Anxiety disorders

Effects of heart rate variability (HRV) biofeedback on HRV and immune response in patients with panic disorder

The aim of the present study is to analyse the effects of HRV biofeedback on HRV, symptom severity and cytokine concentration in patients diagnosed with panic disorder (PD). Patients with anxiety disorders, especially PD patients, exhibit reduced HRV indices. First results suggest an association between PD and elevated levels of pro-inflammatory cytokines. Prior studies showed that HRV biofeedback is effective in reducing symptoms of mental disorders associated with autonomic dysbalance. It has not been explored yet to what extent HRV biofeedback alone could be an effective treatment since most studies implemented HRV biofeedback in addition to treatment as usual. Further it is unknown if HRV biofeedback is capable of modulating cytokine production. At follow-up six weeks after the last training sessions, HRV, symptom severity and cytokine concentration will be analysed again. This study tests for the first time (1) if HRV biofeedback will be effective in the treatment of PD, and (2) if HRV biofeedback will positively modulate cytokine production.

Inclusion criteria:

  • PD with or without agoraphobia according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
  • Age between 18 and 65 years
  • Other secondary mental disorders (specific phobias, minor episode of major depression) are allowed

Exclusion criteria:

  • Current psychotherapy
  • Psychotropic drugs affecting the central nervous system (e. g. antidepressants)
  • Medication affecting heart rate (e. g. beta blocker), cardiac disorders
  • Acute suicidal tendency
  • Comorbid disorders according to DSM-IV: substance abuse, schizophrenia, bipolar or personality disorder
  • Dementia, pregnancy and severe chronic physical diseases (e.g. diabetes or cancer)

Exposure therapy for patients with agoraphobia with an innovative 360° real life virtual reality-technique

Agoraphobia with or without panic disorder (PD) is an anxiety disorder characterized by avoiding certain places, such as public transportation or bridges. Due to the high stress on those affected, it is one of the most common diagnoses in outpatient psychotherapy. Cognitive behavioral therapy (CBT) with exposure in vivo is considered to be the “gold standard” of psychotherapeutic treatment because of its consistently high therapeutic effects. However, studies show that 90% of agoraphobic patients receive psychotropic drugs and only 8% receive exposure therapy. Instead, therapists primarily conduct interoceptive or in sensu exposure. Obstacles in the implementation of in vivo exposures, such as large expenditure of time and money, could be overcome with exposure therapy in virtual reality (VRET). VRET has been shown to be effective for specific phobias and social phobia. Some studies also show a reduction in subjectively reported symptoms and arousal in patients with PD and agoraphobia. The main problems of these studies are the assessment of predominantly subjective symptoms, whereby psychophysiological measures were mostly neglected, the results were rarely replicated, only small sample sizes were examined and no real images were used for the VR scenarios. The planned study examines the effectiveness of VRET in comparison to CBT without in vivo exposure in patients with agoraphobia with regard to subjective symptom burden. In addition, psychophysiological measures such as heart rate (HR), heart rate variability (HRV), pulse wave velocity (PWV), skin conductance (SC) and salivary cortisol are recorded during the exposure sessions.

Key inclusion criteria:

  • Agoraphobia with/ without PD
  • age between 18 and 65 years
  • ability to understand, read and respond to German language and give informed consent

Key exclusion criteria:

  • specific mental disorders (drug or alcohol abuse/ addiction, schizophrenia, bipolar disorder, dementia, eating disorder, PTSD, severe depressive episode)
  • severe medical diseases (e. g. cancer, cardiovascular disease, epilepsy)
  • psychopharmacotherapy or any medication influencing the cardiovascular system (e. g. beta blocker)
  • ongoing psychotherapy

Comparison of the habituation processes between healthy people and patients with social phobia before and after exposure treatment

Social phobia is one of the most common anxiety disorders. It is proposed that dysfunctional strategies for coping with social phobic anxiety reduce the possibility of relearning and habituation. The most effective therapy is confrontation in vivo. Social phobic patients are confronted with anxiety-provoking situations to make experiences incongruent with their fears and in turn show a reduced physiological reaction. In this way, confrontation leads to a correction of social-phobic cognitions and to physiological habituation. For now, it is unclear why manualized confrontation therapy does not work for all social phobic patients. It is proposed that reasons may be security behavior and differences in the ability of habituation. It seems that the autonomic nervous system and the Hypothalamic-pituitary-adrenocortical (HPA) axis play an important role. Studies show that if a standardized combination of tasks like the TSST is used for stress induction with social phobic patients, they show a cortisol-hyperreactivity. This supports the idea of differences in habituation between healthy and social phobic persons. Based on the current literature it is unclear if this differences in stress-responsivity are related with differences in habituation and therapy success and if a change of social-phobic cognitions throughout therapy is related with changes in stress-responsivity.

Inclusion criteria patient sample:

  • Presence of a social phobia as the primary diagnosis according to ICD-10
  • Second, a specific phobia may be present, otherwise no further comorbidities
  • Age between 18 and 65 years
  • Patients' cycle status: testing in the luteal phase

Inclusion criteria healthy control group:

  • No current or previous mental disorder (lifetime) according to ICD-10
  • Age between 18 and 65 years
  • The subjects' cycle status: testing in the luteal phase

General exclusion criteria:

  • Presence of one of the following (comorbid) disorders according to ICD-10: major depression, substance addiction, psychotic disorder, bipolar disorder, post-traumatic stress disorder, generalized anxiety disorder, obsessive-compulsive disorder, eating disorder, panic disorder, agoraphobia
  • psychotropic drugs
  • contraceptives

For further information, please contact our site staff:

Dr. Mareike Ernst, Telephone number: 06131-17-7649,


get in touch with us via our general e-mail address:

University Medical Center Mainz
Study Center for Clinical Trials in Mental Disorders
Untere Zahlbacher Str. 8
55131 Mainz