Sage Journals: Discover world-class research

Abstract

Background:

Somatic complaints are a critical burden to women, particularly to those women who survived intimate partner violence (IPV). The way women feel, perceive, and relate to their own body, that is, interoception, seems to have a significant role in the pathway to somatic complaints. However, to the best of our knowledge, no study has yet explored the relationship between interoception and somatic complaints of women survivors of IPV.

Objectives:

To deepen the understanding of the underlying interoceptive mechanisms of somatic complaints experienced by women survivors of IPV.

Design:

Cross-sectional study.

Method:

Women with (N = 44) and without (N = 52) history of IPV were assessed regarding interoceptive accuracy, interoceptive sensibility, and somatic complaints. Associations between both variables in each group were examined, and a hierarchical regression analysis assessed to what extent somatic complaints were explained by the interoceptive abilities, with the mediating role of IPV group membership.

Results:

Women survivors of IPV reported more somatic complaints (p < 0.001), which were negatively associated with interoceptive attention regulation. The opposite association was found in women who have never experienced IPV. For the IPV group, the interoceptive attention regulation, added to age and the index of the violence suffered, explains 43% of the variance in somatic complaints.

Conclusion:

The findings suggest that for women with history of IPV, but not for those without, the ability to regulate the attention given to bodily sensations is a mediator of women’ somatic complaint. Thereby we suggest that interoceptive attention regulation can be a promising therapeutic aim, for women recovering from IPV.

Plain language summary

Regulating attention to bodily sensations contributes to decreasing the health complaints of women survivors of intimate partner violence

Why was the study done? Women who suffered violence in an intimate relationship report more health complaints than women who have never suffered such violence. In general, it is known that different ways of feeling the body distinctively influence how many and how intensively one’s report health complaints. It is also known that women who suffered violence have a different way of feeling the body and its sensations. However, how this way of feeling influences the health complaints of women survivors of intimate partner violence remains unexplored. What did the researchers do? The research team studied different abilities of feeling the body of women with (44) and without (52) history of intimate partner violence. Also, the health complaints of each were assessed, and how those were influenced by feeling the body was examined. What did the researchers find? Women survivors of intimate partner violence reported more difficulties falling asleep, migraines, panic attacks, anxiety and attention and memory struggles. Furthermore, for women who have experienced this type of violence—but not for those who have not—greater ability to regulate attention toward the body (i.e., focusing on the body only when necessary) was associated with fewer health complaints. What do the findings mean? The findings suggest that for women who suffered intimate partner violence, health care must promote the ability to regulate the attention given to the body, helping women to have better health, better emotional regulation, and lower risk of developing negative symptoms.

Keywords

somatic complaints Portugal interoception attention regulation domestic violence

Introduction

Somatic complaints are frequently reported by survivors of intimate partner violence (IPV).^1,2 Complaints like back pain, headache, and dizziness generally derive from the distressing perception of bodily sensations, impairing daily functioning.³ Indeed, the so-called interoception, that is, the process of sensing and perceiving internal bodily sensations, like heartbeat, breathing, or pain, has been argued as a critical explanatory mechanism for the experience of somatic complaints.⁴ However, external factors have also a role in this pathway. For example, the experience of traumatic situations, such as IPV, may have an impact on interoceptive abilities. Understanding if and how this perception and interpretation of bodily signals exacerbates somatic complaints of IPV survivors is paramount for improving medical care and developing effective integrative therapeutic interventions.

For years, the evidence has pointed to somatic complaints arising from the ability to perceive bodily signals accurately—interoceptive accuracy; thus, bottom-up sensory information would originate and exacerbate the perception of a symptom.^5,6 However, contradictory findings got this link questioned, suggesting that top-down cognitive and affective processes significantly alter this relationship and influence bodily signals’ perception, interpretation, and reporting.^3,4,7,8

Heightened arousal is one of the main interferences in interoception.^9,10 It reflects mainly on increased bodily signals,^9,11 increased perception of minor bodily signals^4,12,13 or on even minor bodily signals being categorized as threatening, pathological, or stressful.^10,13,14 The resulting misinterpretation of actual physiological signals and their slight changes result in a cycle of hypervigilance toward the body that continuously exacerbates symptoms’ perception, thereby contributing to symptom maintenance.^3,15,16 Simultaneously, dysfunctional behavioral processes—such as avoiding physical activities and withdrawing from beneficial social contacts—may contribute to distress and other somatic symptoms.¹⁷

Considering this, an approach to understanding somatic complaints as a more complex process involving both bottom-up and top-down processes arose. The concept of somatosensory amplification refers to the tendency to experience bodily sensations as intense, catastrophic, and disturbing,^4,12,13 involving either bottom-up processes (bodily signals) and top-down processes (as body hypervigilance; focus on slight and weak body sensations, and cortical reactions to sensations). According to Wolters et al.,¹³ the brain generates predictions about internal bodily states based on incoming interoceptive information and adjusts these predictions accordingly. However, when there is a misinterpretation or misperception of interoceptive sensations, those predictions do not match with the sensory input, resulting in perceived somatic symptoms that do not correspond to physiological changes.^3,13 Furthermore, this biased interoception leads to individuals affirming symptoms readily in ambiguous situations.¹⁸ Altogether, these processes contribute to exacerbating somatic complaints, resulting in health worries, expectations of symptoms, and amplified perception of external threats.^12,13

Moreover, studies on somatization, the tendency to express emotional distress as somatic symptoms,¹⁹ suggest that maladaptive defense mechanisms such as suppression and displacement of negative emotions are associated with the formation of somatic symptoms, possibly through difficulties handling emotional stimuli that interfere with sensorial information interpretation.²⁰ In this sense, showing an inflexible response (as opposed to a flexible adaptation) to repeated or severe threats to the body (as is the case of IPV) is suggested to compromise the accurate perception of bodily signals and resulting in interoceptive illusions, therefore contributing to somatic complaints.²¹ Somatization is often found in people exposed to traumatic experiences, in particular in those experiencing posttraumatic stress disorder (PTSD)²⁰ which, in turn, is based on a condition of dysregulated arousal.²²

Taken together, these findings contribute to the current efforts to conceptualize the different Posttraumatic Orientations to Bodily Signals, an umbrella term that encompasses the tendency to interpret bodily signals as catastrophic and frightful after exposure to trauma.^23,24 However, in the literature review that supports this term, only 8% of the included studies were on interpersonal trauma or IPV,²⁵ which highlights the need of more studies.

The case of IPV

Women survivors of IPV often report medically unexplained symptoms in gastrointestinal, cardiopulmonary, neurological, sexual, and reproductive dimensions.^26,27 Such symptoms have been reported by adults who suffered violence in childhood,²⁸ adolescence,²⁹ and adulthood,^30,31 corroborating the long-lasting detrimental effects of interpersonal violence. Furthermore, the more violence a woman is exposed to, the higher the number of somatic symptoms reported,¹ especially if they suffered sexual violence or abuse and if the abuse came from someone close to them.³²

Trauma consequences, such as maladaptive defense mechanisms, altered brain connectivity, hypervigilance, dissociation, and psychopathology, contribute to either heightened or reduced alertness, a misinterpretation of interoceptive sensations, and somatic symptoms reporting.^16,33
–35 Also, bodily dissociation (i.e., the feeling of being separate from the body and with difficulty expressing emotions),³⁶ another consequence of IPV,^31,35 has already proven to be a significant mediator between traumatic experiences and emotion dysregulation.³⁷ Bodily dissociation decreases the ability to be aware of bodily sensations, sustain attention toward the body, and trust in interoceptive sensations,³⁸ thus adding as a possible mechanism linking interoception to somatic complaints in violence-related trauma.¹⁶

So far, research has shown that women survivors of IPV show a high report of somatic complaints, a low interoceptive accuracy, and difficulties in interoceptive self-regulation and in trusting in bodily sensations which relate to increased symptoms of PTSD, anxiety and depression.^31,39 Despite these significant findings, the dynamics between interoception and somatic complaints of survivors of IPV remain unexplored. Moreover, considering that the cumulative aspect of IPV (co-occurrence of various forms of violence) has been related to the experience somatic symptoms of women exposed to violence across the lifespan, it is necessary to account for a violence index in related research.^40,41 Hence, there is a need of a deeper understanding of the interplay between violence severity and interoceptive abilities and their role on somatic symptoms of IPV survivors.

The present study

Somatic complaints have a heavy impact on daily functioning. Regarding survivors of IPV, the experience of somatic complaints increases if they experience more than one form of violence.⁴¹ One of the most acknowledged mechanisms for perceiving and reporting somatic complaints is interoception, namely interoceptive accuracy and interoceptive sensibility. As detailed in the sections above, biased interoception (e.g., high sensitivity to internal sensations combined with poor accuracy or misinterpretation of such signals) was both found in people with somatic symptom disorders¹³ and with violence-related trauma.^16,33,42 However, the contribution of interoceptive abilities for somatic complaints of survivors of IPV still lacks research.

Therefore, the main aim of this study is to gain a deeper understanding of the relationship between somatic complaints and interoceptive abilities (accuracy and sensibility) of women survivors of IPV, accounting factors that knowingly contribute to both somatic complaints and/or interoception, such as age,⁴³ mental health,^3,33,39 and the violence suffered.⁴¹

To attain the aim of this study, the research strategy was threefold. First, we examined the somatic complaints, interoceptive abilities, violence index, and mental health (PTSD, depression and anxiety diagnoses) of women survivors of IPV, and compared them with women who have not experienced IPV. Based on previous research,^{26,30,31,35,38} we hypothesized that survivors of IPV show higher rates of somatic complaints, and a higher tendency for not-distracting themselves from negative sensations, as well as lower interoceptive accuracy, attention regulation, self-regulation, and trusting in bodily sensations (H1). In parallel, we expected a higher violence index, and a higher report of mental health diagnoses.^1,16,31,35

Second, we examined how somatic complaints were related with interoceptive abilities and violence index, for women survivors of IPV and for women with no IPV history. Considering that age,⁴³ mental health,^3,33,39 and the history of violence⁴¹ influences both somatic complaints and/or interoception, these factors were accounted. Considering previous research, we hypothesized a positive association between Violence Index and somatic complaints (H2), and a negative association between somatic complaints and interoceptive accuracy,³⁹ attention regulation, self-regulation, and trusting for women survivors of IPV (H3).^31,38 However, for women non-victims of IPV, we hypothesized a negative association of somatic complaints with interoceptive accuracy, and the noticing, not-worrying, emotional awareness, and self-regulation scales of interoceptive sensibility (H4).^5,44,45

Third, we investigated to what extent somatic complaints were explained by the interoception abilities correlated in the previous step, with the mediating role of IPV group membership. Although no previous study has examined this, we hypothesized that IPV group would play a mediating role in the relationship between somatic complaints and interoception, possibly in the accuracy, attention regulation, and trusting abilities (H5), since preliminary evidence suggests they behave differently for people with and without a history of IPV.

Methods

This was a comparative study, for which the STROBE guidelines for cross-sectional studies were followed when preparing this manuscript.⁴⁷

Participants and procedure

OpenEpi was used to calculate the minimum required sample size for unmatched case–control studies.⁴⁸ For this calculation, significance level (alpha) was set at 0.05, power at 90%, proportion of controls with exposure at 30%, ratio of sample size at 1, and hypothetical proportion of cases with exposure at 80%.⁴⁹ Results indicated that a minimum of 23 women survivors of IPV and 23 women without experience of IPV were required. A total of 96 women (18–68 years old) participated in this study (Table 1). Of this, 44 were women survivors of IPV living in shelter homes (IPV group; 18–68 years old), and 52 were women recruited from the community who reported never suffering IPV (no-IPV group; 19–64 years old).

Table 1.

Sample characteristics and descriptives.

Variables	Group IPV (N = 44)	Group no-IPV (N = 52)	p-value
Variables	Mean (SD)	Mean (SD)	p-value
Age	40.3 (11.2)	43.1 (12.5)	0.254
Mental health diagnosis
PTSD, n (%)	6 (11.5)	0 (0.0)	0.021
Anxiety, n (%)	15 (28.8)	10 (22.7)	0.501
Depression, n (%)	32 (61.5)	12 (27.3)	<0.001
Violence index	2.9 (1.0)	0.3 (0.5)	<0.001
Somatic complaints	0.36 (0.27)	0.18 (0.18)	<0.001
Sleep problems	0.65 (0.48)	0.34 (0.48)	0.002
Panic attacks	0.21 (0.41)	0.02 (0.15)	0.006
Anxiety attacks	0.46 (0.50)	0.25 (0.44)	0.033
Respiratory problems	0.19 (0.40)	0.11 (0.32)	0.295
Auto-immune diseases	0.10 (0.30)	0.09 (0.29)	0.936
Chronic pain	0.29 (0.46)	0.16 (0.37)	0.136
Migraines	0.44 (0.50)	0.21 (0.41)	0.014
Attention and memory difficulties	0.42 (0.49)	0.23 (0.42)	0.044
Gastrointestinal problems	0.33 (0.59)	0.16 (0.48)	0.070
Cardiac/vascular problems	0.27 (0.49)	0.16 (0.37)	0.264

PTSD: posttraumatic stress disorder; IPV: intimate partner violence; SD: standard deviation.

The inclusion criteria were (a) being female, (b) aged ⩾18 years, and (c) having suffered IPV (for the IPV group) or (d) not having suffered IPV (for the no-IPV group). Women under 18 and/or with significant cognitive impairments that could affect comprehension of the assessments were excluded of this study.

For the IPV group, the study was presented to four shelter homes from the central and southern regions of Portugal. After approval from their managing entities, women were asked to participate, and a total of 47 accepted to enroll. Of these, 44 completed the assessments and were included in the analysis.

For the no-IPV group, a presentation of the study with an invitation to participate was disseminated using social media and the university communication channels, through a snowball effect. Of the 53 women from the local community who showed interest in participating, 52 completed the assessments and were included in the analysis.

Confidentiality was maintained and participation was subject to informed consent. Each testing session took about 45 min and was performed individually in a quiet room of the shelter—for the IPV group—or at university facilities or participants’ home—for the no-IPV group. After a brief explanation of the purpose of the study, participants filled out a sociodemographic survey assessing sociodemographic data, age, mental health diagnosis, medication, somatic complaints and forms (psychological, physical, and sexual), and contexts (intimate relationship, family relationship, or work relationship) of the violence suffered. Data were collected between November 2021 and January 2023.

This study followed trauma-informed and trauma-sensitive practices, namely through a researcher experienced in therapy, in establishing physical and relational safety and trust in the assessment setting, and in knowing how to avoid re-traumatization in such context.

Instruments

Somatic complaints were assessed through a checklist of 10 somatic symptoms developed following previous conceptual frameworks.^50,51 Women reported which complaints they experienced (e.g., sleep difficulties, migraines, chronic pain) in the past week. The total score was obtained by the mean of all the reported symptoms, with higher scores indicating more symptoms. In the present study, the Cronbach’s alpha of this instrument was 0.723.

Interoception was evaluated in two dimensions: interoceptive accuracy and interoceptive sensibility. For assessing interoceptive accuracy, we administered the heartbeat counting task.⁵² In a sitting position, participants were asked to count the heartbeats felt during each trial of 45, 35, 55, and 25 s, presented in a fixed order. A pulse oximeter was fitted on the index finger of their left hand for physiological heartbeat detection. For each trial, an accuracy score was derived: 1 − (real beats − reported beats)/((real beats + reported beats)/2). Resulting accuracy scores were averaged over the four trials, yielding an average value for each participant. Interoceptive sensibility was assessed through the self-report questionnaire multidimensional assessment of interoceptive awareness (MAIA).⁵³ The Portuguese version of MAIA consists of 33 items and uses a 6-point Likert scale (0: never; 5: always), where higher scores indicate greater positive interoceptive sensibility. It evaluates seven dimensions: noticing (i.e., awareness of body sensations), not-distracting (i.e., tendency not to distract oneself from sensations of pain or discomfort), not-worrying (i.e., tendency not to worry with sensations of pain or discomfort), attention regulation (ability to sustain and control attention), emotional awareness (i.e., awareness of the connection between body sensations and emotional states), self-regulation (i.e., ability to regulate distress by attention to body sensations), and trusting (i.e., experience of one’s body as safe and trustworthy).^38,52 In this study, the not-worrying scale showed a Cronbach’s alpha of 0.497; therefore, it was removed from the analysis. For all the other scales, Cronbach’s alphas ranged from 0.701 (noticing) to 0.876 (attention regulation).

Violence index was obtained by computing the sum of all the forms of violence suffered (psychological, physical, and sexual) ranging from 0 (zero) to 3 (three).

Statistical analysis

The analysis plan followed the three steps and hypothesis testing mentioned in the “The Present Study” section.

Primarily, descriptive statistics of sociodemographic data, somatic symptoms, mental health medical diagnosis, violence history, and interoception skills were performed for both IPV and no-IPV groups. The Shapiro–Wilk test was used to check data normality. Reliability of the somatic complaints checklist and of each subscale of MAIA was checked through Cronbach’s alpha and inter-item correlation (Table 2). Independent sample t-tests (reporting t-test statistics, degrees of freedom, and p-values) were used to compare age, somatic complaints, mental health, and interoception between women with and without IPV history.

Table 2.

Psychometric properties and mean scores (standard deviations) of the measures.

Variables	N items	Scale range	Cronbach’s α	Mean (SD)		U	p
Variables	N items	Scale range	Cronbach’s α	IPV	No-IPV	U	p
Somatic complaints checklist	10	0.0–1.0	.723	0.4 (0.3)	0.2 (0.2)	691	<0.001
Interoceptive accuracy, HCT	1	0.0–0.9		0.4 (0.3)	0.4 (0.3)	1014	0.625
Interoceptive sensibility, MAIA
Noticing	3	0.0–5.0	.701	3.8 (1.1)	3.8 (1.1)	1124	0.882
Not-distracting	4	0.0–5.0	.806	1.4 (1.1)	1.6 (1.1)	1068	0.578
Not-worrying	4	0.0–5.0	.497	2.6 (1.0)	2.5 (0.8)	1052	0.496
Attention regulation	7	0.4–5.0	.876	3.3 (1.2)	3.2 (0.8)	1099	0.743
Emotional awareness	5	0.2–5.0	.871	4.3 (0.8)	4.1 (0.9)	955	0.160
Self-regulation	7	0.0–5.0	.863	3.0 (1.2)	3.2 (0.8)	1080	0.640
Trusting	3	0.3–5.0	.857	3.1 (1.5)	3.8 (1.0)	904	0.076

HCT: heartbeat counting task; MAIA: multidimensional assessment of interoceptive awareness; IPV: intimate partner violence; SD: standard deviation.

Second, for each group, Spearman’s rho for non-normal variables was used to check partial correlations between somatic complaints, violence index, and interoceptive abilities, controlling for age, PTSD, and depression diagnosis, since those are known confounders for interoception variability and/or somatic complaints.

Third, hierarchical regression analysis was used to assess the moderating role of interoceptive abilities and violence index on somatic complaints (model 1), adding an interaction term between each factor and the group (model 2), to assess IPV-group membership mediator role. Adjusted R-squared terms were calculated to assess the proportion of variation in somatic symptoms predicted by the statistical models. Normality, linearity, and heteroscedasticity checks performed on the data confirmed that all model assumptions were met.

Data cleaning

Few values (<5%) were missing, and Little’s test of missing completely at random (Little’s MCAR test; p > 0.05) indicated that these were missing at random. Therefore, all participants were included, and missing values were replaced by the mean value of the respective item scores. All statistical analyses were conducted using version 24.0 of SPSS (IBM Corp., Armonk, NY, USA, 2017) and significance level was set at p < 0.05 (two-tailed).

Results

Sociodemographics, mental health, somatic complaints, violence index, and interoceptive abilities of women with and without history of IPV

A total of 96 women participated in this study. Table 1 presents the characteristics of both IPV (n = 44) and no-IPV (n = 52) groups. The majority of IPV victims had a secondary educational level or less, whereas most of the non-victims had an educational level above the secondary level (p = 0.001). When compared to non-victims, IPV victims showed significantly higher frequency of PTSD and depression diagnosis, along with an increased violence index (p < 0.001) and report of somatic complaints (p < 0.001), namely sleep problems (p = 0.002), panic attacks (p = 0.006), anxiety attacks (p = 0.033), migraines (p = 0.014), and attention and memory difficulties (p = 0.044). IPV and no-IPV groups did not differ in age, interoceptive accuracy, or interoceptive sensibility.

Correlations between somatic complaints and interoceptive abilities and violence index of women with and without history of IPV

Results from the second step showed that, for the IPV group, higher rates of somatic symptoms correlate with higher violence index (p < 0.001) and with lower attention regulation (p = 0.006), that is, lower ability to regulate the attention given to internal sensations. On the other hand, no significant correlations with somatic complaints were found for the no-IPV group (see Table 3).

Table 3.

Correlations of violence and interoception with somatic complaints.

Variables	Somatic complaints
	Group IPV (N = 44)	Group no-IPV (N = 52)
	Rho	Rho
Violence index	0.418*	0.126
IAc	0.173	−0.157
Noticing	−0.026	0.232
Not-distracting	−0.102	−0.050
Not-worrying	−0.217	0.028
Attention regulation	−0.295*	0.019
Emotional awareness	0.154	0.117
Self-regulation	−0.118	−0.035
Trusting	−0.041	−0.197

Controlled for age, PTSD, anxiety, and depression. IAc: interoceptive accuracy; IPV: intimate partner violence; PTSD: posttraumatic stress disorder; *p-value < .05.

Examining the mediator role IPV-group membership in the contribution of interoceptive abilities to somatic complaints

In the final analysis, a hierarchical linear regression was used including age, violence index, and attention regulation as possible moderators of somatic complaints, adding an interaction term with group membership. Results (see Table 4) showed that when group interaction was added, interoceptive attention regulation explained the variations in somatic complaints of women survivors of IPV, above and beyond the contribution of age and of cumulative violence. This model explains 43% of the variance in somatic complaints. In the IPV group, interoceptive attention regulation is negatively associated with somatic complaints, while the opposite happens in the no-IPV group.

Table 4.

Hierarchical regression analyses for interoception on somatic complaints.

Variable	Somatic complaints
Variable	B	p	95% CI
Step 1	R² = 0.378, p = <0.001
Age	0.386	<0.001	0.005, 0.012
Violence index	0.522	<0.001	0.058, 0.111
Attention regulation	−0.162	0.060	−0.079, 0.002
Step 2	∆R² = 0.051, p = 0.053
Age	0.253	0.018	0.001, 0.010
Violence index	0.460	0.264	−0.057, 0.206
Attention regulation	0.137	0.314	−0.031, 0.097
Group × age	0.485	0.066	0.000, 0.011
Group × violence index	0.233	0.614	−0.104, 0.175
Group × attention regulation	−0.765	0.007	−0.175, −0.029

CI: confidence interval.

The scatterplots (Figure 1) confirm the contribution of interoceptive attention regulation to somatic complaints behave differently for women with and without IPV history, unlike the other interoceptive abilities assessed.

Figure 1.

Scatterplot of the relationship between somatic complaints and interoceptive attention regulation, per group.

Discussion

Somatic complaints are a critical burden to women, and particularly to those women who survived IPV. The way women feel, perceive, and relate to their own body seems to have a significant role in the pathway to somatic complaints. The current study examined the relationship between somatic complaints and interoceptive abilities of women with and without experience of IPV, in order to deepen our understanding of the underlying mechanisms of the experience of somatic complaints within this population. Indeed, our study showed that women survivors of IPV experience more somatic complaints than those without IPV, and that, above and beyond age and cumulative violence, interoceptive attention regulation plays a significant role in the experience of somatic complaints by women survivors of IPV.

The present study showed that IPV survivors were more likely to have a mental health diagnosis. In particular, 11.5% of these women had PTSD, and 61.5% had a diagnosis of depression, twice as much as the women who did not have a IPV history, which is in line with other studies.^35,54 Although the prevalence of anxiety disorder was slightly higher (29%) for IPV survivors, than for women with no IPV history (23%), these differences were not statistically significant. Moreover, both frequencies were higher than a previous report on Portuguese adults’ mental health (21%).⁵⁵ Nevertheless, survivors reported more anxiety symptoms and panic attacks than women with no IPV history. Altogether, these findings might suggest that women who suffer from IPV have fewer opportunities to access medical care.^56,57

In general, as hypothesized (H1), women survivors of IPV reported more somatic complaints than women who have never suffered IPV.^1,26,30 Besides, the experience of somatic complaints was related to a higher violence index, supporting Hypothesis 2. This finding strengthens the theory of exposure–response association between violence and symptoms, and reinforces the idea that somatic symptoms can be interpreted as markers of victimization.^17,29

It is important to note that IPV survivors reported more somatic-cognitive complaints, that is, memory and attention difficulties, than non-victims of IPV (H1). These findings are consistent with previous studies^58,59 and give support to Negrón-Oyarzo et al.’s⁶⁰ hypothesis that those somatic-cognitive symptoms can be a consequence of IPV-related phenomena such as distress⁶⁰ or PTSD,⁶¹ showing the impact of IPV on neuropsychological functioning.⁵⁸ Alternatively, those somatic-cognitive complaints might be an indicator of attention-deficit and hyperactivity disorder (ADHD).⁶² It has been suggested a co-occurrence of genetic risks for both ADHD and severe IPV, either by parental mental illness leading to adverse childhood experiences that increase the risk of mental illness and IPV in adulthood, or by inherited genetic risk for mental illness increasing the likelihood of experiencing risk factors for IPV victimization.⁶³ Therefore, symptoms of attention and memory difficulties are currently understood as either a risk factor or a sequelae of IPV victimization,^64
–67 and can be a crucial pathway to understand the relationship between interoception and somatic complaints in survivors of violence.

Considering the somatic complaints most frequently reported by women survivors of IPV, namely panic and anxiety attacks, attention and memory impairments, sleep difficulties and migraines, those fall under a symptomatic framework of heightened arousal and hypervigilance.^13,68,69 Moreover, the prevalence of PTSD diagnosis among the IPV group supports this framework and is consistent with IPV-PTSD subjects showing increased activation and decreased connectivity among the anterior insula and the amygdala, expressing a disconnection among affective and limbic sensory systems, and an exaggerated sensitivity to contextual cues.⁷⁰ These findings strengthen the ongoing conceptualization of a posttraumatic orientation to bodily signals²³ and reinforce the need of studies specifically focused on the IPV-PTSD cluster. For instance, our findings partially support Hypothesis 3, as they show that, for women survivors of IPV, somatic complaints are negatively associated with interoceptive attention regulation, self-regulation and trusting in bodily sensations, but not with interoceptive accuracy. However, for women who never experienced IPV, the hypothesized negative correlation was only confirmed between somatic complaints, interoceptive accuracy and self-regulation, which were not statistically significative, therefore rejecting Hypothesis 4.

The influence of interoceptive attention regulation on somatic complaints differs for women based on their history of IPV. Our findings indicate that interoceptive attention regulation explains somatic complaints in women with a history of IPV, but not in those without, supporting Hypothesis 5. This sheds light on the varying impact of interoceptive bias on health within different relational contexts. Indeed, previous research showed that for populations with no history of violence, interoception (accuracy and sensibility) is not related to the experience of somatic complaints,⁷¹ which reinforces the idea that healthy individuals living in healthy environments and situations do not need to consciously focus on their bodies or divert their attention from external surroundings.⁷² In a somatic and emotionally healthy state, attention can be regulated to detect and interpret signals from the body only when needed, since it is generally focused on the external world.⁷³ However, when external relational cues are frequently threatening and the body’s integrity or identity is at risk, one’s attention must constantly shift between cues to ensure survival. Hence, the negative impact of unpredictability on the experience of bodily sensations might increase the interoceptive bias and emotional distress.^3,74

Concerning women survivors of IPV, the current study showed that interoceptive attention regulation plays a significant role in the experience of somatic complaints by women survivors of IPV. These findings suggest that for women who have lived in a violent relationship, it is of paramount importance to be able to sustain and control attention to body sensations. An adaptive attention regulation ability can help survivors to either divert attention from the distressing surroundings (preventing them from being continuously misinterpreted as dangerous) or use bodily sensations to self-regulate and manage health and illness symptoms adaptively.^74
–77 Indeed, such interoceptive ability has been shown to improve emotional and physiological regulation.⁷⁶ Thereby, therapeutic interventions that focus on interoceptive attention regulation abilities can allow women survivors of IPV an inner distancing from ruminating negative and catastrophic emotions and a flexible application of regulatory strategies, leading to a more adaptive coping and a lower risk of somatization.^{20,21,71,75,76} Moreover, to comfortably sustain attention in bodily sensations, those must not be perceived as catastrophic, threatening, or misleading.^25,73 Thus, IPV-targeted interventions must also consider the importance of restoring the safety and acquaintance of the survivor’s traumatized body.^78
–80

Limitations and future directions

This study does not come out without limitations. The assessments were conducted in two distinct regions of Portugal, which limits the generalizability of the findings to other regions/countries. Additionally, differences in educational levels between the IPV and non-IPV groups may indicate variations in socioeconomic status (SES), potentially affecting overall health. Due to the temporary employment and household characteristics of the IPV group, socioeconomic data were not collected in this study, preventing control for this variable. Therefore, future research on the health and somatic complaints of IPV survivors should account for SES. Considering the cross-sectional nature of the casual relations between IPV, somatic complaints, and interoceptive abilities cannot be assumed. Therefore, future longitudinal studies will be helpful to gain a deeper understanding of our findings. Valuable research advances currently allow for a more robust and complex examination of the violence index, including not only types of violence but also its severity.^81,82 Cross-cultural adaptation of such measures will be crucial to replicate the findings of the present study and enrich its discussion. Moreover, our study endorsed the importance of future studies examining the experience of violence in individuals reporting medically unexplained symptoms, especially concerning symptoms of hyperarousal such as hypervigilance, state anxiety, attention difficulties, sleep disturbances, and migraines. Furthermore, future research should consider the between individuals’ characteristics (besides between groups) regarding interoception attention regulation abilities and somatic complaints, as well as to extend these findings to men victims of IPV.

Conclusion

The present findings provide insight into the contribution of interoception to the experience of somatic complaints by women who suffered IPV. Those women report significant somatic complaints consistent with a framework of heightened arousal. Furthermore, the ability to regulate the attention given to bodily sensations seems crucial for them to improve emotional and physiological regulation, leading to a lower risk of somatization and better health. Therapeutic interventions for survivors of IPV must consider promoting interoceptive attention regulation to help them use bodily sensations to self-regulate and manage health and illness symptoms adaptively.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251326013 – Supplemental material for Attention to the body! Comparing the connection between interoceptive abilities and somatic complaints of women with and without history of intimate partner violence

Supplemental material, sj-docx-1-whe-10.1177_17455057251326013 for Attention to the body! Comparing the connection between interoceptive abilities and somatic complaints of women with and without history of intimate partner violence by Joana Machorrinho, José Marmeleira, Graça Duarte Santos and Guida Veiga in Women’s Health

Footnotes

Acknowledgements

The authors would like to express their special gratitude to all women who participated in this study for giving us their valuable time and sharing their bodily experiences. We are also thankful to all the managing entities of the victim’s shelters for approval of the project and for inviting women to participate. We finally wish to thank Brenda de Sousa Silva and Daniela Guerreiro for their valuable input.

Declarations

ORCID iDs

Joana Machorrinho

José Marmeleira

Graça Duarte Santos

Guida Veiga

Supplemental material

Supplemental material for this article is available online.

References

Nair

Nataraj

Satyanarayana

, et al. Intimate partner violence among women with somatoform disorders: a systematic review. Ind J Soc Psychiatry 2023; 39(4): 384–387.

World Health Organization. Violence Against Women [cited 5 October 2023], https://www.who.int/news-room/fact-sheets/detail/violence-againstwomen (2021).

Van den Bergh

Witthöft

Petersen

, et al. Symptoms and the body: taking the inferential leap. Neurosci Biobehav Rev 2017; 74: 185–203.

Köteles

Witthöft

Somatosensory amplification—an old construct from a new perspective. J Psychosom Res 2017; 101: 1–9.

Ma-Kellams

Cross-cultural differences in somatic awareness and interoceptive accuracy: a review of the literature and directions for future research. Front Psychol 2014; 5: 01379.

Bogaerts

Walentynowicz

Van Den Houte

, et al. The Interoceptive Sensitivity and Attention Questionnaire: evaluating aspects of self-reported interoception in patients with persistent somatic symptoms, stress-related syndromes, and healthy controls. Psychosom Med 2022; 84(2): 251–260.

Brand

Petzke

Witthoeft

. Interoceptive accuracy or attention? Which weighs more in the development of somatic symptoms: A latent modeling approach. Z Psychosom Med Psychother 2023; 69(2): 150.

Petzke

Weber

Van den Bergh

, et al. Illustrating the pathway from affect to somatic symptom: the Affective Picture Paradigm. Cogn Emot 2024; 38(5): 801–817.

Khalsa

Craske

, et al. Altered interoceptive awareness in anorexia nervosa: effects of meal anticipation, consumption and bodily arousal: interoception in anorexia nervosa. Int J Eat Disord 2015; 48(7): 889–897.

10.

Rief

Broadbent

Explaining medically unexplained symptoms-models and mechanisms. Clin Psychol Rev 2007; 27(7): 821–841.

11.

Schulz

Rost

Flasinski

, et al. Distinctive body perception mechanisms in high versus low symptom reporters: a neurophysiological model for medically-unexplained symptoms. J Psychosom Res 2020; 137: 110223.

12.

Barsky

Goodson

Lane

, et al. The amplification of somatic symptoms. Psychosom Med 1988; 50(5): 510–519.

13.

Wolters

Gerlach

Pohl

Interoceptive accuracy and bias in somatic symptom disorder, illness anxiety disorder, and functional syndromes: a systematic review and meta-analysis. PLoS One 2022; 17(8): e0271717.

14.

Van Den Bergh

Zacharioudakis

Petersen

. Interoception, categorization, and symptom perception. In: Tsakiris

De Preester

(eds) The interoceptive mind: From homeostasis to awareness. Oxford: Oxford University Press, 2019, pp. 212–226.

15.

Henningsen

Gündel

Kop

, et al. Persistent physical symptoms as perceptual dysregulation: a neuropsychobehavioral model and its clinical implications. Psychosom Med 2018; 80(5): 422–431.

16.

Fani

Fulton

Botzanowski

. The neurophysiology of interoceptive disruptions in trauma-exposed populations. In: Ellenbroek

Barnes

Paulus

et al. (eds) Current topics in behavioral neurosciences Berlin, Heidelberg: Springer Berlin Heidelberg, 2024.

17.

Witthöft

Bräscher

A-K

Jungmann

, et al. Somatic symptom perception and interoception: a latent-variable approach. Z Psychol 2020; 228(2): 100–109.

18.

Petersen

Van Staeyen

VÃgele

, et al. Interoception and symptom reporting: disentangling accuracy and bias. Front Psychol 2015; 6: 732.

19.

De Gucht

Fischler

. Somatization: a critical review of conceptual and methodological issues. Psychosomatics 2002; 43(1): 1–9.

20.

Lee

Kim

Cheon

, et al. Changes in interoceptive accuracy related to emotional interference in somatic symptom disorder. BMC Psychol 2024; 12(1): 279.

21.

Zacharioudakis

Vlemincx

Van den Bergh

Categorical interoception and the role of threat. Int J Psychophysiol 2020; 148: 25–34.

22.

Rabellino

D’Andrea

Siegle

, et al. Neural correlates of heart rate variability in PTSD during sub-and supraliminal processing of trauma-related cues. Hum Brain Mapp 2017; 38(10): 4898–4907.

23.

Tsur

The link between trauma and chronic pain: exploring the role of pain flashbacks in chronic pain following interpersonal trauma. J Pain 2024; 25(4): 6.

24.

Tsur

Solomon

Posttraumatic orientation to bodily signals: The engraving of trauma in bodily perceptions. Eur Psychiatry 2023; 66(Suppl 1): S475–S476.

25.

Tsur

Talmon

Post-traumatic orientation to bodily signals: a systematic literature review. Trauma Violence Abuse 2023; 24(1): 174–188.

26.

Lown

Vega

WA.

Intimate partner violence and health: self-assessed health, chronic health, and somatic symptoms among Mexican American women. Psychosom Med 2001; 63(3): 352–360.

27.

Campbel

JC.

Health consequences of intimate partner violence. Lancet 2002; 359(9314): 1331–1336.

28.

Eilers

Aan Het Rot

Jeronimus

BF.

Childhood trauma and adult somatic symptoms. Psychosom Med 2023; 85(5): 408–416.

29.

Halpern

Tucker

Bengtson

, et al. Somatic symptoms among US adolescent females: associations with sexual and physical violence exposure. Matern Child Health J 2013; 17(10): 1951–1960.

30.

Ilosson

Möller

Sundfeldt

, et al. Symptoms within somatization after sexual abuse among women: a scoping review. Acta Obstet Ggynecol Scand 2021; 100(4): 758–767.

31.

Machorrinho

Veiga

Santos

, et al. Battered body, battered self: a cross-sectional study of the embodiment-related impairments of female victims of intimate partner violence. J Aggress Maltreat Trauma 2023; 32(11): 1589–1603.

32.

Hilden

Schei

Swahnberg

, et al. A history of sexual abuse and health: a Nordic multicentre study. BJOG 2004; 111(10): 1121–1127.

33.

Paulus

Stein

MB.

Interoception in anxiety and depression. Brain Struct Funct 2010; 214(5–6): 451–463.

34.

Khalsa

Adolphs

Cameron

, et al. Interoception and mental health: a roadmap. Biol Psychiatry Cogn Neurosci Neuroimaging 2018; 3(6): 501–513.

35.

Machorrinho

Veiga

Santos

, et al. Embodiment-related risk factors for posttraumatic stress, anxiety and depression in female victims of intimate partner violence. J Trauma Dissociation 2022; 23(3): 212–228.

36.

Price

Thompson

EA.

Measuring dimensions of body connection: body awareness and bodily dissociation. J Altern Complement Med 2007; 13(9): 945–953.

37.

Schmitz

Back

Seitz

, et al. The impact of traumatic childhood experiences on interoception: disregarding one’s own body. Borderline Personal Disord Emot Dysregul 2023; 10(1): 5.

38.

Mehling

Price

Daubenmier

, et al. The Multidimensional Assessment of Interoceptive Awareness (MAIA). PLoS One 2012; 7(11): e48230.

39.

Reinhardt

Zerubavel

Young

, et al. A multi-method assessment of interoception among sexual trauma survivors. Physiol Behav 2020; 226: 113108.

40.

Eberhard-Gran

Schei

Eskild

Somatic symptoms and diseases are more common in women exposed to violence. J Gen Intern Med 2007; 22(12): 1668–1673.

41.

Loeb

Joseph

Wyatt

, et al. Predictors of somatic symptom severity: the role of cumulative history of trauma and adversity in a diverse community sample. Psychol Trauma 2018; 10(5): 491–498.

42.

Tsakiris

Critchley

Interoception beyond homeostasis: affect, cognition and mental health. Philos Trans R Soc Lond B Biol Sci 2016; 371(1708): 20160002.

43.

Nusser

Pollatos

Zimprich

Age-related effects on interoceptive accuracy, general interoceptive sensibility, and specific interoceptive sensibility. Eur J Health Psychol 2020; 27(4): 154–170.

44.

Verkuil

Brosschot

Meerman

, et al. Effects of momentary assessed stressful events and worry episodes on somatic health complaints. Psychol Health 2012; 27(2): 141–158.

45.

Wei

Liu

Zhuang

, et al. Brain structures associated with individual differences in somatic symptoms and emotional distress in a healthy sample. Front Hum Neurosci 2020; 14: 492990.

46.

General Assembly of the World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent 2014; 81(3): 14–18.

47.

von Elm

Altman

Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147(8): 573–577.

48.

Sullivan

Dean

Soe

MM.

OpenEpi: a web-based epidemiologic and statistical calculator for public health. Public Health Rep 2009; 124(1): 471–474.

49.

Moreira

Pinto

Cloninger

, et al. Understanding the experience of psychopathology after intimate partner violence: the role of personality. PeerJ 2019; 7: e6647.

50.

Olatunji

Deacon

Abramowitz

, et al. Dimensionality of somatic complaints: factor structure and psychometric properties of the Self-Rating Anxiety Scale. J Anx Dis 2006; 20(5): 543–561.

51.

Schat

Kelloway

Desmarais

The Physical Health Questionnaire (PHQ): construct validation of a self-report scale of somatic symptoms. J Occup Health Psychol 2005; 10(4): 363.

52.

Schandry

Heart beat perception and emotional experience. Psychophysiology 1981; 18(4): 483–488.

53.

Machorrinho

Veiga

Fernandes

, et al. Multidimensional assessment of interoceptive awareness: psychometric properties of the Portuguese version. Percept Mot Skills 2019; 126(1): 87–105.

54.

Pico-Alfonso

Garcia-Linares

Celda-Navarro

, et al. The impact of physical, psychological, and sexual intimate male partner violence on women’s mental health: depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide. J Womens Health (Larchmt). 2006; 15(5): 599–611.

55.

Direção-Geral da Saúde (DGS). Programa nacional para a saúde mental. Lisbon, Portugal, http://www.fnerdm.pt/wp-content/uploads/2014/05/DGS (2017).

56.

Cho

Kwon

Shamrova

, et al. Factors for formal help-seeking among female survivors of intimate partner violence. J Fam Violence 2021; 36(2): 143–152.

57.

Warshaw

Gugenheim

Moroney

, et al. Fragmented services, unmet needs: building collaboration between the mental health and domestic violence communities. Health Aff (Millwood) 2003; 22(5): 230–234.

58.

Fernández Fillol

Daugherty

Hidalgo-Ruzzante

, et al. Working memory, episodic memory and sustained attention in women survivors of intimate partner violence in Spain: the Believe Battery. Bethlehem Univ J 2023; 39(1): 2022.04.

59.

Raskin

DeJoie

Edwards

, et al. Traumatic brain injury screening and neuropsychological functioning in women who experience intimate partner violence. Clin Neuropsychol 2024; 38(2): 354–376.

60.

Negrón-Oyarzo

Aboitiz

Fuentealba

Impaired functional connectivity in the prefrontal cortex: a mechanism for chronic stress-induced neuropsychiatric disorders. Neural Plast 2016; 2016: 7539065.

61.

Twamley

Allard

Thorp

, et al. Cognitive impairment and functioning in PTSD related to intimate partner violence. J Int Neuropsychol Soc 2009; 15(6): 879–887.

62.

Arrondo

Osorio

Magallón

, et al. Attention-deficit/hyperactivity disorder as a risk factor for being involved in intimate partner violence and sexual violence: a systematic review and meta-analysis. Psychol Med 2023; 53(16): 7883–7892.

63.

Ratanatharathorn

Quan

Koenen

, et al. Polygenic risk for major depression, attention deficit hyperactivity disorder, neuroticism, and schizophrenia are correlated with experience of intimate partner violence. Transl Psychiatry 2024; 14(1): 119.

64.

Lagdon

Armour

Stringer

Adult experience of mental health outcomes as a result of intimate partner violence victimisation: a systematic review. Eur J Psychotraumatol 2014; 5: 24794.

65.

Lehrer

Buka

Gortmaker

, et al. Depressive symptomatology as a predictor of exposure to intimate partner violence among US female adolescents and young adults. Arch Pediatr Adolesc Med 2006; 160(3): 270–276.

66.

Wymbs

Dawson

Suhr

, et al. ADHD symptoms as risk factors for intimate partner violence perpetration and victimization. J Interpers Violence 2017; 32(5): 659–681.

67.

Valera

Campbell

Gill

, et al. Correlates of brain injuries in women subjected to intimate partner violence: Identifying the dangers and raising awareness. J Aggress Maltreat Trauma 2019; 28(6): 695–713.

68.

Cripe

Sanchez

Gelaye

, et al. Association between intimate partner violence, migraine and probable migraine: February 2011. Headache 2011; 51(2): 208–219.

69.

Gallegos

Trabold

Cerulli

, et al. Sleep and interpersonal violence: A systematic review. Trauma Violence Abuse 2021; 22(2): 359–369.

70.

Fonzo

Simmons

Thorp

, et al. Exaggerated and disconnected insular-amygdalar blood oxygenation level-dependent response to threat-related emotional faces in women with intimate-partner violence posttraumatic stress disorder. Biol Psychiatry 2010; 68(5): 433–441.

71.

Ferentzi

Horváth

Köteles

Do body-related sensations make feel us better? Subjective well-being is associated only with the subjective aspect of interoception. Psychophysiology 2019; 56(4): e13319.

72.

Köteles

Simor

Modern health worries, somatosensory amplification and subjective symptoms: a longitudinal study: a longitudinal study. Int J Behav Med 2013; 20: 38–41.

73.

Nord

Garfinkel

SN.

Interoceptive pathways to understand and treat mental health conditions. Trends Cogn Sci 2022; 26(6): 499–513.

74.

Camola

MF.

Perception of bodily states in fibromyalgia: is cognitive functioning related to interoception? Lisbon, Portugal: Universidade Católica Portuguesa, 2021.

75.

Tan

Wang

Blain

, et al. Interoceptive attention facilitates emotion regulation strategy use. Int J Clin Health Psychol 2023; 23(1): 100336.

76.

Lee

Kim

, et al. The relationship between Interoceptive Awareness, emotion regulation and clinical symptoms severity of depression, anxiety and somatization. Psychiatry Investig 2024; 21(3): 255–264.

77.

Price

Herting

JR.

Changes in post traumatic stress symptoms among women in substance use disorder treatment: The mediating role of bodily dissociation and emotion regulation. Subst Abuse 2013; 7: 147–153.

78.

Machorrinho

Marmeleira

Veiga

, et al. Feel-Own-Move: a psychomotor therapy program for victims of intimate partner violence living in shelter homes. Feasibility and effects on mental health, bodily dissociation, and quality of life. Front Psychol 2023; 14: 1154385.

79.

Marmeleira

Machorrinho

Santos

, et al. Psychomotor intervention in intimate partner violence: empirical support for preventive and therapeutic approaches. Hauppauge, NY: Nova Science Publishers, 2023.

80.

Punkanen

Buckley

Embodied safety and bodily stabilization in the treatment of complex trauma. Eur J Trauma Dissociation 2021; 5(3): 100156.

81.

Wuest

Ford-Gilboe

Merritt-Gray

, et al. Pathways of chronic pain in survivors of intimate partner violence. J Women Health (Larchmt) 2010; 19(9): 1665–1674.

82.

Scott-Storey

O’Donnell

Perrin

, et al. Cumulative lifetime violence, gender, social determinants of health and mental health in Canadian men: a latent class analysis. J Fam Viol 2024; 39: 665–680.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB