Breathlessness catastrophising after COVID-19 involves both interoceptive and visceromotor connectivity

Qiu, L.; Raman, B.; Cassar, M.; Fraser, E.; Atkinson, L. Z.; Clare, S.; Clarke, W. T.; Neubauer, S.; Davies, H. E.; Harrison, N. A.; Evans, C. J.; Ezra, M.; Pattinson, K. T. S.

doi:10.64898/2026.09.11.750997

bioRxiv · 10.64898/2026.09.11.750997

Breathlessness catastrophising after COVID-19 involves both interoceptive and visceromotor connectivity

Qiu, L.·Raman, B.·Cassar, M.·Fraser, E.·Atkinson, L. Z.·Clare, S.·Clarke, W. T.·Neubauer, S.·Davies, H. E.·Harrison, N. A.·Evans, C. J.·Ezra, M.·Pattinson, K. T. S.

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Abstract

Persistent breathlessness is common after COVID-19, yet its severity typically correlates weakly with objective clinical measures. This discordance is often attributed to perceptual inference amplified by anxiety. Because breathing involves a closed perception-action loop, breathlessness may also reflect alterations in interoceptive and visceromotor pathways. We acquired 7-tesla resting-state functional MRI in 53 post-COVID patients with varying breathlessness and estimated functional connectivity across 18 pre-defined interoceptive and visceromotor regions. Linear regression identified two connections associated with breathlessness catastrophising: reduced dorsal periaqueductal grey-posterior insula (dPAG-PoI1) and increased basolateral amygdala-dorsal anterior cingulate (BLA-dACC) connectivity. The dPAG-PoI1 association was stronger in patients who had required mechanical ventilation, whereas the BLA-dACC association was attenuated at higher generalised anxiety. These findings are consistent with two potentially separable contributions to symptom burden: weakened interoceptive signalling between brainstem and sensory cortex, and heightened visceromotor influence of threat processing on autonomic control, rather than anxiety-driven misperception alone.

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Qiu, L., Raman, B., Cassar, M., Fraser, E., Atkinson, L. Z., Clare, S., Clarke, W. T., Neubauer, S., Davies, H. E., Harrison, N. A., Evans, C. J., Ezra, M., Pattinson, K. T. S.. 2026-09-14. Breathlessness catastrophising after COVID-19 involves both interoceptive and visceromotor connectivity. https://doi.org/10.64898/2026.09.11.750997

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