The Strange Case of Interoception and Resilience or How to Become a Superhero

Steel is a very resilient material: it has the capacity to absorb the energy produced by a hit without breaking. Translating this original definition of resilience into the Psychology field, a person is resilient when they can cope well with stressful situations. No wonder Superman is called “man of steel”!

Back to more scienc-y stuff, recently Haase and colleagues [1] supported the idea of a link between resilience and interoception. Specifically, they found that people who are less aware of their own body’s internal changes (low interoception levels) are also less able to cope with stress (low resiliency levels). Hence, for example, if you are able to predict you will have the flu from small changes in your body, you might also be very good at managing stressful situations. The authors’ hypothesis is centred on the concept of body prediction error, i.e. the amount of error yielded by the comparison between a current interoceptive state and an anticipated or predicted state. Thus, the smaller the error, the better the performance. Hence, people more aware of their body state (i.e. more skilled in interpreting interoceptive signals) are also better performers and, in turn, they are better in coping with stressful situations than people who are less aware of their body state. For example, elite athletes are very good at interpreting their own body signals in order to maintain their activity level within both biomechanical and metabolic limits. Ultimately, this ability enables them to cope with highly stressful situations without getting hurt. As often happens, the relation of causality between body awareness and being an athlete[*] is not clear, but nonetheless a link does exist.

Furthermore, in low resilient participants (as distinct from normally and high resilient participants) a higher activation of thalamus and middle insula has been found during the anticipation phase of an aversive stimulus and during the administration of the aversive stimulus itself. To clarify, the “aversive stimulus” was a simulated momentary condition of breathing discomfort artificially induced by a machine.  An aversive event provokes a cascade of internal body changes (such as increased heart rate, vasoconstriction, and sweating) that are interpreted by the brain. In particular, middle and posterior insula have been identified as primarily interoceptive cortex. People with high interoceptive levels do not really need to allocate lots of mental processing resources in order to efficiently interpret these signals. Consequently, these people can employ those resources for other tasks (i.e. being able to score a goal even if tired and hearing the opposing supporters’ boos). On the other hand, people needing to gather more mental resources to deal with the physiological (and psychological) consequences of an aversive stimulus, will probably fail or, at least, be less efficient in completing a task. For instance, low resilient and anxious people usually need to allocate a great amount of processing resources to interpret their own interoceptive signals. However, this does not mean that people with low levels of interoception are doomed! Low resilience participants involved in this study were well functioning individuals in their everyday life, confirming that, in fact, human beings can develop and nurture alternative strategies to face everyday challenges despite their own natural predispositions.

Interestingly, resilience has a crucial role in pain [2]: being resilient has been proven to be a positive characteristic for both recovery and acceptance processes [3-5]. Given the close link existing between interoception and resilience  [1], and that chronic pain patients have indeed a poor representation of their affected part (see, for example [6]), low interoception/low resilience might have a crucial role in the development and maintenance of chronic pain. In other words, perhaps it is possible that when generally low interoceptive/low resilient individuals experience a stressful situation (e.g. a sprained ankle), they are unable to efficiently deal with the corresponding interoceptive signals. For instance, jogging causes a physiological increase in heart rate. Sports people know that it is normal, and this specific interoceptive signal has little impact. On the other hand, people not used to sports might be alarmed because in their experience an increase in heart rate means “you are fatigued or you are having some troubles with your heart: you should rest”. Thus, the same interoceptive signals (increase in heart rate) will be interpreted as “irrelevant” by the sports people (potentially highly interoceptive) and as “dangerous” by the newbies (potentially poorly interoceptive), leading the latter to stop. Similarly perhaps the interoceptive signals are overwhelming and confusing to people in pain with low interoception levels. An inefficient interpretation of those signals affects the ability to cope with the aversive stimulus that induced such an interoceptive response (poor resilience). They might also unconsciously go back many times to check their body signals in order to try and make sense of them. People with high interoceptive abilities, instead, would know their own body so well that they would easily interpret those signals. The resources needed for the signal’s interpretation are obviously subtracted to other tasks, for example coping better with a stressful painful situation.

The positive effects of practice such as mindfulness on pain fit very well in this interesting link between interoception and resilience. Mindfulness increases one’s own body awareness  –  we can argue that it somehow trains people to be more aware of the interoceptive signals, to become familiar with them. We now know that increased interoceptive abilities leave more resources to other tasks, such as coping with pain. Indirectly, thus, increased body awareness might be able to improve resilience, by unloading the overwhelmed interoceptive system.

New research will clarify the clinical relevance of the link between interoception and resilience. In the meantime, even if we were not born on Krypton, we can still call ourselves women and men of steel. It looks like we just need a bit of practice.

About Valeria Bellan

Valeria BellanValeria obtained her degree in Cognitive and Neuro Psychology at the University of Pavia, Italy. She worked for one and a half years as a psychologist at Niguarda Hospital in Milan with children and adults affected with Focal Epilepsy and Parkinson Disease.  Since then she has finished her PhD (entitled ‘Body representation, body localisation and body size perception: a study of bodily modulations’) at the University of Milano Bicocca under the supervision of Dr Alberto Gallace and now is with the BiM team as a post doc fellow.

Valeria’s work investigates the processing of tactile and painful stimuli in the context of multisensory integration and body representation. In particular, Valeria uses the Mirage box to perform bodily illusions in order to investigate self-localisation in chronic pain (especially in people with CRPS).

Valeria used to practice track and field, running the 400 metres and recently achieved her aim of running a marathon. As Helen (Gilpin) can confirm she has a special ability to open containers and key rings. What she misses most about Italy is having breakfast with biscuits but is enjoying learning the Aussie lingo and developing quite an Aussie twang!


  1. Haase, L., et al., When the brain does not adequately feel the body: Links between low resilience and interoception. Biol Psychol, 2016. 113: p. 37-45.
  2. Yeung, E.W., A. Arewasikporn, and A.J. Zautra, Resilience and Chronic Pain. Journal of Social and Clinical Psychology, 2012. 31(6): p. 593-617.
  3. Sturgeon, J.A. and A.J. Zautra, Psychological Resilience, Pain Catastrophizing, and Positive Emotions: Perspectives on Comprehensive Modeling of Individual Pain Adaptation. Current Pain and Headache Reports, 2013. 17(3): p. 1-9.
  4. Sturgeon, J.A. and A.J. Zautra, Resilience: A New Paradigm for Adaptation to Chronic Pain. Current Pain and Headache Reports, 2010. 14(2): p. 105-112.
  5. Ruiz-Parraga, G.T., et al., A confirmatory factor analysis of the Resilience Scale adapted to chronic pain (RS-18): new empirical evidence of the protective role of resilience on pain adjustment. Qual Life Res, 2015. 24(5): p. 1245-53.
  6. Moseley, G.L., A. Gallace, and C. Spence, Bodily illusions in health and disease: physiological and clinical perspectives and the concept of a cortical ‘body matrix’. Neurosci Biobehav Rev, 2012. 36(1): p. 34-46.

[*]The nature-nurture dilemma: does one becomes an athlete because innately predisposition to body awareness or is it rather the constant training that increases body awareness?

Editor:  Lorimer Moseley


  1. Excellent article. And good food for thought. I recognize the altered body map that is associated with pain by simply putting my hand near the area lightly, and approaching or retreating away from the pain. Where my hand goes is an exploratory process and collaboratively engaging of the client’s interoception/ exteroception. based on both of us engaged in a dialogue about sensation (unless we are talking about CRPS which is done differently). For short hand explanation for the client I say I am feeling for the difference between a happy cat and an unhappy cat. One is fluid and there is fine motor regulation. The other quality lacks the subtle movement into my hand. Or it can be as bad as feeling like no one is home. This process helps my clients begin to find where their body feels both more towards normal and where it is more towards somewhat disconnected. This process is part of my evaluation, documentation, and treatment. I can titrate where to be, how long to be somewhere (long enough to facilitate perceptual processing, short enough to not become accommodated to. The goal is restoration of the body map, and reduction in somatic dissociation, restoration of fine motor engagement, and alteration of muscle spasm. I have found this type of mindfulness to be highly effective and even beneficial in severe pain situations. I have been working with a case of severe CRPS for 2.5 years. Initially we used these principles off body at the edge of the reactive boundary space. It took over a year to begin to get near the shoulder of the affected arm. Interestingly, this client is highly resilient, and has extremely good kinesthesia elsewhere in his body.

  2. A great article! The connection between our awareness of the subtle changes in the body and the resilience to find coping mechanisms to interpret change, adapt to change and make changes is fascinating. The example of elite athletes having a greater degree of management control over changes perceived in the body is very significant as this may suggest that performance athletes not only react more proficiently without stress to internal changes but they may actually invoke, consciously or otherwise, pro-active changes to enhance their body’s performance capability. Perhaps this is a phenomenon already under study in different areas of neuroscience? I’d love to know! The concept of visualisation or guided imagery as a performance enhancing technique used by Sports Psychologists proves the effectiveness of invoking change inside the body to create enhanced muscle memory to peak performance. This concept re-sets or redefines an expectation of internal capability of cellular expression that is perceived to be able to happen, be achievable and ultimately to be achieved. What would happen if we applied the same conceptual thinking of invoking change pro-actively inside the body through visualised thought, just like in sports psychology, to predict health performance outcomes that we could perceive to be able to happen, be achievable and ultimately to be achieved. In other words, change the way we think about our mind-body health and performance. After all, everything starts with a single thought! What do you think? Adrian Jones, In Mind In Body

  3. I have a sports med background and have often contemplated the ‘nature/nurture’ thing here.
    Convinced nurture is big role as my weekend warriors (and those in my cycling group) come from all sorts of paths and end up with similar excellent resilience given motivational factors as they get so much enjoyment from what they / we do (includes me).

    Really enjoyed this article.
    Resilience is a major interest as a doctor and as a PARENT.
    Concern to me is the background sociological shift effect of under-exercising, over-eating, over-diagnosis, over-medicalisation, over-parenting, over-everything.
    Do you see kids playing in the streets / dirt as much as they used to?
    And then they inevitably suffer pain …

    Graham Reply:

    The excellent positive psychology book “The Upside of your Darkside”
    makes an excellent point that since the 80’s we have become more and more comfortable and the problem with this is discomfort becomes more and more intolerable. I agree we are setting up our children for problems by not allowing them out to play , climb trees and take general risks that will create resilience.

  4. Thanks Valeria & EG

    It’s not just interoception – because I’ve come across a few long term meditators who have dug a hole for themselves with pain because of their excellent interoceptive skills. It’s about the calacity to shift attention between sensory targets – and more importantly it’s about compasionate awareness. And also it’s about a general mindset of resilience, which probably includes a lot of socialisation traits and some kind of (maybe unconscious) decision as to what is important in life. This would be a positive-oriented attitude (“I look for what I want”) rather than a negative oriented one (“I have to keep checking that I’m safe by looking for threats”)

    On athletes and the nurture-nature dlilemna – I once thought that athletes had to have good proprioception, but then I came across a circus acrobat who told be she had no conscious awareness of any of the movements – she just intended to do a sumersault and then it happened! The body-mind connection is far more complex and varied than can be encapsulated by a few soundbites – or by an investigative protocol that insists on proof by falsification. There will always be examples in one population group that falsify real processes in other population groups.

    EG Reply:

    Hi Andrew,

    I agree with you about meditating on pain itself. It doesn’t work. I prefer to get clients to meditate on a pleasant sensation applied over the top of the painful body part. This avoids the judgmental, hateful attitude which meditating on pain can evoke. As you say, the aversive attitude is damaging.

    Re: high level aheletes – they aren’t always good with words. But the interoception has to be there operating at a high level if they are to learn such skills. Once perfected, such skills get shunted into the subcon., so maybe that’s why it can be difficult to access and describe. Whilst I don’t see such people nowadays, I do recall them coming in with the tiniest, most miniscule complaints, and that requires high body awareness.

  5. It’s been posited that all psychological disturbances result from experiential avoidance. Chronic pain fits with this thinking.

    A good measure of body awareness comes during the interview. Clients who say “my whole back hurts… all the time” are almost always demonstrating high aversion to their symptoms. This is when getting out the body map helps. Tell them to very carefully draw where there’s pain and where there’s none…. where it’s strong, and where it’s moderate. Such an exercise forces them to pay attention and to witness the pain, but it won’t be therapeutic unless judgment is removed from the equation. It’s the self that judges, and going beyond self is what therapy is all about. The therapists’s sole job is to provide an environment which is conducive to letting go (since the self’s primary role is to grasp and fear).

    Looking at DIM-SIM theory, the main reason it helps reduce pain is because the practice itself requires that we first feel our feelings (interospection). We can’t do what’s enjoyable if we don’t know what we feel. We can approximate safety by paying attention to inner feelings and acting on them (‘following one’s heart’, in other words). I say ‘approximate safety’ because real safety is not a possibility until the self is completely let go (ie. enlightenment).

    Of course all this stuff has already been investigated in much more detail than us scientists can figure! If one cares to skip ahead a few decades, I can highly recommend Nisagardatta’s classic “I Am That”, chapter 91. Pleasure and Happiness.