A reflexive thematic analysis
Kiera Adams, Jonahs Smith, Mary Brown, Geoff Bird, and Polly Waite (2025)
We all know the feeling: your heart races before a big event, your stomach twists with nerves, and your hands feel clammy when you’re anxious. But what if you couldn’t recognize these signals? Or worse, what if they felt so overwhelming that they themselves became a source of anxiety?
For many autistic adolescents, this is not just a hypothetical scenario.
Anxiety is a well-documented challenge, with studies estimating that at least 40% experience at least one anxiety disorder. Autistic adolescents are nearly twice as likely to have an anxiety disorder compared to their peers. While social interactions and sensory overload are commonly discussed contributors to this anxiety, another crucial factor deserves more attention: interoception. This is our ability to tune into our internal bodily signals, such as heart rate, breathing patterns, and feelings of hunger.
Researchers conducted semi-structured interviews with 13 autistic adolescents (aged 14-17) who reported significant day-to-day anxiety. Through thematic analysis, the researchers identified three overarching themes that highlight the complex and two-way relationship between interoception and anxiety in autistic adolescents: interoception can both contribute to and be affected by anxiety.
Interoceptive Awareness- The Spectrum of Hyper Awareness to Hypo Awareness
Interoception is the ability to notice and understand internal bodily sensations, like your heartbeat, hunger, or the need to take a deep breath. For autistic adolescents, this ability can be hyperactive (feeling every tiny change in the body) or underactive (barely noticing bodily cues until it’s too late). Both extremes can contribute to anxiety.
One of the most striking findings was the participants’ wide variability in interoceptive awareness. Some described hyperawareness, where bodily signals were impossible to ignore, making them more anxious, while others experienced hypoawareness, struggling to notice changes in their body until it was too late.
When the Body Feels Overwhelming
Imagine feeling your heartbeat constantly, thumping in your ears, a constant reminder of every little change in your body.
Some participants reported a heightened awareness of bodily sensations that felt overwhelming and anxiety-inducing. Rather than providing helpful feedback, these sensations contributed to sensory overload, making it difficult to focus on anything else. Instead of remaining in the background, bodily signals became an unavoidable focal point, often intensifying feelings of distress. This cycle of hyperawareness and anxiety created a reinforcing loop, making it even harder to find relief.
“The physical response is exceptionally scary… it feels like you’re dying.” (Orangedog)
When Signals Go Unnoticed
At the opposite end of the spectrum, some participants experienced hypoawareness, struggling to detect bodily signals until they became extreme. This led to missing early signs of anxiety, making it more difficult to manage emotions before reaching a crisis point.
Basic physical needs were also frequently overlooked, with some unable to recognise sensations like hunger or thirst until they became severe. As a result, they might go an entire day without eating or drinking, unaware of their body’s needs until discomfort set in. This disconnect often led to exhaustion, heightened anxiety, and difficulty maintaining overall well-being.
Many also described fluctuating between heightened and reduced awareness, with their ability to tune into bodily signals shifting depending on stress levels, environment, or sensory load. These unpredictable changes made it even more challenging to maintain a consistent connection with their physical state, further complicating emotional regulation.
Interoceptive Evaluation- How We Interpret Bodily Signals
Beyond awareness, the study found that the way these teenagers interpreted bodily signals played a crucial role in anxiety. Negative interpretations often led to increased distress, even among those who could perceive interoceptive signals.
Catastrophising and Anxiety Loops
A common experience among participants was catastrophising bodily signals, particularly those associated with anxiety, such as an increased heart rate. This often created a self-reinforcing cycle of panic.
For some, interoceptive signals were misinterpreted as signs of a medical emergency, leading to overwhelming fear and a sense of impending danger.
This heightened awareness also contributed to a deep sense of losing control, making it even more challenging to feel in control of emotions.
The Importance of Reframing Signals
A small number of participants described neutral or adaptive interpretations of their bodily signals, showing an ability to recognise and manage them effectively. One participant noted that while these signals can sometimes trigger anxiety, they can also help to reduce it. This suggests that teaching autistic adolescents to reframe their interoceptive experiences could be a valuable strategy for managing anxiety.
The Role of Context and Masking
Situational interoception, describes how contextual factors influenced participants’ interoceptive experiences.
The Impact of Stress and Arousal
Many participants reported that high-arousal situations sent their interoceptive awareness into overdrive, making them hyper-aware of every bodily sensation when anxious. One described feeling everything in their body all at once in intense moments. This overwhelming flood of sensations could amplify distress, trapping individuals in a vicious cycle where anxiety and interoception fuel each other.
Masking and Disconnection from the Body
Many participants revealed that masking didn’t just suppress their autistic traits—it cut them off from their own bodies. So focused on blending in, they failed to notice their anxiety creeping up until they hit full shutdown. Some only began to reconnect with their bodily needs when they finally stopped masking, realising they hadn’t truly felt hunger, thirst, or even the urge to use the toilet until they unmasked at home. These accounts expose the hidden tolls of masking, showing how social pressures sever autistic individuals from their own physical experiences.
These insights suggest that reducing the need to mask isn’t just about comfort—it’s about reclaiming bodily awareness and managing anxiety before it spirals out of control. Reducing the need for masking and having support to tune into bodily signals could both help with anxiety management.
Implications for Autism & Anxiety Interventions
The study suggests that better understanding interoception could lead to new approaches for managing anxiety in autistic adolescents.
- Self-awareness training: Helping autistic teens recognize and name their bodily signals early could be a game-changer.
- Tech tools: Smartwatches that track heart rate might help those with low interoceptive awareness notice anxiety building up before it becomes overwhelming.
- Reframing bodily signals: Teaching autistic individuals with cognitive behavioural techniques to interpret bodily cues in a neutral (rather than fearful) way may help break the cycle of anxiety helping those who struggle with catastrophising
- Addressing the role of masking: Supporting autistic individuals in reducing the cognitive load of masking should help them maintain better interoceptive awareness and self-regulation.
Paper summary by Zahra