Received: 21 March 2019

| Revised: 7 August 2019

| Accepted: 19 August 2019

DOI: 10.1111/psyp.13474

PRESIDENTIAL ADDRESS

Fear, anxiety, and their disorders from the perspective of

psychophysiology

Alfons O. Hamm

Department of Psychology, University of

Greifswald, Greifswald, Germany
Correspondence
Alfons O. Hamm, Department of
Psychology, University of Greifswald,
Franz‐Mehring‐Strasse 47, 17487
Greifswald, Germany.
Email: hamm@uni-greifswald.de
Funding information
Bundesministerium für Bildung
und Forschung, Grant/Award
Number: 01GV0615; Deutsche
Forschungsgemeinschaft, Grant/Award
Number: Ha 1593/6‐1,6‐2; 10‐1,10‐2; 15‐1;
18‐1; PA 2737/1‐1
Abstract
Psychophysiology is a central hub connecting neurobiological and behavioral do-
mains with clinical science, thus providing ideal tools for increasing the understand-
ing of mental disorders beyond the level of symptom reports. The present article
provides an overview of how psychophysiological research can contribute toward
efforts directed at an improved understanding of anxiety disorders. Starting with
the behavioral domain, it is demonstrated that defensive behaviors are fundamental
to anxiety disorders and that these behaviors are dynamically organized depending
upon the proximity of a specific threat. The next section reviews neural networks
that are activated during the encoding of threat‐relevant information and during the
organization of the cascade of defensive responses, including how passive avoidance
might be conceptualized within a neurobehavioral framework. The last section ad-
dresses the translation of these behavioral and neuronal findings from experimental
psychopathology research to clinical populations. Finally, evidence is presented to
support how behavioral approaches may be helpful in predicting treatment outcomes.

KEYWORDS
anxiety, anxiety disorders, defensive neural networks, defensive responses, fear, personalized treatment

1 | IN T RO D U C T ION 1.1 | Fear and anxiety: The clinical

perspective
Psychophysiology is a scientific discipline that intersects
From a clinical and health care perspective, anxiety disor-
with other scientific disciplines (Cacioppo, Tassinary, &
ders are among the most frequent and costly conditions of all
Berntson, 2000). In an effort to describe the relationship
mental disorders (Bandelow & Michaelis, 2015). Thus, it is
between psychological functions and brain actions and to
important to understand the mechanisms associated with the
better understand how this association is modulated, psy-
development of such disorders to develop treatments that are
chophysiologists can be described as pedestrians who must
effective and—even more importantly—mechanism based.
be aware of traffic coming from many directions before
According to DSM 5, all mental disorders included in the
crossing a busy intersection (Dawson, 1990). This article
section of anxiety disorders “share features of excessive fear
reflects the spirit of our discipline by providing a psycho-
and anxiety and related behavioral disturbances” (American
physiological perspective on fear, anxiety, and their dis-
Psychiatric Association [APA], 2013). While fear is defined
orders while carefully observing the busy “traffic” at the
in DSM 5 as an emotional response to a real or perceived
intersection of clinical, behavioral, and functional brain
imminent threat, anxiety refers to the anticipation of a future
science.

Psychophysiology. 2020;57:e13474. wileyonlinelibrary.com/journal/psyp © 2019 Society for Psychophysiological Research | 1 of 14

https://doi.org/10.1111/psyp.13474
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threat. Although both feeling states can obviously overlap,
they also differ, particularly regarding their profile of re-
ported symptoms. While fear is “more often associated with
surges of autonomic arousal, necessary for fight or flight,
thoughts of immediate danger, and escape behaviors, anxiety
is more often associated with muscle tension and vigilance
in preparation for future danger and cautious avoidance be-
havior” (DSM 5, 189). Thus, phobic disorders are defined
as marked fear or anxiety elicited by specific situations.
Accordingly, phobic disorders are further categorized based
on the type of feared situation. Phobic disorders include spe-
cific phobia (fear or anxiety about specific objects or situa-
tions, such as a type of animal, heights, etc.), social phobia
(fear or anxiety about one or more social situations in which
the individual is exposed to possible scrutiny by others, such
as participating in social interactions, being observed or per-
forming in front of others), and agoraphobia. In contrast to
other phobic disorders, fear and anxiety associated with ago-
raphobia are more generalized because the diagnosis requires
fear and anxiety occurring in at least two of five situations.
These situations can be grouped into two clusters: (a) situa-
tions of entrapment (e.g., using public transportation, being
in enclosed places, being in a crowd, or standing in line), or
(b) situations in which there are potential emergencies (e.g.,
heart attack, stroke, etc.) but no immediate help is available
(e.g., being outside of the home alone, being in open spaces).
In these instances, the source of the threat is not in the feared
situation itself (e.g., agoraphobic patients are not afraid of
the shopping mall itself), but instead the feared situation
provides a context in which a potential threat arising from
inside the body might become fatal. Accordingly, agorapho-
bia is often associated with unexpected (i.e., the individual
does not perceive any obvious cue or trigger) panic pathology
(Kessler et al., 2006; Pané‐Farré et al., 2014). The majority
of panic attacks—clinically defined as an abrupt surge of in-
tense fear that reaches a peak within minutes during which
four (or more) symptoms from a list of 13 cardio‐respiratory,
autonomic‐somatic, and cognitive symptoms occur—are ex-
perienced during the day (85%) and outside of home (73%);
thus, they tend to occur in the contexts that are typical for
agoraphobic situations (Johnson, Federici, & Shekhar, 2014;
Pané‐Farré et al., 2014). If such panic attacks are followed by
persistent concerns and worries about additional panic attacks
or their consequences (e.g., losing control, having a heart at-
tack, going crazy), a panic disorder is diagnosed. A general-
ized anxiety disorder is diagnosed if such worries extend to
other domains (e.g., health, finances, job performance), are
persistent, are difficult to control, and invoke symptoms such
as irritability, restlessness, and muscle tension.
While such classifications of anxiety disorders have been
progressively refined across different versions of the noso-
logical systems to increase the reliability of clinical diagno-
ses, basically by providing more specific descriptive criteria
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HAMM
based on patients' phenomenological symptom reports, valid-
ity has been unintentionally sacrificed (Insel, 2013; Kozak &
Cuthbert, 2016). Thus, to provide a more mechanism‐based
approach for understanding fear, anxiety, and its disorders,
one should go beyond the level of symptom reports.
1.2 | Fear and anxiety: The behavioral
science perspective
From the perspective of behavioral science, emotions such as
fear and anxiety can be functionally conceived as action dis-
positions evoked by particular patterns of threat‐related stim-
uli that in turn cause patterns of adaptive behaviors in order
to cope with the threat and survive (Adolphs, 2013; Lang &
Bradley, 2010). Thus, to understand anxiety disorders from
a behavioral science perspective, one has to describe how
threat information is encoded and how defensive behaviors
are organized. Starting from this behavioral perspective, one
can then investigate (a) the neural networks that are involved
in the detection and integration of threat information, and (b)
how these networks communicate with those circuits organ-
izing defensive actions, including the accompanying adjust-
ments of the autonomic nervous system. Such an approach
follows the strategic aim of the Research Domain Criteria
(RDoC) program (Cuthbert & Insel, 2013), as proposed by
the National Institute of Mental Health (NIMH) and the
European Roadmap for Mental Health Research (ROAMER;
Wittchen et al., 2014). Thus, instead of investigating emo-
tional reactivity and cognitive functioning in a group of
individuals with a specific illness, the research agenda of
the Greifswald lab starts with a biopsychological model
of dynamic defense network activations and its behavioral
adjustments derived from basic research with animals. The
translation of this model to humans allows a new approach
that will finally lead to a better understanding of adaptive
but also maladaptive human defensive behaviors. According
to this model, defensive adjustments to threats are character-
ized by a close interplay between cognitive and emotional
processes.
1.2.1 | A transdiagnostic dimensional
model of defensive behaviors
Animal data suggest that defensive behaviors are organized
along a dimension depending upon the distance, proximity,
or imminence of the threat (see Blanchard & Blanchard,
1990; Fanselow, 1994). When an organism is in a context
in which a threat has been encountered previously (or, in
the case of humans, a context in which the individual be-
lieves that a threat might occur) but has not yet been detected
(preencounter defense; Fanselow, 1994), a class of adaptive
defensive behaviors are engaged. These behaviors involve
emotional‐motivational and cognitive processes that preempt

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hostile encounters, such as the inhibition of appetitive be-
haviors, threat‐nonspecific hypervigilance, and increased
autonomic arousal. Humans report feelings of anxiety, ap-
prehension, or worry if they encounter such uncertain, novel,
and ambiguous contexts in which potential threats might
occur (see Davis, Walker, Miles, & Grillon, 2010; Perusini
& Fanselow, 2015). Pharmacological and lesion studies with
rodents measuring defensive behavior during open field tests
or contextual conditioning (i.e., entering a context where un-
predictable aversive events might occur) demonstrate that the
bed nucleus of the stria terminalis (BNST)—a major target
area of projections from the basolateral and central amyg-
dala—is critically involved in the regulation of anxiety‐like
preemptive safety or avoidance behavior (e.g., staying cau-
tiously at the edge of an open field; Goode & Maren, 2017;
Tovote, Fadok, & Lüthi, 2015).
When a threatening stimulus is detected (postencounter
defense) but is still distant, a defensive response pattern is
activated. This response is characterized by an increase in
selective attention directed to the threatening cue and by
heart rate deceleration (“fear bradycardia”; Campbell, Wood,
& McBride, 1997). In addition, animals show potentiation
of the startle reflex gated through the central nucleus of the
amygdala (for review, see Hamm, 2015a) and motor “freez-
ing” depending on the projections from the central amygdala
to the ventral periaqueductal gray (vPAG) in the midbrain
(Fanselow, 1994; Leaton & Borszcz, 1985; Maren, 2001;
Morgan & Carrive, 2001; Tovote et al., 2015). In humans,
these same defensive responses are often accompanied by a
feeling of fear, and individuals are typically able to report
specific fear triggers (e.g., a snake or a dog). If the reported
fear also causes significant distress or impairment or is out
of proportion to the actual danger (according to the cultural
context), these defensive responses are diagnosed as symp-
toms of a phobia specified and categorized based on the
threat cues.
With increasing imminence of the threat (circa‐strike
defense), defensive response mobilization becomes an ac-
tive action that—depending on the available behavioral op-
tions—can result in either a flight/fight response or, during a
traumatic event where fight/flight is not an option, in tonic,
unresponsive immobility (Marks, 1987; Schauer & Elbert,
2010). Humans often report feelings of panic during circa‐
strike defense. Animal data suggest that the initiation of such
defensive actions is mediated by the dorsal periaqueductal
gray (dlPAG), which regulates the expression of escape be-
havior (Kim et al., 2013; LeDoux, 2012). Circa‐strike de-
fense mobilization is accompanied by general discharge of
the sympathetic nervous system (Cannon, 1932) that stimu-
lates the adrenal medulla to secrete two catecholamines, epi-
nephrine (adrenaline) and norepinephrine (noradrenaline),
into the bloodstream. Apart from direct physiological ef-
fects (e.g., increased heart rate, sweating), adrenergic system
|
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    3 of 14
activity modulates cognitive processes, especially the forma-
tion and consolidation of emotional memories (McGaugh,
2004; Weymar et al., 2009), thus resulting in better memory
of emotionally arousing events and, unfortunately, traumatic
events. Again, these data confirm the strong connection be-
tween emotional and cognitive processes involved in the de-
velopment of a psychopathology.
The dynamic organization of defensive behaviors has
been recognized and refined by many researchers and has
been formalized as the threat imminence model (Blanchard
& Blanchard, 1990; Fanselow, 1994) or the defense cascade
model (Lang, Bradley, & Cuthbert, 1997), including its ex-
tension to trauma‐related defense (Schauer & Elbert, 2010;
for reviews, see Adolphs, 2013; Lowe & Ziemke, 2011;
McNaughton, 2011). This theoretical framework, which has
been translated recently into a transdiagnostic model for con-
ceptualizing anxiety disorders (panic disorder and agorapho-
bia; Hamm et al., 2016; specific phobias; Hamm, 2015b), is
depicted in Figure 1.
2 | EM PIRICAL EVALUATION OF
THE M ODEL IN HUM ANS
2.1 | Preencounter defense: Generalized
hypervigilance
The predictions of the theoretical model outlined above were
tested in our laboratory by measuring ERPs during situations
in which a potential threat might occur. Informing individu-
als with high fear of spiders that pictures of spiders might be
presented in the following experiment resulted in greater P1
amplitudes over occipital areas; this result occurred not only
for fear‐relevant spider pictures but also for fear‐irrelevant
neutral stimuli (Michalowski et al., 2009), supporting the hy-
pothesis that preencounter defense is characterized by a gen-
eralized hypervigilance to all cues in a potentially dangerous
environment. Following up on this research, Michalowski,
Pané‐Farré, Löw, and Hamm (2015) tested whether context
change is explicitly associated with changes in P1 ampli-
tudes. In this study, 32 neutral pictures were presented in a
safe context to both individuals with elevated spider fear and
control subjects, and P1 amplitudes were measured. A cover
story was prepared (all participants were instructed that they
had been selected because of their good selective attention
performance) to ensure that spider fearful individuals did not
establish any relation between their spider fear and the study.
Figure 2a shows the P1 amplitudes and the distribution map
of the scalp potential differences (amplitudes of the spider
phobia individuals minus those of the controls) for this con-
dition. There were no group differences between individuals
with a spider phobia and controls in P1 amplitude in this con-
dition. Then, participants were informed that they would see
pictures of spiders during the next block of trials and were
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4 of 14 HAMM

F I G U R E 1 The transdiagnostic
dimensional model of defensive behaviors
suggests that defensive reactivity is
dynamically organized along a continuum
depending on the imminence or proximity
of the threat (threat‐imminence model,
Fanselow, 1994; defense cascade model,
Blanchard & Blanchard, 1990; Lang,
Bradley, & Cuthbert, 1997; adapted from
Hamm et al., 2016)

F I G U R E 2 (a) P1 amplitudes of the evoked brain potentials in response to neutral pictures in individuals with spider phobia (red) and
healthy controls (black) prior to the instruction that pictures of spiders might be presented. The distribution map of the scalp potential differences
(activations of the spider phobia individuals minus those of the controls) for this condition is depicted in the inlay. (b) P1 amplitudes in response to
the same neutral pictures (upper panel) for both groups after the instruction that phobia‐relevant pictures might be presented. Lower panel shows
the P1 amplitudes of both groups in response to phobia‐relevant pictures. Again, the distribution map of the scalp potential differences is presented
in the inlay of Panel (b)

asked to provide written consent to continue with the experi- 2b, upper, shows the P1 amplitudes corresponding to neu-
ment. After this instruction, a block of 32 neutral stimuli was tral pictures after the instruction, and the lower part of the
presented and then pictures of spiders were presented. Figure figure shows the P1 amplitudes corresponding to the block

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of spider pictures presented after the neutral block. The high
spider fearful individuals showed significantly higher P1 am-
plitudes over the occipital cortex (see inlay) in response to
the neutral pictures than did the controls in a context where
pictures of spiders could occur. This increase in amplitude
was comparable to that observed for the P1 amplitudes in
response to spider pictures (see Figure 2b, lower). These
data clearly support the hypothesis that a change from a safe
context to an environment with potential threats resulted in
generalized hypervigilance in the individuals for whom the
context was threatening.
Evidence that these changes in vigilance might be caused
by an increase in the afferent sensory gain is provided in an
earlier study conducted in our laboratory (Weymar, Keil, &
Hamm, 2013). In this study, relative to controls, high spider
fearful individuals showed enhanced C1 amplitudes—the
earliest cortical component in visual processing in the V1—
to both fearful and nonfearful targets in a visual search task.
That is, whenever there is a possibility that a spider stimu-
lus might occur in the visual field (preencounter defense),
high fearful individuals show increased vigilance to all vi-
sual targets. The sensory gain might generally be increased
during this phase of preencounter defense, and this theory
is supported by a recent study from Cornwell and cowork-
ers (2017). These investigators used a threat of unpredictable
shock paradigm to create a potentially dangerous context.
Participants had to complete an auditory oddball task either
during the potentially dangerous context or during a safe con-
text while whole head magnetoencephalogram (MEG) was
recorded. Threat shock increased auditory cortical responses
to deviant tones, which is an effect that could be reduced by
the administration of anxiolytic alprazolam. Dynamic causal
modeling of the MEG data revealed that the threat of shock
increased the gain of the primary auditory cortex, thus gating
feedforward connectivity. Interestingly, using the same threat
of shock paradigm, Bublatzky and Schupp (2012) also found
higher P1 amplitudes in response to pictures, irrespective of
their emotional content, presented in a context where an aver-
sive electric shock might be delivered than the P1amplitudes
in response to visual stimuli presented in a safe context. The
same unspecific enhancement of the visual evoked potentials
can also be observed when words are encoded under a threat
of shock (Weymar, Bradely, Hamm, & Lang, 2013).
These data suggest that generalized hypervigilance (or
broadening attention; Eysenck, 1992) during preencounter
defense is realized by an increase in the gain of the primary
sensory processing areas in the brain. This hypothesis is
also supported by the findings in a study by Straube and co-
workers (2007), who measured brain activation using fMRI
while high spider fearful individuals waited for pictures of
spiders to appear. During this stage of preencounter defense,
the authors found enhanced activity in the extrastriate visual
cortex and in the thalamus. Moreover, increased activation
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    5 of 14
during this stage was also found in the BNST, supporting the
findings of pharmacological and lesion studies with rodents
(Davis et al., 2010; Tovote et al., 2015). Direct projections
from the BNST to cholinergic neurons in the midbrain may
mediate increases in synaptic transmission in thalamic sen-
sory relay neurons. This cholinergic activation in addition
to increases in thalamic transmission, which is accompanied
by activation of the locus coeruleus, may lead to generalized
hypervigilance during preencounter defense (see Davis &
Whalen, 2001; Rosen & Schulkin, 1998).
2.2 | Postencounter defense:
Defensive freezing
As soon as a threat cue is detected (e.g., a spider is spot-
ted in the upper corner of the room), increased amounts of
selective attention are allocated to the threat cue, the level
of sympathetic arousal increases, heart rate decelerates, and
potentiation of protective reflexes occurs. This response pat-
tern has been described as defensive freezing or attentive
immobility (Galdwin, Hashemi, van Ast, & Roloefs, 2016;
Marks, 1987), which is contrasted to passive tonic immo-
bility (“playing dead”). Accordingly, compared to nonfear-
ful individuals, individuals who report excessive spider fear
show enhanced late positive potentials when viewing spider
pictures (Kolassa, Musial, Mohr, Trippe, & Miltner, 2005;
Michalowski et al., 2009, 2015; see Figure 3), supporting the
idea that more attentional resources are allocated to phobia‐
relevant stimuli. However, the LPP was similarly increased
F I G U R E 3 Late positive potentials (LPPs) occurring in the time
window between 300 and 550 ms over parietal brain regions in the
evoked potentials to phobic (spider pictures) unpleasant, and neutral
pictures in individuals with elevated spider fear (red) and control
subjects (black). LPPs evoked by spider pictures were specifically
increased in the phobia group but did not exceed the LPPs evoked by
other unpleasant pictures. LPPs in response to emotionally relevant
contents were larger than those evoked by neutral pictures (adapted
from Michalowski et al., 2015)
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in response to other unpleasant pictures (in this case for both
fearful and nonfearful individuals; see Figure 3), demon-
strating that increased selective attention is not specific for
phobia‐relevant cues but is a more general phenomenon that
occurs in response to all motivationally relevant stimuli, in-
cluding pleasant ones (Schupp et al., 2000, 2004).
Moreover, compared with controls, high fearful indi-
viduals consistently show larger potentiation of their star-
tle responses and increased skin conductance responses
when viewing phobia‐relevant pictures (Hamm, Cuthbert,
Globisch, & Vaitl, 1997). In this study, the levels of star-
tle potentiation and increases in sympathetic arousal were
of greater magnitude than the changes in blink magnitudes
and skin conductance evoked by other unpleasant pictures.
The same defensive response pattern is observed during fear
conditioning (i.e., when viewing a cue that predicts the oc-
currence of an exteroceptive threat—a moderately painful
stimulus; Hamm & Vaitl, 1996; Hamm, Greenwald, Bradley,
& Lang, 1993; Lipp, Sheridan, & Siddle, 1994). Interestingly,
while sweat gland activity increases with sympathetic acti-
vation, heart rate—which is mainly under parasympathetic
control—decreases for some individuals with a conditioned
stimulus (Hamm & Vaitl, 1996; Hodes, Cook, & Lang, 1985).
Such a response pattern resembles fear bradycardia, which is
observed in prey animals confronting a predator from a dis-
tance (Campbell et al., 1997). On the other hand, some indi-
viduals show an acceleration in their heart rate when viewing
a cue that predicts the occurrence of an aversive electrical
stimulus (Hamm & Vatil, 1996; Hodes et al., 1985; Moratti
& Keil, 2005). Moreover, high spider fearful individuals also
showed heart rate acceleration when viewing phobia‐relevant
pictures (Hamm et al., 1997). These data suggest that, during
defensive freezing, both branches of the autonomic nervous
system become activated. The pattern of defensive responses
varies depending on which system is dominant at a certain
point in time. Which autonomic pattern is dominant during
defensive response activation may be influenced by trait fac-
tors as well as environmental aspects (for review, see Roelofs,
2017). Animal data suggest that the distance from the pred-
ator and the presence of escape routes play important roles
in this respect (Blanchard, Griebel, Robbe, & Blanchard,
2011). Recent findings from our laboratory support these
findings from animal data. Löw and coworkers (2015) traced
the dynamics of defensive response activation by assessing
the autonomic arousal, brain stem reflex activity, and evoked
brain potentials in response to changes in threat proximity
and the presence of an escape route. In this instructed‐fear
experiment, the color of a frame signaled whether there was
a behavioral option to escape from the threat (a moderately
painful stimulus) or not (active vs. passive). At 500 ms after
frame onset, a symbol was presented in the frame that sig-
naled whether the threat would occur (safe vs. threat). This
cue increased in size in five stages as it approached the
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participant, signaling the decreasing distance of the threat. In
the safe condition, no aversive stimulus was delivered. Figure
4 shows the modulation of the startle response (upper panel)
when there was no escape route available (passive condition,
left) and when the individual had the option to actively avoid
the electrical stimulus by quickly pressing a response button
(active condition, right). The lower part of Figure 4 shows the
changes in heart rate during these conditions.
Animal studies that measured both freezing and poten-
tiated startle simultaneously during fear conditioning found
strong correlations between both measures (Fendt, 2001;
Gerwitz, Falls, & Davis, 1997; Leaton & Borszcz, 1985).
In accordance with the findings from these animal studies,
humans showed the same pattern of attentive freezing when
there was no possibility to actively avoid the aversive stim-
ulus. Startle potentiation increased linearly with increasing
proximity of the inevitable threat. In addition, heart rate de-
creased substantially starting at Stage 5 (i.e., immediately
prior to the delivery of the aversive stimulus). Thus, during
such a state of attentive immobility, the alerted individual re-
mains motionless, monitors the source of danger, and is very
responsive to abruptly occurring external stimuli (Marks,
1987). Interestingly, the level of skin conductance, which
is a measure of sympathetic activation, linearly increased
throughout the entire defense cascade, suggesting that both
counteracting branches of the autonomic nervous system
(the sympathetic and the parasympathetic nervous system)
are activated during defensive freezing. Individual differ-
ence factors, such as vagally mediated heart rate variability,
might influence the physiological response pattern evoked
during defensive freezing. Recent data from our laboratory
suggest that individuals with high heart rate variability seem
to be more flexible in adapting to environmental demands
than those with low heart rate variability (i.e., showing more
conditioned inhibition in an extinction paradigm; Wendt,
Neubert, Koenig, Thayer, & Hamm, 2015). Moreover, trans-
cutaneous stimulation of the auricular branch of the vagus
nerve has also been shown to increase flexible behavioral
adaption in a response conflict task (Fischer, Ventura‐Bort,
Hamm, & Weymar, 2018).
2.3 | Circa‐strike defense:
Initiation of action
A different pattern of defensive reactivity was observed
when an escape route was present and the individuals had the
option to actively avoid painful stimulation. A sharp increase
in skin conductance and a large acceleration in heart rate oc-
curred (see Figure 4, lower right). This autonomic pattern was
associated with the preparation of effective motor responses
that were systematically sped up in the behavioral context of
circa‐strike defense. Notably, a pronounced reversal of fear
potentiated startle became evident; a strong inhibition of the
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F I G U R E 4 Mean difference in response magnitudes between the passive threat and passive safe conditions (blue line: no behavioral option
to escape) across five different stages of increasing threat imminence in fear potential startle (upper left) and heart rate (lower left). Mean difference
in response magnitudes between active (escape was possible) and passive (no escape was possible) threat conditions in fear potentiated startle (red
line: upper right) and heart rate (red line: lower right). (Mean response magnitudes for all four conditions are depicted separately in the original
publication from Löw et al., 2015)

startle reflex occurred just before the preparation for an active
action (see Figure 4, upper right). Moreover, the P3 compo-
nent of the evoked potentials elicited by the invariant acous-
tic probe stimuli was also significantly reduced, suggesting
a shift in attention to the relevant foreground stimuli and a
simultaneous block in the processing of irrelevant stimuli in
the context of the action. Interestingly, animals show hypoal-
gesia during the activation of circa‐strike defense, which is
mediated by the dPAG (Fanselow, 1994).
3 | F U NC T IO NA L B R A IN
ACT IV IT Y D UR ING D E F E N SE
Detecting and responding effectively to various threats are
fundamental requirements of life. Thus, the neural networks
that organize defensive actions are part of the survival cir-
cuits of the brain (LeDoux, 2012). As described above, these
defense circuits feed signals back to the sensory systems,
increasing the gain to facilitate the detection of potentially
threatening and harmful stimuli. Increased activation during
this stage or preencounter defense was found in the primary
sensory areas as well as in the bed nucleus of the stria ter-
minalis, promoting hypervigilance to external stimuli (see
Cornwell et al., 2017; Rosen & Schulkin, 1998). The neural
circuits underlying postencounter defense have been exten-
sively explored in animal research using Pavlovian fear condi-
tioning as an experimental model. The conditioned stimulus,
which predicts the occurrence of a threat, activates neurons in
the lateral amygdala, which propagate neural activity to the
central nucleus of the amygdala (CeA). Efferents traveling
from the CeA to the ventrolateral part of the periaqueductal
gray (vlPAG) then interrupt ongoing behavior and promote
attentive freezing and potentiation of the startle reflex (Gross
& Canteras, 2012; for reviews, see Hamm, 2015a; Tovote et
al., 2015) as well as bradycardia (Bandler, Keasy, Floyd, &
Price, 2000). Human fear conditioning studies using fMRI
techniques found transient activation of the amygdala during
early phases of learning (see meta‐analysis by Sehlmeyer et
al., 2009). More recent meta‐analyses of fMRI data obtained
from human fear conditioning studies (Fullana et al., 2015)
suggest that conditioned stimuli activate a larger network, in-
cluding increases in activation of the anterior cingulate and
of the anterior insula. It is a hallmark finding in pain research
 |   

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8 of 14 HAMM

that the anticipation of pain (in fear conditioning studies, the
unconditioned stimulus is often a moderately painful stimu-
lus) is associated with the activation of the anterior insula
(Wiech et al., 2010). Moreover, decreased activation during
a conditioned stimulus is observed in the ventromedial pre-
frontal cortex (Lindner et al., 2015; Milad & Quirk, 2012).
The change from defensive freezing to an action during circa‐
strike defense (e.g., flight, fight, active avoidance) is medi-
ated by the dorsolateral section of the PAG (Fanselow, 1994;
Kim et al., 2013). Lesions of the dlPAG increase freezing in
rodents (DeOca, DeCola, Maren, & Fanselow, 1998), while
damage of the vlPAG disrupts freezing (Fanselow & Poulos,
2005), suggesting that attentive freezing might obstruct ac-
tive avoidance and vice versa (Benaroch, 2012). Guided by
these animal findings, Mobbs and coworkers investigated the
brain activation of humans as a function of threat proxim-
ity. In their fMRI study, they used an active avoidance video
game setting in which participants (represented by a triangle
on the screen that could be moved by the participants dur-
ing the “chasing” period) were pursued through a maze by
a virtual “predator” (represented by a red circle) endowed
with an ability to chase, capture, and inflict pain (cutaneous
electrical shocks). The findings of this study supported those
from animal studies and showed that the brain activity shifted
from prefrontal brain areas to the amygdala and the PAG
(Mobbs et al., 2007, 2009). In a recent study, we followed
up on this research by varying the proximity of the threat and
by varying the option to actively avoid the threat, using the
threat imminence paradigm developed by Löw and cowork-
ers (2015). The physiological data were in accordance with
our previous findings (see Wendt, Löw, Weymar, Lotze, &
Hamm, 2017). Analyses of the functional brain data revealed
increased activity in the ventromedial prefrontal cortex at the
beginning of the defense cascade (i.e., when the anticipated
threat was still distant). This prefrontal activation decreased
with increasing proximity of the upcoming threat. In contrast,
activation of the PAG increased with increasing proximity of
the threat, particularly when individuals had the option to ac-
tively avoid the threat, thus supporting the previous findings
of Mobbs and coworkers. The main findings of this study are
summarized in Figure 5, left panel, while the shift in activa-
tion from the prefrontal areas to the midbrain is illustrated
in a schematic model in Figure 5, right panel (adapted from
Maren, 2007).
Taken together, these recent imaging results not only sug-
gest that physiological changes associated with fear and anx-
iety are dynamically organized according to the proximity of
a potential threat and the available behavioral options but also
suggest that brain activations are distributed and shift from
the prefrontal areas to the midbrain when distal threats be-
come more proximal. The dynamic conceptualization of de-
fensive adaptions can render debates unnecessary on whether
cognitive or emotional processes are more important for
the understanding of psychopathology. In fact, the dynamic
model outlined above instead suggests that both processes
closely interact depending upon the imminence of the threat.
4 | AVOIDANCE BEHAVIOR
AS AN INDEX OF FUNCTIONAL
IM PAIRM ENT
The transdiagnostic dimensional model outlined above can
also be used to advance our understanding of the mechanisms

F I G U R E 5 (a) Prefrontal, amygdala, and periaqueductal gray activations as a function of threat imminence. Statistical parametric maps
illustrate brain areas in which activity decreased from Stage 1 to Stage 5 in threat conditions (green) and brain areas in which activity increased
from Stage 1 to Stage 5 with increasing threat imminence (purple; figure obtained from Wendt et al., 2017). (b) Schematic depiction of the brain
circuits activated during a distal threat, including the prefrontal cortex (PFC) and lateral amygdala (LA), and the circuits activated during a
proximal threat, including the central amygdala (CA) and the periaqueductal gray (adapted from Maren, 2007)

HAMM
involved in maladaptive avoidance behaviors. According to
the model, passive avoidance occurs very early in the defense
cascade, even before preencounter defense occurs (i.e., indi-
viduals avoid the context in which a potential threat might
occur). Clinically, avoidance is related to functional impair-
ment, the main criterion for defining mental disorders in ad-
dition to the distress criterion (Barlow, 2002; DSM5‐APA,
2013). There is evidence that such maladaptive passive avoid-
ance behavior is motivated by the effort to avoid uncertainty
or to maintain safety (Talkovsky & Norton, 2016) rather than
by elevated levels of fear or anxiety (see also early work by
Solomon, Kamin, & Wynne, 1953). In other words, patients
with a panic disorder and agoraphobia are not afraid of the
supermarket, but they avoid this context because they expect
an increased probability of being exposed to an interoceptive
threat (i.e., a panic attack) in this context. Supporting this
view, Craske, Rapee, and Barlow (1988) demonstrated in a
variety of tests that not the rated fear level but rather the per-
ceived probability of panicking in a specific situation was the
strongest predictor (r = .49) for active and passive avoidance.
Indeed, persistent avoidance prevents the disconfirmation of
central concerns about the increased risk of encountering a
potential threat. A recent study from our laboratory investi-
gating the development of stable passive avoidance over time
supports this view (see Benke, Krause, Hamm, & Pané‐Farré,
2018). In this study, individuals breathed through a tightly
fitting mask connected to a two‐way, Y‐shaped nonrebreath-
ing valve that enabled unrestrictive expiration through the
expiratory port of the valve. The inspiratory port of the valve
connected via a controller to different flow resistors that in-
creased the inspiratory resistance (for methodological details
of breathing circuit, see Benke, Hamm, & Pané‐Farré, 2017),
producing increasing feelings of dyspnea in three steps: slight
(inspiratory resistive Load 1), strong (Load 2), and maximally
tolerable unpleasant feelings of dyspnea (Load 3). Each step
lasted for 60 s. The sequence was terminated by a postex-
piratory breathing occlusion lasting 15 s. Important for the
current discussion, participants were provided with a button
that could be used to terminate each of the eight sequences
of increasing loads and the occlusion at any point in time to
avoid any additional feelings of dyspnea. Of the total number
of participants (N = 69), 35% (N = 24) repeatedly (more than
once) prematurely terminated the exposure to increasing lev-
els of dyspnea. In accordance with the findings from animal
studies (see Solomon, Kamin, & Wynne, 1953), individuals
ceased exposure to the increasing interoceptive threat at in-
creasingly lower threat levels and at increasingly shorter time
periods of exposure. Moreover, relative to a matched control
group who did not avoid exposure to the threat, these indi-
viduals showed initial avoidance behavior that was accom-
panied by a linear increase in autonomic arousal (increases
in heart rate and skin conductance) prior to termination. This
autonomic activation was completely absent during the last
|
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    9 of 14
termination of the exposure, showing that autonomic arousal
did not trigger repetitive passive avoidance. Reported anxiety
also linearly increased prior to the initial termination of the
exposure. In contrast to the physiological responses, reported
anxiety increased from the first to the last termination and
lasted for a longer duration before the actual time of termina-
tion (Benke et al., 2018). Moreover, high levels of anxiety
sensitivity and short durations of breath holding predicted
avoidance behavior. Thus, increased concerns about poten-
tially harmful body symptoms combined with a biobehavio-
ral indicator of the habitual avoidance of feelings of dyspnea
but not trait anxiety or reported fear of suffocation predicted
avoidance behavior in this task (Benke, Krause, Hamm, &
Pané‐Farré, 2019). These findings suggest that expectations
and concerns about the occurrence of a potential threat are
more important triggers of passive avoidance than is auto-
nomic arousal. Thus, exposure therapy aiming at a change in
persistent avoidance should probably focus more on experi-
ences that explicitly induce expectancy violations in order to
increase prediction errors promoting extinction learning than
on fear augmentation by increasing fear levels and autonomic
arousal in order to induce habituation processes (see Hamm
et al., 2016).
5 | TRANSLATION TO THE
CLINIC
This article introduced a transdiagnostic model of defensive
behaviors derived from animal research that might be use-
ful in better understanding the psychopathology of anxiety
disorders beyond the level of symptom reports. As a first
step, empirical evidence was provided supporting the view
that human defensive behaviors, similar to the defensive be-
haviors of other animals, are dynamically organized by the
proximity of the relevant threat and the available behavioral
options. It was also shown that the dynamic organization of
the processes of encoding threat‐relevant information and
organizing the behavioral adaptation, including the accom-
panying physiological changes, are regulated by distributed
neural networks in the brain, including prefrontal and mid-
brain circuits. In the last part of this address, I want to provide
some clinical data to illustrate how such psychophysiological
models might help in better understanding the psychopathol-
ogy of anxiety disorders. We tested defensive reactivity in
a subgroup of N = 345 (259 female) patients from a total
sample of N = 369 patients, all of whom were diagnosed
with a principal diagnosis of panic disorder with agorapho-
bia (PD/AG) and enrolled for a multicenter randomized
controlled clinical trial (for details, see Gloster et al., 2009,
2011). Because marked fear of entrapment and avoidance of
being in enclosed places is a prominent symptom in patients
with PD/AG (Arrindell, Cox, Van der Ende, & Kwee, 1995;
 |   
10 of 14
Rodriguez, Pagano, & Keller, 2007), we measured defensive
reactivity during anticipation (10 min) and exposure (maxi-
mum duration of 10 min) of a behavioral avoidance test (i.e.,
sitting in a small, 75‐cm wide, 120‐cm long, 190‐cm high,
dark, closed test chamber with the door locked from outside
by the experimenter; for details, see Richter et al., 2012).
Defensive reactivity differed substantially, although the same
principal diagnoses were assigned to all patients based on
their symptom reports. Thirty‐nine patients (11.3%) refused
to enter the chamber after anticipation, showing strong pas-
sive avoidance, 72 patients (20.9%) entered the test chamber
but terminated the exposure prematurely (active avoidance),
and the remaining patients completed the avoidance task. The
analysis of defensive reactivity of patients who showed ac-
tive avoidance revealed that heart rate and skin conductance
increased linearly during the last 60 s prior to escape, sup-
porting the hypothesis that strong increases in somatic symp-
toms were an imminent threat for these patients (for a more
detailed description of these data, see Richter et al., 2012).
Startle response magnitudes that were elevated during anx-
ious apprehension (i.e., when patients entered the test cham-
ber) were inhibited during the last seconds prior to escape.
This pattern of defensive responses was remarkably similar to
the response profile observed in the defense cascade study by
Löw and coworkers (2015), when individuals had the option
to actively avoid the imminent threat (see Figure 4, right).
These findings were replicated and extended in a more recent
study in which we used the same experimental approach de-
veloped by Löw et al. (2015) but included, in addition to the
threat of pain, a third condition of respiratory threat (Krause
et al., 2018). During respiratory threat, a different symbol
signaled the occurrence of a forced breath‐holding period
(by closing the inspiratory port; see Krause et al., 2018, for
more methodological details) set at the end of expiration of
the first breathing cycle after the most proximal cue. Again,
the color of the frame signaled whether an escape route was
available. Startle responses were again potentiated, and the
heart decreased just prior to both the inevitable exteroceptive
and inevitable interoceptive respiratory threats. However,
when individuals could actively avoid forced breath holding
or electrical shock by pressing a button, their heart rate ac-
celerated and blink magnitudes substantially decreased, sug-
gesting that the same circa‐strike defense is activated with
an imminent interoceptive threat when there is an option to
terminate the threat. However, a more clinically meaningful
finding is that this pattern of circa‐strike defense was also
observed during acute panic attacks. Twenty‐six patients re-
ported 34 panic attacks during exposure by pressing a “panic
button.” In line with the findings from an ambulatory moni-
toring study (Meuret et al., 2012), heart rate rapidly increased
approximately 20 s prior to the button press, suggesting that
this increase in autonomic arousal indeed triggered the panic
attack (see Hamm et al., 2016). In contrast, blink magnitudes
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HAMM
were inhibited during panic attacks relative to the blink mag-
nitudes elicited prior to the attacks. These data suggest that
acute panic attacks are instances of circa‐strike defense pos-
sibly triggered by the perception of imminent threat signals
arising from inside the body. Interestingly, the early reports
by Nashold, Wilson, and Slaughter (1974) show that electri-
cal stimulations of the PAG evoked acute panic attacks in
humans (see Schenberg et al., 2014, for review), supporting
the view that panic attacks might be instances of circa‐strike
defense modulated by the dlPAG (Goossens et al., 2014).
In contrast, a more proximal interoceptive threat evokes
a defensive response pattern that is observed during posten-
counter defense. The processing of cues that predict the
occurrence of mild body symptoms (evoked by a guided hy-
perventilation task; postencounter defense) is associated with
a potentiation of the startle response and a stronger activation
of prefrontal areas of the brain in individuals who are at risk
of developing a panic disorder (Holtz et al., 2012; Melzig
et al., 2011). In a recent study, we extended this research by
investigating a group of 58 treatment‐seeking patients diag-
nosed with a panic disorder (with and without agoraphobia).
In this study, patients completed a highly standardized hy-
perventilation task (patients were guided by tones of falling
and rising pitches to breathe at a rate of 20 cycles per minute)
for 3 min; the task was designed to reduce the level of CO2
in the expired air (petCO2) to 20 mm/Hg. During the follow-
ing 10‐min recovery period, the petCO2 returned to the level
prior to the hyperventilation task. During the first 3 min of
this recovery period, the petCO2 levels were still so low that
patients experienced a large number of mild body symp-
toms that resemble those experienced during a panic attack.
Delivering startle probes during this recovery period resulted
in a significant potentiation in the blink magnitudes in the
patient group, supporting the view that such mild symptoms
elicited postencounter defense in these patients (see Benke,
Alius, Hamm, & Pané‐Farré, 2019). In this study, 38 patients
received manual‐based cognitive behavior therapy (CBT),
while 20 patients were assigned to a wait list control group.
All patients completed the hyperventilation task again after
treatment and after the waiting period. Startle probes were
delivered during the recovery period. Patients of the wait list
control group showed the same potentiation of their startle re-
sponses during the experience of mild body symptoms in the
recovery period of the hyperventilation task, thus showing
persistent defensive response mobilization during a proximal
threat from inside the body. In contrast, no such defensive re-
sponse mobilization was observed in patients after CBT treat-
ment, particularly in those patients who showed a stable and
broad therapeutic response not only in self‐reported anxiety
but also in self‐reported depression and severity of symptoms
(e.g., Clinical Global Impression Scale), as rated by clinical
experts (Benke, Alius, et al., 2019). These data suggest that
a stable and broad treatment response is associated with a

HAMM
normalization of defensive responses to a proximal threat,
while persistent defensive response mobilization to such
threats is associated with persistent psychopathology, as
assessed by clinical symptom reports. Such results are en-
couraging because they provide evidence that psychophysi-
ological data might help in discriminating the conditions of
patients along a basic dimension (e.g., defensive response ac-
tivations to specific proximal and distal threats), relating this
information to psychopathology and categorical diagnoses
and predicting and assessing treatment responses in clinically
diagnosed patients.
ACKNOWLEDGMENTS
This research was continuously supported by grants from the
German Research Society (Ha 1593/6‐1,6‐2; 10‐1,10‐2; 15‐1;
18‐1; PA 2737/1‐1) and by the Federal Ministry of Education
and Research (BMBF; project no. 01GV0615). I would like
to thank all of the national and international collaborators
and all members of my research team in Greifswald without
whom this research would never have happened.
ORCID
Alfons O. Hamm https://orcid.org/0000-0002-3352-6231
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How to cite this article: Hamm AO. Fear, anxiety,
and their disorders from the perspective of
psychophysiology. Psychophysiology.
2020;57:e13474. https​://doi.org/10.1111/psyp.13474​