The autonomic nervous system (ANS) carries the signals that control the functions of organs and tissues that include heart rate, breathing rate, and sweating on the heads. Many of these functions are outside of conscious control, maintaining coordinated body activity to support life such as supporting digestion and keeping blood pressure within specific limits. However, this autonomic maintenance is sensitive to changes in current conditions and prepares the body for anticipated needs. When a person moves into a defensive state, the autonomic nervous system can override the typical ways that organs work to prepare for a threat response.

Defensive reactions involve many parts of the body. In addition to changes in breathing that help fuel mobilization, they also include the heart, which speeds up and beats harder to circulate blood, and the gut, which may have its digestive functions suppressed to allocate resources to other parts of the body. These functions and moment-to-moment changes are coordinated by the autonomic nervous system. When the ANS is frequently responsive to threat or is inhibited from recovery, the disruption to regular body system functioning can affect day-to-day life.

The Body Perception Questionnaire Autonomic Symptoms Form (BPQ20-ANS) was developed to measure experiences of these types of disruptions in body functions. This questionnaire asks how often disruptions in autonomically-controlled functions are experienced. High scores indicate more disruption of typical organ function. Though any one disruption can have an individual cause (for example, shortness of breath may be caused by poor air quality), when disruption in multiple functions over time are combined in a single measure, they can provide an overall picture of a person’s autonomic state.

The BPQ20-ANS is scored by totaling responses for each question, which can then be calculated in three subscales.

Subscale	Description	Item Count	Items
Supradiaphragmatic Symptoms	Symptoms in autonomically-innervated organs above the diaphragm.	15	1-15
Subdiaphragmatic Symptoms	Symptoms in autonomically-innervated gastrointestinal organs below the diaphragm.	6	15-20
Autonomic Symptoms (Combined Supra- and Sub-diaphragmatic)	A combined measure of both supra- and sub-diaphragmatic symptoms.	20	1-20

Calculating Raw Scores.

Responses are calculated by converting participant responses to numbers by reported frequency of symptom experiences: Never = 1, Occasionally = 2, Sometimes = 3, Usually = 4, Always = 5. You can use the table above to combine item responses to raw subscales scores. For better interpretability, you can convert the raw scores to percentile or T scores (see below).

Scoring is most accurate when responses are as complete as possible, but some individuals may have reasons for skipping a particular question. If there is uncertainty about answering a particular question, you can encourage the individual to provide their best guess. However, if the individual thinks that they cannot respond to one of the questions accurately, it is better to leave that question unanswered than to make a random guess.

When missing data are present, imputation may be used at the researcher’s discretion. Scores for participants with a high amount of missing item-level data should be interpreted with extreme caution or not at all.

Percentile Rank and T Scores

Percentile rank scores reflect the percentage of scores in a general population that are equal or lower to the individual’s score. A high percentile means that a person is experiencing more autonomic symptoms than that percentage of a typical sample. For example, a supradiaphragmatic symptom score of 37 is in the 70th percentile. That means that client has autonomic disruption of typical function more frequently than 70% of general population sample.

T scores reflect a standardized value according to a normal distribution based on a mean of 50 and a standard deviation of 10. This transformation is recommended for parametric statistical models.

Percentile rank and T scores are available for raw scores computed by the sum of full item responses. These transformed scores are based on a combined sample of American participants recruited online (n = 2048). Participant age ranged from 18 to 95 years (Mean = 46.34, SD = 17.19). 50.6% were female. Age- and sex-specific norms are not yet available.

High scores on BPQ-ANS20 subscales means that a person is experiencing high levels of autonomic symptoms.

It is common for people to experience some sensations of autonomic symptoms throughout their daily life so some symptoms are to be expected even if the person does not experience chronic threat responses. These low scores may still be very low and not of clinical significance. To contextualize the scores, they can be compared to a general adult U.S. population by converting to percentiles (see Scoring).

Factor Structure

The initial Body Perception Questionnaire Short Form (BPQ-SF) factor analysis was conducted in three samples with American and Spanish participants (total n = 1320; Cabrera et al., 2018). The factor analysis supported two separate autonomic symptoms scales – a subscale for symptoms above the diaphragm (supra-diaphragmatic) and below the diaphragm (sub-diaphragmatic). One item about urge to vomit is consistently associated with both supra- and sub-diaphragmatic symptoms, likely because autonomic circuits that coordinate vomiting need to coordinate the gut with structures above the diaphragm. The dual association results in that item being included in both subscales. Studies with follow up factor analyses have replicated this structure (Kolacz et al., 2023; Jokic et al., 2023). However, supra- and sub-diaphragmatic symptoms can be highly correlated and thus may be scored as one combined autonomic symptoms subscale (Kolacz et al., 2023). The factor structure in a group of mind-body therapy practitioners, whose training and practice includes close attention to body sensations, was consistent with general populations from other studies, indicating that scoring and interpretation can be consistent whether participants are experienced or new to tracking body sensations (Jokic et al., 2023).

Validity: How do autonomic symptom scales measured on the BPQ-ANS20 compare to sensor-based measures of autonomic activity?

To assess how the BPQ autonomic symptom scores are associated with non-invasive sensors of autonomic activity, a lab study used a simple exercise maneuver to evoke an autonomic response (Kolacz et al., 2023). Study participants sat in a chair, lifted their legs so that they are parallel to the floor, held them still for 30 seconds, and then set them down to rest. During this maneuver, the autonomic nervous system makes adjustments to provide resources to leg and core muscles to support the lifts. Repeating the maneuver several times tests how a person’s autonomic nervous system adjusts to the needs of the moment.

In the study, participants performed these leg lifts while they had their vital signs monitored. One of these measures was respiratory sinus arrhythmia measured from an electrocardiogram (ECG), which provides information about the strength of parasympathetic “calming” effect on the heart. A second measure of electrodermal activity, which provides information on sympathetic activation, was observed using a set of sensors on the fingers to measure sweating. The use of these two signals provided information about the parasympathetic and sympathetic branches of the autonomic nervous system, which can work together to adjust to physiological needs.

The results showed that study participants who reported few autonomic symptoms in everyday life had well-organized physiological responses. In these participants, the parasympathetic and sympathetic autonomic branches worked together to support mobilizing metabolic resources during lifts, then returning back to resting levels once their legs were on the floor. However, participants who experienced more everyday autonomic symptoms had less flexible responses.

Though they could mobilize when they needed the strength to lift their legs, their sympathetic activation did not turn off when their legs were resting on the floor. This tells us that a person who experiences autonomic symptoms may be more likely to get stuck in a mobilization state and may have difficulty returning to resting levels. Participants in the study at the very highest scores did not have a consistent coordinated response in either their parasympathetic or sympathetic branches, which suggests they may have particularly high levels of dysregulation. Overall, the results show that autonomic symptoms may exist on a gradient. Low levels of symptoms suggest efficient and flexible autonomic adjustments to needs, moderate levels suggest difficulty with calming the body after mobilization, and high levels may indicate dysregulation.

Reliability: How consistent are scores on the BPQ-ANS20?

The BPQ-ANS20 is intended to capture some stable patterns of autonomic responses as well as fluctuations in autonomic symptoms over time, the BPQ-ANS20 has been found to be reliable when the same person fills out the questionnaire on multiple occasions when they are not receiving an intervention that is designed to influence their autonomic activity.

The currently available translations are hosted on the TSRC webpage. Several research studies have been conducted on BPQ translations - including Spanish, Italian, and Chinese. So far, all have been found to have similar psychometric properties like factor structure, reliability, and validity.^2,3,4,5,6

The TSRC hosts a free archive of BPQ translations that make it accessible to a larger international user base. If you are interested in conducting a translation, please complete our translation web form.

See Available Translations ▾

• Catalan BPQ-SF
• Dutch BPQ-SF V.1
• Dutch BPQ-SF V.2
• French BPQ-SF
• French BPQ-VSF
• German BPQ-SF
• Hebrew BPQ-SF
• Hebrew BPQ-VSF
• Italian BPQ-SF
• Japanese BPQ-SF
• Polish BPQ-SF
• European Portuguese BPQ-SF
• Serbian BPQ-SF
• Spanish BPQ-SF
• Swedish BPQ-SF
• Ukrainian BPQ-SF

Overview

There are a number of reasons why a clinician may want to track autonomic symptoms over the course of therapy. Doing so provides an opportunity to check in on threat and safety states with limited need to connect with autobiographical memories and layering psychological meaning. If a particular treatment is intended to help manage threat states and better regulate toward safety, then tracking autonomic symptoms may help provide a simple, standardized method to assess whether the client is benefiting from the intervention. Clients may fill out the BPQ20-ANS during therapy sessions, while waiting for their appointment, or on their time outside of session.

Guidelines for Clinical Use

Below are guidelines for using and interpreting the BPQ20-ANS with clients

How far apart should I space measurements?

It is a good idea to give clients a time frame to report on, particularly if you are administering the BPQ repeatedly. Specifying a time window and using it consistently can help to make measurements standard. If you want to track a single client, you may use a consistent time window so that you are clear about the length of time that the client is reporting on during each measurement (for example, “Over the past week”, “Since our last session”). Likewise, if you are collecting data on multiple clients and want to be able to compare them to one another, using consistent instructions on the length of the reporting window will make comparisons between them easier to interpret.

Typical time windows range between 1 week and 1 month. When deciding on the measurement spacing, it is important to avoid overlapping measurement windows. For instance, if you are repeating the assessment every week the reporting window should not be more than 1 week. Consideration should also be taken to structure measurement around events, such as the start of a new therapy. There is a trade off in the length of the reporting window. Longer windows allow for more opportunity to observe situations where autonomic disruptions occur, but - on the other hand - longer windows may be less reliable due to limitations of memory.

What factors can explain scores?

Physical symptoms may have many possible causes. While chronic threat responses may be one, it is also important to rule out other reasons that a person may be experiencing symptoms. Some diseases and medications may specifically affect organs that are controlled by the autonomic nervous system or change autonomic function itself. Medications such as anticholinergics affect the signaling of the vagus nerve. In some cases, the medication creates a “chicken-or-the-egg” problem, where it is unclear whether the autonomic symptoms (or chronic threat responses) are man-aged by the medication or are caused by it.

If you are comparing client change over the course of therapy, tracking autonomic symptoms with the BPQ20-ANS may still be informative and valid regardless of other influences. As long as a client’s medical conditions and medication use is stable, changes in autonomic symptoms over time can be a useful measure of changes in autonomic threat response patterns.

If you are interpreting results for a client who has a high score from a single measurement (for instance, an intake), it may be important to rule out causes due to medication or medical conditionbefore concluding that the symptoms are caused by chronic threat responses. If you have questions about your client’s medication, you can be in touch with your client’s medication manager or psychiatrist. However, even if clients are on medication or have a disease that impacts the autonomic nervous system, they may still benefit from interventions that help to manage chronic defense states and may demonstrate improvements.

How much change is reliable?

Although scores on the BPQ have been found to be reliable, there are expected fluctuations that might occur between measurements, even if the person’s underlying autonomic state regulation has not changed. Some of those small differences may be due to slight changes in how a person responds to each question when asked again. Others may have to do with differences in a person’s demands from one observation window to another. There are no absolute cut offs for where a score may be reliable, but a rule of thumb may be that a change has to be more than 5 percentile points to be considered different from the last measurement.

1993: Body Perception Questionnaire (Discontinued)

The original 122-item Body Perception Questionnaire was developed by Dr. Stephen Porges at the University of Maryland (Porges, 1993). Its goals were to assess body awareness, stress response, autonomic symptoms to measures autonomic nervous system reactivity, stress style, and health history. To due its length and developments based on psychometric data, the BPQ is now discontinued.

2018: BPQ Short Form (BPQ-SF)

In 2018, the questionnaire was revised into a new version: The Body Perception Questionnaire Short Form (Cabrera et al., 2018). To improve the BPQ’s usability for research and clinical studies, the length was reduced by first limiting to the domains that were most widely used – body awareness and autonomic symptoms. The length was further reduced by selecting body awareness items which had precision in capturing aspects of direct functional control of autonomic pathways. To maintain compatibility between forms, no new items were added, nor was item wording altered.

2026: BPQ-SF Division into BPQ-BA and BPQ-ANS20

To simplify use and align with the varying goals that the BPQ Short Form is used for, the short form has since been separated into body awareness (BPQ-BA) and autonomic symptoms forms (BPQ-ANS20).

Online Self-Scoring Form

• BPQ Short Form (docx)
• BPQ20-ANS (docx)

1. Porges, S. W. (1993). Body perception questionnaire. Laboratory of Developmental Assessment: University of Maryland.
2. Cerritelli, F., Consorti, G., D’Alessandro, G., Galli, M., Kolacz, J., Porges, S.W. (2021) Cross-cultural adaptation and validity of the Italian version of the Body Perception Questionnaire. PLOS ONE, 16(5), e0251838.
3. Poli, A., Maremmani, A. G. I., Chiorri, C., Mazzoni, G. P., Orrù, G., Kolacz, J., ... & Miccoli, M. (2021). Item Reduction, Psychometric and Biometric Properties of the Italian Version of the Body Perception Questionnaire—Short Form (BPQ-SF): The BPQ-22. International Journal of Environmental Research and Public Health, 18(7), 3835.
4. Wang, N., Ren, F., & Zhou, X. (2020). Factor Structure and Psychometric Properties of the Body Perception Questionnaire–Short Form (BPQ-SF) Among Chinese College Students. Frontiers in Psychology, 11, 1355.
5. Cabrera, A., Kolacz, J., Pailhez, G., Bulbena-Cabre, A., Bulbena, A., & Porges, S. W. (2018). Assessing body awareness and autonomic reactivity: Factor structure and psychometric properties of the Body Perception Questionnaire-Short Form (BPQ-SF). International journal of methods in psychiatric research, 27(2), e1596.
6. Kobayashi R, Honda T, Machizawa M, Ichikawa N, Nakao T. (2021) Factor structure, reliability and validation of the Japanese version of the Body Perception Questionnaire-Body Awareness Very Short Form (BPQ-BAVSF-J). Japanese Journal of Research on Emotions, 28, 38–48.
7. Kolacz, J., Chen, X., Nix, E. J., Roath, O. K., Holmes, L. G., Tokash, C., Porges, S. W., & Lewis, G. F. (2023). Association of self-reported autonomic symptoms with sensor-based physiological measures. Psychosomatic Medicine. Advance Online Publication.
8. Kolacz, J., Hu, Y., Gesselman, A. N., Garcia, J. R., Lewis, G. F., & Porges, S. W. (2020). Sexual function in adults with a history of childhood maltreatment: Mediating effects of self-reported autonomic reactivity. Psychological trauma: theory, research, practice, and policy, 12(3), 281.
9. Jokic, B., Puric, D., Grassmann, H., Walling, C. G., Nix, E. J., Porges, S. W., & Kolacz, J. (2023). Association of childhood maltreatment with adult body awareness and autonomic reactivity: The moderating effect of practicing body psychotherapy. Psychotherapy, 60(2), 159-170. https://doi.org/10.1037/pst0000463
10. Kolacz, J., Dale, L. P., Nix, E. J., Roath, O. K., Lewis, G. F., & Porges, S. W. (2020). Adversity History Predicts Self-Reported Autonomic Reactivity and Mental Health in US Residents During the COVID-19 Pandemic. Frontiers in psychiatry, 11, 1119.