Reactivity to unpredictable threat as a treatment target for fear-based anxiety disorders

S. M. Gorka*, L. Lieberman, H. Klumpp, K. L. Kinney, A. E. Kennedy, O. Ajilore, J. Francis, J. Duffecy, M. G. Craske, J. Nathan, S. Langenecker, Stewart A Shankman, K. L. Phan

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


Background Heightened reactivity to unpredictable threat (U-threat) is a core individual difference factor underlying fear-based psychopathology. Little is known, however, about whether reactivity to U-threat is a stable marker of fear-based psychopathology or if it is malleable to treatment. The aim of the current study was to address this question by examining differences in reactivity to U-threat within patients before and after 12-weeks of selective serotonin reuptake inhibitors (SSRIs) or cognitive-behavioral therapy (CBT). Methods Participants included patients with principal fear (n = 22) and distress/misery disorders (n = 29), and a group of healthy controls (n = 21) assessed 12-weeks apart. A well-validated threat-of-shock task was used to probe reactivity to predictable (P-) and U-threat and startle eyeblink magnitude was recorded as an index of defensive responding. Results Across both assessments, individuals with fear-based disorders displayed greater startle magnitude to U-threat relative to healthy controls and distress/misery patients (who did not differ). From pre- to post-treatment, startle magnitude during U-threat decreased only within the fear patients who received CBT. Moreover, within fear patients, the magnitude of decline in startle to U-threat correlated with the magnitude of decline in fear symptoms. For the healthy controls, startle to U-threat across the two time points was highly reliable and stable. Conclusions Together, these results indicate that startle to U-threat characterizes fear disorder patients and is malleable to treatment with CBT but not SSRIs within fear patients. Startle to U-threat may therefore reflect an objective, psychophysiological indicator of fear disorder status and CBT treatment response.

Original languageEnglish (US)
Pages (from-to)2450-2460
Number of pages11
JournalPsychological Medicine
Issue number14
StatePublished - Oct 1 2017


  • Anxiety
  • distress
  • fear
  • startle potentiation
  • temporal stability
  • unpredictable threat

ASJC Scopus subject areas

  • Applied Psychology
  • Psychiatry and Mental health


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