In recent years, a construct labeled “body awareness” has emerged as a subject of scientific research across a wide range of health topics. Although a clear definition is rarely provided 
, body awareness involves an attentional focus on and awareness of internal body sensations. The term has traditionally been used in studies of anxiety and panic disorders to describe a cognitive attitude characterized by an exaggerated patient focus on physical symptoms, magnification (“somatosensory amplification”), rumination, and beliefs of catastrophic out-comes 
. In this conceptualization of body awareness, the number of perceived and presumed potentially distressing body sensations has been widely used as a marker for hypochondriasis, anxiety and somatization 
, all strongly associated with unfavorable clinical outcomes such as the trajectory of pain 
. Accordingly, the dominant view in medical and behavioral science considers heightened awareness of somatic information as potentially distressing and maladaptive. There remains considerable concern among clinicians that efforts to enhance body awareness or to focus attention on body symptoms may lead to an obsession or undue dwelling on bodily functions, subsequently creating somaticizing “cripples” with anxiety and depression 
. Consequently, when this understanding of body awareness is applied to studies of pain, for example, one would expect benefits from distraction, an attentional focus directed away from pain sensations and towards mental tasks, such as solving mathematical problems. Indeed, studies of experimental pain or other acute pain models demonstrate such benefits 
However, distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain 
. Furthermore, recent studies have shown that somatosensory amplification, the tendency to experience normal bodily sensations as intense and noxious, does not reflect heightened sensitivity to bodily sensations 
. Rather, subjects who experience body sensations of normal quality and intensity as intense and disturbing are less accurate in detecting subtle bodily sensations 
. Thus, the ability to notice subtle bodily sensations can be viewed as a process distinct from somatosensory amplification. When body awareness is defined as the ability to recognize subtle body cues 
, preliminary evidence suggests that it may be useful in the management of chronic diseases such as chronic low back pain 
, congestive heart failure 
, chronic renal failure 
, and irritable bowel syndrome 
. Regarding pain research, studies using specific cognitive interventions provided by clinical psychologists, such as guided attention allocation to the sensory aspect of pain or sensory discrimination training, have shown significant benefits for patients with chronic pain 
. For example, in patients with chronic low back pain, a recent study confirmed that a focus on the sensory components of pain was more beneficial than attempts to suppress awareness of that pain 
. Similarly, studies with patients suffering from phantom pain have shown that sensory discrimination training can reduce pain 
and reorganize phantom pain-related representation areas of the sensory cortex.
. These findings seem to contradict the traditional understanding of body awareness and suggest that body awareness is a complex, multi-dimensional construct in need of more nuanced conceptualization.
Another construct related to body awareness is “body image”. “Image” implies that this aspect of body awareness includes an exteroceptive, visual channel of perception. This aspect is explored in a vast literature from psychiatry (i.e. anorexia) to feminist psychology (i.e. self-objectification) and neuroscience (i.e. rubber hand illusion, amputees) reflecting a preferential reliance on visual appearance over perceptions from inside the body 
. An integration of all ramifications and aspects of body awareness from such disparate and rarely converging fields of discourse and research would constitute an intellectual challenge beyond the scope of our study. For the purpose of this paper we are primarily concerned with those aspects of inner body awareness that, although interacting with thoughts and exteroceptive stimuli, are distinguishable from these and are potentially of key relevance for a deeper understanding of the interaction of mind and body. Therefore, we limit our review and restrict our definition of body awareness to the core-awareness of sensations from inside the body and exclude exteroceptive channels.
From a neuro-physiological viewpoint, this definition of the core-construct of inner body awareness, though more narrowly defined, relates primarily to proprioception and interoception. Proprioception is the perception of joint angles and muscle tensions, of movement, posture and balance and has become an integral part of neuromuscular rehabilitation after injuries and of the prevention of falls in the elderly 
. Objective measurement of proprioception requires sophisticated technical equipment with limited feasibility for a broader application in clinical settings outside the laboratory 
. Interoception is the perception of sensations from inside the body and includes the perception of physical sensations related to internal organ function, such as heart beat, respiration, satiety, and autonomic nervous system activity related to emotions 
. Neuroscience has suggested a network of brain regions where interoception is processed, how it is related to emotions and pain, and how essential it is for decision making 
. Awareness of internal physical sensations has been linked with activations in specific brain areas including the right anterior insula and cingulate cortices 
and the pathways for a multi-level integrated representation of inner-body experience have been clarified 
. Awareness of physical sensations associated with emotions is a key element for affect regulation and for the sense of self 
. Inter-individual variations in interoceptive capacity have been found to be associated with right anterior insula activity 
, and a meditative practice involving sustained mindful attention to internal (and external) sensory stimuli with right anterior insula cortical thickness 
, and grey matter density 
suggesting a potential, although still speculative, neuroplasticity effect due to meditation (practicing sustained attention to respiratory and other sensations) and interoceptive body awareness 
To clarify our use of terms: Interoception is the processing of sensory input from inside the body in contrast to exteroception, the processing of input from outside the body (vision, hearing, smell, taste and touch, with touch and taste having components of both). Proprioception and interoception are terms of sensory perception, a complex process that includes the objective processes of neural coding, transduction and central representation of peripheral stimuli and, most importantly, entails both afferent (bottom-up) and efferent (top-down or gating) mechanisms. Much of this information is processed “before we know it”, pre-cognitive, unconsciously. Interoceptive information, for example, is not identical to interoceptive awareness. Some of this information can enter consciousness, and we become aware of it. Subjective awareness, in turn, is strongly influenced by mental processes including attention, interpretation, appraisal, beliefs, memories, conditioning, attitudes and affect. Much of perception research has been directed toward the study of either exteroception or pain. In both fields the involved mechanisms have long been acknowledged for their enormous complexity, and experimental research is beginning to uncover the complexity of interoception as well. Body awareness, as we define it here, is the subjective, phenomenological aspect of proprioception and interoception that enters conscious awareness, and is modifiable by noted mental activities.
How can we understand the construct of body awareness when paying increased attention to one's sensory features, be they appraised as comfortable or uncomfortable (i.e. pain), can be both adaptive and maladaptive? As chronic pain and depression are closely associated, findings from pain research are intriguingly similar to findings from depression research: self-awareness or the awareness of symptoms in depressed patients can be adaptive or maladaptive according to “distinct and incompatible modes of mind”; a ruminative self-focus appears to be maladaptive whereas focusing attention directly on immediately experienced feelings appears to be adaptive 
. These distinct modes of attention or self-reference can be dissociated through attentional training and identified by their distinct neural activation and connectivity in the brain 
. In pain research a parallel distinction between different modes of attention has been reported to be of prognostic key importance: Although pain seems to have an attention-redirecting function (from an external attention focus towards the pain region), hypervigilance is associated with worse chronic pain and seems to have a negative impact on cognitive function 
. A diffuse, emotion-based hypervigilance seems to be maladaptive, whereas “concrete somatic monitoring” or “sensory discrimination” of the precise details and present-moment characteristics in physical sensations appear to be adaptive 
. However, the traditional view of the construct of body awareness does not account for these “distinct and incompatible modes of mind” 
(or modes of attention). In the past, most research and clinical therapies were based on a conceptual understanding of body awareness that focused on the negative aspects of heightened body awareness as it overlaps with hypochondriasis and somatization. As new research suggests a potential value of interoceptive awareness of subtle bodily sensations, the traditional view of body awareness is challenged to recognize the complexity and ambiguity of this construct for psychosomatic research and therapies 
Yet another perspective on body awareness comes from academic disciplines outside of medical and behavioral sciences: contemporary philosophers 
, anthropologists 
, and linguists 
dedicate a growing body of literature to the theme of ‘embodiment’. Embodiment is understood as the felt sense of being localized within one's physical body 
and references the lived immediate experience of one's own body 
. Overcoming the constraints of Cartesian dualism, embodiment recognizes the role that our body plays in shaping our thinking and culture 
. “It has often been observed that modern Western society is typified by a certain ‘disembodied’ style of life…. A rising interest in finding ways to ‘return to the body,’ whether via exercise, Hatha yoga, body therapies, craft-work, or intimacy with nature, is but a reaction to this general trend toward a ‘decorporealized’ existence” 
. The growing public interest in methods for stress reduction that use interoceptive awareness i.e. of sensations related to respiration 
has led to a fascinating discourse among neuro-scientists, philosophers and spiritual teachers 
regarding the relationship of mind and body. Neurobiologist Edelman states: “Consciousness is embodied” 
. Going beyond Descartes' “cogito ergo sum” 
, a distinction is emphasized between thinking about the body and an ‘embodied presence’ in the body 
, a quality of immediate present-moment perception barely altered by beliefs and appraisal 
. From contemplative traditions, stress reduction methods borrow the practice of a particular attentional focus on subtle physical sensations, such as breathing, in order to relax into an ‘embodied’ awareness of mind-body integration 
with early evidence of some health benefits 
. It is precisely this mental movement beyond rational or irrational thinking about physical symptoms (interpreting, appraising and eventually ruminating with fearful hypervigilance) to a meta-cognitive (controlled and monitored) state of sustained present-moment attention to events within the body, often labeled as mindfulness 
, that is both the subject of philosophical discourse and a particular quality of inner body awareness 
Attempts to define, operationalize and measure the construct of ‘mindfulness’ have been facing challenges similar to body awareness 
. How does body awareness relate to mindfulness? The most comprehensive measure of mindfulness is based on a five-factor model with the following labels: 1) Non-reactivity to inner experience; 2) observing/noticing/attending to sensations/perceptions/thoughts/feelings; 3) Acting with awareness/automatic pilot/concentration/nondistraction; 4)describing/labeling with words; and 5) nonjudging of experience 
. Close observation of internal experience was defined as awareness of internally generated stimuli, such as sensations, cognition, and emotions. Thus, mindfulness encompasses more than awareness of inner sensations by including awareness of cognitive thoughts of any kind, which are not excluded from the body awareness construct 
. Moreover, the mindfulness facet of ‘Observing’ does not explicitly separate attention to internal (thoughts, feelings, sensations) from attention to external stimuli, such as sights, sounds, and smells 
. Thus, the scope of awareness is more narrowly defined in the construct of body awareness compared to mindfulness. However, mindfulness skills (sustained attention, concentration, non-reactivity, nonjudging of experience) are expected to play a major role in the shaping of body awareness.
A variety of therapeutic approaches in common use throughout the world claim to enhance body awareness 
including yoga 
, TaiChi, massage 
, Body-Oriented Psychotherapy 
, mindfulness based therapies/meditation 
, Feldenkrais 
, Alexander Method 
, Breath Therapy 
, and even mental training for athletic exercise and sport performance 
. These approaches are often categorized as mind-body approaches and/or manual therapies 
and enjoy a growing popularity in the Western world 
but frequently suffer from a lack of theory and methodologically weak research behind esoteric formulations and unfounded statements of benefits. Related therapeutic approaches offered by physical therapists in Sweden, Norway and the Netherlands explicitly carry names such as Body Awareness Therapy (BAT) or Body Awareness Program (BAP) 
. Generally speaking, all of these approaches aim to cultivate a particular quality of body awareness characterized not by its intensity (exaggerated or ignored) but by non-judgmental ‘mindfulness’, “a quality of non-elaborative awareness to current experience and a quality of relating to one's experience with an orientation of curiosity, experiential openness, and acceptance” 
. By today, they have been studied to a preliminary degree in patients with a variety of medical conditions including chronic low back pain 
, pelvic pain 
, fibromyalgia 
, musculoskeletal pain 
, chronic pain in general 
, disordered eating and obesity 
, irritable bowel syndrome 
, sexual abuse trauma 
, coronary artery disease 
, congestive heart failure 
, chronic renal failure 
, falls in the elderly 
, anxiety 
and depression 
. In order to determine whether body awareness indeed plays a role in these clinical areas and therapeutic approaches, we need a more precise understanding and reliable, valid measurement of this construct.
Cameron stated: “Bodily awareness is essential to the concept of self” 
. Although there is a great need to study practices of interoception and body awareness and their potential clinical benefits, few attempts have been made to measure changes in body awareness associated with such interventions 
, and to link intervention-related changes in body awareness to clinical outcomes.
Considerable research effort is underway to illuminate proprioceptive and interoceptive processes and their neural basis. This research is generally conducted in laboratories assessing singular perception modalities, such as perception of heart rate, gastric motility, respiratory load, joint angles, muscle tension and others. The topic of body awareness is further complicated by the fact that individuals do not experience atomistic “sensations”, e.g. complaining about a painful sensation in the neck, but, even within one modality, rather “perceptual wholes” in which bodily sensations are integrated into “gestalts” that also include affect, intention, values etc. Present moment, immediate experience is habitually integrated with narrative self-reference linking present with past experiences across time 
. Interoceptive afferents within uni-modular sensory systems are centrally integrated into a larger neural system that has been termed the Homeostatic Interoceptive System 
. There is very preliminary experimental support for the notion that interoceptive accuracy might have trait and state aspects that co-vary across modalities 
reflecting a general sensitivity for visceral processes. Objective measures (discussed below) allow for experimental studies but are restricted to laboratory settings and reflect singular aspects of a person's complex experience.
We feel that this research field could benefit from a multi-modal self-report measure that could be used with experimental protocols as well as in clinical settings and that could potentially discriminate between beneficial and maladaptive types of body awareness. Numerous self-report instruments of body awareness have been developed that exclusively measure anxiety related symptoms 
. Newer instruments reflect an increasingly complex conceptualization of body awareness 
. The purpose of this paper is to answer the following questions: Are we able to appropriately measure this ambiguous construct of body awareness by self-report in a clinical context outside of a laboratory? And, how is the construct of body awareness understood in existing measures?
We conducted a systematic review of self-report instruments attempting to measure body awareness with two aims: a) to review the instruments' psychometric properties and b) to further examine the understanding of the construct that underlies the various instruments and their dimensions queried. The review was used to explore the current understanding of the construct, to support this expanding field of research and to suggest next steps for further research development.
As a starting point, a multidisciplinary group of researchers (Katrina Carlsson; Jennifer Daubenmier; Eric Jacobson; Janet Kahn; Catherine Kerr; Wolf Mehling; Cynthia Price; Stephanie Shields; Jim Stephens.) engaged in research related to the construct developed a working definition of body awareness:
Body awareness is the perception of bodily states, processes and actions that is presumed to originate from sensory proprioceptive and interoceptive afferents and that an individual has the capacity to be aware of.
Body awareness includes the perception of specific physical sensations (e.g., awareness of heart activity; proprioception of limb position) as well as complex syndromes (e.g., pain; sense of relaxation; ‘somatic markers’ of emotions).
Body awareness is hypothesized as the product of an interactive and dynamic, emergent process that a) reflects complex afferent, efferent, forward and back-projecting neural activities, b) includes cognitive appraisal and unconscious gating, and c) is shaped by the person's attitudes, beliefs, experience and learning in a social and cultural context.
Our definition attempts to integrate some of the above summarized research and perspectives from primary care medicine, behavioral science, health psychology, cognitive neuroscience, anthropology, massage therapy, physical therapy, body-oriented psychotherapy, martial arts, Yoga, Feldenkrais, breath therapy and Rolfing.