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. Author manuscript; available in PMC: 2026 Jun 28.
Published in final edited form as: Behav Ther. 2025 Jun 28;56(6):1170–1184. doi: 10.1016/j.beth.2025.06.004

Interoceptive Accuracy, Sensitivity, and Attention are Associated with Suicidal Thoughts and Behaviors

Azure Reid-Russell 1, Matthew K Nock 1
PMCID: PMC12553913  NIHMSID: NIHMS2093894  PMID: 41139111

Abstract

Suicide is a leading cause of death. Although significant research has focused on suicide, surprisingly little examines the role of interoception, or the perception of internal bodily states. We examined associations between dimensions of interoception and suicidal thoughts and behaviors (STBs). This online study (N = 450) assessed self-reported interoceptive accuracy, sensitivity, and attention as well as STBs. People with recent STBs reported: perceiving body sensations less accurately (i.e., lower interoceptive accuracy), difficulty perceiving lower intensity sensations (i.e., lower interoceptive sensitivity), and paying more attention to sensations (i.e., greater interoceptive attention). Interoceptive sensitivity moderated the association between negative affect and recent suicidal behaviors, such that people with lower interoceptive sensitivity (i.e., difficulty perceiving lower intensity sensations) were more likely to report suicidal behaviors at all levels of negative affect, whereas people with higher interoceptive sensitivity were more likely to report suicidal behaviors only at high levels of negative affect. This study examines cross-sectional, self-reported associations between interoceptive processes and STBs. Future work should focus on examining objective measures of interoception and longitudinal associations. We provide evidence that the process of perceiving and understanding internal body states may differ for people with suicidal thoughts and behaviors – people with suicidal thoughts and behaviors described perceiving their body sensations inaccurately, especially when sensations were low intensity, and attending to their body sensations often. Interoception may represent an important, underexamined process for understanding STBs.

Keywords: suicide, suicidal, interoception, interoceptive

Introduction

Suicide is a leading cause of death worldwide (CDC, 2020). Despite advances in our understanding of suicidal thoughts and behaviors (STBs), suicide rates have remained consistent over the last century. Suicide research has focused on a relatively small set of risk factors (e.g., symptoms of mental disorders, environmental and demographic factors), with little progress in the prevention, prediction, and treatment of STBs (Franklin et al., 2017). Identifying and targeting new risk factors for STBs may lead to progress in this area. We hypothesize that new risk factors for STBs focused on body-related psychological processes may be important. Broadly, a person’s relationship to and experience of their own body is a central component of STBs. For example, STBs involve imagining methods to harm the body and how each method might feel, obtaining tools for bodily harm, and taking action to harm the body. Yet, there is surprisingly little understanding of how body-related psychological processes may relate to risk for STBs.

Interoception and STBs

Interoception refers to the perception, interpretation, and integration of internal bodily signals (Desmedt et al., 2023). We contend that greater focus on the connections between interoception and STBs can advance our understanding of suicide. Disrupted interoception is associated with the presence of psychopathology symptoms (Bevins & Besheer, 2014; Brewer et al., 2021; Khalsa et al., 2018; Khalsa & Lapidus, 2016; Murphy et al., 2017), and STBs (DeVille et al., 2020; Duffy et al., 2019; Forkmann et al., 2019; Forrest et al., 2015; Hagan et al., 2019; Hielscher et al., 2019; Hielscher & Zopf, 2021; Rogers et al., 2018, 2021). There is evidence that interoception is linked to bodily self-consciousness (i.e., the recognition of a bodily self, involving self-identification, self-location, and first-person perspective) (Park & Blanke, 2019). Disrupted interoception, therefore, may perturb the way people represent their bodies, selves, and sense of bodily and temporal continuity, and perhaps lead to increased propensity for dissociation, depersonalization, or self-objectification as a result. Disrupted interoception and bodily representation may be a pathway through which people develop the capacity to think about and attempt suicide. More plainly, if you do not subjectively experience your body clearly and consistently, perhaps you will be more able and likely to harm it.

Several authors have proposed that disconnection from or objectification of one’s own body may contribute to the capacity to harm one’s own body (Hielscher et al., 2019; Maltsberger, 1993; Orbach, 2003; Orbach et al., 1995, 2001), and past work on interoception and STBs has provided some initial support for the association between disrupted interoception and STBs. More specifically, less accurately perceiving internal body states (i.e., lower interoceptive accuracy, measured via a heartbeat counting task; Schandry, 1981) and self-reported distrust of one’s own body (i.e., lower body trust) have been associated with engagement in lifetime suicide attempts and suicidal thinking (DeVille et al., 2020; Duffy et al., 2019; Forkmann et al., 2019; Forrest et al., 2015; Gioia et al., 2022; Perry et al., 2021; Rogers et al., 2018, 2021; A. R. Smith et al., 2023). Notably, this work has focused on cross-sectional associations between interoceptive accuracy, body trust, and the presence of suicidal thinking or lifetime suicide attempts.

Initial findings suggest there is an association between interoceptive processes and STBs; however, there are important gaps in the understanding of this association. First, we do not understand how other dimensions of interoception may be associated with STBs. Interoception, like other sensory processes, is multi-faceted, and emerging research on interoception has called for greater specificity in identifying and measuring distinct dimensions of interoception (Desmedt et al., 2023; Suksasilp & Garfinkel, 2022) and its associations with psychopathology (Khalsa et al., 2018). Existing work has largely focused on one perceptual dimension of interoception – interoceptive accuracy, or how accurately people perceive internal body states– and interpretations of interoceptive states (i.e., the belief that one “trusts” one’s body). In the study of interoception and STBs, there is a lack of understanding of how interoceptive attention (i.e., amount of attention paid to internal states) and other perceptual dimensions of interoception are associated with STBs. Second, many self-report measures of interoception used in STB research conflate affective and interoceptive processes; for example, in the commonly used Multidimensional Assessment of Interoceptive Awareness (MAIA; Mehling et al., 2018), 30% of the items refer directly to interoceptive processing in the context of an affective state (i.e., worry and calmness). This has limited our ability to understand how STBs may be associated with other perceptual dimensions of interoception and with the interaction of affective and interoceptive processes. To address these theoretical and empirical gaps, we propose that examining three distinct dimensions of interoception may be particularly important in the context of STBs: interoceptive accuracy, attention, and sensitivity.

Interoceptive accuracy and STBs

Interoceptive accuracy refers to the ability to correctly perceive internal bodily states. Prior work supports associations between lower interoceptive accuracy and both lifetime engagement in suicidal behaviors (DeVille et al., 2020) and the presence of past week suicidal thinking (Forkmann et al., 2019). Importantly, depression severity accounts for most of the association between interoceptive accuracy and suicidal thinking, and other studies find no associations between the presence/severity of suicidal thinking or lifetime suicidal behaviors and interoceptive accuracy (Gioia et al., 2022; A. R. Smith et al., 2023). We seek further clarity on whether lower accuracy perceiving internal states may be associated with STBs.

Interoceptive attention and STBs

Interoceptive attention refers to the process of attending to internal body states, and here we focus specifically on the amount of time paid to internal body states (Suksasilp & Garfinkel, 2022). We do not yet understand how interoceptive attention may be associated with STBs. Two facets of interoceptive attention— the tendency to ignore pain or discomfort and the ability to effortfully attend to body sensations during competing stimuli (measured by the Multidimensional Assessment of Interoceptive Awareness [MAIA]; Mehling et al., 2018)— have been studied in the context of STBs (Perry et al., 2021; Rogers et al., 2018; A. R. Smith et al., 2023). These facets of interoceptive attention measured by the MAIA, though important, conflate interoceptive attention with negative affect, pain, and effort. In this study, we hypothesize that lower interoceptive attention (i.e., attending less often to internal body sensations) will be associated with STBs. Perhaps, attending less to body sensations may be caused by or contribute to greater experiential avoidance, which may contribute to emotion dysregulation and STBs.

Interoceptive sensitivity and STBs

We define interoceptive sensitivity as the ability to perceive lower intensity internal body states. Some have used the term “interoceptive sensitivity” synonymously with the term interoceptive accuracy (Garfinkel et al., 2015) or as a broad term encompassing several dimensions of interoception, similarly to the term “interoceptive awareness.” We define interoceptive sensitivity as a perceptual dimension of interoception that encompasses how intense or different (in the case of just-noticeable-differences) internal body sensations must be to be perceived. This definition is more similar to definitions of visual or audial perceptual sensitivity (e.g., Maher et al., 2014). Someone with lower interoceptive sensitivity may only notice body states at higher intensities, impeding one’s ability to respond to states when they are more manageable and less urgent. Lower interoceptive sensitivity may contribute to STBs by preventing people from identifying and regulating affective and physical states at lower levels, leading to regulation only when body states are at their most uncomfortable or most distressing. There are no studies examining interoceptive sensitivity (as defined here) and STBs.

Affective states, interoception, and STBs

Affective states may be important to consider in the context of the interoception-STBs association as well. Psychological scientists have long posited that interoception is an essential component of emotion processing, from early theoretical work by William James through contemporary neuroscience-informed approaches (Barrett, 2017; Feldman et al., 2024; James, 1884). Interoception, therefore, may play a role in emotion processing (Critchley & Garfinkel, 2017; Dunn et al., 2010; Feldman et al., 2024) and emotion regulation (Kever et al., 2015; Zamariola et al., 2019), such that interoception may support the ability to adaptively identify and regulate affective states. There is also a body of work linking affective states and STBs, such that strong, negative emotions characterize STB episodes and precede suicidal behaviors (Baumeister, 1990; Bentley et al., 2021; Harris et al., 2018; Selby et al., 2014). Despite evidence linking interoception to affective states and affective states to STBs, we do not yet understand how interoception and affective states may interact in the context of STBs. Perhaps, lower interoceptive “attunement” (i.e., lower interoceptive accuracy, attention, and sensitivity) leads to greater emotion dysregulation as people fail to access helpful bodily cues in the context of intense affective states, as well as a stronger coupling between negative affect and engagement in STBs.

Current study

Here we aim to better understand how three interoceptive processes may associate with STBs: self-reported interoceptive accuracy, attention, and sensitivity. We hypothesize that participants with more severe suicidal thinking and recent history of suicidal behaviors will experience lower self-reported interoceptive accuracy, lower self-reported interoceptive attention, lower self-reported interoceptive sensitivity than participants with lower suicidal thinking and participants without recent histories of suicidal behaviors. Our rationale is that lower interoceptive accuracy, attention, and sensitivity (or lower interoceptive “attunement” more broadly) lead to a greater sense of disconnection with one’s body, as fewer signals from the body are being accurately perceived or attended to. This sense of “disconnection,” or altered bodily representation, may increase someone’s capacity for lethal bodily self-harm in moments of distress. Lower interoceptive “attunement” may doubly lead to greater distress, as the inability to correctly perceive, attend to, and identify internal body states may impede homeostatic and affective regulation and lead to engagement in STBs.

We also hypothesize that lower interoceptive accuracy, attention, and sensitivity will interact with recent high levels of negative affect to associate with more severe suicidal thoughts and behaviors, such that at low levels of interoceptive accuracy, sensitivity, and attention, there will be greater coupling between negative affect and STB engagement.

Method

Participants

We recruited 450 adult participants through Prolific to participate in an online assessment of interoception and psychopathology. We aimed to test whether disruptions in interoception were specific to those with STBs or were observed among those with psychopathology more generally. Therefore, we recruited three samples of participants: (1) STBs: participants with past month suicidal thinking and/or past five year history of suicidal behaviors (~200 participants), (2) Psychopathology Control: participants with at least mild past month levels of depression, anxiety, or direct or indirect forms of self-injury (i.e., nonsuicidal self-injury or substance use) without lifetime STBs (~150 participants), as measured by the Global Appraisal of Individual Needs (GAIN 2; Dennis et al., 2006) questionnaire and (3) No Psychopathology Control: participants with low levels of recent psychopathology symptoms and no lifetime STBs (~100 participants). Power analyses (using InteractionPoweR; Baranger et al., 2023; Finsaas et al., 2021) indicated that a sample of 200 people provided 80% power to detect small-medium interaction effects. Therefore, we set our number of participants with STBs at 200 and included 250 participants without STBs, with additional participants to ensure varied psychopathology symptoms. Participants completed a <5 minute screening questionnaire assessing demographics and psychopathology symptoms using the GAIN-2 and items assessing presence and timing of suicidal thinking and behaviors from the Self-Injurious Thoughts and Behaviors Interview-Revised (SITBI-R; Fox et al., 2020; Nock et al., 2007). We invited participants to participate in the study if they: (1) showed no signs of using bots on the screening questionnaire (i.e., via Qualtrics Captcha verification), (2) indicated residence in the United States, proficiency with English, and aged 18–65 years, and (3) met criteria for one of three patterns of psychopathology listed above. To recruit our final sample of 450 participants, we screened 2,930 participants and invited 502 participants to complete the full study following screening. Five and 10 participants declined to provide information about suicidal thinking and suicidal behaviors, respectively.

Participants’ genders, races/ethnicities, and ages are reported in Table 1. With regard to highest levels of education obtained, 68 participants endorsed some or all high school (15.11%), 143 endorsed some college or a vocational or Associate’s degree (31.78%), 171 endorsed a Bachelor’s degree (38.00%), 8 endorsed some postgraduate education (1.78%), and 60 endorsed obtaining a master’s degree or higher (13.33%). See Supplementary Materials S1 (Table S1) for further demographic information.

Table 1.

Sociodemographic Variables and Variables of Interest by Past Month Suicidal Thinking

Past month suicidal thinking (N=142) No past month suicidal thinking (N = 303) Total Sample (N = 450)
M SD M SD M SD t
Age 33.90 9.43 38.44 11.00 36.89 10.72 4.48***
Depression severity 16.36 6.76 6.00 5.92 9.18 7.80 −15.28***
Suicidal thinking severity 8.01 5.51 0.00 0.00 2.52 4.83 −17.12***
Interoceptive accuracy 80.00 15.92 86.34 11.15 84.23 13.16 4.03***
Interoceptive sensitivity 57.02 32.47 37.68 19.57 43.76 25.92 −6.43***
Interoceptive attention 52.65 16.95 47.77 16.55 49.39 16.80 −2.77**
N % N % N % χ2
Cisgender woman 66 46.48% 148 48.84% 216 48.00% 0.13
Transgender woman 1 0.70% 0 0.00% 1 0.22% 2.13
Cisgender man 61 42.96% 150 49.50% 214 47.56% 0.93
Transgender man 3 2.11% 1 0.33% 4 0.89% 3.40
Gender nonconforming 9 6.34% 3 0.99% 12 2.67% 10.20**
White 102 71.83% 212 69.97% 316 70.22% 0.03
Black or African American 15 10.56% 33 10.89% 51 11.33% 0.01
Asian 7 4.93% 17 5.61% 24 5.33% 0.09
Hispanic, Latino, or Spanish Origin 4 2.82% 16 5.28% 20 4.44% 1.32
Middle Eastern or North African 0 0.00% 1 0.33% 1 0.22% 0.47
Multiple races/ethnicitiesa 14 9.86% 19 6.27% 34 7.56% 1.65
Other race, not listed 0 0.00% 3 0.99% 3 0.67% 1.41
Endorsed lifetime suicidal thinking 142 100.00% 59 19.47% 202 44.89% 138.00***
Endorsed lifetime suicide attempt(s) 72 50.70% 29 9.57% 102 22.67% 71.64***
Endorsed past 5-year suicide attempt(s) 52 36.62% 16 5.28% 69 15.33% 61.80***
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a

Races/ethnicities endorsed in multiple race/ethnicity category included those listed above and American Indian/Alaska Native.

*

p < .05,

**

p < .01,

***

p < .001

Note: Suicidal thinking severity represents a sum of past month ratings of suicidal urge and intent. Depression severity, Interoceptive accuracy, Interoceptive sensitivity, and

Interoceptive attention are measured using sum scores of the PHQ-9, IAS, ISQ, and IATS, respectively.

All data were collected anonymously through Prolific. Participants were paid $1 for participating in the screening questionnaire and $7 for participating in the 30-minute study. Several steps were taken to ensure high data quality. We used Qualtrics Captcha verification and survey settings to protect against bots and repeated responses. Moreover, all survey responses were inspected for: (1) appropriate time spent on survey (10+ minutes), (2) logical (i.e., response coheres to prompt) and unique (i.e., distinct responses to different prompts and across participants) text entry responses, (3) and signs of bots from Qualtrics Captcha verification. Only three participants received Captcha scores indicating potential bots, and these survey responses contained both logical and unique text entry responses upon inspection. No participants were removed from the full study due to suspicion of bot responding. All procedures were deemed exempt from review by the Institutional Review Board at Harvard University.

Measures

Suicidal thoughts and behaviors

Participants completed a shortened self-report version of the Self-Injurious Thoughts and Behaviors Interview-Revised (SITBI-R), a widely-used structured interview assessing the presence, frequency, and characteristics of self-injurious thoughts and behaviors (Fox et al., 2020; Nock et al., 2007). This interview has shown strong test-retest reliability and concurrent validity (Gratch et al., 2021; Nock et al., 2007). The current study focused on the presence (1) or absence (0) of lifetime suicidal ideation (“Have you ever had thoughts of killing yourself?”), past month suicidal ideation (“Have you had thoughts of killing yourself in the past month?”), and lifetime suicide attempts (“Have you ever tried to kill yourself? In other words, have you ever purposefully hurt yourself with some intent to die?”). If a participant endorsed past day suicidal thinking, they were presented with a survey for creating a step-by-step safety plan and informing them of national helplines and emergency resources for suicide risk. Then, they were encouraged to save this safety plan or, if they prefer, download a blank PDF of the safety plan document. Suicidal thinking severity was calculated as a sum score of items assessing (1) past month intent to kill yourself and (2) past month urge to kill yourself, rated on a scale from 0 (Not at all) to 10 (Very much). This modification from the original SITBI scoring (i.e., ratings from 0–4) was used to be in line with ecological momentary assessments of suicidal urge and intent, which use ratings from 0–10 (Coppersmith et al., 2022; Fortgang et al., 2021). The distribution of suicidal thinking severity sum scores can be found in Supplemental Figure 1. We assessed the date of participants’ most recent suicide attempt. Among those with lifetime suicide attempts, most participants reported multiple lifetime suicide attempts (M# attempts = 3.78, SD = 2.95, Range = 1 – 15).

Depression symptoms

To assess depression symptoms, participants completed the Patient Health Questionnaire – 9 (PHQ-9; Kroenke et al., 2001; Pilkonis et al., 2011). The PHQ-9 has sound psychometric properties, including internal consistency, test-retest reliability, and discriminant validity (Beard et al., 2016; Pilkonis et al., 2014). A sample item reads, “Over the last 7 days, how often have you been bothered by any of the following problems: Little interest or pleasure in doing things.” Items were rated on a scale of 0 (Not at all) to 3 (Nearly every day). We calculated a sum score to represent depression severity. When using depression severity as a covariate, we excluded item 9 of the scale assessing self-injurious thoughts and behaviors. Internal consistency in our sample was excellent, α = .93. Thirty-seven percent of the sample reported moderate-severe depression symptoms (i.e., PHQ-9 total score > 9).

Negative affect

To assess negative affect, we used the Positive and Negative Affect Schedule (Watson et al., 1988). Participants view a list of affect words and are asked to indicate how much they have felt each affective state during the past week on a scale from 1 (Very slightly or not at all) to 5 (Extremely). Higher sum scores of the negative affect word ratings (i.e., Disinterested, Upset, Guilty, Scared, Hostile, Irritable, Ashamed, Nervous, Jittery) indicate greater levels of negative affect.

Interoceptive processes

Interoceptive accuracy.

To examine self-reported interoceptive accuracy, participants completed the 21-item Interoceptive Accuracy Scale (IAS; Murphy et al., 2020). Participants were instructed to rate agreement with statements relating to the ability to accurately perceive an internal body sensation in daily life. A sample item reads, “I can always accurately perceive when my heart is beating fast.” Items were rated on a scale of 1 (Disagree Strongly) to 5 (Strongly Agree). Higher sum scores indicate greater accuracy perceiving internal body sensations. Internal consistency in our sample was excellent, α = .92.

Interoceptive sensitivity.

To examine self-reported interoceptive sensitivity, participants completed the 20-item Interoceptive Sensory Questionnaire (ISQ; Fiene et al., 2018). Participants were instructed to rate agreement with statements relating to the ability to detect low intensity body sensations without external cues, and confusion toward body sensations. A sample item reads, “I have difficulty making sense of my body’s signals unless they are very strong.” Items were rated on a scale of 1 (Not at all true of me) to 7 (Very true of me). Higher sum scores indicate greater difficulties with interoceptive sensitivity. Internal consistency in our sample was excellent, α = .97.

Interoceptive attention.

To examine self-reported interoceptive attention, participants completed the 21-item Interoceptive Attention Scale (IATS; Gabriele et al., 2022). Participants were instructed to rate agreement with statements relating to how much attention they pay toward internal body sensations in daily life. A sample item reads, “Most of the time my attention is focused on whether my heart is beating fast.” Items were rated on a scale of 1 (Disagree Strongly) to 5 (Strongly Agree). Higher sum scores indicate more attention paid to internal body sensations. Internal consistency in our sample was excellent, α = .93.

Statistical Analyses

Analyses were conducted in line with our preregistered hypotheses and data, code, and supplemental materials are publicly accessible on OSF (https://osf.io/z4fcp/). We conducted ordinal (ordinal package; Christensen, 2022) and logistic regressions (stats package; R core team, 2023) in R (R core team, 2023) to assess whether suicidal thinking severity or suicidal behaviors are associated with self-reported interoceptive accuracy, sensitivity, and attention. To assess whether interoceptive processes moderated the association between negative affect and STBs, we used regressions to examine whether an interaction term of negative affect and interoceptive processes (NegativeAffect*InteroceptiveProcess) statistically predicted the suicidal thinking severity sum score or a binary variable representing the presence or absence of suicidal behaviors. Missing data were handled by including only complete cases for analyses. Between 5–13% of the data were missing for a given analysis. For each of these analyses, we examined whether results remained significant after the addition of depression severity as a covariate.

Results

Descriptive statistics

The means and standard deviations of all measures for participants with and without past month suicidal thinking are presented in Table 1. People with and without suicidal ideation in our sample do not significantly differ on racial identities or gender, with the exception of more gender nonconforming individuals endorsing past month suicidal thinking. Participants with past month suicidal thinking were younger than those without. Zero-order correlations among all measures are presented in Table 2. Means of interoception measures by participants without psychopathology, with depression or anxiety and without STBs, and with STBs are presented in Supplemental Table 2. Correlations between individual depression symptoms and interoceptive processes are presented in Supplemental Table 3. Full outputs of all regression analyses are presented in Supplemental Tables 4-12.

Table 2.

Correlations between Variables of Interest

Measures 1 2 3 4 5 6 7
1. Suicidal thinking severity -
2. Depression symptom severity (without item 9) .54*** -
3. Presence of past month suicidal thinking .93*** .56*** -
4. Presence of past 5-year suicide attempt .50*** .38*** .70*** -
5. Interoceptive accuracy −.20*** −.32*** −.18*** −.17*** -
6. Difficulties with interoceptive sensitivity .32*** .50*** .29*** .28*** −.52*** -
7. Interoceptive attention .18*** .25*** .14** .09 −.25*** .36*** -
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Note:

*

p < .05,

**

p <.01,

***

p < .001

Suicidal thinking and interoceptive accuracy, sensitivity, and attention

We examined associations between self-reported interoceptive accuracy, sensitivity, and attention, and past month suicidal thinking severity (Table 3). We found that higher past month suicidal thinking severity was associated with lower self-reported interoceptive accuracy (n=393, β=−0.57, p<.001), lower interoceptive sensitivity (i.e., greater difficulties with interoceptive sensitivity; n=432, β=0.89, p<.001), and greater interoceptive attention (n=418, β=0.40, p<.001) (see Figure 1). After adding depression as a covariate, these effects largely disappeared except in the case of interoceptive sensitivity, which remained associated with suicidal thinking even after accounting for depression severity (n=425, β=0.28, p=.028). We additionally examined associations between interoceptive processing and suicidal thinking severity among only those with past month suicidal thinking, and found that lower interoceptive sensitivity and higher interoceptive attention were associated with suicidal thinking severity among people with past month suicidal thinking (Supplemental Materials, p. 5).

Table 3.

Associations with between Interoceptive Accuracy, Sensitivity, and Attention and Recent Suicidal Thoughts and Behaviors

Response: Past month suicidal thinking severity
 Response: Presence of past 5-year suicide attempt
Bivariate modela
 Additive model with Depressionb
 Bivariate modela
 Additive model with Depressionb
OR
[95% CI]		 p OR
[95% CI]		 p OR
[95% CI]		 p OR
[95% CI]		 p

Interoceptive accuracy		 0.57
[ 0.46, 0.70]
<.001
 0.81
[0.64, 1.03]
.080
 0.59
[0.44, 0.77]
<.001
 0.82
[0.60, 1.11]
.199

Interoceptive sensitivity		 2.43
[1.97, 3.00]
<.001
 1.32
[1.03, 1.69]
.028
 2.38
[1.86, 3.08]
<.001
 1.48
[1.10, 2.00]
.010

Interoceptive attention		 1.49
[1.21, 1.85]
<.001		 1.12
[0.87, 1.45]
.365		 1.26
[0.96, 1.64]
.090		 0.91
[0.65, 1.26]
.797
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a

Bivariate model includes only the interoception variable as a predictor

b

Additive model with depression includes the interoception variable and depression severity as predictors

Note: Suicidal thinking severity represents a sum of past month ratings of suicidal urge and intent and ordinal regressions were used in models this variable as an outcome. Depression severity, Interoceptive accuracy, Interoceptive sensitivity, and

Interoceptive attention are measured using sum scores of the PHQ-9, IAS, ISQ, and IATS, respectively.

Figure 1.

Figure 1.

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Associations of interoceptive accuracy, sensitivity, and attention with suicidal thinking severity and engagement in suicidal behaviors.

Suicidal behaviors and interoceptive accuracy, sensitivity, and attention

We examined associations between self-reported interoceptive accuracy, sensitivity, and attention and engagement in past five-year suicidal behaviors (Table 3). We found that endorsing a suicide attempt in the past five years was associated with lower interoceptive accuracy (n=391, β=−0.53, p<.001) and lower interoceptive sensitivity (i.e., greater difficulties with interoceptive sensitivity; n=429, β=0.87, p<.001) (see Figure 1). Interoceptive attention was not associated with a suicide attempt in the past five years (n=416, β=0.23, p=.090). We conducted a post-hoc exploratory analysis examining the association between interoceptive attention and lifetime suicide attempts and found that greater interoceptive attention was associated with endorsing a lifetime suicide attempt (n=417, β=0.302, p=.009, OR=1.353). After adding depression as a covariate, these effects largely disappeared except in the case of interoceptive sensitivity, which remained associated endorsing a recent suicide attempt even after accounting for depression severity (n=422, β=0.39, p=.010).

Interoceptive sensitivity-negative affect interaction and STBs

We examined whether self-reported interoceptive accuracy, sensitivity, or attention moderated the association between negative affect and suicidal thoughts and behaviors. Interoceptive sensitivity significantly moderated the association between negative affect and past five-year suicidal behaviors (n=426, β=−0.24, p=.038), such that people with lower interoceptive sensitivity were more likely to report past five-year suicidal behaviors regardless of their past week levels of negative affect, whereas people with higher interoceptive sensitivity were more likely to report suicidal behaviors if they also report high levels of past week negative affect (see Figure 2). This interaction did not remain after controlling for depression severity (n=419, β=− 0.15, p=.242). Further, we examined whether individual negative emotions interacted with past five-year suicide attempt history, and found that the interaction between feeling disinterested, scared, and nervous and interoceptive sensitivity was associated with engagement in a past five-year suicide attempt (Supplemental Materials, p. 5). Self-reported interoceptive sensitivity did not moderate the association between negative affect and past month suicidal thinking severity (n=429, β=−0.191, p=.064). Self-reported interoceptive accuracy and attention did not moderate the association between negative affect and suicidal thoughts or behaviors.

Figure 2. Interaction of Negative Affect and Interoceptive Sensitivity and Engagement in Past Five-year Suicidal Behavior.

Figure 2.

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Discussion

There are three key findings from this study. First, we found that, in line with our hypotheses, lower interoceptive accuracy and sensitivity were associated with more severe suicidal thinking in the past month and past five-year engagement in suicidal behaviors. In contrast, higher interoceptive attention was associated more severe past month suicidal thinking and lifetime engagement in suicidal behaviors. Second, after accounting for depression severity, only the associations between interoceptive sensitivity and STBs remained statistically significant. Third, interoceptive sensitivity significantly moderated the association between negative affect and recent suicidal behaviors, such that people with lower interoceptive sensitivity (i.e., difficulty perceiving lower intensity bodily sensations) were more likely to report past five-year suicidal behaviors regardless of levels of past-week negative affect, whereas people with higher interoceptive sensitivity were more likely to report past five-year suicidal behaviors only if they also reported high levels of past-week negative affect. Each of these findings warrants additional comment.

Lower interoceptive accuracy (i.e., lower accuracy perceiving internal body sensations), as well as lower interoceptive sensitivity (i.e., lower ability to perceive less intense internal body sensations) were both associated with more severe recent suicidal thinking and recent suicidal behaviors. We also found that greater interoceptive attention (i.e., the amount of attention paid to internal body sensations) was associated with more severe recent suicidal thinking and engagement in lifetime suicidal behaviors.

We propose a theoretical explanation for these findings. Perhaps, lower interoceptive accuracy and sensitivity and greater interoceptive attention may contribute risk for STBs through difficulty regulating affective and physical states, as well as greater disconnection from one’s own body. Lower interoceptive accuracy and sensitivity may contribute to an inability to correctly identify bodily states and only notice states at high intensities. This may impede regulation of both affective and physical states – accurate identification of an internal bodily state is important for choosing the most effective response and the regulation of bodily states may be most effective when bodily needs are low or medium intensity. Therefore, lower interoceptive accuracy and sensitivity may predispose someone to have greater difficulties with emotion and homeostatic regulation, leading to increased distress, discomfort, and engagement in STBs. Additionally, greater interoceptive attention may impact this process. People with lower interoceptive accuracy and sensitivity may be more uncertain about their body sensations, leading them to attend more to their body sensations to try to clarify bodily signals. This greater attention to internal body states may serve to draw attention feelings of distress and to irrelevant body sensations, increasing distress more generally (but perhaps not increasing suicide risk specifically, as interoceptive attention was not associated with suicidal thinking or recent suicidal behaviors above and beyond depression severity). Finally, these dysfunctional interoceptive processes may serve to “disconnect” someone from their body as they struggle to understand or regulate their body sensations, which may make them more likely to harm their body. More specifically, interoceptive dysfunction may have implications for disrupted body representation and sense of bodily self-consciousness (Park & Blanke, 2019), and be associated with dissociation, depersonalization, and self-objectification as a result. As people represent their bodies differently sensorily over time, they may view their bodies an object rather than as a part of the self through self-objectification (Hielscher et al., 2019; Hielscher & Zopf, 2021; Orbach, 2003; Orbach et al., 2001). They may then be more likely to consider lethally harming their bodies in moments of distress.

These findings in conjunction paint an interesting, clear phenomenological picture of interoception and STBs. People with more severe STBs describe an internal sensory landscape characterized by imprecision and confusion, with greater chance of incorrectly identifying internal body states and only noticing internal body states when they are intense and urgent. Further, they report spending significant amounts of time attending to these internal body states, potentially preoccupied with internal feelings while feeling less certain about them. Importantly, depression severity may be an important factor to consider in this phenomenological picture, though depression does not entirely account for these findings. Body regulation may be important for mood and homeostatic regulation in the context of depression, such that interoceptive processing may impact one’s experience and regulation of both negative and positive affect, as well as energy and hunger regulation. This work adds greater specificity to existing work on interoception and STBs. Much existing work on interoception and STBs has illuminated general interoception differences (i.e., “worse” or “lower” interoception) in people with STBs or has focused on dimensions of interoceptive interpretations (i.e., body trust), setting foundation of work that builds a case for further study on interoception and STBs (DeVille et al., 2020; Duffy et al., 2019; Forkmann et al., 2019; Forrest et al., 2015; Gioia et al., 2022; Hagan et al., 2019; Hielscher & Zopf, 2021; Rogers et al., 2018, 2021; A. R. Smith et al., 2023). However, to translate this work into phenomenological insights and new avenues for interventions, greater specificity in the study of interoception is needed (Suksasilp & Garfinkel, 2022). This study provides scaffolding for further work by discriminating between self-reported interoceptive accuracy, sensitivity, and attention in our examination.

One novel aspect of this study is the examination of how affective states and interoception may interact in the context of risk for STBs. We found that people with lower interoceptive sensitivity were likely to endorse past five-year suicidal behaviors regardless of their past week levels of negative affect, whereas people with higher interoceptive sensitivity were more likely to endorse recent suicidal behaviors only if they also reported higher levels of past week negative affect. This interaction is different than hypothesized; given that both low interoceptive sensitivity and high negative affect are associated with engagement in STBs, we expected that those with both low interoceptive sensitivity and high negative affect would be the most likely to have histories of suicidal behaviors. Instead, we found that people with high levels of negative affect were more likely to report engagement with suicidal behaviors regardless of interoceptive sensitivity. In people with low negative affect, only those with lower interoceptive sensitivity were likely to report engagement in suicidal behaviors. Perhaps, low interoceptive sensitivity, or difficulty perceiving low intensity body sensations, may impede effective emotion regulation, such that emotion regulation is more difficult when levels of negative affect are lower. This may lead to increases in suicidal behaviors at low or medium levels of negative affect only for those people with lower interoceptive sensitivity – those who struggle to regulate negative emotions when affect intensity is not high enough to perceive. Alternatively, perhaps high levels of negative affect may be salient and overwhelming, and therefore interoceptive processing may matter only when negative affect is lower. Though this effect is small and should be interpreted as such, this finding may shed light on new avenues for theories of interoception, affect, and STBs.

Limitations and future directions

These findings should be interpreted in the context of limitations. Most importantly, this study examines self-reported interoceptive accuracy, sensitivity, and attention, rather than objectively measured interoceptive processes through psychophysiological tasks. Interoception researchers call for a distinction between self-reported interoception and objectively measured interoception, as these measures often diverge and measure different constructs (Desmedt et al., 2023; Garfinkel et al., 2015, 2022; Suksasilp & Garfinkel, 2022). Extending this work to laboratory-based psychophysiological examinations of interoception and STBs is an essential next step for this work. This study provides rationale for using multi-dimensional psychophysiological examinations of interoception beyond the commonly used heartbeat counting task (Schandry, 1981), as this task measures only interoceptive accuracy and suffers from several confounds, including heartbeat knowledge and non-interoceptive sensory information (Desmedt et al., 2018). Future work on interoception and STBs should expand to psychophysiological tasks that objectively measure interoceptive sensitivity specifically. For example, the Heartrate Discrimination Task, developed by Legrand and colleagues (2022), determines the threshold of detectable difference between one’s own heartrate and a tone played slightly faster or slower than one’s heartbeat. Additionally, a psychophysiological task involving perceiving a difference between an interoceptive stimuli at rest and during an interoceptive perturbation, such as a breath hold (R. Smith et al., 2021) condition, would allow for a measure of interoceptive sensitivity.

Additionally, this study is cross-sectional, and cannot speak to these associations over time or the direction of these associations. For example, it is possible that the presence of STBs precede changes in interoceptive processing, or a third factor (i.e., depression) may contribute to both disrupted interoception and STBs. Relatedly, the time windows of measurement of interoception, negative affect, and STBs in this study vary – we assess past week negative affect, past month suicidal thinking, and past five year engagement in suicidal behaviors. This poses a challenge for our negative affect-interoception interaction analysis in particular. The inconsistency of the interaction analysis results for lifetime vs. past month STB outcomes introduces some uncertainty about the robustness of the observed effects. Given the stability over time of both suicidal behaviors (Ribeiro et al., 2016) and negative affect (Watson & Walker, 1996), we believe it makes sense to examine the associations among these constructs over the life course. However, the fact that the hypothesized associations are present in past-five-year suicidal behavior but not past-month suicidal thinking analyses suggest the temporal stability of such associations warrants scrutiny in future studies. Further, interoceptive accuracy, sensitivity, and attention are assessed as trait-like constructs, as participants reflect on their engagement in these interoceptive processes in general. This limits the interpretations of our findings, as we cannot speak to how our findings may apply to real-time suicide risk, moments of increased negative affect, or periods of especially disrupted interoception. There are likely important associations between these factors as they change dynamically over time, and future studies would benefit from measuring these constructs as they unfold over time. Future work would benefit from multiple study assessments or an ecological momentary assessment design to examine longitudinal associations between interoception and STBs.

This study also suffers from common limitations with online research: the possibility of bots or invalid survey responses. We have minimized this possibility by carefully screening each participant invited to the study for signs of bots or invalid responses, and we have inspected all text entries from each participant to examine validity. Finally, this sample was mostly white and heterosexual, which limits the ability to generalize these results to more diverse samples.

Conclusions

Here, we established that lower interoceptive accuracy, lower interoceptive sensitivity, and greater interoceptive attention were associated with more severe recent suicidal thinking and engagement in suicidal behaviors. We also found support for interoceptive sensitivity moderating the association between negative affect and engagement in recent suicidal behaviors, such that those with lower interoceptive sensitivity were most likely to report recent suicidal behaviors, even at low levels of negative affect. Perceiving and understanding internal body states is essential for managing homeostatic needs, emotion regulation, and survival. We provide evidence that the process of perceiving and understanding internal body states may differ for people with suicidal thoughts and behaviors – people with suicidal thoughts and behaviors described perceiving their body sensations inaccurately, especially when sensations were low intensity, and attending to their body sensations often.

Supplementary Material

1

highlights.

  • Interoception is important for homeostasis, emotion processing, and survival

  • People with suicidal thoughts and behaviors report differences in interoception

  • People with suicidal thoughts and behaviors perceive body states less accurately

  • Those with suicidal thoughts and behaviors struggle to perceive subtle body cues

  • Individuals with suicidal thoughts and behaviors may attend more to body sensations

Acknowledgements

We would like to acknowledge Elizabeth Wu and Cate MacDonald for support developing online questionnaires and study protocols.

Funding

Azure Reid-Russell is supported by the National Institute of Mental Health (NIMH) NRSA Predoctoral Fellowship F31MH132231 and the Harvard University Innovation Funds Talley Grant. Matthew K. Nock is supported by NIMH U01MH116928 and the Fuss Family Research Fund.

Footnotes

Declaration of Interest

Dr. Nock receives publication royalties from Macmillan, Pearson, and UpToDate. He has been a paid consultant in the past three years for Apple, Microsoft, COMPASS Pathways, Cambridge Health Alliance, and for legal cases regarding a death by suicide. He has stock options in Cerebral Inc. He is an unpaid scientific advisor for Empatica, Koko, and TalkLife.

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