{"id":4638,"date":"2021-12-22T14:02:10","date_gmt":"2021-12-22T13:02:10","guid":{"rendered":"https:\/\/psychosomatic-osteopathy.com\/vagus-activation-and-stress-response-from-an-osteopathic-perspective\/"},"modified":"2026-05-31T10:10:39","modified_gmt":"2026-05-31T09:10:39","slug":"vagus-activation-and-stress-response-from-an-osteopathic-perspective","status":"publish","type":"post","link":"https:\/\/psychosomatic-osteopathy.com\/en\/vagus-activation-and-stress-response-from-an-osteopathic-perspective\/","title":{"rendered":"Vagus Activation and Stress Response from an Osteopathic Perspective"},"content":{"rendered":"<p><b>Summary<\/b>In addition to the overarching regulation by the mesencephalic periaqueductal gray, the neurovegetative system\u2014among other things, vagal activity\u2014is essential in regulating stress responses. This article explains, discusses, and presents key study findings and relationships, mechanisms of dysfunction, diagnostics, and osteopathic treatment approaches and techniques, as well as self-management approaches for regulating the vagus.<b>Keywords<\/b>vagal mechanisms of action, vagus dysfunction, diagnosis and interpretation of vagus activity, self-help approaches, osteopathic vagus nerve stimulation (VNS), mesencephalic periaqueductal gray, psychosomatic osteopathy<b>Abstract<\/b>Besides the superordinate regulation by means of the mesencephalic periaqueductal grey, the neurovegetative \u2013 among others the vagus activity \u2013 is essential in the regulation of stress reactions. This article explains, discusses and presents essential study results and correlations, dysfunction mechanisms, diagnostics and osteopathic treatment approaches and techniques as well as self-management approaches for the regulation of the vagus.<b>Keywords<\/b>vagal mechanisms of action, vagus dysfunction, diagnosis and interpretation of vagus activity, self-help approaches, osteopathic vagus nerve stimulation (VNS), mesencephalic periaqueductal grey, psychosomatic osteopathy<b>Introduction<\/b>  At a higher level, behavioral states such as fight and flight, immobilization or freezing, and risk assessment\u2014with their associated motor, autonomic, and endocrine effects\u2014are coordinated by the mesencephalic periaqueductal gray (PAG) [21], [45], [49], [92]. Vagal afferents are relayed via the nucleus tractus solitarii to the PAG, hypothalamus, amygdala, and to the insular, cingulate, and prefrontal cortex, where they are integrated into emotional and cognitive processes [7], [19], [20], [95]. Even though the popular polyvagal theory does not adequately take these anatomical conditions and mechanisms of action into account, the vagus is nevertheless of great importance [65], [66]. Thus, subdiaphragmatic vagal afferents appear to influence innate anxiety, learned fear, and other behaviors [53], [54]. In addition, vagal afferents modulate spinal nociceptive processes in various experimental models [29], [50]. From an evolutionary perspective, the autonomic nervous system regulated\u2014and continues to regulate\u2014the maintenance of the most important bodily functions. Prey animals responded to danger from predators by freezing and downregulating metabolism. This behavior was regulated by the parasympathetic nervous system, which, if necessary, prioritized such behavior over metabolic functions. This illustrates how, in regulatory systems, the survival of the organism as a whole takes precedence over <i>above<\/i> individual organ functions. The sympathetic nervous system developed in connection with flight instead of freezing behavior, as well as hunting instincts and combat control mechanisms. This manifests as pupil dilation (better twilight vision and sharper peripheral observation), expansion of the blood vessels in the limbs and lungs (necessary for flight and fight behavior), and an increase in stress hormones for faster reactions and glucose availability. Here, too, the focus is on the entire organism and not exclusively on the functioning of individual organs. In this process, the parasympathetic and sympathetic systems do not necessarily act antagonistically. Unmyelinated fibers, primarily originating from the dorsal nucleus of the vagus nerve, regulate the blood flow and activity of the abdominal organs, while myelinated fibers, originating from the nucleus ambiguus, regulate the thoracic organs (heart and lungs) as well as speech (superior and recurrent laryngeal nerves) and the hearing of human speech (including the stapedius nerve after connection with the facial nerve). There are also vagal influences on heart rate variability (HRV), blood sugar control, and the immune system, as well as vocal pitch, appetite, and bronchial function. The vagus nerve acts as a link between the peripheral autonomous nervous system and the brain. It also facilitates the storage of memories. It has been shown that vagus nerve stimulation achieves effects that promote brain plasticity and memory [69]. Afferents exist particularly from the intestine and other abdominal organs. For example, afferent fibers of the vagus nerve metabolically influence the microglia of the brain [108]. Normally, the central nervous system is protected by the blood-brain barrier. However, it can potentially be damaged by the vagus, in that the microglia in vagal structures can be activated efferently from the gastrointestinal tract, potentially altering gut-brain communication [4]. Pathophysiologically, the vagus is significant in conditions such as headaches, depression, and post-traumatic stress disorder (PTSD). Furthermore, the vagus nerve also has a strong influence on the immune system, heart rate variability, blood sugar control, the development and modulation of headaches (including migraines via serotonin release), our vocal pitch, the function of our bronchi, appetite control, the development of depression, etc. [49], [61], [76], [94], [104]. With increasing age, changes occur at least in the thicker somatomotor vagus fibers, which thin out over time [109].<b>Vagus Dysfunctions<\/b><b>Decreased Vagus Activity<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400\">Decreased vagus activity occurs, for example, in autoimmune diseases such as ulcerative colitis, in cases of decreased immunity, malabsorption, and obesity.<\/li>\n<li style=\"font-weight: 400\">Hypotonic vagal activity with normotonic activity of the enteric nervous system can occur in cases of alcohol abuse and type 2 diabetes mellitus. In addition to alcohol abstinence, the vagus nerve can be stimulated therapeutically in these cases (see below). <\/li>\n<li style=\"font-weight: 400\">Hypotonic vagal activity with hypotonic activity of the enteric nervous system carries a high risk for neurodegenerative disease patterns. In this case, the low immune status should first be improved and the viral load reduced [59], [60], and only then should the vagus nerve be stimulated. Additionally, the small intestine region can be stretched to increase myenteric activity [59], [60].  <\/li>\n<\/ul>\n<p><b>Increased Vagus Activity<\/b>Vagus activity can be dysfunctional not only when it is decreased, but also when it is increased.<\/p>\n<ul>\n<li style=\"font-weight: 400\">Increased vagus activity occurs, for example, in allergies, Crohn&#8217;s disease, and obesity.<\/li>\n<li style=\"font-weight: 400\">In the case of hypertonic vagus activity, the diaphragm, the radix mesenterii, and the high cervical region can be stretched using OMT.<\/li>\n<li style=\"font-weight: 400\">Increased vagus activity in young people can lead to an increase in stomach acid production, increased gastric emptying, and potentially diarrhea. In addition to manual approaches, the oral region should be cleaned and the pathogen load reduced. <\/li>\n<\/ul>\n<p><b>Diagnostics<\/b><b>By means of the sense of smell <\/b><b> \u2013 <\/b>Hold lavender essential oil under the nose: stimulation of the vagus promotes gastric emptying. This is audible, e.g., with a stethoscope in the region of the pylorus [113].<b>By means of swallowing \u2013 <\/b>Drinking a glass of water serves to test the vagus in the esophagus (normal is about 5 seconds; in cases of reduced activity and, for example, Parkinson&#8217;s disease, the swallowing period is reduced).<b>By means of HRV measurement \u2013 <\/b>HRV measurement parameters provide insight into the autonomous function of the heart and allow for assessments of the functioning of the autonomous nervous system [39]. The vagus nerve conducts information much faster than the sympathetic system. For instance, vagus activation of the heart rate is up to 8 times faster compared to sympathetic activation, so that fluctuations in heart rate are determined much more strongly by the vagus [23]. <b>By means of the Ruffier-Dickson test to determine hypotonia of the vagus nerve \u2013<\/b> Measure the pulse rate after 1 minute in a supine position (P1), perform 30 squats or squat for 45 seconds, then measure the pulse rate while standing immediately afterwards (P2) and again after 1 minute in a supine position (P3). The Dickson index serves to assess the heart&#8217;s ability to recover after exertion. This value correlates with HRV and O2max measurements, lung elasticity, diaphragmatic mobility, gastric emptying, and nitric oxide. <b>Calculation of the Dickson Index<\/b>((P2\u201370) + 2 (P3\u2013P1))\/10    <b>Evaluation<\/b>&lt;0 = excellent, 0\u20132 = very good, 2\u20134 = good, 4\u20136 = average, 6\u20138 = weak, 8\u201310 = very weak,  &gt;10 = poor adaptation<b>Further possible indications of decreased vagus activity<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400\">Reduced neck mobility and jaw disorders, CMD (craniomandibular dysfunction).<\/li>\n<li style=\"font-weight: 400\">Visceral fat: A waist circumference measurement can be taken here (in cases of overweight, vagus activity is decreased; in cases of obesity, it is dysfunctionally increased).<\/li>\n<li style=\"font-weight: 400\">Compression of the descending part of the duodenum with the risk of reflux.<\/li>\n<li style=\"font-weight: 400\">Positive trigger points of the neck and jaw musculature.<\/li>\n<li style=\"font-weight: 400\">Tension restrictions in the area of the carotid sheath.<\/li>\n<li style=\"font-weight: 400\">Positive Gesret point: This is usually located intercostally under the left armpit, less frequently on the right. The test is positive if there is pressure tenderness and palpation of a kind of fat ball in this region. <\/li>\n<li style=\"font-weight: 400\">Viral loads: through blood tests.<\/li>\n<li style=\"font-weight: 400\">Presence of Propionibacteria in the oral area: assessment using a UV lamp.<\/li>\n<\/ul>\n<p><b>Vagus Nerve Stimulation (VNS)&nbsp;<\/b>For an overview, see also [62]. Stimulation of the vagus nerve during exposure therapy \u2013 as potentially applied in the osteopathic approach of multimodal bifocal integration according to Liem \u2013 eliminates anxiety, hypervigilance, avoidance behavior, and antisocial behavior in animal experiments on post-traumatic stress disorder (PTSD) [3], [82], [86], [99], [100], [101], [102]. In experiments on rats, VNS enhanced the extinction of conditioned fear, both without [82], [85] and with PTSD [55], [98]. VNS can also counteract anxiety extinction disorders, reduce anxiety-like behavior, improve other PTSD symptoms [32], and facilitate conditioned fear reactions [86]. It has also been shown that the number of key molecules that promote synaptic plasticity can be increased by VNS, e.g., acetylcholine [81], serotonin [75], norepinephrine [93], fibroblast growth factor-1 (FGF-1), and the growth factor BDNF (brain-derived neurotrophic factor) [28], neurogenesis [89], Fos (a nuclear protein expressed under conditions of high neuronal activity) [80], tropomyosin receptor kinase&nbsp;B (TrkB) [31], neurexin, cadherin, and calcium channels [2], NMDA receptors (NMDA&nbsp;= N-methyl-D-aspartate) [2], [3]. Transcutaneous electrical vagus nerve stimulation simultaneously shows an improvement in neuronal plasticity, especially in combination with training [42], [43], e.g., in the locus coeruleus [41], [46] and memory consolidation [17], [18], [85]. The combination of VNS with sensory or motor events is capable of reorganizing the sensory or motor cortex [11]. The combination of VNS and exposure to unreinforced conditioned signals was able to improve the extinction of infralimbic prefrontal cortex \u2013 basolateral amygdala signaling pathways in animal experiments [3], [86]. There are indications that VNS should be used for the extinction of conditioned fear in combination with exposure-based approaches and that its isolated application is not sufficient [78]. An autonomous vagovagal loop reaches visceral impulses in the nucleus tractus solitarii (NTS), which transmits efferents to the dorsal nucleus of the vagus nerve (DMN), to the rostral ventrolateral medulla (RVLM), and to the intermediate lateral medulla (ILM), with the aim of achieving a balance between the sympathetic and parasympathetic responses to various bodily states. The vagus does not act in isolation here. Modulations of the vagovagal loop are made possible by an autonomous forebrain loop, through interactions between the NTS and other brain areas such as the hypothalamus, amygdala, cingulate cortex, insular cortex, and prefrontal cortex, which are also involved in neuroendocrine, emotional, and cognitive behavioral controls (see Fig. 1).<\/p>\n<p><em>Fig. 1: Vagovagal loop and influencing factors (from [62]; \u00a9 Thieme-Verlag, with kind permission)<\/em><\/p>\n<p><b>Indication<\/b>Reorganization of the sensory or motor cortex [11], post-traumatic stress disorder and anxiety disorders [13], [34], [58], [78], [82], as well as chronic low-grade inflammation, for anti-inflammatory purposes, e.g., in rheumatoid arthritis; anti-tumor necrosis factor \u03b1 (anti-TNF-\u03b1), i.e., anti-inflammatory effect, gastroduodenal emptying disorders, possibly drug-resistant epilepsy, depression [9].<b>Vagus stimulation in the craniocervical region according to Liem <\/b><b>Hand position<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400\">Thumbs in the area of the cavum conchae (auricular branch of the vagus nerve).<\/li>\n<li style=\"font-weight: 400\">Index fingers at the mastoid angles.<\/li>\n<li style=\"font-weight: 400\">Middle fingers on the mastoids.<\/li>\n<li style=\"font-weight: 400\">Ring finger and little finger in the area of the atlanto-occipital joint (see Fig. 2).<\/li>\n<\/ul>\n<p>Fig. 2 Legend: Vagus stimulation in the craniocervical region<b>Execution<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400\">Manually, the skin in the area of both auricular conchae [44] is gently stimulated using the thumbs, and the auricular branches at the mastoid process are gently stimulated using the middle fingers. <\/li>\n<li style=\"font-weight: 400\">The index fingers anteriorize the lower jaw.<\/li>\n<li style=\"font-weight: 400\">The ring finger and little finger exert suboccipital inhibition or decompression in the area of the suboccipital region and near the jugular foramen. Not only a vagus-stimulating effect but also an improvement in cerebral blood flow has already been demonstrated here [24], [88], [91]. <\/li>\n<\/ul>\n<p><b>Note<\/b>The vagus nerve runs through the middle part of the jugular foramen, caudal to the glossopharyngeal nerve and superficial to the internal jugular vein. Stimulation can also be performed by electrical stimulation in the ear area based on Bonaz, or on the mastoid and below the diaphragm [9]. The vagus can be stimulated at the mastoid and diaphragm with a TENS device at 10 Hertz. Needling is also possible [44].<b>Vagus stimulation in the area of the carotid sheath <\/b>The vagus nerve can also be gently stimulated in the area of the carotid sheath. The middle fingers of both hands are positioned about 1 cm apart, medial to the sternocleidomastoid muscle \u2013 between the common carotid artery and the internal jugular vein, immediately below the thyroid cartilage. Stimulation in the region of the course of the vagus nerve is performed by means of gentle craniocaudal mobilization. Fig. 3. Legend: Vagus stimulation in the area of the carotid sheath<b>Vagus stimulation in the area of the diaphragm<\/b>Relax the deep diaphragmatic region medially in the area of the esophagus (<a href=\"https:\/\/de.wikipedia.org\/wiki\/Truncus_vagalis_anterior\">anterior and posterior vagal trunks<\/a>). To do this, let the thumbs sink deep on both sides of the xiphoid and follow micro-movements in the area of the esophagus while the other fingers rest on the lower intercostal spaces. At the same time, the patient slows their breathing by about half. In the second step, relax the celiac ganglion, approximately midway between the navel and the xiphoid (see also Fulford technique [62], p. 520).<b>Reorganization of the sensory or motor cortex<\/b>This allows sensory stimuli or motor stimuli, movements, postures, and functional OMT to be combined with VNS. Furthermore, VNS is also used within the framework of multimodal bifocal integration according to Liem. A vagus-stimulating effect was demonstrated when performing osteopathic heart-focused palpation according to Liem [112].<b>Further OMT approaches<\/b>Rib-raising techniques [24] and high-velocity\/low-amplitude techniques (HVLAT) [88] can have a vagus-activating effect. A single OMT session in healthy participants already led to a faster recovery of heart rate and sympathovagal balance and prevented the typical increase in cortisol levels after a psychological stressor [30].<b>Self-help approaches<\/b>Patients can independently stimulate the vagus through the following measures to reduce stress reactions. These can be used supportively in treatment [63], [64]:<b>Deep and slowed breathing with or without HRV feedback<\/b> [1], [57], [77]<b> \u2013 <\/b>In a study in which further yogic breathing techniques and kriyas<b> \u2013 <\/b>which are physical cleansing techniques (Ujjayi breathing, Bhastrika, Sudarshan Kriya) \u2013 practiced were, it was suspected that these have a parasympathetic activating effect [14].<b>Autogenic training<\/b> [79], <b>yoga<\/b> [103], <b>and Tai Chi<\/b> [15], [71], [72], [111] are said to show vagal activating effects.            However, since there are very different types of yoga, e.g., very calm ones like Yin Yoga and simultaneously very dynamic types like Power Yoga, future studies should investigate the different forms for their vagal effect.<b>Meditation<\/b> [35], [106]<b> \u2013 <\/b>For example, &#8220;Loving-Kindness Meditation&#8221; increased positive emotions through an improved perception of social relationships, which in turn led to an increase in vagal tone. However, this effect was only achieved in individuals who actually felt increased joy and social connectedness [56]. It is suspected that vagal activation also occurs through deep breathing during meditation [35]. Since there are very different types of meditation, just as in yoga, these variations could be taken into account in future studies.<b>Increase in oxytocin \u2013<\/b> All interventions that lead to an increase in oxytocin (and vasopressin), such as massage, touch, etc., can be recommended, as these improve parasympathetic function [25], [48], [90].<b>Singing, humming, mantra chanting \u2013 <\/b> Singing increases HRV in healthy 18-year-old women and men. However, this has only been investigated in a single study so far. Humming, hymn and energetic singing, as well as mantra chanting are each said to increase HRV in slightly different ways [107]. For example, singing, especially vigorous singing, is said to be simultaneously arousing, but without significant sympathetic activity, possibly because the vagally triggered activity dampens the sympathetic one. This physiological reaction during singing is said to be able to trigger the homeostatically acting state of flow (&#8220;flow&#8221;) [107]. Music could communicate the state of the ANS between singers in two ways: through the laryngeal vocal cord muscles used during singing, mediated by the recurrent nerve of the vagus nerve, as well as through a kind of vagal pump that is stimulated during singing [107]. Chanting the mantra &#8220;Om&#8221; also activates the vagus. The authors suspect that this possibly occurs through stimulation of its auricular branches [51]. Both mantra and prayer recitations in a study of 23    &nbsp;adults caused an increase in existing cardiovascular rhythms, HRV, and a reduction in blood pressure in rhythm formulas involving breathing at 6 breaths per minute [6]. Singing is also said to release oxytocin [36]. <b>Laughter \u2013 <\/b>in a pilot study on laughter yoga, participants showed improved immediate mood and increased HRV after a laughter intervention [22]. <b>Pleasant social interaction \u2013<\/b> Vagal activity increase through the interaction of parental and child positive socialization [87]. <b>Cold exposure \u2013 <\/b>Cold showers and other cold interventions increased parasympathetic activity through the activation of cholinergic neurons by the vagus nerve [114], especially when practiced repeatedly over a longer period. This can lead to habituation with reduced sympathetic and simultaneously increased parasympathetic activation during cold exposure [40]. The study in humans was conducted at 10\u00b0C cold [74]. Acute cold interventions of 4\u00b0C also led to parasympathetic stimulation in animal experiments [114]. Before starting cold intervention, it should be medically clarified whether cold applications should be modified or are contraindicated for certain diseases, such as heart disease. Tip: Take a cold shower every morning. <b>Nutrition, dietary supplements<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400\">Probiotics such as Lactobacillus rhamnosus, which caused a reduction in stress hormones, depression, and anxiety behavior via the vagus nerve [12]. Bifidobacterium longum was also able to reduce anxiety behavior via the vagus nerve [5]. <\/li>\n<li style=\"font-weight: 400\">Omega-3 fatty acids, contained in high amounts particularly in fatty fish species [16], [83], [96], [97].<\/li>\n<li style=\"font-weight: 400\">Serotonin: Intestinal serotonin stimulates 5-HT3 receptors of vagal afferent fibers to stimulate vagal sensory neurons [115].<\/li>\n<li style=\"font-weight: 400\">Choline: Through increased vagal activity, choline, found for example in eggs, can improve cardiovascular damage [68].<\/li>\n<li style=\"font-weight: 400\">Zinc: Orally administered zinc increases food intake through vagal stimulation in rats during early-stage zinc deficiency (i.e., without a decrease in zinc concentration in plasma and tissue) [84].<\/li>\n<\/ul>\n<p>Tip: Ensure sufficient zinc in the diet.<b>Fasting \u2013 <\/b>Fasting increases vagal activity [52]: In animal experiments, intermittent fasting as well as calorie-restricted food intake led to a decrease in the low-frequency component of the HRV spectra, a marker for sympathetic tone, and to an increase in the high-frequency components of the HRV spectra, a marker for parasympathetic activity [73].<b>Physical exercise \u2013 <\/b>Light to moderate physical exercise appears to stimulate gastric emptying through increased vagal activity [110].<b>Massage \u2013 <\/b>For example, foot massage [70]. In premature births, massage can also support weight gain through vagal stimulation [26], [27]. Massage of the carotid sinuses can even suppress epileptic seizures [37]. This type of massage should only be performed by professional therapeutic personnel.<b>Sleep position \u2013 <\/b>Sleeping on the right side: In a study of the effect of lying positions on autonomous nerve modulation in patients with coronary heart disease, it was found that in the right lateral position, vagal activity was highest and sympathetic arousal was lowest. Vagal modulation in the supine position was significantly the lowest of all sleep positions studied [113].<b>Electromagnetic fields \u2013 <\/b>Exposure to pulsed electromagnetic fields for 20 minutes led to a faster recovery of heart rate variability, especially in the very low frequency range after physical exertion. After the magnetic field exposure was ended, the described effects quickly subsided [38].<b>Glucagon-like peptide-1 secretion \u2013 <\/b>GLP-1 inhibits gastric emptying via vagal-afferent mediated central mechanisms [47]. Stimulating endogenous GLP-1 secretion by manipulating the composition of the diet can be a relevant strategy for the treatment of obesity and type 2 diabetes. GLP-1 is primarily synthesized and secreted by enteroendocrine L-cells of the digestive tract. Its secretion is partially mediated by direct nutrient intake through G-protein-coupled receptors. These bind to monosaccharides, peptides and amino acids, monounsaturated and polyunsaturated fatty acids, as well as short-chain fatty acids. Fiber-rich food, nuts, avocados, and eggs also appear to influence GLP-1 [8].          <\/p>\n<p style=\"font-weight: 400\">Liem T. Vagus activation and stress response from an osteopathic perspective, Osteop Med 2021; 22(4), 10-15.<\/p>\n<p style=\"font-weight: 400\"><a href=\"https:\/\/www.sciencedirect.com\/science\/article\/pii\/S1615907121001118\" data-saferedirecturl=\"https:\/\/www.google.com\/url?q=https:\/\/www.sciencedirect.com\/science\/article\/pii\/S1615907121001118&#038;source=gmail&#038;ust=1640333468815000&#038;usg=AOvVaw02XXhT-pNRDAhkxDRgQgSI\">https:\/\/www.sciencedirect.com\/science\/article\/pii\/S1615907121001118<\/a><\/p>\n<p><b>Literature<\/b><\/p>\n<ol>\n<li style=\"font-weight: 400\">Alayan N, Eller L, Bates ME et al. Current evidence on heart rate variability biofeedback as a complementary anticraving intervention. J Altern Complement Med. 2018; 24 (11): 1039\u20131050  <\/li>\n<li style=\"font-weight: 400\">Alexander GM, Huang YZ, Soderblom EJ et al. Vagal nerve stimulation modifies neuronal activity and the proteome of excitatory synapses of amygdala\/piriform cortex. 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Intestinal serotonin acts as a paracrine substance to mediate vagal signal transmission evoked by luminal factors in the rat. J Physiol. 2001; 530 (3): 431\u2013442   <\/li>\n<li>Lecture by Bruno Donatini at the OSD, Hamburg 2021<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Summary In addition to the overarching regulation by the mesencephalic periaqueductal gray, the neurovegetative system \u2013 including vagal activity \u2013 is essential in the regulation of stress responses. 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