Why Interoception Should Matter to Adults With DID

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Interoception.
It sounds like a mis-spelled movie title.  It is not.
Spellcheck will ALWAYS ask you if that is what you really meant to write.

But for people with dissociative disorders, problems with interoception can be a big deal.  A big deal that very few psychotherapists understand at a neurological level (not basic right brain/left brain stuff they picked up in a free webinar), and know how to address in ways that make a difference.

It isn’t all their fault.  Neuroscientists are still trying to work out all the pathways for interoceptive awareness, and the specific ways in which it affects self-perception, health, and movement in human beings.  There IS a lot that is already known about interoception, and some surprisingly simple things that improve this sense.

Yup, interoception is a sensory thing.

It isn’t a psychological mechanism, but it does affect self-regulation.  Interoception is the ability to register and process internal (not surface) sensory input related to physical homeostasis.  Self-regulation requires the ability to attune to the physical state.  At least, attuned enough to know when you have physical needs.  Being in a condition of physical need and not being able to care for the body leaves you unable to self-regulate in the most basic way.  “Somatic tolerance” is what a trauma therapist calls being OK with having a physical body, experiencing it as yours, and being able to tolerate the perception of your body’s signals and connect sensation with emotions.  Greater somatic tolerance leads to being more grounded.

Trigger Warning:  This section can be skipped if you are susceptible to being triggered by discussions of self-harm.  Jump to the next paragraph! When someone with DID or OSDD develops parasympathetic nervous system activation from a trigger, interoception tends to plunge.  Not being able to feel connected to your body, and not be able to change it, can lead to self-harm.  One reason self-harm works so well to bring trauma survivors out of a parasympathetic state is that damaging the body stimulates the internal sensors that send information to the insula, the brain’s home for interoception.  Two problems with this strategy are that the physical cost of self-harm is far too high, and it isn’t a permanent solution.  In fact, like many addictive processes, people find they need to use more severe self-harm to get the same results.  Understanding how to use other sensory processes to enhance interoception is so much more effective and kinder to people who have endured a lifetime’s worth of pain.

Anything that affects self-regulation is going to affect co-regulation, the “Mt. Everest” for a lot of psychotherapists working with trauma survivors.  Co-regulation is responding and connecting socially with other people, and allowing another person’s calm connection help you regulate your emotions and physiology.  Healthy attachment to a caregiver early in life is where co-regulation is first encountered.  Something that adults with DID were not experiencing as children.

As you read posts on this blog, you will learn that occupational therapists think that charity begins at home, and so does regulation.  Nobody has vibrant and easy co-regulation without being able to feel safe in their own bodies. Being able to perceive and manage your internal state is foundational for feeling safe.   This isn’t magic.  It is logic.  And OTs work on helping their clients feel safe and be able to self-regulate by working with their client’s body.  That is the site of the trauma in so many cases, and also the site of feeling truly safe.  The journey to a stable sense of safety starts there.  And feeling safe in their bodies is something that matters a great deal to adults with DID.

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One problem with getting help for interoceptive issues is that it is difficult for professionals without a sensory processing disorder or a dissociative disorder, or who haven’t done training to treat sensory problems, to understand what their clients are experiencing when they have poor interoception.  Some simply cannot imagine what it could be like to live disconnected from the body.

It is such a subtle sense. Essential, but subtle.  Interoceptive registration and processing issues can be confused with digestive issues, ADHD, even autism.  Interoception processing seems to most lay people to be so foundational a skill that they struggle to understand how an adult without brain damage or a diagnosable physical ailment could possibly NOT perceive and process internal physical input.  Not feeling tired.  Not feeling pain when injured.  Not feeling the need to drink for hours on end.  Lack of registration of body signals appears to be almost impossible to imagine.  It can be misinterpreted; a client with a trauma history is simply in denial, refusing to acknowledge their feelings of fatigue, need to eliminate, hunger, or thirst.

Not understanding the complexity of sensory processing often leads to incompletely addressing poor interoception.

Interoception is a physical sense, and OTs know that their clients of all ages can have pathways that are neurologically intact, and can send accurate information that is not processed correctly by the brain.

Limited awareness and ineffective processing can be due to developmental problems, and physical OR psychological trauma.  The mind-body doesn’t necessarily differentiate at a sensory level.

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How do occupational therapists work with a client to develop better interoception?

Well, it depends on their overall sensory processing abilities.  An occupational therapy evaluation includes understanding the wide range of sensory processing skills each person uses to get through their day.  Some sensory systems overlap and make interoception harder.  Knowing more about an individual’s abilities and challenges through an evaluation allows a skilled therapist to design a treatment plan that will work better than issuing a stress ball and a jump rope (this isn’t made-up; I have read this suggested in the literature!).

Treating interoception is usually done by creating a daily “sensory diet” that an individual uses independently.  What is a sensory diet?  Specific activities and targeted tools are used to enhance perception and processing throughout a client’s day.  It is always mindful of aiming to expand the length of a person to remain in a physiologically regulated state, in which a client is not overwhelmed from or deprived of meaningful sensory input.

Adults with dissociative disorders can have a tremendous amount of difficulty tolerating greater sensory awareness from a body that has been the site of past abuse.  While they may appear to be functioning well at work, at home, and in the community, it has to be assumed that trauma survivors are working incredibly hard at times to keep functioning, and are dissociating more often than others may notice.  Their sensory diet has to appreciate that sustaining a high level of function may be fragile.   Care needs to be placed on creating a sensory diet that emphasizes sustained safety throughout the day rather than on advancing multi-sensory processing quickly.

Want to learn more about using sensory processing to build stabilization in medical and dental appointments, and throughout your day?

I wrote a book for you!!

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“Staying In the Room:  Managing Medical And Dental Care When You Have DID” covers practical sensory strategies as part of stabilization skill development.  It also helps trauma survivors build a wide toolkit of skills that they can use to handle receiving physical care.  There are chapters on how to practice skills so they are available under stress, and specific adaptations that providers can use to make well visits, invasive procedures, and even pelvic and prostate exams less challenging.

“Staying In The Room” is available as a paperback (you know you want to underline/highlight/write in the margins!) or as a digital download on Amazon  .

Published by Cathy Collyer

I am a licensed occupational therapist and a licensed massage therapist, in private practice in the NYC area. I have over 25 years of professional experience in adult and pediatric treatment, with a focus on sensory processing issues and treating the consequences of complex trauma. I am the author of four books, including "Staying In The Room: Managing Medical And Dental Care When You Have DID" and "The Practical Guide To Toilet Training Your Child With Low Muscle Tone". Over the years I have lectured about trauma treatment and pediatric development.

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