Interoception, commonly defined as the sense of the physiologic condition of the body,1
and interoceptive awareness may play important mediating roles in self-rated health2
– particularly in the perception of pain.3
Pain is intimately entwined with emotions.5
Craig described the neurological pathways by which pain activates some of the same cortex areas as interoception does.7
The close similarities between pain and interoception in their neural connections and activated brain regions led Craig to the notion that pain could be viewed as a “homeostatic emotion.”8
Emotions include a felt, somatosensory aspect that may become conscious in interoceptive awareness.9
As with emotion regulation, attention regulation is a key element of interoceptive awareness. Given the close relationships between pain, emotion, and interoceptive awareness, further exploration of interoceptive awareness in a clinical pain population is warranted.
A pain patient can focus attention (eg, on her low back pain), in quite different ways: (1) ignore the pain (endurance);11
(2) focus on it with worry and anxiety-driven hypervigilance (fear-avoidance);12
or (3) focus on it with mindful attention.13
These different styles of attention or distraction, respectively, have been found to have a major impact on the perceived intensity of chronic pain.14
And psychologists studying the effect of mindfulness on emotions and pain have pointed out that:
[…] one problem in chronic pain is not only the pain itself, but […] the averting of attention from, the regions that give rise to painful sensations, either through deliberate distraction, or by thinking about the pain (conceptually) rather than experiencing the sensations directly.21
Attention Regulation thus appears to be a major element of interoception with potential applications for pain management. A recent study showed that focusing on sensory/discriminative aspects of experimental pain might be a useful pain regulation strategy when severe pain is expected.20
The authors suggested that directing attention in specific ways toward sensations of chronic pain may be a promising new way of coping with chronic pain and awaits longitudinal studies in a clinical setting.
Interoceptive awareness has been conceptualized in various ways using different terms (eg, somatic awareness, interoceptive awareness, body awareness [see a detailed discussion in Mehling et al]22
). In psychology and neuroscience, interoceptive awareness has commonly been defined as the sense of the physiological condition of the body.23
In clinical medicine, body awareness has been defined as the ability to recognize subtle body cues.24
In this study we are using Cameron’s conceptualization of interoception (with or without awareness) as “the afferent information that arises from anywhere and everywhere within the body …[involving] higher mental processes such as emotions, conscious awareness, and behavior.”25
This conceptualization broadens the former definition by including higher order psychological processes. In an attempt to integrate the various views from different disciplines, and following suggestions by other authors,26
in this study we use the term in the broader conceptualization by Cameron and consider this as interchangeable with earlier definitions of “body awareness.”27
Interoceptive awareness has been examined in its relationship to pain, primarily with objective measures, such as the heartbeat detection task, measuring the interoceptive accuracy of the perception of heartbeat sensations. A major limitation of this objective measure is its inability to detect changes that can be expected from mindfulness and other mind–body trainings.28
Interoceptive awareness includes changes in interoceptive-awareness qualities beyond accuracy,31
thus a self-report measure that taps into the subjectively experienced aspects of interoceptive awareness in mind–body interventions32
Furthermore, interoceptive awareness has been studied, mostly using pain paradigms of acute experimental pain. Few studies have examined interoceptive awareness and attention regulation with directing attention toward pain sensations in clinical pain patients15
(overview in Johnston et al20
). Clinical trials of mind–body therapies, such as mindfulness meditation, yoga, Tai Chi, and Feldenkrais, for patients with pain, including low back pain, have provided encouraging results for these approaches that claim to improve body awareness as one potential mechanism of action for their purported benefits (). However, to examine the latter assertion, a measure for body awareness or interoceptive awareness that has been validated with pain patients is needed.
Mind–body therapies purportedly enhancing body awareness and studied in clinical research that use pain as primary outcome
The Multidimensional Assessment of Interoceptive Awareness (MAIA) is a new 32-item multidimensional self-report instrument designed for use in research studies for which there is the need to measure key aspects of mind– body interaction, namely, interoceptive awareness.22
The initial development (focus groups and expert panel) and preliminary validation (field-test sample) of the MAIA was done primarily with individuals familiar with the concept of bodily awareness, either as students, patients, or instructors of therapeutic approaches that explicitly aim to enhance bodily awareness, including meditation,34
yoga, Tai Chi, and Feldenkrais.32
Eight MAIA scales were constructed to measure different modes of attention toward bodily sensations (including pain) with the goal of distinguishing between beneficial and maladaptive interoceptive attention styles. The initial item pool was based on therapists’ and patients’ focus groups and expert consensus using an initial operational definition for bodily awareness that was iteratively developed into a conceptual framework reflected in the eight scales. These scales of three to seven items each, were defined as follows:
- Noticing – awareness of uncomfortable, comfortable, and neutral body sensations
- Not Distracting – tendency not to ignore or distract oneself from sensations of pain or discomfort
- Not Worrying – tendency not to worry or feel emotional distress with sensations of pain or discomfort
- Attention Regulation – ability to sustain and control attention to body sensation
- Emotional Awareness – awareness of the connection between body sensations and emotional states
- Self-Regulation – ability to regulate psychological distress by attention to body sensations
- Body Listening – active listening to the body for insight
- Trusting – experiences of one’s body as safe and trustworthy.
The prefix “not” for the labels “Not Distracting” and “Not Worrying” is owed to our intention that, for every scale, higher scores mean higher levels of awareness. For further details, we refer readers to the original publication.22
Because several MAIA scales may contribute to the assessment of patients with pain and their pain-related emotions, coping styles, and interoceptive attention styles, and because the conceptual framework and specific items were designed to reflect awareness of pain, we decided to apply the MAIA scales and explore their performance among primary care patients who had experienced low back pain (LBP).
Measuring key aspects of interoceptive Attention Regulation may be essential to move forward research on therapies for chronic pain patients. The purpose of this study is twofold: (1) describe results of a confirmatory factor analysis of the scale structure and the psychometric characteristics of the MAIA in primary care patients with past or current LBP, including internal-consistency reliability, item-scale correlations, variability, and scale–scale correlations; and (2) explore the construct validity of the MAIA scales by comparing levels of self-reported interoceptive awareness between the mind–body therapy-naïve primary care patients with past or current LBP and mind–body therapy-experienced individuals from the original validation study22
and by examining correlations of the MAIA scales with several validity variables.