Interoception or Neuroplasticity

Mad in America recently ran a Webinar on Neuroplasticity as a way to manage one of our greatest challenges – Protracted Withdrawal Syndrome.

The presenters, as described by Mad in America, included:
Ben Ahrens, a chronic illness recovery expert, TEDx Speaker, and CEO of a brain retraining program Re-Origin. This program stemmed from his use of neuroplasticity concepts to manage protracted benzodiazepine and antidepressant withdrawal and severe Lyme disease.

Kay Loveland, PhD, a Clinical Psychologist in Asheville, NC, who has personal and professional experience with protracted withdrawal.

Gustav F who after being inappropriate psychiatrized and being five years in protracted withdrawal sensations and chronic pain turned to a mind-body approach originated by Dr. John Sarno and cured himself.

All 3 came over as decent folk and likely to give listeners the impression neuroplasticity programs offer something.

The word neuroplasticity came on the radar for most of us in the last 1990s with claims that SSRIs promoted neuroplasticity through brain derived neurotrophic factor (BDNG). The presentations didn’t mention anything like this or offer any explanation of what neuroplasticity is – other than some magic wand that puts things right.

While all 3 came over as decent, there was an undertow – the hints were if things don’t work out just right, there must be some prior trauma or current stressors you haven’t taken into account.  Once you do this everything will fall into place.

This leaves the door open to thinking neuroplasticity might be a good-for-sales buzzword. Saying this doesn’t mean it can’t help – it means there may be other ways to do the same thing that don’t involve this buzzword.

In Germany

150 years ago, 3 different German doctors had 3 patients who developed severe anxiety after experiencing an I’m-going-to-die moment in a market-place. One doctor said his patient’s problem was triggered by a visual information processing problem. The others said it’s a neurological problem.

The patients all avoided market-places afterwards, giving the new condition its name – agoraphobia. We later learnt that blocking avoidance with behaviour therapy could help us manage these problems. Expose the person to the stimuli that triggered the problem until they habituated to the trigger.

Behavior Therapy began 50 years before what most people know of as Cognitive Behavior Therapy (CBT). BT had and has no mention of neuroplasticity or cognitions. Its most pugnacious advocate was Isaac Marks.

A century later, Don Klein came out with the idea of a Panic Attack. This took us back to the I’m-going-to-die experience. Klein said we need to correct this rather than just manage avoidance behaviour. Klein figured the death experience was caused by a suffocation reflex. It’s not.

We now use Cognitive Behavior Therapy to manage panic attacks.  But the main evidence that CBT works, for depression as much as for panic attacks, comes from its Behavior Therapy Elements.  In promoting itself in the 1970s and 1980s, as an evidence based therapy, CBT grabbed the evidence from BT trials and used these to make its claims.

BT gets by without the C component but not vice versa.

The form of CBT now used for panic attacks gave rise to what is called Interoceptive Exposure Therapy – see below.  IET is BT but focussed on exposing us to stimuli from our bodies that make us anxious rather than external stimuli like spiders or market-places or to cognitions.

The latest version of agoraphobia and panic attacks, Persistent Postural Perceptual Dizziness PPPD, appeared ten years ago.  A woman who was liaising with RxISK for over a decade who had what she and we agreed was Protracted Withdrawal Syndrome, introduced us to PPPD.  It’s a better fit she said.  See PPPD and Balancing our Bodies.

At the heart of PPPD lies severe dizziness. Even with the word severe added, dizziness sounds like a mild problem. Vertigo comes closer to describing the horror. Imagine having Vertigo on a tightrope. This will for sure cause an enduring shock and avoidant behaviors.

There are up to a 100 different balance problems we know about – see Ondine’s Curse.

Balance takes 2 or more years to master early in life. It has input from the vestibules in our ear, our visual systems and our proprioceptive systems – a set of nerve endings in muscles, bones and joints that tell us where our bodies are. It’s got nothing to do with our brain cortex.

Serotonin is critical for the working of sensory receptors and nerves linked to bones, joints, muscles, eyes and vestibules. Mess with serotonin and things fall apart.

Vestibular Rehabilitation Therapy appears helpful for PPPD. It aims at overcoming avoidant behavior by exposing people to vertigo and balance problems.  VRT can help a lot but the waiting lists are long and while waiting you are likely to be referred for trauma therapy or an SSRI – based on the idea that anxiety is a big part of your problem and ‘curing’ this means unearthing the buried trauma.

There are lots of Coaches (the word of the day) getting involved in this area such as The Steady Coach – a neuroplasticity version of VRT

Balance is a common early side effect of SSRIs. The originators of PPPD do not think starting an SSRI can trigger PPPD although RxISK has several reports of PPPD starting with an SSRI.

Balance problems and vertigo are among the most common and severe problems on stopping SSRIs – even in healthy volunteers after only 2 weeks on the drug.  The creators of PPPD agree SSRIs can definitely cause PPPD on stopping. Folk with PPPD however get put on SSRIs, and told these drugs are a Cure, even if their PPPD has come on after stopping an SSRI.

PPPD is a dysregulation of balance systems.  It is not linked to the speed of a Taper. It can start on treatment rather than just be linked to stopping.

Interoceptive Exposure

Vestibular Rehabilitation Therapy (VRT) is a form or what is often now called Interoceptive Exposure Therapy. This appears to be the best treatment for PPPD but not a cure.  What is IET?

The section below comes from this document – Interoceptive Exposure  I am reproducing what the link says but removed large chunks. The risk is I will make IET sound like a Magic Cure – it’s not.

Why remove chunks from the original document?  Three reasons. One is to avoid it being too long. Second to strip out references to you needing a trained therapist to guide your through all this. It can be nice to have someone but you don’t absolutely need someone else.

Third the growing IET industry seems to me to be putting its foot into the quicksand neuroplasticity has stepped into – blaming trauma or stresses when you don’t get well rather than thinking maybe IET isn’t right for you.

Core Interoceptive Exposure

“Interoceptive exposure is a type of therapy that helps people get comfortable with uncomfortable body sensations like a racing heart or shallow breathing. By practicing specific exercises under guided supervision, individuals learn how to understand and manage these feelings, making it easier to cope with anxiety or stress.

“With Interoceptive Exposure you practice feeling uncomfortable body sensations on purpose. The idea is to help you get used to those feelings so they don’t freak you out as much. It’s like learning to ride a bike; at first, it’s scary, but once you get the hang of it, your fear drops away.

“Why should we care about our body’s sensations? Our bodies give us all kinds of signals, like when we’re hungry or tired. These signals also clue us in on our emotional state.

“Understanding what our bodies are trying to tell us is super important. By getting to know these sensations through interoceptive exposure, we can learn to manage our feelings better and live happier lives.

The History

“Interoceptive Exposure has its roots in Cognitive Behavioral Therapy (CBT), a form of psychological treatment that was developed in the 1960s. CBT aims to help people change harmful patterns of thinking or behavior.

“As part of this broader approach, interoceptive exposure was developed to focus on the physiological, or body-based, symptoms of mental health conditions. Dr. David Barlow, a pioneer in the field of clinical psychology, is often credited with developing this technique.

“In the late 1980s, Barlow and his colleagues realized that many people who experienced anxiety or panic attacks were reacting to uncomfortable bodily sensations like a racing heart or shallow breathing.

“Initially, interoceptive exposure was most commonly used for treating panic disorders. If you’ve ever experienced a panic attack, you’ll know that it involves intense physical sensations, such as heart palpitations and hyperventilation.

“Barlow and his team reasoned that exposing people to these sensations in a controlled setting would help them become less sensitive to them. So, therapists started using exercises like breath-holding or spinning in a chair to induce these sensations, guiding their patients through the process of experiencing and tolerating them.

“Over the years, the use of interoceptive exposure began to expand. By the early 2000s, researchers and clinicians like Dr. Michelle Craske started applying it to other anxiety disorders.

“Studies began to show that the technique could be effective for a variety of conditions, not just panic disorder. This led to the development of a wider range of exercises tailored to different sensations and symptoms. For instance, a person with a social anxiety disorder might work on tolerating the feeling of blushing or sweating in public.

“In recent years, advances in technology have allowed for even more personalized approaches. Virtual reality setups, biofeedback machines, and smartphone apps are now being used alongside traditional methods to enhance the interoceptive exposure experience.

“These tools help people track their bodily sensations and offer new ways to practice exposure exercises.

“Interoceptive exposure has provided a whole new angle for tackling mental health issues. Moreover, its effectiveness is supported by a considerable body of scientific research, making it a well-respected method in the healthcare community.

“Who Can Benefit?

“Is interoceptive exposure right for me?” Well, the technique has shown promise for a variety of people dealing with emotional difficulties. Initially designed for those experiencing panic attacks, it has since widened its scope.  So if you struggle with any sort of anxiety or stress that has a big physical component—like a pounding heart or fast breathing—this approach could be worth exploring.

“Therapists have adapted techniques to suit different age groups. So whether you’re a teenager worried about exams or an adult stressed about work, there’s likely a form of interoceptive exposure that can help you.

“While interoceptive exposure is a powerful tool, it’s not for everyone. People with medical conditions that cause similar sensations—like heart issues—should consult a healthcare provider before attempting this therapy.

Step by Step

“So what does this practice look like? Usually, it goes something like this:

1. Identification: You and your therapist figure out which sensations bother you the most. Maybe it’s a racing heart or feeling dizzy.
2. Simulation: You’ll do exercises that mimic these sensations. For example, if your issue is a racing heart, you might jog in place.
3. Observation: You’ll be asked to pay close attention to these sensations. What does it feel like? Can you describe it?
4. Reflection: Afterwards you’ll be asked – Did it feel as bad as you thought it would? Did anything surprise you?
5. Repetition: Practice makes perfect. You’ll repeat these exercises multiple times, gradually getting used to the sensations.

“Linked into this is goal-setting, monitoring of progress and an emphasis on gradual exposure”.

Toppling into Mind Over Matter

The next section is included because it shows Interoceptive Exposure toppling over into Neuroplasticity.  I find these chunks interesting for this reason. You should read the entire thing and make your own mind up.

“First off, let’s talk about how your body and your mind are connected. You’ve probably heard the phrase “mind over matter,” right? While that saying is catchy, it’s actually a little bit true when it comes to your mental and physical well-being.

“Our thoughts and feelings often show up in our bodies in ways we might not even notice. Maybe you clench your fists when you’re angry, or maybe your stomach knots up when you’re nervous. Interoceptive exposure helps you pay attention to these signals so you can understand what your body is telling you.

“Life today is super busy and filled with all sorts of stressors, from schoolwork and exams to job pressures and social obligations. This can really crank up your stress levels, and if you don’t know how to handle that, it can affect your health over time.

“Interoceptive exposure can be a useful tool in your stress-busting toolkit. It equips you with the skills to handle life’s curveballs more effectively.

“Have you ever done something you regretted because you were just too emotional at the moment? It happens to the best of us. Managing our emotions is a key part of being a happy, well-adjusted person.

“By understanding the physical sensations that come with different emotions, interoceptive exposure helps you get better at controlling how you react to situations. Think of it as an “emotional thermometer” that helps you gauge how you’re feeling so you can take steps to cool down or warm up as needed”.

Where’s the Problem?

I have a few problems with this.  One is the document has a heavy emphasis on the need to get yourself a therapist  It does not entertain the audacity of you getting to grips with the principles and treating yourself.

In the 1990s, as computers and the internet came on stream, Behavior Therapy moved quickly to develop computer based programs to help you manage your Fear.  This may have been a kiss of death for BT and a big boost for CBT. Clinical Psychologists in the UK led the charge against you being able to help yourself in this way. They had problems with services mass delivering cheap treatments you could use on your own.

At the same time clinical psychologists doing CBT were actively involved in recovering memories of abuse that not only did not happen – but which any sensible person could see could not possibly have happened. I say this as someone who was faced with patients who, supported by experienced therapists, claimed they had been abused on an alien spaceship at the age of 1.

Behavior Therapy in contrast stuck to the things you had difficulties with that it could find a way to manage with exposure. In its classic form it didn’t talk about minds or bodies and didn’t dig into your past. This meant it openly recognized there were thing it could not help.

When it comes to problems like drug induced Panic Attacks or PPPD and other Protracted Withdrawal or Drug Dysregulation problems, there seem to me to be three worries with the Quicksands that appear to tempt IET therapists and neuroplasticity coaches.

First, there is something wrong with engaging a person in traumas that may never have happened, while refusing to confronting an abusive prescriber with them.

Second, antidepressant induced dysregulation syndromes, drug toxicity, are increasingly viewed by physicians, especially specialists as evidence of Functional Neurological Disorder (FND).

The word functional in FND means your mind is causing you to be ill.

FND is the latest incarnation of Hysteria and a kiss of death for anyone who wants to be taken seriously. Neuroplasticity comes very close to endorsing the FND idea.

Third, when a drug toxicity has caused the dysregulation, this needs to be recognized and distinguished from what Interoceptive and Neuroplasticity Therapists are likely to call an emotional dysregulation.

If you become anxious after stopping a beta-blocker, you do not need neuroplasticity or interoceptive coaching – you need to be told this is an expected effect that has nothing to do with your emotions. Its a case of Matter over Mind and will disappear pretty quickly.

Where an antidepressant induced effect last longer – again it is Matter over Mind. PPPD may be helped, not cured, by VRT. There are efforts to do the same with Visual Snow Syndrome but this seems less likely to help.  For PSSD and PGAD and other problems, including ongoing anhedonia or akathisia, Matter can triumph over Mind for decades and hinting people are getting the way of their own recovery is plain wrong.

If you wouldn’t tell a menopausal woman that her problems were all emotional dysregulation, you should not take this line with someone whose problems were triggered by a drug.

Mad in America

Mad in America have provided a link to the Neuroplasticity Webinar – you can view the recording here.

They have also provided a set of resources and comments from others in this area including the wonderful Angie Peacock.

What I Think about Neuroplasticity Programs by Angie Peacock

Angie takes a very similar line to the one outlined above – a lot of what is now labelled neuroplasticity or interoception is applied common sense, much of which you can do for yourself.  It definitely can be helpful with components of the withdrawal problem but is not an answer to everything.

These issues are all going to be covered in more detail in a forthcoming Mad in America Webinar on Stopping Antidepressants.