Emotion Dysregulation Links Interoceptive Accuracy and Vagal Activity to Psychopathology in Male but not Female Adolescents

Background: Emotion dysregulation is common across psychiatric disorders, but the biological mechanisms underlying emotional vulnerability remain poorly understood. Cardiac vagal regulation and interoception, the perception of bodily signals, may jointly contribute to emotion regulation. We examined whether their interaction is associated with emotion dysregulation and psychopathology in adolescents receiving psychiatric inpatient treatment. Methods: We studied 279 adolescent psychiatric inpatients. Cardiac vagal regulation was assessed using heart rate variability and interoceptive accuracy using a measure of bodily signal perception. Structural equation modeling tested associations between cardiac vagal regulation, interoceptive accuracy, emotion dysregulation, depressive symptoms, and personality dysfunction, including sex specific pathways and interactions. Results: Here we show that associations between autonomic regulation, interoception, and psychopathology differ by sex. In male adolescents, lower cardiac vagal regulation is associated with greater emotion dysregulation, which is associated with higher depressive symptoms and greater personality dysfunction. These associations depend on interoceptive accuracy and are most evident at low to intermediate levels of bodily signal perception. Comparable pathways are absent in female adolescents. Conclusions: These findings indicate that interactions between cardiac regulation and bodily signal perception contribute to emotional vulnerability in a sex-dependent manner. Altered body-brain communication may contribute to divergent developmental pathways of psychopathology. Integrating sex specific autonomic and interoceptive processes may improve models of emotion regulation and psychiatric risk during adolescence.