Greater sustained anxiety but not phasic fear in women compared to men

Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review

This narrative state-of-the-art review paper describes the progress in the understanding and treatment of Posttraumatic Stress Disorder (PTSD). Over the last four decades, the scientific landscape has matured, with many interdisciplinary contributions to understanding its diagnosis, etiology, and epidemiology. Advances in genetics, neurobiology, stress pathophysiology, and brain imaging have made it apparent that chronic PTSD is a systemic disorder with high allostatic load. The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based. However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal. These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system. All of this aims to improve symptom relief and clinical outcomes. Finally, a phase orientation to treatment is recognized as a tool to strategize treatment of the disorder, and position interventions in step with the progression of the pathophysiology. Revisions to guidelines and systems of care will be needed to incorporate innovative treatments as evidence emerges and they become mainstream. This generation is well-positioned to address the devastating and often chronic disabling impact of traumatic stress events through holistic, cutting-edge clinical efforts and interdisciplinary research.

Threat Responses in Schizophrenia: A Negative Valence Systems Framework

PURPOSE OF REVIEW

Emotions are prominent in theories and accounts of schizophrenia but are largely understudied compared to cognition. Utilizing the Research Domain Criteria (RDoC) Negative Valence Systems framework, we review the current knowledge of emotions in schizophrenia. Given the pivotal role of threat responses in theories of schizophrenia and the substantial evidence of altered threat responses, we focus on three components of Negative Valence Systems tied to threat responses: responses to acute threat, responses to potential threat, and sustained threat.

RECENT FINDINGS

Individuals with schizophrenia show altered responses to neutral stimuli during acute threat, bed nucleus of the stria terminalis connectivity in response to potential threat, and threat responses associated with sustained threat. Our review concludes that Negative Valence Systems are altered in schizophrenia; however, the level and evidence of alterations vary across the types of threat responses. We suggest avenues for future research to further understand and intervene on threat responses in schizophrenia.

Tactile P300 to unpredictable electric shocks: Association with anxiety symptoms, intolerance of uncertainty, and neuroticism

The no, predictable, and unpredictable threat (NPU-threat) task is an experimental paradigm that delineates the anticipation of predictable vs. unpredictable threat. The current literature suggests that heightened defensive motivation in anticipation of unpredictable threat is associated with anxiety disorders and increased symptoms. Few investigations have examined whether a heightened response to actual threat is also associated with anxiety-related phenomenology. The present study examined the relationship between the tactile P300 to shock delivery during the NPU-threat task and individual differences in anxiety symptoms, intolerance of uncertainty, and neuroticism. Overall, the tactile P300 was enhanced in response to unpredictable shocks relative to predictable shocks. Greater tactile P300 enhancement to unpredictable shocks was associated with greater anxiety symptoms, intolerance of uncertainty, and neuroticism. The present study suggests that temporal unpredictability enhances attentional engagement to threat, which is greater in individuals characterized by narrow and broad anxiety constructs.

Patients with anxiety disorders rely on bilateral dlPFC activation during verbal working memory

One of the hallmarks of anxiety disorders is impaired cognitive control, affecting working memory (WM). The dorsolateral prefrontal cortex (dlPFC) is critical for WM; however, it is still unclear how dlPFC activity relates to WM impairments in patients. Forty-one healthy volunteers and 32 anxiety (general and/or social anxiety disorder) patients completed the Sternberg WM paradigm during safety and unpredictable shock threat. On each trial, a series of letters was presented, followed by brief retention and response intervals. On low- and high-load trials, subjects retained the series (five and eight letters, respectively) in the original order, while on sort trials, subjects rearranged the series (five letters) in alphabetical order. We sampled the blood oxygenation level-dependent activity during retention using a bilateral anatomical dlPFC mask. Compared to controls, patients showed increased reaction time during high-load trials, greater right dlPFC activity and reduced dlPFC activity during threat. These results suggest that WM performance for patients and controls may rely on distinct patterns of dlPFC activity with patients requiring bilateral dlPFC activity. These results are consistent with reduced efficiency of WM in anxiety patients. This reduced efficiency may be due to an inefficient allocation of dlPFC resources across hemispheres or a decreased overall dlPFC capacity.

Gender differences in anxiety: The mediating role of sensitivity to unpredictable threat

Anxiety disorders and symptoms disproportionately impact women relative to men, but it is unclear what mechanism(s) contribute to this phenomenon. The present study examined sensitivity to unpredictable threat as a potential mechanism of gender differences in panic symptoms. The sample included 67 participants (35 women) who completed the no, predictable, and unpredictable threat (NPU-threat) startle paradigm with electric shocks as the aversive stimulus. Participants also completed the self-report Inventory of Depression and Anxiety Symptoms to assess current panic and depression symptoms. Results indicated that women, relative to men, reported greater panic symptoms and demonstrated increased startle potentiation in anticipation of predictable and unpredictable threat. Furthermore, across all participants increased startle potentiation in anticipation of unpredictable (but not predictable) threat was associated with greater panic symptoms, but there was no relationship with depression symptoms. Finally, the gender difference in panic symptoms was mediated by startle potentiation in anticipation of unpredictable (but not predictable) threat. The present study suggests that a heightened sensitivity to unpredictable threat might be a mechanism that contributes to increased anxiety in women.

Mechanistic link between right prefrontal cortical activity and anxious arousal revealed using transcranial magnetic stimulation in healthy subjects

Much of the mechanistic research on anxiety focuses on subcortical structures such as the amygdala; however, less is known about the distributed cortical circuit that also contributes to anxiety expression. One way to learn about this circuit is to probe candidate regions using transcranial magnetic stimulation (TMS). In this study, we tested the involvement of the dorsolateral prefrontal cortex (dlPFC), in anxiety expression using 10 Hz repetitive TMS (rTMS). In a within-subject, crossover experiment, the study measured anxiety in healthy subjects before and after a session of 10 Hz rTMS to the right dorsolateral prefrontal cortex (dlPFC). It used threat of predictable and unpredictable shock to induce anxiety and anxiety potentiated startle to assess anxiety. Counter to our hypotheses, results showed an increase in anxiety-potentiated startle following active but not sham rTMS. These results suggest a mechanistic link between right dlPFC activity and physiological anxiety expression. This result supports current models of prefrontal asymmetry in affect, and lays the groundwork for further exploration into the cortical mechanisms mediating anxiety, which may lead to novel anxiety treatments.

Interpersonal trauma exposure and startle reactivity to uncertain threat in individuals with alcohol use disorder

BACKGROUND

Exposure to interpersonal trauma is highly prevalent within individuals with alcohol use disorder (AUD); however, the mechanisms underlying the pathway between trauma exposure and AUD are unclear. Preliminary evidence suggests that heightened reactivity to threats that are uncertain (U-threat) may characterize individuals with AUD and interpersonal trauma exposure and contribute to alcohol abuse within this subgroup of individuals; however, this hypothesis has yet to be tested.

METHOD

The aim of the study was to examine whether heightened reactivity to U-threat characterizes individuals with AUD and a history of interpersonal trauma. Specifically, the study compared defensive reactivity to U-threat (and predictable threat [P-threat]) in those with: 1) AUD and a history of interpersonal trauma (AUD + Trauma); 2) AUD and no history of interpersonal trauma (AUD-Trauma); and 3) matched controls. Participants (N = 77) completed a well-validated threat-of-shock task and startle eyeblink potentiation was collected as an index of aversive responding.

RESULTS

Results revealed a group by threat condition interaction (F[4, 142] = 3.17, p = 0.03; ηG2 = 0.08) such that individuals with AUD + Trauma exhibited greater startle reactivity to U-threat, but not P-threat, compared with individuals with AUD-Trauma and controls (who did not differ from each other). The findings were significant even when controlling for current anxiety and depression symptoms.

CONCLUSIONS

Within individuals with AUD, those with a history of interpersonal trauma exposure may be a neurobiologically unique subtype characterized by exaggerated U-threat reactivity and high levels of anticipatory anxiety. Reactivity to U-threat may be a promising alcohol use prevention and intervention target for trauma-exposed individuals.

Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges

Post-traumatic stress disorder (PTSD) is arguably the most common psychiatric disorder to arise after exposure to a traumatic event. Since its formal introduction in the DSM-III in 1980, knowledge has grown significantly regarding its causes, maintaining mechanisms and treatments. Despite this increased understanding, however, the actual definition of the disorder remains controversial. The DSM-5 and ICD-11 define the disorder differently, reflecting disagreements in the field about whether the construct of PTSD should encompass a broad array of psychological manifestations that arise after trauma or should be focused more specifically on trauma memory phenomena. This controversy over clarifying the phenotype of PTSD has limited the capacity to identify biomarkers and specific mechanisms of traumatic stress. This review provides an up-to-date outline of the current definitions of PTSD, its known prevalence and risk factors, the main models to explain the disorder, and evidence-supported treatments. A major conclusion is that, although trauma-focused cognitive behavior therapy is the best-validated treatment for PTSD, it has stagnated over recent decades, and only two-thirds of PTSD patients respond adequately to this intervention. Moreover, most people with PTSD do not access evidence-based treatment, and this situation is much worse in low- and middle-income countries. Identifying processes that can overcome these major barriers to better management of people with PTSD remains an outstanding challenge.

Sex differences and personality in the modulation of the acoustic startle reflex

The modulation of the eyeblink component of the acoustic startle reflex (ASR) has been used to study human motivation, attention, and emotion towards affective stimuli of different valence. However, sex and individual differences in personality have been rather overlooked concerning the change in the ASR to brief affective sequences. In this study, we aimed to evaluate sex differences in the ASR, together with the influence of sensitivity to punishment (SP) and sensitivity to reward (SR) in the affective modulation of the ASR to pleasant and unpleasant pictures. We addressed this topic with a latent curve model (LCM) representing the change in the ASR of an extensive group of men (n = 166) and women (n = 109). There was a significant habituation of the ASR to the pleasant pictures, and a significant sensitization of the ASR to the unpleasant pictures. Both effects were higher and more variable for women than for men. There were in addition interactive and quadratic effects of SP and SR on the ASR to the pleasant and unpleasant pictures. Men and women with extreme scores in SP, and women with low scores in SR habituated faster to the pleasant stimuli. For men scoring low in SP, higher scores in SR related with an attenuated initial ASR to the unpleasant stimuli. Women with extreme scores in SP had a higher initial ASR to the unpleasant stimuli. There were remarkable asymmetries between men and women concerning personality effects on the change in the ASR to affective stimuli.

If or when? Uncertainty's role in anxious anticipation

Uncertainty is often associated with subjective distress and a potentiated anxiety response. Occurrence uncertainty, or the inability to predict if a threat will occur, has rarely been compared experimentally with temporal uncertainty, or the inability to predict when a threat will occur. The current study aimed to (a) directly compare the anxiogenic effects of anticipating these two types of uncertain threat, as indexed by the eyeblink startle response, and (b) assess the relationship between startle response to occurrence and temporal uncertainty and individual differences in self-reported intolerance of uncertainty and anxiety. The findings indicated that anticipation during occurrence uncertainty elicited a larger startle response than anticipating a certain threat, but anticipation during temporal uncertainty was superior at potentiating startle blink overall. Additional analyses of the effects of order and habituation further highlighted temporal uncertainty's superiority in eliciting greater startle responding. This suggests that, while uncertainty is physiologically anxiety provoking, some level of certainty that the threat will occur enhances the robustness of the physiological anxiety response. However, self-reported anxiety was equivalent for temporal and occurrence uncertainty, suggesting that, while defensive responding may be more affected by temporal uncertainty, people perceive both types of uncertainty as anxiogenic. Individual differences in the intolerance of uncertainty and other anxiety measures were not related to anticipatory startle responsivity during any of the conditions.

Startling Differences: Using the Acoustic Startle Response to Study Sex Differences and Neurosteroids in Affective Disorders

PURPOSE OF REVIEW

Neuroactive steroid hormones, such as estradiol and progesterone, likely play a role in the pathophysiology of female-specific psychiatric disorders such as premenstrual dysphoric disorder (PMDD) and postpartum depression and may contribute to the marked sex differences observed in the incidence and presentation of affective disorders. However, few tools are available to study the precise contributions of these neuroactive steroids (NSs). In this review, we propose that the acoustic startle response (ASR), an objective measure of an organism's response to an emotional context or stressor, is sensitive to NSs. As such, the ASR represents a unique translational tool that may help to elucidate the contribution of NSs to sex differences in psychiatric disorders.

RECENT FINDINGS

Findings suggest that anxiety-potentiated startle (APS) and prepulse inhibition of startle (PPI) are the most robust ASR paradigms for assessing contribution of NSs to affective disorders, while affective startle response modulation (ASRM) appears less diagnostic of sex or menstrual cycle (MC) effects. However, few studies have appropriately used ASR to test a priori hypotheses about sex or MC differences. We recommend that ASR studies account for sex as a biological variable (SABV) and hormonal status to further knowledge of NS contribution to affective disorders.

Anxiety and Depression Symptom Dimensions Demonstrate Unique Relationships with the Startle Reflex in Anticipation of Unpredictable Threat in 8 to 14 Year-Old Girls

There is growing evidence that heightened sensitivity to unpredictability is a core mechanism of anxiety disorders. In adults, multiple anxiety disorders have been associated with a heightened startle reflex in anticipation of unpredictable threat. Child and adolescent anxiety has been linked to an increased startle reflex across baseline, safety, and threat conditions. However, it is unclear whether anxiety in youth is related to the startle reflex as a function of threat predictability. In a sample of 90 8 to 14 year-old girls, the present study examined the association between anxiety symptom dimensions and startle potentiation during a no, predictable, and unpredictable threat task. Depression symptom dimensions were also examined given their high comorbidity with anxiety and mixed relationship with the startle reflex and sensitivity to unpredictability. To assess current symptoms, participants completed the self-report Screen for Child Anxiety Related Emotional Disorders and Children's Depression Inventory. Results indicated that social phobia symptoms were associated with heightened startle potentiation in anticipation of unpredictable threat and attenuated startle potentiation in anticipation of predictable threat. Negative mood and negative self-esteem symptoms were associated with attenuated and heightened startle potentiation in anticipation of unpredictable threat, respectively. All results remained significant after controlling for the other symptom dimensions. The present study provides initial evidence that anxiety and depression symptom dimensions demonstrate unique associations with the startle reflex in anticipation of unpredictable threat in children and adolescents.

Anxiety Patients Show Reduced Working Memory Related dlPFC Activation During Safety and Threat

BACKGROUND

Anxiety patients exhibit deficits in cognitive tasks that require prefrontal control of attention, including those that tap working memory (WM). However, it is unclear whether these deficits reflect threat-related processes or symptoms of the disorder. Here, we distinguish between these hypotheses by determining the effect of shock threat versus safety on the neural substrates of WM performance in anxiety patients and healthy controls.

METHODS

Patients, diagnosed with generalized and/or social anxiety disorder, and controls performed blocks of an N-back WM task during periods of safety and threat of shock. We recorded blood-oxygen-level dependent (BOLD) activity during the task, and investigated the effect of clinical anxiety (patients vs. controls) and threat on WM load-related BOLD activation.

RESULTS

Behaviorally, patients showed an overall impairment in both accuracy and reaction time compared to controls, independent of threat. At the neural level, patients showed less WM load-related activation in the dorsolateral prefrontal cortex, a region critical for cognitive control. In addition, patients showed less WM load-related deactivation in the ventromedial prefrontal cortex and posterior cingulate cortex, which are regions of the default mode network. Most importantly, these effects were not modulated by threat.

CONCLUSIONS

This work suggests that the cognitive deficits seen in anxiety patients may represent a key component of clinical anxiety, rather than a consequence of threat.

Food-Restriction Lowers the Acoustic Startle Response in both Male and Female Rats, and, in Combination with Acute Ghrelin Injection, Abolishes the Expression of Fear-Potentiated Startle in Male Rats

Food restriction has been reported to reduce anxiety-like behaviour in male rats, whereas the effects of food restriction on anxiety in female rats are less clear. Ghrelin is a peptide hormone produced and secreted in the stomach that stimulates food intake and is considered to play a role in reward and emotional responses such as fear expression. Under food restriction, endogenous ghrelin levels increase. In the present study, we examined the effect of moderate food restriction (80% of ad libitum fed weight), with or without an acute application of a small dose of exogenous ghrelin intended to cause an immediate hunger response, on the expression of the acoustic startle reflex (ASR). This was carried out under basal conditions (baseline ASR to 90- and 95-dB noise bursts), and in the presence of a light cue associated with a mild foot-shock, as measured by fear-potentiated startle, which compares the proportional change in ASR in the presence of the conditioned stimulus. The results obtained show that food-restriction reduces basal ASR in both male and female rats, apart from any concomitant change in motor activity, suggesting that food-restriction reduces anxiety levels in both sexes. In addition, the data show that food-restriction reduces fear-potentiated startle in male but not female rats. Acute ghrelin injection, prior to fear-potentiated startle testing, eliminates the expression of fear-potentiated startle in food-restricted male rats alone, suggesting a role for ghrelin in the reduction of fear expression in food-restricted male rats. These data imply that, although food-restriction decreases anxiety in both sexes, learned fear responses remain intact after food-restriction in female but not male rats.

Allopregnanolone in the bed nucleus of the stria terminalis modulates contextual fear in rats

Trauma- and stress-related disorders are among the most common types of mental illness affecting the U.S. population. For many of these disorders, there is a striking sex difference in lifetime prevalence; for instance, women are twice as likely as men to be affected by posttraumatic stress disorder (PTSD). Gonadal steroids and their metabolites have been implicated in sex differences in fear and anxiety. One example, allopregnanolone (ALLO), is a neuroactive metabolite of progesterone that allosterically enhances GABA_A receptor activity and has anxiolytic effects. Like other ovarian hormones, it not only occurs at different levels in males and females but also fluctuates over the female reproductive cycle. One brain structure that may be involved in neuroactive steroid regulation of fear and anxiety is the bed nucleus of the stria terminalis (BNST). To explore this question, we examined the consequences of augmenting or reducing ALLO activity in the BNST on the expression of Pavlovian fear conditioning in rats. In Experiment 1, intra-BNST infusions of ALLO in male rats suppressed freezing behavior (a fear response) to the conditioned context, but did not influence freezing to a discrete tone conditioned stimulus (CS). In Experiment 2, intra-BNST infusion of either finasteride (FIN), an inhibitor of ALLO synthesis, or 17-phenyl-(3α,5α)-androst-16-en-3-ol, an ALLO antagonist, in female rats enhanced contextual freezing; neither treatment affected freezing to the tone CS. These findings support a role for ALLO in modulating contextual fear via the BNST and suggest that sex differences in fear and anxiety could arise from differential steroid regulation of BNST function. The susceptibility of women to disorders such as PTSD may be linked to cyclic declines in neuroactive steroid activity within fear circuitry.

Anxiety sensitivity and the anticipation of predictable and unpredictable threat: Evidence from the startle response and event-related potentials

There is growing evidence that heightened sensitivity to unpredictable threat is a core mechanism of dysfunction in anxiety disorders. However, it is unclear whether anxiety sensitivity is also associated with sensitivity to unpredictable threat. In the present study, 131 participants completed the Anxiety Sensitivity Index-3, which includes physical concerns (PC), social concerns (SC), and cognitive concerns (CC) subscales, and a predictable vs. unpredictable threat-of-shock task. Startle eyeblink and ERP responses (N100, P300) to the acoustic startle probes were measured during the task. PC and CC were associated with heightened and attenuated, respectively, startle for the unpredictable (but not predictable) condition. CC were also associated with attenuated probe N100 for the unpredictable condition only, and PC were associated with increased P300 suppression across the predictable and unpredictable conditions. This study provides novel evidence that the different anxiety sensitivity dimensions demonstrate unique relationships with the RDoC domains "acute" and "potential" threat.

Psychophysiology in the study of psychological trauma: where are we now and where do we need to be?

Posttraumatic stress disorder (PTSD) is a major public health concern, which has been seeing increased recent attention partly due to the wars in Iraq and Afghanistan. Historically, research attempting to understand the etiology and treatment of PTSD has made frequent use of psychophysiological measures of arousal as they provide a number of advantages in providing objective, non-self-report outcomes that are closely related to proposed neurobiological mechanisms and provide opportunity for cross-species translation. Further, the ongoing shift in classification of psychiatric illness based on symptom clusters to specific biological, physiological, and behavioral constructs, as outlined in the US National Institute of Mental Health (NIMH) Research Domain Criteria project (RDoC), promises that psychophysiological research will continue to play a prominent role in research on trauma-related illnesses. This review focuses on the current state of the knowledge regarding psychophysiological measures and PTSD with a focus on physiological markers associated with current PTSD symptoms, as well as markers of constructs thought to be relevant to PTSD symptomatology (safety signal learning, fear extinction), and psychophysiological markers of risk for developing PTSD following trauma. Future directions and issues for the psychophysiological study of trauma including traumatic brain injury (TBI), treatment outcome studies, and new wearable physiological monitoring technologies are also discussed.

A potentiated startle study of uncertainty and contextual anxiety in adolescents diagnosed with autism spectrum disorder

Background

Beyond the core symptoms of autism spectrum disorder (ASD), associated symptoms of anxiety can cause substantial impairment for individuals affected by ASD and those who care for them.

Methods

We utilized a potentiated startle paradigm with a puff of air to the neck as the unconditioned stimulus in order to investigate differences between response to cued fear and contextual anxiety among cognitively able adolescents diagnosed with ASD and an age- and IQ-matched typically developing group.

Results

In a threat-modulated startle paradigm, response patterns to neutral, predictable, and unpredictable conditions were comparable across typically developing and ASD youth in terms of startle response magnitude and latency. However, the ASD group showed significantly greater absolute startle responsivity at baseline and throughout the experiment, suggesting possibly enhanced general sensitivity to threatening contexts. The ASD group, but not the control group, demonstrated moderate to strong negative correlations between psychophysiological response to unpredictable threats (uncertainty) and questionnaire measures of generalized anxiety, intolerance of uncertainty, and repetitive behavior.

Conclusions

Our data suggest enhanced general reactivity among the ASD group, possibly reflecting greater sensitivity to the threatening context of the startle paradigm. Associations with the response to uncertainty may help explain shared neurobehavioral mechanisms in ASD and anxiety. This task can provide useful targets for future neuroimaging and genetics studies as well as specific avenues for intervention. We emphasize the importance of further basic and clinical research into links among these important constructs.

Acute tryptophan depletion increases translational indices of anxiety but not fear: serotonergic modulation of the bed nucleus of the stria terminalis?

Serotonin is strongly implicated in the mammalian stress response, but surprisingly little is known about its mode of action. Recent data suggest that serotonin can inhibit aversive responding in humans, but this remains underspecified. In particular, data in rodents suggest that global serotonin depletion may specifically increase long-duration bed nucleus of the stria terminalis (BNST)-mediated aversive responses (ie, anxiety), but not short-duration BNST-independent responses (ie, fear). Here, we extend these findings to humans. In a balanced, placebo-controlled crossover design, healthy volunteers (n=20) received a controlled diet with and without the serotonin precursor tryptophan (acute tryptophan depletion; ATD). Aversive states were indexed by translational acoustic startle measures. Fear and anxiety were operationally defined as the increase in startle reactivity during short- and long-duration threat periods evoked by predictable shock (fear-potentiated startle) and by the context in which the shocks were administered (anxiety-potentiated startle), respectively. ATD significantly increased long-duration anxiety-potentiated startle but had no effect on short-duration fear-potentiated startle. These results suggest that serotonin depletion in humans selectively increases anxiety but not fear. Current translational frameworks support the proposition that ATD thus disinhibits dorsal raphé-originating serotonergic control of corticotropin-releasing hormone-mediated excitation of the BNST. This generates a candidate neuropharmacological mechanism by which depleted serotonin may increase response to sustained threats, alongside clear implications for our understanding of the manifestation and treatment of mood and anxiety disorders.

Depressed mood enhances anxiety to unpredictable threat

BACKGROUND

Depression and anxiety disorders (ADs) are highly co-morbid, but the reason for this co-morbidity is unclear. One possibility is that they predispose one another. An informative way to examine interactions between disorders without the confounds present in patient populations is to manipulate the psychological processes thought to underlie the pathological states in healthy individuals. In this study we therefore asked whether a model of the sad mood in depression can enhance psychophysiological responses (startle) to a model of the anxiety in ADs. We predicted that sad mood would increase anxious anxiety-potentiated startle responses.

METHOD

In a between-subjects design, participants (n=36) completed either a sad mood induction procedure (MIP; n=18) or a neutral MIP (n=18). Startle responses were assessed during short-duration predictable electric shock conditions (fear-potentiated startle) or long-duration unpredictable threat of shock conditions (anxiety-potentiated startle).

RESULTS

Induced sadness enhanced anxiety- but not fear-potentiated startle.

CONCLUSIONS

This study provides support for the hypothesis that sadness can increase anxious responding measured by the affective startle response. This, taken together with prior evidence that ADs can contribute to depression, provides initial experimental support for the proposition that ADs and depression are frequently co-morbid because they may be mutually reinforcing.

A review on the relationship between testosterone and the interpersonal/affective facet of psychopathy

Testosterone (T) has received increasing interest in the recent years as a probable biological determinant in the etiology of male-biased clinical conditions such as psychopathy (i.e. psychopathy is more prevalent in men and leads to an earlier onset and more severe expression of antisocial and aggressive behavior in men compared to women). In this review, the authors evaluated the potential relationship between T and different constructs closely related to the core characteristics of psychopathy (affective empathy, fear-reactivity, and instrumental aggression). After a thorough examination of the literature, it is concluded that high T exposure in utero and high circulating T levels throughout important life phases (most notably adolescence) or in response to social challenges (e.g. social stress, competition) could be an important etiological risk factor in the emergence of psychopathic behavior. Nevertheless, studies consistently indicate that high T is not related to a significantly reduced fear-reactivity and is only indirectly associated with the increased levels of instrumental aggression observed in psychopathic individuals. Therefore, psychopathy is likely to arise from an interaction between high T levels and other biological and socio-psychological risk factors, such as a constitutionally based dampened fear-reactivity, insecure/disordered attachment processes in childhood, and social discrimination/rejection in adolescence and/or adulthood.

Assessing fear and anxiety in humans using the threat of predictable and unpredictable aversive events (the NPU-threat test)

The threat of predictable and unpredictable aversive events was developed to assess short-duration (fear) and long-duration (anxiety) aversive states in humans. A typical experiment consists of three conditions: a safe condition (neutral (N)), during which participants are safe from aversive stimuli, and two threat conditions-one in which aversive events are administered predictably (P) (i.e., signaled by a threat cue), and one in which aversive stimuli are administered unpredictably (U). During the so-called NPU-threat test, ongoing change in aversive states is measured with the startle reflex. The NPU-threat test has been validated in pharmacological and clinical studies and can be implemented in children and adults. Similar procedures have been applied in animal models, making the NPU-threat test an ideal tool for translational research. The procedure is relatively short (35 min), simple to implement and generates consistent results with large effect sizes.

Measuring anxious responses to predictable and unpredictable threat in children and adolescents

Research has highlighted the need for new methods to assess emotions in children on multiple levels to gain better insight into the complex processes of emotional development. The startle reflex is a unique translational tool that has been used to study physiological processes during fear and anxiety in rodents and in human participants. However, it has been challenging to implement developmentally appropriate startle experiments in children. This article describes a procedure that uses predictable and unpredictable aversive events to distinguish between phasic fear and sustained anxiety in children and adolescents. We investigated anxious responses, as measured with the startle reflex, in youths (N=36, mean age=12.63 years, range=7-17) across three conditions: no aversive events (N), predictable aversive events (P), and unpredictable aversive events (U). Short-duration cues were presented several times in each condition. Aversive events were signaled by the cues in the P condition but were presented randomly in the U condition. Participants showed fear-potentiated startle to the threat cue in the P condition. Startle responses were also elevated between cues in the U condition compared with the N condition, suggesting that unpredictable aversive events can evoke a sustained state of anxiety in youths. This latter effect was influenced by sex, being greater in girls than in boys. These findings indicate the feasibility of this experimental induction of the startle reflex in response to predictable and unpredictable events in children and adolescents, enabling future research on interindividual differences in fear and anxiety and their development in youths.

Validating the inhalation of 7.5% CO(2) in healthy volunteers as a human experimental medicine: a model of generalized anxiety disorder (GAD)

Anxiety is a complex phenomenon that can represent contextually different experiences to individuals. The experimental modelling in healthy volunteers of clinical anxiety experienced by patients is challenging. Furthermore, defining when and why anxiety (which is adaptive) becomes an anxiety disorder (and hence maladaptive) is the subject of much of the published literature. Observations from animal studies can be helpful in deriving mechanistic models, but gathering evidence from patients and reverse translating this to healthy volunteers and thence back to laboratory models is a more powerful approach and is likely to more closely model the clinical disorder. Thus the development and validation of a robust healthy volunteer model of anxiety may help to bridge the gap between the laboratory and the clinic and provide 'proof of concept' in screening for novel drug treatments. This review considers these concepts and outlines evidence from a validated healthy volunteer model of generalized anxiety disorder (GAD) following the inhalation of 7.5% CO(2).

The effect of induced anxiety on cognition: threat of shock enhances aversive processing in healthy individuals

Individuals with anxiety disorders demonstrate altered cognitive performance including (1) cognitive biases towards negative stimuli (affective biases) and (2) increased cognitive rigidity (e.g., impaired conflict adaptation) on affective Stroop tasks. Threat of electric shock is frequently used to induce anxiety in healthy individuals, but the extent to which this manipulation mimics the cognitive impairment seen in anxiety disorders is unclear. In this study, 31 healthy individuals completed an affective Stroop task under safe and threat-of-shock conditions. We showed that threat (1) enhanced aversive processing and abolished a positive affective bias but (2) had no effect on conflict adaptation. Threat of shock thus partially models the effects of anxiety disorders on affective Stroop tasks. We suggest that the affective state of anxiety-which is common to both threat and anxiety disorders-modulates the neural inhibition of subcortical aversive processing, whilst pathologies unique to anxiety disorders modulate conflict adaptation.

Does intolerance of uncertainty predict anticipatory startle responses to uncertain threat?

Intolerance of uncertainty (IU) has been proposed to be an important maintaining factor in several anxiety disorders, including generalized anxiety disorder, obsessive-compulsive disorder, and social phobia. While IU has been shown to predict subjective ratings and decision-making during uncertain/ambiguous situations, few studies have examined whether IU also predicts emotional responding to uncertain threat. The present study examined whether IU predicted aversive responding (startle and subjective ratings) during the anticipation of temporally uncertain shocks. Sixty-nine participants completed three experimental conditions during which they received: no shocks, temporally certain/predictable shocks, and temporally uncertain shocks. Results indicated that IU was negatively associated with startle during the uncertain threat condition in that those with higher IU had a smaller startle response. IU was also only related to startle during the uncertain (and not the certain/predictable) threat condition, suggesting that it was not predictive of general aversive responding, but specific to responses to uncertain aversiveness. Perceived control over anxiety-related events mediated the relation between IU and startle to uncertain threat, such that high IU led to lowered perceived control, which in turn led to a smaller startle response. We discuss several potential explanations for these findings, including the inhibitory qualities of IU. Overall, our results suggest that IU is associated with attenuated aversive responding to uncertain threat.

Modulation of nociceptive and acoustic startle responses to an unpredictable threat in men and women

The present study examined whether a moderately aversive abdominal threat would lead to greater enhancement in affect- and pain-related defensive responding as indexed by the acoustic startle reflex (ASR) and nociceptive flexion reflex (NFR) in women compared to men. We also predicted sex differences in threat-related autonomic arousal measured by skin conductance responses (SCRs) to acoustic startle and noxious sural nerve stimulation. Unpredictable threat was manipulated by alternating 30-second safe ("no abdominal stimulation will be given") and threat ("abdominal stimulation may occur at anytime") periods. The experiment consisted of 2 blocks, each containing 4 safe and 4 threat periods in which the ASR or NFR was randomly probed 9-21 seconds following period onset. Unpredictable abdominal threat potentiated both ASR and NFR responses compared to periods signaling safety. SCRs to acoustic startle probes and noxious sural nerve stimulation were also significantly elevated during the threat vs safe periods. No sex differences in ASR or startle-evoked SCRs emerged. However, nociceptive responding was moderated by sex; females showed significant increases in NFR magnitudes across both safe and threat periods compared to males. Females also showed greater threat-potentiated SCRs to sural nerve stimulation than males. Our findings indicate that both affect- and pain-related defense and arousal systems are strongly influenced by threat of an aversive, unpredictable event, a situation associated with anticipatory anxiety. Females, compared to males, showed greater nociceptive responding and pain modulation when exposed to an unpredictable threatening context, whereas affect-driven ASR responses showed no such sex differentiation.

Effects of predictability of shock timing and intensity on aversive responses

An important characteristic of aversive stimuli that determines emotional responses is whether the stimuli are predictable. Human laboratory studies in this area have typically operationalized predictability as being able to predict the occurrence of aversive events, but animal studies suggest that being able to predict other characteristics of the stimuli may also play a role in aversive responding. To examine this, the present study examined two characteristics: the timing and intensity of aversive stimuli. Specifically, participants were randomly assigned to receive shocks that were either predictable or unpredictable in terms of when they would occur (timing) and/or their intensity. Indicators of aversive emotional responses were EMG startle responses and subjective anxiety ratings. Results revealed that aversive responding was elevated for unpredictable timing and intensity suggesting that the predictability of both characteristics play a role in aversive responding (though the effects for timing were stronger). In sum, the anxiogenic effects of unpredictability may generalize to situations beyond unpredictable timing.

Sex differences in heart rate responses to script-driven imagery soon after trauma and risk of posttraumatic stress disorder

OBJECTIVE

To investigate in trauma survivors the predictive validity of heightened physiological responsivity to script-driven imagery for the development of posttraumatic stress disorder (PTSD) and to evaluate the interactive effect of survivors' sex. Physiological responses to idiosyncratic trauma reminders may be predictive of later PTSD. The majority of previous studies have been cross sectional and have produced mixed findings. Sex differences may contribute to this heterogeneity.

METHODS

Heart rate (HR) and respiratory sinus arrhythmia were measured at 2 weeks post trauma in 158 assault survivors during baseline and as they listened to an idiosyncratic trauma script. At 6 months, 15.2% of male and 28.1% of female participants met the diagnostic criteria for PTSD.

RESULTS

Generalized linear model and logistic regression analyses showed that HR response to script-driven imagery and sex interacted in predicting PTSD symptom severity at 6 months. Women had greater PTSD symptom severities overall. Female HR responders to script-driven imagery showed the highest PTSD symptom severities and were almost three times more likely to develop PTSD at 6 months compared with men and female nonresponders (odds ratio, 2.72; 95% confidence interval, 1.13-6.57). Respiratory sinus arrhythmia responder type did not predict PTSD (odds ratio, 0.64; 95% confidence interval, 0.30-1.33).

CONCLUSION

Female trauma survivors who respond to trauma reminders with increased HR may be at particular risk of developing PTSD. Physiological reactivity to trauma cues may be a useful index for screening and prevention of PTSD.

Phasic vs sustained fear in rats and humans: role of the extended amygdala in fear vs anxiety

Data will be reviewed using the acoustic startle reflex in rats and humans based on our attempts to operationally define fear vs anxiety. Although the symptoms of fear and anxiety are very similar, they also differ. Fear is a generally adaptive state of apprehension that begins rapidly and dissipates quickly once the threat is removed (phasic fear). Anxiety is elicited by less specific and less predictable threats, or by those that are physically or psychologically more distant. Thus, anxiety is a more long-lasting state of apprehension (sustained fear). Rodent studies suggest that phasic fear is mediated by the amygdala, which sends outputs to the hypothalamus and brainstem to produce symptoms of fear. Sustained fear is also mediated by the amygdala, which releases corticotropin-releasing factor, a stress hormone that acts on receptors in the bed nucleus of the stria terminalis (BNST), a part of the so-called 'extended amygdala.' The amygdala and BNST send outputs to the same hypothalamic and brainstem targets to produce phasic and sustained fear, respectively. In rats, sustained fear is more sensitive to anxiolytic drugs. In humans, symptoms of clinical anxiety are better detected in sustained rather than phasic fear paradigms.

Increased anxiety during anticipation of unpredictable aversive stimuli in posttraumatic stress disorder but not in generalized anxiety disorder

BACKGROUND

Uncontrollability and unpredictability are key concepts related to re-experiencing, avoidance, and hypervigilance symptoms of posttraumatic stress disorder (PTSD). However, little is known about the differential sensitivity of PTSD individuals to unpredictable stressors, relative to either healthy individuals or individuals with other anxiety disorders. This study tested the hypothesis that elevated anxious reactivity, specifically for unpredictable aversive events, is a psychophysiological correlate of PTSD.

METHODS

Sixteen patients with PTSD (34.5 +/- 12.4 years) were compared with 18 patients with generalized anxiety disorder (GAD) (34.0 +/- 10.5 years) and 34 healthy control subjects (30.2 +/- 8.5 years). Participants were exposed to three conditions: one in which predictable aversive stimuli were signaled by a cue, a second in which aversive stimuli were administered unpredictably, and a third in which no aversive stimuli were anticipated. Startle magnitude was used to assess anxious responses to the threat cue and to contexts associated with each condition.

RESULTS

Posttraumatic stress disorder and GAD patients showed normative enhancement of fear to the predictable threat cue, but the PTSD group displayed elevated anxiety during the unpredictable condition compared with participants with GAD and healthy control subjects.

CONCLUSIONS

Anxious reactivity to unpredictable aversive events was heightened in PTSD but not in GAD and healthy subjects. Prior works also found signs of increased reactivity to unpredictable threat in panic disorder (PD), suggesting that PTSD and PD may involve shared vulnerability. As such, the current results inform understandings of classification, pathophysiology, and psychopharmacology of anxiety disorders, generally, and PTSD and panic disorder specifically.

Models and mechanisms of anxiety: evidence from startle studies

RATIONALE

Preclinical data indicates that threat stimuli elicit two classes of defensive behaviors, those that are associated with imminent danger and are characterized by flight or fight (fear), and those that are associated with temporally uncertain danger and are characterized by sustained apprehension and hypervigilance (anxiety).

OBJECTIVE

The objectives of the study are to (1) review evidence for a distinction between fear and anxiety in animal and human experimental models using the startle reflex as an operational measure of aversive states, (2) describe experimental models of anxiety, as opposed to fear, in humans, (3) examine the relevance of these models to clinical anxiety.

RESULTS

The distinction between phasic fear to imminent threat and sustained anxiety to temporally uncertain danger is suggested by psychopharmacological and behavioral evidence from ethological studies and can be traced back to distinct neuroanatomical systems, the amygdala and the bed nucleus of the stria terminalis. Experimental models of anxiety, not fear, are relevant to non-phobic anxiety disorders.

CONCLUSIONS

Progress in our understanding of normal and abnormal anxiety is critically dependent on our ability to model sustained aversive states to temporally uncertain threat.