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Autonomic balance revisited: Panic anxiety and heart rate variability
Abstract
The analysis of heart rate variability (HRV) is becoming widely used in clinical research to provide a window into autonomic control of HR. This technique has been valuable in elucidating the autonomic underpinnings of panic disorder (PD), a condition that is marked by reports of heart palpitations. A body of research has emerged that implicates a relative reduction in HRV and cardiac vagal tone in PD, as indicated by various HRV measures. These data are consistent with the cardiac symptoms of panic attacks, as well as with developmental evidence that links high vagal tone with enhanced attention, effective emotion regulation, and organismic responsivity. Implications of these findings for nosology and pathophysiology are discussed. Reports of reduced HRV in PD contrast with portrayals of excess autonomic lability in anxiety. This contradiction is addressed in the context of traditional homeostatic models versus a systems perspective that views physiologic variability as essential to overall stability.
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“the vagus nerve innervates a number of end organs that are involved in emotion and communication (i.e., larynx, facial muscles, Porges, 1995), and the vagal input to the heart can be quickly withdrawn to allow rapid mobilization of the body to meet a variety of environmental and metabolic demands; these include physical exercise, coping with negative emotion (e.g., Beauchaine, 2001; Friedman & Tha”
From Psychological flexibility as a fundamental aspect of health (2010) · cites this paper as Friedman & Thayer, 1998
In the citing paper
“Processes that may contribute to this over-responsivity include increased threat perception, increased and misinterpreted perception of bodily sensations [34], or decreased inhibition of the fear response.”
From Functional autonomic nervous system profile in children with autism spectrum disorder (2014) · cites this paper as [34]
In the citing paper
“Highlighting the role of the physiological dimension, chronically elevated HR has been reported in anxiety disorders [32-34].”
From Functional autonomic nervous system profile in children with autism spectrum disorder (2014) · cites this paper as [34]
In the citing paper
“At this level, hyperarousal may be associated with over-responsivity of networks involved in perception, processing, and responding to emotional stimuli [34].”
From Functional autonomic nervous system profile in children with autism spectrum disorder (2014) · cites this paper as [34]
In the citing paper
“Reduced HRV is a clinically relevant feature of stress-related disorders including anxiety, depression, and epilepsy (Carney et al., 1995b; Friedman and Thayer, 1998; Brown and Gerbarg, 2005; Mativo et al., 2010).”
From Hypothesis: Pulmonary Afferent Activity Patterns During Slow, Deep Breathing Contribute to the Neural Induction of Physiological Relaxation (2019) · cites this paper as Friedman and Thayer, 1998
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“52 55 From this perspective, maladaptive perseverative behavior and poor emotion regulation, such as those manifested in PIU, may result from reduced resting HRV.”
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“Depression and anxiety symptoms were measured as covariates because of their potential associations with HRV (e.g., Cohen et al., 2000; Friedman and Thayer, 1998; Galetta et al., 2012; Hughes and Stoney, 2000; Koschke et al., 2009; Nahshoni et al., 2004), using the Beck Depression Inventory–II (BDI-II; Beck et al.”
BackgroundMethodInfluentialHeart Rate Variability (HRV) reflecting from oral reports of negative experience
Rantanen, A. P., Laukka, S. J., Lehtihalmes, M., & Seppänen, T. (2010) · Procedia - Social and Behavioral Sciences · doi:10.1016/j.sbspro.2010.07.128 · Cited by 21
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BackgroundAnalgesia Nociception Index: Heart Rate Variability Analysis of Emotional Status
Abdullayev, R., Yildirim, E., Çelik, B., & Sarica, L. T. (2019) · Cureus · doi:10.7759/cureus.4365 · Cited by 22
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“An example is heart rate variability: after many years it was found that whereas the average rate provides some information, each individual’s heart rate variability also provides great insights and has been proven valuable in several ways [25–28].”
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“, 1999), age, fitness, illness duration and illness severity (Asmundson and Stein, 1994; Stein and Asmundson, 1994), or even methodological differences in the analysis of HRV (Friedman and Thayer, 1998).”
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“Increases in anxiety are associated with autonomic nervous system dysregulation (Friedman and Thayer, 1998).”
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“In addition, gender and ethnicity are both linked to differences in several indices of physiological reactivity (Anderson & McNeilly, 1991; Friedman & Thayer, 1998).”
BackgroundHeart Rate Variability and Skin Conductance Biofeedback: A Triple-Blind Randomized Controlled Study
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“A variety of psychopathological and pathological illnesses such as depression, anxiety disorders and (post-traumatic) stress have been shown to be associated with low heart rate variability ([3] [4] [5](1)).”
BackgroundStudy of The Effect of Stress on Skeletal Muscle Function in Geriatrics
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“Many studies have suggested that there is autonomic dysfunction and reduced HRV in patients with PD [23–27].”
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“Given that HRV is thought to reflect adaptive autonomic nervous system regulation, caregivers who are physiologically equipped to manage stress in their environment may be less likely to experience psychological distress 12,57 .”
BackgroundResultLipschutz, R. S., Gray, S. A. O., Weems, C. F., & Scheeringa, M. S. (2017) · Applied Psychophysiology and Biofeedback · doi:10.1007/s10484-017-9377-x · Cited by 19
“Lower resting RSA has been implicated with the greater psychophysiological arousal observed in chronic stress activation and anxiety disorders (Friedman and Thayer 1998; Kawachi et al.”
Randomized neural networks for preference learning with physiological data
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“In essence, such children may face a double jeopardy, given their inaccurate beliefs about the consequences of their symptoms as well as their lack of physiological flexibility to appropriately respond to environmental demands (Friedman & Thayer, 1998; Hinnant & El-Sheikh, 2009; Porges, 1992).”
BackgroundThe impact of trait worry and emotion regulation on heart rate variability
Knepp, M. M., Krafka, E. R., & Druzina, E. M. (2015) · Cogent Psychology · doi:10.1080/23311908.2015.1038896 · Cited by 18
“Furthermore, Friedman and Thayer (1998) have previously hypothesized that the low vagal tone and reduced heart rate variability found in patients with panic disorder are indicative of limited psychophysiological flexibility.”
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“This relatively short-lasting increase in body temperature is generally referred to as stress-induced hyperthermia (Friedman and Thayer, 1998;Nijsen et al., 1998; Olivier et al., 1998; Bouwknecht et al., 2000).”
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“…have yielded inconsistent data regarding differences in HR between PD and control samples (e.g., Freedman, Ianni, Ettedgui, & Puthezhath, 1985; Friedman & Thayer, 1998; Hofmann & Barlow, 1996; Stein & Asmundson, 1994), physiological disturbances in HR have been regarded as an unreliable…”
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“HRV is suggested to be a good index that reflects those neural mechanisms of central nervous system/autonomic nervous system integration [47,67].”
BackgroundResultNonlinear features of heart rate variability in paranoid schizophrenic
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“Also, it is a reliable and quantitative measure of autonomic nervous system (ANS) activity where ANS is a common characteristic of a variety of psychiatric disorders, including schizophrenia, depression and panic disorder [6, 16, 26, 35, 47, 86].”
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“Examples of this strategy can be found studies in which individual CV control patterns were extracted from a range of heterogeneous ANS tasks, and then group aggregated (Friedman et al., 1993; Friedman & Thayer, 1998a).”
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“…reduced HRV, parasympathetic activity, and negative emotions such as hostility (Kawachi et al., 1995), worry or generalized anxiety disorder (Thayer et al., 1996), depression (Yeragani, 2000), panic disorder (Friedman and Thayer, 1998), and posttraumatic stress disorder (PTSD) (Cohen, 2000).”
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“This CNS network is associated with the processes of response organization and selection, and serves to control psychophysiological resources in attention and emotion (Friedman & Thayer, 1998a,b; Thayer & Friedman, 1997).”
BackgroundSelf-citationSelf-implication and heart rate variability during simulated exposure to flight-related stimuli
Bornas, X., Llabrés, J., Noguera, M., Ana, M., Lopez, L., Barceló, F., Tortella‐Feliu, M., & Fullana, M. A. (2004) · Anxiety Stress & Coping · doi:10.1080/10615800512331328777 · Cited by 15
“Although analogue research has been conducted in similar studies (e.g., Friedman and Thayer, 1998a), caution is necessary when looking at the clinical value of the results of the study (e.g., the same pattern of association between HRV and self-implication should be found in flight phobics).”
BackgroundMethodResultResponse Differences of Spontaneous Panic and Fear
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“…it is important to acknowledge that both decreased vagal tone and reduced autonomic flexibility may predict CAD (Brosschot & Thayer, 1998; Friedman & Thayer, 1998a, 1998b; Stein & Kleiger, 1999), both of which were found among high-hostile individuals (Demaree & Everhart, in press) to…”
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“…lower HRV is associated with various forms of psychosocial distress, including depression and anxiety (Chalmers, Quintana, Abbott, & Kemp, 2014; Friedman & Thayer, 1998; Horsten et al., 1999; Rottenberg, 2007), episodes of worry (Pieper, Brosschot, van der Leeden, & Thayer, 2007; Thayer,…”
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“If resting RSA is an index of physiological flexibility, higher resting RSA is expected to be associated with more effective deployment of the vagal brake, or in other words, with less extreme emotional responses (Friedman & Thayer, 1998a, 1998b; Thayer, Friedman, & Borkovec, 1996).”
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Physiological and Relational Predictors of Mother-Infant Behavioral Coordination
Waters, S. F., & Mendes, W. B. (2016) · Adaptive Human Behavior and Physiology · doi:10.1007/s40750-016-0045-9 · Cited by 14
“One body of research has focused on adult clinical samples, consistently finding that low cardiac vagal tone or resting RSA is associated with various psychiatric difficulties (Demaree and Everhart 2004; Friedman and Thayer 1998; Licht et al. 2008).”
BackgroundHeart Rate Variability Predicts Treatment Outcome in Major Depression
(2017) · Journal of Psychiatry and Brain Science · doi:10.20900/jpbs.20170017 · Cited by 13
“HRV has been investigated in psychiatric populat ions, and decreased HRV has been associated with anxiety disorder, bipolar mania, schizophrenia, and MDD ([21-23]).”
BackgroundRen, H., Shi, M., & Zhang, J. (2024) · Buildings · doi:10.3390/buildings14040997 · Cited by 14
Zheng, S., Lal, S., Meier, P., Sibbritt, D. W., & Zaslawski, C. (2014) · Journal of Acupuncture and Meridian Studies · doi:10.1016/j.jams.2014.01.003 · Cited by 14
Psychophysiological Markers of Anxiety Disorders and Anxiety Symptoms
Lee, S., & Park, G. (2011) · InTech eBooks · doi:10.5772/20164 · Cited by 12
“, 2000; Ellis & Thayer, 2010) There is converging evidence suggesting that reduced HRV—indicating autonomic dysregulation associated with elevated sympathetic activity and reduced vagal activity of the heart—is commonly observed in patients with panic disorder, GAD, and even children of patients with panic disorder (s…”
BackgroundPanic Disorder and Serotonin Reuptake Inhibitors Predict Coupling of Cortical and Cardiac Activity
Mueller, E. M., Panitz, C., Nestoriuc, Y., Stemmler, G., & Wacker, J. (2013) · Neuropsychopharmacology · doi:10.1038/npp.2013.224 · Cited by 13
“As cardiovascular sensations (ie, tachycardia, palpitations) are the most frequent peripheral manifestations of panic attacks (Barlow et al, 1985) the coupling of central and cardiac activity could be of particular relevance in PD (Friedman and Thayer, 1998).”
BackgroundHsiao, C. Y., Tsai, H. C., Chi, M. H., Chen, K. C., Chen, P. S., Lee, I. H., Yeh, T. L., & Yang, Y. K. (2016) · Medicine · doi:10.1097/md.0000000000003498 · Cited by 13
Fu, S. R., Lee, M. F., & Ou, S. J. (2018) · Ageing and Society · doi:10.1017/s0144686x18001058 · Cited by 13
“%) and SDNN increase (Friedman and Thayer, 1998; Sheps and Sheffield, 2001).”
McGreevy, C. A., Bonanno, G. A., & D'Andrea, W. M. (2015) · Personality and Individual Differences · doi:10.1016/j.paid.2015.04.033 · Cited by 13
“Decreases in RSA have been related to autonomic dysregulation (Friedman & Thayer, 1998) and thus indicate negative consequences of regulation.”
BackgroundLindberg, R., McDonough, K., & Trofimovich, P. (2022) · Studies in Second Language Acquisition · doi:10.1017/s0272263122000523 · Cited by 19
“For both state-and trait-anxiety, physical symptoms include increased heart rate, trembling, and sweaty palms through activation of the autonomic nervous system (Croft et al., 2004; Friedman & Thayer, 1998; Witt et al., 2006).”
BackgroundMatsangidou, M., Solomou, T., Frangoudes, F., Papayianni, E., & Pattichis, C. S. (2023) · JMIR Aging · doi:10.2196/45799 · Cited by 12
“Earlier research has shown that stress can affect heart rate [39]; therefore, particularly promising results from our study were the heart rate data collected before, during, and after VR session.”
Hua, A. Y., Roy, A. R. K., Kosik, E. L., Morris, N., Chow, T. E., Lukic, S., Montembeault, M., Borghesani, V., Younes, K., Kramer, J. H., et al. (2023) · NeuroImage Clinical · doi:10.1016/j.nicl.2023.103522 · Cited by 10
“At rest, the vagus nerve inhibits the heart, slowing its rate from that set by intrinsic pacemaker cells and creates beat-to-beat variability in the cardiac cycle that wax and wane across respiration (Allen et al., 2007; Berntson et al., 1994; Friedman & Thayer, 1998).”
BackgroundMohamed, I. I., Aboamer, M. A., Azar, A. T., Wahba, K. K., Schumann, A., & Bär, K. J. (2017) · Neural Computing and Applications · doi:10.1007/s00521-017-3245-8 · Cited by 12
Panic disorder and subthreshold panic in the light of comorbidity: a follow-up study
Oral, E., Aydın, N., Güleç, M., & Oral, M. (2012) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2012.01.009 · Cited by 12
“Tachycardia and palpitations are among the most frequent symptoms [6].”
BackgroundInfluence of experimentally induced anxiety on rectal sensorimotor function in healthy humans
Geeraerts, B., Oudenhove, L. V., Vos, R., & Tack, J. F. (2008) · Neurogastroenterology & Motility · doi:10.1111/j.1365-2982.2008.01158.x · Cited by 12
An Evaluation Method of Safe Driving for Senior Adults Using ECG Signals
Koh, D.-W., & Lee, S.-G. (2019) · Sensors · doi:10.3390/s19122828 · Cited by 12
“[43,44] described the manifestation of stress as a feeling of anxiety followed by physical transformation (increased heart rate) with behavioral adaptation for recognizing signs of danger (hypervigilance).”
BackgroundBrain–body states as a link between cardiovascular and mental health
Villringer, A., Nikulin, V. V., & Gaebler, M. (2025) · Trends in Neurosciences · doi:10.1016/j.tins.2025.08.004 · Cited by 18
“These concepts are also applicable to brain – body interactions [7,34,37].”
Evaluation of measurement accuracy of wearable devices for heart rate variability
Li, X.-C., Song, Y.-T., Wang, H., Su, X., Wang, M., Li, J., Ren, Z., Zhong, D.-D., & Huang, Z.-Y. (2023) · iScience · doi:10.1016/j.isci.2023.108128 · Cited by 10
La phobie du sang-injection-accident : spécificités psychophysiologiques et thérapeutiques
Ducasse, D., Capdevielle, D., Attal, J., Larue, A., Macgregor, A., Brittner, M., & Fond, G. B. (2012) · L Encéphale · doi:10.1016/j.encep.2012.06.031 · Cited by 11
“[17] Friedman BH, Thayer JF.”
BackgroundServant, D., Lebeau, J. C., Mouster, Y., Hautekèete, M., Logier, R., & Goudemand, M. (2008) · Journal de Thérapie Comportementale et Cognitive · doi:10.1016/j.jtcc.2008.04.003 · Cited by 11
“[15] Friedman BH, Thayer JF.”
BackgroundLinear model-based estimation of blood pressure and cardiac output for Normal and Paranoid cases
Aboamer, M. A., Azar, A. T., Wahba, K. K., & Mohamed, A. S. A. (2014) · Neural Computing and Applications · doi:10.1007/s00521-014-1566-4 · Cited by 11
“The ANS has common characteristic of a variety of psychiatric disorders, including schizophrenia, depression and panic disorder [8, 11, 12, 19, 30, 78].”
BackgroundDiamond, L. M. (2015) · Springer eBooks · doi:10.1007/978-1-4614-9622-9_5 · Cited by 12
“1993), as well as higher levels of anger, hostility, mental stress, and generalized anxiety (reviewed in Brosschot and Thayer 1998; Friedman and Thayer 1998; Horsten et al. 1999).”
BackgroundLiu, Y., Yin, H., Ma, H., Yu, X., Liu, G., Guo, L., & Geng, Q. (2019) · Neuroscience Letters · doi:10.1016/j.neulet.2019.134613 · Cited by 11
Psychosomatik der Herzinsuffizienz
Herrmann‐Lingen, C. (2011) · Herz · doi:10.1007/s00059-011-3420-0 · Cited by 11
Relationships between oriental medical pattern diagnosis and cardiovascular autonomic function
Park, Y.-J., Lee, J.-M., & Park, Y.-B. (2013) · European Journal of Integrative Medicine · doi:10.1016/j.eujim.2013.07.007 · Cited by 11
Shioiri, T., Kojima-Maruyama, M., Hosoki, T., Kitamura, H., Tanaka, A., Yoshizawa, M., Bando, T., & Someya, T. (2005) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-005-0561-2 · Cited by 11
“First, the sample size was relatively small, although three-fifths or greater than 50 previous studies had a similar sample size (see review; Friedman and Thayer 1998; Gorman and Solan 2000; Jeejeebhoy et al. 2000).”
ResultTóth, M., & Zupan, B. (2007) · Wiley eBooks · doi:10.1002/9780470101001.hcn023 · Cited by 12
“Autonomic arousal, an integral part of neuroticism, is also a characteristic of anxiety disorders and is manifested as tachycardia, increased blood pressure, and elevated core temperature [44].”
Seeing is believing: making wellbeing more tangible
Vella-Brodrick, D. A., Gill, A., & Patrick, K. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.809108 · Cited by 10
“Higher vagal activity is associated with greater autonomic flexibility or the capacity of the autonomic nervous system to change according to environmental needs (Friedman and Thayer, 1998; Porges, 2007).”
BackgroundHong, S., Park, D., Ryu, S., Ha, J. H., & Jeon, H. J. (2022) · Clinical Psychopharmacology and Neuroscience · doi:10.9758/cpn.2022.20.4.737 · Cited by 10
“generalized anxiety disorder, post-traumatic stress disorder, social anxiety disorder, and panic disorder [13,40-43].”
BackgroundGanne, C., Talkad, S. N., Srinivas, D., & Somanna, S. (2016) · British Journal of Neurosurgery · doi:10.3109/02688697.2016.1159656 · Cited by 10
“Such segments were identified from the following stages: (1) baseline reading (BL), (2) Sylvian fissure dissection (SFD), (3) perianeurysmal dissection (PAD), (4) clipping of the aneurysm (CLIP) and (5)”
Background
Metadata
- Authors
- Friedman, B. H., & Thayer, J. F.
- Affiliations
- Washington University in St. Louis (US)
- University of Missouri (US)
- Corresponding author
- Friedman, Bruce H.
- Venue
- Journal of Psychosomatic Research
- Publisher
- Elsevier BV
- Published
- 1998-01
- Volume
- 44
- Issue
- 1
- Pages
- 133-151
- ISSN
- 0022-3999 (ISSN-L)
- OpenAlex
- W2167377065
- Cited by
- 616
- References
- 173
- Citations by year
- 2026: 6 · 2025: 14 · 2024: 15 · 2023: 16 · 2022: 18 · 2021: 20 · 2020: 25 · 2019: 27 · 2018: 22 · 2017: 36 · 2016: 43 · 2015: 28 · 2014: 33 · 2013: 25 · 2012: 29
- FWCI
- 2.04
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Psychosomatic Research (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- heart rate variability, panic disorder, sympathovagal balance, cardiac vagal tone, palpitations, anxiety, emotion regulation, homeostatic model, systems approach, disease classification, pathophysiology
- MeSH terms
- Anxiety Disorders, Arrhythmias, Cardiac, Autonomic Nervous System, Epinephrine, Heart Rate, Homeostasis, Humans, Models, Biological, Sympathetic Nervous System, Vagus Nerve, Comorbidity, Panic Disorder
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