PONE-D-24-17726A systematic review and meta-analysis of the relationship between subjective interoception and alexithymia: Implications for construct definitions and measurementPLOS ONE

Dear Dr. Van Bael,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Overall, the feedback from all three reviewers was extremely positive. This manuscript is an important, comprehensive, and methodologically sound endeavor to provide in-depth insights into the association between alexithymia and interoception.

From a methodological standpoint, there are no major issues to resolve, except for providing inter-rater reliability for study selection and data extraction, as recommended by several systematic review and meta-analysis guidelines.

From a conceptual standpoint, there are some important topics that need to be clarified or discussed in the manuscript, particularly regarding the criteria for classifying questionnaires and how alternative classification approaches could also be feasible.

Lastly, despite the manuscript being extremely well-written, I believe there is still some room for improvement, particularly considering the complexity of the analysis and results. The reviewers provide several comments that can be useful for the authors to make the manuscript clearer to the reader (e.g., summary figure).

Please submit your revised manuscript by Aug 17 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Carlos Campos

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note that your Data Availability Statement is currently as follows: [All relevant data are within the manuscript and its Supporting Information files]

Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition).

For example, authors should submit the following data:

- The values behind the means, standard deviations and other measures reported;

- The values used to build graphs;

- The points extracted from images for analysis.

Authors do not need to submit their entire data set if only a portion of the data was used in the reported study.

If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories.

If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access.

3. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This systematic review and these meta-analyses are excellent for several reasons. The authors greatly explained the actual state of the literature on self-report interoception and followed the most up-to-date recommendations in the field. The method is overall very good. The discussion is complete and insightful for the field. Once published, this review will have a huge and, more importantly, a very positive impact on the literature, as it promotes valid and nuanced interpretations of data. I have rarely read such a well-written manuscript. Many congrats to the authors!

You can find below my minor comments:

1. Please report the inter-rater reliability for the selection of papers, their extraction, and their assessment.

2. There seems to be a typo in this sentence as the correlation between ICQ and alexithymia is reported twice with different results: “Meta-analysis demonstrated a strong positive association for the ICQ and alexithymia, r(9) = 0.57, p <.001, suggesting greater struggles to interpret non-affective interoceptive states coincides with difficulties identifying and describing feelings, and a preference for externally oriented thinking. A strong positive effect was further observed between the ICQ and alexithymia, r(2) = 0.53, p <.001, indicating that greater difficulty registering or interpreting interoceptive sensations relates to higher alexithymia.”

3. I do not agree that the THISQ is a measure of neutral interoceptive attention, as attentional aspects are not mentioned in the items of this questionnaire. Neutral interoceptive detection would be more relevant. Similarly, I don’t think that the BAQ is a measure of adaptive interoceptive attention. Items are more related to the capacity to notice and predict body reactions to internal and external factors such as weather, seasons, foods, blows, diseases, and energy level. In sum, the THISQ and the BAQ are questionnaires assessing the capacity to detect, notice, or predict bodily cues that should be detected/predicted for maintaining well-being or homeostasis (i.e., adaptive interoceptive abilities).

4. The authors propose to differentiate questionnaires based on their adaptivity aspects. Three comments: (1) Could the authors further discuss their definition of this criterion? (2) Could we categorize these questionnaires differently (e.g., based on the valence of sensations reported in the questionnaire)? (3) They should recommend future studies to test the validity of this classification into two categories (i.e., maladaptive vs. adaptive).

Reviewer #2: I commend the authors for what was clearly a massive undertaking. This area, as they clearly articulate, is a like a field of land-mines and they navigated it gracefully. I think, once cleaned up, this work will represent a clear contribution to research on interoception and alexithymia, as well as to research on emotional expertise more broadly. Really it is a tour-de-force. Please interpret my comments as constructive! I would ultimately love to see this published.

Overall comments:

1. I'll note first and foremost that I do not have personal experience conducting meta-analyses so I will leave it to another reviewer to comment on whether statistical analysis have been performed appropriately and rigorously. However I do want to applaud the careful approach the authors took to data disaggregation. I especially appreciated that the authors attempted to examine variability in effects across geographic regions.

2. I do want to acknowledge with full transparency that I had some difficulty following the logic of several sections. I recognize that it must be very difficult organizing so many theoretical perspectives, constructs, and ultimately, findings. I cant help but wonder if a bit more structure (e.g., headings) or sign-posting (e.g., in each results section we break down results based on effect size) would help the reader keep things straight in their mind. I also found several broken or grammatically messy sentences throughout, so I would encourage the authors to do another round of careful editing.

Additional comments:

3. I think the authors need to be a bit more explicit about how their paper contributes above and beyond what's already been published by Trevisan et al. To be clear, I think this paper DOES contribute above and beyond what's already been published, but I think it wouldn't hurt to make this more explicit RIGHT AWAY (before overviewing Trevisan et al's specific findings). When you introduced the paper (which I hadn't read), my first thought was, "wait, did someone do this already?"

4. Related to point 2 above, in the introduction, the authors discuss (a) popular frameworks for organizing interoceptive CONSTRUCTS and (b) the various MEASURES used in interoceptive research with the goal (as I understand it) being to clarify how these two things are somewhat incoherent and poorly aligned. I wonder if using the language of "constructs" versus "measures" (i.e., a more explicit construct validity framework) would be helpful. As it is, the introduction mixes up discussions of both (a) and (b) in a way that was difficult to follow.

5. I recognize the need for acronyms but I would encourage the authors to go through and reduce their use of acronyms wherever possible. Particularly in the discussion, I found the prevalence of acronyms made it difficult to follow the narrate arc of each section. Acronyms should also be spelled out in footnotes for tables and figures. Especially given the complexity of your findings. Someone should be able to look at your figures and get the whole story.

6. Please add a mean and standard deviation for participant ages if possible. 18-91 is a very broad age range and, given evidence that both self-report and task-based measures of interoception vary across the lifespan, this seems like a relevant detail.

7. On line 331, can you clarify what you mean by "self-reported psychiatric diagnoses"? Are you distinguishing between formal and informal diagnosis here?

8. Take this or leave it -- I personally think risk of bias assessments can go to the supplemental so that the main analyses about relationships among measures has a bit more breathing room.

9. Line 527, you say "meta-analysis demonstrated a strong positive association for the ICQ and alexithymia..." and then on 530, "A strong positive effect was further observed between the ICQ and alexithymia..." I assume this is a mistake?

10. Throughout the paper, and in the discussion in particular, be careful when you use "interoceptive accuracy" since that will conjure up images of behavioral tasks for many readers given Garfinkel et als work. I would be very clear when you're referring to "task-based interoceptive accuracy" (e.g., on line 777?) vs self-reported interoceptive accuracy.

11. Line 835, you say, "DIF exhibited the highest magnitudes in associations with interoceptive self-report scales, which could be due scale construction and emotion generation processes. " I know this sentence has a typo, but on top of that I found it a bit confusing. Maybe consider something like, "which could be due to specific aspects of scale construction or to more general features of emotion generation processes. For example, ..."

13. On line 841 you write, "Additionally, theories of emotion propose that the interpretation of physiological sensations and changes plays an essential role in the generation of emotions, as they may initiate an affective state." The constructionist model (whose proponents you cite) would argue that "physiological sensations and changes" partially CONSTITUTE core affect. They would not argue that these sensations INITIATE affect. This is an important detail that these folks may be finicky about.

14. I'm not sure i'm clear on your logic why the THISQ is a measure of "neutral interoceptive attention." You never really describe what you mean by "neutral."

15. Would love to see a sentence or two on geographic variability given that you ran those analyses. Otherwise I would omit them from reporting and just say somewhere higher up in the results or methods that you ran those pre-registered subgroup analyses but have reported them in the supplement given small sample sizes. In general, I think any analyses that don't contribute to the main analyses (which are already complex) should be placed in the supplement.

Reviewer #3: Van Bael et al., conducted a thorough systematic review and several meta-analyses of currently used self-report interoceptive and alexithymia measures. Strengths of this research include the pre-registration and clear approach to assess the different measures used within the literature. I think that this study adds value to the current literature as it adds clarity to a field which is limited by its lack of consistency in definitions and measures. Further, the study is well-written. Therefore, my comments are minor, and I think that this will be a useful work to guide future researchers interested in investigating interoception and alexithymia.

• In the eligibility criteria, I think that it should be noted that clinical disorders were considered (i.e., they were not excluded).

• Given that the meta-analyses produces a lot of results, a summary figure/s would also enhance this study and help readers to understand the overall picture. This could be for example in the form of a spider plot or heat map showing the negative and positive correlations between each alexithymia domain and the interoceptive measures.

• Revise manuscript for repetition in results to increase conciseness. For example,

-Regarding the primary meta-analyses: can authors provide a workflow or diagram which summarises how many meta-analyses were conducted across the alexithymia scales? Instead of repeating this at the beginning of each subheading of the results (i.e., line 521, 582, 671).

-Lines: 568-571; 620-622; 695-697: regarding subgroup analyses. This sentence is repeated throughout the results but should be placed in the statistical analysis section of the methods and stated once.

- Broadly, I think that references to the statistical thresholds and effect size cut-offs could be moved to the methods (Line 510-518), together with the information about the sub-group analyses.

• In discussion, avoid using “positive” or negative” association and instead explain the relationship “i.e., greater alexithymia was associated with higher levels of interoceptive confusion” Line 754.

• Some measures are more popular or well-known than others (i.e., TAS-20, MAIA) and therefore may have had more weight in each meta-analysis. Authors should mention how this might have influenced their results, as some frequencies of use = 1 (i.e., Figure 2), so I would think that these results need to be interpreted with some caution.

Minor comments:

Line 174: wording “as meta-analysis” change for “meta-analytic approaches should enable the quantification”

Line 245: wording “meta-analysed”

Line 281: Typo “Supplemental”

Line 380: Move the section of excluded scales to end of section to improve flow.

Line 714: Avoid using the word “forced” due to negative connotations. Replace with more neutral word like “used” or “employed”

Line 1076-1078: Link results of current study to this sentence as it is currently not clear that using appropriate measures of interoception and alexithymia will likely improve therapeutic outcomes.

Figure 1: check figure quality

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Jessica L. Hazelton

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-24-17726R1A systematic review and meta-analysis of the relationship between subjective interoception and alexithymia: Implications for construct definitions and measurementPLOS ONE

Dear Dr. Van Bael,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. I believe that you addressed most of the major concerns expressed by the reviewers in the original revision, but one important conceptual issue is not completely addressed. One of the reviewers questioned the classification of interoception attention measures (particularly THISQ and BAQ) and how this interferes with the conclusions regarding the association between this construct and alexithymia. The comments are sound, well-grounded and extremely important considering the conceptual debate regarding interoception measurement. The authors should consider these comments and either adjust the manuscript accordingly or provide a strong rebuttal addressing the presented concerns. Regardless, the authors should also provide a more in-depth discussion about this issue on the Discussion section so that the lack of a consensual classification is clear for the reader. Lastly, some minor recommendations were given regarding inter-rater reliability, but I believe that these will be easy to acommodate. Please submit your revised manuscript by Sep 27 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Carlos Miguel Martins Campos

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I would like to thank the authors for their exhaustive answers. I, nevertheless, have some remaining comments.

1. The methodology employed to assess inter-rater reliability is overall good, but also reveals some areas for potential improvement. For the title and abstract screening phase, the reported kappa values (κ = 0.10-0.39) indicate slight to fair agreement following the most liberal guidelines (Landis & Koch, 1977), but poor (Fleiss, 1981; Altman, 1991) following more conservative ones. This means that the replicability of this selection phase is not optimal and should be acknowledged in the limitations. For the extraction phase, the percentage agreement shows a high level of reliability (84.4 to 90.6%), which is commendable, but the reliance on percentage agreement alone, without considering chance agreement, may overestimate true reliability. This should also be acknowledged in the limitations.

2. Although I have explained that the THISQ and the BAQ are not measures of interoceptive attention, the authors stand by their interpretation based on the following arguments: (1) The authors of the THISQ (Vlemincx et al., 2023) note that THISQ scores correlated moderately with other measures of non-emotional interoceptive attention, such as the BAQ and the Noticing scale of the MAIA; (2) The BAQ is currently classified as a self-report of interoceptive attention in the literature (e.g., Trevisan et al. 2020; Vlemincx et al. 2023), as noticing and frequency of awareness involves orienting attention to salient interoceptive signals (Mehling, 2012). Here are my answers: (1) the authors of the THISQ wrote: “Self-reported interoception as assessed by the THISQ is defined as the self-reported awareness or observation of these sensations, assessed by the rate at which persons notice or feel (changes in) these internal bodily sensations. By assessing the ‘noticing’ and ‘feeling’ of sensations, we excluded interoceptive features such as discrimination, accuracy and attention, to avoid specific emotional or cognitive interpretations of sensations (similar to the BAQ and BPQ)” (p.1238). They also wrote: “… the THISQ assesses self-reported interoception... However, it does not explicitly assess interoceptive accuracy, nor interoceptive attention… The THISQ items are not subjective evaluations of whether one pays attention to these sensations, nor of whether one perceives these sensations accurately.” (p.1249) A moderate correlation does not support the conclusion that two measures evaluate the same construct. It is expected that a measure of attention correlates with a measure of awareness, as more attention should lead to more awareness; the two constructs are related but distinct. Put differently, while attention is necessary for individuals to notice and be aware of their sensations, it is not sufficient. (2) For the BAQ, it is more debatable as the original authors have themselves qualified this questionnaire as a measure of interoceptive attention. Again, however, although I agree that attention would help to better notice or predict bodily sensations, I do not agree that the BAQ is a direct measure of interoceptive attention given that no item refers to attention per se.

3. This debate about the construct (i.e., whether or not it is interoceptive attention) measured by certain questionnaires is not without consequences. Indeed, the authors conclude that alexithymia is associated with more interoceptive attention. I do not agree. Questionnaires relevant to interoceptive attention are the Interoceptive Attention Scale (IATS) and the subscales MAIA-SR and MAIA-AR. Each of these (sub-)scale, however, measures different subcomponents of interoceptive attention. While the IATS evaluates whether individuals pay their attention “most of the time” towards bodily states indicating homeostatic disturbances (or hypervigilance towards body needs), the MAIA subscales evaluate the ability to sustain and control attention to body sensations and the ability to regulate distress through bodily attention. Based on the results, and to simplify, we could thus conclude that alexithymia is associated with more maladaptive interoceptive attention and less adaptive interoceptive attention. This conclusion further demonstrates that “interoceptive attention” covers different subcomponents and should not be uniformly assigned to multiple questionnaires (THISQ, IATS, BAQ, and MAIA subscales), especially when their items do not refer to attention.

Besides these concerns, the manuscript is excellent. Once my comments have been further addressed, I recommend its publication.

Reviewer #2: Thank you to the authors for their thorough response to my review. I believe the paper is both clearer and more concise.

I can happily recommend this paper for publication. I look forward to citing it.

A few remaining comments below:

1.Regarding the use of “neutral” – I still struggle a bit with this. I think it’s valid to relay that the authors of the THISQ used the term, but I’m not sure the term is useful in the context of your larger discussion. Specifically, it’s not clear to me that-on-the-whole, people have great access to physiological sensations that are “neutral.” Given the neurobiology of the system and available data, it seems moreso that most “typical” physiological phenomena are not experienced within conscious awareness. I’m also thinking of the newer ESM paper by Geoff Bird’s group, demonstrating that most often when people report attending to bodily sensations, they also report small increases in negative affect. All-in-all, I can’t imagine I’m the only one that will get distracted by the term “neutral.” Perhaps the distinction is more-so “self-reported perception of body sensations at rest (e.g., normal breathing) versus at times of physiology strain or exertion (e.g., dyspnea)?”

2.Lines 95-96, I would recommend using a different phrasing besides “heartbeat tracking tasks”. This phrasing is often used to describe heartbeat counting or tapping tasks. For both these tasks, I’ve seen disagreement in the literature about whether they belong in the “accuracy” or “sensibility” categories. I would maybe recommend instead citing “heartbeat detection or discrimination tasks.”

3.Lines 104-107 (and elsewhere in the manuscript)—I would place the different constructs in quotations to clarify that these are terms introduced by the meta-analyzed work, and not terms that are necessarily endorsed by the authors. This would also help to differentiate when you’re engaging in “review” verses “inference.”

4.Very nit-picky, but on 114-115, I may also recommend including “sickness” (e.g., chills or fever) or “injury” (e.g., bruising) as bodily signals represented in common self-report measures of interoceptive ability. I say this because sickness in particular, unlike hunger, thirst, fatigue, or cardiovascular sensations are not typically discussed in work on interoception (and is not objectively measured by behavioral tasks). This is one place where I think refinement of our construct is vital.

5.Line 565-566, please include a parenthetical indicating where these “weak associations” can be found (e.g., “see Table X).

Reviewer #3: The authors carefully addressed my concerns and revised their manuscript thoroughly. Well done to the authors on this solid piece of work.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Jessica L. Hazelton

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

A systematic review and meta-analysis of the relationship between subjective interoception and alexithymia: Implications for construct definitions and measurement

PONE-D-24-17726R2

Dear Dr. Van Bael,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Carlos Miguel Martins Campos

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: