Mental Health in the Brain: The Insula

Hi there. My name is Dr. Jennifer Sweetin and I'm a licensed clinical psychologist here in the Kansas City area. I wanted to start a sort of video series about a topic that I'm really interested in and have been for a long time, and one that I speak a lot about, which is neuroscience based approaches to psychotherapy or brain based therapy. So about once or twice a month, I'm usually on the road giving full day workshops, generally speaking, on this topic, talking to therapists about how the brain can change with different types of interventions, looking at what we want to target in the brain, what we want to change, and then how we can do it using different interventions. So really how to begin conceptualizing our clients a little bit differently by thinking about what's going on in the brain, where the strengths are, where the deficits are, and how we might help them heal through more targeted interventions and techniques. So what I want to do is a video series where I go over different areas of the brain that tend to be involved in mental health or mental illness and highlight what they're doing and then also begin to emphasize how we can actually use this in therapy for clients to be able to change their own brains. So what I want to do with this first video is talk a little bit about the insula. And I like to start here because the insula, I think, is one of the most important areas to understand and it's one of the main ones that most clinicians don't understand. So in my workshops, when I ask people who has heard of this brain area, almost nobody raises their hand, which is really surprising because there's some other areas of the brain that people do tend to know more about, like the amygdala or the prefrontal cortex. But interestingly, not many people really know much about the insula. And I think it's critical because if the insula is not working least kind of properly, then it makes it hard to do any other type of therapy. So I want to start here. So I'm starting at what I see as the most basic level or the most basic brain area that we need to have online and to some extent intact to even do therapy. So the insula. Those of you who've come to my workshops, you probably remember a little bit of what I said about this. So this might be a little bit of a refresher for those of you who haven't. I hope this is helpful information that I can give you. So the insulin insula, it's spelled I N S U L A. And along with this video, I'm going to make it available on my website a couple of links to the insula. So you can see exactly where this is in the brain and so you can understand it a little more. So there's going to be more information on my website, which is www.jennifersweetin.com in the blog section, so that you can look into this area a little bit also on your own, but just to give you a little bit of an overview. So the insula is this little part of the brain. It's a limbic structure. So what I mean by that is it's part of that emotion brain where there's a lot of different mental health brain areas, I guess you could say, in this big area. So it's a little limbic structure. And what it does, what it's meant for is it helps you feel into internal states. So if you're sitting there and you're feeling cold, or if you're feeling hungry, that would be your insula. The insula is telling you. So it's giving you some information on internal physical states. This is also the area of the brain that's probably active. If you suddenly notice that maybe you just feel on edge, anxious or upset, and you think to yourself, gosh, why am I feeling so nervous or so anxious? Is there something wrong? Or is it just that I drank too much coffee today? Maybe that coffee was just too strong. That's you trying to interpret internal signals. And that's actually, that's just a lot of insight. If you're able to do that and being able to question that and say, is this really just like a physical response to caffeine or is this something else? But it's the insula that allows you to do that, to feel into the body. The insula is also involved in something called proprioception. So proprioception is your sense of balance. And it's that. It's kind of hard to put it in words, but it's that awareness of where your body is in space. So if I lift my arm out, I can kind of just feel, I kind of know where it is. That's part of proprioception. But for our purposes as therapists, the more important piece is that first piece of feeling into internal experiences. And we call that interoception, the ability to feel into internal states. And I really consider this to be the first step in therapy, the first thing that we've got to do in order to treat the symptoms. We have to know what the symptoms are to begin with. And if you think of therapy as having the goal of managing emotions and symptoms related to emotions, the body. And feeling into the body becomes really, really critical because our experience of emotion is largely physical. So back to maybe early grad school or even in your undergrad work, you might have learned about what an emotion is. And I remember being in a basic emotion course at Stanford way back in the day, like 2004, and learning that an emotion is feelings and thoughts, but also physical sensations. And a lot of emotion experts say that not only are the physical sensations just one third of your experience of emotion, but they're more like 60 to 70%. So it's one of three components of emotions, but it's actually the main way that we experience them. So we have to be able to feel into the body in order to really experience emotion. And when you take the body away, it's not actually emotion that you're experiencing anymore. So an example that sometimes I'll give with this kind of drive this point home, imagine that you have panic attacks, really severe panic attacks, and you go and you get diagnosed with panic disorder, and you're getting therapy for these really horrible panic attacks. And let's say one day you wake up and you just no longer have a body. So everything else is intact, but you don't have a body. I know that's a really hard thing to imagine because it's totally unrealistic. But imagine if you didn't have a body. My question to you would be, would you still have panic disorder? And the answer is probably no. Sometimes people will say, well, you know, I might still have the thoughts that go along with panic, but even keep in mind that usually the thoughts that you have are related to the physical symptoms, their interpretations usually of the physical symptoms you're having during panic. So really, a large part of panic disorder is the physical sensations and how aversive, scary those physical sensations are. And that's the insula. So let me say a little bit about what's going on in the insula with different types of disorders. And then what I'm going to do is when I put this kind of pair this video with the blog I'm going to give a couple of articles to read and treatment recommendations for how we can begin to work with the insula. But let me tell you what's going wrong in it. So when we have something like, let's say, depression, maybe there's addiction present, and sometimes in trauma, you might have an underactive insula. And if you have an underactive insula, what this means is that you have a difficult time feeling into internal experiences. So in depression, this is going to present as vague symptoms. Somebody's going to come into your office, they sit down, they say they just generally feel crummy. But when you ask them to expand on that and say what that actually means, they have a really hard time putting it into words. And part of this is that even though they know they feel crummy, they're having a hard time getting more specific because they likely have some under activation in this area in something like trauma or ptsd. The way it's going to present will be as numbing, essentially. So somebody's going to come in and they're going to say, you know, I just don't have any loving feelings that I can access. I know I love my husband, but I can't access those feelings. And they're not linking it to connection with the physical body, but it is. It's actually a slightly different part of the insula that's involved in the emotional numbing. And what it's largely dependent on is the physical numbing piece. So these are also a lot of times the clients that, if they're extremely traumatized, may not remember to eat, they don't feel hunger, they may cut. I think of a lot of times cutting as an insula regulation strategy where somebody's trying to get back into the body. Not always, but sometimes when they cut, they're trying to get back into the body, they're trying to activate that insula. So when it's under activated, symptoms can be really vague. And it can also be a lot of numbing symptoms. So that's underactive. If the insula is overactive, we also got a problem. So this is like an anxiety, and sometimes in trauma as well, you're gonna see this. So what this looks like are the clients that come in and they seem very preoccupied with physical sen. So every little thing, every little ache and pain, every tweak, their attention goes right to it. And it's like they can't get their attention away from it. And I've heard clinicians before say, well, you know, maybe that's just their way of avoiding talking about some harder topics that can be pretty painful in therapy. And while that might be the case, also keep in mind, though, that when the insula is hyperactivated, what it's doing is it's giving you very strong, loud signals about what's going on in your body that are not actually accurate. So it's giving misinformation. So, classic example of this would be somebody with panic who has racing heart. And once they notice that their heart is racing, beating faster and faster and faster, they start to catastrophically interpret it. They'll say, oh my gosh, I can feel it on my chest, I can hear it in my ears. I'm going crazy, I'm dying, I'm having a heart attack. And this is usually when they end up in the error. And then they're diagnosed with panic disorder or anxiety, something like that. But what's happening with the insula is that it's hyperactivated and it's giving you incorrect signals. So in a way, it's telling you the truth. It's telling you that your heart's speeding up, but it's also lying to you, because what it's telling you is that that is magnified and that it's catastrophic that there's something dangerous about this physical sensation that you're having. So that's oftentimes what's happening in anxiety. And when you have a hyperactive insula, if you've ever had this before, you know what I'm talking about, you can't get your mind off of it. So if you injured your back and you get really anxious about having a back injury and you find yourself kind of testing your back, kind of tweaking, it kind of moving, oh my gosh, it still hurts. Let me test it again. Oh my gosh, it still hurts. Let me test it again. And your attention keeps getting drawn back to it. It's very anxiety based, right? That's actually a hyperactive insula. And a lot of times in anxiety, we know that from neuroimaging research that the insula is hyperactivated. But also that fear center, or that smoke alarm of the brain called the amygdala, there will be a different video on that that's also hyperactive in anxiety. And we have some evidence showing that the wiring between these two structures, the insula for internal experiences and the amygdala, that fear brain, and the wiring is too tight, meaning those two areas are communicating a little more than they should, which makes everything feel dangerous in the body and catastrophic. So we start to misinterpret these physical cues. So that's what's going on with the insula. What we want with the insula, we want it to be strong and robust, we want it to be online, but we don't want it magnifying physical sensations, contributing to an interpretation of them being dangerous or catastrophic when they're in fact not actually dangerous or catastrophic. So this is a really important area again, because I think we have to have this area at least a little bit intact and working or else there's really no therapy we can do. So for instance, if a person doesn't have a body or can't feel into the body, there's really no work on emotions that we can do as therapists. So usually when I'm training other therapists, I say this is first and foremost really the first area of the brain to look at. And when you're working with clients, what you want to know from day one is are they in their body? Can they feel into it? Can they describe what they're experiencing, put language to it, or are they numbed out? Or does it seem like they're misinterpreting these cues, these physical cues as being dangerous? So I'm going to stop here, but I'm going to do a follow up blog, kind of adding on to this. That'll go with this video with some resources and a couple of ideas for helping folks to be able to begin to regulate the insula, to have a strong, but also a regulated insula.