Bull. Grad. School Educ. Hiroshima Univ., Part Ⅲ , No. 68, 2019, 111−120

Interoceptive Attention Tendencies Predict Trait
Anxiety in Undergraduate Students andHospital Nurses Participating inStress Management Programs
Russell Sarwar Kabir（Received. October 3, 2019）

Abstract: Interoceptive attention tendencies have been posited as the dimensions of change
in body awareness gained through the acquisition of self-regulatory skills from engaging incontemplative and body-mind health practices such as mindfulness meditation, yoga, andrelaxation training. However, eﬀorts are still needed to conﬁrm the model of the dimensions andto delineate the “positive” (adaptive) and “negative” (maladaptive) forms of attention to the bodydue to their relationships with anxiety. This study tests the factor and predictive incremental
validity assumptions of positive body awareness through correlational and regression analysis
of interoceptive attention tendencies measured by the Multidimensional Assessment ofInteroceptive Awareness (MAIA) with trait anxiety as the response variable measured by theState-Trait Anxiety Inventory (STAI). Data were analyzed from one-hundred and sixty-nineundergraduate students (n = 169; M age = 19.07, SD = 0.73) and sixty-six early-career nurses (n= 66, M age = 25.68, SD = 3.01) participating in stress management programs in southwesternJapan. Negative correlations between trait anxiety and the MAIA dimensions suggested
divergent validity in both samples in line with previous studies, except for Noticing. Providing
evidence that contrasts with other work on the instrument in Japan, Self-Regulation was foundto negatively correlate with and predict trait anxiety with regressions that were consistentin direction with the original MAIA validation for both samples. Among hospital nurses, theregression coefficient for Body Listening was consistent in direction but shown to differ inmagnitude from the original validation. Implications for these relationships as they relate toresearch on the MAIA are discussed.
Key words: body awareness, Multidimensional Assessment of Interoceptive Awareness,anxiety

1. Introduction
Prior research on body awareness processes has illustrated relationships between the awarenessof physiological signals from the body and the emergence of anxious arousal. Former constructs forThis paper, as a part of the authorʼs doctoral dissertation, has been examined by the following
reviewers. Reviewers: Yutaka Haramaki (chief academic advisor), Masamichi Yuzawa, Kazumi
Sugimura and Kenʼichiro Nakashima─ 111 ─

Russell Sarwar Kabir

understanding these relationships considered body awareness as a singular phenomenon in whicha conscious level of awareness toward bodily signals represented a negative form of attention (e.g.
somatosensory ampliﬁcation) that typically indicates symptoms of psychopathology (e.g. health anxiety
or illness behavior). These models of especially health anxiety were posited to depend on cognitive
construal, particularly via catastrophic evaluations that misinterpret or magnify bodily signals (e.g.,
Rachman, 2012), although eﬀorts to delineate empirical support for the somatic pathogenesis of healthanxiety are ongoing. In contrast, contemporary research on the psychometric measurement of related
processes outside of negative forms of bodily attention have shed light on a role for attention in therelationship between body awareness and anxiety such that oneʼs awareness of the signals from thebody can be co-opted to regulate oneʼs incumbent distress or anxious arousal. This regulatory role
as a style of attention is understood as a facet of mindful attention and is thus supposed to conformto a positive form of body awareness by means of the conferred ability to perform open or sustained
attention that manifests as a learned skill when regulating awareness toward the body.
The nature of body awareness as a singular entity was called into question by Mehling andcolleagues (2009) who systematically reviewed and evaluated all available body awareness constructs
for their psychometric quality. As a result, psychologically accessible body awareness constructs
were found to encompass multiple dimensions related to processes that result from neurobiologicalprocesses tied to interoception, or the sense of the physiological condition of the body. In a subsequentattempt to capture the collection of senses tied to interoceptive processes, Mehling and colleagues (2012)
developed a comprehensive instrument known as the Multidimensional Assessment of Interoceptive
Awareness (MAIA; Mehling et al., 2012). The MAIA attempts to measure the aforementioned
regulatory dimensions and attentional styles to neutral and adaptive (“positive”) forms of bodyawareness, especially such that conceptions can be discriminated from maladaptive and anxious
forms of body vigilance or arousal (Mehling et al., 2012). The MAIA includes eight dimensions of thisawareness labeled as follows: (1) Noticing, (2) Not-Distracting, (3) Not-Worrying, (4) Attention Regulation, (5)Emotional Awareness, (6) Self-Regulation, (7) Body Listening, and (8) Trusting. In subsequent research andreviews, the dimensions have been called modes of attention to perceived bodily signals as subjectively
measured by self-report methods and categorized as interoceptive attention tendencies (Khoury, Lutz, &Shuman-Oliver, 2018).
The MAIA was developed in reference to the definition of interoception elucidated by Craig(2009) and went through extensive external validation against constructs such as deﬁcits in emotional
regulation, facets of mindfulness, pain catastrophizing, emotional approaches to coping, bodily
dissociation, body responsiveness, body consciousness, anxiety sensitivity indexes, and state and trait
anxiety (Mehling et al., 2012; Mehling, 2016). In a key test of construct validity for the multidimensional
character of interoceptive attention tendencies, predicting incremental validity using state and trait
anxiety was of special importance for providing evidence of the MAIA as a measure of body awarenesswith implications for clinical outcomes. Mehling and colleagues (2012) performed a series of correlationaland regression analyses using the MAIA dimensions to predict trait anxiety from the State-Trait
Anxiety Inventory (STAI; Spielberger, 1983). A contribution of multiple MAIA subscales as dimensions
were found to demonstrate negative relationships with trait anxiety which were used to infer a degreeof validity for the multidimensional hypothesis of body awareness. In particular, all dimensions except
for Attention Regulation and Body Listening provided statistically signiﬁcant or marginally signiﬁcant
paths in the negative direction for levels of trait anxiety. However, an unexpected suppressor eﬀect
was observed for Emotional Awareness, which was found to share variance with Self-Regulation, andwas shown to change directions when removed from the analysis. Fascinatingly, according to Mehling
et al. (2012), this suggested that the mere recognition of body signals from awareness of the relationshipbetween emotional states and body awareness alone in the absence of a perceived ability to use that─ 112 ─Interoceptive Attention Tendencies Predict Trait Anxiety in Undergraduate Students andHospital Nurses Participating in Stress Management Programs

awareness to regulate distress could lead to anxiety. This was posited as a possible role for the MAIA
as a proving ground for “dual theories” of body awareness and anxiety, however, the authors oﬀeredthat this conclusion be cautiously interpreted as their sample was limited to experienced mind-bodypractitioners and required conﬁrmation in another sample.
The MAIA has tracked body awareness changes in numerous applications of behavioral healthpractices (Bornemann et al., 2015; Fissler et al., 2016; De Jong et al., 2016) and continues to be theorized
to harmonize across them due to the common goals of programs to leverage interoceptive awareness(Gard et al., 2014; Farb et al., 2015; Kabir, Haramaki, Ki, & Ohno, 2018; Price & Hooven, 2018). Comparedto the sample of experienced practitioners of behavioral health practices described in Mehling et al.
(2012), the current study aims to draw conclusions from two other samples: university students andearly-career nurses.
University students have been the target of two of the validation studies of the Japanese MAIA
items (Shoji et al., 2018; Fujino, 2019), however, the test of construct validity by predicting STAI-T was
not performed in either study. Young adults embarking on a path to higher education go through anumber of psychological changes that are amenable to the transition from home to the university (Michie
et al., 2001). The sources of stress and anxiety aﬀorded by this period of growth and change in college
include academic issues, financial concerns, and social strains related to interpersonal relationships(Pierceall & Keim, 2007; Smith & Renk, 2007), making them an important target population for anxiety
and stress reduction. In addition, early-career nurses tend to demonstrate greater proximity to subclinical outcomes related to anxiety due to the numerous occupational stressors associated withnursing work that often lead to burnout (Laal, 2013; Chang & Chan, 2015; Edwards & Burnard, 2003).
In a notable effort illustrating improvement in occupational health outcomes for nurses, an 8-weekyoga intervention was utilized as a prevention program for nurse burnout (Alexander, Rollins, Walker,
Wong, & Pennings, 2015). In a similar vein but with an eye on brief sessions of psychoeducation as avehicle, the primary prevention programs to which data was obtained for the current study utilized aform of relaxation training used in an original Japanese psychotherapy that shares elements of mindbody and third-wave approaches (Kabir et al., 2018; Haramaki, Kabir, Abe, & Yoshitake, 2019).
This study tests incremental predictive validity for the MAIA dimensions as identified in theoriginal validation by examining their relationships with trait anxiety in a sample of university students
and a sample of hospital nurses (Hunsley & Meyer, 2003). The same statistical procedure for bodyawareness and anxiety was performed as a test of construct validity using the MAIA and STAI (Mehling
et al., 2012). This analysis aims to contribute to the cumulative evidence base on the status of the
MAIA dimensions as “positive” (adaptive) and “negative” (maladaptive) forms of attention to the bodyand to oﬀer insights on the relationships between body awareness and anxiety from data in known
groups targeted for mental health promotion and primary prevention. Additionally, this analysis aims
to build upon and oﬀer insights on issues of construct validation and factor structure of the Japanese
MAIA documented by Shoji et al. (2018) and Fujino (2019).

2. Methods
2.1 Study design and participants
One-hundred and eighty-one undergraduate students and sixty-seven early-career nurses
participated in a stress management lecture and relaxation training workshop. The stress management
education program was based on the content and format established by Yamanaka and Tominaga (2000)
and implemented by Ki (2015) with relaxation training. The program involved learning about, noticing,and ﬁnding ways to cope with stress and experiencing mood state changes by performing movementtasks designed to induce relaxation.

─ 113 ─

Russell Sarwar Kabir

The measurements of the study variables were taken before and after the program in a pre-post
design. All participants took part in the program. The points explaining the purpose of the researchand request for informed consent were distributed in a single questionnaire packet and written
informed consent was obtained. The research protocol was approved by the ethical research committeeof the Graduate School of Education at Hiroshima University. To adhere to the scope of the present
study, only the results of the speciﬁc tests of incremental predictive validity performed by Mehling etal. (2012) for the MAIA and STAI at pre-test are described in this report.
2.2 Measures

State-Trait Anxiety Inventory (STAI, Spielberger, 1983; Japanese adaptation by Hidano, Fukahara, &Spielberger, 2000). STAI is a domain-speciﬁc measure of negative aﬀect that consists of 2 factors: stateanxiety (STAI-S, 20 items) and trait anxiety (STAI-T, 20 items). The current study focuses only on thescores for STAI-T. Responses to the STAI-T scale are made on a 4-point scale ranging from 1 (almost

never) to 4 (almost always), garnering raw scores that range from 20-80. STAI has been validated acrossnumerous populations from as many as 8000 studies and has been translated into at least 58 languages.
Examinations of its psychometric properties have shown that the instrument typically has a Cronbachalpha-based internal consistency of 0.89 and a test-retest reliability of 0.88 (Grös, Antony, Simms, &McCabe, 2007).

Multidimensional Assessment of Interoceptive Awareness. (MAIA, Mehling et al., 2012; Japanese
items translated by Shoji, Mehling, Hautzinger, & Herbert, 2018). The MAIA is a 32-item self-reportmeasure of body awareness. It is designed to capture eight dimensions in the tendencies in beliefs,
attitudes, thoughts, and emotions toward interoceptive stimuli from the body. A 6-point scale from 0 (notat all) to 5 (always) is used to rate each item. The MAIA has been translated into at least 16 languages
and validated in 8 diﬀerent cultural contexts (Mehling, 2016; Machorrinho, Veiga, Fernandes, Mehling,& Marmeleira, 2019; Shoji et al., 2018).

3. Results
3.1 Descriptive statistics and reliability analysis
Descriptive statistics were generated using JASP (Version 0.8.6, JASP Team, 2018) and are depicted
in Table 1. A total of 181 university students (85 males, 96 females; 53% female) and 67 hospital nurses(2 males, 65 females; 97% female) gave their informed consent to participate in the stress management
programs and granted the use of their questionnaire data. During screening, data from 12 university
students and 1 hospital nurse were missing. Listwise deletion left a subset of 169 undergraduate
students (n = 169, M age = 19.07, SD = 0.73) and 66 hospital nurses (n = 66, M age = 25.68, SD = 3.01)
with fully completed data that was retained for analysis. Cronbachʼs alpha and McDonaldʼs omega
estimates were selected for evaluating internal consistency of the items and performed using JASP.
Acceptable internal consistency was observed for the STAI-T subscale in both samples ( α range:
0.74-0.88, ω range: 0.77-0.90) in accordance with conventional guidelines for determining reliability
via Cronbachʼs alpha ( α ) and McDonaldʼs omega ( ω ) that favor values greater than 0.7. For the
MAIA, internal consistency was supported at pre-test and post-test for the dimensions Not-Distracting,Attention Regulation, Emotional Awareness, Self-Regulation, Body Listening, and Trusting ( α range:
0.71-0.93, ω range: 0.73-0.93). In line with previous studies on the Japanese MAIA (Fujino, 2019), thesubscale for Not-Worrying (pre-test: α = 0.22, ω = 0.44, post-test: α = 0.32, ω = 0.50) demonstrated
poor internal consistency and in both samples and were thus cautiously interpreted. In contrast to
previous ﬁndings on the instrument in global settings, reliability coeﬃcients for Noticing were notably
poor in the case of the sample of nurses, but not the undergraduate students.

─ 114 ─Interoceptive Attention Tendencies Predict Trait Anxiety in Undergraduate Students andHospital Nurses Participating in Stress Management Programs
Table 1. Descriptive statistics and tests of internal consistency for the study variables at pre-test.

Instrument

STAI
MAIA-J

Study variable

Trait anxiety

items

20

(STAI-T)

Undergraduate students

No.
M

SD

Hospital nurses

C r o n b a c h ’s M c D o n a l d ’s

48.20 9.57

α

ω

.74

.77

M

SD

C r o n b a c h ’s M c D o n a l d ’sαω50.38 7.09

.84

.85
.48

Noticing

4

2.77

.92

.79

.80

2.53

.73

.33

Not-Distracting

3

2.57

1.03

.80

.81

3.62

1.02

.76

.77

Not-Worrying

3

2.40

.72

.34

.37

2.99

.78

.22

.44

7

2.74

.85

.90

.90

2.24

.75

.84

.85

5

2.94

.84

.81

.82

2.75

.85

.77

.79

Self-Regulation

4

2.89

.89

.79

.79

2.38

.77

.71

.73

Body Listening

3

2.41

1.05

.87

.87

1.88

.90

.80

.82

Trusting

3

2.99

.96

.84

.86

2.18

.99

.82

.84

Attention
Regulation
Emotional
Awareness

3.2 Correlational analysis
Table 2 depicts the correlations for the dimensions of the MAIA and trait anxiety from both
samples at pre-test. As shown, a pattern and direction of negative correlations for trait anxiety
was established for all MAIA dimensions in both samples with the exception of Noticing among
undergraduate students. Undergraduate students also provided correlations of greater magnitude thanthe hospital nurses.
Table 2. Bivariate correlations for STAI-T scores and MAIA dimensions.
STAI-T

Undergraduate
students
Hospitalnurses

Not-

Not-

Attention

Emotional

Self-

Body

Distracting

Worrying

Regulation

Awareness

Regulation

Listening

0.14

-0.12

-0.42***-0.25***-0.10-0.45***-0.18*-0.44***-0.01-0.21*

-0.06

-0.13

-0.21*-0.20*

-0.04

-0.09

Noticing

Trusting

Note. Coefficients with asterisks: p < 0.05*, p < 0.01**, p < 0.001***.

3.3 Regression analysis
Simultaneous entering of the MAIA dimensions as predictors with STAI-T scores of trait anxiety
as the response variable through a linear regression was chosen in line with the analysis conducted in
the original MAIA validation study by Mehling et al. (2012). The former study resulted in the following
estimates for the MAIA regressed onto STAI-T: Noticing ( β = -0.16, p = 0.005), Not-Distracting ( β= -0.15, p = 0.003), Not-Worrying ( β = -0.26, p < 0.0001), Attention Regulation ( β = 0.04, p = 0.55),
Emotional Awareness ( β = 0.11, p = 0.07), Self-Regulation ( β = -0.29, p < 0.0001), Body Listening ( β =0.03, p = 0.63), Trusting ( β = -0.19, p = 0.0001), with a model R2 of 0.41 (Mehling et al., 2012).
The results for undergraduate students are depicted in Table 3.1. In line with the original
validation, Not-Worrying and Self-Regulation showed the two strongest paths for negatively predicting
trait anxiety. The direction of supported regressions also matched the original validation for the restof the dimensions except for Noticing, which was positive in association, and Not-Distracting, which─ 115 ─

Russell Sarwar Kabir
Table 3.1. Regression analysis demonstrating incremental validity for the MAIA dimensions in the prediction of
STAI-T scores for undergraduate students.
STAI-T

B

SE

β

t

p

Noticing

2.42

0.80

0.22

3.02

.003

Not-Distracting

0.01

0.62

0.001

0.01

.99

Not-Worrying

-4.29

0.81

-0.33

-5.30

<.001

Attention Regulation

-0.41

0.91

-0.03

-0.45

.66

Emotional Awareness

1.12

0.85

0.10

1.32

.19

Self-Regulation

-4.53

0.96

-0.43

-4.72

<.001

Body Listening

0.93

0.73

0.10

1.28

.20

Trusting

-2.31

0.83

-0.24

-2.78

.006

Note. R = .67, R2 for model = .45.

was neutral. In favor of the predictive validity test by Mehling et al. (2012), the paths for Emotional

Awareness and Body Listening were also convergent for the undergraduate students, although amodestly higher standardized regression coeﬃcient for Body Listening was observed.
The results of the regression for hospital nurses are depicted in Table 3.2. The direction of
supported regressions matched the original validation for dimensions except for Noticing and Trusting,although the latter was of a smaller magnitude in association. Again, Not-Worrying and Self-Regulation
provided supported standardized regression coefficients that were consistent with the original
validation. Compared to incremental validity observed in the original study, however, our sample ofnurses showed a larger supported regression coeﬃcient for Body Listening.

Table 3.2. Regression analysis demonstrating incremental validity for the MAIA dimensions in the prediction of
STAI-T scores for hospital nurses.
STAI-T

B

SE

β

t

p

Noticing

1.74

1.52

0.18

1.14

0.26

Not-Distracting

-2.01

0.93

-0.29

-2.15

0.04

Not-Worrying

-2.37

1.21

-0.26

-1.95

0.06

Attention Regulation

-1.70

1.77

-0.18

-0.96

0.34

Emotional Awareness

-1.65

1.45

-0.20

-1.14

0.26

Self-Regulation

-3.65

1.68

-0.40

-2.18

0.03

Body Listening

2.52

1.36

0.32

1.85

0.07

Trusting

0.63

1.22

0.09

0.52

0.61

Note. R = .45,

R2 formodel = .20.

─ 116 ─Interoceptive Attention Tendencies Predict Trait Anxiety in Undergraduate Students andHospital Nurses Participating in Stress Management Programs

4. Discussion
The present study provided notable replications and new insights on the ability for the MAIA
to predict trait anxiety. As more than one dimension showed paths predicting trait anxiety at pretest, this study replicated that there are psychometrically identifiable sources of body awarenessthat support the notion of multidimensional construct validity established by Mehling et al. (2012).
With the exception of Noticing, STAI-T scores were generally not positively associated with the
MAIA dimensions (Table 2.1) in favor of the generalizability of the results of the original validation.
In contrast, the poorer reliability among hospital nurses whose trait scores were elevated and theobservation of positive relationships with STAI-T in both samples suggest that the Noticing subscale
might contain elements of awareness that encompass negative attention to the body. As this has notbeen previously reported in studies on the MAIA, this observation should be cautiously interpreted
but explored in future studies perhaps investigating item content validity or the plausible inﬂuence ofissues in translation or cultural factors as they relate to Japan. However, as the chief interpretation of
the results, the supported path coeﬃcients for Not-Worrying and Self-Regulation especially oﬀer support
in favor of the original validation and add to the evidence base that suggests that the MAIA measuresmultidimensional and positive forms of attention related to body awareness (Bornemann et al., 2015;
Brown et al., 2018) that are generally separate and divergent from trait anxiety itself.
The inconsistencies in reliability and path coeﬃcients for Not-Worrying and Not-Distracting are
well-documented in previous studies and have since been addressed in work on the MAIA-2 (Mehling
et al., 2018) whose revised version and items were not available at the time of the study. Thus, the mostinterpretable results are those for Self-Regulation as a strong and supported predictor of trait anxiety
in both samples, but especially among undergraduate students, and represents a key ﬁnding for theconstruct in Japan. This is due to the fact that validation studies on the Japanese MAIA by Shojiand colleagues (2018) and Fujino (2019) provided support for a 6-factor model that was investigated inundergraduate students but did not specify Self-Regulation as a dimension. Instead, their model did
not identify Self-Regulation but retained one item from the original subscale that loaded onto Body
Listening. Our study used a known groups validation approach to incremental predictive validity fortrait anxiety and replicated the construct validity test of the original validation by Mehling et al. (2012).
The results depicted in Table 3.1 do not support the speciﬁcation of the proposed 6-factor model of theJapanese MAIA among undergraduate students in its loss of the theoretically important dimension
of Self-Regulation. Enhanced self-regulation continues to be one of the most important drivers of themechanisms of mindful attention to and awareness of the body (Hölzel, Lazar, Gard, Schuman-Olivier,Vago, and Ott, 2011) and Self-Regulation was the result of a theory-driven component of the a prioriconceptual framework for identifying “mind-body integration” in the original MAIA (Mehling et al.,2012). Our ﬁndings for trait-related prediction of Self-Regulation also align with the major ﬁnding byBornemann et al. (2015) who observed longitudinal changes in Self-Regulation from body scan training
which serves as a key indicator for the merits of the MAIA framework of constructs. Given synthesis
with these results, our findings that indicate trait-relevant support for Self-Regulation in Japanesesamples of participants suggest that the limitations in sample characteristics noted by Shoji et al. (2018)
and Fujino (2019) might be inﬂuencing the idiosyncrasies in conﬁrmatory factor structure identiﬁcation
for the Japanese MAIA.
Our ﬁndings also oﬀer implications for trait anxiety and attention tendencies among university
students in Japan. Adaptation to university life is facilitated by eﬀective time management, access tosocial support, belief in academic abilities, and the development of eﬀective coping styles for new tasks(Shankland et al., 2010; Macan et al., 1990). As interoceptive attention tendencies have shown sensitivity
to change from interventions (Bornemann et al., 2015; Mehling et al., 2018), the present study suggests

─ 117 ─

Russell Sarwar Kabir

that the MAIA dimensions might be a worthy target for evaluating outcomes from stress managementwith relaxation training (Ki, 2015) or health promotion that emphasizes self-regulatory management
through educational vehicles of body awareness (Landsman-Dijkstra, van Wijck, Groothoﬀ, and Rispens,
2004).
This study also yielded unique insights on the relationship between body awareness and anxiety
in hospital nurses undergoing a stress management program for burnout prevention. The mean
STAI-T scores for the nurses in our study were higher than normative data by Iwata et al. (1998) on
Japanese professional adults, but less than the cutoﬀ score of 54 suggested to signify or detect clinicalsymptoms of anxiety in adults. This suggests that the hospital nurses represented a known group withhigher anxiety proneness that is suitable for a primary prevention context. The mean scores for Body
Listening among hospital nurses were comparably lower than the undergraduate students in our study,
and a positive regression coeﬃcient for Body Listening was observed for the nurses as a predictor of
marginal signiﬁcance for trait anxiety. Previous studies have observed characteristically lower meanscores for Body Listening in adults with eating disorders in Brown et al. (2018) and veterans undergoingan exercise program for post-traumatic symptoms in Mehling et al. (2018). Our ﬁndings oﬀer further
support for Body Listening as an attention tendency of relevance to public mental health outcomesand suggests that altered interoceptive sensibility in samples with higher anxiety proneness might beworthy of further study.

5. Limitations
This study was limited by its cross-sectional design. For the sample of hospital nurses, as in otherstudies of nurse burnout, our sample was also overwhelmingly female, limiting the generalizability
across genders. Future studies could work to incorporate other predictors or investigate the model ina larger sample size in ways that could continue to account for sample variation. Finally, as burnout
symptoms were not directly measured, future studies or efforts to provide primary prevention
should consider including relevant psychometric instruments such as the Maslach Burnout Inventory
for greater specificity of effects or relationships with interoceptive attention tendencies (e.g., Body

Listening).

6. Conclusion
This study largely replicated the ﬁndings of the original validation by Mehling et al. (2012) insupport of incremental validity for the MAIA as a measurement tool for interoceptive attention
tendencies in public mental health educational settings. Key convergence occurred in self-regulatory
body awareness and key diﬀerences emerged for the tendency to notice and inform changes about
the body and listen to the body for insight. With the exception of Noticing, the assumption that the
instrument measures “positive” body awareness dimensions was maintained from comparison andconﬁrmation of predicted relationships to trait anxiety.

References
Alexander, G. K., Rollins, K., Walker, D., Wong, L., & Pennings, J. (2015). Yoga for self-care and burnout
prevention among nurses. Workplace Health & Safety, 63, 462-470.
Bornemann, B., Herbert, B. M., Mehling, W. E., & Singer, T. (2015). Diﬀerential changes in self-reported
aspects of interoceptive awareness through 3 months of contemplative training. Frontiers in

Psychology, 5.

─ 118 ─Interoceptive Attention Tendencies Predict Trait Anxiety in Undergraduate Students andHospital Nurses Participating in Stress Management Programs

Brown, T. A., Berner, L. A., Jones, M. D., Reilly, E. E., Cusack, A., Anderson, L. K., ... & Wierenga, C. E.
(2017). Psychometric evaluation and norms for the Multidimensional Assessment of Interoceptive
Awareness (MAIA) in a clinical eating disorders sample. European Eating Disorders Review, 25(5),411-416.
Craig, A. D. (2009). How do you feel--now? The anterior insula and human awareness. Nature Reviews
Neuroscience, 10(1).
Chang, Y., & Chan, H. (2015). Optimism and proactive coping in relation to burnout among nurses.

Journal of Nursing Management, 23, 401-408.
De Jong, M., Lazar, S. W., Hug, K., Mehling, W. E., Hölzel, B. K., Sack, A. T., et al. (2016). Eﬀects ofmindfulness-based cognitive therapy on body awareness in patients with chronic pain and comorbid
depression. Frontiers in Psychology, 7:967. doi: 10.3389/fpsyg.2016.00967
Edwards, D., & Burnard, P. (2003). A systematic review of stress and stress management interventions
for mental health nurses. Journal of Advanced Nursing, 42, 169-200.
Farb, N., Daubenmier, J., Price, C. J., Gard, T., Kerr, C., Dunn, B. D., ... & Mehling, W. E. (2015).
Interoception, contemplative practice, and health. Frontiers in Psychology, 6.
Fissler, M., Winnebeck, E., Schroeter, T., Gummersbach, M., Huntenburg, J. M., Gaertner, M., &Barnhofer, T. (2016). An investigation of the effects of brief mindfulness training on self-reported
interoceptive awareness, the ability to decenter, and their role in the reduction of depressive
symptoms. Mindfulness, 7(5), 1170-1181.
Fujino, H. (2019). Further validation of the Japanese version of the Multidimensional Assessment ofInteroceptive Awareness. BMC Research Notes, 12(1), 1-6.
Gard, T., Noggle, J. J., Park, C. L., Vago, D. R., & Wilson, A. (2014). Potential self-regulatory
mechanisms of yoga for psychological health. Frontiers in Human Neuroscience, 8, 770. doi: 10.3389/
fnhum.2014.00770
Grös, D. F., Antony, M. M., Simms, L. J., & McCabe, R. E. (2007). Psychometric properties of the StateTrait Inventory for Cognitive and Somatic Anxiety (STICSA): comparison to the State-Trait Anxiety
Inventory (STAI). Psychological Assessment, 19(4), 369.
Haramaki, Y., Kabir, R. S., Abe, K., & Yoshitake, T. (2019). Promoting Self-regulatory Management ofChronic Pain through Dohsa-Hou: Single-Case Series of Low-Functioning Hemodialysis Patients.

Frontiers in Psychology, 10, 1394.
Hidano, T., Fukahara, M., & Spielberger, C. D. (2000). State Trait Anxiety Inventory (Form JYZ) Test
Manual. (Japanese adaptation of STAI). Tokyo, Japan: Jitsumi Shuppan.
Hölzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., & Ott, U. (2011). How does
mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural
perspective. Perspectives on Psychological Science, 6(6), 537-559.
Hunsley, J., & Meyer, G. J. (2003). The incremental validity of psychological testing and assessment:
conceptual, methodological, and statistical issues. Psychological Assessment, 15(4), 446.
Iwata, N., Mishima, N., Shimizu, T., Mizoue, T., Fukuhara, M., Hidano, T., & Spielberger, C. D. (1998).
The Japanese adaptation of the STAI Form Y in Japanese working adults: The presence or absenceof anxiety. Industrial Health, 36, 8-13.
JASP Team. (2018). JASP (Version 0.8.6) [Computer software].
Kabir, R. S., Haramaki, Y., Ki, H., & Ohno, H. (2018). Self-Active Relaxation Therapy (SART) and selfregulation: a comprehensive review and comparison of the Japanese body movement approach.

Frontiers in Human Neuroscience, 12, 21.
Khoury, N. M., Lutz, J., & Schuman-Olivier, Z. (2018). Interoception in psychiatric disorders: a review of
randomized, controlled trials with interoception-based interventions. Harvard Review of Psychiatry,
26(5), 250-263.

─ 119 ─

Russell Sarwar Kabir

Ki, H. (2015). The effectiveness of relaxation for stress management II: The principle of Self-Active
Relaxation Therapy (SART). Bulletin of Training and Research Center for Clinical Psychology, 14,
12-16. (Title translated by author). [in Japanese]
Laal, M. (2013). Job stress management in nurses. The Procedia - Social and Behavioral Sciences, 84,
437-442.
Landsman-Dijkstra, J. J., van Wijck, R., Groothoﬀ, J. W., & Rispens, P. (2004). The short-term eﬀects ofa body awareness program: better self-management of health problems for individuals with chronic
a-speciﬁc psychosomatic symptoms. Patient Education and Counseling, 55(2), 155-167.
Macan, T. H., Shahani, C., Dipboye, R. L., & Phillips, A. P. (1990). College studentsʼ time management:
Correlations with academic performance and stress. Journal of Educational Psychology, 82(4), 760.
Machorrinho, J., Veiga, G., Fernandes, J., Mehling, W., & Marmeleira, J. (2019). Multidimensional
assessment of interoceptive awareness: Psychometric properties of the Portuguese version.

Perceptual and Motor Skills, 126(1), 87-105.
Maslach, C., Schaufeli, W. B. & Leiter, M. P. (2001). Job Burnout. Annual Review of Psychology, 52,
397-422.
Mehling W. (2016). Diﬀerentiating attention styles and regulatory aspects of self-reported interoceptive
sensibility. Philosophical Transactions of the Royal Society of London B, 371: 20160013.
Mehling W. E., Gopisetty V., Daubenmier J., Price C.J., Hecht F.M., Stewart A. (2009) Body Awareness:
Construct and Self-Report Measures. PLoS One 4(5): e5614. doi:10.1371/journal.pone.0005614
Mehling, W. E., Price, C., Daubenmier, J. J., Acree, M., Bartmess, E., & Stewart, A. (2012). The
multidimensional assessment of interoceptive awareness (MAIA). PLoS One , 7(11), e48230. doi:
10.1371/journal.pone.0048230
Michie, F., Glachan, M., & Bray, D. (2001). An evaluation of factors inﬂuencing the academic self-concept,
self-esteem and academic stress for direct and re-entry students in higher education. Educational

Psychology, 21(4), 455-472.
Pierceall, E. A., & Keim, M. C. (2007). Stress and coping strategies among community college students.

Community College Journal of Research and Practice, 31(9), 703-712.
Price, C. J., & Hooven, C. (2018). Interoceptive Awareness Skills for Emotion Regulation: Theory andApproach of Mindful Awareness in Body-Oriented Therapy (MABT). Frontiers in Psychology, 9.
Rachman, S. (2012). Health anxiety disorders: a cognitive construal. Behaviour Research and Therapy,50(7-8), 502-512.
Shankland, R., Genolini, C., França, L. R., Guelﬁ, J. D., & Ionescu, S. (2010). Student adjustment to higher
education: the role of alternative educational pathways in coping with the demands of student life.

Higher Education, 59(3), 353-366.
Shoji, M., Mehling, W. E., Hautzinger, M., & Herbert, B. M. (2018). Investigating multidimensional
interoceptive awareness in a Japanese population: Validation of the Japanese MAIA-J. Frontiers in

Psychology, 9.
Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (Form Y). Menlo Park, CA: Mind
Garden.
Yamanaka, H., & Tominaga Y. (2000). Dohsa and image-based stress management education: a primer.
Kitaohji-Shobo. (Title translated by author). [in Japanese]─ 120 ─