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I recently wrote about interoception.

I promised I will share my go-tos when it comes to emerging research into interoception and the role it plays in the mind-body connection, emotions, mental health and health.

Some are popularly written articles, some are hands-on manuals on how to work on improving interoception and some more heavy duty research papers.

General

• A really good interoception for dummies including a number of key definitions

  ​​What is Interoception and Why is it Important?

• A paper on different dimensions of interoception

  Knowing your own heart: distinguishing interoceptive accuracy from interoceptive awareness - PubMed

• Scientific American feature about interoception

  Interoception Is Our Sixth Sense, and It May Be Key to Mental Health | Scientific American

Interoception & Consciousness

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People don’t believe me when I say this, but it is true. When practicing some pretty hard core breathwork stuff, like power breathing - essentially tummo or the prolonged breath of fire kind of practices - at some point, I will start feeling a curious sensation around the small of my back. It is a strange sensation. It is neither fully painful nor pleasurable, it is somewhere there in the uncanny valley of sensations. Somewhere in between the pleasant and the unpleasant. But is is one that is hard to ignore, and as the practice continues, it typically only ever becomes stronger and stronger until it becomes the main sensation that I can feel in my body and the sole focus of my perception. Kind of radiating spillover from my kidneys into the space around them that diffuses into other sensations. Really hard to describe.

I have no idea what it is - really, no idea at all - but I know I feel it. I feel it through my sense of interoception. The capacity to feel the internal body states.

There is a lot going on under the hood in the body, as we go about our day, while we are mostly stuck in our head and thoughts. Most of it happens outside of awareness and on autopilot. The heart is beating, the chemicals are constantly being released into the bloodstream, the blood pressure adjusted, the gases being exchanged and all remaining within some fairly narrow parameters that are conducive to life.

The only conscious signal we get from those processes is through our interoceptive awareness.

The opposite of interoception is exteroception, and it feels as though we are generally more, at least declaratively, focused on exteroception. Right? It is somehow easier to describe what we see, taste or hear than what we feel inside. I will talk about that a little bit more later.

Body & Mind

There is a growing body of research today around the relationship between the mind, the body and what and how we feel. There proves to be more interconnection and interdependence than meets the cartesian eye.

The picture emerges where the whole shebang seems to be intertwined more than the science has initially assumed. In some respects, the boundary between the mental and the physical is becoming increasingly blurred. The body is taking on more and more important role in understanding of the mental states. In fact, the body is taking a big role in understanding of the purpose of the brain itself.

Now, the brain is a part of the body, alright - but quite a particular one. The central notion that links the two that is in the nexus of all of the things above seems to be interoception.

The aim of this post is to take stock of some elements of what emerging neuroscience tells us, cross that with some lived experience and see whether we can see working on interoception as a synergetic addition to whatever therapy direction we are using with the clients.

If you are NOT a therapist, that does not matter, because the same thing is valid for you too - I assume you are a psychonaut wanting to understand the inner workings of your mind, conclusion I make on the ground that you are reading this piece in the first place.

My goal is to give you some introductory notions about what interoception is and how it links to our mental states, mental health and overall health and what we can do about it. It covers the following:

• What is interoception and some of its neural underpinnings

• Talk about the roles of interoception in emotions

• Touch on the relationship between interoception and the concept of allostasis

• Links interoception to mental health (very superficial overview - deeper dive into this later)

• Suggestions for some clinical implications and ideas as to how to improve interoception

I will write a separate post where I will be sharing some of my essential references when it comes to thinking about interoception, in relation to psychotherapy.

Let’s dig in.

What is Interoception: Definitions & Basics

Interoception is the process of sensing and becoming aware of the internal states of the body. Examples range from feeling hunger, feeling our own heartbeat, (cardioception), feelings of fatigue, feeling perked up, activated and energetic, sleepy, experiencing the breathing sensations and their pace and the list goes on and on. Even wanting to go for a wee.

As mentioned already, the opposite of interoception is exteroception - the sensing and perception of external stimuli. Interestingly, neuroscience is much more advanced in understanding exteroception than interoception, and as therapists we might ask ourselves why - if we are inclined to analyse the scientific psyche. Which i am not, at this specific moment, but would love to hear your thoughts.

Other, maybe more philosophical questions arise, once we start thinking about this more deeply. For example: how does the brain know where the ‘us’ ends and ‘outside’ of us begins? Does interoception affect exteroception? And what about the vice versa?

Like for any other sense, when it comes to interoception, we are not all equal - some people end up being better at it than others.

Through this piece, I hope to make it self-evident why exploring client’s interoception might be an important piece of information in therapy, why we might want to improve it and how it can be done.

Interoception, as a sense, is thought to have three different aspects:

1. interoceptive accuracy

2. interoceptive sensibility

3. interoceptive attention

Interoception Neural Correlates

Our old friend, the vagus nerve is one of the main conduits of the interoceptive signals. Around 80% of vagal fibers are afferent - meaning that they send the signal from the body to the brain. But, once the signal has been transmitted, how is this signal processed and interoceptive awareness formed?

To give an idea of the journey of the information from its point of origin in the body until it reaches the awareness, I will give you a simplified itinerary.

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Everyone knows what emotions are until they are asked to define them.

—

Le cœur a ses raisons que la raison ignore.

(The heart has its reasons which reason knows nothing of)

What Did Emotions Ever Do For Me?

Emotions get me into a lot of trouble. But I love my emotions. Yet, when I try to explain why, I struggle.

Is it because they make me feel alive?

Because they reveal that some things matter far more than they may seem to?

Because they push me to act, even in situations where I would rather not?

For me, my emotions show me what is my heart's desire. A compass of sorts. But then again, someone else might have a very different relationship with their emotions. They may experience emotions as something darker, a negative force. A shadow hanging over them. Or any other number of things.

As such, we already can see that emotions are not the same thing for everyone. They are shaped by the context of our biological makeup and our personal histories, as well as by our belonging to a particular human 'tribe' (our culture).

For sure, we experience emotions, but where and how?

Are emotions in the body? Yes. Are emotions in the brain? Yes.

Are emotions innate? Yes. Are emotions learned? Yes.

Emotions are paradoxical. They are wild and bewildering.

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Psychotherapy And Emotions

To me, emotions are absolutely central to therapy. Thinking and cognitive reappraisal may play a role, and can indeed come in handy at times, but only insofar as they allow emotions to be changed, processed, or in some way tempered. However one approaches it, emotions are to me the undisputed sovereign in the therapeutic process. They are the boss of my therapy world.

But why? It is a million-dollar question, and probably as difficult to answer as the question of what emotions actually are. To begin with, 'working with emotions' in therapy can mean many different things. Here are some examples that come to my mind.

We pay attention to the emotions in therapy. We pay them respect.

As therapists, we want our clients to feel they can express their emotions with us.

There is a sense that all strong emotions fundamentally carry a meaning and that our job is to help the client bring that meaning to their awareness. So, meaning of emotions.

But then we also work with regulation of emotions. In other ways finding ways to modulate emotions volitionally, whether through reappraisal, co-regulation or using the body.

We also work with reconsolidation of emotions. Changing how strong the emotional memory about something is.

And the list could go on. As I have said, and I shall repeat, emotions are central to therapy. For that reason, for me it is so interesting to explore the neuroscience of emotions. But the crucial question is: which neuroscience of emotions?

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What Are Emotions? The Big Theories of Emotions

The problem is...not only emotions are wild. The debates within the field of affective neuroscience about what emotions actually are pretty wild too.

Today, there are two dominant lines of thought regarding how emotions should be understood. One considers emotions as innate biological expressions, while the other takes a post-modern view of sorts, seeing emotions as, in essence, shaped by culture and supported by brain's capacity to learn. However, before we explore these perspectives, it is worth revisiting a seminal bifurcation in thinking about emotions that occurred in the early days of neuroscience.

Oldies But Goldies: James-Lange Vs. Cannon-Bard Theories of Emotions

These classic and opposing theories, dating back to the early twentieth century and the beginnings of experimental neuroscience, may no longer hold practical value in contemporary research. New and more nuanced theories have since emerged.

However, I find them genuinely thought-provoking when reflecting on the nature of emotions. We can build the two views down down to how they answer the following question:

"Do you run away from the bear because you are afraid, or are you afraid because you are running away from the bear?"

According to the Cannon–Bard theory, we run away from the bear because we are afraid. In this view, the conscious and subjective experience of emotion is independent of bodily physiological responses. Emotion can occur without preceding physiological arousal.

In contrast, the James–Lange theory argues the opposite: we are afraid of the bear because we are running away. In this view, emotion arises as a consequence of the body’s physiological arousal. The feeling of fear, for instance, is the mind’s interpretation of bodily states such as increased heart rate and muscle tension.

I shall leave it to you to decide where you stand in this debate, but one important takeaway for me here is that the echoes of this debate are still felt not only in the modern theories of emotion but also in how we think about emotions in therapy and in everyday life. I find that typically clients come with (unknowingly to them) Cannon-Bard view and I see my job as moving them more towards James-Lange view.

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The Classic Theory of Emotions: the Basic Emotion

This view contends that a set of basic emotions is innate and that all the other more complex emotions arise as a combination of these hard-wired basic emotions, shaped by evolutionary needs. The idea here is that each one of these basic emotions evolved with a specific brain circuity and was adapted to a specific, 'primordial threats', so to speak.

The typical basic emotions, according to this view, would be: happiness, sadness, fear, anger, and disgust. And each one of these basic emotions corresponds to a dedicated neural circuitry or a module.

I feel that this view is still very much utilised in psychotehrapy circles.

This theory stems typically from animal research that is then extrapolated and consolidated to thinking about human emotions.

It is said that these theories deal first and foremost with emotions as opposed to feelings. According to this distinction, an emotion is an objective, physical state and the felt experience of that state. Feelings, on the other hand would be, the conscious and elaborated experience of that emotion.

Killer argument: Intuitive. Simple. Continuity between non-human and human animals.

Weak spot: Driven by research on animals - lacking the humanistic perspective and broader cultural considerations. How much can be translated? Also, not in line with more recent view about the brain as predictive processor.

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Theory of Constructed Emotions

The theory of constructed emotion takes a whole different and unexpected approach to the question of what emotions are. It can be described as a paradigm shift , and truth be told, it is probably one of the reasons I find it so compelling.

To begin with, the theory of constructed emotion challenges what was long considered a universally accepted premise: that all emotions possess distinct neural and physiological 'fingerprints', and that these fingerprints are also reflected in recognisable and universally expressed facial configurations for each core emotion. To the theory of constructed emotions, we learn emotions through culture; they are not hard-wired at birth or determined by genetics. What is hard-wired, rather, is the capacity to remain open to experience and to learn emotional responses from our environment. Emotions are constructed through our ongoing adaptation to the world around us and to the fulfilment of our needs within that environment.

Emotions: Active Inference Framework And Maintaining Homeostasis Through Allostasis

To explain further the shift in perspective brought about by the theory of constructed emotion, allow me to take a brief detour. In my post The Devil You Know: The Free Energy Principle and Psychotherapy I discussed the active inference framework. Within this framework, the brain is conceived as a predictive 'device' that uses the sensory channels available to the organism and, crucially, past experience, to anticipate the future needs of the organism. It adjusts the organism’s expectations and moment-to-moment state - both body and mind - accordingly.

Importantly, in this view, the organism is not a passive recipient of information but an active agent that participates in shaping its environment.

When we speak of these moment-to-moment adjustments in response to the ever-changing external and internal conditions of the organism, we are effectively referring to the concept of allostasis. The brain's role, according to this model, is to maintain homeostasis (state of internal equilibrium) through allostasis, by drawing upon prior experiences and current information about both the external world and the body’s internal environment.

According to the theory of constructed emotion, emotions are the conscious interpretation of interoceptive signals from the body. Emotions are the meanings we attribute to the interoceptive signals of the body that end up reaching our awareness. This process of choosing the interoceptive signals and assigning an interpretation would all be conducted according to the principle of brain as active inference.

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I kind of think of this in the following way: the body is constantly reacting to the environment - and, to be fair, also to our thoughts - and at the same time it exists in a particular state. That state might involve fatigue, hunger, discomfort, or any number of physiological conditions. Depending on all of these parameters, our “next step” - the action we choose to take - will be influenced by the combined effect of the body’s state, the external context, and the conscious processes of thinking and decision-making.

Now, the body does not possess language in the same way that thinking does. It cannot “speak” in a literal sense, and so I see emotions as the way in which the implicit signals from the body become available to conscious awareness and cognitive apparatus of the brain. This, in turn, opens up a whole new swaths of possibilities and problem-solving capacities when attending to a given situation.

One example that helped me personally to get my head around these ideas is the experience of a jittery, restless sensation in the body. Imagine: high sympathetic arousal, a loss of appetite, butterflies in the stomach. What is this? For me, it could be excitement. It could be infatuation. It could be anxiety. The underlying bodily state is identical, yet the meaning we give it depends entirely on context and on personal history.

Killer argument: Changing the 'meaning' changes emotion.

Weak spot: The evolutionary link between animal emotions (which are bound to be circuitry based) and human emotions.

Brain On Emotions

Hopefully, by now (if you follow my writing at all), we can agree on the following:

• Emotions are NOT in the amygdala (only)

• Emotions are NOT to be found in one isolated area of the brain

• Emotions are NOT in the limbic system or any other brain 'layer' per se (contrary to the ideas of the Triune Brain Theory)

Alright then, where are emotions in the brain?

In fact, both the classical theories of emotion (the basic emotions theory) and the theory of constructed emotions agree that emotions are a distributed phenomenon in the brain. The difference lies in how distributed they are believed to be. The former posits that there are specific neural circuits for each basic emotion, while the latter argues that emotions arise as domain-general processes. That means that emotions would not have a dedicated circuity but rather use the general circuitry of the brain that is used for cognition, decision making, interception etc. Therefore, the answer to the question of how emotions are organised in the brain will largely depend on whom we ask really.

Nonetheless, we can still examine the brain regions that are most commonly studied in relation to human emotions and they are as follows:

• the insula - deeper cortical structure that is considered to be a hub for interoception, involved in processing complex social emotions such as emotional pain and disgust (both gustatory and moral)

• the amygdala - subcortical brain structure involved in salience detection, threat processing and emotional memory formation as well as in human sociality

• the anterior cingulate cortex (ACC) - deeper cortical structure involved in emotional processing especially to the visceral and autonomic components of emotions

• ventromedial prefrontal cortex (vmPFC) - area of the prefrontal cortex with strong connections to the amygdala, thought to be involved in regulation of emotions

• orbitofrontal cortex - a prefrontal area of the brain that, amongst other things, seems to be implicated in motivational aspects of emotions as well as impulse control, inculcation of cultural norms, and the ability to appreciate the consequences of one’s own behaviour. Phineas Gage, one of the most famous patients in history of early neuroscience, had sustained the injury in this brain area.

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Should the Wild Things Be Tamed At All? Emotions Are Cognition.

As therapists, we know how important emotions are. We work with them every day. We connect through emotions. We communicate using emotions. We find deeper meaning in experiencing emotions. Changing or understanding our emotions can be healing; it is often a watershed moment. Emotions are the spice of life, and we do not need neuroscience to tell us that.

However, perhaps neuroscience can help us shift our own paradigms of how we think of and work with emotions? That would be nice.

As you have probably noticed, I am somewhat biased. I am a sucker for exciting new ideas that challenge received wisdom and the status quo, and in that sense, the theory of constructed emotions gets a clear advantage. I shall therefore be leading the witness (you), so to speak, by introducing a few ideas about how this theory could influence the way we think about and work with emotions in therapy. This is still work in progress, but here are couple of takeaways:

Takeaway 1 There is no pre-defined, ready-made, hard-wired set of emotions that we are to identify in our client's experience. Rather, emotions are culturally and contextually learned. As such, we need to work with the client's specific and subjective description of their emotional experience, however complex or layered it may be. Our task is to help them understand what their emotions mean for them personally, rather than attempting to mould their experience into a set of pre-existing emotional categories.

Takeaway 2 The brain is a meaning-maker, and the theory of constructed emotions tells us that emotions exist to provide meaning and access to conscious experience to the physical experiences that have no language or voice, otherwise. Unlike fixed neural circuitry, meaning can be changed - in therapy or through other life experiences. And as we change the meaning, we change the emotion. That is good news for therapy.

Through thinking about this, over time, I have come to understand emotions as a source of knowledge about the world that surrounds us and how we need to adjust to it. To me, therefore, emotions are cognition. Please, feel free to be emotional about that.

As always, thank you for reading🙏.

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Deeper Dive Into Theories of Emotions

• Video: Lisa Feldman-Barrett talking about the Theory of Constructed Emotions and misconceptions around emotions

• The Neuroscience of Emotion A New Synthesis

• How Emotions Are Made

• The theory of constructed emotion: an active inference account of interoception and categorization

• The Theory of Constructed Emotion: More Than a Feeling

• Basic Emotions or Constructed Emotions: Insights From Taking an Evolutionary Perspective

Neuroscience & Psychotherapy Lab 🧫

If you are new in this space, for a crash course about the theory of constructed emotions in the context of psychotherapy, please see here, here, here and here.

When You Know You Know?

If emotions are socially and psychologically constructed, this is good news for therapy. Indeed, if the Theory of Constructed Emotion is onto something, emotions represent the meanings or categories we assign to our affective experiences - meanings that can be changed - in therapy or through other life events. Yet, with the power to change comes the responsibility. This gives rise to new ethical considerations. Or maybe not so new, but old considerations dressed in some new clothes.

The ‘psyche’ of psychotherapy as a whole is fragmented, with its different fragments sometimes contradicting each other. My sense is that, within therapy, we understand that changing the story - transforming the underlying narrative - can often mark a key turning point where difficult emotions are resolved in therapy. Yet, at the same time, the field largely continues to embrace the Basic Emotions model and its accompanying neurobiological narrative centred on survival circuitry.

As a result - and this was certainly the case during my own therapy training - we often tend to think of the new meaning a client discovers for their experience as the right or true one, the meaning that was hidden and waiting to be uncovered. Because finding new meaning can feel so powerful and emotionally charged in therapy, I too used to believe that these newly discovered emotions must be the authentic ones - when you know, you know - the real feelings finally emerging to replace the ‘inauthentic’ ones. The process of therapy was simply revealing them.

I don’t think that anymore. Through my work with clients (for some examples, see below) and by becoming more familiar with the neuroscience and psychological evidence emerging from the nexus of the Theory of Constructed Emotions, I have come to realise that not only emotions can be changed - as there is no fundamentally pre-programmed emotions for any given situation - but that they are, or can be, co-constructed in therapy.

The prefix co- is key here, as the influence personality, beliefs, script and even political positions of the therapist suddenly move from a supporting character into the main cast of the process of client’s transformation. And maybe sometimes, that is OK. Sometimes it is definitely not OK. Sometimes, it is hard to know. At any rate though, with this power comes responsibility.

That is what I set to explore in this piece.

In this piece, you will find three case studies and ensuing ethical dilemmas:

• Social injury versus social pain (Case study)

• Affective realism and the perils of offered interpretation. Emotions are constructed but should they be co-constructed in therapy? (Case study)

• Finding the right middle-ground between therapeutic neutrality and directiveness. In (rare) defense of offering interpretation. (Case study)

• With power comes responsibility: Handle With Care (Some ethical guidelines I use)

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Neuroscience & Psychotherapy Lab Post 🧫

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In my therapy training, we were always taught that there are five basic emotions: happiness, sadness, anger, fear, and disgust. This idea was pretty much drilled into us, and as therapists, we were to help the client identify which of these five emotions they were experiencing, and then work in a way that was specific to that emotion. As far as I am aware, the idea of core emotions - otherwise known as the Basic Emotions Theory - remains the dominant view of emotions in psychotherapy. Imagine my surprise when I learned about the theory of constructed emotions!

While therapists are really good in embracing complexity when it comes to human nature, behaviour and motivations, and also in understanding how and why people feel certain ways, we tend to stay stuck with outdated and oversimplified narratives when it comes to neuroscience - and emotions are no exception. It is about time we move things forward and shake it up a little.

In this piece, you will find:

• A brief intro to the principles of both the Basic Emotions Theory - the dominant theory of emotions throughout the twentieth century - and the Theory of Constructed Emotions (TCE) - the new kid on the block.

• I explain why the Theory of Constructed Emotions is, in my view, a particularly useful framework for working with emotions in therapy.

• I outline some general principles for working with emotions reflecting the spirit of TCE

• Three case studies illustrating presentations commonly encountered in therapy that fit nicely the TCE framework (and do not fit the basic emotions).

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Are You Hangry, Hungry or Tired? Affect as Proto-Emotion

Bored, motivated, tired, cranky, hungry, jittery, and excited are just a few examples of mental experiences that are referred to as affect. They can be thought of as proto-emotional states.

Both the Basic Emotions Theory (BET) and the Theory of Constructed Emotions (TCE) see affect as crucial for emotions. However the two theories don’t align on what the neural and biological correlates of affect are.

What they do agree on though is that emotions emerge from affect. Affect has at least two properties: arousal and valence.

But are there clear boundaries and distinct qualities when it comes to the experience of affect? Can we always tell the difference between hunger and fatigue? How about between excitement and apprehension, or even the feeling that we might be coming down with the flu? The Basic Emotions Theory assumes that these boundaries are biological and distinct, whereas the Theory of Constructed Emotions challenges this view.

Let us look at it experientially. I don’t know about you, but I often feel the need to eat when, in fact, I am simply tired. I can also feel very tired and sluggish when I am actually dehydrated. And what about the butterflies in the stomach? They could signify excitement, infatuation or apprehension. It depends on the context, and sometimes my brain makes a mistake in attribution.

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I am preparing a talk about neuroscience of emotions and therapy, titled “How Are Emotions Made? Lessons For Psychotherapist” and as a part of that process, I am sharing the curated references with you. All my go-tos when I think about emotions, neuroscience and psychotherapy.

A Neuroscience And Psychotherapy Lab🧫 Post.

Popular

• Video: Lisa Feldman-Barrett Talks About the Theory of Constructed Emotions and Misconceptions Around Emotions And the Brain

• Joseph LeDoux on Theory of basic emotions vs constructed emotions: Have We Misunderstood Our Emotions? | Psychology Today United Kingdom

• What is an emotion: An Emotion Is... | Psychology Today United Kingdom

• Emotion Revisited: How a Classic Debate About Brain and Body Is Driving Modern Neuroscience

• Creative Re-interpretation of Emotions

• Facial Expressions Do Not Reveal Emotions

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Neuroscience & Psychotherapy Lab Post 🧫

In this piece I explore the neuroscience of top-down and bottom-up emotional regulation and what are the implications for psychotherapy practice.

I first define top-down and bottom-up emotional regulation and the processes involved, and I revisit the main brain areas thought to play a role in these mechanisms. As you shall see, top-down versus bottom-up processes cannot be simply reduced to brain versus body narrative.

In the same way that we classify strategies for emotional regulation as top-down or bottom-up, different therapeutic approaches can also be categorised according to the preferred strategies they employ when working with emotions. These approaches can be then thought of as top-down or bottom-up. Majority of what we do in therapy however, will be a combination of the two.

I also look into approaches that are traditionally considered to be bottom-up - such as mindfulness or breathwork - and show how the story appears to be less clear cut - making them more of a versatile, top-down x bottom-up type interventions.

Furthermore, in therapy, we often think of emotions as bottom-up processes that are subsequently inhibited and regulated through top-down activity. I will challenge this assumption and, building on my previous piece on the neuroscience of emotions (Where the Wild Things Are?), argue that emotions arise through the interaction of top-down and bottom-up processes.

Finally, I will argue that there is no ‘good’ or ‘bad’ forms of emotional regulation and that all forms of emotional regulation are important. While terminology such as “top-down” might echo aspects of language associated with undesirable power dynamics, this semantic parallel is arbitrary. The most effective strategy, I will argue, is to maintain choice and flexibility between different ways to regulate emotions.

Top-Down & Bottom-Up Regulation: Definitions And Examples

First, what is emotional regulation?

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Have you heard of the insula, I wonder? The word 'insula' means 'island' in Latin, but it’s also the name of a brain region.

Historically, the insula has been less 'famous' than the amygdala (which, incidentally, means 'almond'), but it’s just as important for emotions. In the therapy world, we don’t often hear much about it. Most of us are familiar with terms like the 'amygdala hijack,' but the insula hasn’t inspired any similarly striking expressions.

It is of course very wrong to classify brain regions as 'good' or 'bad' (but let’s do it anyway). However, the amygdala is more infamous than famous; we focus so much on it because of its role in negative processes like threat conditioning, fear, PTSD, and trauma. The insula, on the other hand, is involved in many of the traits we value most in social cognition and emotional processing, such as empathy, compassion, and emotional awareness.

Even more interestingly still, at least for psychotherapy, the history of the insula is somewhat intertwined with the growing interest in neuroscience that emerged in certain corners of the psychotherapy world about 25 years ago. So, please hear me out.

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The Somatic-Marker Hypothesis

It all comes down to Antonio Damasio and his now-classic book Descartes’ Error. In this work, and the research that inspired it, Damasio famously revives the James-Lange theory of emotions and argues that there is no thought without emotion - that all thinking is inevitably and fundamentally colored by some degree of emotion. A modern reader might be tempted to see this book as slightly outdated or its claims as self-evident, but that’s only because it was so influential. Its ideas have permeated the 'Overton window' of our time.

The linchpin of Damasio’s argument is our little island: the insula. With his work, Damasio and his collaborators, have propelled the insula from relative obscurity into the spotlight.

In a nutshell, the somatic marker hypothesis posits that all decision-making is, in fact, influenced by some level of emotion - either conscious or, more often, unconscious (implicit). This happens through what Damasio calls somatic markers. According to this view, anything we see or think about triggers a visceral or somatic experience - whether positive or negative - that he refers to as a marker. These positive or negative sensations then influence our decision-making process, often below the threshold of our awareness.

And he insula is relevant here because it serves as a hub for interoceptive awareness: in other words, it’s through the insula that we feel how our body 'feels.' But more on that a little later. For now, let’s take a look at where the insula is actually located in the brain.

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On the Neural Crossroads

In the human brain, the insula is hidden deep within the cortical tissue, and located in the area where the frontal, parietal, and temporal lobes meet. It is actually a part of the cortex itself, referred to as the insular cortex. Which is, I am guessing, where its name comes from: a little island between the cerebral cortex and other subsortical areas.

I say 'insula,' but technically, it's insulae or insulas, as the insula, like most other subcortical structures, is found in both hemispheres. The insula is divided into the posterior and anterior regions, and while these two work together, they have quite different roles

The insula, due to its location between the cortex and the deeper subcortical structures, is a neural crossroad.

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Interoception

Interoception is often referred to as our sixth sense - it’s the ability to feel how our body 'feels,' including the visceral sensations, the 'inside' of the body, so to speak. The insula serves as a hub for interoception and functions as a kind of mind-body center. It has also been called the 'visceral brain,' though I suspect some people might cringe at this term, so let’s better leave that one aside.

Signals from the body are transmitted to the posterior part of the insula, which then remaps them to the anterior insula (the frontal part). From there, neural connections relay this sensory information to cortical areas, bringing it into conscious awareness. Or something like that...

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Emotions and Feelings

It turns out, perhaps unsurprisingly given its role in interoception, that insula activity is associated with experiencing feelings and emotions. This often occurs alongside the activation of the anterior cingulate cortex (ACC), but that’s a story for another time. What’s interesting is that this is true not only for feelings and emotions directly linked to somatic experiences, like pain or anxiety, but also for more abstract emotions such as social exclusion, unfairness, and social pain (through the salience of the self).

Empathy

In the therapy world, when we think about empathy, we often think of mirror neurons. But the insula plays a role here too. In fact, just as the insula is involved in feeling my own pain, it is also implicated in me feeling your pain.

Specifically, the insula mediates the affective, but not the sensory, component of pain.

The Insula and the Amygdala

Interestingly, the insula has been compared to the amygdala, with the key difference being that the amygdala is central to the implicit (unconscious) experience of emotion, while the insula plays a crucial role in the conscious or explicit experience of emotions.

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Physical and Moral Disgust/Shame

The insula has been found to be involved in feelings of physical disgust. But not only. The insula is also activated when I see your disgust. But then, that is not so surprising given its role in empathy, right?

But here’s an even more fascinating twist: the insula is implicated in feelings of moral disgust. Much like physical and emotional pain, the connection between physical and moral disgust turns out to more than just a metaphor.

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And Finally ... the Self

In Descartes' Error, Antonio Damasio recounts the case of a patients who, due to seizures, had their complete sense of the body and interoception removed. The seizures impacted the somatosensory maps in the brain - in other words, the areas that 'link' somatic feelings to perceptions, one of which is, of course, the insula. These patients typically not only lose the sense of what is happening to their body but also the sense of who they are.

However, one such patient had an area that remained intact: the anterior insula. Coincidentally, this patient also preserved an acute sense of self and awareness of what was happening to her, despite not 'feeling' her body, so to speak

And this, amongst other things, has led Damasio to believe that the insula had also a role to play in selfhood...

Alright, alright. I am letting you off now.

I might not have gotten everything right - after all, the brain is incredibly complex, and I am still learning. I guess all I hope to achieve with this piece is to put the insula onto your mind map, especially if you are a therapist or interested in emotional life. Pet it, look after it, become the insula whisperer. And if you happen to dream of a little island tonight, I’ll meet you there 🏝️.

As always, thank you for reading.