Received: 23 March 2017 Revised: 1 September 2017 Accepted: 4 October 2017

DOI: 10.1002/mpr.1596

ORIGINAL ARTICLE

Assessing body awareness and autonomic reactivity: Factor

structure and psychometric properties of the Body Perception
Questionnaire‐Short Form (BPQ‐SF)
Ana Cabrera1,2* | Jacek Kolacz3* | Guillem Pailhez1,2 | Andrea Bulbena‐Cabre2,4† |

Antonio Bulbena1,2‡ | Stephen W. Porges3,5

1
Institute of Neuropsychiatry and Addictions,
Barcelona, Spain Abstract
2
Department of Psychiatry and Forensic Body awareness and reactivity dysfunction are characteristic of a range of psychiatric disorders.
Medicine, Universitat Autonoma de Barcelona, Although the neural pathways communicating between the body and brain that contribute to these
Barcelona, Spain experiences involve the autonomic nervous system, few research tools for studying subjective
3
Kinsey Institute Traumatic Stress Research bodily experiences have been informed by these neural circuits. This paper describes the factor
Consortium, Indiana University, Indiana, USA
4
structure, reliability, and convergent validity of the Body Awareness and Autonomic Reactivity
Icahn School of Medicine at Mount Sinai,
New York, USA
subscales of the Body Perception Questionnaire‐Short Form (BPQ‐SF). Exploratory and confirma-
5
Department of Psychiatry, University of
tory factor analyses were applied to data from three samples collected via the internet in Spain and
North Carolina at Chapel Hill, North Carolina, the US and a college population in the US (combined n = 1320). Body awareness was described by a
USA single factor. Autonomic reactivity reflected unique factors for organs above and below the dia-
Correspondence phragm. Subscales showed strong reliability; converged with validation measures; and differed
Jacek Kolacz, the Kinsey Institute Traumatic
by age, sex, medication use, and self‐reported psychiatric disorder. Post hoc analyses were used
Stress Research Consortium, Indiana
University, Bloomington, IN 47405 to create the 12‐item Body Awareness Very Short Form. Results are discussed in relation to the dis-
Email: [email protected] tinct functions of supra‐ and sub‐diaphragmatic autonomic pathways as proposed by the Polyvagal
Theory and their potential dysfunction in psychiatric disorders.

KEY W ORDS

autonomic nervous system, autonomic reactivity, body awareness, interoception, polyvagal theory

1 | I N T RO D U CT I O N has grown considerably (e.g., Craig, 2009; Critchley & Harrison, 2013;
Damasio, 1999; Porges, 2009a). With these developments, there is a
Increasingly, the role of disordered body awareness and reactivity is need for self‐report methods that can conceptually bridge subjective
described across a range of clinical problems including anxiety body experiences with neuroscience, physiology, and medicine. Self‐
(Domschke, Stevens, Pfleiderer, & Gerlach, 2010; Mallorquí‐Bagué reports provide indispensable information about internal experiences
et al., 2013), depression (Harshaw, 2015;), post‐traumatic stress (van in naturalistic settings and provide an important complement to labora-
der Kolk, 2015), autism (DuBois, Ameis, Lai, Casanova, & Desarkar, tory‐based measures, physiological monitoring, and quantification of
2016), schizophrenia (Wylie & Tregellas, 2010), and eating disorders neural processes. However, few psychometrically‐tested self‐report
(Kaye, Fudge, & Paulus, 2009). With rising interest and methodological measures informed by the neural links between body and brain are
availability, knowledge about how physiological and neural processes available to study the embodied experiences involved in typical indi-
are related to subjective body experiences and psychiatric dysfunction vidual differences and clinical populations.

*A. C. and J. K. contributed equally to this work.

1.1 | Physiological circuits underlying body
†
Mental Illness, Research, Education, and Clinical Center (MIRECC), James J. awareness and reactivity
Peters VA Medical Center, Bronx, New York City, USA.
‡
Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Body awareness, sometimes called the “sixth sense”, is the subjective
Madrid, Spain. experience of information arising from within the body. It emerges

Int J Methods Psychiatr Res. 2018;27:e1596. wileyonlinelibrary.com/journal/mpr Copyright © 2017 John Wiley & Sons, Ltd. 1 of 12
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2 of 12 CABRERA ET AL.

from a complex network of afferent and efferent pathways and their with efferent pathways originating in the dorsal nucleus of the vagus.
feedback loops between body structures and the central nervous sys- Animal models show that induced activity in dorsal motor nucleus of
tem (Cameron, 2001; Craig, 2002; Gellhorn, 1964; Mandler, Mandler, the vagus (DVC) produces changes in digestive function via descend-
& Uviller, 1958; Mehling et al., 2009; Porges, 1993b; Sherrington, ing vagal pathways (Zhang, Ai, & Cui, 2006; Zhu, Chang, Xie, & Ai,
1906). Signals about internal body functions originate in sensors that 2016). Unlike the diverging efferent projection sites in the VVC and
carry information from target organs and tissues, are integrated and DVC, afferent vagal fibers from both the subdiaphgragmatic organs
propagated through afferent pathways that include the spinal and cra- and supradiaphragmatic organs terminate largely in the same loca-
nial nerves, are routed to brain structures that monitor incoming infor- tion, the NTS.
mation, and are regulated by descending efferent signals. These
efferent signals also regulate the function of individual tissues and
organs in response to internal and external conditions. Many of these 1.2 | The Body Perception Questionnaire
signals travel along autonomic pathways, a system that has tradition- Although many instruments have been introduced to measure subjec-
ally been divided into two antagonistic components—the sympathetic tive experiences of body awareness and the body's activation responses,
nervous system and the parasympathetic nervous system (e.g., Lang- Mehling et al. (2009) observed that few had been developed with atten-
ley, 1921; Wenger, 1966). However, contemporary views point toward tion to rigorous psychometric testing. Psychometric testing assesses the
autonomic function as reflecting multiple coordinated control systems, measurement properties of research instruments, without which
which are activated or dampened in response to internal and external reliability and validity is unknown. In the years since, several new
situational demands. Though each innervated organ and tissue may have psychometrically‐rigorous scales have been introduced (e.g., Mehling
individual neural feedback loops that regulate its specific function, the et al., 2012; Tove, Målfrid, & Liv Inger, 2012). However, those that have
physiological needs of an organism and functional integrative circuits been shown to have strong psychometric properties have not been devel-
can produce widespread changes across the body (e.g., Jänig, 2006). oped with a foundation in organization of peripheral neural pathways.
The Polyvagal Theory (Porges, 1995, 2009b, 2011) provides a The Body Perception Questionnaire (BPQ; Porges, 1993a) was
neurophysiological framework for the study of the organization of developed to assess the subjective experiences of the function and
autonomic systems. Using evidence from comparative anatomy, reactivity of target organs and structures that are innervated by the
neurophysiology and behavioral observations, this theory describes autonomic nervous system. The original BPQ, totaling 122 items,
two distinct vagal circuits within the parasympathetic nervous system assessed body awareness, autonomic nervous system reactivity, cogni-
that form a ventral vagal complex (VVC) and a dorsal vagal complex tive‐emotional‐somatic stress response, body and cognitive stress
(DVC). The organization of these individual circuits, along with the response styles, and health history. Since its introduction, the BPQ
sympathetic nervous system, can affect subjective experiences of body has been used in more than 25 peer‐reviewed publications (see Sup-
awareness by modulation of signals that arise from the body by top‐ plemental Material Table S6) and has been translated into several lan-
down post‐processing, including cortical areas informed by the guages. However, broader application of this instrument has been
information traveling through the body‐integrative circuits of the brain limited by a lack of psychometric testing and its extensive length. The
(e.g., Craig, 2002). BPQ aspects that have been of highest research interest are the body
First, the VVC regulates the striated muscles of the face and head awareness and autonomic reactivity subscales, with studies often using
(e.g., pharynx, larynx, mastication muscles, and middle ear muscles) and only these subscales (e.g., Bernátová & Svetlak, 2017; Critchley, Wiens,
visceral organs above the diaphragm (e.g., heart and bronchi; see Rotshtein, Öhman, & Dolan, 2004). In addition, many stress coping ques-
Porges 2001, Porges, 2009b, 2011) through efferent pathways that tionnaires and health history inventories are already widely available.
originate in the nucleus ambiguus in the brainstem. In addition to the Thus, with the aim of developing a shorter questionnaire, we focus here
efferent action of this system, these bodily structures also contain on the two subscales that may prove most useful for research purposes.
afferent fibers that route information about supradiaphragmatic
organs and the striated muscles of face and head to the brain, with
many of these sensory pathways terminating in the brainstem in the 1.3 | The present study
nucleus of the solitary tract (NTS).
This paper examines the psychometric properties of the body aware-
Second, the sympathetic nervous system innervates many of the
ness and autonomic reactivity BPQ subscales to create a shorter, psy-
same organs throughout the body as the VVC (see above) and the
chometrically supported measurement instrument (BPQ‐Short Form)
DVC (see below) as well as additional efferent connections to skin,
and examine the relations of the subscales to demographics and psy-
skeletal muscle, the trunk, and extremities. Some afferent signals
chiatric illness diagnosis.
involved in these functions are routed to uniquely pre‐sympathetic
pathways such as A1 catecholaminergic cell group and the rostral ven-
trolateral medulla and others terminate in integrative brainstem sites
2 | METHOD
that are shared with vagal afferents, including the NTS, parabrachial
nucleus, and insula (Craig, 2002), and thus may share some functional
integration with VVC and DVC activity.
2.1 | Participants
Third, the DVC carries signals that regulate the organs below the Data were collected from three sources: a Spanish online sample, an
diaphragm (e.g., stomach, liver, gallbladder, pancreas, and intestines), undergraduate American college sample, and an American online
CABRERA ET AL. 3 of 12

sample. All procedures were approved by the IRB of the institution Participants in the Spanish sample completed a version that was
overseeing data collection. translated and back‐translated by native Spanish speakers fluent in
First, a sample of Spanish‐speaking adults (n = 500) completed an English. Item wording in the back translation converged well with
online survey distributed through the University of Barcelona. Recruit- the original English‐language version, supporting translation fidelity.
ment was conducted using Spanish‐language websites and online news-
papers. Participants were excluded if they were younger than 18 years 2.2.2 | Validation measures
of age, reported taking psychotropic drugs and/or beta‐blockers, or did In the Spanish sample, the Stress Reactivity Index (SRI; de Rivera, De
not complete the questionnaires. No incentive was provided for survey las Cuevas, Monterrey, Rodriguez‐Pulido, & Gracia, 1993) and the
completion. The final sample consisted of 465 participants (Mean Spanish‐language version of the SomatoSensory Amplification Scale
age = 33.91, SD = 12.26; 62% female). These participants completed (SSAS; Barsky, Wyshak, & Klerman, 1990; Nakao & Barsky, 2007)
the BPQ, criterion validity measures, and demographic questions. were used for testing convergent validity. The SRI consists of 32
Fifty‐three randomly selected participants completed the BPQ a week Likert‐type questions regarding habitual reactions under stress or
after their initial responses for test–retest reliability. tension (e.g., digestive discomfort), which are summed to generate a
A second dataset was collected as part of a larger study distributed global stress reactivity score. The SRI was developed in Spanish
through an online portal at Indiana University. English‐speaking (Gonzalez de Rivera, Rodriguez‐Abunim, & Hernandez, 1996;
American residents were recruited using Amazon's Mechanical Turk. Monterray, 1996) and captures both intra‐individual stability and
Respondents received $.30 for survey completion. Responders were stress reactivity (Monterrey, Gonzalez de Rivera, De las Cuevas, &
excluded if they did not complete the survey (n = 64), incorrectly Rodríguez, 1991). The SSAS consists of 10 Likert‐type items that
answered attention‐testing questions (e.g., “Please select ‘Very much’ assess the extent to which participants are bothered by uncomfort-
for this response”, n = 52), or submitted from duplicate IP addresses able visceral and somatic sensations that are not typical of serious
(n = 5). The final sample consisted of 540 participants (Mean age = 35.13, disease. Its single‐factor dimensionality, reliability, and validity are
SD = 10.97; 63% female; 84% White, 7% African‐American/Black, 6% documented in multiple studies (Barsky et al., 1990; Speckens,
Asian, and 5% Hispanic or Latina/o). Spinhoven, Sloekers, Bolk, & van Hemert, 1996).
A third dataset was collected at the University of Maryland from
an English‐speaking undergraduate student population enrolled in an 2.2.3 | Demographic information
introductory psychology course (n = 315). Participants completed a In the Spanish sample, participants self‐reported their sex, age, current
paper version of the BPQ. All students present on the day of data col- medication use, and psychiatric disorder diagnosis.
lection participated and no incentive was provided for survey comple-
tion. Specific demographic information was not collected at the time of
2.3 | Procedures
questionnaire administration. The freshman cohort at the time of col-
lection was 53% male and 60% Caucasian (University of Maryland, Data analysis was conducted using SPSS, R version 3.3.3 (R Core Team,
2017). Most participants were under the age of 20 but the exact age 2017), RStudio version 1.0.136 (RStudio, Inc., 2009–2016), and Mplus
distribution is unavailable. 7.31 (Muthen & Muthen, 1998–2015).

2.3.1 | Data preparation

2.2 | Measures
Categorical exploratory factor analysis (EFA) using full item distribu-
2.2.1 | The Body Perception Questionnaire (BPQ) tions resulted in solutions requiring untenably high numbers of fac-
Twenty‐eight items from the original 45‐item body awareness sub- tors and loadings with complex structure before adequate fit could
scale were selected by the original questionnaire's author. Items were be achieved. Thus, items were dichotomized (0 = never, 1 = occasion-
selected on the basis of the insight that has been gained about the ally or more often) to examine whether threshold‐based categorical
relation of these experiences with autonomic circuits since the original responses could be better described by a simple factor structure. This
BPQ was developed over 20 years ago. Items were retained on the threshold was to selected and to preserve acceptable response distri-
basis of their precision in capturing aspects of direct functional control bution cell sizes for factor analysis. Data on all items in the Spanish
via autonomic pathways. For instance, the item “an urge to swallow” sample were complete. In the American online sample, missing values
was retained due to its focus on the swallowing muscles and their comprised less than 3% of any one item and .9% of all data. In the
feedback, which are innervated by vagal and glossopharyngeal path- American undergraduate sample, missing values comprised less than
ways that have a well‐documented peripheral neural circuit (see 1% of any one item and less than 0.2% of all data. Inspection of
Kolacz, Lewis, & Porges, in press). Items which bear relation to auto- these missing values did not reveal any systematic patterns of
nomic circuits but were “noisy” in their likely relation to complex missingness.
extra‐autonomic underpinnings (e.g., “clumsiness or bumping into peo-
ple”) were dropped. All items from the autonomic reactivity subscale 2.3.2 | Factor analysis
were retained. Subscale dimensionality was assessed by a combination of exploratory
Item responses for both subscales are on a 5‐point ordinal scale and confirmatory factor analysis. We applied a robust weighted least
spanning never (1) to always (5). Participants in the American sam- squares estimator (WLSMV; see Muthén & Muthén, 1998–2013), as
ples completed the original English‐language version of the measure. recommended for models with discrete responses by Barendse, Oort,
4 of 12 CABRERA ET AL.

FIGURE 1 Exploratory factor analysis scree plots for body awareness and autonomic reactivity items in the Spanish internet sample

and Timmerman (2015). Exploratory factor retention was guided by substantially on both factors. Thus, given the support for the one fac-
model fit, factor loading simple structure, theoretical predictions, and tor solution by the RMSEA, scree plot, and simple structure, the one‐
scree plots (Cattell, 1966). Goodness of fit to the data was evaluated factor solution was retained. Geomin rotated standardized loadings
using the root mean squared error of approximation (RMSEA; Steiger using this solution ranged from .57 to .76 (see Table 2).
& Lind, 1980; Steiger, 1990), the Tucker‐Lewis index (TLI; Tucker &
Lewis, 1973); and the Comparative Fit Index (CFI; Bentler, 1990). As
3.1.2 | Autonomic reactivity
suggested by Hu and Bentler (1999), we considered good fit to be evi-
The autonomic reactivity EFA scree plot and fit indices did not clearly
denced by an RMSEA value near .06 or lower as well as CFI and TLI
converge on one solution in the first iteration. The scree plot indi-
values near .95 or greater. Scree plots were examined for the last sub-
cated one large eigenvalue followed by relatively low values that
stantial drop in eigenvalue magnitude (Fabrigar, Wegener, MacCallum,
did not have a clear second substantial drop, pointing to a one‐factor
& Strahan, 1999). EFA results were subject to oblique rotation
solution (Figure 1); the RMSEA approached good fit in the three‐fac-
according to the geomin criterion (Yates, 1987), which produces solu-
tor solution (Table 1); and the CFI and TLI suggested a 4‐factor solu-
tions with simple interpretations when factor structure is not highly
tion (Table 1). Thus, the 1–3‐ and 4‐factor solutions were
complex (Sass & Schmitt, 2010) and can reproduce correlated or
examined. One item was dropped due to its singular driving of a
uncorrelated factor structures (Fabrigar et al., 1999). EFA results from
the Spanish dataset were then applied to the American datasets as
confirmatory factor analysis (CFA) models and assessed for goodness TABLE 1 Exploratory factor analysis model fit statistics for the
Spanish internet sample
of fit using the cut off values described above.
RMSEA 90%
Factors χ2 df RMSEA confidence intervals CFI TLI
2.3.3 | Reliability, validity, and relation to demographic
Body awareness subscale
variables
1 647.20 299 .050 .045 .055 .94 .93
Subscale scores based on the observed factor structure were
computed and used to assess reliability, validity, and relation to 2 433.87 274 .035 .029 .042 .97 .97

demographic variables in the Spanish sample. 3 330.28 250 .026 .018 .034 .99 .98
4 253.56 222 .016 .000 .026 1.00 .99

5 194.19 205 .000 .000 .016 1.00 1.00

3 | RESULTS
Autonomic reactivity subscale initial item set

3.1 | Exploratory factor analysis 1 1330.49 324 .082 .077 .086 .85 .84
2 909.58 298 .066 .062 .071 .91 .89
3.1.1 | Body awareness
3 703.02 273 .058 .053 .064 .94 .92
The EFA was conducted on the body awareness and autonomic reac- 4 490.55 249 .046 .040 .052 .97 .95
tivity items separately. Two items from the body awareness subscale 5 362.89 226 .036 .029 .043 .98 .97
were removed (“An urge to urinate” and “Fullness of my bladder”)
due to their bivariate cross tables with other items resulting in Autonomic reactivity subscale final item set
unpopulated cells, which can produce unreliable results in factor anal- 1 728.75 170 .084 .078 .090 .89 .87
ysis. The body awareness subscale results supported a one‐factor 2 327.96 151 .050 .043 .058 .96 .96
structure, as evidenced by the scree plot (Figure 1) and RMSEA 3 210.52 133 .035 .026 .044 .98 .98
(Table 1). CFI and TLI values approached good fit in the one‐factor 4 148.29 116 .024 .010 .035 .99 .99
solution but did not fully reach our criteria for good fit until a second 5 107.00 100 .012 .000 .028 1.00 1.00
factor was included in the model (Table 1). When examined, the two‐ RMSEA = root mean square error of approximation; CFI = Comparative Fix
factor solution lacked a simple structure, with many items loading Index; TLI = Tucker‐Lewis Index.
CABRERA ET AL. 5 of 12

TABLE 2 Body awareness subscale exploratory (EFA) and confirmatory (CFA) factor analysis standardized factor loadings
Loading
Item EFA (Spanish, internet) CFA (US, internet) CFA (US, college)

Swallowing frequently .62 .73 .72

An urge to cough to clear my throat .57 .74 .64
My mouth being dry* .66 .80 .69
How fast I am breathing* .67 .83 .66
Watering or tearing of my eyes .70 .82 .60
Noises associated with my digestion .59 .80 .51
A swelling of my body or parts of my body* .71 .83 .67
An urge to defecate .70 .76 .56
Muscle tension in my arms and legs* .67 .87 .65
A bloated feeling because of water retention* .63 .84 .73
Muscle tension in my face .60 .81 .63
Goose bumps* .65 .85 .71
Stomach and gut pains* .68 .90 .82
Stomach distension or bloatedness* .66 .86 .80
Palms sweating .64 .78 .58
Sweat on my forehead .69 .79 .61
Tremor in my lips* .76 .85 .76
Sweat in my armpits .61 .80 .58
The temperature of my face (especially my ears) .58 .81 .65
Grinding my teeth .58 .76 .63
General jitteriness .59 .85 .66
The hair on the back of my neck “standing up”* .75 .82 .67
Difficulty in focusing .58 .86 .63
An urge to swallow* .75 .87 .74
How hard my heart is beating* .70 .87 .66
Feeling constipated .58 .84 .61

*Items composing the Body Awareness Very Short Form

fourth factor (“I have difficulty adjusting my eyes to changes in illumi- 3.2 | Confirmatory factor analysis
nation”), two items were dropped due to their substantial loadings on
The EFA results were tested using a CFA on the American datasets.
multiple factors (“I drool, especially when I am excited”, “I produce a
This structure fit the data well in both the internet sample
lot of saliva even when I am not eating”), and two items were
(RMSEA = .035 [90% CI: .032, .038], CFI = .98, TLI = .98) and the college
dropped due to their lack of substantial loadings on any factor (“My
sample (RMSEA = .029 [90% CI: .023, .034], CFI = .94, TLI = .94). CFA
nose is runny, even when I am not sick”; “I have trouble focusing
loadings were similar to EFA results (Table 2 and 3). The
when I go into dimly or brightly illuminated places”). The resulting
supradiaphragmatic reactivity factor was correlated with
item pool was reanalyzed. The scree plot showed two deviating
subdiaphragmatic reactivity in both confirmatory samples (US internet
eigenvalues, indicating that one or two factors could be used to
r = .78; US undergraduate r = .65). The body awareness factors were
explain the data (Figure 1). Fit indices supported a two‐factor solu-
correlated with supradiaphragmatic reactivity (US online r = .72; US
tion (RMSEA = .050 [90% CI: .041, .056], CFI = .96, TLI = .95). Thus,
undergraduate r = .57) and with subdiaphragmatic reactivity (US online
we accepted the two‐factor solution. All items but one (“I feel like
r = .70, US undergraduate r = .49).
vomiting”) demonstrated simple structure by loading substantially
on only one factor.
The resulting factors corresponded with reactivity of organs above
3.3 | Reliability and validity
the diaphragm (supradiaphragmatic) and below the diaphragm
(subdiaphragmatic). These factors were moderately correlated 3.3.1 | Descriptive statistics
(r = .50). One item (81: “I get dizzy when urinating or having a bowel The BPQ‐SF was scored using the sum of dichotomized responses
movement”) loaded onto the supradiaphragmatic factor but did not (0 = never, 1 = occasionally or more often) according to the factor struc-
conceptually coalesce with the other items. Its removal did not sub- ture described above, with “I feel like vomiting” included in both reac-
stantially affect the factor loadings, factor correlations (r = .49), fit indi- tivity scales. Descriptive statistics for BPQ‐SF measures are presented
ces (Table 1), or eigenvalues (bottom right panel of Figure 1). Resulting in Table 4. Subscales deviated from normality, as assessed by skew-
factor loadings are presented in Table 3. ness, kurtosis, visual examination of qq plots, and Shapiro–Wilk tests
 6 of 12

TABLE 3 Autonomic reactivity exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) standardized loadings
Loadings
EFA (Spain, internet) CFA (US, internet) CFA (US, college)
Supradiaphragmatic Subdiaphragmatic Supradiaphragmatic Subdiaphragmatic Supradiaphragmatic Subdiaphragmatic
Item reactivity reactivity reactivity reactivity reactivity reactivity

I have difficulty coordinating 0. 94 −0.22 0.88 0.74

breathing and eating.
When I am eating, I have 0.72 −0.10 0.76 0.58
difficulty talking.
My heart often beats irregularly. 0.60 0.01 0.76 0.59
When I eat, food feels dry and 0.68 0.02 0.87 0.70
sticks to my mouth and throat.
I feel shortness of breath. 0.79 0.04 0.84 0.79
I have difficulty coordinating 0.89 −0.21 0.87 0.67
breathing with talking.
When I eat, I have difficulty 1.02 −0.24 0.95 0.75
coordinating swallowing,
chewing, and/or sucking
with breathing.
I have a persistent cough 0.52 0.19 0.83 0.67
that interferes with my
talking and eating.
I gag from the saliva in my 0.49 0.13 0.85 0.75
mouth.
I have chest pains. 0.58 0.12 0.78 0.57
I gag when I eat. 0.60 0.13 0.81 0.80
When I talk, I often feel I 0.64 0.03 0.81 0.68
should cough or swallow
the saliva in my mouth.
When I breathe, I feel like I 0.73 0.10 0.84 0.70
cannot get enough oxygen.
I have difficulty controlling 0.61 0.02 0.85 0.70
my eyes.
I feel like vomiting. 0.45 0.32 0.29 0.61 0.26 0.50
I have “sour” stomach. 0.21 0.53 0.88 0.65
I am constipated. 0.07 0.50 0.87 0.75
I have indigestion. −0.01 0.97 0.88 0.85
After eating I have 0.14 0.81 0.88 0.88
digestive problems.
I have diarrhea. 0.29 0.43 0.81 0.82
CABRERA ET
AL.
CABRERA ET AL. 7 of 12

TABLE 4 Descriptive statistics for the Body Perception Questionnaire‐Short Form (BPQ‐SF) subscales and the Body Awareness Very Short Form
Measure Mean Median SD Skew Kurtosis Min Max

Spanish internet sample

BPQ‐SF Body Awareness 16.83 17.00 6.17 −.37 −.64 0.00 26.00
BPQ‐SF Supradiaphragmatic Reactivity 5.79 5.00 4.13 .49 −.65 0.00 15.00

BPQ‐SF Subdiaphragmatic Reactivity 3.30 4.00 1.96 −.28 −1.18 0.00 6.00

Body Awareness Very Short Form 7.53 8.00 3.15 −.36 −.71 0.00 12.00
American internet sample
BPQ‐SF Body Awareness 16.95 19.00 8.24 −.66 −.83 0.00 26.00
BPQ‐SF Supradiaphragmatic Reactivity 5.00 4.00 4.75 .78 −.62 0.00 15.00
BPQ‐SF Subdiaphragmatic Reactivity 3.05 3.00 2.27 −.08 −1.49 0.00 6.00
Body Awareness Very Short Form 7.62 9.00 4.02 −.57 −1.02 0.00 12.00
American college sample
BPQ‐SF Body Awareness 21.97 23.00 4.35 −1.31 1.48 3.00 26.00
BPQ‐SF Supradiaphragmatic Reactivity 6.49 6.00 4.04 .34 −.82 0.00 15.00
BPQ‐SF Subdiaphragmatic Reactivity 4.01 4.00 1.87 −.73 −.56 0.00 6.00
Body Awareness Very Short Form 10.10 11.00 2.27 −1.48 1.95 0.00 12.00

(all subscale scores p < .05). Thus, reliability and validity tests were con- corrected and accelerated bootstrapping with 1000 draws. Results are
ducted using measures that do not rely on normality assumptions. presented in Table 5. All internal consistency estimates were within a
typical range compared to the psychometric studies cited above.

3.3.2 | Internal consistency

Internal consistency was assessed using the categorical omega coeffi- 3.3.3 | Test–retest reliability
cient (Green & Yang, 2009; Kelley & Pornprasertmanit, 2016) imple- Test–retest reliability was assessed using the intra‐class correlation
mented in the MBESS R package (Kelley, 2017). This method provides coefficient (ICC) in the Spanish sample. Each subscale demonstrated
internal consistency assessments superior to Cronbach's alpha when high test–retest reliability (body awareness = .99; supradiaphragmatic
items are categorical and factor loadings are variable, as was the case reactivity = .97, subdiaphragmatic reactivity = .96).
with BPQ‐SF items. Like Cronbach's alpha, categorical omega ranges
from 0 to 1 and its assessments of internal consistency for published
psychometrically‐examined scales includes ranges from .68 to .97 3.3.4 | Convergent validity
(Roberson & Renshaw, 2017; Voskuil, Pierce, & Robbins, 2017; Zhu & Spearman correlations were used to examine convergent validity in the
Lowe, 2017). We computed 95% confidence intervals using bias‐ Spanish internet sample (Table 6). SRI scores (M = 22.38, SD = 5.82)

TABLE 5 Internal consistency (categorical ω) for Body Perception Questionnaire‐Short Form subscales and Body Awareness Very Short Form;
values in brackets are 95% confidence intervals
Body Perception Questionnaire‐Short Form
Body awareness Supradiaphragmatic reactivity Subdiaphragmatic reactivity Body Awareness Very Short Form

Spanish internet sample .92 [.91–.93] .89 [.86–.90] .77 [.72–.80] .86 [.82–.87]
American internet sample .96 [.94–.97] .94 [.92–.95] .87 [.84–.89] .91 [.88–.92]
American college sample .92 [.88–.91] .88 [.85–.89] .78 [.71–.82] .83[.68–.87]

TABLE 6 Spearman correlation (Rho) table for Body Perception Questionnaire‐Short Form (BPQ‐SF) subscales, Body Awareness Very Short Form,
Stress Reactivity Index (SRI), SomatoSensory Amplification Scale (SSAS), and age in the Spanish internet sample
2 3 4 5 6 7

1. BPQ‐SF Body awareness 0.67* 0.57* 0.94* 0.57* 0.51* −0.14*

2. BPQ‐SF Supradiaphragmatic reactivity 0.57* 0.66* 0.65* 0.46* −0.05
3. BPQ‐SF Subdiaphragmatic reactivity 0.56* 0.58* 0.42* 0.00
4. Body Awareness Very Short Form 0.55* 0.48* −0.11*
5. SRI 0.51* −0.03
6. SSAS −0.11*
7. Age

*p < .05.
8 of 12 CABRERA ET AL.

and SSAS scores (M = 7.40, SD = 1.98) were moderately correlated (Table 7). Too few participants reported disorders to permit sufficient
with all BPQ‐SF subscales. power for assessing differences among specific diagnoses.

3.5 | Post hoc analysis: Body Awareness Very Short

3.4 | BPQ‐SF relation to sample, demographics, and Form
clinical variables Given the number of items included in the body awareness subscale for
the measurement of a single factor, we examined whether the item count
Wilcoxon‐Mann–Whitney U tests were used to test BPQ‐SF subscale
differences among samples and between categorical demographic var- could be reduced for research applications in which scale brevity is of

iables. Effect sizes were calculated using Cliff's d (Cliff, 1993), imple- utmost concern. We assessed whether 10 to 15 items with the highest
factor loadings across all datasets could be used to generate scores with
mented in the orddom R package (Rogmann, 2013), and are included
for relative comparison of effect strength and as a reference for plan- high fidelity to the 26‐item score (criterion Rho = .90). The lowest item

ning future studies. Nearly all between‐sample contrasts were statisti- count that met our criteria was a 12‐item subscale (Spanish sample

cally significant (Figure 2). The American college sample deviated most Rho = .94, US online Rho = .97, US undergraduate Rho = .91). The items
that compose the resulting Body Awareness Very Short Form are marked
substantially from the others, showing the highest scores on all sub-
scales and deviating most strongly in body awareness. with an asterisk in Table 2. Descriptive statistics are displayed in Table 4.

Data from the Spanish sample was used to assess relations of Internal consistency was acceptable but lower than the full BPQ‐SF body
awareness subscale (Table 5). Test–retest reliability was excellent
BPQ‐SF subscales with demographics and self‐reported clinical vari-
ables. Body awareness was negatively associated with age (Table 6). (ICC = .97). Differences between samples, sex, medication use, and

Females scored higher on all three BPQ‐SF subscales and medication self‐reported psychiatric disorders, as measured by effect size, were very
similar to the full BPQ‐SF body awareness subscale (Figure 2; Table 7).
use predicted higher subdiaphragmatic reactivity scores (Table 7). Sev-
enty participants self‐reported having a psychiatric disorder (15.15%).
Of these, the most commonly reported were anxiety, depression, dys- 4 | DISCUSSION
thymia, or their combination (n = 41); eating disorders (n = 5); and
obsessive–compulsive disorder (n = 5). Participants who reported a The goal of this study was to assess the factor structure, reliability,
psychiatric disorder had elevated scores on all BPQ‐SF subscales convergent validity, and demographic variability of the BPQ‐SF.

FIGURE 2 Body Perception Questionnaire‐Short Form (BPQ SF) and Body Awareness Very Short Form subscale comparisons between samples.
Statistical significance [*p < .05] was computed using Wilcoxon‐Mann–Whitney U tests (see Supplementary Material Table S6 for test statistics).
Effect sizes (ES) were computed using Cliff's d
CABRERA ET AL. 9 of 12

TABLE 7 Differences in Body Perception Questionnaire‐Short Form (BPQ‐SF) subscales and Body Awareness Very Short Form by sex, medication
use, and self‐reported psychiatric disorder in the Spanish internet sample. U = Wilcoxon‐Mann–Whitney U test statistic; p = statistical significance
at alpha = .05; ES = effect size as measured by Cliff's d; Mdn = Median
BPQ‐SF
Supradiaphragmatic Subdiaphragmatic Body Awareness
Body awareness reactivity reactivity Very Short Form
Variable / percent
of sample U p ES Mdn U p ES Mdn U p ES Mdn U p ES Mdn

Sex 29162 .008 .15 28747 .018 .13 30572 <.001 .20 30901 <.001 .22

Female 62.15% 18.00 6.00 4.00 8.00

Male 37.85% 16.00 5.00 3.00 7.00

Medication use 18799 .851 .01 17282 .150 .09 15861 .008 .17 18213 .501 .04
No 77.20% 17.00 5.00 3.00 8.00
Yes 22.80% 17.00 5.50 4.00 8.00
Self‐reported psychiatric 16279 .013 .19 17071 .001 .24 16792 .003 .22 16274 .013 .19
disorder
No 84.85% 17.00 5.00 4.00 8.00
Yes 15.15% 19.00 7.00 4.50 9.00

Results suggest that body awareness can be described using a single vomiting” in the Spanish sample EFA. However, in the CFA factor load-
factor while items measuring autonomic reactivity cluster into ings in the American samples, the item was associated more strongly
subdiaphragmatic and supradiaphragmatic responses. This structure with subdiaphragmatic reactivity than supradiaphragmatic reactivity.
is consistent across a Spanish online sample as well as online and Although this could reflect cross‐cultural differences in the subscale
undergraduate college samples recruited in the United States, provid- structure, self‐reports of bodily reactivity have been found to show
ing evidence that the structure of these BPQ‐SF subscales may be remarkable stability across cross‐cultural samples (e.g., Nummenmaa,
robust to cultural differences across these populations. Post hoc anal- Glerean, Hari, & Hietanen, 2014). Additional data are needed to exam-
yses showed that the 12‐item Body Awareness Very Short Form pro- ine whether this discrepancy can be replicated or may be attributable
vides an alternative to the BPQ‐SF body awareness subscale for to random sampling variability.
studies in which questionnaire length is particularly constrained. The BPQ‐SF body awareness scores were positively related with
The single body awareness factor may reflect the shared afferent the SomatoSensory Amplification Scale, supporting convergent valid-
targets of cranial and spinal pathways in the brainstem. Although some ity that this subscale provides an assessment of the strength of per-
afferent pathways among these systems are unique, much of afferent ceived visceral and somatic sensations. Furthermore, both supra‐
cranial and spinal traffic is routed through shared integrative brainstem and sub‐diaphragmatic scores converged with Stress Reactivity Index
regions while traveling to higher brain structures (Craig, 2002). Con- scores, indicating that both subscales provide information on bodily
versely, the autonomic reactivity subscale structure was described by stress reactivity.
two factors, reflecting supra‐ and sub‐diaphragmatic responses. This There was a small but substantial negative association between
clustering suggests distinct efferent control systems that give rise to body awareness and age, which replicates previous work showing
individual differences in physiological responses in separate parts of decreased interoception associated with age (e.g., Khalsa, Rudrauf, &
the body. Supradiaphragmatic responses are likely driven by outflow Tranel, 2009; Murphy, Geary, Millgate, Catmur, & Bird, 2017) and is
from the VVC, which contains efferent source nuclei in the nucleus consistent with the American undergraduates, our youngest sample,
ambiguus, while responses below the diaphragm are likely coordinated showing highest levels of body awareness. Age‐related declines are
with the enteric nervous system through efferent pathways via the also observed in cardiac autonomic regulation by the VVC, as mea-
unmyelinated vagal fibers that originate in the dorsal motor nucleus. sured by respiratory sinus arrythmia (Antelmi et al., 2004; Byrne, Fleg,
Sympathetic efferent pathways innervate organs both above and Vaitkevicius, Wright, & Porges, 1996; Zhang, 2007), suggesting that
below the diaphragm and thus the role of this system is difficult to the co‐occurring changes in body sensation may reflect dampened sig-
interpret in light of the observed factor structure. It is likely that sym- nal transmission between body and brain over time.
pathetic reactivity contributes to both supra‐ and sub‐diaphragmatic Women scored higher than men on all BPQ‐SF subscales. It is pos-
reactivity and may contribute the strength of the association between sible that these scores reflect physiological sex differences, though
the two autonomic reactivity factors observed in both samples. Nota- other studies have been inconclusive in this area. Respiratory sinus
bly, all items had substantial unique effects not described by common arrhythmia has been found to be both higher (Zhang, 2007) and lower
factors, likely reflecting unique feedback loops that regulate individual (Ramaekers, Ector, Aubert, Rubens, & Van de Werf, 1998) in women
functions, in addition to capturing measurement error. compared to men (note these differences may be age‐dependent; see
The results of the autonomic reactivity factor analysis showed that Byrne et al., 1996). It is probable that the higher rates of body aware-
items have strong simple structure, with the exception of the supra‐ ness and autonomic reactivity in women in our study are the result of
and sub‐diaphragmatic reactivity loadings of the item “I feel like complex physiological and cultural interactions. However, women's
10 of 12 CABRERA ET AL.

elevated physiological reactivity in our study is in line with women's (combined n = 1320) provides a strong foundation for future work
elevated clinical prevalence of anxiety (McLean, Asnaani, Litz, & using more population‐representative samples.
Hofmann, 2011) and functional gastro‐intestinal disorders (Chang, Our assessment of convergent validity with the SRI was limited by
2004). Medication use was also related to elevated sub‐diaphragmatic the incomplete published psychometric information about that mea-
reactivity, which may be caused by medication side effects or use spe- sure. Thus, its inclusion provides a weak test of convergent validity.
cifically to reduce problems with subdiaphragmatic organ regulation. However, its development as a Spanish‐language questionnaire offers
All BPQ‐SF subscale scores were elevated in participants with a an important benefit and complements the use of the SSAS, which has
self‐reported psychiatric diagnosis. These results are consistent with extensive psychometric information but is used in translated form.
previous clinical observations showing altered interoceptive functions Finally, our measurement of psychiatric problems in the Spanish
across a range of psychiatric diagnoses (e.g., Harshaw, 2015; van der internet sample was based on a simple self‐report, rather than diagnos-
Kolk, 2015). While our small sample of self‐reported psychiatric diag- tic criteria, which may produce reporting bias or incomplete informa-
noses does not permit the assessment of altered function in specific tion. Participants may be unaware that they meet diagnostic criteria
disorders, there is abundant converging physiological and medical evi- if they lack access to psychiatric services or have beliefs that prevent
dence from other studies to support altered efferent and afferent them from seeking services. Though our results of altered body aware-
autonomic functions in specific diagnoses. Examples include Autism ness and autonomic reactivity in those with psychiatric diagnoses are
Spectrum Disorders (ASD), wherein reduced VVC control of the heart consistent with previous research that utilized more stringent criteria,
is inversely related to the severity of social impairment (Patriquin, future studies should use more precise psychiatric disorder
Scarpa, Friedman, & Porges, 2013; Porges et al., 2013, 2014) and measurement.
heightened risk of gastrointestinal disorders (Horvath & Perman,
2002) may be underpinned by DVC function. PTSD is related to ele-
vated rates of cardio‐respiratory issues, which involve regulation via
5 | CO NC LUSIO N
multiple autonomic circuits, and gastrointestinal issues, which are reg-
ulated in part by the DVC (Pacella, Hruska, & Delahanty, 2013).
Our results support the BPQ‐SF and Body Awareness Very Short Form as
Patients with gastrointestinal problems have also been found to have
tools for the measurement of subjective experiences of autonomic state
elevated rates of anxiety and depression and the number of gastroin-
and reactivity. We found that body awareness of autonomically inner-
testinal symptoms highly increases the probability of an anxiety disor-
vated organs is best described by a single factor, supporting neuroana-
der (Mussell et al., 2008). More than half of the psychiatric self‐report
tomical evidence that information from multiple afferent streams is
diagnoses in our sample included anxiety and/or depression, and these
integrated in the brain. We also found support for the individual
disorders likely have an outsize role in the observed effects. Additional
perceptions of bodily reactivity to stress as organized according sub‐dia-
work with specific samples is needed to better elucidate the effects of
phragmatic and supra‐diaphragmatic regions, which may reflect func-
individual disorders on BPQ‐SF subscales.
tional organization via distinct autonomic circuits. Although the
activation and function of autonomic circuits is not directly available to
subjective awareness, the monitoring of the function of target organs
4.1 | Limitations can be individually observed and reported. Applying such self‐report
methods with neurophysiologically informed organizing principles of
The results of this study are based on self‐reported subjective experi-
bodily experiences may help identify the status of individual circuits that
ences only. Though the clustering of autonomic reactivity items is con-
contribute to dysfunction and the development of novel interventions
sistent with predictions derived from neurophysiology, further
that can target specific system dysfunction.
research is needed to test whether subjective experiences are indica-
tive of differences in autonomic control systems. Future studies will
ACKNOWLEDGEMENTS
need to investigate how experiences of supradiaphragmatic and
The authors wish to thank Eric Lara, for his advice and computer sup-
subdiaphragmatic reactivity relate to objective physiological
port; A. Rafaela Castro, Narciso Cabrera, and Carlos Cabrera for their
measurements.
support and confidence in the project; Justin Garcia and Amanda
The internet and college recruitment methods also provide limita-
Gesselman for their help in planning and gathering data for the US
tions for this study. Internet‐based recruitment and data collection
online sample; Katie Gates for her input on an early version of this
introduces bias by being limited to respondents with internet access.
manuscript; Danny Rahal for compiling a list of studies that have used
Undergraduate sampling introduces bias due to a restricted age range
the BPQ; and all our participants. This research complies with the APA
and other population characteristics associated with advanced educa-
ethical standards for research with human populations. The authors do
tion, such as socioeconomic status. These features limit generalizability
not have any conflicts of interests to report.
to broader populations. The lack of specific demographic information
in the undergraduate dataset limits assessment of how these charac-
teristics may have impacted results. However, the convergence of
the factor structure across three samples provides support for the gen- D E C L A R A T I O N OF I N T E RE S T ST A T E M E N T
eralizability of BPQ‐SF dimensionality across populations and the large
multi‐national, age‐diverse group of samples used in this study The authors have no conflicts of interest to declare.
CABRERA ET AL. 11 of 12

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