when it was, ah, that went really well, it was, ooh, you really have to go to the toilet. And I knew Cory would ring, so it was, hey, how are you going?
Cory: I should have let you go, but that is my not cueing, I just wanted to talk about this. Fun times.
Michelle: I did too. So eventually it was, okay, safety, safety, Cory, juicy content, this is awesome, suppress the need to go to the toilet, hang in there, chill, while interoception was saying, you will wet your pants if you do not leave. Is that about the attentional system, Trace? I think about attention and the ability to shift in and out, and certainly in that focus state, with sympathetic activation to hold your focus, we are less able to tune in, and we are driven to stay in that state, to have the meeting or this podcast, so we tune out a little. Under my conscious awareness, am I really monitoring my internal landscape as much as I would be if I were just going back into the house after the podcast? So do I not shift my attention internally and externally as frequently and automatically when I am really invested in something? Can the attentional system drive issues with interoception?
Tracy: Oh, absolutely it can. If you have a harder time using or shifting that attention, it definitely makes it harder. It is a cognitive resource to pay attention to it, but you do not need to pay attention to your bladder control once you have bladder control, until your bladder gets full. It is the stretch receptors and the full feeling that shift the signal to say, wait, pay attention to me, something meaningful is happening here, so the meaning of the sensation becomes heightened. Until then you are not inhibiting it, it just is not salient enough, the valence has not called your attention to it. Attention is a tricky function and a huge topic we could take up in a future episode in more detail, but I think about it in the anterior insula. As soon as you have a deep thirst and the valence tips, and this is not just ignoring your body, you really are deeply thirsty and you need it, the interoceptive awareness becomes a stronger signal, and whatever the rest of your frontal cortex is doing in the attentional system, it is, hey buddy, knock it off, pay attention over here, finally. Once the anterior insula gets fussy like that, it draws your attention from the other things. The insula becomes nudgy, and we want it to, that is its job.
Michelle: So that is the individual differences, Tracy, because I see that some kids’ valence is set differently. I had a really articulate little girl I was working with, and she could draw out on a scale that her first knowing, her first perception that she had to go to the toilet, was when her bladder was about eight or nine out of ten, full. So if she was in the playground with a long way to go, she would have to go immediately, but she could not run, because that put pressure on her. There was no valence tipping for her earlier, the anterior insula was not getting nudgy and demanding attention sooner, and that is why continence was such an issue for her. When she got the signal, she knew to go, it just came late for her. So can we shift that, Trace, can we shift valence at that receptor?
Tracy: Yes, and it also brings up the really important dual processing of discrimination. If you have urgency, that is a valence tip and it drives it, but before the urgency becomes critical, the urgent signal should be closer to a four or five, and that should be enough for you to have discriminative awareness of those interoceptors. Awareness can come not just from the valence tip, but from, there is a qualitative difference here that I am tuning into. For a lot of kids that takes a long developmental course, and some kids, especially boys, are a little slower, it takes longer to develop that awareness of urgency for urination, for instance. You can improve both. You can improve your reactivity to the valence, we see a lot of kids for toileting who are averse to it because they hate the feeling, and that is more of a modulation, valence-based intervention, versus the kiddo where you are trying to build the awareness when it is not urgent, the pre-urgent, sensory-discrimination-driven piece. Kelly Mahler is an OT who, with her colleagues in Pennsylvania, has done incredible work researching this and developing interventions, and they are very interoceptive-awareness based, so you build actual awareness of tactile discrimination, knowing whether something is soft or hard, wet or dry, cold or hot, squishy or pushable. You do all that sensory-discrimination building across the tactile system, across all our systems, including our internal sensory-motor ability to squeeze our tummies, take a deep breath, blow hard, all these functions that are interoceptive but also in our awareness. But for a lot of our kids the issue is pre that, more in the posterior insula, in the lower functions. So we have to be discerning. If you work with that little girl only around valence and urgency, we miss the part around her sensory discrimination. If we only work on the discrimination, she may always feel some level of negative valence about going to the toilet, because she associates it with urgency, with, I never make it on time, and then it brings up all these sense-of-self issues. Interoceptive cues can be deep shame triggers for any of us, even very little children, and we have to be really aware of that. So it brings up a lot of issues for our treatment.
Cory: That is probably where we should go in our next episode, because I am amazed we have chewed through the time today and I did not even realise.
Michelle: There you go, perception of time. We obviously did not get any interoceptive cues to say, hey, pull up, you guys.
Cory: Maybe I just ignored them, I was so invested. That has been such a useful conversation. I do not know if I have heard this discussed before, and I am hoping other people will have some fun thoughts about it too. We can think about what we jump into in the next episode, off the back of this one.
Tracy: Yes, we will look forward to hearing from listeners around this topic or any of the topics, and to going in the treatment direction in a bit more detail. Great.
And that’s a wrap on today’s episode of Spirited Conversations. We hope this sparks something for you, whether it’s a new clinical idea, a fresh perspective, or just the reminder that you are definitely not alone in this work. If this conversation resonated, we would love for you to share it with anyone on their own learning journey. You can find information about the podcast on our website, and you can join us in the courses and communities the Developmental FX team have put together at developmentalfx.org. And if you’re enjoying listening, please subscribe or leave a review, it genuinely helps more people find us. Until next time, keep the conversations spirited!