Not-distracting in body sensations: interoceptive focus and somatic symptom in adolescent bipolar disorder patients

doi:10.21203/rs.3.rs-5297700/v1

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Research Article

Not-distracting in body sensations: interoceptive focus and somatic symptom in adolescent bipolar disorder patients

https://doi.org/10.21203/rs.3.rs-5297700/v1

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Background

Bipolar disorder (BD) with somatic symptoms is prevalent in adolescent patients. Interoception has an important impact on physical and emotional regulation. However, it is unclear the characteristics of interoception and its relationship to somatization and emotional symptoms in adolescents with BD.

Methods

This study recruited 71 adolescent BD subjects during rehabilitation and 111 age-matched controls. Demographic characteristics, interoception, somatization, depression, and anxiety symptoms were assessed. Mann-Whitney U tests, partial correlation analysis, and multiple linear regression were used to explore the alteration of interoception in BD patients and its association with clinical symptoms.

Results

After adjusting for differential demographic variables, adolescent BD patients scored lower on several dimensions of interoception and higher on somatization and emotional symptoms than controls. Moreover, there were significant differences on the interoceptive dimensions of not-distracting, not-worrying, and trusting between BD patient groups with and without somatization. Correlational analysis revealed that the interoceptive indicators of BD patients were significantly correlated with emotional and somatic symptoms. The dimension of not-distracting was the only interoceptive predictor of somatization symptoms and emotional problems in adolescents with BD, maintaining its predictive stability even after controlling for emotional symptoms. This indicates that the capacity for focused attention is a key interoceptive element affecting the expression of somatic and emotional issues in BD adolescent patients.

Conclusion

Adolescents with BD exhibit deficits in interoception, somatization and emotional issues. The not-distracting aspect of interoception significantly correlates with emotional and somatic symptoms in adolescents with BD, offering insights and targeted strategies for managing psychosomatic symptoms in this demographic.

Bipolar disorder

Adolescent

Interoception

Somatization

Depression

Anxiety

Bipolar disorder (BD) is a high-recurrence chronic mental illness characterized by alternating episodes of mania and depression (1). Patients with BD are found across all age groups, but the early symptoms of BD usually appear during adolescence (age during 10–24 years old), with the highest incidence occurring between the ages of 15 and 19 years old (2). Epidemiological survey data show that the average prevalence rate of BD among adolescents is 1.8% (3). BD patients frequently experience a range of somatic symptoms such as pain, sleep disturbances, and gastrointestinal symptoms, with nearly half of the patients affected by somatization symptoms (4). A recent study further revealed that among individuals with BD-1, those with higher somatization scores were more likely to experience rapid cycling, indicating a poorer prognosis(5). It has been shown that somatic symptoms closely connect with the onset, symptomatic severity, treatment efficacy and reoccurrence of BP. For example, somatization may serve as precursors to the onset of BD and are associated with more severe symptomatic responses and recurrent episodes (6, 7). Research by Ritter and colleagues found that sleep disorders in adolescents are not only early symptoms of BD but also that poor sleep quality significantly increases the risk of developing BD (8, 9). Meanwhile, although current pharmaceutical treatment can ameliorate emotional symptoms, it lacks efficacy on somatic symptoms of BD, and a high proportion of somatic symptoms can persist into adulthood (10). More obvious somatic issue in adolescent patients may attribute to the rapid psychological, physiological, and neurological development at this stage. Adolescent patients frequently complain of physical pain, such as stomachaches and headaches, or exhibit eating disorders, either overeating or undereating (11). These indicates the necessity of illustrating the pathological mechanisms of physical and emotional disturbance in adolescent BD patients.

Interoception refers to the individual's perception of their own internal physiological states and emotional sensations(12). It serves as the physiological foundation for emotional regulation, cognitive processes, and the formation of self-consciousness (13, 14). The most widely accepted classification of interoception is Garfinkel's three-dimensional model of interoception, which divides interoception into Interoceptive Accuracy (IAC), the performance of interoceptive abilities in behavioral tests; Interoceptive Sensitivity (IS), the subjective sensitivity to internal sensations as measured by self-report questionnaires; and Interoceptive Awareness (IA), the personal insight capacity for interoception (15). It has shown that difficulties in interoception are significantly associated with somatization. For example, it was found that somatic symptoms of depression (such as sleep and eating disturbances) are significantly linked to interoception (16). A study on chronic pain and interoception found that patients with chronic pain exhibit lower interoceptive accuracy and higher interoceptive sensitivity (17).

Existing research has found that abnormalities in interoception vary across different psychiatric conditions. For instance, individuals with depression exhibit impaired interoceptive accuracy (18), while patients with severe anxiety symptoms report more bodily sensations, showing heightened interoceptive sensitivity (19, 20). In schizophrenia, the manifestation of interoception is more complex; some studies have found that individuals with schizophrenia have lower interoceptive accuracy compared to healthy populations (21). Other research has reported that patients with psychosis score higher on average than healthy controls in assessments of interoceptive awareness across four dimensions: attention, emotion awareness, self-regulation, and body listening. This is considered an abnormal manifestation of excessive coupling between internal and external interoception (22). However, there are currently no studies investigating the characteristics of interoceptive changes in adolescent BD patients and their relationship with emotional and somatic symptoms.

The main purpose of this study is to investigate whether there is interoceptive dysfunction in adolescent BD patients and the relationship between interoception and emotional and somatization symptoms. We hypothesize that abnormal interoception may predict emotional and somatization symptoms in BD. This will provide a new explanation for the high incidence and susceptibility of psychosomatic disorders in adolescents with BD and offer a basis for developing targeted intervention strategies.

2.1 Subjects and process

We enrolled 71 adolescents diagnosed with BD from the outpatient and inpatient psychiatric departments of Weifang Mental Health Centre, Shandong Province. The DSM-5 criteria and scale assessments were utilized by seasoned psychiatrists to confirm the diagnoses. All participants were in remission and receiving medication treatment. The inclusion criteria were as follows: (1) age 14–25 years; (2) age of onset within 5 years. The exclusion criteria were as follows: (1) drug/alcohol dependence/abuse (except smoking); (2) history of psychiatric disorders in two or three generations of paternal or paternal relatives; patients with comorbid serious physical, infectious, and immune diseases; patients with serious neurological disorders; and patients with mental developmental delays; and (3) pregnant or breastfeeding women. All of these BD patients were Han Chinese.

Recruitment and assessment process of BD subjects: Questionnaire data collection will be conducted in an independent and quiet place to ensure that the subjects have self-awareness and the ability to answer independently. Prior to the formal testing, the main examiner will explain the instructions and precautions. Subjects will be recruited according to the inclusion and exclusion criteria and assessed one-on-one for demographic information, interoception, somatization, and emotional symptoms during the rehabilitation period. All subjects received professional training to ensure consistency in instructions and procedures, familiarity with the subjects, and mastery of communication skills.

The control group consisted of 111 university students, selected based on the absence of mental disorders, no family psychiatric history, and being aged 16 to 22. Exclusion criteria were aligned with the BD group. Assessments were conducted online using Questionnaire Star, with voluntary participation and immediate submission.

2.2 Research tools

2.2.1 Patient Health Questionnaire (PHQ-15)

The PHQ-15 is a reliable and valid screening tool for somatization. The items of the scale include the assessment of patients' pain (e.g., headache, chest pain), sleep, gastrointestinal reactions and other dimensions(23). The assessment tool features 15 items, each scored on a 3-point Likert scale, with a possible range from 0 to 2 points per item. The aggregate score thus varies from 0 to 30, the higher the score, the greater the symptom severity experienced by the patient. A total score of 10 and above indicates that the patient has significant somatization symptoms (24). The Chinese version of the PHQ-15 has high reliability and validity (25), and the Cronbach's alpha coefficient was 0.919 in the study.

2.2.2 Generalized Anxiety Disorder-7 (GAD-7)

The GAD-7 scale efficiently screens for generalized anxiety disorder with 7 items rated on a scale from 0 to 3. Total scores range from 0 to 21, with higher scores indicating increased severity of anxiety symptoms(26). The Chinese version of the GAD-7 has been validated to have good reliability and is suitable for psychiatric outpatients (27). The Cronbach's alpha coefficient was 0.972 in this study.

2.2.3 Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 scale is a valid tool for screening the severity of depression, with scores ranging from 0 to 3 for each of its 9 items. Total scores from 0 to 27 indicate increasing levels of depressive symptoms, with higher scores reflecting greater severity (28). The Cronbach's alpha coefficient in this study was 0.964.

2.2.4 Multidimensional Assessment of Interoception Perception Scale (MAIA-2)

The MAIA2 is a scale commonly used to measure interoception (29) and allows for comparisons between disorders (30), with 37 entries on a Likert 5 scale from 1 to 5 on a 5-point Likert scale. It consists of eight dimensions, Noticing, Not-Distracting, Not-worrying, Attention Regulation, Emotional Awareness, Self-Regulation, Body Listening, and Trusting, with the scores of the dimensions using the sum of the mean scores of all its items. The total score ranges from 37–185, with higher scores representing greater interoception(31) (29), and the MAIA-2 has demonstrated superior internal consistency and reliability, the scale's Cronbach's alpha coefficient of 0.918.

2.3 Analyses

Analyses utilizing SPSS Statistics 25.0 addressed missing data, constituting less than 3%. The data were analyzed as follows: First, Mann-Whitney U-tests and chi-square tests were used to compare the BD group with the control group in terms of age, gender, education level, and interoception and clinical symptoms. Second, the same method was used to compare somatization and no-somatization BP patients. Third, the partial correlation between interoception and different clinical symptoms was investigated using correlation analysis. Fourth, the predictive role of interoception on clinical symptoms was assessed using adjusted multiple linear regression.

2.4 Sample size

Given the non-normal distribution and variance heterogeneity, the minimum sample size was determined using G*Power (32), ensuring the regression analysis with three independent variables had at least 30 subjects in the BD group, as per the statistical guidelines The current number of enrolled subjects meets this requirement, in line with previous research (33).

3.1 comparison of descriptive, clinical, and interoception difference between BD and control groups

As shown in Table 1, there was no significant difference between the BD group and the control group in terms of age and sex (p > 0.05), but had significant difference in education status (p < .001). After adjusting for education, the BD group scored higher on clinical symptoms (somatization, anxiety, and depression) than the control group, with a significant difference (p < .001). There was a significant difference in the internal perception score and its dimensions (p < .001), except for the dimension of not-worrying (p > .05).

Table 1

Descriptive and statistics of demographic and clinical variables between BP and control group.
Variable	BP(n = 71)	Control(n = 111)	χ²/U	p
Age	19.06 ± 3.10	18.46 ± 1.26	3698.5	.47
Sex (Female %)	57.7	53.2	.37	.54
Education-level (%)			34.97	< .001
Junior education or less	25.0	0
High school	50.0	45.9
College or more	25.0	54.1
Interoceptive Score	19.84 ± 6.75	28.67 ± 3.38	965	< .001
Noticing	2.55 ± 1.38	3.67 ± 1.02	2024.5	< .001
Not-Distracting	2.72 ± 1.00	2.20 ± 1.08	2902.5	< .001
Not-worrying	2.32 ± 1.11	2.60 ± 0.98	3372	.14
Attention Regulation	2.84 ± 1.37	3.65 ± 0.82	1572	< .001
Emotional Awareness	2.84 ± 1.37	4.23 ± 0.59	1447.5	< .001
Self-Regulation	2.00 ± 1.48	3.87 ± 0.87	1245	< .001
Body Listening	2.11 ± 1.36	4.00 ± 0.69	968	< .001
Trusting	2.88 ± 1.51	4.38 ± 0.62	1684.5	< .001
Somatization	11.11 ± 8.57	4.21 ± 4.47	2081	< .001
Anxiety	8.82 ± 7.49	2.18 ± 3.01	1828	< .001
Depression	12.03 ± 9.79	3.21 ± 3.43	1942	< .001
Note:^* p < .05, ^ p < .01, ^* p < .001

3.2 Differences in interoception and emotional symptoms between BD patients with and without somatization

As shown in Table 2, the BD patients were divided into two groups, the somatization group (n = 38) and the no-somatization group (n = 33), according to the somatization threshold. Clinical symptom scores were higher in the somatization subgroup than in the no-somatization subgroup, and there were significant differences between the two groups in terms of anxiety, and depression (p < .001). There were no significant differences between the two groups on total interoception scores, with the somatization subgroup scoring lower than the no-somatization subgroup on the not-worrying (p < .001)、self-regulation (p < .05) and trusting (p < .05) dimensions, and scoring lower than the no-somatization subgroup on the not-distracted dimension (p < .01).

Table 2

Descriptive and statistics of demographic and clinical variables between BP patients with and without somatization.
Variable		Somatization(n = 38)	No somatization(n = 33)	χ²/ U	p
Age		18.39 ± 3.11	19.82 ± 2.96	456	.05
Sex (Female %)		73.7	39.4	.8.51	.004
Education-level (%)				.58	.75
Junior education or less		28.1	20.8
High school		50.0	50.0
College or more		21.9	29.2
Interoceptive Score	18.42 ± 4.92		21.49 ± 8.16	473	.08
Noticing	2.84 ± 1.01		2.21 ± 1.66	484	.10
Not-Distracting	2.40 ± 0.85		3.10 ± 1.06	405	.011
Not-worrying	1.91 ± 1.10		2.81 ± 0.92	330	< .001
Attention Regulation	2.35 ± 0.90		2.45 ± 1.56	590	.67
Emotional Awareness	2.89 ± 1.01		2.78 ± 1.71	612	.87
Self-Regulation	1.53 ± 1.14		2.53 ± 1.66	412	.01
Body Listening	2.00 ± 1.15		2.25 ± 1.57	566	.48
Trusting	2.48 ± 1.29		3.34 ± 1.63	415	.014
Anxiety	13.03 ± 6.63		3.97 ± 5.16	172.5	< .001
Depression	18.05 ± 8.12		5.09 ± 6.39	158.5	< .001
Note:^* p < .05, ^ p < .01, ^* p < .001

3.3 Correlation analysis of not-distracting, not-worrying, self-regulation and trust with clinical symptoms

As shown in Table 3. Not-distracting was significantly negatively correlated with somatization (r = − .45, p < .001), anxiety (r = − .38, p < .01) and depression (r = − .39, p < .001). Not-worrying was negatively correlated with somatization (r = − .40, p < .001), anxiety (r = − .46, p < .001), and depression (r = − .51, p < .01). Self-regulation was negatively correlated with somatization (r = − .30, p < .05), depression (r = − .29, p < .05). Trusting was negatively correlated with somatization (r = − .40, p < .001), anxiety (r = − .34, p < .001), and depression (r = -41, p < .001).

Table 3

Correlation analysis between MAIA Subscales and Somatization, Anxiety, and Depression.
	Not-Distracting	Not-worrying	Self-Regulation	Trusting	Somatization	Anxiety
Not-worrying	.22
Self-Regulation	.02	.35^**
Trusting	-..16	.39^***	.55^***
Somatization	− .45^***	− .40^***	− .30^*	− .40^***
Anxiety	− .38^**	− .46^***	− .20	− .34^***	.74^***
Depression	− .39^***	− .51^***	− .29^*	− .41^***	.71^***	.82^***
Note: Adjusting for age and sex. ^* p < .05, ^ p < .01, ^* p < .001

3.4 The predictive role of not-Distracting, not-worrying, and trust on clinical symptoms.

As shown in Table 4. The results showed that the BD group had a greater effect on somatization (B = -2.19, 95% CI [-4.55,-1.28], p < .001), anxiety (B = -2.09, 95% CI [-3.62,-.55], p < .01), depression (B = -2.52, 95% CI [-4.37,-.67], p < .01) were all predicted by not-distracting, indicating that for each unit increase in not-distracting score, controlling for other variables, there was a mean increase of -2.19 units in somatization scores, a mean increase of -4.37 units in anxiety scores, and a mean increase in depression scores of -2.52 units.

Table 4

Unadjusted Estimates of Multidimensional Assessment of Somatization and Anxiety and Depression with MAIA Subscales as Predictors
	Somatization
	B	95%CI	B	95%CI	B	95%CI
Not-Distracting	-2.91^***	-4.55,-1.28	-2.09^**	-3.62,-.55	-2.52^**	-4.37,-.67
Not-worrying	-1.59	-3.20,.01	-2.26^**	-3.77,-.75	-3.07^**	-4.89,-1.25
Trusting	-1.37^**	-2.54,-.21	− .77	-1.87,.32	-1.35^*	-2.68,-.03
Note: Adjusting for age and sex. ^* p < .05, ^ p < .01, ^* p < .001

As shown in Table 5. After controlling for anxiety, it was found that only not-distracting still significantly predicted somatization (B = -1.55, 95% CI [-2.91,-.18], p < .05). After adjusting for depression, not-distracting continued to significantly predict somatization (B = -1.66, 95% CI [-2.91,-.18], p < .05). After controlling for both anxiety and depression, not-distracted still significantly predicts somatization (B = -1.40, 95% CI [-2.76,-.04], p < .05).

Table 5

Adjusted Estimates of Multidimensional Assessment of Somatization with MAIA Subscales as Predictors
	Stratum 1				Stratum 2				Stratum 3
	β	SE	t	p	β	SE	t	p	β	SE	t	p
Constant	1.83	5.5	0.33	0.74	1.97	5.85	0.34	0.74	-0.30	5.56	-0.05	0.96
Not-Distracting	-1.55^*	0.69	-2.26	0.03	-1.66^*	0.72	-2.31	0.02	-1.40^*	0.68	-2.06	0.04
Not-worrying	-0.12	0.68	-0.17	0.87	-0.06	0.73	-0.08	0.93	0.12	0.69	0.17	0.87
Trusting	-0.87	0.47	-1.84	0.07	-0.7	0.5	-1.4	0.17	-0.72	0.47	-1.53	0.13
Age	0.19	0.21	0.91	0.36	0.23	0.22	1.03	0.31	0.23	0.21	1.08	0.29
Sex	4.3^**	1.31	3.30	0.002	3.42^*	1.39	2.46	0.02	3.83^**	1.32	2.91	0.005
Anxiety	0.67^***	0.11	6.26	< .001					0.22	0.13	1.71	0.09
Depression					0.5^***	0.09	5.5	< .001	0.46^***	0.15	3.04	0.003
R²	0.67				0.64				0.68
Adjusted R²	0.64				0.6				0.65
F	21.31^***				18.53^***				19.24^***
Dependent Variable(Y): Somatization ^* p < .05, ^ p < .01, ^* p < .001

The study aims to investigate the characteristics of interoceptive alterations in adolescents with BD and their relationship with emotional and somatization issues. Findings indicate that, after controlling for demographic variables, adolescents with BD have more severe somatization, emotional problems, and poorer interoception than the control group. Key disparities in interoceptive regulation between BD patients with and without somatic symptoms are noted in the dimensions of not-distraction, not-worry, self-regulation and trust, though no total score difference exists. Somatization is linked to heightened anxiety and depression. Notably, not-distraction significantly forecasts somatization and emotional symptoms in BD patients, maintaining its predictive role for somatization even after adjusting for anxiety and depression. Adolescents with BD exhibit poorer interoception compared to the control group. This finding aligns with previous research on the relationship between interoception and clinical symptoms in emotional disorders. For instance, patients with depression and anxiety also display abnormal interoception, with more severe clinical symptoms correlating with more pronounced interoceptive abnormalities (19, 34–36). Barbato reported that adolescents with psychosis generally have impaired interoceptive function (37). Additionally, somatization patients have been found to have issues with interoceptive deficits. For example, patients with eating disorders exhibit more severe interoceptive impairments compared to the control group(38).

In exploring the relationship between interoceptive and somatization in adolescents with BD, it was found that although there was no difference in total interoception scores, significant differences were observed in the subdimensions of not-distraction, not-worry, self-regulation and trust. Not-distraction refers to the tendency to ignore or distract oneself from pain or discomfort; the lower the degree of not-distraction, the more patients tend to focus on their discomfort. Not-worry refers to the tendency not to worry or experience emotional distress associated with pain or discomfort. Patients who worry less about their bodily troubles feel more reassured and report milder symptom severity. Self-regulation refers to the ability to regulate psychological distress by attention to body sensations. Individuals with weaker this skills may be more prone to experiencing somatic symptoms, as well as anxiety and depression. Trust pertains to the feeling that one's body is safe and trustworthy. The higher the subjective trust in their perceived bodily condition, the lower the severity of symptoms they report (29). This suggests that patients with somatization issues excessively focus on and worry about their bodies, lack self-regulatory abilities, and also perceive their bodies as unsafe or untrustworthy.(31).

Moreover, somatization is associated with more severe anxiety, and depressive symptoms, suggesting that the presence of somatization may exacerbate clinical symptoms. This finding is consistent with previous research on adolescents with depression and anxiety (6, 7). In this study, "not-distraction" emerged as the only interoceptive dimension predictive of both emotional and somatic symptoms, significantly predicting somatization, anxiety, and depression. Even after adjusting for emotional variables, it continues to significantly predict somatization symptoms. This suggests that "not-distraction" plays a significant and stable role in the somatization symptoms among adolescents with BD. A recent study on adolescents have shown that the not-distraction dimension of interoception can significantly predict the risk of psychosis (37). A study involving patients with schizophrenia also found that the not-distraction subscale scores were higher than those in the control group (39).

Studies reviewing randomized controlled trials with interoception-based interventions have found these interventions to be efficacious for psychosomatic and anxiety disorders (40, 41). After adjusting for all emotional variables, the ability to not get distracted still stably predicts somatization symptoms. Our research indicates that adolescents with affective disorders and somatic symptoms may benefit from targeted interoceptive intervention programs. This group displays distinctive age-related traits and interoceptive features, particularly regarding difficulties with not-distraction. Therefore, clinical strategies should concentrate on improving attentional and cognitive flexibility to alleviate the preoccupation with bodily sensations.

This study has three main limitations: Firstly, the reliance on self-report scales to measure interoception could introduce subjective bias. Secondly, the limited sample size may restrict the broader applicability of the results, suggesting a need for larger-sample validation in future studies. Thirdly, given the cross-sectional nature of the research, longitudinal and interventional studies are essential to confirm the long-term effects of interoception on somatic and emotional symptoms in BD patients.

In summary, this study is the first to explore the relationship between somatization and interoception in adolescents with BD. The findings expand our understanding of the characteristics of interoceptive changes in adolescent BD patients and their relationship to emotional and somatic symptoms. Additionally, the results provide clinical insights for the intervention of somatization issues in adolescent BD patients. Further research is needed to deepen our understanding of the role of interoception in psychiatric disorders and their treatment.

Ethics approval and consent to participate

The study was approved by the Institutional Review Board of the Institute of Psychology, Chinese Academy of Sciences (H23078). The purpose of this study was explained, and written informed consent was obtained from all the participants. Informed consent was obtained from the parent or legal guardian of all participants younger than 16 years of age.

Consent for publication

We hereby confirm that all participants whose identifying images or personal/clinical details are included in this study have provided their explicit consent for publication. They have been informed about the research and its potential publication, and have been assured of their confidentiality and data anonymization.

We have taken measures to anonymize or alter any data that could identify participants. Should any participant withdraw their consent post-submission, we commit to promptly informing the journal and adhering to their decision.

Availability of data and materials

The data that support the findings of this study are available from corresponding authors, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available.

Competing interests

The authors declare that there is no conflict of interest regarding the publication of this article.

Funding

This work was supported by the National Natural Science Foundation of China [Grant No. 82071517, U21A20364, 31771217, 32300920]; National Key R&D Program of China [Grant No. 2017YFE0126500], and the Scientific Foundation of Institute of Psychology, Chinese Academy of Sciences (No. E2CX4115CX).

Authors' contributions

Data curation and investigation, writing-original draft & editing: Jialin Lv. Data curation: Juan Li. Methodology, Writing-review＆editing: Hang Xu. Research conceptualization and data curation: Lin Sun. Clinical Diagnosis and data curation: Guohui Zhu. Research conceptualization, project administration, funding acquisition, supervision and writing-review & editing: Weiwen Wang.

Acknowledgments

We would like to thank all the participants in this study and extend appreciation to all team members and co-authors for their contributions to this manuscript.

Clinical Trial Number

Clinical trial number: not applicable

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No competing interests reported.

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Not-distracting in body sensations: interoceptive focus and somatic symptom in adolescent bipolar disorder patients

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Abstract

Background

Methods

Results

Conclusion

1 Introduction

2 Method

2.1 Subjects and process

2.2 Research tools

2.2.1 Patient Health Questionnaire (PHQ-15)

2.2.2 Generalized Anxiety Disorder-7 (GAD-7)

2.2.3 Patient Health Questionnaire-9 (PHQ-9)

2.2.4 Multidimensional Assessment of Interoception Perception Scale (MAIA-2)

2.3 Analyses

2.4 Sample size

3 Results

3.1 comparison of descriptive, clinical, and interoception difference between BD and control groups

3.2 Differences in interoception and emotional symptoms between BD patients with and without somatization

3.3 Correlation analysis of not-distracting, not-worrying, self-regulation and trust with clinical symptoms

3.4 The predictive role of not-Distracting, not-worrying, and trust on clinical symptoms.

4 Discussion

Declarations

References

Additional Declarations

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