The Multidimensional Assessment of Interoceptive Awareness (MAIA)

The Multidimensional Assessment of Interoceptive
Awareness (MAIA)
Wolf E. Mehling1*, Cynthia Price2, Jennifer J. Daubenmier1, Mike Acree1, Elizabeth Bartmess3,
Anita Stewart4
1 University of California San Francisco, Osher Center for Integrative Medicine, San Francisco, California, United States of America, 2 University of Washington,
Biobehavioral Nursing and Health Systems, Seattle, Washington, United States of America, 3 University of California San Francisco, Center for AIDS Prevention Studies, San
Francisco, California, United States of America, 4 University of California San Francisco, Institute for Health & Aging, Center for Aging in Diverse Communities, San
Francisco, California, United States of America
Abstract
This paper describes the development of a multidimensional self-report measure of interoceptive body awareness. The
systematic mixed-methods process involved reviewing the current literature, specifying a multidimensional conceptual
framework, evaluating prior instruments, developing items, and analyzing focus group responses to scale items by
instructors and patients of body awareness-enhancing therapies. Following refinement by cognitive testing, items were
field-tested in students and instructors of mind-body approaches. Final item selection was achieved by submitting the field
test data to an iterative process using multiple validation methods, including exploratory cluster and confirmatory factor
analyses, comparison between known groups, and correlations with established measures of related constructs. The
resulting 32-item multidimensional instrument assesses eight concepts. The psychometric properties of these final scales
suggest that the Multidimensional Assessment of Interoceptive Awareness (MAIA) may serve as a starting point for research
and further collaborative refinement.
Citation: Mehling WE, Price C, Daubenmier JJ, Acree M, Bartmess E, et al. (2012) The Multidimensional Assessment of Interoceptive Awareness (MAIA). PLoS
ONE 7(11): e48230. doi:10.1371/journal.pone.0048230
Editor: Manos Tsakiris, Royal Holloway, University of London, United Kingdom
Received June 1, 2012; Accepted September 24, 2012; Published November 1, 2012
Copyright: ß 2012 Mehling et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This research was supported by National Institutes of Health (NIH) grants K23-AT002298 and R21-AT004467 awarded to WM, K01AT004199 awarded to
JD, K01AT003459 awarded to CK from the National Center For Complementary & Alternative Medicine (NCCAM). The funders had no role in study design, data
collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: [email protected]
Introduction distressing body sensations have served as markers for anxiety and
somatization [2], and somatic or body awareness has commonly
Terms such as body awareness, somatic awareness, or interoceptive been viewed as maladaptive. (As the terms body awareness and
awareness are used in many different ways in medicine, psychology, somatic awareness are essentially synonymous, we will use only the
neuroscience, anthropology, philosophy, and popular discourse, simpler term body awareness.).
often without precision or distinctive definitions, and generally More recently, an alternate view of body awareness as
with discipline-specific meanings and implications. Definitions for potentially beneficial for health has emerged [3], for example,
interoception may differ, for example, between psychophysiolo- the ability to recognize subtle body cues [1], and accordingly a
gists and neuroscientists. We attempt to provide more clarity for number of therapeutic approaches now aim deliberately to
these constructs by integrating viewpoints and language from the
enhance body awareness. Clinical research has suggested health
multiple disciplines, for which mind-body processes and the
benefits of body awareness for patients with a variety of diagnoses
interaction of mind and biology have become major research
(for a review see [4,5]). Proponents of the body awareness
topics. This paper describes the systematic development of a new
construct as beneficial for health usually refer to a particular kind
self-report instrument for these constructs.
of awareness characterized by mindfulness, nonjudgmental accep-
Starting from a health science and clinical practice background
tance, and a sense of self grounded in experiencing physical
with a particular interest in integrative pain management, we
sensations in the present moment, sometimes summarized as a
found that contradictory views exist in Western medicine
sense of embodiment [6–8].
regarding the value of body awareness. Much of the earlier
literature considers a patient’s attentional focus on body symptoms By differentiating aspects of body awareness, such as different
as an expression of anxiety, depression, or somatization [1]. For modes of attention towards body sensations, we may be able to
example, the terms body awareness and somatic awareness have been understand contradictory views of body awareness. Whether body
used in studies of anxiety and panic disorders to describe a awareness is beneficial or maladaptive may depend on ‘‘distinct
cognitive attitude characterized by an exaggerated focus on and incompatible modes of mind’’ [9–11] associated with brain
physical symptoms, magnification (‘‘somatosensory amplifica- functions that are habitually integrated but may be uncoupled
tion’’), rumination, and catastrophic outcome beliefs [2]. Conse- after, for example, a few weeks of meditation [12]. Focusing
quently, the numbers of perceived and presumed potentially attention directly on immediately experienced feelings appears to
PLOS ONE | www.plosone.org 1 November 2012 | Volume 7 | Issue 11 | e48230

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be adaptive, whereas an abstract ruminative self-focus appears to behavior (e.g. avoidance, coping), anticipation, and past experi-
be maladaptive [13]. Learning to regulate one’s attention in ence. Leading neuroscientific models of emotion and interoception
specific ways may be a key feature of body awareness-enhancing only tangentially mention these psychological aspects as attribu-
practices and, therefore, a dimension to be differentiated within tion processes [49]. Yet, interoceptive awareness is a product of
the body awareness construct. Similarly, enhanced body aware- conscious perception, and as such is a psychobiological process
ness by means of a specific form of attention regulation training that is modified by complex bidirectional interactive evaluative
has been used in a therapeutic approach to phantom pain. This functions, which are influenced by appraisal, beliefs, past
training is termed ‘‘concrete somatic monitoring’’ or ‘‘sensory experience, expectations, and contexts. Like the psychophysiolo-
discrimination’’ [14] of the detailed characteristics of physical gist Cameron [50] and others [51], we propose to broaden the
sensations as opposed to a rather diffuse, emotion-based vigilance conceptualization of interoceptive awareness as commonly used in
[2,15]. neuroscience to one that includes these interpretational and
These findings and notions imply that different modes of organizing aspects of perception.
attention and variations in the ability to regulate attention may In summary, a more complex, multidimensional view of body
explain seemingly contradictory interpretations of body awareness. awareness has emerged in recent years, which distinguishes modes
A more differentiated view may help to overcome the ambiguity of of attention such as thinking about the body and presence in the
the body awareness construct by discerning multiple dimensions body. The human capacity to move from thinking about physical
within the construct, such as modes of attention [4], and relating symptoms (interpreting, appraising, and eventually ruminating
these to established concepts in the biomedical literature, namely with fearful hypervigilance) to a state of perceptual presence within
to proprioception, interoception, and mindfulness. the body, often labeled as mindfulness [9,52,53], is both the subject
For the biomedical literature, a neuroscientific and physiological of philosophical discourse and a particular quality of body
understanding of body awareness would presumably entail both awareness [54–56]. Reflecting the complexity of the construct,
proprioceptive and interoceptive awareness. Although most Mehling et al. operationally defined body awareness as the sensory
proprioceptive and interoceptive perception remains unconscious, awareness that originates from the body’s physiological states,
proprioceptive awareness refers to the conscious perception of joint processes (including pain and emotion), and actions (including
angles and muscle tensions, of movement, posture, and balance movement), and functions as an interactive process that includes a
[16]; interoceptive awareness refers to the conscious perception of person’s appraisal and is shaped by attitudes, beliefs, and
sensations from inside the body that create the sense of the experience in their social and cultural context [4]. Dimensions
physiological condition of the body, such as heart beat, respiration, of critical importance have been laid out in [4,5]. This
satiety, and the autonomic nervous system sensations related to conceptualization encompasses both proprioceptive and intero-
emotions [17–20]. The term interoception was introduced 1906 by ceptive awareness from psycho-physiological as well as neurosci-
Sherrington [21] and has had its own history of definitions, at entific viewpoints, is biologically based on proprioceptive and
times including proprioception [19] or suggesting its inclusion interoceptive neural activity, and includes well-established cogni-
[17], while other times it was clearly separated from proprioceptive and behavioral aspects of perception.
tion as visceral perception. On the basis of newer neuroanatomy Considering the potential clinical importance of the construct,
research, Craig redefined interoception as the sense of the particularly as a mediator of therapies for painful conditions, very
physiological condition of the material body [18], which includes few attempts have been made to date to measure body awareness,
autonomic sensory nerve input from the entire body as well as pain including whether it changes in response to therapies claiming to
and sensuous touch and is neuroanatomically distinct from enhance it [57]; and even fewer attempts have been made to link
proprioception. intervention-related changes in body awareness to clinical
Within the fast-growing literature on interoception, a body of outcomes [58].
research is emerging that links awareness of all internal physical Objective measures for the accuracy of proprioceptive and
sensations to regional brain activities, specifically in the somato- interoceptive awareness have been increasingly developed and
topically organized anterior insular cortex. These insula activities applied in recent years. Proprioceptive awareness has been studied
appear to provide a multilevel integrated metarepresentation of by objective measures, such as joint repositioning angles or
the state of the entire body and include the inner-body experience biofeedback devices, and applied in research on Tai Chi [59,60]
of emotions and pain [22]. It has been experimentally demon- and yoga [61], but not on meditation. Objective measures for
strated that the link between interoceptive awareness and physical interoceptive awareness have been widely used in an organ-
sensations (e.g., of emotions) is a key element for affect regulation specific fashion with heart-rate detection accuracy tasks, respira-
[23,24], decision making [23,25], and for the sense of self [26–29]. tory resistance threshold detection and discrimination tasks, and
Interindividual variations in interoceptive capacity have been the detection of intestinal stimuli. However, none of these has been
found to be associated with right anterior insula cortical thickness, shown sensitive to changes by body awareness-enhancing
suggesting potential neuroplasticity effects of interoceptive aware- approaches, with the exception of the heart rate detection task
ness [30,31], an interpretation further supported by recent in meditators when subjected to dramatic arousal by intravenous
longitudinal studies of a mindfulness-based stress reduction infusions with adrenaline [62,63]. So far it is unclear whether these
intervention [32,33]. Much of this research is related to organ-specific methods are appropriate to show training-related
interoceptive awareness as a key element in meditation and stress changes in interoceptive or body awareness [64]. Interoceptive
reduction [34–36] and has become the subject of increasing afferents within unimodular sensory systems are centrally inte-
research activities in recent years [23,30,37–42]. grated into a larger neural system that has been termed the
Although this research has led to a new understanding of how homeostatic interoceptive system [18,65], and preliminary studies
emotions [27,40,43–46] and the perception of pain [47,48] are support the notion that interoceptive awareness may reflect a
related to interoception, it has to a large degree stayed away from general sensitivity for visceral processes with trait and state aspects
key behavioral and cognitive aspects well-known in perception and that covary across modalities [66–68]. Objective measures allow
psychological pain research, such as appraisal and beliefs (e.g. for experimental studies, but are restricted to laboratory settings
catastrophizing), attention regulation (e.g. ignoring, distraction), and reflect singular aspects of a person’s complex experience.

MAIA
A recent review of existing body awareness questionnaires and 2. As discussed above, the quality of attention was seen as a key
their psychometric properties showed that most questionnaires dimension that should enable us to distinguish beneficial and
were based on the earlier conceptualization of body awareness as maladaptive forms of body awareness It was differentiated into
proxy measures for anxiety, lacked systematic development, were three subdomains: (a) The intensity of attention along a bipolar
unidimensional, and missed key domains that might help discern continuum – ranging from paying attention to sensations (an
between adaptive and maladaptive aspects of body awareness [4]. active response to the perception of sensations) on one end to
Commonly used measures of the closely related mindfulness distracted avoidance, ignoring and suppression of perceptions,
construct include a much broader awareness focus on thoughts on the other end - is a key factor, e.g., in the perception of pain
and exteroceptive stimuli and lack a more specific sensory focus on sensations [73–75]. (b) The self-efficacy of attentional control,
inner body sensations. or the individual’s confidence in the ability to focus on a
Therefore, we used a mixed methods approach to systematically sensation and sustain or control the mode of attention, is
develop a self-report instrument for experimental interoception increasingly studied with mind-wandering, and it can be
research and for assessment of mind-body therapies. The study improved by mind-body interventions [76,77]. (c) The mode of
and all procedures were approved by the university’s Institutional attention describes how an individual pays attention to a
Review Board. The paper is organized into six main parts: (a) sensation, whether her attention is more in a mode of (i)
Concept and Item Development, (b) Field Test, (c, d, and e) three thinking about, reflecting on, judging, analyzing her sensation,
Construct Validity sections, and (f) Overall Discussion. A figure with the extreme of ruminating, or (ii) nonjudgmental,
depicting the sequence is provided for ease of understanding the immediate experience and sensory awareness of that sensation,
complexity of the approach (Figure 1). Because of our iterative with mindful presence as the polar opposite to rumination.
mixed-methods approach [69], the concepts evolved during scale This second dimension reflects a process component of body
development. Thus this paper describes modifications to the awareness, the active act of paying attention, which modifies,
filters, or augments the sensory input from the body and is
conceptual framework throughout the process.
related to the broader concept of mindfulness.
Part 1: Concept and Item Development 3. The attitude of interoceptive awareness refers to two domains
that describe how individuals relate to bodily cues. (a) Trusting
As the common view of interoceptive awareness rarely includes or viewing bodily sensations as helpful for decision-making is
any aspects of interpretation or organization of perception, and as an important component of chronic pain management [78]
no general consensus exists in the scientific literature regarding the and the sense of self [18]. (b) Worry and catastrophizing about
body awareness construct, the first phase was to refine the bodily cues are well-known major psychological attitudes
multidimensional conceptual framework and develop a set of items modifying the perception, e.g., of pain [79–81]. This dimension
reflecting its dimensions. Development of this framework and was understood as a general trait-like bias towards appraisal of
items was an iterative process involving six steps: (a) initial the perceived sensation and a modifier of the perceived
conceptual framework and item pool, (b) focus groups of sensations, a second key trait, relatively stable but potentially
instructors and patients to review concepts, (c) expert panel review modifiable by targeted therapeutic interventions. Its effect on
of concepts and items, (d) second focus group with instructors and perceived sensations was thought to be mediated by the mode
patients to review concepts and items, (e) analysis of all results, of attention (2c) [82,83].
revision of framework and items by research team, and (f) pretest 4. Mind-body integration was viewed as a goal inherent in mind-
of items and analysis to prepare for field testing. body therapies that can be experienced in two subdomains: (a)
as emotional awareness, the awareness that certain physical
1. Initial Conceptual Framework and Item Pool sensations are the sensory aspect of emotions (as in the theory
The initial conceptual framework had previously been devel- of ‘‘somatic markers’’ [27,84]); or (b) as an overall felt sense of
oped in an iterative process [4] and included four dimensions with an ‘‘embodied self,’’ representing a second-order perception of
subdimensions. In their sequential order, these may be viewed as sensations that contains within it a felt sense of the
developmental qualities associated with ascending levels of body interconnectedness of mental, emotional, and physical process-
awareness [5]. As it can be expected that each dimension would es as opposed to a disembodied sense of alienation and of being
correlate differently with other psychological constructs, measur- disconnected from one’s body [26,85,86].
ing these dimensions reliably and separately may enhance our Using this framework as well as recent literature and
understanding of (a) processes of mind-body interaction (e.g. which investigator clinical experience, we compiled an initial item pool
dimensions affect pain perception), (b) variations in aspects of body of 306 items from twelve full and 10 partial body-awareness-
awareness among individuals and groups, and (c) the appropri- relevant scales and subscales reviewed previously [4].
ateness of targeted therapeutic interventions.
1. The awareness of body sensations includes the ability to 2. Focus Group 1: Instructors’ and Patients’ Review of
identify inner sensations and to discern subtle bodily cues Concepts
indicating varying functional states of the body and the We conducted focus groups to obtain input from leading senior
emotional/physiological state. This dimension was seen as instructors of body awareness therapies, including mindfulness
the primary sensory, physiological aspect of body awareness. meditation, yoga, Tai Chi, Feldenkraı̈s, Alexander technique,
Four subdomains were distinguished: (a) sensations of distress, breath therapy, and Somatic Experiencing, and from patients who
worry, pain, and tension; (b) sensations of well-being; (c) neutral received treatment from these instructors. Instructor and patient
or ambiguous sensations; and (d) an affective aspect of these focus groups were held separately; both instructors and patients
sensations, such as bothersomeness. The affect component of a were recruited to attend two focus groups, the first to review and
body sensation was understood as resulting from early develop the concepts (FG-1), and the second to review items in
preconscious [70,71] or secondary, evaluative appraisal [72]. relation to the concepts (FG-2). All focus group sessions were
moderated by an independent professional moderator, digitally

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Figure 1. Iterative Sequence of Development and Testing of the MAIA.

doi:10.1371/journal.pone.0048230.g001
recorded, and transcribed verbatim. Details on recruitment and well the item could capture changes as a result of their particular
content are described elsewhere [5]. therapeutic modality. They also were asked to cross out or revise
In the first set of focus groups (FG-1), the conceptual framework any items they did not like, write new items, or suggest moving an
(defined above) was provided for reference (see details in [4]). The item to another dimension. At the meeting, for each dimension,
discussion focused on which dimensions were considered most individual items favored by 3 or more instructors were discussed as
important for their practice, and whether any dimensions were to how well they reflected the dimension, and how well these items
missing or needed modification. captured any changes that might occur in practice.
In FG-1 analysis, a table was organized by dimensions and After the meeting, each instructor’s rating of relevance and
subdimensions, including new subdimensions identified in FG-1. likelihood to change was tabulated and summarized in a table,
For each subdimension, items from the original item pool and new including open-ended suggestions. Items with clearly poor ratings
items generated by the focus groups were listed along with relevant were dropped, and items with the best ratings were highlighted.
instructor and patient phrases. The research team reviewed these New items suggested by instructors were added for a total of 133
and modified the conceptual framework and items (see details in items. The research team reviewed the instructors’ item ratings
[87]). The result was a revised conceptual framework and a list of and comments and dropped items that were considered redundant
67 items from older instruments and 101 items or item stems from or problematic, or that were uniformly rejected. The team created
patients and instructors, organized by concepts or dimensions. a revised conceptual framework and a set of 119 items for review
by the patients.
3. Expert Panel Review of Framework and Items Patient FG-2: Prior to the meeting, participants were mailed the
The study team and a group of invited experts held an all-day revised framework and items and asked to review the items, revise
conference to further refine the conceptual framework, review and or delete items, and write new ones. In addition, they were asked
rearrange items based on how well they fit with the revised to individually rate each item using structured responses ranging
conceptual framework, and create additional items. from 0 (useless question) to 5 (perfect question) for how well the
Prior to the meeting, the expert group was sent the conceptual item captured what they had learned from practicing their
framework and the items including the patient and instructor respective method. During the meeting, each dimension and the
quotes with guidelines for selecting the five best items from each items with the highest ratings were discussed by the group and new
dimension, and for modifying items or writing new ones as items were created.
necessary: (a) item language should be such that it would make
sense to everyone, including body-work-naı̈ve individuals; (b) items 5. Final Analysis of Focus Group Results by Research
should be able to capture any changes that might happen in Team to Refine Framework and Items
individuals who receive training in these modalities; (c) breath The research team synthesized the results from the focus groups
should be reflected in each dimension if possible, as improving and each patient’s item ratings and open-ended suggestions, and
breath awareness was uniformly seen by practitioners in the first revised items based on the patients’ comments. Using a structured
focus group as a key element of all approaches [5]; (d) items should rating form, each team member individually indicated for each
reflect positive, negative, and neutral sensations; and (e) positively item whether it should be included in the next phase (cognitive
worded items were preferred. pretest) and suggested alternative item wordings. A summary of
Examples of the topics discussed at the meeting were conceptual these suggestions used by the team, along with guidelines from the
distinctions among catastrophizing, distracting, ruminating, sup- earlier expert panel (Section 3 above) to finalize a set of 66 items
pressing, and avoidance; thinking vs. feeling; whether to split for pretesting. Probes were designed for items that were potentially
directing attention from sustaining attention; distinction between confusing, difficult to understand, or otherwise problematic.
ability to feel sensations and capacity to use that information as a Multiple options for format, instructions, and response scales
behavior; whether trusting versus catastrophizing or controlling were reviewed at this time. After selecting 3–4 possible response
versus allowing are separate dimension; how to write items that are choice sets on a 0–5 response scale, we created sample
relevant to totally naı̈ve respondents and social desirability issues. ‘‘questionnaires’’ with the different options and their respective
At the end of the meeting, the group reached consensus as to instructions. We decided to pretest the items using a format in
whether the structure and definitions in the revised conceptual which respondents would rate ‘‘how true’’ an item was for them.
framework adequately reflected the various issues discussed. After However, after a few pretests, this proved to be difficult, so we
the meeting, the research team reviewed all comments and the changed to ‘‘how often’’ with endpoints labeled 0 = never and
revised framework and organized the 121 remaining and new 5 = always.
items according to the new framework.
6. Pretest of Items
4. Focus Group 2: Instructors’ and Patients’ Review of Cognitive interview testing refers to in-depth interviews
Questionnaire Items designed to assess respondents’ understanding of questions and
The goal of the second set of focus groups (FG-2), with specific terms, and to identify difficulties with the response choices.
instructors first and patients thereafter, was to review the revised We designed the pretest to consist of standard administration of all
conceptual framework and item pool, to improve item language 66 items followed by in-depth probes for a subset of 28 items
and create new items. considered likely to be misinterpreted or otherwise problematic on
Instructor FG-2: Prior to the meeting, the revised framework and the basis of patient and instructor ratings and comments. Probes
items were mailed to participants with a request to rate each item were developed to determine whether respondents understood the
using 0–5 structured response choices according to (a) how intended meaning of specific words or phrases; whether similar
relevant the item was to its hypothesized dimension, and (b) how questions were perceived as redundant; whether questions were

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offensive; to identify the cognitive processes used in responding; subdimensions: (a) emotional awareness, the awareness that
and to describe examples from respondents’ experience. For certain physical sensations are the sensory aspect of emotions;
example, the item ‘‘I notice when I am uncomfortable in my (b) self-regulation of emotions, sensations, and behavior
body’’ was probed to query ‘‘What does the phrase ‘uncomfortable (developed in the focus groups); and (c) ability to feel a sense
in your body’ mean to you?’’ Most probes depended on the of an embodied self, representing a sense of the interconnec-
response to the item. tedness of mental, emotional, and physical processes as
We recruited a convenience sample of 16 patients and staff from opposed to a disembodied sense of alienation and of being
the University Medical Center and the School of Medicine and of disconnected from one’s body [26,85,86].
individuals known to the study team, including 6 patients with
chronic pain, 5 ‘‘body awareness-naı̈ve’’ and 5 ‘‘body awareness-
experienced’’ staff. The pretest sample was primarily female (15/ Part 2: Field Test
16), age ranged from 23 to 72 (mean = 44), education ranged from
Phase 2 was to conduct a field test of the preliminary survey and
high school only to graduate school (4 high school or some college,
conduct psychometric analyses to identify a final set of scales. We
10 college degree, 2 post-graduate). Pretest interviews were audio
describe here the survey and methods of data collection, the
recorded.
sampling and recruitment methods, and methods of analysis.
All pretest data including responses to probes were summarized
Results of the field test are then described, including model testing
for the 66 items, including information on the distribution of
and the final scales, internal consistency reliability, descriptive
responses to each item. Seven items were dropped, and several
statistics, and scale-scale intercorrelations.
items were revised or split into two items, resulting in 63 items
Respondents completed a one-time self-administered online
retained for the field test.
survey using Survey Gizmo [88]. The survey consisted of 63 items
assessing the concepts described above, demographic questions,
7. Resulting Conceptual Framework for Field Test and measures of related constructs.
The result of this iterative process was the following multidi-
mensional conceptual framework, with 5 overarching dimensions
Methods: Participants
and a total of 13 subdimensions. It reflects a slight modification of
Eligibility. Our goal was to sample students and instructors
the initial framework described in Part 1.1.
experienced with at least one of the following therapies that
1. Awareness of body sensations includes awareness of negative, include body awareness components: meditation/mindfulness,
positive, and neutral sensations, with no subdimensions or yoga, Tai Chi, Feldenkraı̈s Method, Alexander Technique, Breath
distinction as to whether these are perceived actively or Therapy, Massage (as professional training or practice only), or
passively. Sensations of breath were added as neutral body-oriented psychotherapy (including Somatic Experiencing,
sensations. Items from the original subdimension of affect were Hakomi, and Rosen). To be eligible, the minimum requirement
moved to become a subdimension of Emotional Reaction to was at least 20 hours of exposure to formal training/instruction/
Bodily Sensations. therapy sessions.
Sampling design. To obtain variability in the sample, to
2. Emotional reaction and attentional response to sensations
examine whether there is a ‘‘developmental’’ aspect to learning
includes four subdomains: (a) the affective response to a
these skills, and to conduct known-groups validity analyses by
sensation, expressed as its bothersomeness or pleasantness
comparing means across experience levels, we aimed for about
(moved from Dimension 1); (b) suppressing, ignoring, or
half of the sample to comprise individuals with extensive
avoiding perceptions of sensations such as by distracting
experience and half with less experience. We defined highly
oneself; (c) narrative, judgmental awareness that ‘‘analyzes’’
experienced as instructors with at least 5 years teaching experience in
sensation, including worrying that something is wrong; and (d)
a mind-body therapy, and less experienced as students with at least 20
present-moment awareness with nonjudgmental awareness of
hours formal training/experience or instructors with less than 5
sensations, i.e., a mindful presence. This reflects a substantial
years of teaching experience in the mind-body therapy they were
refinement of the original Dimension 2 labeled Quality of
most familiar with. We aimed for a balance across the categories of
Attention.
therapies.
3. Capacity to regulate attention pertains to various ways of To identify those with extensive and less experience, we decided
controlling one’s attention as an active regulatory process. to recruit people from all of the types of therapies to complete the
These include the ability to (a) sustain awareness, (b) actively survey, and determine the level of experience at the time they
direct attention to various parts of the body, (c) narrow or started the survey. This allowed us to fill cells as surveys were
widen the focus of attention, and (d) allow sensations without completed depending on their answers to the experience questions.
trying to change them. This is a new dimension based on To ensure that our final sample included people from multiple
splitting the original ‘‘quality of attention.’’ Attentional control traditions and approximately equal numbers of more and less
was originally a subdimension of Dimension 2, Quality of experienced participants, our survey automatically capped partic-
Attention, and now distinguishes several ways in which one can ipation based on pre-set categories.
control attention. Recruitment. For each of the therapy categories, we
4. Trusting body sensations, beliefs about importance of sensa- identified instructors, practitioners, and teachers, a group hence-
tions reflects the extent to which one views awareness of bodily forth characterized as teachers. We used listservs suggested by our
sensations as helpful for decision making or health. This single regional experts to contact members around the world who
dimension was developed during the focus groups from items forwarded the request to their peers. Our e-mail recruitment letter
pulled from the original Dimensions 3 (Attitude of Interocep- explained the study and said that we were seeking ‘‘serious
tive Awareness) and 4. students and experienced teachers’’ to complete our survey.
5. Mind-body integration (original Dimension 4) is viewed as the We explained why we were interested in somatic awareness, as a
ultimate goal of mind-body therapies and includes three key element to many mind-body practices, and provided a link to

MAIA
our website where potential participants could determine if they did not impose a hierarchical structure on the clustering, so that
were eligible. Flyers describing the same information and variables could be assigned to clusters of which they were not
providing the website address were posted at local Bay Area yoga originally a part. Cluster components, unlike principal compo-
studios and meditation centers. We asked the teachers contacted nents, are not orthogonal because they are derived from principal
individually or via listserv to pass information on to students they components analyses of different subsets of items, rather than from
thought might want to participate and attached a flyer that they the whole set. The output of PROC VARCLUS looks like what
could post for others to see or forward by e-mail. many investigators appear to be seeking with factor analysis: a
Once individuals logged onto the website, they were asked to partition of items into disjoint clusters, listing the squared
select the mind-body therapy they were most familiar with. Next correlation of each item with its own cluster and with the next
they were asked whether their experience in that therapy was as a closest cluster. The structure matrix looks very much like that from
student (i.e. learning the practice or receiving the therapy), factor analysis; the scoring coefficient matrix differs in having 0s
teacher, or both. Those who responded ‘‘student’’ were then asked for the items not in a given cluster. Our experience with PROC
how many hours of formal training/instruction/therapy they had, VARCLUS supports the recommendation and is discussed in
and those with less than 20 hours were ineligible. Those who more detail below.
responded ‘‘teacher’’ were asked how many years of teaching As input to PROC VARCLUS, we imputed a covariance
experience they had with the method. matrix using the EM algorithm via SAS PROC MI. For the
Based on these responses, the program automatically classified sample size we conservatively used the smallest N for any pair of
eligible individuals into the two groups of less experienced or items, 309.
highly experienced and created eight categories, for one of two Iterative decision process. The methods applied in the
levels of experience for each of four types of therapy. Initial analyses were part of an iterative decision process with elimination
participation caps for the four therapy groups were 100 individuals of items that performed poorly during various steps of the analyses
for meditation/mindfulness, 100 for yoga or Tai Chi, 50 for and decisions about the final number of scales that would provide
massage, and 50 for Feldenkraı̈s, Alexander, breath therapy, or a good model. Because our initial conceptual framework was
body-oriented psychotherapy. In each therapy group, additional hierarchical, with some dimensions of awareness having compo-
caps were put in place to obtain equal sized groups of less or highly nents or subdimensions, we also had to determine whether to
experienced individuals. combine any subscales into combined summary scales or retain
them as subscales. Conceptually, we had defined 13 possible
Methods: Analysis Plan subscales (see final conceptual framework above) reflecting all sub-
Our analyses aimed to identify a set of scales and items from the dimension in the framework.
pool of 63 items that would provide a good fit to the data. As there Our VARCLUS and CFA analyses were the primary approach
is no ‘golden rule’ for determining the number of factors or to identifying the final number of scales. However, we also
number of items [89], we took a common-sense approach, seeking examined correlations among all MAIA subscales (high correla-
a number of subscales that was neither too large nor too small, tions indicated overlapping constructs), item-scale correlations
each comprising not too many items nor too few. Theory dictated (item-scale correlations corrected for overlap were at least .30), and
that the scales not be independent, but neither did we want them internal-consistency, and patterns of correlations between each
too highly correlated. MAIA scale and the validity measures described below (completely
Item analysis. We began our pruning operation with an redundant patterns of correlation indicated overlapping con-
inspection of item means, standard deviations, and correlations. structs). The number of potential subscales multiplied by these
From this item analysis we eliminated two highly skewed items. several ways of exploring their interrelationships precluded
Exploratory and confirmatory factor analyses. Given a specifying hard criteria for each step. We tried to determine if
theoretical structure that organized items into subscales, the usual apparently overlapping constructs using one method (e.g., scale-
next step would have been a confirmatory factor analysis. We are scale correlations) were consistent across approaches (also had
grateful to Steve Gregorich, however, for the suggestion of starting similar patterns of correlations with the validity measures). Thus,
with SAS PROC VARCLUS. Because this procedure has not many of our judgments were based on a synthesis of evidence from
been widely used, we offer a brief description. all of these analyses.
Under the default options we elected, PROC VARCLUS Final confirmatory factor analysis (CFA). For the final
begins with a principal components analysis of the correlation CFA, using Mplus Version 5.21 [90] with the same imputed
matrix. Starting from a conceptualization of the entire item set as a covariance matrix as with PROC VARCLUS, we were especially
single cluster, at each step the cluster chosen for splitting is the one guided by the comparative fit index (CFI) and the root mean
with the highest second eigenvalue (provided that that value is square error of approximation (RMSEA), as well as modification
greater than 1). Splitting is accomplished by a principal indices. Following conventional guidelines [91], we required at
components analysis of the items in that cluster, with a quartimax least two [92] of the following fit indices to fall in the desired range:
rotation. The quartimax rotation, maximizing variances of CFI $.90; RMSEA #.06; Tucker-Lewis index (TLI) $.95;
loadings within rows of the structure matrix, tends to produce a standard root mean square residual (SRMR) #.08.
general first component, accounting for the maximum amount of
variance within the cluster. (The varimax rotation maximizes Results
variances within columns of the matrix, precluding the emergence Recruitment was slower for certain participant categories, and
of a general factor, and favoring interpretation of factors in terms we ultimately were short 2 participants in the experienced yoga/
of variables.) Each variable within the cluster is provisionally Tai Chi condition, and 3 in the Western somatic therapies. To
assigned to whichever of the first two components with which it is compensate, we reopened the meditation/mindfulness conditions
most highly correlated. The procedure then tests each variable to and recruited another 6 participants. Only participants who fully
see whether assigning it to a different cluster would increase the completed our survey counted toward our cap of 300; we included
amount of variance explained; if a variable is reassigned, the 47 partially complete cases in our analyses who met our criterion
components are recomputed before testing the next variable. We of answering at least half of our 63-item questionnaire. The sample

MAIA
(N = 325) was primarily female (79%), Caucasian (about 85%), and summarizes the internal-consistency reliability and descriptive
well educated (more than half completed graduate school). Mean statistics of the scales. These scales include items that either
age was 48 years. Sixty-two percent had more than 10 years of duplicate or are similar to items from previously published and
practice. Of the types of therapy they were most familiar with, developed scales: five items (MAIA items 1, 6, 18, 20, 27) from the
proportions had been predetermined with most meditation/ SBC [57], one item from the BRS [93] (MAIA item 29), one item
mindfulness (37%) and yoga/tai chi (32%). Table 1 shows from the Mindful Attention Awareness Scale [94] (MAIA item 5)
participant characteristics separated by experience level. and one item from the Kentucky Inventory of Mindfulness Skills
As described above, item selection was data-driven and based [95] (MAIA item 4).
on an iterative process that allowed for regrouping of items around The eight final scales reflected five overall dimensions, with up
changing latent variables and dimension constructs. to three subscales representing each dimension. Internal-consis-
For an 8-factor model that was identified by the iterative process tency reliabilities ranged from .66 to .82; unstandardized alphas
described above, the CFA (N = 309; Table 2) showed good model were over .70 for five of the eight scales. Mean scores tended to be
fit according to CFI and RMSEA (Table 3) and acceptable fit high; on a 0–5 scale, means ranged from a low of 3.20 (Not
according to CFI and TLI. Nine items had modification indices Distracting) to a high of 4.16 (Emotional Awareness). For some
above 10 (eight in the range of 10 to 13.4 and one item 21.5). We scales, the lowest observed score was well above the minimum;
also attempted to determine whether a summary score for all 32 e.g., the minimum observed score for Emotional Awareness was
items would simplify the measurement of our construct by forcing 1.8 and for Self-Regulation, 1.75.
all items into a single factor model. However, the fit indices Correlations among the eight scales (Table 6) ranged from.09
showed a predictably poor fit (Table 3). To determine whether all to.60 (median .35) indicating independence. The highest correla-
eight factors could support an overall interoceptive awareness tions were between Body Listening and Emotional Awareness
construct, we also tested a hierarchical model, with the eight (.60), Noticing and Attention Regulation (.56), and Self-Regulation
factors as indicators of one overall second-order factor. The fit and Attention Regulation (.55).
indices showed a fit to the data almost as good as the first-order
CFA. All loadings were significant at p,.001 for all three models Changes in Conceptual Framework Resulting from Field
(Table 3). Test
The final MAIA survey consists of 32 items comprising eight Compared to the conceptual framework on which the field test
scales ranging from 3 to 7 items each. The final scales organized was based (Part 1.7), the final scales reflect all of its five dimensions
according to the final conceptual framework are presented in and most subdimensions.
Table 4 with their definitions and factor loadings, and Table 5
Table 1. Sample Characteristics (total N = 325).
Less Experienced Highly Experienced p
Female (N, %) 135 (86) 103 (71) .001 (exact test)

Age (years, mean, SD) 42.2 (11.5) 53.1 (10.5) ,.0001
Race (N, %) .20 (exact test)
White 139 (86) 132 (90)
Latino 8 (5) 5 (3)
Asian American 8 (5) 7 (5)
African American 6 (4) 1 (1)
Other 0 2 (1)
Education (N, %) x2(2) = 4.42, p = .11
No college degree 15 (9) 18 (12)
College degree 72 (43) 49 (32)
Graduate degree 81 (48) 88 (57)
Years experience (mean, SD) x2(3) = 99.48, p,.0001
1-4 42 (27) 0 (0)
5-6 25 (16) 3 (2)
7-10 34 (22) 15 (10)
.10 56 (36) 135 (88)
Primary practice (N, %) x2(4) = 5.86, p = .21
Meditation/mindfulness 64 (40) 55 (36)
Yoga/Tai Chi 48 (30) 44 (29)
Massage 27 (17) 27 (18)
Body-oriented therapy 15 (9) 11 (7)
Other somatic therapy 6 (4) 16 (10)
doi:10.1371/journal.pone.0048230.t001

MAIA
Table 2. Items and Standardized CFA Loadings.
Standardized
loading SE
Noticing
1. When I am tense I notice where the tension is located in my body. .697 .039
2. I notice when I am uncomfortable in my body. .594 .045
3. I notice where in my body I am comfortable. .711 .038
4. I notice changes in my breathing, such as whether it slows down or speeds up. .452 .053
Not-Distracting
5. I do not notice physical tension or discomfort until they become more severe. .631 .050
6. I distract myself from sensations of discomfort. .644 .050
7. When I feel pain or discomfort, I try to power through it. .622 .051
Not-Worrying
8. When I feel physical pain, I become upset. .629 .049
9. I start to worry that something is wrong if I feel any discomfort. .724 .046
10. I can notice an unpleasant body sensation without worrying about it. .577 .051
Attention Regulation
11. I can pay attention to my breath without being distracted by things happening around me. .589 .041
12. I can maintain awareness of my inner bodily sensations even when there is a lot going on around me. .766 .027
13. When I am in conversation with someone, I can pay attention to my posture. .625 .038
14. I can return awareness to my body if I am distracted. .728 .031
15. I can refocus my attention from thinking to sensing my body. .758 .028
16. I can maintain awareness of my whole body even when a part of me is in pain or discomfort. .747 .029
17. I am able to consciously focus on my body as a whole. .721 .031
Emotional Awareness
18. I notice how my body changes when I am angry. .518 .045
19. When something is wrong in my life I can feel it in my body. .534 .044
20. I notice that my body feels different after a peaceful experience. .817 .024
21. I notice that my breathing becomes free and easy when I feel comfortable. .809 .025
22. I notice how my body changes when I feel happy/joyful. .837 .023
Self-Regulation
23. When I feel overwhelmed I can find a calm place inside. .730 .032
24. When I bring awareness to my body I feel a sense of calm. .736 .032
25. I can use my breath to reduce tension. .773 .029
26. When I am caught up in thoughts, I can calm my mind by focusing on my body/breathing. .735 .032
Body Listening
27. I listen for information from my body about my emotional state. .761 .030
28. When I am upset, I take time to explore how my body feels. .769 .030
29. I listen to my body to inform me about what to do. .822 .026
Trusting
30. I am at home in my body. .601 .042
31. I feel my body is a safe place. .831 .028
32. I trust my body sensations. .817 .029
Dimension 1, Awareness of Body Sensations, stayed intact and contributing to any single item cluster, or being highly skewed.
was relabeled as Noticing. Dimension 2B, Ignoring or Avoiding Perceptions of Sensations
For Dimension 2, Emotional Reactions and Attentional such as by Distracting Oneself, remained intact and was relabeled
Response to a Sensation, two of the four subdimensions were as Not Distracting, so that higher scores represented more body
retained in the final scales. Items for Affective Response to awareness (less distracting). For 2C, Narrative, Judgmental
Sensations (2A) were not retained, after one item moved to our Awareness, we lost two items due to low factor loadings, and
Not Worrying scale (details below); and we dropped the remaining gained one item from the Emotional Reaction to a Body Sensation
four items for being pulled in multiple directions, lack of scale. As the resulting scale items were specific to worrying and no

MAIA
Table 3. Confirmatory Factor Analyses Model Fit Indices. as the remaining items did not represent a clear construct, we
dropped this subdimension.
x2/DOF/p CFI TLI RMSEA (CI) SRMR Discussion

According to the results from three models of CFA, a
1-Factor Model 2126.5/464/.0000 .615 .588 .108 (.103–112) .088
conceptual model that includes eight separate dimensions of
Hierarchical 1035.6/456/.0000 .866 .854 .064 (.059–069) .067 interoceptive awareness seems to best fit the data sampled in a
Model
mind-body therapy-experienced population. The field test data
8-Factor Model 927.3/436/.0000 .886 .870 .060 (.055–066) .056 allowed the reduction of the tested item pool from 63 items to 32
x2/DOF/p: Chi Square/degrees of freedom/p value.
items.
CFI: Comparative Fit Index. The mixed-method process chosen in the development of the
TLI: Tucker-Lewis Index. MAIA is an attempt to respect the relative newness and
RMSEA (CI): Root Mean Square Error of Approximation (95% Confidence abstractness of the construct. As is common in measure
Interval).
SRMR: Standard Root Mean Square Residual.
development, we conceive of CFA as a framework for model
doi:10.1371/journal.pone.0048230.t003 development, where different phases may be more exploratory or
more confirmatory (example in [96]). Since PROC VARCLUS
longer adequately represented the original construct, we renamed does not provide good measures of fit, we used CFA, not as a test,
this scale Not Worrying. We also could not retain our 2D or strict confirmation, but for a quantitative assessment of
subdimension of Present-Moment Awareness, as four items were goodness of fit.
dropped due to lack of contributing to any single factor and the The clustering that PROC VARCLUS yielded consistently
remaining item asked to be moved to another factor. constituted a good match to our theoretical grouping of items; any
differences that emerged were often interpretable in theoretical
For Dimension 3, Capacity to Regulate Attention, the
terms. In addition, the PROC VARCLUS output typically
subdimension Allowing was lost after its three items were dropped
performed well when input to a CFA. In contrast, the initial
due to low factor loadings and lack of clarity. After dropping four
CFAs done prior to using PROC VARCLUS did not show a good
items from the remaining subscales due to redundancy and high
fit and suggested changes by the modification indices that were
modification indices, separate subdimensions could not be
often not theoretically appealing. We speculate that the superior
distinguished in the CFA, resulting in a single merged scale for
performance of PROC VARLCUS over exploratory and confir-
Attention Regulation, containing seven items.
matory factor analysis may be explained by its use of item clusters,
For Dimension 4, Trusting Body Sensations, we dropped three defined by correlations, which may approximate human cognition
items that were highly skewed or had low factor loadings, and better than analyses by weights defining straight lines in
gained one item from the earlier 5C, Sense of an Embodied Self multivariable space. PROC VARCLUS appears to function
construct. The remaining items still fit well with the earlier effectively as an intermediary between clustering and scale
concept, and thus constituted our final Trust scale. definition by using principal components analysis as a means of
In Dimension 5, Mind-Body Integration, Emotional Awareness clustering items.
(5A) stayed intact through all analyses and lost one item due to lack The emergence of separate new subdimensions from our
of factor contribution. Subdimension 5B, Self-Regulation of original framework may, therefore, be appreciated as improved
Emotions, Sensations, and Behavior, lost one item for low factor discrimination of our dimensions based on the focus group
loadings and split off into two new scales: Body Listening and Self- participants and on responses from our field test participants. The
Regulation. Subdimension 5C, Sense of an Embodied Self, lost loss of subdimensions from our initial conceptual framework,
two items due to low factor loadings and high modification indices; particularly of Allowing, which was introduced by the instructor
focus group, and the critical distinction of Judgmental, Narrative
Table 4. Final Multidimensional Conceptual Framework of Body Awareness and Scales.
1) Awareness of Body Sensations

Noticing: Awareness of uncomfortable, comfortable, and neutral body sensations
2) Emotional Reaction and Attentional Response to Sensations
Not Distracting: Tendency to ignore or distract oneself from sensations of pain or discomfort
Not Worrying: Emotional distress or worry with sensations of pain or discomfort (reversed)
3) Capacity to Regulate Attention: ability to stay focused when facing numerous sensory stimuli competing for attention
Attention Regulation: Ability to sustain and control attention to body sensation
4) Awareness of Mind-Body Integration: access to more developed levels of body awareness
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: Actively listens to the body for insight
5) Trusting Body Sensations
Trusting: Experiences one’s body as safe and trustworthy
NOTE: Numbered, italicized concepts are overall dimensions; scale names are bolded.

MAIA
Table 5. Reliability, Item-scale correlations, and Descriptive Statistics for MAIA Scales.
Range of item-scale
Scale # of items Item numbers Alpha correlations Mean (SD)a Observed rangeb
Noticing 4 1–4 0.69 0.35–0.56 3.94 (.59) 1.50–5.00

Not-Distracting 3 5R, 6R, 7R 0.66 0.45–0.49 3.20 (.87) 0.00–5.00
Not-Worrying 3 8R, 9R, 10 0.67 0.44–0.47 3.27 (.84) 0.67–5.00
Attention regulation 7 11–17 0.87 0.54–0.74 3.79 (.64) 1.67–5.00
Emotional awareness 5 18–22 0.82 0.51–0.72 4.16 (.64) 1.80–5.00
Self-regulation 4 23–26 0.83 0.63–0.70 3.86 (.74) 1.75–5.00
Body listening 3 27–29 0.82 0.64–0.73 3.50 (.87) 0.67–5.00
Trusting 3 30–32 0.79 0.53–0.68 4.13 (.74) 1.00–5.00
a
All scales are scored so that a higher score is more positive body awareness; thus Distracting and Worrying are scored so that a high score is less distracting and less
worrying.
b
Possible range from 0–5.
R = reversed scored items.
Awareness from Present-Moment Awareness, may be viewed as Our finding that the scales tended to be skewed toward higher
limitations of the MAIA and warrant further discussion. Is it levels of body awareness is consistent with the sampling strategy
possible that our choice of using experienced mind-body (adults with at least some experience in body awareness therapies).
instructors as the field test sample population biases the responses Because an important application is to detect changes over time, it
to these items in a way that these dimensions are unable to form is important to assure that the scales also work in more naı̈ve
separate item clusters or factors? We will explore this question in a subjects. In our construct validity analyses, we report descriptive
separate test sample of body awareness-naı̈ve subjects in a statistics separately for the more and less experienced participants
subsequent paper. However, two of the original items for (see Table 7). As seen there, variability increases slightly in the less
Judgmental, Narrative Awareness remained in another dimension; experienced group. In patients with little experience with mind-
and the largest MAIA dimension, Attention Regulation, with body therapies, we expect to observe the full range for all scales
seven items, includes key elements of attention skills that can be and substantially lower means than in this sample (separate
viewed as conditional for present moment awareness, a key aspect publication).
of mindfulness. For example, the item ‘‘I can pay attention to my
breath without being distracted by things happening around me’’ Part 3: Construct Validity: Relationships between
refers to skills of sustained attention and attention control that are Maia and Other Constructs
elements of mindfulness and have been described as a component
through which mindfulness may exert its effects [97]. Similarly, the For new measures such as the MAIA scales, evaluation of
item ‘‘I can refocus my attention from thinking to sensing my correlations with other measures provides the first step in
body’’ relates to the ability to switch from narrative to mindful understanding the meaning of the measures. Using the field test
awareness, the precise elements of awareness we had intended to sample, we performed two integrated analyses of these relation-
have separate dimensions for. Although we are moderately ships: (a) determining if the measures relate to other measures in
confident that assessing this critical element is not lost from our ways consistent with plausible hypotheses [98,99], and (b)
instrument, we would like to invite the research community to take examining correlations of each MAIA scale across all of the
part in the further refinement of these conceptual dimensions of validity measures and interpreting the meaning of each scale in
interoceptive body awareness. terms of the correlation patterns.
Table 6. Pearson Product-Moment Correlations among the Eight MAIA Scales.
Attention Emotional
Scale Noticing Distracting Worrying regulation awareness Self-regulation Body listening Trusting
Noticing –
Not-distracting .26 –
Not-worrying .16 .33 –
Attention regulation .56 .31 .35 –
Emotional awareness .47 .23 .09 .45 –
Self-regulation .35 .19 .31 .55 .50 –
Body listening .44 .29 .19 .45 .60 .54 –
Trusting .38 .32 .31 .50 .34 .52 .44 –

MAIA
Table 7. Mean Differences in MAIA Scales by Level of Experience.
Teachers with .5 years of experience

Subscale Students and less experienced teachers N$164 N$155
Mean (SD) Observed range Mean (SD) Observed range p (t-test)
Noticing 3.79 (.60) 1.50–5.00 4.09 (.54) 2.00–5.00 ,.0001

Not-Distracting 3.13 (.79) 0.67–5.00 3.28 (.93) 0.00–5.00 0.13
Not-Worrying 3.13 (.88) 0.67–4.67 3.42 (.77) 0.67–5.00 0.002
Attention Regulation 3.65 (.68) 1.67–5.00 3.95 (.56) 1.71–5.00 ,.0001
Emotional Awareness 4.13 (.68) 1.80–5.00 4.19 (.61) 2.20–5.00 0.38
Self-Regulation 3.79 (.74) 1.75–5.00 3.93 (.72) 1.75–5.00 0.07
Body-Listening 3.41 (.94) 0.67–5.00 3.60 (.78) 1.33–5.00 0.04
Trusting 4.09 (.75) 1.00–5.00 4.17 (.74) 1.67–5.00 0.33
a
All scales are scored so that a higher score is more positive body awareness;
b
Possible range from 0–5.
Methods sensations. FFMQ subscale internal-consistency reliabilities ranged

To test convergent and discriminant validity, we included in the from .76 to .92.
survey several published measures of constructs related to body Body Consciousness Questionnaire, Private Body
awareness. Four types of instruments were chosen for this analysis: Consciousness (PBCS) [104]. The PBCS, a 5-item self-report
(a) aspects of body awareness and mindful attention: Five Factor subscale of the Body Consciousness Questionnaire, assesses
Mindfulness Questionnaire, Body Consciousness Questionnaire, sensitivity to internal bodily tensions and the ability to notice
Body Responsiveness Questionnaire; (b) anxiety as state and trait sensations such as one’s mouth or throat getting dry, the heart
or as distress in response to bodily symptoms or pain: State-Trait beating, stomach hunger contractions, and changes in body
Anxiety Inventory, Anxiety Sensitivity Index, Pain Catastrophiz- temperature. The PBCS, largely focusing on awareness of inner
ing Scale; (c) dissociation from the body and bodily sensations: bodily sensations, thus involves interoceptive skills. Internal-
Multiscale Dissociation Inventory (MDI [100]) Depersonalization consistency reliability of the PBCS was .74.
subscale, Body Dissociation subscale of the Scale of Body Body Responsiveness Questionnaire (BRQ) [93]. The
Connection; and (d) the ability to regulate emotions: Emotional BRQ is a 7-item self-report measure consisting of two dimensions
Approach Coping Scales, Difficulties in Emotion Regulation that assesses general attitudes towards and responsiveness to bodily
Scale. For some multidimensional measures, we selected a subset sensations. The first dimension, Importance of Interoceptive
of dimensions that would be potentially associated with our scales. Awareness, assesses the importance of listening to bodily sensations
Two of these measures (MDI, STAI-S) were extremely skewed in (LSTN) to enhance self-awareness and guide decision-making.
our sample (minimal scores for dissociation and state anxiety) and The second dimension, Perceived Disconnection (PD), assesses the
were dropped from further analysis. perceived lack of integration between psychological and bodily
states (reversed scored for total measure). Higher scores on the
overall BRQ have been associated with yoga practice and less
Measures of Aspects of Mindful Attention and Body
disordered eating [93] and greater psychological well-being [105].
Awareness Body responsiveness also increased among overweight and obese
Because one of our goals was to develop an instrument that can women participating in a mindfulness intervention for stress eating
distinguish between an anxiety-driven hypervigilance to body compared to waitlist controls [106]. The internal-consistency
sensations and a present-moment, mindful and accepting attention reliability of the two BRQ scales was .73 (PD) and .82 (LSTN).
style to the same body sensations, measures of mindful attention
were included to assess convergent validity of this aspect of the
Measures of Anxiety as State or Trait or as Distress in
new instrument. We describe each measure including the rationale
for including it, and report the internal-consistency reliability of
Response to Bodily Symptoms or Pain
the measures in our sample. A systematic review of existing body awareness instruments [4]
Five Factor Mindfulness Questionnaire (FFMQ)
found no validated measures of body awareness that can
[101,102]. The FFMQ, a 39-item, multidimensional self-report
distinguish between anxiety-related hypervigilance toward pain
scale, is one of the most widely used, well-established measure for and a nonjudgmental, meditative, mindful awareness of these
mindfulness. Body awareness, although integral to the mindfulness sensations. The new measure is designed to discriminate between
these. Thus, we included well-established anxiety measures for
construct [53,94,97,103], has not been assessed as such in
confirmatory and discriminant validity assessment.
mindfulness instruments. Mindfulness extends beyond body
Anxiety Sensitivity Index (ASI), Physical Concern subscale
awareness to the awareness of exteroceptive stimuli and thoughts.
(ASI-PC) [107]. Anxiety sensitivity is defined as the fear of
The FFMQ subscales include items assessing the ability to observe
anxiety-related bodily sensations based on the belief that these
body sensations among various other stimuli (Observing; OBS),
sensations have harmful somatic, social, or psychological conse-
describe emotions (Describing; DSC), attending to one’s activities
quences. It is seen as a trait, the proneness or enduring tendency to
of the moment (Acting with Awareness; AWA), and attend to
become frightened by anxiety-related sensations [108]. The ASI is
(Nonjudging; NOJ) and accept (Nonreactivity; NOJ) body
a 16-item measure that assesses fear of arousal symptoms by three

MAIA
subscales. The Physical Concerns 7-item subscale (ASI-PC) processing emotions. The EACS-EPS internal consistency reli-
assesses the tendency to worry when experiencing bodily ability was .85.
sensations of quickened respiration or heartbeat, chest constric- Difficulties in Emotion Regulation Scale (DERS)
tion, or generalized bodily discomfort. The ASI-PC subscale [121]. The DERS has five subscales to assess various aspects
internal-consistency reliability was .93. of emotion regulation difficulties, including nonacceptance of
Pain Catastrophizing Scale (PCS) [109]. The PCS is a 13- emotion (NAC), difficulty in engaging in goal-directed behaviors
item measure to assess catastrophizing in response to pain (GLS), impulse control difficulties (IMP), lack of emotional
sensations, with three subscales: Rumination, the inability to awareness (AWR), limited access to strategies for emotion
inhibit persisting pain-related thoughts (RUM); Magnification, the regulation (STR), and lack of emotional clarity (CLR). Although
concern that the pain will get worse or have a negative outcome interoceptive awareness is integral to emotion regulation, atten-
(MAG); and Helplessness, worry about pain and the sense of being dance to the body is not explicit in measures of emotion
overwhelmed by it (HLP). Pain catastrophizing overlaps with regulation. It is thus theoretically important to examine the
anxiety [110], but is a more pain-specific, worry-related construct. relationship between emotion regulation and body awareness
Internal consistency reliabilities were .70 (MAG), .89 (HLP), and scales, particularly scales such as the MAIA that explicitly include
.93 (RUM). dimensions specific to emotion regulation. Internal consistency
State-Trait Anxiety Inventory (STAI) [111]. We used the reliabilities for the six DERS subscales ranged from .80 to .90.
original 20-item STAI Trait Anxiety scale for convergent validity
assessment of the MAIA-Worrying subscale (reverse scored to Hypotheses for Correlations between MAIA Scales and
show tendency not to worry). Anxiety measures often include body Scales of Related Constructs
symptoms or sensations, but it is one of our key assumptions that Because similar measures tend to correlate in general (one can
the interoceptive ability to notice subtle body sensations is distinct expect modest correlations among most of our measures and the
from the typical automatic and reactive processes that underlie validity measures), we stated our hypotheses in terms of relative
worry and anxiety. Internal consistency reliability for the STAI-T magnitudes. To create the hypotheses, two clinical researchers
was .92. (CP, WM) independently reviewed a matrix of MAIA scales with
each of the scales of related constructs. In light of the large number
Measure of Dissociation from the Body of validity measures for each MAIA scale, they specified
A lack of awareness of or connection to the body is recognized hypotheses for a limited subset of validity measures in terms of
as integral to the bodily dissociation process and experience [8,112– which pairs would be most highly correlated (including the
114]. Bodily dissociation does not intrinsically indicate pathology, direction of the association), which would be the next most highly
though separation from physical and sensory experience is integral correlated, and which would have little or no correlation. The
to the construct of pathological dissociation, [115] understood as a clinicians then met and discussed and resolved any instances in
mechanism to cope with emotional and physical pain. Bodily which they disagreed. Thus, for each of the eight MAIA scales, we
dissociation has been shown to be conceptually independent from made from 3 to 11 specific hypotheses across validity measures in
body awareness, [57] hence our interest in assessing its correlation terms of the direction and magnitude, i.e. which would be higher,
with the MAIA scales. lower, or in the middle range. We then rank-ordered the actual
Scale of Body Connection, Bodily Dissociation Subscale correlations to determine if the measures hypothesized to be most
(SBC-BD) [57]. The Bodily Dissociation (BD) subscale of the highly correlated were in the top ranks, measures hypothesized to
Scale of Body Connection is an 8-item measure to assess a sense of be moderately correlated were mid-rank, and measures hypoth-
separation from sensory and emotional experience. Women in esized to have small or no correlation were in the low ranks.
treatment for substance use disorder undergoing a body-oriented The MAIA Noticing scale, assessing the awareness of
therapy intervention aimed at increasing body awareness and uncomfortable, comfortable, or neutral body sensations, was
association improved in scores of bodily dissociation compared expected to be more highly correlated with aspects of mindful
with treatment as usual [116]. Significant reductions in bodily attention and body awareness, particularly and most strongly with
dissociation were also demonstrated among women in recovery the FFMQ-OBS. As the Noticing scale assesses the ability to notice
from sexual trauma in response to body-oriented therapy and and focus on interoceptive stimuli, we also expected a high positive
massage [117]. The SBC-BD internal-consistency reliability was correlation with the PBCS, but lower than with FFMQ-OBS. In
.76. contrast, we expected a smaller and negative correlation with
STAI-T.
Measures of Ability to Regulate Emotions The MAIA Not Distracting scale, assessing the tendency not
Emotions are often experienced in association with sensations to use distraction to cope with discomfort, was expected to have
within the body, so-called somatic markers, and there is an the highest correlation with the FFMQ-NOR. Owing to its
intimate link between body awareness or interoception and the behavioral responses of ignoring or powering through sensations of
ability to regulate emotion [26,27,118]. An increased awareness of discomfort, we expected a smaller correlation with FFMQ-OBS
the body’s response to an emotional stimulus is expected to lead to and the PBCS. We hypothesized that it would be negatively
greater awareness of one’s emotions, and, conversely, an correlated in the middle rank with the BRQ-PD and the SBC-BD.
awareness of one’s emotions is a precondition for being able to For measures of emotion regulation, we expected a smaller
regulate those emotions [97]. correlation with DERS-GLS.
Emotional Approach Coping Scales, Emotional The MAIA Not Worrying scale, assessing the tendency not to
Processing Subscale (EACS-EPS) [119]. The Emotional experience emotional distress with physical discomfort, was
Processing subscale (EPS), one of two self-report Emotional expected to have a higher correlation with the FFMQ-NOR. In
Approach Coping subscales, assesses the acknowledgment or relation to measures of anxiety, we hypothesized highly negative
exploration of emotion in response to stressful situations. Such correlations with the STAI-T, all subscales of the PCS, and the
exploration, which is integral to emotion regulation [120], is akin ASI-PC. For measures of emotion regulation, we also expected
to ‘‘listening’’ to the body and is closely tied to accessing and relatively high correlations with DERS-NAC, GLS, and IMP.

Table 8. Correlations between MAIA Scales and Validity Measures.
Measure of
Measures of Body Awareness/Mindful Awareness Measures of Anxiety Dissociation Measures of Emotion Regulation
Validity Scales MAIA AASI- EEACS-

Scales FFMQ PBCS BRQ PC PCS STAI-T SBC-BD EPS DERS
OBS DSC AWA NOJ NOR PD LSTN RRUM MAG HLP NAC GLS IMP AWR STR CLR
PLOS ONE | www.plosone.org

Noticing .53 .20 .38 .19 .34 .40 2.31 .46 2.19 2.27 2.20 2.23 2.33 2.30 .25 2.26 2.22 2.24 2.36 2.27 2.39
Not-Distracting .22 .17 .41 .36 .30 .20 2.38 .31 2.18 2.24 2.17 2.21 2.35 2.32a .15 2.33c 2.28 2.27 2.24c 2.32 2.26
Not-Worrying .16 .13 .44 .38 .47 .01 2.35 .19 2.36 2.46 2.40 2.41 2.46 2.27 .11 2.35 2.44 2.35 2.11 2.39 2.16
Attention regulation .55 .38 .42 .28 .53 .43 2.33 .48 2.31 2.30 2.19 2.19 2.38 2.41 .33 2.24 2.23 2.30 2.41 2.25 2.42
Emotional awareness .50 .30 .27 .14 .27 .32 2.24 .48 2.12 2.25 2.15 2.18 2.19 2.33 .34 2.18 2.13 2.17 2.44 2.19 2.38
Self-regulation .46 .18 .36 .22 .45 .29 2.27 .45 2.20 2.34 2.32 2.28 2.46 2.27 .27 2.20 2.26 2.27 2.38 2.28 2.28
Body listening .50c .29 .29 .21 .41 .33 2.33 .64b 2.18 2.34 2.24 2.25 2.29 2.34 .43 2.21 2.21 2.22 2.54 2.22c 2.36
Trusting .42 .27 .36 .28 .37 .28 2.40 .53 2.23c 2.31 2.24 2.30c 2.46 2.39 .21 2.22 2.22 2.30 2.39 2.28 2.36
Correlations ..14 are significant at p,.01; correlations ..18 at p,.001; correlations ..21 at p,.0001.
Bolded are the highest correlations in each column, italicized are the highest correlations in each row.
Validity measures:
FFMQ - Five Facet Mindfulness Questionnaire (OBS-Observing, DSC-Describing, AWA-Acting with Awareness, NOJ–Nonjudging, NOR-Non-Reactivity).
PBCS - Private Body Consciousness Scale.
14
BRQ - Body Responsiveness Questionnaire (PD-Perceived Disconnection, LSTN-Listening to bodily sensations).
ASI-PC - Anxiety Sensitivity Index – Physical Concern.
PCS - Pain Catastrophizing Scale (RUM-Rumination, MAG-Magnification, HLP-Helplessness).
STAI-T - Trait Anxiety Inventory.
SBC-BD - Scale of Body Connection – Bodily Dissociation.
EACS - Emotional Approach Coping Scales – Emotional Processing.
DERS - Difficulties in Emotion Regulation Scale (NAC-Non-acceptance of emotion, GLS-Difficulty engaging in goal-directed behaviors, IMP-Impulse control difficulties, AWR-Lack of emotional awareness, STR-Limited access to
strategies for emotion regulation, CLR-Lack of emotional clarity).
a
227 if overlapping item omitted.
b
60 if overlapping item omitted.
c
six correlation did not confirm a priori hypothesized rank order.
MAIA
November 2012 | Volume 7 | Issue 11 | e48230

MAIA
The MAIA Attention Regulation scale, assessing the ability measures. We add a brief discussion for each scale to obviate going
to sustain and control attention to body sensations, was expected forth and back between results and subsequent discussion sections.
to be positively and highly correlated with measures of mindful Noticing. All three hypotheses were confirmed. Awareness of
awareness, FFMQ-OBS, FFMQ-AWA, and FFMQ-NOR, the uncomfortable, comfortable, or neutral body sensations appears to
PBCS, and to a lesser degree with the BRQ-PD. We also expected mean a high capacity to observe with mindfulness (FFMQ-OBS),
a negative middle rank correlation with PCS-RUM and, to a lesser experience interoceptive stimuli (PBCS), and, not hypothesized,
degree, with DERS-GLS. mind-body listening (BRQ-LSTN). As all correlations with
The MAIA Emotional Awareness scale assesses the ability to measures of anxiety and worry are below .30 (in absolute
attribute specific physical sensations to physiological manifesta- numbers; maximum .27), with the exception of 2.33 for trait
tions of emotions, an internal process involving a more developed anxiety (STAI-T), it appears that noticing body sensations, the
interoceptive awareness or meta-awareness that has matured more basic, sensory aspect of body awareness, is not particularly
beyond reflexive reactivity with fear and worry about unfamiliar or strongly related to trait anxiety, at least in mind-body practition-
irritating bodily sensations. Thus, we expected higher correlations ers.
with FFMQ-OBS and DERS-AWR and middle rank correlations The strong correlations between this MAIA scale and scales of
with FFMQ-DSC and NOR and the EACS-EPS, as well as with a basic perception of body sensations in mindful awareness measures
measure of dissociation, SBC-BD. We also expected lower make intuitive sense. Although not hypothesized, the correlation
correlations with the anxiety measures of ASI-PC and STAI-T with the BRQ-LSTN is in line with these results. The lack of high
and a smaller negative correlation with the DERS measure for correlation between noticing body sensations and trait anxiety
nonacceptance of emotions. scores for mind-body instructors is particularly remarkable, as it is
The MAIA Self-Regulation scale, assessing the ability to consistent with findings from prior studies that anxious individuals
regulate distress by attention to body sensations, was expected to may have heightened vigilance toward body sensations but do not
be more highly correlated with mindful attention scales of FFMQ- exhibit an increased accuracy of these [124]. This finding confirms
NOR, BRQ-LSTN, and to a lesser degree with FFMQ-AWA. We our position that at least the basic noticing aspect of the awareness
expected a middle-rank correlation with SBC-BD. In regard to of body sensations can be separated from anxiety; the MAIA-
emotion regulation measures, we expected a middle-rank corre-
Noticing scale cannot serve as a proxy measure of anxiety. This
lation with the EACS-EPS and DERS scales for GLS, IMP, and
result, however, may be specific to mind-body practitioners, and
STR, and to a lesser degree with DERS-NAC.
we would not necessarily expect it to be confirmed in a mind-body
The MAIA Body Listening scale, assessing the tendency to
therapy-naı̈ve population.
actively listen to the body for insight, was expected to be more
Not distracting. Six of our eight hypotheses were confirmed.
highly correlated with the mindful attention measures of FFMQ-
At least in practitioners of mind-body approaches, the tendency not
OBS, FFMQ-NOR, and the BRQ-LSTN, as well as with the
to ignore or distract oneself from sensations of pain or discomfort
EACS-EPS and, negatively, the DERS-AWR. We expected
appears to mean having a good awareness of when mind-body
middle-rank negative correlations with SBC-BD dissociation and
connection is lacking (BRQ-PD) and, although not hypothesized,
emotion regulation measures of DERS-GLS and IMP, as well as a
smaller negative correlation with DERS-STR. having a high awareness of how emotions affect one’s behavior
The MAIA Trusting scale, assessing the experience of one’s (FFMQ-AWA). As expected, not distracting oneself from negative
body as safe and trustworthy, was expected to show a high positive sensations is moderately correlated with FFMQ-NOR and
correlation with the BRQ-LSTN. For anxiety measures we minimally correlated to FFMQ-OBS. A moderate correlation
expected higher negative correlations with the ASI-PC and was confirmed with bodily dissociation as measured by the SBC-
PCS-HLP and middle-rank negative correlations with PCS- BD. This quality is rather distinct from anxiety sensitivity (ASI),
MAG and STAI-T. For a dissociation measure, the SBC-BD, the perception of interoceptive stimuli (PBCS), the tendency to
we expected a middle-rank negative correlation, as well as for magnify negative sensations (PCS-MAG) and the acknowledgment
BRQ-PD and the emotion regulation aspect of the DERS-NAC. or exploration of emotions in response to stressful situations
(EACS) (all correlations lower than .20). Trait anxiety (STAI-T)
Examining Patterns of All Correlations was found to be moderately correlated with ignoring and
In addition to testing specific hypotheses about the relationships, distracting oneself from negatively appraised body sensations as
we were able to build a knowledge base about the meaning of the the strongest (2.35) correlation with any of the anxiety measures.
measures based on the pattern across all measures irrespective of a In regard to measures of emotion regulation, we found smaller
priori hypotheses. This second approach has previously been taken correlations with DERS lack of emotional awareness and engaging
in exploring the construct validity of the Multidimensional in goal-directed behavior and a higher than expected correlation
Experiential Avoidance Questionnaire [122], as well as in testing with DERS nonacceptance of emotions.
the construct validity of the Medical Outcomes Study (MOS) It makes sense to ignore or distract oneself from emotion-related
measures of functioning and well-being [123]. In presenting the physical sensations when one does not accept a negative emotion.
results we are integrating both approaches. The moderate correlation with trait anxiety supports the notion
that trait anxiety may be associated with a coping style that ignores
Results and Discussion unpleasant body sensations, whereas mindful awareness and
As noted above, the internal-consistency reliability of each of nonreactivity (FFMQ) show almost symmetric, opposite correla-
the 21 validity measures ranged from .70 to .93 (median .85). tions. The moderate correlation with bodily dissociation supports
Table 8 presents the correlations of each MAIA scale with the 21 the idea that ignoring or distracting behaviors and bodily
subscales included in the 9 validity instruments. This table also dissociation are conceptually linked, a result important for better
shows the six correlations (out of 63) for which the hypothesized understanding and treatment of pain and physical discomfort.
strength ranks were not confirmed. These findings underscore the important role of not distracting
In the following section, we report the results organized by the oneself from body sensations and the utility of this MAIA scale
eight MAIA scales and further explore the inferred meaning of the within the body awareness assessment.

MAIA
Not worrying. All nine hypotheses were confirmed. The and clarity suggest that the ability to sustain and control awareness
tendency not to experience emotional distress or worry with in the body may go along with emotional attunement.
sensations of pain or discomfort appears to mean, at least in mind- Emotional awareness. All nine hypotheses were confirmed.
body practitioners, to accept (negative) body sensations (FFMQ- The awareness of the connection between body sensations and
NOR) and, unexpectedly, to be aware of how emotions affect emotional states means strong skills in mindful observation
one’s behavior (FFMQ-AWA). Moderate correlations were seen (FFMQ-OBS), valuing the importance of listening to body
with four measures of emotion regulation: At least in mind-body sensations (BRQ-LSTN) and, as expected, a lack of difficulties in
practitioners, less worrying appears to mean less difficulty in emotional awareness and clarity as measured by the DERS AWR
engaging in goal-directed behaviors (DERS-GLS), increased and CLR scales. Although anxiety is an important emotion, being
acceptance of emotions (DERS-NAC), increased access to aware of the connection between body sensations and emotional
strategies of emotion regulation (DERS-STR), and fewer difficul- states is, as expected, clearly distinct from anxiety as measured by
ties in impulse control (DERS-IMP). It also means not to all included anxiety measures, most clearly with anxiety sensitivity
catastrophize pain sensations (all three PCS scales $.40), to be (ASI) and trait anxiety (STAI-T). It is also distinct from several
low on trait anxiety (STAI-T), and not to worry when aspects of emotion regulation (DERS), namely acceptance of
experiencing bodily sensations of quickened respiration or emotion (NAC), engaging in goal-directed behaviors (GLS),
heartbeat, chest constriction, or generalized bodily discomfort impulse control (IMP), and access to strategies for emotion
(ASI-PC). Interestingly, this latent variable or construct is distinct regulation (STR). Moderate correlations were found with FFMQ
(r = .01) from sensitivity to internal bodily tensions and the ability ability to describe emotions and nonreactivity, awareness of body
to notice sensations such as one’s mouth or throat getting dry, the sensation assessed by PBCS, EACS acknowledgment or explora-
heart beating, hunger contractions, and changes in body tion of emotion in response to stressful situations, and negatively
temperature (PBCS); it is also rather distinct (all rs ,.20) from with body dissociation (SBC-BD).
the ability to describe emotions (FFMQ-DSC), emotional aware- The awareness of body sensations as being associated with
ness (DERS-AWR), emotional clarity (DERS-CLR), and an emotions has the highest correlations with two scales of mindful
acknowledgment or exploration of emotion in response to stressful attention and, interestingly, the lowest correlations with measures
situations (EPS). of anxiety. The specific pattern of correlations with emotion
A stronger tendency not to experience emotional distress or regulation scales is noteworthy: The MAIA scale for awareness of
worry with sensations of pain or discomfort is consistent with physical symptoms as related to emotions is mostly concordant
having fewer difficulties in emotion regulation (four of six DERS with measures for acknowledging or exploring emotions in
subscales $.35). As expected, this MAIA scale is the one with the response to stressful situations and with DERS scales of
strongest correlations with all measures of anxiety. It is possible perception, such as having fewer difficulties with emotional
that the consistently small correlation with emotional awareness awareness and clarity; but it is distinct from DERS scales assessing
and clarity on the DERS, and exploration of emotion on the EPS, coping behavior and behavioral outcomes, such as nonacceptance
means that engagement in these emotional exploratory processes of emotions, difficulty in engaging in goal-directed behaviors, and
happens regardless of worry in response to bodily discomfort impulse control difficulties.
among mind-body practitioners. With these exceptions, this scale Self-Regulation. All nine hypotheses were confirmed. As
has the strongest correlations with measures of emotion regulation: expected, a strong ability to regulate distress by attention to body
Not worrying when perceiving pain or discomfort may be a sensations appears to mean high skills in mindful nonreactivity
condition or a consequence of emotion regulation. (FFMQ-NOR) and valuing the importance of body-listening
Attention regulation. All seven hypotheses were confirmed. (BRQ-LSTN), in individuals practicing mind-body approaches.
The ability to sustain and control attention to body sensations Unexpectedly, it is also positively correlated relatively highly with
appears to mean a high capacity for mindful observation, mindful observation (FFMQ OBS), highly negatively with trait
awareness, and nonreactivity (FFMA-OBS, AWA, and NOR), anxiety, and moderately with fewer difficulties in emotional
awareness of interoceptive indicators (PBCS), and (not hypothe- awareness (DERS-AWR). It is moderately correlated with skills in
sized) valuing the importance of listening to body sensations the awareness of how emotions affect one’s behavior (FFMQ-
(BRQ-LSTN). This ability is also moderately correlated with an AWA), and little correlated with a lack of difficulties (DERS) in
acknowledgment or exploration of emotion in response to stressful goal-directed behaviors (GLS), impulse control (IMP), and
situations (EPS). At least in mind-body practitioners, it also means strategies for emotion regulation (STR), with exploring emotions
not to separate oneself from sensory and emotional experience in response to stressful situations (EACS), and with all scales of
(SBC-BD), and not to lack emotional awareness or clarity (DERS- catastrophizing (PCS). It shows a low negative correlation with
AWR and CLR) (not hypothesized). It may additionally mean the SBC-Body-Dissociation.
absence of rumination, but it is clearly distinct from other aspects The MAIA scale that measures the ability to regulate distress by
of catastrophizing (PCS-MAG and HLP). attention to body sensations has its strongest concordance with
Of all MAIA scales, Attention Regulation, defined as the ability scales of mindful observation, listening to body sensations, and
to sustain and control attention to body sensations, shows the nonreactivity, and clearly less concordance with scales of emotion
strongest correlations with the FFMQ-OBS and NOR subscales. regulation that do not explicitly assess emotion regulation by
Skills in attention regulation are a precondition for the capacity to attention to body sensations. That a similarly high concordance
be nonreactive and accepting of body sensations, key elements of with the STAI-T was found is no surprise: The body awareness-
more general mindfulness [97]. This scale appears to measure based self-regulation skills measured with this MAIA scale may be
skills related to but distinguishable from aspects of mindfulness associated with less trait anxiety.
captured by the FFMQ. The highest correlations with PCS Body listening. Eight of ten hypotheses were confirmed. The
rumination, anxiety sensitivity, and trait anxiety are only moderate tendency to actively listen to the body for insight means valuing
(between .30 and .38), confirming that this scale measures aspects body-listening skills (BRQ-LSTN), having high skills in mindful
of body awareness independent from anxiety. The moderate observation (correlation stronger than expected) and nonreactivity
correlations with measures of emotional connection, awareness, (FFMQ), and lacking difficulties with emotional awareness (DERS

MAIA
AWR). It is moderately correlated with not ruminating (PCS- correlations), and approximately two fifths of the correlations
RUM), acknowledging or exploring one’s emotions in response to being less than .30 (24 out of 64). Whereas the five FFMQ scales
stressful situations (EPS), and body dissociation (SBC-BD). It has each find their highest correlations with only two MAIA scales
little relationship to anxiety sensitivity (ASI). (Attention Regulation and Not Worrying), the BDQ finds its
The strong concordance of this measure with the BRQ scale for highest correlation with Body Listening and Trust, suggesting that
the importance of listening to the body is no surprise, particularly these MAIA scales assess aspects that are related but distinguish-
as one item is virtually identical between the two scales. A .50 able from each other. The close relationship between the MAIA
correlation with the FFMQ-OBS scale shows that both scales parameters and the FFMQ-OBS scale in individuals that have had
measure related constructs. Whereas this MAIA scale is exclusively exposure to mind-body approaches may be explained by the
interoceptive, the FFMQ assesses mindful attention to any following hypothesis: Although the FFMQ-Observe scale does not
perceivable stimulus, including thoughts and exteroceptive input. differentiate between awareness towards interoceptive, exterocep-
Actively listening to the body for insight was highly (.54) correlated tive, or cognitive stimuli, mind-body therapy-experienced individ-
with fewer difficulties with emotional awareness. Interestingly, this uals may have learned skills in interoceptive awareness as much as
was the strongest correlation of any DERS scale with any MAIA in other objects of mindful observation. This hypothesis needs to
scale in our mind-body-experienced field test sample, stronger be tested in a subsequent study with a separate sample of less
than the correlation of any other emotion regulation measure with experienced individuals.
MAIA Emotional Awareness and Self-Regulation. It confirms the Anxiety and distress in response to bodily symptoms or
construct validity of this scale for our field test sample, though not pain. The results suggest a distinct split in level of relationship
necessarily in less body-aware individuals. between the MAIA and measures of anxiety or worry. Of the three
Trusting. Six of eight hypotheses were confirmed. Frequently measures chosen to examine aspects of anxiety and distress in
experiencing one’s body as safe and trustworthy means having response to bodily sensations, only trait anxiety resulted in more
strong body-listening skills (BRQ-LSTN) and being relatively free than one negative correlation with MAIA scales above .40.
of trait anxiety (STAI-T). Other anxiety measures (ASI-PC, PCS) Negative correlations above .40 between MAIA and other
showed low to moderate correlations. Moderate correlations were anxiety/worry measures were with the Worrying MAIA scale
found with other mindful awareness measures: with mindful only. Three of the MAIA scales, Not Worrying, Self-Regulation,
observation (FFMQ-OBS), being aware of how emotions affect and Trust, were moderately or highly negatively (greater than
one’s behavior, and nonreactivity (FFMQ-AWA, NOR), having 2.40) correlated with the STAI-T. It appears from these findings
little difficulty with emotional awareness or clarity (DERS-AWR that trait anxiety is associated with aspects of body awareness, as
and CLR), and not being dissociated from one’s body (SBC-BD). would be expected given the inverse relationship between anxiety
Correlations with anxiety measures were only moderate, intensity and the ability to respond positively to sensations in and
confirming that the body awareness-related Trust scale measures experience of the body among individuals with anxiety [37]. In
an independent construct that is not simply the inverse of anxiety. contrast, with the exception of the Not-Worrying scale, the MAIA
The somewhat unexpectedly high (.42) correlation with the scales appear to have little overlap with assessments specific to fear
FFMQ-OBS scale may be specific to people with mind-body of arousal or catastrophizing, indicating the discriminant validity
experience. of all other MAIA scales in relation to these measures for this
In summary, 57 of the 63 hypothesized correlations (90%) were sample of mind-body practitioners. The result that trait anxiety is
found to be rank ordered as expected, confirming the vast majority as much positively correlated with worrying as it is negatively
of MAIA convergent and discriminant hypotheses. The direction correlated with Trust and Self-Regulation underscores the ability
of the expected correlation was confirmed in all cases. of the MAIA scales to distinguish between anxiety-driven and
mindful modes of body awareness, and strongly distinguishes the
Discussion: Overall Patterns of Relations between Body new MAIA scale from older measures using awareness of bodily
Awareness and Other Constructs symptoms as a proxy for anxiety.
We conclude this part by discussing our findings for the MAIA Dissociation from the body. The SBC Bodily Dissociation
scales in the light of four related constructs: mindfulness, anxiety scale showed moderate-level correlations with all MAIA scales.
and worry, dissociation, and emotion regulation. The previously shown lack of correlation between body awareness
Aspects of mindful attention and body awareness. The and bodily dissociation [57] did not apply here presumably
results indicate that MAIA scales were most highly and positively because of the BD focus on emotion and the overlap with this
correlated with aspects of mindful attention and body awareness, aspect of awareness on the MAIA. Bodily dissociation inhibits the
particularly strong with the FFMQ-OBS scale, and BRQ-LSTN. ability to sustain or control awareness in the body, and to
This is an expected result given that these validity measures are experience trust in the body; thus it is not surprising that the
most similar in construct to the MAIA, to the fundamental aspect MAIA Attention Regulation scale was the aspect of body
of body awareness assessed across the MAIA scales, the ability to awareness most strongly (2.41) and negatively correlated with
notice body sensations. The strong focus of the MAIA on assessing BD, followed by Trust (2.39).
the ability to respond positively to body sensations and experience Ability to regulate emotions. The overall findings indicate
of the body is confirmed by the BRQ, the only validity measure a moderate relationship between the MAIA and emotion
that focuses specifically on aspects of awareness and response to regulation as measured by the EACS and the DERS. Of the
body sensation. Both scales show moderate to high correlations multiple emotion regulation subscales examined, only the DERS-
with six of the eight MAIA scales and support the construct AWR is designed to specifically assess awareness of emotion (or the
validity of the MAIA. MAIA Not Distracting and Not Worrying lack thereof), with awareness of emotion-related body sensations
show little or no correlation with these two related scales, with Not being a key aspect of body awareness. The high negative
Distracting being more similar to the FFMQ-AWA and Not correlations (..40) between the MAIA scales of Attention
Worrying to FFMQ-NOR. The discriminant validity of the MAIA Regulation, Emotional Awareness, and, strongest, Body-Listening
with respect to these measures is supported by the large majority of (.54) and the DERS-AWR subscale support the construct validity
the correlations being less than .40 (42 out of 64 possible for this integral aspect of the MAIA body awareness construct.

MAIA
The correlations between the MAIA and other emotion regulation Part 5: Construct Validity: Incremental Validity for
subscales indicate that these subscales assess aspects of emotion the Maia Scales
regulation that, while generally moderately correlated, are less
strongly associated with body awareness as represented on the To examine whether a multidimensional assessment of body
MAIA. Although listening to the body was associated with awareness provides incremental validity in explaining the
emotional awareness, and attention regulation with emotional relationship between body awareness and clinical outcomes, we
clarity, in general a style of emotion regulation that is based on examined the relationship between scores on the MAIA scales and
body awareness (as assessed by the Self-Regulation MAIA scale) the STAI-T. As described earlier, body awareness may be
appears to be related to, but clearly distinct from, emotion associated with more or less anxiety depending on whether it is
regulation skills assessed by EACS and DERS. conceptualized as an adaptive or maladaptive form of attention.
Thus, it is also of theoretical interest to examine the extent to
Part 4: Construct Validity: Differences between which different aspects of body awareness are associated with
Known Groups anxiety.
For further evaluating construct validity of the MAIA, we Method

examined whether the MAIA scales show differences in body For these purposes, we entered all of the MAIA scales
awareness between known groups that are theoretically expected simultaneously into a linear regression model to predict anxiety
to be different. scores. While each MAIA scale bore a significant bivariate
correlation with anxiety, a substantial contribution by a multiplic-
Methods ity of MAIA scales provides evidence of incremental validity, and
Using t tests for data collected in the field test population, we suggests that consideration of multiple aspects of body awareness is
compared mean scores on the eight MAIA scales between the two helpful in understanding the relationship between body awareness
groups of more and less highly experienced participants according and anxiety.
to the sampling design reported in Part 2.
Results
Results Results of this analysis can be seen in Table 9. Noticing, Not
We had a total of 165 less experienced and 157 highly Distracting, Not Worrying, Self-Regulation, and Trusting were
experienced field test respondents (Table 2). The two groups did significant, and Emotional Awareness marginally so, indicating
not differ in ethnicity or education. The highly experienced group that each scale accounts for a portion of the variance in anxiety
had a higher percentage of male participants (29% versus 14%) not accounted for by the others.
and was on average 11 years older.
As presented in Table 7, the highly experienced group had Discussion
significantly higher mean scores on four of the eight MAIA scales.
It appears that both maladaptive aspects of body awareness
All differences were in the expected direction. The largest (most
(including ignoring and worrying about body sensations) and
significant) differences were for the Noticing and Attention
adaptive aspects (including noticing body sensations, having the
Regulation scales.
ability to reduce distress by attending to bodily sensations, and
experiencing the body as safe and trustworthy) are important in
Discussion understanding the relationship between body awareness and
The results support the scales’ ability to distinguish between anxiety. Interestingly, while Emotional Awareness is related
known groups. As the less experienced group also included a group negatively to anxiety in a bivariate correlation, in the regression
of nonteaching students with more than 5 or 10 years of practice model greater emotional awareness was related to greater anxiety,
(73% and 36%, respectively), as well as junior teachers, we did not although the effect was of marginal significance. To understand
expect differences as large as one would expect between beginners this unexpected suppressor effect, separate regressions were run
and teachers. Nevertheless, differences were highly significant for with Emotional Awareness and each of the other MAIA scales to
key elements of mind-body training that have been claimed to predict anxiety (results not shown). In all cases, the relationship
improve with more practice: Highly experienced participants were
more often aware of their body sensations, less frequently worried
about sensations of pain and discomfort, better able to regulate Table 9. Regression Analysis Showing Incremental Validity of
their attention focus, and listened more frequently to the body for MAIA Scales in the Prediction of Trait Anxiety.
insight. Also, results were marginally significant for highly
experienced respondents being more often able to regulate
psychological distress by attention to body sensations. B SE b t p
For the tendency to ignore or distract oneself from sensations of Noticing 22.45 0.87 20.16 22.82 0.005
pain or discomfort, we reported elsewhere some preliminary Not Ignoring 21.56 0.53 20.15 22.96 0.003
results showing that common primary care patients with past or
Not Worrying 22.77 0.54 20.26 25.17 ,0.0001
present low back pain significantly more often (,.001) distract
themselves and ignore their pain or discomfort than our field test Attention Regulation 0.52 0.87 0.04 0.60 0.55
participants practicing a mind-body approach (separate manu- Emotional Awareness 1.50 0.83 0.11 1.81 0.07
script in preparation). [125] It is possible that a moderate amount Self-Regulation 23.46 0.74 20.29 24.67 ,0.0001
of experience may suffice to improve emotional awareness and Listening 0.30 0.62 0.03 0.48 0.63
more frequently experience the body as safe and trustworthy, and
Trusting 22.27 0.66 20.19 23.42 0.0001
that longer practice duration does not further enhance these
aspects of body awareness; this hypothesis remains to be tested by 2
Note: R for model = .41.
comparing mind-body therapy-naı̈ve with experienced individuals. doi:10.1371/journal.pone.0048230.t009

MAIA
between Emotional Awareness and trait anxiety remained standing of questionnaire items may change during this learning
negative, except for Self-Regulation, in which case the coefficient process. This difficulty was encountered and well-described in the
became positive. These findings indicate that Emotional Aware- development of the FFMQ. For the FFMQ, the problem with the
ness shares variance with Self-Regulation, and, once the shared ‘‘observe’’ facet, created by factor analysis and not well-validated in
variance is removed, the relation with anxiety becomes positive, individuals without meditative experience, was described as a
suggesting that aspects of emotional awareness are both positively shortcoming in the original publication [101]. The authors
and negatively related to anxiety. One interpretation is that mere addressed this issue in a later publication after the questionnaire
awareness of how body sensations correspond to emotional states, was submitted to individuals with meditative experience [102];
without the ability to use awareness of those sensations to reduce however, they admittedly were unable to resolve it [126]. For our
distress, could increase anxiety. This distinction could help to study, we decided to do the analysis in a reverse order, to generate
clarify the dual theories of how body awareness affects anxiety. As the factor structure and subscales first in a sample of experienced
a word of caution, this incremental validity test was performed individuals with a more developed understanding of the questions,
among experienced mind-body practitioners, and not among those and then test the questionnaire in individuals without that
with an anxiety disorder, thus these results may have limited experience. This way we expected to obtain a selection of items
generalizability and need confirmation in a separate sample. with greater face validity for the qualities we expect to improve in
In general, results of the incremental validity regression suggest individuals undergoing these approaches. We are well aware that
that a multidimensional assessment of body awareness may be reversing the order of analysis does not solve the more general
valuable in understanding clinical outcomes. As the MAIA is problem of different understanding of the items in different
meant to be useful for understanding a multitude of medical and populations. However, we attempted to avoid in part the problem
psychological conditions, future research will need to be conducted the FFMQ team encountered and gave preference to face validity
to determine the incremental validity for other outcomes. of items in more experienced individuals in order to ensure that
the new insights individuals gain during their exposure to these
Part 6: Overall Discussion approaches (described in the report of the focus groups [87]) are
well captured.
This paper describes the development and preliminary valida-
Several limitations need to be considered. First, as we
tion of the MAIA. The CFA confirmed eight scales reflecting
particularly wanted to develop a measure that would capture
distinct but related dimensions of interoceptive body awareness.
potential changes in body awareness over time as people learn and
The results indicated adequate goodness-of-fit indices, supporting
practice therapies that claim to enhance body awareness, we were
the construct validity of the MAIA scales. As a word of caution, we
interested in correlations between established validity measures
need to emphasize that this preliminary validation requires
and scores on our MAIA scales for individuals who had exposure
confirmation in a separate sample.
to these approaches. Their exposure to mind-body therapies likely
The study also generally demonstrated the internal consistency
affected the way the questions were understood [125]. However,
reliability of the scales. The three alphas slightly below .70 may be
the language that was used in creating the items was cognitively
of some concern. We decided to accept alphas greater than 0.65
tested with a sample that included individuals without any such
for three- to four-item scales, in an effort to reduce questionnaire
exposure. The psychometric performance of the MAIA requires
burden. Because scales with as few as three items are more
assessment in a population without such exposure, which will be
sensitive than longer scales to the similarity of the questions, it may
the subject of a separate study.
be helpful for future research to explore the addition of items to
enhance these particular scales. It should also be borne in mind Second, the current paper presents the psychometric evaluation
that correlations between MAIA scales and scales of related of the MAIA scales in a single population. The observed
constructs are theoretically limited by the reliability of each scale. correlational patterns could be idiosyncratic to the present sample
For a short scale with an alpha, for example, of 0.69, a correlation and need psychometric exploration in additional samples.
of .53 with a scale of a related construct is near its theoretical Third, the current paper presents the results of the field test in a
maximum. healthy population. We tested the construct validity of the new
To explore the construct validity of the MAIA scales, we took MAIA scales with a large number of measures of related constructs
three broad approaches. First, construct validity was assessed by measured concurrently, and used the STAI-T trait anxiety scale to
correlations between MAIA scales and scales of related constructs. determine the ability of the MAIA scales to independently predict
Expected correlations were specified and largely confirmed by the subclinical levels of this important outcome. Future research could
data from a field test in a mind-body therapy-experienced explore validity further by examining its associations to more
population sample. The meaning of the new MAIA scales was clearly defined clinical conditions, such as chronic pain, addiction,
explored by examining the resulting correlations irrespective of the or eating or anxiety disorders.
a priori hypotheses. Correlation patterns demonstrated differential Fourth, we started the field test with 63 items and dismissed
relationships between the MAIA and similar scales of body many of the original items during our item selection process. This
awareness, mindfulness, and emotion regulation, providing resulted in a data-driven modification of our original construct and
support for the MAIA scales as both a distinct and multidimen- the loss of several aspects of body awareness discussed in Part 2.
sional conceptualization of body awareness. Second, construct Owing to poor psychometric performance in the field test, we lost
validity was also shown by differences in MAIA scale scores the dimensions of Allowing, Judgmental, Narrative Awareness,
between less and more highly experienced mind-body therapy and Present-Moment Awareness. These aspects should be
practicing individuals. And third, regression analysis showed considered in future editions of the instrument. However, as we
incremental validity for multiple dimensions of the MAIA scale argued above, the loss of these dimensions may in part be
in understanding anxiety as an example of a clinical outcome. compensated by the 7-item scale of Attention Regulation. The
Any psychometric assessment of a measure for a construct that Attention Regulation scale showed the largest difference between
involves skills and new language learned during a practice or more and less highly experienced mind-body practitioners. We
intervention necessarily encounters the difficulty that the under- would expect that this is a particularly important skill that

MAIA
continues to be strengthened with increasing training in mind- scales. A field test in a sample of individuals familiar with a variety
body approaches. of mind-body therapies provided acceptable psychometric results
The fundamental limitation of the MAIA is that it is self-report. and support for construct validity. It needs to be determined how
One consequence is that it is largely capturing intra- rather than the MAIA scales function in a population that has not been
interindividual variability, since respondents have so little infor- exposed to these therapies, and whether the scales are sensitive to
mation about other people’s body awareness; of necessity they will changes in longitudinal studies. Further cross-sectional and
be reporting deviations from their own baseline. This is of course a longitudinal validity data using the MAIA in different populations
limitation of all psychological self-report scales. Indeed, given that are currently being collected and analyzed. As the constructs of
all of our validity measures themselves contain the same validation interoception and body awareness warrant a multidisciplinary
gap, our imposing validity matrix is still a monomethod matrix. team approach for their operationalization, we would like to invite
But, as an assessment of awareness, the MAIA adds another other researchers across disciplines for broad cooperation in the
significant difficulty: the special challenge of reporting something refinement and further development of valid measures of
of which we may be unaware. Hence it will be especially important interoceptive body awareness. We view the MAIA as an
in the case of the MAIA to seek validation by other, more appropriate starting point in this important research field.
‘‘objective,’’ means, such as behavioral measures (heart rate and
airway resistance detection tasks) or fMRI changes in brain Supporting Information
activities.
A major strength of the MAIA instrument is its multidimen- Supporting Information S1 The Multidimensional Assessment
sionality. Whereas prior instruments were unable to distinguish of Interoceptive Awareness (MAIA), questionnaire with scoring
between beneficial and maladaptive aspects of interoceptive body instructions.
awareness, the new scales allow a more differentiated assessment of (DOCX)
essential psychological aspects of the perception and evaluation of
body sensations. This instrument has the potential to further our Acknowledgments
understanding of psychosomatic mechanisms of action for a
We are grateful to Viranjini Gopisetty and David Goldman for their work
variety of mind-body interventions. In terms of treatment for on this project. We thank Cathy Kerr, Margaret Kemeny, Jocelyn Sze,
clinical conditions, such as anxiety, understanding which aspects of Judith Wrubel, and Theresa Silow for important input into the
body awareness are related to clinical outcomes could help inform development of the questionnaire and valuable comments on earlier
the design of mind-body therapies aimed at treating those versions of this manuscript. We are especially thankful to all participants of
conditions. Future research on mind-body interventions could the focus groups and cognitive interviews.
also use a multidimensional assessment of body awareness to
understand which aspects of body awareness contribute to Author Contributions
improvements in clinical outcomes. Conceived and designed the experiments: WM CP JD AS. Performed the
In summary, the systematic development of a new self-report experiments: WM CP JD MA EB AS. Analyzed the data: WM CP JD MA
instrument for interoceptive awareness resulted in the MAIA, a EB AS. Contributed reagents/materials/analysis tools: WM CP JD MA
32-item multidimensional instrument with eight separately scored EB AS. Wrote the paper: WM CP JD MA EB AS.
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The Multidimensional Assessment of Interoceptive

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Figure 1. Iterative Sequence of Development and Testing of the MAIA.

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Table 1. Sample Characteristics (total N = 325).

Less Experienced Highly Experienced p

Female (N, %) 135 (86) 103 (71) .001 (exact test)

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Table 2. Items and Standardized CFA Loadings.

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x2/DOF/p CFI TLI RMSEA (CI) SRMR Discussion

Table 4. Final Multidimensional Conceptual Framework of Body Awareness and Scales.

1) Awareness of Body Sensations

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Noticing 4 1–4 0.69 0.35–0.56 3.94 (.59) 1.50–5.00

Table 6. Pearson Product-Moment Correlations among the Eight MAIA Scales.

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Table 7. Mean Differences in MAIA Scales by Level of Experience.

Teachers with .5 years of experience

Mean (SD) Observed range Mean (SD) Observed range p (t-test)

Noticing 3.79 (.60) 1.50–5.00 4.09 (.54) 2.00–5.00 ,.0001

Methods sensations. FFMQ subscale internal-consistency reliabilities ranged

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Validity Scales MAIA AASI- EEACS-

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For further evaluating construct validity of the MAIA, we Method

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