Advertisement

Autonomic characteristics of nonclinical panic and blood phobia

      This paper is only available as a PDF. To read, Please Download here.

      Abstract

      Autonomic characteristics of nonclinical panic and blood phobia were compared using spectral analysis of the electrocardiogram (EKG), as well as more conventional cardiovascular measures. The cardiovascular responses of 11 subjects who reported recent occureence of frequent severe panic attacks, and 10 subjects who reported intense somatic reactions to the sight of blood (including episodes of syncope) were recorded during a variety of laboratory tasks (quiet rest, reaction time/shock avoidance, face immersion, and combined reaction time/face immersion). Results suggest distinct autonomic patterns in the groups. Panickers showed (a) higher heart rate and reduced heart-rate variability (b) aberrant associations among cardiovascular measures, and (c) dominant sympathetic control of heart rate coupled with diminished vagal tone. Blood phobics generally displayed an opposite pattern. The relevance of these findings to the etiology of panic and blood phobia, as well as to biological models of anxiety disorders in general, is discussed.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Biological Psychiatry
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Agras W.S.
        • Sylvester D.
        • Oliveau D.
        The epidemiology of common fears and phobias.
        Compr Psychiatry. 1969; 10: 151-156
        • Akselrod S.
        • Gordon D.
        • Ubel F.A.
        • et al.
        Power spectrum analysis of heart rate fluctuation: A quantitative probe of beat-to-beat cardiovascular control.
        Science. 1981; 213: 220-222
        • Allen M.T.
        • Crowell M.D.
        Patterns of autonomic response during laboratory stressors.
        Psychophysiology. 1989; 26: 603-614
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders.
        in: 3rd ed, rev. American Psychiatric Press, Washington, DC1987
        • Anastasiades P.
        • Clark D.M.
        • Salkovskis P.
        • Middleton H.
        • Hackman A.
        • Johnston O.W.
        Psychophysiological responses in panic and stress.
        J Psychophysiol. 1990; 4: 331-338
        • Arabian J.
        • Furedy J.
        • Morrison J.
        • Szalai J.
        Treatment of PAT: Bradycardic reflexes induced by dive vs. body tilt.
        Pavlovian J Biol Sci. 1983; 18: 88-93
        • Ballenger J.C.
        Biological aspects of panic disorder.
        Am J Psychiatry. 1986; 143: 516-518
        • Bandura A.
        On paradigms and recycled ideologies.
        Cog Res Ther. 1978; 2: 79-103
        • Barlow D.H.
        Anxiety and its Disorders.
        Guilford Press, New York1988
        • Baseli G.
        • Cerutti S.
        • Civardi S.
        • et al.
        Heart rate variability signal processing: A quantitative approach as an aid to diagnosis in cardiovascular pathologies.
        Int J Biomed Comput. 1987; 20: 51-70
        • Berne R.M.
        • Levy M.N.
        Cardiovascular Physiology.
        6th ed. Mosby-Year Book, St. Louis, MO1992
        • Bernstein D.A.
        Some comments on therapy analogue research with small animal “phobias”.
        J Behav Ther Exp Psychiatry. 1973; 2: 225-237
        • Berntson G.G.
        • Cacioppo J.T.
        • Quigley K.S.
        Autonomic determinism: The modes of autonomic control, the doctrine of autonomic space, and the laws of autonomic contraint.
        Psychol Rev. 1991; 98: 459-487
        • Borkovec T.D.
        • O'Brien G.T.
        Methodological and target behavior issues in analogue therapy outcome research.
        in: Hersen M. Elsier R.M. Miller P.M. Progres in Behavior Modification. Academic Press, New York1976
        • Borkovec T.D.
        • Rachman S.J.
        The utility of analogue research.
        Behav Res Ther. 1979; 17: 253-261
        • Borkovec T.D.
        • Stone N.M.
        • O'Brien G.T.
        • Kaloupek D.G.
        Evaluation of clinically relevant target behavior for analogue outcome research.
        Behav Ther. 1974; 5: 505-514
        • Brick I.
        Circulatory responses to immersing the face in water.
        J Appl Physiol. 1966; 21: 33-36
        • Byrne D.G.
        • Byrne A.E.
        Anxiety and coronary heart disease.
        in: Byrne D.G. Rosenman R.H. Anxiety and the Heart. Hemisphere, New York1990
        • Carasnos G.J.
        Neurocirculatory asthenia.
        in: Eliot R.S. Stress and the Heart. Futura Publishing, Mount Kisco, NY1974
        • Carruthers M.
        • Taggart P.
        Vagotonicity of violence: Biochemical and cardiac responses to violent films and television programmes.
        Br Med J. 1973; 3: 384-389
        • Charney D.S.
        • Heninger G.R.
        Abnormal regulation of noradrenergic function in panic disorders.
        Arch Gen Psychiatry. 1986; 43: 1042-1054
        • Charney D.S.
        • Woods S.W.
        • Price L.H.
        • Goodman W.K.
        • Glazer W.M.
        • Heninger G.R.
        Noradrenergic dysregulation in panic disorder.
        in: Ballenger J.C. Neurobiology of Panic Disorder. Wiley-Hiss, New York1990
        • Cohn C.
        • Kron R.
        • Brady J.
        A case of blood-injury-illness fear.
        J Nerv Ment Dis. 1976; 162: 62-68
        • Colombo R.
        • Mazzuero G.
        • Soffiatino F.
        • Ardizzoia M.
        • Minuco G.
        A comprehensive PC solution to heart rate variability analysis in mental stress.
        1989 IEEE Comp Cardiol. 1990; : 475-478
        • Connolly J.
        • Hallam R.S.
        • Marks I.M.
        Selective association of fainting with blood-injury-illness fear.
        Behav Ther. 1976; 7: 8-13
        • Coryell W.
        Panic disorder and mortality.
        Psychiatr Clin North Am. 1988; 11: 433-440
        • Coryell W.
        • Noyes R.
        • Clancy J.
        Excess mortality in panic disorder: A comparison with primary unipolar depression.
        Arch Gen Psychiatry. 1982; 39: 701-703
        • Costello C.G.
        Anxiety and the persisting novelty of input from the autonomic nervous system.
        Behav Ther. 1971; 2: 321-333
        • Craske M.G.
        • Rachman S.J.
        • Tallman K.
        Mobility, cognitions, and panic.
        J Psychopathol Behav Assess. 1986; 8: 199-210
        • Crowe R.R.
        Molecular genetics and panic disorder: New approaches to an old problem.
        in: Ballenger J.C. Neurobiology of Panic Disorder. Wiley-Liss, 1990
        • Crowe R.R.
        • Noyes
        • Pauls D.L.
        • Slymen D.J.
        A family study of anxiety neurosis: Morbidity risk in families of patients with and without mitral valve prolapse.
        Arch Gen Psychiatry. 1983; 37: 77-79
        • Curtis G.
        • Thyer B.
        Fainting on exposure to phobic stimuli.
        Am J Psychiatry. 1983; 140: 771-774
        • Dawson M.E.
        • Nuechterlein K.H.
        The role of autonomic dysfunctions within a vulnerability-stress model of schizophrenic disorders.
        in: Magnusson D. Ohman A. Psychopathology: An Interactional Perspective. Academic Press, Orlando, FL1987
        • Dielman T.E.
        Pooled cross-sectional and time series data: A survey of current statistical methodology.
        Am Statistician. 1983; 37: 111-122
        • Ehlers A.
        • Margraf J.
        • Roth W.
        Experimental induction of panic attacks.
        in: Hand I. Wittchen H.-U. Panic and Phobias. Springer-Verlag, Berlin1986
        • Engel G.L.
        Psychologic stress, vasodepressor syncope, and sudden death.
        Ann Intern Med. 1978; 89: 403-412
        • Eysenck H.J.
        The Structure of Human Personality.
        Methuen, London1970
        • Finley J.P.
        • Bonet J.F.
        • Waxman M.B.
        Autonomic pathways responsible for bradycardia during facial immersion.
        J Appl Physiol. 1979; 47: 1218-1222
        • Fox N.A.
        • Fitzgerald H.E.
        Maturation of autonomic control in pretern infants.
        Merril-Palmer Q. 1990; 36: 27-51
        • Fox N.A.
        Maturation of autonomic control in preterm infants.
        Dev Psychol. 1983; 16: 495-504
        • Fraser F.
        • Wilson R.M.
        The sympathetic nervous system and the “irritable heart of soldiers”.
        Br Med J. 1918; 2: 27-29
        • Freisinger G.C.
        • Likar I.
        • Biern R.O.
        • Mason R.E.
        Vasoregulatory asthenia: A cause for false-positive exercise electrocardiograms.
        Circulation. 1965; 32: 90
        • Friedlander A.
        • Freyhof W.L.
        Intensive study of fifty cases of neurocirculatory asthenia.
        Arch Intern Med. 1918; 22: 693-718
        • Frohlich E.D.
        • Tarazi R.C.
        • Dustan H.P.
        Hyperdynamic beta adrenergic circulatory state: Increased beta-receptor responsiveness.
        Arch Intern Med. 1969; 123: 1-7
        • George D.T.
        • Nutt D.J.
        • Walker W.V.
        • Porges S.W.
        • Adinoff B.
        • Linnoila M.
        Lactate and hyperventilation substantially attenuate vagal tone in normal volunteers.
        Arch Gen Psychiatry. 1989; 46: 153-156
        • Glick G.
        • Yu P.N.
        Hemodynamic changes during spontaneous vasovagal reactions.
        Am J Med. 1963; 34: 42-51
        • Gilmour R.F.
        • Zipes D.P.
        Evidence for prejunctional and postjunctional antagonism of the sympathetic neuroeffector junction by acetylcholine in canine cardiac Purkinje fibers.
        J Am Coll Cardiol. 1984; 3: 760-765
        • Goldberger A.L.
        Is the normal heartbeat chaotic or homeostatic?.
        News Physiol Sci. 1991; 6: 87-91
        • Goldberger A.L.
        • Rigney D.R.
        Sudden death is not chaos.
        in: Krasner S. The Ubiquity of Chaos. American Association for the Advancement Science, Washington, DC1990
        • Gorman J.M.
        • Liebowitz J.M.
        • Gorman J.M.
        • et al.
        Effect of acute beta-adrenergic blockade on lactate-induced panic.
        Am J Psychiatry. 1983; 40: 1079-1082
        • Graham D.T.
        • Kabler J.D.
        • Lunsford L.
        Vasovagal fainting: A diphasic response.
        Psychosom Med. 1961; 23: 485-507
        • Granville-Grossman K.L.
        • Turner P.
        The effect of propranolol on anxiety.
        Lancet. 1966; 1: 788-790
        • Grossman P.
        • Karemaker J.
        • Wieling W.
        Prediction of tonic cardiac parasympathetic control using respiratory sinus arrhythmia: The need for respiratory control.
        Psychophysiology. 1991; 28: 201-216
        • Grossman P.
        • Svebak S.
        Respiratory sinus arrhythmia as an index of parasympathetic cardiac control during active coping.
        Psychophysiology. 1987; 24: 228-235
        • Grossman P.
        • van Beek J.
        • Wientes C.
        A comparison of three quantification methods for estimation of respiratory sinus arrhythmia.
        Psychophysiology. 1990; 27: 702-714
        • Grossman P.
        • Wientjes K.
        Respiratory sinus arrhythmia and parasympathetic cardiac control: Some basic issues concerning quantification, application, and implications.
        in: Grossman P. Janssen K.H. Vaitl D. Cardiorespiratory and Cardiosomatic Psychophysiology. Plenum Press, New York1986
        • Grunhaus L.
        • Gloger S.
        • Weisstub E.
        Panic attacks: A review of treatments and pathogenesis.
        J Nerv Ment Dis. 1981; 169: 608-613
        • Hoehn-Saric R.
        A comparison of generalized anxiety disorder with panic disorder patients.
        Psychopharmacol Bull. 1982; 18: 104-108
        • Hoehn-Saric R.
        • McLeod D.R.
        The peripheral sympathetic nervous system: Its role in pathological anxiety.
        Psychiatr Clin North Am. 1988; 11: 375-386
        • Holden A.E.
        • Barlow D.H.
        Heart rate and heart rate variability recorded in vivo in agoraphobics and nonphobics.
        Behav Ther. 1986; 17: 26-42
        • Jacob R.G.
        • Waldstein S.R.
        Panic disorder, anxiety, and the autonomic nervous system.
        in: Shapiro A.P. Baum A. Behavioral Aspects of Cardiovascular Disease. Lawrence Erlbaum, Hillsdale, NJ1991
        • Jennings J.R.
        Could the vagal responses during information processing be related to clinically significant arrhythmia?.
        in: Twentyman C. Epstein L. Blanchard E. Brady J.V. Progress in Behavioral Medicine. Springer-Verlag, New York1985
        • Kagan J.
        • Reznick J.S.
        • Snidman N.
        • Johnson M.O.
        • Gibbons J.
        • Gersten M.
        • Biderman J.
        • Rosenbaum J.
        Origins of panic disorder.
        in: Ballenger J.C. Neurobiology of Panic Disorder. Wiley-Liss, 1990
        • Katona P.G.
        • Jih F.
        Respiratory sinus arrhythmia: Non-invasive measure of parasympathetic control.
        J Appl Physiol. 1975; 39: 801-805
        • Kawakami Y.
        • Natelson B.H.
        • DuBois A.B.
        Cardiovascular effects of face immersion and factors affecting diving reflex in man.
        J Appl Physiol. 1967; 23: 964-970
        • Kazdin A.E.
        Evaluating the generality of findings in analogue therapy research.
        J Consult Clin Psychol. 1978; 46: 673-686
        • Kent K.M.
        • Smith E.R.
        • Redwood D.R.
        • Epstein S.E.
        Electrical stability of acutely ischemic myocardium.
        Circulation. 1973; 47: 291-298
        • Kleinknecht R.A.
        Vasovagal syncope and blood/injury fear.
        Behav Res Ther. 1987; 25: 175-178
        • Kollai M.
        • Koizumi K.
        Cardiovascular reflexes and interrelationships between sympathetic and parasympathetic activity.
        J Autonom Nerv Sys. 1981; 4: 135-148
        • Kolman B.S.
        • Verrier R.L.
        • Lown B.
        The effect of vagus nerve stimulation upon vulnerability of the canine ventricle: Role of sympathetic-parasympathetic interactions.
        Circulation. 1975; 52: 578-585
        • Lacey J.I.
        Somatic response patterning and stress: Some revisions of activation theory.
        in: Appley M.H. Trumbull R. Psychological Stress: Issues in Research. Appleton-Century-Crofts, New York1967
        • Lader M.H.
        The Psychophysiology of Mental Illness.
        Routledge & Kegan Paul, London1975
        • Lader M.H.
        The psychophysiology of anxiety.
        in: Handbook of Biological Psychiatry. Marcel Dekker, New York1980
        • Lader M.H.
        • Wing L.
        Habituation of the psycho-galvanic reflex in patients with anxiety states and in normal subjects.
        J Neurol Neurosurg Psychiatry. 1964; 27: 210-218
        • Lang P.J.
        Discussant in symposium, What we learn by making people anxious.
        in: Presented at the Annual Meeting of the Society for Psychophysiological Research, October 1991, Chicago, IL1991 (Chair: W. Roth)
        • Langer A.W.
        • McCubbin J.A.
        • Hutcheson S.
        • Charlton J.D.
        • Obrist P.A.
        Cardiopulmonary adjustment during exercise and an aversive reaction time task: Effects of beta-adrenoreceptor blockade.
        Psychophysiology. 1985; 22: 59-68
        • Levy M.N.
        Cardiac sympathetic-parasympathetic interactions.
        Fed Proceedings. 1984; 43: 2598-2602
        • Levy M.N.
        • Zieske H.
        Autonomic control of cardiac pacemaker activity and atrioventricular transmission.
        J Appl Physiol. 1969; 27: 465-470
        • Liebowitz M.R.
        • Gorman J.M.
        • Fyer A.J.
        • et al.
        Lactate provocation of panic attacks: II. Biochemical and physiological findings.
        Arch Gen Psychiatry. 1985; 42: 709-719
        • Linden R.J.
        Sympathetic and parasympathetic control of the heart.
        in: Orlebeke J.F. Mulder G. van Doornen L.J.P. Psychophysiology of Cardiovascular Control. Plenum Press, New York1985
        • Lombardi F.
        • Sandrone G.
        • Pernpruner S.
        • et al.
        Heart rate variability as an index of sympathovagal interaction after acute myocardial infarction.
        Am J Cardiol. 1989; 60: 1239-1245
        • Malliani A.
        • Lombardi F.
        • Pagani M.
        • Cerutti S.
        Clinical exploration of the autonomic nervous system by means of electrocardiography.
        Ann New York Acad Sci. 1990; 601: 234-246
        • Mandell A.J.
        • Schlesinger M.F.
        Lost choices: Parallelism and topological entropy decrements in neurobiological aging.
        in: Krasners S. The Ubiquity of Chaos. American Association for the Advancement of Science, Washington, DC1990
        • Margraf J.
        • Ehlers A.
        • Roth W.T.
        Biological models of panic disorder and agoraphobia: A review.
        Behav Res Ther. 1986; 24: 553-567
        • Marks I.M.
        • Lader M.
        Anxiety states (Anxiety Neurosis): A review.
        J Nerv Ment Dis. 1973; 156: 3-18
        • Marks I.M.
        Fears, Phobias, and Rituals.
        Oxford University Press, New York1987
        • Mathews A.
        • MacLeod C.
        Discrimination of threat cues without awareness in anxiety states.
        J Abnorm Psychol. 1986; 95: 131-138
        • Michela J.L.
        Within-person correlational design and analysis.
        in: Hendrick C. Clark M.S. Research Methods in Personality and Social Psychology. Sage, Newbury Park, CA1990
        • Michelson L.
        • Marchione K.
        • Greenwald M.
        • Glanz L.
        • Testa S.
        • Marchione N.
        Panic disorder: Cognitive-behavioral treatment.
        Behav Res Ther. 1990; 28: 141-151
        • Michelson L.
        • Mavissakalian M.
        • Marchione K.
        Cognitive, behavioral, and psychophysiological treatments of agoraphobia: A comparative outcome investigation.
        Behav Ther. 1988; 19: 97-120
      1. MINITAB, Inc., State College, Pa.

        • Myers J.K.
        • Weissman M.M.
        • Tischler C.E.
        • et al.
        Six-month prevalence of psychiatric disorders in three communities.
        Arch Gen Psychiatry. 1984; 41: 959-967
        • Nesse R.M.
        • Cameron O.G.
        • Curtis G.C.
        • McCann D.S.
        • Huber-Smith M.J.
        Adrenergic function in patients with panic anxiety.
        Arch Gen Psychiatry. 1984; 41: 771-776
        • Norton G.R.
        • Dorward J.
        • Cox B.J.
        Factors associated with panic attacks in nonclinical subjects.
        Behav Ther. 1986; 17: 239-252
        • Norton G.R.
        • Harrison B.
        • Hauch J.
        • Rhodes L.
        Characteristics of people with infrequent panic attacks.
        J Abnorm Psychol. 1985; 94: 216-221
        • Obrist P.A.
        Cardiovascular Psychophysiology.
        Plenum, New York1981
        • Ohman A.
        • Magnusson D.
        An interactional paradigm for research in psychopathology.
        in: Magnusson D. Ohman A. Psychopathology: An Interactional Perspective. Academic Press, Orlando, FL1987
        • Ost L.-G.
        Psychophysiological assessment of agoraphobia.
        J Psychophysiol. 1990; 4: 315-319
        • Ost L.-G.
        • Lindahl I.-L.
        • Sterner U.
        • Jerremalm A.
        Exposure in vivo vs. applied relaxation in the treatment of blood phobia.
        Behav Res Ther. 1984; 22: 205-216
        • Ost L.-G.
        • Sterner U.
        • Lindahl I.
        Physiological responses in blood phobics.
        Behav Res Ther. 1984; 22: 109-117
        • Pagani M.
        • Lombardi F.
        • Guzzetti S.
        • et al.
        Power spectral analysis of heart rate and arterial pressure variabilities as a marker of sympo-vagal interaction in man and conscious dog.
        Circul Res. 1986; 59: 178-193
        • Pedhazur E.J.
        Multiple Regression in Behavioral Research.
        Holt, Rinehart and Winston, New York1982
        • Pitts F.N.
        • Allen R.E.
        Beta adrenergic blockade in the treatment of anxiety.
        in: Mathew R.J. The Biology of Anxiety. Brunner/Maazel, New York1980
        • Pohl R.
        • Yeragani V.
        • Balon R.
        • Ortiz A.
        • Aleem A.
        Isoproterenol-induced panic: A beta-adrenergic model of panic anxiety.
        in: Ballenger J. Neurobiology of Panic Disorder. Wiley-Liss, New York1990
        • Pomerantz B.
        • Macaulay R.J.B.
        • Caudill M.A.
        • et al.
        Assessment of autonomic function in humans by heart rate spectral analysis.
        Am J Physiol. 1985; 248: H151-H153
        • Porges S.W.
        Respiratory sinus arrhythmia: Physiological basis, quantitative methods, and clinical implications.
        in: Grossman P. Janssen K. Vaitl D. Cardiac Respiratory and Somatic Psychophysiology. Guilford Press, New York1986
        • Porgess S.W.
        • McCabe P.M.
        • Yongue B.G.
        Respiratory-heart rate interactions: Physiological implications for pathophysiology and behavior.
        in: Cacioppo J. Petty R. Perspectives in Cardiovascular Psychophysiology. Guilford Press, New York1982
        • Rapee R.M.
        • Ancis J.
        • Barlow D.H.
        Emotional reactions to physiological sensations: Comparisons of panic disorder and nonclinical subjects.
        Behav Res Ther. 1988; 26: 265-269
        • Richards J.E.
        Power spectral analysis quantification of respiratory sinus arrhythmia.
        Psychophysiology. 1986; 23: 412
        • Roth W.T.
        • Telch M.J.
        • Taylor C.B.
        • et al.
        Autonomic characteristics of agoraphobia with panic attacks.
        Biol Psychiatry. 1986; 21: 1133-1154
        • Rushmer R.F.
        Structure and function of the cardiovascular system.
        in: Handbook of Research Methods in Cardiovascular Medicine. Plenum Press, New York1989
        • Ruetz P.P.
        • Johnson S.A.
        • Callahan R.
        • Meade R.C.
        • Smith J.J.
        Fainting: A review of its mechanisms and a study of blood donors.
        Medicine. 1967; 46: 363-384
        • Saini V.
        • Verrier R.L.
        The experimental study of behaviorally induced arrhythmias.
        in: Handbook of Research Methods in Cardiovascular Behavioral Medicine. Plenum Press, New York1989
        • Sandler L.S.
        • Wilson K.G.
        • Asmundson G.J.G.
        • Larsen D.K.
        • Ediger J.M.
        Cardiovascular reactivity in nonclinical subjects with infrequent panic attacks.
        J Anxiety Disord. 1992; 6: 27-39
        • Sartory G.
        • Olajide D.
        Vagal innervation techniques in the treatment of panic disorder.
        Behav Res Ther. 1988; 26: 431-434
        • Saul J.P.
        Beat-to-beat variations of heart rate reflect modulation of cardiac autonomic outflow.
        News Physiol Sci. 1990; 5: 32-37
        • Sayers B.
        Analysis of heart rate variability.
        Ergonomics. 1973; 16: 17-32
        • Schmidt R.
        Personality and fainting.
        J Psychosom Res. 1975; 19: 21-25
        • Schnur S.
        Cardiac neurosis associated with organic heart disease.
        Am Heart J. 1938; 18: 153-165
        • Shear M.K.
        • Kligfield P.
        • Harshfield G.
        • et al.
        Cardiac rate and rhythm in panic patients.
        Am J Psychiatry. 1987; 144: 633-637
        • Sherwood A.
        • Allen M.T.
        • Obrist P.A.
        • Langer A.W.
        Evaluation of beta-adrenergic influences on cardiovascular and metabolic adjustments to physical and psychological stress.
        Psychophysiology. 1986; 23: 89-104
        • Sledge W.H.
        Antecedent psychological factors in the onset of vasovagal syncope.
        Psychosom Med. 1978; 40: 568-579
        • Smith J.J.
        • Kampine J.P.
        Circulatory Physiology—The Essentials.
        Williams & Wilkins, Baltimore1984
        • Snidman N.
        Behavioral inhibition and sympathetic influence on the cardiovascular system.
        in: Reznick J.S. Perspectives on Behavioral Inhibition. University of Chicago Press, Chicago1989
        • Stampler F.M.
        Panic disorder: Description, conceptualization, and implications for treatment.
        Clin Psychol Rev. 1982; 2: 469-486
        • Syzman M.M.
        An evaluation of the effects of propranolol on the symptoms and electrocardiographic changes in patients with anxiety and the hyperventilation syndrome.
        Ann Inter Med. 1968; 68: 1194
        • Taylor C.B.
        • Sheikh J.
        • Agras W.S.
        • et al.
        Ambulatory heart rate changes in patients with panic attacks.
        Am J Psychiatry. 1986; 143: 478-482
        • Telch M.J.
        • Lucas J.A.
        • Nelson P.
        Nonclinical panic in college students: An investigation of prevalence and symptomatology.
        J Abnorm Psychol. 1989; 98: 300-306
        • Thyer B.A.
        • Curtis G.C.
        On the diphasic nature of vasovagal fainting associated with blood-illness-injury phobia.
        Pavlovian J Biol Sci. 1985; 20: 84-87
        • Thyer B.A.
        • Himle J.
        • Curtis G.C.
        Blood-injury-illness phobia: a review.
        J Clin Psychol. 1985; 41: 451-459
        • Uijtdehaage S.H.J.
        • Thayer J.F.
        Sympathetic-parasympathetic interactions in heart rate responses to laboratory stressors [abstract].
        Psychophysiology (suppl). 1989; 26: S63
        • Vaidhyanathan V.S.
        Regulation and control mechanisms in biological systems.
        Prentice-Hall, Englewood Cliffs1993
        • Vingerhoets A.J.J.M.
        Biochemical changes in two subjects succumbing to syncope.
        Psychosom Med. 1984; 46: 95-103
        • Wallin B.G.
        • Sundlof G.
        Sympathetic outflow to muscles during vasovagal syncope.
        J Autonom Nerv Sys. 1982; 6: 287-291
        • West B.J.
        Fractal Physiology and Chaos in Medicine.
        World Scientific, Teaneck, NJ1990
        • Wittchen H.U.
        Epidemiology of panic attacks and panic disorders.
        in: Hand I. Wittchen H.U. Panic and Phobias: Empirical Evidence of Theoretical Models and Longterm Effects of Behavioral Treatments. Springer-Verlag, Berlin1986
        • Wolf S.
        Psychophysiological influences on the dive reflex in man.
        in: Schwartz P.J. Brown A.M. Malliani A. Zanchetti A. Neural Mechanisms in Cardiac Arrhythmias. Raven Press, New York1978
        • Wolpe J.
        • Rowan V.
        Panic disorders: A product of classical conditioning.
        Behav Res Ther. 1988; 26: 441-450
        • Wood P.
        DaCosta's syndrome (or effort syndrome).
        Br Med J. 1941; 1: 767-845
        • Yeragani V.K.
        • Balon R.
        • Pohl R.
        • et al.
        Decreased R-R variance in panic disorder patients.
        Acta Psychiatr Scand. 1990; 81: 554-559
        • Yeragani V.K.
        • Pohl R.
        • Balon R.
        • et al.
        Effect of imipramine treatment on heart rate variability measures.
        Neuropsychobiology. 1992; 26: 27-32
        • Yule W.
        • Fernando P.
        Blood phobia—beware.
        Behav Res Ther. 1980; 18: 587-590
        • Zal H.M.
        Panic Disorder: The Great Pretender.
        Plenum Press, New York1990