Feeling the heat: Investigating interoception and motivation as risk factors for exertional heatstroke

Exertional heatstroke (EHS) is the most severe form of heat-related illness, occurring during sport competition or military training. Despite substantial progress in understanding its physiological mechanisms, current evidence suggests the need for broader models that also consider cognitive factors. We propose a cognitive model of EHS and conduct a preliminary empirical validation through a case-control study using self-report measures. The central hypothesis is that EHS results from a disrupted cost-benefit trade-off during prolonged physical activity-specifically, an overvaluation of performance-related benefits due to excessive motivation, coupled with an undervaluation of exertion costs linked to low interoceptive awareness, characterized by disrupted processing of signals related to the body's internal state. Individuals with a history of EHS (cases, N = 51) reported significantly lower interoceptive awareness and reduced trait mindfulness compared to controls (n = 43). However, no difference was found in global motivation traits between groups. These findings provide initial support for a cognitive model of EHS and suggest that simple self-report tools may help identify individual vulnerability. Incorporating cognitive dimensions into EHS research could enhance risk stratification and inform new prevention strategies in athletic and military contexts.