Terms such as body awareness, somatic awareness, or interoceptive awareness are used in many different ways in medicine, psychology, neuroscience, anthropology, philosophy, and popular discourse, often without precision or distinctive definitions, and generally with discipline-specific meanings and implications. Definitions for interoception may differ, for example, between psychophysiologists and neuroscientists. We attempt to provide more clarity for these constructs by integrating viewpoints and language from the multiple disciplines, for which mind-body processes and the interaction of mind and biology have become major research topics. This paper describes the systematic development of a new self-report instrument for these constructs.
Starting from a health science and clinical practice background with a particular interest in integrative pain management, we found that contradictory views exist in Western medicine regarding the value of body awareness. Much of the earlier literature considers a patient’s attentional focus on body symptoms as an expression of anxiety, depression, or somatization 
. For example, the terms body awareness
and somatic awareness
have been used in studies of anxiety and panic disorders to describe a cognitive attitude characterized by an exaggerated focus on physical symptoms, magnification (“somatosensory amplification”), rumination, and catastrophic outcome beliefs 
. Consequently, the numbers of perceived and presumed potentially distressing body sensations have served as markers for anxiety and somatization 
, and somatic or body awareness has commonly been viewed as maladaptive. (As the terms body awareness
and somatic awareness
are essentially synonymous, we will use only the simpler term body awareness
More recently, an alternate view of body awareness as potentially beneficial for health has emerged 
, for example, the ability to recognize subtle body cues 
, and accordingly a number of therapeutic approaches now aim deliberately to enhance body awareness. Clinical research has suggested health benefits of body awareness for patients with a variety of diagnoses (for a review see 
). Proponents of the body awareness construct as beneficial for health usually refer to a particular kind of awareness characterized by mindfulness
, nonjudgmental acceptance, and a sense of self grounded in experiencing physical sensations in the present moment, sometimes summarized as a sense of embodiment 
By differentiating aspects of body awareness, such as different modes of attention towards body sensations, we may be able to understand contradictory views of body awareness. Whether body awareness is beneficial or maladaptive may depend on “distinct and incompatible modes of mind” 
associated with brain functions that are habitually integrated but may be uncoupled after, for example, a few weeks of meditation 
. Focusing attention directly on immediately experienced feelings appears to be adaptive, whereas an abstract ruminative self-focus appears to be maladaptive 
. Learning to regulate one’s attention in specific ways may be a key feature of body awareness-enhancing practices and, therefore, a dimension to be differentiated within the body awareness construct. Similarly, enhanced body awareness by means of a specific form of attention regulation training has been used in a therapeutic approach to phantom pain. This training is termed “concrete somatic monitoring” or “sensory discrimination” 
of the detailed characteristics of physical sensations as opposed to a rather diffuse, emotion-based vigilance 
These findings and notions imply that different modes of attention and variations in the ability to regulate attention may explain seemingly contradictory interpretations of body awareness. A more differentiated view may help to overcome the ambiguity of the body awareness construct by discerning multiple dimensions within the construct, such as modes of attention 
, and relating these to established concepts in the biomedical literature, namely to proprioception, interoception, and mindfulness.
For the biomedical literature, a neuroscientific and physiological understanding of body awareness would presumably entail both proprioceptive and interoceptive awareness. Although most proprioceptive and interoceptive perception remains unconscious, proprioceptive awareness
refers to the conscious perception of joint angles and muscle tensions, of movement, posture, and balance 
; interoceptive awareness
refers to the conscious perception of sensations from inside the body that create the sense of the physiological condition of the body, such as heart beat, respiration, satiety, and the autonomic nervous system sensations related to emotions 
. The term interoception
was introduced 1906 by Sherrington 
and has had its own history of definitions, at times including proprioception 
or suggesting its inclusion 
, while other times it was clearly separated from proprioception as visceral perception. On the basis of newer neuroanatomy research, Craig redefined interoception as the sense of the physiological condition of the material body 
, which includes autonomic sensory nerve input from the entire body as well as pain and sensuous touch and is neuroanatomically distinct from proprioception.
Within the fast-growing literature on interoception, a body of research is emerging that links awareness of all internal physical sensations to regional brain activities, specifically in the somatotopically organized anterior insular cortex. These insula activities appear to provide a multilevel integrated metarepresentation of the state of the entire body and include the inner-body experience of emotions and pain 
. It has been experimentally demonstrated that the link between interoceptive awareness and physical sensations (e.g., of emotions) is a key element for affect regulation 
, decision making 
, and for the sense of self 
. Interindividual variations in interoceptive capacity have been found to be associated with right anterior insula cortical thickness, suggesting potential neuroplasticity effects of interoceptive awareness 
, an interpretation further supported by recent longitudinal studies of a mindfulness-based stress reduction intervention 
. Much of this research is related to interoceptive awareness as a key element in meditation and stress reduction 
and has become the subject of increasing research activities in recent years 
Although this research has led to a new understanding of how emotions 
and the perception of pain 
are related to interoception, it has to a large degree stayed away from key behavioral and cognitive aspects well-known in perception and psychological pain research, such as appraisal and beliefs (e.g. catastrophizing), attention regulation (e.g. ignoring, distraction), behavior (e.g. avoidance, coping), anticipation, and past experience. Leading neuroscientific models of emotion and interoception only tangentially mention these psychological aspects as attribution processes 
. Yet, interoceptive awareness is a product of conscious perception, and as such is a psychobiological process that is modified by complex bidirectional interactive evaluative functions, which are influenced by appraisal, beliefs, past experience, expectations, and contexts. Like the psychophysiologist Cameron 
and others 
, we propose to broaden the conceptualization of interoceptive awareness as commonly used in neuroscience to one that includes these interpretational and organizing aspects of perception.
In summary, a more complex, multidimensional view of body awareness has emerged in recent years, which distinguishes modes of attention such as thinking about the body and presence in the body. The human capacity to move from thinking about physical symptoms (interpreting, appraising, and eventually ruminating with fearful hypervigilance) to a state of perceptual presence within the body, often labeled as mindfulness
, is both the subject of philosophical discourse and a particular quality of body awareness 
. Reflecting the complexity of the construct, Mehling et al. operationally defined body awareness as the sensory awareness that originates from the body’s physiological states, processes (including pain and emotion), and actions (including movement), and functions as an interactive process that includes a person’s appraisal and is shaped by attitudes, beliefs, and experience in their social and cultural context 
. Dimensions of critical importance have been laid out in 
. This conceptualization encompasses both proprioceptive and interoceptive awareness from psycho-physiological as well as neuroscientific viewpoints, is biologically based on proprioceptive and interoceptive neural activity, and includes well-established cognitive and behavioral aspects of perception.
Considering the potential clinical importance of the construct, particularly as a mediator of therapies for painful conditions, very few attempts have been made to date to measure body awareness, including whether it changes in response to therapies claiming to enhance it 
; and even fewer attempts have been made to link intervention-related changes in body awareness to clinical outcomes 
Objective measures for the accuracy of proprioceptive and interoceptive awareness have been increasingly developed and applied in recent years. Proprioceptive awareness has been studied by objective measures, such as joint repositioning angles or biofeedback devices, and applied in research on Tai Chi 
and yoga 
, but not on meditation. Objective measures for interoceptive awareness have been widely used in an organ-specific fashion with heart-rate detection accuracy tasks, respiratory resistance threshold detection and discrimination tasks, and the detection of intestinal stimuli. However, none of these has been shown sensitive to changes by body awareness-enhancing approaches, with the exception of the heart rate detection task in meditators when subjected to dramatic arousal by intravenous infusions with adrenaline 
. So far it is unclear whether these organ-specific methods are appropriate to show training-related changes in interoceptive or body awareness 
. Interoceptive afferents within unimodular sensory systems are centrally integrated into a larger neural system that has been termed the homeostatic interoceptive system 
, and preliminary studies support the notion that interoceptive awareness may reflect a general sensitivity for visceral processes with trait and state aspects that covary across modalities 
. Objective measures allow for experimental studies, but are restricted to laboratory settings and reflect singular aspects of a person's complex experience.
A recent review of existing body awareness questionnaires and their psychometric properties showed that most questionnaires were based on the earlier conceptualization of body awareness as proxy measures for anxiety, lacked systematic development, were unidimensional, and missed key domains that might help discern between adaptive and maladaptive aspects of body awareness 
. Commonly used measures of the closely related mindfulness construct include a much broader awareness focus on thoughts and exteroceptive stimuli and lack a more specific sensory focus on inner body sensations.
Therefore, we used a mixed methods approach to systematically develop a self-report instrument for experimental interoception research and for assessment of mind-body therapies. The study and all procedures were approved by the university’s Institutional Review Board. The paper is organized into six main parts: (a) Concept and Item Development, (b) Field Test, (c, d, and e) three Construct Validity sections, and (f) Overall Discussion. A figure depicting the sequence is provided for ease of understanding the complexity of the approach (). Because of our iterative mixed-methods approach 
, the concepts evolved during scale development. Thus this paper describes modifications to the conceptual framework throughout the process.
Iterative Sequence of Development and Testing of the MAIA.