Reviewer #1 (Public Review):
Summary:<br /> I read the paper by Parrotta et al with great interest. The authors are asking an interesting and important question regarding pain perception, which is derived from predictive processing accounts of brain function. They ask: If the brain indeed integrates information coming from within the body (interoceptive information) to comprise predictions about the expected incoming input and how to respond to it, could we provide false interoceptive information to modulate its predictions, and subsequently alter the perception of such input? To test this question, they use pain as the input and the sounds of heartbeats (falsified or accurate) as the interoceptive signal.
Strengths:<br /> I found the question well-established, interesting, and important, with important implications and contributions for several fields, including neuroscience of prediction-perception, pain research, placebo research, and health psychology. The paper is well-written, the methods are adequate, and the findings largely support the hypothesis of the authors. The authors carried out a control experiment to rule out an alternative explanation of their finding, which was important.
Weaknesses:<br /> I will list here one theoretical weakness or concern I had, and several methodological weaknesses.
The theoretical concern regards what I see as a misalignment between a hypothesis and a result, which could influence our understanding of the manipulation of heartbeats, and its meaning: The authors indicate from prior literature and find in their own findings, that when preparing for an aversive incoming stimulus, heartbeats *decrease*. However, in their findings, manipulating the heartbeats that participants hear to be slower than their own prior to receiving a painful stimulus had *no effect* on participants' actual heartbeats, nor on their pain perceptions. What authors did find is that when listening to heartbeats that are *increased* in frequency - that was when their own heartbeats decreased (meaning they expected an aversive stimulus) and their pain perceptions increased.
This is quite complex - but here is my concern: If the assumption is that the brain is collecting evidence from both outside and inside the body to prepare for an upcoming stimulus, and we know that *slowing down* of heartbeats predicts an aversive stimulus, why is it that participants responded in a change in pain perception and physiological response when listened to *increased heartbeats* and not decreased? My interpretation is that the manipulation did not fool the interoceptive signals that the brain collects, but rather the more conscious experience of participants, which may then have been translated to fear/preparation for the incoming stimulus. As the authors indicate in the discussion (lines 704-705), participants do not *know* that decreased heartbeats indicate upcoming aversive stimulus, and I would even argue the opposite - the common knowledge or intuitive response is to increase alertness when we hear increased heartbeats, like in horror films or similar scenarios. Therefore, the unfortunate conclusion is that what the authors assume is a manipulation of interoception - to me seems like a manipulation of participants' alertness or conscious experience of possible danger. I hope the (important) distinction between the two is clear enough because I find this issue of utmost importance for the point the paper is trying to make. If to summarize in one sentence - if it is decreased heartbeats that lead the brain to predict an approaching aversive input, and we assume the manipulation is altering the brain's interoceptive data collection, why isn't it responding to the decreased signal? --> My conclusion is, that this is not in fact a manipulation of interoception, unfortunately.
I will add that the control experiment - with an exteroceptive signal (knocking of wood) manipulated in a similar manner - could be seen as evidence of the fact that heartbeats are regarded as an interoceptive signal, and it is an important control experiment, however, to me it seems that what it is showing is the importance of human-relevant signals to pain prediction/perception, and not directly proves that it is considered interoceptive. For example, it could be experienced as a social cue of human anxiety/fear etc, and induce alertness.
Several additional, more methodological weaknesses include the very small number of trials per condition - the methods mention 18 test trials per participant for the 3 conditions, with varying pain intensities, which are later averaged (and whether this is appropriate is a different issue). This means 6 trials per condition, and only 2 trials per condition and pain intensity. I thought that this number could be increased, though it is not a huge concern of the paper. It is, however, needed to show some statistics about the distribution of responses, given the very small trial number (see recommendations for authors). The sample size is also rather small, on the verge of "just right" to meet the required sample size according to the authors' calculations. Finally, and just as important, the data exists to analyze participants' physiological responses (ECG) after receiving the painful stimulus - this could support the authors' claims about the change in both subjective and objective responses to pain. It could also strengthen the physiological evidence, which is rather weak in terms of its effect. Nevertheless, this is missing from the paper.
I have several additional recommendations regarding data analysis (using an ANOVA rather than multiple t-tests, using raw normalized data rather than change scores, questioning the averaging across 3 pain intensities) - which I will detail in the "recommendations for authors" section.
Conclusion:<br /> To conclude, the authors have shown in their findings that predictions about an upcoming aversive (pain) stimulus - and its subsequent subjective perception - can be altered not only by external expectations, or manipulating the pain cue, as was done in studies so far, but also by manipulating a cue that has fundamental importance to human physiological status, namely heartbeats. Whether this is a manipulation of actual interoception as sensed by the brain is - in my view - left to be proven.<br /> Still, the paper has important implications in several fields of science ranging from neuroscience prediction-perception research, to pain and placebo research, and may have implications for clinical disorders, as the authors propose. Furthermore, it may lead - either the authors or someone else - to further test this interesting question of manipulation of interoception in a different or more controlled manner.
I salute the authors for coming up with this interesting question and encourage them to continue and explore ways to study it and related follow-up questions.