Heart rate variability before and during social stress for people with and without social anxiety

Social anxiety disorder (SAD) is characterized by intense fear of social situations, often accompanied by physiological symptoms like increased heart rate.

Studying heart rate variability (HRV) in SAD is crucial because it provides insights into autonomic nervous system functioning and emotion regulation capacity.

HRV can reveal how individuals with SAD respond physiologically to social stressors, potentially offering clues about the disorder’s underlying mechanisms and informing more effective treatments targeting both psychological and physiological aspects of SAD.

Cheah, C., Lavery, C., Johnson, A. R., Clarke, P. J., Hyett, M. P., & McEvoy, P. M. (2025). Changes and persistence in heart rate variability before and during social stress: A comparison of individuals with and without social anxiety disorder. Journal of Anxiety Disorders, 110, 102960. https://doi.org/10.1016/j.janxdis.2024.102960

Key Points

• The study compared heart rate variability (HRV) between individuals with social anxiety disorder (SAD) and those without SAD across different phases of the Trier Social Stress Test (TSST).
• Contrary to expectations, there were no significant differences in baseline HRV between SAD and non-SAD groups.
• The SAD group, particularly women, showed a larger increase in HRV during the preparation (anticipation) phase compared to the non-SAD group.
• The non-SAD group demonstrated peak HRV during the speech task, while the SAD group’s HRV peaked during the preparation phase.
• No significant differences were found between groups in HRV persistence across TSST phases, though within-group effects suggested some differences in flexibility.
• The findings suggest that individuals with SAD may experience greater perceived threat during anticipation of social-evaluative contexts.
• Results highlight the potential importance of targeting emotion regulation in anticipation of social stressors for treating SAD.

Rationale

Social anxiety disorder (SAD) is characterized by significant fear of social situations and can severely impact various aspects of an individual’s life (Aderka et al., 2012).

While cognitive and behavioral aspects of SAD have been well-studied, less attention has been given to psychophysiological processes that may contribute to its maintenance (Hyett et al., 2018).

Understanding physiological changes in individuals with SAD during anticipation and exposure to social situations could inform more effective treatments.

Heart rate variability (HRV) has emerged as a valuable measure of autonomic nervous system functioning and emotion regulation capacity (Shaffer & Ginsberg, 2017).

Previous research on HRV in SAD has produced mixed results, with some studies finding lower HRV in individuals with SAD (Alvares et al., 2013) and others finding no differences (Klumbies et al., 2014).

These inconsistencies may be due to limited exploration of HRV across different phases of social stress, particularly during anticipation.

This study aimed to extend previous research by examining HRV differences between individuals with and without SAD across multiple phases of the Trier Social Stress Test (TSST), including baseline, preparation (anticipation), speech, and social interaction phases.

Method

Procedure

The study employed a between-groups design using the Trier Social Stress Test (TSST) to compare HRV responses in individuals with and without SAD.

Participants completed self-report measures and then underwent the TSST while their HRV was recorded.

Sample

The study included 94 individuals with SAD (52% men, 48% women) and 59 individuals without SAD (36% men, 64% women).

The SAD group was recruited from a community mental health clinic, while the non-SAD group was recruited from a university research participant pool.

Measures

• Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS): 20-item self-report measures of social interaction and performance anxiety.
• Trier Social Stress Test (TSST): A standardized protocol to elicit social stress, consisting of baseline, preparation, speech, and social interaction phases.
• Heart Rate Variability (HRV): Measured using electrocardiography, focusing on Root Mean Square of Successive Differences (RMSSD) and High-Frequency absolute units (HFabs).

Statistical measures

The study used multi-group autoregressive panel models to analyze HRV data.

Contrasts of model-estimated marginal means were used to assess group differences in baseline HRV and changes across TSST phases.

Autoregressive parameters were examined to assess HRV persistence across phases.

Results

Hypothesis 1: There will be lower trait HRV at baseline in the SAD group compared to the non-SAD group.

Result: This hypothesis was not supported. No significant differences in baseline HRV were found between the SAD and non-SAD groups.

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Hypothesis 2: The SAD group will show smaller mean changes in state HRV when anticipating and experiencing social stress compared to the non-SAD group.

Result: This hypothesis was partially supported, but with unexpected findings.

The SAD group, particularly women, showed a larger increase in HRV during the preparation phase compared to the non-SAD group.

The non-SAD group showed a larger increase from preparation to speech phases.

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Hypothesis 3: HRV will be more persistent (less flexible) across TSST phases in the SAD group compared to the non-SAD group.

Result: This hypothesis was not supported. No significant between-group differences were found in HRV persistence across phases.

However, within-group effects suggested some differences in flexibility, with the non-SAD group showing less persistence between some phases.

Insight

The study’s findings challenge some existing assumptions about HRV in social anxiety disorder.

Contrary to expectations, individuals with SAD did not show lower baseline HRV compared to those without SAD.

This suggests that trait-level differences in autonomic functioning may not be as pronounced as previously thought.

The most striking finding was the larger increase in HRV during the preparation phase for the SAD group, particularly among women.

This suggests that individuals with SAD, especially women, may experience greater anticipatory anxiety and engage more intensively in emotion regulation efforts when preparing for a social-evaluative situation.

This aligns with cognitive models of SAD that emphasize the role of anticipatory processing in maintaining anxiety (Clark & Wells, 1995; Wong & Rapee, 2016).

The difference in HRV patterns between SAD and non-SAD groups across TSST phases provides insight into how these groups may differ in their psychophysiological responses to social stress.

While the SAD group’s HRV peaked during preparation, the non-SAD group’s HRV peaked during the actual speech task.

This suggests that individuals without SAD may be more effective at mobilizing their physiological resources at the most relevant moment, whereas those with SAD may exhaust some of their regulatory capacity in anticipation.

The lack of significant differences in HRV persistence between groups, despite some within-group differences, highlights the complexity of autonomic flexibility in SAD.

It suggests that individuals with SAD may not have globally inflexible physiological responses, but rather context-specific differences in how they regulate their autonomic nervous system.

These findings extend previous research by providing a more nuanced understanding of psychophysiological processes in SAD across different phases of social stress.

They emphasize the importance of considering anticipatory processes and gender differences in both research and treatment of SAD.

Future research could explore the relationship between HRV patterns and specific cognitive processes, such as rumination or attention biases, in individuals with SAD.

Additionally, investigating how these HRV patterns change with treatment could provide valuable insights into mechanisms of change in SAD interventions.

Implications

For practitioners:

1. Targeting anticipatory anxiety: The findings suggest that interventions for SAD, particularly for women, should focus on managing anticipatory anxiety. Clinicians could incorporate techniques to help clients regulate their physiological arousal during the anticipation of social-evaluative situations.
2. Biofeedback interventions: Given the observed differences in HRV patterns, HRV biofeedback training could be a useful adjunct to traditional cognitive-behavioral therapies for SAD. This could help individuals learn to better regulate their autonomic nervous system responses in anticipation of and during social situations.
3. Gender-specific approaches: The more pronounced HRV increase in women with SAD during the preparation phase suggests that gender-specific interventions might be beneficial. Clinicians could explore and address potential differences in anticipatory processing between men and women with SAD.
4. Challenging misperceptions: The lack of baseline HRV differences between groups could be used therapeutically to challenge clients’ beliefs about their physiological differences from others, potentially reducing self-focused attention and anxiety.
5. Optimizing physiological regulation: Interventions could aim to help individuals with SAD learn to mobilize their physiological resources more effectively during actual social situations, rather than exhausting them during anticipation.

For policymakers:

1. Research funding: The findings highlight the need for more research into psychophysiological processes in SAD, particularly focusing on anticipatory anxiety and gender differences. Policymakers could prioritize funding for such research.
2. Treatment guidelines: Guidelines for SAD treatment could be updated to emphasize the importance of addressing anticipatory anxiety and considering potential gender differences in physiological responses.
3. Education and training: Policies could be implemented to ensure that mental health professionals receive training in understanding and addressing the psychophysiological aspects of SAD, including the use of biofeedback techniques.
4. Screening and early intervention: Given the observed differences in anticipatory responses, policies could be developed to implement screening programs that identify individuals at risk for SAD based on their physiological responses to anticipated social stressors.

Implementing these recommendations may face challenges such as the need for additional training for clinicians, potential resistance to incorporating physiological measures into psychological treatments, and the costs associated with biofeedback equipment.

However, the potential benefits of more targeted and effective treatments for SAD could outweigh these challenges.

Strengths

This study had several methodological strengths, including:

• Comprehensive assessment of HRV across multiple phases of social stress, providing a more nuanced understanding of psychophysiological processes in SAD
• Inclusion of both clinical (SAD) and non-clinical control groups
• Use of well-established measures (TSST, SIAS, SPS) and physiological recording techniques
• Consideration of gender differences in analyses
• Use of sophisticated statistical techniques (multi-group autoregressive panel models) to analyze HRV data

Limitations

This study also had several methodological limitations, including:

• Non-equivalent sampling methods for SAD and non-SAD groups (clinical sample vs. university student sample)
• Lack of control for potential confounding variables such as medication use, physical exercise, caffeine intake, and sleep quality
• Relatively small sample size, particularly for detecting subtle between-group differences
• Cross-sectional design limits causal inferences about the relationship between HRV patterns and SAD
• Lack of a genuine rest-only condition to fully delineate the effects of anticipatory anxiety on HRV

References

Primary reference

Cheah, C., Lavery, C., Johnson, A. R., Clarke, P. J., Hyett, M. P., & McEvoy, P. M. (2025). Changes and persistence in heart rate variability before and during social stress: A comparison of individuals with and without social anxiety disorder. Journal of Anxiety Disorders, 110, 102960. https://doi.org/10.1016/j.janxdis.2024.102960

Other references

Aderka, I. M., Hofmann, S. G., Nickerson, A., Hermesh, H., Gilboa-Schechtman, E., & Marom, S. (2012). Functional impairment in social anxiety disorder. Journal of Anxiety Disorders, 26(3), 393-400. https://doi.org/10.1016/j.janxdis.2012.01.003

Alvares, G. A., Quintana, D. S., Kemp, A. H., Zwieten, A. V., Balleine, B. W., Hickie, I. B., & Guastella, A. J. (2013). Reduced Heart Rate Variability in Social Anxiety Disorder: Associations with Gender and Symptom Severity. PLOS ONE, 8(7), e70468. https://doi.org/10.1371/journal.pone.0070468

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social Phobia: Diagnosis, Assessment, and Treatment (pp. 69-93). The Guilford Press.

Hyett, M. P., Bank, S. R., Lipp, O. V., Erceg-Hurn, D. M., Alvares, G. A., Maclaine, E., … & McEvoy, P. M. (2018). Attenuated psychophysiological reactivity following single-session group imagery rescripting versus verbal restructuring in social anxiety disorder: results from a randomized controlled trial. Psychotherapy and Psychosomatics, 87(6), 340-349. https://doi.org/10.1159/000493897

Klumbies, E., Braeuer, D., Hoyer, J., & Kirschbaum, C. (2014). The Reaction to Social Stress in Social Phobia: Discordance between Physiological and Subjective Parameters. PLOS ONE, 9(8), e105670. https://doi.org/10.1371/journal.pone.0105670

Shaffer, F., & Ginsberg, J. P. (2017). An Overview of Heart Rate Variability Metrics and Norms. Frontiers in Public Health, 5, 290215. https://doi.org/10.3389/fpubh.2017.00258

Wong, Q. J., & Rapee, R. M. (2016). The aetiology and maintenance of social anxiety disorder: A synthesis of complementary theoretical models and formulation of a new integrated model. Journal of Affective Disorders, 203, 84-100. https://doi.org/10.1016/j.jad.2016.05.069

Socratic Questions

1. How might the observed differences in HRV patterns between the SAD and non-SAD groups during the preparation phase inform our understanding of anticipatory anxiety in SAD?
2. Given that no significant baseline HRV differences were found between groups, how might this challenge existing theories about trait-level physiological differences in SAD?
3. The study found gender differences in HRV responses, particularly during the preparation phase. How might this inform gender-specific approaches to treating SAD?
4. How could the lack of significant differences in HRV persistence between groups, despite some within-group differences, be interpreted in the context of autonomic flexibility in SAD?
5. The study used a university student sample for the non-SAD group. How might this sampling method affect the generalizability of the results, and what alternative sampling strategies could be considered for future research?
6. Given the findings of this study, how might cognitive-behavioral interventions for SAD be adapted to better address anticipatory physiological responses?
7. The authors suggest that biofeedback could be a useful adjunct to traditional therapies for SAD. How might such an intervention be designed and implemented based on the study’s findings?
8. How might the observed HRV patterns in individuals with SAD relate to other cognitive and behavioral symptoms of the disorder? What additional measures could be included in future studies to explore these relationships?
9. The study focused on HRV as a measure of autonomic nervous system functioning. What other physiological measures might provide complementary information about stress responses in SAD?
10. How might longitudinal research designs extend our understanding of the relationship between HRV patterns and the development or maintenance of SAD over time?