Interoceptive training to target anxiety in autistic adults (ADIE): A single-center, superiority randomized controlled trial

Lisa Quadt, Sarah N Garfinkel, James S Mulcahy, Dennis Eo Larsson, Marta Silva, Anna-Marie Jones, Clara Strauss, Hugo D Critchley, Lisa Quadt, Sarah N Garfinkel, James S Mulcahy, Dennis Eo Larsson, Marta Silva, Anna-Marie Jones, Clara Strauss, Hugo D Critchley

Abstract

Background: This trial tested if a novel therapy, Aligning Dimensions of Interoceptive Experience (ADIE), reduces anxiety in autistic adults. ADIE targets the association of anxiety with mismatch between subjective and behavioral measures of an individual's interoceptive sensitivity to bodily signals, including heartbeats.

Methods: In this superiority randomized controlled trial, autistic adults (18-65 years) from clinical and community settings in Southern England were randomly assigned (1:1) to receive six sessions of ADIE or an active 'exteroceptive' control therapy (emotional prosody identification). Researchers conducting outcome assessments were blind to allocation. ADIE combines two modified heartbeat detection tasks with performance feedback and physical activity manipulation that transiently increases cardiac arousal. Participants were followed-up one-week (T1) and 3-months post-intervention (T2). The primary outcome was Spielberger Trait Anxiety Score (STAI-T) at T2. Outcomes were assessed on an intention-to-treat basis using multiple imputation for dealing with missing values. This trial was registered at International Standard Randomized Controlled Trial Registry, ISRCTN14848787.

Findings: Between July 01, 2017, and December 31, 2019, 121 participants were randomly allocated to ADIE (n = 61) or prosody (n = 60) intervention groups. Data at T1 was provided by 85 (70%) participants (46 [75%] ADIE; 39 [65%] prosody). Data at T2 was provided by 61 (50%) participants (36 [59%] ADIE; 25 [42%] prosody). One adverse event (cardiac anxiety following ADIE) was recorded. A statistically significant group effect of ADIE on trait anxiety continued at T2 (estimated mean difference 3•23 [95% CI 1•13 to 5•29]; d = 0•30 [95% CI 0•09 to 0•51]; p = 0•005) with 31% of ADIE group participants meeting trial criteria for recovery (compared to 16% in the control group).

Interpretation: ADIE can reduce anxiety in autistic adults, putatively improving regulatory control over internal stimuli. With little reliance on language and emotional insight, ADIE may constitute an inclusive intervention.

Funding mq: Transforming Mental Health PsyImpact Grant.

Keywords: Anxiety; Autism; Interoception; Intervention; RCT.

Conflict of interest statement

LQ, SG, HC, and JS report grants from MQ: Transforming Mental Health during the conduct of the study. DL reports other funding from Leverhulme outside the submitted work. All other authors have no conflicts to report.

© 2021 The Authors.

Figures

Fig. 1
Fig. 1
Trial profile.
Fig. 2
Fig. 2
Forest plot of standardized group differences between ADIE and prosody intervention for all outcome measures. Outcomes interpreted as being in favour of the ADIE group whose standardized group difference was below zero were multiplied by −1 for this figure, such that all outcomes higher than zero could be interpreted in favour of the intervention. Error bars are 95% CIs. ADIE = Aligning Dimensions of Interoceptive Experience; STAI = Spielberger Trait-State Anxiety Inventory; GAD-7 = Generalized Anxiety Disorder seven-item; BPQ = Body Perception Questionnaire Awareness Section; MAIA = Multidimensional Assessment of Interoceptive Awareness; TAS = Toronto Alexithymia Scale; DDF = Difficulty Describing Feelings; DIF = Difficulty Identifying Feelings; EOT = Externally orientated Thinking; PANAS=Positive and Negative Affect Scale; PHQ-9 = Patient Health Questionnaire nine-item; ROC = Receiver Operating Curve; ITPE = Interoceptive Trait Prediction Error.
Fig. 3
Fig. 3
Primary outcome (STAI trait anxiety) over time and per trial arm. Data plot of STAI trait anxiety over time and per trial arm (red = ADIE, blue = control). Baseline scores are mean estimates of Baseline Covariate from the predictive model, 1 week and 3 months scores are predictive margins from the mode. ADIE = Aligning Dimensions of Interoceptive Experience; STAI=Spielberger State Trait Anxiety Index. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.).

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