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Auton Neurosci. 2018 Jul;212:42-47. doi: 10.1016/j.autneu.2018.01.004. Epub 2018 Jan 31.

Emotional orienting during interoceptive threat in orthostatic intolerance: Dysautonomic contributions to psychological symptomatology in the postural tachycardia syndrome and vasovagal syncope.

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Lab of Action and Body, Department of Psychology, Royal Holloway, University of London, UK; Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, UK; Autonomic Unit, National Hospital Neurology and Neurosurgery, UCL NHS Trust, London, UK. Electronic address:
School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK.
Neuroscience, Brighton and Sussex Medical School, Brighton, UK; Sussex Partnership NHS Foundation Trust, Brighton, UK; Sackler Centre for Consciousness Science, University of Sussex, UK.
Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, UK; Autonomic & Neurovascular Medicine Centre, Hospital of St John & St Elizabeth, London, UK.


Cognitive and emotional processes are influenced by interoception (homeostatic somatic feedback), particularly when physiological arousal is unexpected and discrepancies between predicted and experienced interoceptive signals may engender anxiety. Due to the vulnerability for comorbid psychological symptoms in forms of orthostatic intolerance (OI), this study investigated psychophysiological contributions to emotional symptomatology in 20 healthy control participants (13 females, mean age 36 ± 8 years), 20 postural tachycardia syndrome (PoTS) patients (18 females, mean age 38 ± 13 years) and 20 vasovagal syncope (VVS) patients (15 females, mean age 39 ± 12 years). We investigated indices of emotional orienting responses (OR) to randomly presented neutral, pleasant and unpleasant images in the supine position and during the induced interoceptive threat of symptom provocation of head-up tilt (HUT). PoTS and VVS patients produced greater indices of emotional responsivity to unpleasant images and, to a lesser degree, pleasant images, during interoceptive threat. Our findings are consistent with biased deployment of response-focused emotion regulation (ER) while patients are symptomatic, providing a mechanistic underpinning of how pathological autonomic overexcitation predisposes to anxiogenic traits in PoTS and VVS patients. This hypothesis may improve our understanding of why orthostasis exacerbates cognitive symptoms despite apparently normal cerebral autoregulation, and offer novel therapeutic targets for behavioural interventions aimed at reducing comorbid cognitive-affective symptoms in PoTS and VVS.


Autonomic nervous system; Dysautonomia; Interoception; Orienting response; Orthostatic intolerance; Postural tachycardia syndrome; Vasovagal syncope

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