From accuracy to expectation: A reframed view of heartbeat counting and panic disorder

Enhanced heartbeat perception is believed to contribute to the development and maintenance of panic disorder. Studies have demonstrated better Heartbeat Counting Task (HCT) performance in individuals with panic disorder compared to controls. This has been proposed to reflect increased interoceptive accuracy, which is thought to increase the risk of individuals perceiving bodily sensations, which in turn may trigger panic attacks. Drawing on contemporary evidence that HCT performance may reflect heartbeat estimation, rather than perception, we argue that greater HCT performance in panic disorder likely reflects greater heart rate knowledge, and thus existing data do not provide evidence for enhanced perceptual acuity predisposing to panic attacks. We propose that a more parsimonious explanation of these data is that body monitoring drives elevated HCT performance through increased knowledge and predisposes to panic attacks, by narrowing the range of 'acceptable' cardiac sensations, which, when coupled with misinterpretation of these sensations as problematic, may trigger panic attacks. This novel reinterpretation clarifies mixed results in the literature and provides useful future directions for the identification of targeted interventions and future work in this area.