Interoception has been determined to be an elemental aspect of the neural foundations of physiological homeostasis, subjective experience, and motivated behavior. This paper reviews current neuroscience research regarding interoception and forms of interoceptive dysfunction that may result in psychopathology, focusing on depression, and anxiety, in a manner conducive to psychotherapists engaging with it to consider clinical applications. Pertinent aspects of interoceptive system processes in relation to psychopathology are addressed: Functional interoceptive ability and the forms of its expression, the difficulty of accurate measurement of such within an individual or group, interoceptive inference processes and perturbations. Predictive coding, considered in this context as interoceptive inference, a process that integrates bottom-up and top down lines of neural information emerging from the multitude of bidirectional, anatomically hierarchical connections the insular cortex makes with other cortical, and subcortical structures, will be addressed regarding its place in psychopathological formulations. Clinical vignettes will elucidate how interoceptive disturbances might present in the therapeutic relationship, supporting the evaluation and application of scientific theory, and research findings by psychotherapists. The clinical implications of this neuroscientific research have received little attention in the psychotherapeutic setting. Increasing the knowledge base of psychotherapists and furthering awareness of the functional interactions of body and brain toward the creation of healthy and psychopathological experience benefits the patient. There is immediate need for the translational expression of scientific findings into the psychological evaluation of patients, therapeutic process, and treatment. While it may seem distant and unrelated to the affective processes that occur within the psychotherapeutic exchange, neuroscience adds a unique perspective from which to observe and live such experience for the therapist and patient. With the therapeutic relationship as the backdrop, a scientific perspective will support psychotherapists' comprehension of their patients' experience and the process of change, either through direct information, or the development of different perspectives from which to observe and interact with their patients. This paper will serve not only as a guide for psychotherapists concerning this expanding knowledge base, but also a source for neuroscience researchers intent on formulating research protocols that could produce clinical benefit.

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Alexithymia is a disorder that stands at the border of mind and body, with psychological/ affective and physiological/experiential disturbances. The purpose of this article is to propose a new clinical access point for the evaluation and treatment of the deficits in emotional awareness demonstrated in alexithymia. This will be based on insights from recent neuroscientific research, which is adding to the psychodynamic understanding of alexithymia, regarding clinical presentation and etiology. Following a brief review of definitions, forms of measurement, and potential etiologic elements of alexithymia, current neuroscientific theory and research into "predictive processing" approaches to brain function will be outlined, including how "interoception" and "interoceptive inference" underpins emotion and emotional awareness. From this synergistic perspective, I will outline how interoceptive inference provides a key to the link between: problems in early life relational experiences and the patient's long held, but suboptimal models of their inner and outer world. This is reflected in the deficits in affective experiencing and emotional awareness described in alexithymia. Three clinical cases will be presented to illustrate this nuanced consideration of alexithymic etiology and treatment. The implications of the historical, psychological, and somatic aspects of experience will be considered, regarding the patients' diminished ability to: experience and represent emotional experience as distinct feeling states; signify the relevant meaning of affective experience; and incorporate such with cognitions to adaptively guide behavior. These will be addressed using psychometric, psychological, neuro-cognitive, and neurocomputational approaches. Elements from current theory, research, and treatment of alexithymia, will be highlighted that are salient to the clinician, in order to support their understanding of patients against the backdrop of current psychodynamic and neuroscientific research, which will thereby increase treatment options and benefits. The focus, and conclusion, of this article is the role that attention to interoception can play (within the safety of the therapeutic relationship and within any therapeutic process) in allowing updating of the patient's strongly held but dysfunctional beliefs.

To understand our patients and optimize their treatment, psychotherapists of all theoretical orientations may benefit from considering current scientific evidence alongside psychodynamic constructs. There is recent neuroscientific evidence that subjective awareness, feelings and emotions depend upon “interoception,” defined as the neural signaling to the brain from all tissues of the body. Interoception is the obvious basis of homeostasis (in the brainstem) but some interoceptive signals rise above this level and contribute to inferential processes that substantiate intrapersonal and interpersonal experience. The focus of this paper is on the essential role that their “interoception” plays in our patients’ emotional experience and subjective awareness, and how the process referred to as “mentalizing interoception” may be harnessed in therapy. This can best be understood in terms of “predictive processing,” which describes how subjective states, and particularly emotion, are inferred from sensory inputs – both interoceptive and exteroceptive. Predictive processing assumes that the brain infers (probabilistically) the likely cause of sensation experienced through the sense organs, by testing this sensory data against its innate and learned “priors.” This implies that any effort at changing heavily over-learned prior beliefs will require action upon the system that has generated that set of prior beliefs. This involves, quite literally, acting upon the world to alter inferential processes, or in the case of interoceptive priors, acting on the patient’s body to alter habitual autonomic nervous system (ANS) reflexes. Focused attention to bodily sensations/reactions, in the safety of the therapeutic relationship, provides a route to “mentalizing interoception,” by means of the bodily cues that may be the only conscious element of deeply hidden priors and thus the clearest way to access them. This can: update patients’ characteristic, dysfunctional responses to emotion and feelings; increase emotional insight; decrease cognitive distortions; and engender a more acute awareness of the present moment. These important ideas are outlined below from the perspective of psychodynamic psychotherapeutic practice, in order to discuss how relevant information from neuroscientific theory and current research can best be applied in clinical treatment. A clinical case will be presented to illustrate how this argument or treatment relates directly to clinical practice.

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