Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
Phase: NA
Conditions: Anxiety Disorders
Sponsor: National Institute of Mental Health (NIMH)

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
1
                          
Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
03-M-0093 October 4, 2021
Identifying Words: Anxiety disorders, generalized anxiety disorder, panic disorder, agoraphobia, 
fear conditioning, context conditioning, startle, psychophysiology
Monique Ernst, MD, Ph.D..:
Section on the Neurobiology of Fear and Anxiety 
National Institute of Mental Health
Building 15K, Rm 118
15K North Drive
Bethesda, MD 20892
Phone: 301-402-9355
E-mail: ernstm@mail.nih.gov
Total requested accrual: 1271
 Healthy volunteers:
663
 Patients
608
Sub-study 1:  110 patients     44 healthy volunteers
Sub-study 2:  115 patients     86 healthy volunteers
Sub-study 3:  38 patients       38 healthy volunteers
Sub-study 4:  30 patients
     30 healthy volunteers
Sub-study 5:  30 patients
     30 healthy volunteers
Sub-study 6: 30 patients
Sub-study 7: 40 patients  
40 healthy volunteers
Project uses ionizing radiation: 
no
IND/IDE:
no 
Durable power of attorney:
no
Multi-institutional project:
no
Data and Safety Monitoring Board:
no
Technology Transfer Agreement:
no

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
2
Samples are being stored:
yes
Flesch Kincaid reading level of consents
Control:
7.3
Cognition:  
8.4

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
3
PRECIS
High-generalized anxiety is a concomitant of many anxiety disorders and is often regarded as a 
vulnerability marker for these disorders (Barlow, 1988). One characteristic of patients with anxiety 
disorders and high trait-anxious individuals is inappropriate expectancies of aversive events. The 
overall aim of the present protocol is to investigate mechanisms that may promote the development 
of these aversive expectancies using expectancy-based, associative-learning models.
During aversive conditioning in which a phasic explicit-cue (e.g., a light) is repeatedly associated 
with an aversive unconditioned-stimulus (e.g., a shock), the organism develops fear to the explicit 
cue as well as to the environmental context in which the experiment took place. We have obtained 
preliminary evidence suggesting that contextual fear represents aspects of aversive states that are 
central to anxiety disorders (Grillon, Ameli, Goddard, Woods, & Davis, 1994; Grillon & Morgan, 
1999; Grillon, Morgan, Davis, & Southwick, 1998). In this protocol, we seek further evidence for 
the relevance of contextual fear to mood and anxiety disorders.
 
One important determinant of contextual fear in both humans and animals is predictability: 
contextual fear increases when aversive events (e.g., electric shock) are unpredictable, as opposed to 
when they are predictable. The present protocol will examine the role of predictability of aversive 
states and of conditioning on threat appraisal in individuals with mood and anxiety disorders. 
A second aim is to examine the interaction between experimentally-induced anxiety and cognitive 
processes, more specifically working memory, in mood and anxiety disorders. 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
4
Contents
PRECIS...........................................................................................................................................................3
1. INTRODUCTION......................................................................................................................................3
2. STUDY OBJECTIVES ..............................................................................................................................3
3. SUBJECTS .................................................................................................................................................3
4. STUDY DESIGN AND METHODS .........................................................................................................3
5. MANAGEMENT  OF DATA AND SAMPLES .......................................................................................3
6. ADDITIONAL CONSIDERATIONS........................................................................................................3
7. RISKS AND DISCOMFORTS ..................................................................................................................3
8. SUBJECT SAFETY MONITORING ........................................................................................................3
9. OUTCOME MEASURES ..........................................................................................................................3
10. STASTISTICAL ANALYSIS..................................................................................................................3
11. HUMAN SUBJECT PROTECTIONS.....................................................................................................3
12. ANTICIPATED BENEFIT ......................................................................................................................3
13. CLASSIFICATION OF RISK..................................................................................................................3
14. CONSENT DOCUMENTS AND PROCESS..........................................................................................3
15. DATA AND SAFETY MONITORING...................................................................................................3
16.  QUALITY ASSURANCE.......................................................................................................................3
17. ADVERSE EVENT AND UNANTICIPATED PROBLEM REPORTING ...........................................3
18. ALTERNATIVES TO PARTICIPATION...............................................................................................3
19. PRIVACY................................................................................................................................................3
20. CONFIDENTIALITY ..............................................................................................................................3
21. CONFLICT OF INTEREST/ TECHNOLOGY TRANSFER..................................................................3
23. RESEARCH AND TRAVEL COMPENSATION...................................................................................3
24.  REFERENCES ........................................................................................................................................3

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
5
LIST OF ABBREVIATIONS:
N:  Neutral
P:  Predictable aversive event
U: Unpredictable aversive event
WM: Working memory
US:   Unconditioned stimulus
GAD:    Generalized anxiety disorder
SAD:    Social anxiety disorder
MDD:  Major depressive disorder
BP:       Bipolar disorder
SCID:   Structured Clinical Interview for DSM-IV
DSM:    Diagnostic and Statistical Manual of Mental Disorders

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
6
1. INTRODUCTION
Fear and anxiety are normal adaptive responses to threat. Anxiety is considered pathological when it is 
either excessive or inappropriate to the context. Thus, pathological anxiety could result from overactive 
structures involved in responses to threat, abnormal relational learning (conditioning), or from inefficient 
affective information processing that prevents an organism from effectively implementing goal-directed 
behaviors. The present protocol builds on our past results to study the impact of induced anxiety (e.g., 
during anticipation of shock) on physiological and subjective measures on fear and anxiety and on task 
performance in patients with mood and anxiety disorders.  
1- Past studies
One past objective was to better understand aversive conditioning processes in anxiety disorders.  We 
have reported 1) increased stimulus generalization in panic disorder (Lissek, et al., 2010), 2) relational 
learning deficits in panic disorder (Grillon, Lissek, Pine, McDowell, & Levenson, 2007), and 3) 
heightened conditioning with socially relevant stimuli in social anxiety disorder (Lissek, et al., 2008).
Another objective was to study the processes that separate fear and anxiety. While fear is a phasic 
response associated with an identifiable source that is thought to predict occurrence of an aversive 
stimulus, anxiety is a more persistent feeling of apprehensive anticipation of future danger (Barlow, 
1988). We have demonstrated that the characteristics of these two forms of aversive responses – cued fear 
and generalized anxiety - could be modeled by administering predictable and unpredictable aversive 
events (shocks), respectively (Grillon, 2002; Grillon & Davis, 1997). Fear is operationally defined as an 
increase in startle amplitude during a threat cue that predicts an aversive event (fear-potentiated startle). 
Anxiety is operationally defined as an increased in startle amplitude during long periods of unpredictable 
aversive events (anxiety-potentiated startle). One of the past objectives of this protocol was to examine 
far-potentiated startle and anxiety-potentiated startle in anxiety disorders. We have found that patients 
with panic disorder and PTSD, but not generalized anxiety disorder (GAD), showed elevated anxiety-
potentiated startle (Grillon, et al., 2008; Grillon, et al., 2009). Given that the underlying neural mediators 
of fear and anxiety are partially distinct (amygdala versus bed nucleus of the stria terminalis) (Davis, 
Walker, Miles, & Grillon, 2010), these results provide clues to potential pathophysiological mechanisms 
and targets for treatment.  
2- Current studies
We are currently pursuing this line of research to address new questions. As indicated above we found 
increased anxiety-potentiated startle in PTSD and panic disorder but not GAD. Failure to obtain increased 
anxiety-potentiated startle in GAD may have been due to the use of mildly aversive stimuli (e.g., 
airblasts). We are currently examining whether more potent aversive stimuli such as shocks will lead to 
elevated anxiety-potentiated startle in GAD. We are also examining the specificity of the heightened 
anxiety-potentiated startle in patients with various types of anxiety disorders (e.g., social anxiety 
disorder). We are also testing patients with major depression (MDD) and bipolar disorder (BP) of 
contradictory finding regarding fear-potentiated startle and more generally emotional responses to 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
7
aversive stimuli in MDD. While MDD has been associated with a blunting of emotional responses not 
only to positive stimuli but also to negative stimuli, and reduced fear-potentiated startle in studies that use 
mildly evocative emotional stimuli (McTeague, et al., 2009) we have reported that depressive mood 
increased anxiety-potentiated startle (Robinson, Overstreet, Letkiewicz, & Grillon in press) during shock 
threat. This protocol will clarify whether MDD is associated with emotional blunting or with increased 
fear and/or anxiety.
Anxiety and Cognition
Our past research has mainly focused on response expression. Our new objective is to examine the 
interaction between induced anxiety, goal-directed behaviors, and emotional pathology.  Anxiety can be 
adaptive, but it can be debilitating when it interferes with our daily life and our goals. High levels of 
anxiety have been associated with poor performance and processing inefficiencies on cognitive tasks 
(Eysenck & Calvo, 1992) suggesting that cognitive changes may be a key component of clinical anxiety. 
Yerkes and Dodson proposed that the detriment in performance due to high emotional arousal (e.g., 
anxiety) can described by a U-shaped function, where performance increases as arousal increases to an 
optimal level and then as arousal levels continue to increase, performance begins to decrease (Yerkes & 
Dodson, 1908). In support of this proposal, high trait anxious individuals (i.e., those with an above-
optimal level of emotional arousal) have been shown to experience disruption in executive processes 
(Eysenck & Calvo, 1992) and in the ability to perform at work, which can lead to career dissatisfaction 
and job loss. However, the mechanisms by which performance is affected (e.g., attentional narrowing, 
executive processing deficiencies, perceptual focus), and the degree to which performance is reliably 
hindered or facilitated by anxiety is not clear. The current study will allow us to address this gap in our 
knowledge. Inarguably, understanding the link between emotion and cognition in patient groups with 
emotional pathology is of particular importance to the development of successful therapeutic 
interventions.
We will focus on the interaction between anxiety and working memory (WM). WM is the ability to 
maintain relevant information in mind and to keep irrelevant information out of mind. As such, WM will 
enable us to examine two of the main symptoms of anxiety, inability to focus and increased distractibility. 
Anxiety may be especially detrimental to WM by decreasing one’s ability to keep irrelevant anxious 
thoughts out of mind, hence compromising efficient information processing. It has been suggested that 
high-load cognitive tasks may be more susceptible to anxiety-related disruption (Eysenck, Derakshan, 
Santos, & Calvo, 2007). This proposal, known as the processing efficiency theory (Eysenck & Calvo, 
1992), is based on the claim that the deleterious effects of anxiety on cognition are greatest when task 
demands are high because the executive processing resources that subserve working memory are also 
engaged by worrisome thoughts.  In contrast to Eysenck et al., (2007)’s cognitive theory, Bishop has 
argued that anxiety has a greater impact on perceptual tasks that place a lower demand on processing 
resources, while tasks that place a higher demand on resources reduce the deleterious impact of anxiety 
(Bishop, 2008). In order to lend clarity to these competing views, we will investigate the extent to which 
induced-anxiety interferes with WM as memory load increases (using n-back and digit span tasks 
described below). Further, we will investigate the impact of anxiety on spatial versus verbal WM, using a 
verbal and spatial n-back task and the Corsi test (another visuospatial test of WM). Previous research 
suggests that spatial WM tasks may be more susceptible to anxiety-related disruption when anxiety is 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
8
induced in healthy subjects (Shackman et al. 2006; Vytal et al., 2013). However, it is unclear whether or 
not pathological anxiety results in a similar pattern of disruption. By addressing this question, we will be 
better informed about the nature of anxiety-related disruption and be closer to delineating the mechanisms 
of such disruption.
While the detrimental effect of anxiety on cognition is well-known, less is known about how task 
performance affects anxiety. However, it is clear that being engaged in a WM task is an effective way of 
reducing anxiety. One of the aims of this protocol will be to examine whether patients with mood and 
anxiety disorders can similarly use WM engagement to reduce anxiety.
In contrast to WM where anxiety appears to be only detrimental, there is evidence to suggest that the 
anxiety can both impair and facilitate performance on sustained attention tasks (e.g., Go-NoGo task). It is 
unknown whether anxiety acts a distractor, impairing response inhibition to infrequent “NoGo” trials 
(resulting in commission errors), or whether anxiety improves the ability to withhold these prepotent 
responses. Some research suggests that commission errors are the result of “mind wandering” (Smallwood 
et al., 2004), which may be increased when subjects are anxious. Other research suggests that anxiety can 
increase inhibition of motor responses (prepulse inhibition; Grillon and Davis, 2007), which would lead to 
better performance when subjects are anxious. Here we hope to clarify whether or not pathological anxiety 
impairs or facilitates performance on non-emotional sustained attention tasks. 
2. STUDY OBJECTIVES
a.
Objective 1: To examine fear-potentiated startle and anxiety-potentiated startle in mood and 
anxiety disorders. To what extent does heightened anxiety-potentiated startle cut across distinct 
anxiety disorders? Are fear-potentiated startle and anxiety-potentiated startle also elevated in mood 
disorders? 
b. Objective 2: To examine the interaction between induced-anxiety and WM as cognitive load 
increases. Does anxiety affect WM performance and is this effect dependent on cognitive load?  
Can patients with mood or anxiety disorder reduce their anxiety by being engaged in a WM task?
3. SUBJECTS 
a.
Description of Study Populations

Participants will be 18 to 50 years old and will be diagnosed with one of the following: 
generalized anxiety disorder, panic disorder, SAD, specific phobias, major depression, and 
bipolar depression according to DSM-IV. Patients on scheduled/regular psychotropic 
medications, other than lithium or Depakote, will stay on their medication. Although patients 
will not be taken off medications for the purposes of this study, included patients will not be 
currently taking psychiatric medications or any other medications that may interfere with 
study results (see exclusion criteria for other characteristics of patient sample). The only 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
9
exception is that bipolar depressed patients may be taking mood stabilizers, either lithium 
carbonate or Depakote. Subjects taking PRN medication that is allowed according to the 
medication table below, must be both willing and safely able to hold the medication for 5 
half-lives. Additionally, healthy controls who are age and sex matched to patients will be 
studied.

The accrual ceiling is 608 patients with mood or anxiety disorders and 663 healthy volunteers. 
This accrual ceiling includes a drop out/withdrawal/non-analyzable data rate of 15% for sub-
studies 1 (11 patients, 44 controls) and 2 (115 patients, 86 controls) and 25% for sub-study 3 
(38 patients, 38 controls). 

NIH, but not NIMH, employees may participate. NIH employee participation is guided by 
intramural institute policy.
b. Inclusion criteria for both patients and healthy controls

All subjects must be able to give written informed consent prior to participation in this study.

PATIENTS ONLY: May have DSM-IV-TR diagnoses of an anxiety disorder (GAD; SAD; 
Panic disorder; specific phobia) or mood disorder (MDD; BP).  

PATIENTS ONLY:  May be taking the mood stabilizers, Depakote or Lithium Carbonate.  

Speaks English fluently 

c.
Exclusion criteria for healthy subjects 

Female subjects who are currently pregnant

Subjects who meet DSM-IV criteria for current alcohol or substance abuse

Subjects with a history of alcohol or substance dependence within 6 months prior to screening

Current Axis I psychiatric disorders as identified with the Structured Clinical Interview for 
DSM-IV-TR axis disorders, non-patient edition (SCID-np). Past history of any psychotic 
disorder or bipolar disorder.

IQ < 80

Medical illnesses (such as diabetes or hypertension) or neurological illnesses (such as carpal 
tunnel syndrome for shocks to be delivered on affected arm; organic brain impairment; seizure 
disorder) likely to interfere with the study. 

Subjects who are on a medication that may interfere with the study (see Table below).

Employee of NIMH or an immediate family member who is a NIMH employee.
d. Exclusion criteria for patients

Patients who would be unable to comply with study procedures or assessments;

Female patients who are currently pregnant;

Patients who meet DSM-IV criteria for current alcohol or substance abuse

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
10

 Subjects with a history of alcohol or substance dependence within 6 months prior to screening;

Patients who are on a medication (other than mood stabilizers lithium carbonate or Depakote) 
that may interfere with the study (see Table below).

Medical illnesses (such as diabetes or hypertension) or neurological illnesses (such as carpal 
tunnel syndrome; organic brain impairment; seizure disorder) likely to interfere with the study. 

Patients will be excluded if they have a current or past history of, delirium, dementia, amnestic 
disorder, any of the pervasive developmental disorders; or cognitive impairment. 

Current Axis I psychiatric disorders as identified with the Structured Clinical Interview for 
DSM-IV-TR axis disorders, non-patient edition (SCID) with the exception of the mood and 
anxiety disorders.  Past history of any psychotic disorder or bipolar disorder.

IQ < 80

Employee of NIMH or an immediate family member who is a NIMH employee.
e.
Additional exclusion criteria for the active avoidance task

Color blindness
Table of drug exclusions for both healthy volunteers and patient volunteers (Y=acceptable; N=exclusion).  
Excluded medications are those that are known to cross the blood brain barrier and/or affect physiological 
responses (ex: beta blockers like Inderal, antihistamines like Benadryl or systemic corticosteroids like 
cortisone). 
Drug Class
Episodic Use
(p.r.n.)
Chronic Use
Restrictions
Analgesics
Y
N
Non-narcotic analgesics only Ex. Advil (Ibuprofen), 
Tylenol (Acetaminophen) 
Antacids
Y
Y
 e.g.., Zantac (Ranitidine) except episodic (p.r.n.) use, is
acceptable if subject has not taken medication for 5 
half-lives prior to study  
Antianginal Agents
N
N
  
Antiarrhythmics
N
N
 
Antiasthma Agents
Y
Y
Systemic corticosteroids are not allowed e.g., Cortisone
Antibiotics
Y
N
 
Anticonvulsants
N
Y
 For bipolar subjects – only Depakote or lithium 
permitted
Systemic Antifungal 
Agents
N
N
Acceptable for episodic (p.r.n.) use if subject has not 
taken the medication for 5 half-lives prior to sudy visit 
Antihypertensive 
N
Y
Except for Beta-Blockers, e.g., Inderall (Propranolol) or 
Lopressor/Toprol  (metoprolol)

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
11
Antihistamines 
-Sedating
Y
N
 Sedating: e.g., Benadryl (Diphenhydramine), 
Sudafed PE (diphenhydramine), Alka-Setzer and 
Aller-Chor (chlorpheniramine) as long as the 
subject has not taken in the last 5 half-lives prior to 
the study visit
Antihyperlipidimics
N
Y
 e.g., Zocor (simvastatin, )
Anti-inflammatory 
Drugs
Y
Y
Systematic corticosteroids are NOT allowed, e.g.,  
Cortisone 
Antivirals
N
N
  Except for treatment of HSV with agents without CNS 
activity e.g., Zovirax (acyclovir), 
Cytovene(ganciclovir), Famvir (famciclovir), Valtrex 
(valacyclovir)
Cough/Cold 
Preparations
Y
N
Non-sedating antihistamines are allowed (e.g.Zyrtec-
D (cetirizine), Claritin-D or Alavert-D (loratadine) 
and Allegra (fexofenadine)
Dextromethorphan preps N/N
Guanfacine Y/Y
Pseudoephedrine N/N 
e.g., Nyquil, Dayquil or Mucinex preparations, that 
include sedating antihistamines, are acceptable if 
subject has not taken the medication for 5 half-lives 
prior to study visit 
Hormones
N
Y
Only thyroid hormone replacement, oral 
contraceptives, and estrogen replacement therapy are 
allowed.
Muscle Relaxants
N
N
 e.g., Flexeril (Cyclobenzaprine)
Psychotropic 
Medication 
Y
N
Acceptable for episodic (p.r.n.) use if subject has 
not taken the medication for 5 half-lives prior to 
study visit. 
4. STUDY DESIGN AND METHODS
a. Study Overview 

Sub-study 1 examines fear-potentiated startle and anxiety-potentiated startle in individuals 
with mood and anxiety disorders. It requires a single testing session lasting up to 4 hours.

Sub-study 2 examines the interactions between anxiety and working memory in mood and 
anxiety disorders. It requires a single testing session lasting up to 4 hours.

Sub-study 3 will examine the effect of CBT on emotional reactivity and on the ability to focus 
on task-demand during threat. This study is restricted to patients with anxiety disorders and 
will not include patients with mood disorder.  We do not include mood disorder patients 
because 1) we do not run CBT treatment for mood disorders and 2) individuals with mood 
disorders are recruited for treatment studies by Dr. Zarate’s group. The study will require an 
initial pre-treatment testing phase requiring 1 or 2 visits lasting up to 4 hours each, an 8-session 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
12
CBT, and a post-treatment testing phase requiring 1 or 2 visits lasting up to 4 hours each. This 
study is stopped. 

Sub-study 4 examines the effects of threat on cognitive processes through the use of an 
emotion recognition task. It requires a single testing session lasting up to 2 hours. 

Sub-study 5 examines emotional attention conflict using a modified Stroop task under threat 
and safe conditions. It requires a single testing session lasting up to 2 hours.

Sub-study 6 examines the influence of acute physical exercise on the interaction between 
anxiety and cognition. It requires 3 outpatient sessions lasting up to 5 hours each. This study is 
stopped. 

Sub-study 7 examines whether threat impacts the initiation and inhibition of behavioral 
responses. It requires a single outpatient testing session lasting up to 3 hours. 

All the studies will be conducted in one of Dr. Ernst’s laboratories.

All subjects will be screened face to face under the Screening Protocol 01-M-0254. A series of 
clinical assessments and treatment services (as delineated in Sections H and I) have been 
implemented for patients with an anxiety and mood disorder. 

Following study completion, patients will receive psychiatric treatment within the adult anxiety 
treatment team for a 1-2 month period before being referred to long-term psychiatric care 
outside of NIH in the DC Metro area.
b. Recruitment 

Healthy subjects and individuals with either high trait anxiety or an anxiety disorder or major 
depression will be recruited. 

Healthy subjects (will be recruited through the lists from NIH office of Public Relations and 
Public Liaison (PRPL). Individuals with either high trait anxiety or an anxiety disorder or 
major depression will be recruited through mechanisms developed by PRPL. 

Patients with anxiety disorders are recruited directly into this protocol. .

Mechanisms include advertisements placed through university newspapers, the city paper, and 
local gazettes, Web Links, and public service announcements, and advertisements in 
Montgomery County and DC Metro buses.  These advertisements are or will be approved by 
the IRB prior to use. The written advertisements will be used in color as submitted, or may be 
printed in black and white.  The color of the ads may vary. Color changes will not be used to 
change the emphasis of an ad. The size of the ads may vary, but all parts of the ads, including 
fonts and pictures, will be changed proportionately to the rest of that ad.  Disproportionate 
changes in size will not be used to change the emphasis of an ad.  Recruitment methods for 
healthy subjects and patients will include advertisements placed in university newspapers, city 
newspapers or magazines, local gazettes, web links, listservs, public service announcements, 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
13
Instagram, and posting of flyers in local eateries or small businesses or sites such as public 
libraries. IRB-approved Tabletop tent cards will be displayed on tables in public areas such as 
the NIH cafeterias, with the approval of the venue owner/manager. Moreover, recruitment 
efforts will include advertisements in Montgomery County buses. We also will utilize websites, 
such as college papers and local media.  The web ads will direct readers to the NIH Patient Info 
website.  We also will advertise on approved listservs as provided by Public Relations and Public 
Liaison office.  One such site will be the Club PCR site used by the research assistants at NIH. 
Notecards and/or flyers may be posted in places such as grocery stores, coffee shops. community 
centers, and bookstores, or placed in advocacy group offices, in doctor’s office waiting rooms, libraries, 
and retail establishments with approval of the venue or in accord with their policy.  They may be made 
available at outreach exhibits, speaking engagements, and professional meetings with approval of the 
venue or in accord with their policy.  They may be given directly to those requesting study information. 
Postcards may be sent using commercially-available mailing lists via direct mail. The postcards will 
identify the source of the mailing list. ResearchMatch may be used to recruit participants for this 
protocol.   Ads may be placed on the CC Twitter, Facebook pages, and newsletters. IRB approved ads 
may be place on website such as advocacy groups, university student sites, and newspaper sites.  In 
addition ads will be place on Craigslist under the “Volunteer” category.  The email address will be 
hidden from public view to prevent spam. Mood disorder patients are not directly recruited for this 
protocol; rather; these patients will be referred by Carlos Zarate’s group (NIMH).  Patients 
from Dr. Zarate’s group will already have been cleared under the screening protocol (01-M-
0254).   A physician in Dr. Zarate’s group will approach subjects who meet criteria for this 
protocol and give them information about the study.  If they choose to participate, we will 
follow with the consent process.  Consenting practice will comply with the NIH Clinical 
Center MAS Policy pertaining to consent of non-English speaking speakers.  Additionally, 
study information will be distributed to local chapters of such self-help organizations as 
Anxiety Disorders Association of America, Freedom from Fear, and the National Alliance for 
the Mentally Ill. Last, speakers from Drs. Zarate or Pine groups may distribute flyers at venues 
where they have discussed NIH research protocols.  All such advertisements and flyers have 
been submitted to the IRB and received IRB approval. Any new advertisements or changes to 
existing advertisements will be submitted to the IRB for approval prior to publication. 

Healthy volunteers may also be identified or screened through the NIMH protocol #17-M-0181 
titled “Recruitment and Characterization of Research Volunteers for NIMH Intramural 
Studies.”

Audio advertisements will be played during radio or podcasts, Potential radio stations may be 
public radio (i.e., WAMU) or other mainstream radio stations (i.e., 97.1 Fresh FM). Potential 
podcasts may be ones like Ted Radio Hour, Moth, Criminal, Diane Rehm, etc. 

An animated short video advertisement may also be posted on the NIMH YouTube channel. 
This video may be posted on official NIH, NIMH, and NIH Clinical Center social media 
accounts such as Facebook, Instagram, and Twitter.  It may be sent via sent via electronic 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
14
listservs such as NIH postbac listserv, community listservs, advocacy and provider listservs, 
and running/ health listservs.

We may use paid advertising on social media sites, such as Facebook, Instagram, and Twitter, 
to recruit potential volunteers whom are within our age range and located near the NIH (within 
50 miles). We will not use behavioral targeting for any advertising campaign. We will target 
all potential volunteers within that age range (18-50 years old) and location (within 50 miles) 
and will not specifically target anxiety volunteers.  We will only use advertisements and videos 
that have been previously IRB approved. Accounts used for Twitter, Facebook, and Instagram 
are the NIH sponsored accounts. 

Potential subjects will undergo an initial pre-screening by phone. (See Appendix A) This is 
done prior to consent procedures to determine potential eligibility.  During the phone screen, 
the following will be described: a) purpose and goals of the study, b) the experimental 
procedures involved, c) the time commitment required, d) compensation, and e) 
inclusion/exclusion criteria. It will be emphasized to participants that unpleasant shocks and air 
puffs will be administered during the course of the study. If individuals are interested in 
participating in the study they will be given an appointment to come to NIH for a first visit. In 
addition to receiving information via telephone, potential participants will receive complete 
information about this study by mail including actual copies of the consent form. 

Mood Disorder Patients will be referred by Carlos Zarate’s group (NIMH/).  We will be 
recruiting patients from Dr. Zarate’s group, who already have been cleared under the screening 
protocol (01-M-0254).   
o
A physician in Dr. Zarate’s group will approach subjects who meet criteria for protocol 
03-M-0093 and give them information about the study so that they may decide whether 
or not to participate.
o
Study information will also be distributed to local chapters of the Anxiety Disorders 
Association of America, Freedom from Fear, and the National Alliance for the 
Mentally Ill. All such advertisements have been submitted to the IRB by Susanna Sung 
and recently received IRB approval. Any new advertisements or changes to existing 
advertisements will be submitted to the IRB for approval prior to publication.

NIH Employees, staff and family members will not be directly recruited by or through their 
supervisors or coworkers to participate in this study.
c.
Screening

Upon arrival for their face to face screening visit, participants will have the opportunity to fully 
review the 0093 protocol consent form and to ask questions. If they express interest in 
participating in the study, they will then be screened under the MAP Screening Protocol 01-M-
0254 with the following measures to evaluate if they are indeed eligible for the study: 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
15
o
Pregnancy test (urine test) for women of child bearing age 
o
Urine drug screen (amphetamines, benzodiazepines, cocaine/metabolites, opiates, 
morphine, codeine, THC)
o
Wechsler Abbreviated Scale of Intelligence (WASI) (Weschler, 1999)
o
Subject demographic information
o
Vital signs (sitting blood pressure and pulse), height, weight
o
Medical history and physical examination
o
Structured Clinical Interview for DSM-IV  (patients only)
o
Structured Clinical Interview for DSM-IV-TR  non-patients edition (non-patients only)
o
Concomitant medication and pharmacotherapy history
o
Inclusion/exclusion criteria

Following the medical and psychiatric screening assessment under protocol 01-M-0254,  
English-speaking participants will be asked to fill out the following questionnaires:
o
State-Trait Anxiety Inventory (STAI) (Spielberger, 1983) 
o
NEO-Personality Inventory (Costa & McCrae, 1992)
o
Anxiety Sensitivity Index (Peterson & Reiss, 1992) 
o
Beck Anxiety Inventory (Beck & Steer, 1987)
o
Beck Depression Inventory (BDI) (Beck & Steer, 1987)
o
Fear Questionnaire (Marks & Mathews, 1979)
o
Penn State Worry Questionnaire (Meyer, Miller, Metzger, & Borkovec, 1990)
o
Positive and Negative Affectivity Scale PANAS (Watson, Clark, & Tellegen, 1988)

Mood and anxiety disorders are associated with deficits in attention control. As an exploratory 
aim, we will examine whether measures of memory and sustained attention relate to any 
experimental measures. English-speaking participants will be tested on the following cognitive 
tests:

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
16
o
Digit Span: In this test of memory capacity, subjects are presented with a series of 
digits (e.g., 2, 4, 9, 7) and must repeat them back;
o
Corsi test: In this visuo-spatial short-term memory test, subjects are shown 9 blocks on 
a monitor. The subjects observe a sequence of blocks that lit up. Their task is to repeat 
the sequence. The task begins with a small number of blocks and then gradually 
involves more blocks; 
o
Go-NoGo Task; in this test of sustained attention and impulsivity, subjects are shown 
different letters one at a time. They have to press a button to each letter except 
infrequent x. 

Some participants may have participated in the NIMH healthy volunteer protocol #17-M-
0181.  For those participants, identifiable data may be shared between protocols 17-M-0181, 
01-M-0254 and this protocol 03-M-0093.  The information from 17-M-0181 may be used for 
screening for this protocol as long as: it has been within a year for the demographic 
information, medical history and physical examination, SCID, WASI, and questionnaires. The 
urine pregnancy and drug screen will need to be within two weeks. The urine pregnancy is also 
repeated prior to any study procedures on the study visit day under this protocol. 

Additional laboratory examinations (i.e. blood testing or EKG) may be completed if clinically 
indicated and if consent is obtained for those procedures. 

If the screening protocol (01-M-0254) finds them to be eligible, they will undergo the informed 
consent process for 03-M-0093.  

Following informed consent of the 03-M-0093 protocol, participants will complete the studies 
described below. Female participants will first have a urine pregnancy test.  At the completion 
of each visit, patients will be clinically assessed for adverse reactions to experimental 
procedures and psychiatric intervention will follow when clinically indicated.

Patients with an anxiety disorder will undergo an initial psychiatric evaluation with Dr. Ernst 
as well as an additional structured clinical interview with a credentialed staff clinician to assess 
the patient’s suitability for the study as a part of the screening protocol (01-M-0254),  The staff 
clinician will have clinical experience with either inpatient or outpatient psychiatric 
populations. All clinical work with anxiety patients will be supervised by Dr. Ernst.   
 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
17
d. Study Procedures
Prior to the study visit, the study clinician will review the subject medication list. If the subject takes a 
PRN medication (such as Claritin PRN for seasonal allergies) the clinician will assess how often the 
subject takes the PRN medication and determine the half-life of the medication. Study visits will be 
planned when the subject is not taking the PRN medication on a regular basis. The clinician will notify 
subject when study visit is planned and how long medication needs to be held prior to the study visit. If the 
subject needs to take the PRN medication such that 5 half-lives cannot pass before the study visit then the 
study visit will be rescheduled.

Sub-study 1: fear-potentiated startle and anxiety-potentiated startle: Sub-study 1 will test 
110 patients and 44 healthy controls (See 10. STATISTICAL ANALYSIS). This experiment 
examines fear and anxiety responses during anticipation of predictable and unpredictable 
aversive events (shocks or airpuffs). There are three different conditions, neutral (N), 
unpredictable aversive events (U), and predictable aversive events (P). Each of these 
conditions will be signaled by a written text displayed on a computer monitor (e.g., shock only 
when blue square present). In each condition, an additional cue (e.g., blue square) will be 
presented.  The cues will be different for P, N, and U. They will be meaningless in the U and N 
conditions. However, in the P condition they will signal a possible shock/airpuff. The cues will 
be presented for 8 sec. The N, P, and U conditions will last approximately 2 minutes each. The 
cues will be presented twice per condition. These conditions will be presented in two blocks 
with the following predetermined orders: 1) P-N-U-N-U-N-P (FPS1) and 2) U-N-P-N-P-N-U 
(FPS2). The two blocks will be counterbalanced across subjects. In the P condition, 25-35% of 
the cues will be reinforced with an aversive event. Variation in fear and anxiety will be 
evaluated with the startle reflex evoked by loud sounds (see below). 
o
Saliva: Up to 10 saliva samples per subject may be obtained to measure levels of 
cortisol and DHEA-S. Samples will be collected just after screening during study visit 
1, after baseline heart-rate assessments during study visits 1 and 2, before and after the 
verbal-threat task of study visit 1, before and after the aversive-conditioning procedure 
and before and after the retention of aversive-conditioning procedure of study visit 2. 
Although cortisol samples would ideally be collected at the same time of day for all 
subjects, doing so would significantly slow data collection. Because cortisol analyses 
are of secondary importance to the current protocol and because time of collection can 
be statistically controlled during analyses, saliva will be collected during morning or 
afternoon visits, the time at which the samples are collected will be documented, and 
the variance associated with time of day will be covaried out of cortisol analyses. Of 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
18
note, each participant will be scheduled consistently in morning or afternoon time-slots 
to reduce the within-subject variability in the time saliva samples are collected. 
o
Startle response: The startle reflex will be elicited with a 102 dB white noise (40-ms 
duration) delivered via headphone. The eyeblink component of the startle reflex will be 
recorded binaurally with two AgCl electrodes placed under each eye. Eyeblink 
responses will be scored in the 20-100 ms window following the onset of the startle 
stimulus.
o
Autonomic measures: Heart rate, pulse, skin conductance activity (responses and 
spontaneous fluctuation), and respiration rate will be recorded during testing to evaluate 
changes in autonomic arousal. The heart rate will be monitored with two disposable 
electrodes, one on each wrist. A computer algorithm will detect the R-wave in each 
cardiac cycle and will calculate the number of whole and fractional heart beats for 500 
ms periods in each condition. The skin conductance will be measured using two (Ag-
AgCl) electrodes in conjunction with a .05M NaCl electrolyte. Electrodes will be 
placed on the distal phalange of the index and second finger of the left hand. 
o
Unconditioned stimulus (US): The US will be an electric shock or a strong jet of air 
directed to the throat (airpuff). We have shown that anticipation of these stimuli 
produces a robust and reliable potentiation of startle. We have decided not to use a US 
of shock for the verbal-threat task in order to limit the number of shocks given to 
participants during the course of this study. 
o
Electric shock: Electric shocks are among the most efficient ways to induce anxiety in 
the laboratory. The shocks will be delivered through two disk electrodes placed on one 
of the forearms, wrists, or hands. The shock will have intensity up to 4.0 mA and 
duration up to 500 ms. The PI has used shocks in various experiments in over 600 
subjects in the last 10 years at Yale University. The shock is generally described by 
subjects as rather anxiogenic and unpleasant. The mean rating of aversiveness on a 
scale of 1 (not at all painful) to 10 (extremely painful) is about 5. Subjects will be given 
sample shocks before shocks are used in experimental procedures to give participants 
the opportunity to avoid experimental tasks involving electric shocks if they wish. Our 
experience is that over 95% of subjects who received the shock chose to participate in 
the experiment. The Yale IRB committee has not received any complaints resulting 
from these experiments. 
Jet of air: The system that produces the jet of air consists of a compressed air cylinder, 
a regulator, a solenoid valve controlled by an AC switch, and 4-mm internal diameter 
polyethylene tubing. The jet of air will have duration up to 200 ms and intensity up to 
80 psi (measured at the level of the regulator). The tubing will be fixed on the subjects’ 
neck via a special collar. It will be directed to the throat at the level of the larynx. 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
19

Sub-study 2: Interaction between anxiety and working memory: Sub-study 2 will test 115 
patients and 46 healthy controls. We will also need approximately 40 healthy controls to pilot 
various versions of the tasks for a total of 86 controls.  (See 10. STATISTICAL ANALYSIS).  
These subjects will perform memory tasks under one of two anxiogenic conditions: 1) shock 
threat and 2) a social stressor (either a speech stressor or social observation). The speech 
stressor will serve as a more ecologically-valid stressor than the shock threat.
o
Memory tasks: Subjects will be asked to remember verbal and nonverbal stimuli. These 
stimuli consist of words, pictures, letters or spatial locations in series of stimuli. 
Participants will be instructed to remember one, two, or three stimuli back from the current 
stimulus on the screen (n-back task). They will also be asked to remember lists of these 
stimuli after a short delay. 
o
Shock threat experiment: This experiment will be conducted in a single session. Subjects 
will perform a working memory task during alternating periods of shock threat and safety. 
Startle stimuli will be administered occasionally in the safe and threat conditions to assess 
changes in anxiety level. 
o
Social stressor experiment: This experiment will be conducted in two parts, one, where 
subjects will be observed and given negative verbal feedback, and another where subjects 
will anticipate giving a speech. The impact of these social stressors will be measured by 
performance on the memory tasks described above. The observation stressor will be 
comprised of a single session where subjects will engage in memory task under observation 
by two investigators who will remain in the periphery. Subjects will be told that 
investigators may come into the room to periodically monitor performance.  Half of the 
task runs will not be observed. When the investigators are present, they will give negative 
feedback throughout the run (e.g., “Focus your attention on the task,” “Please improve your 
performance”). This session will last around 90 minutes.
o
The speech stressor portion will be comprised of two sessions, one in an anxiogenic 
context (speech stressor) and the other in an emotionally-neutral context (no speech 
stressor; subject are just asked to read a text). Subjects will be shown a short video 
depicting other “participants” (actors) giving a brief speech in the presence of three judges. 
The video will be used to familiarize the participants with the task, as well as to induce 
anticipatory anxiety. Subjects will be told that they will be giving a similar speech on a 
different topic in an hour or so. They will be told that they will have a short time to prepare 
after they have completed a series of tasks. After the video, subjects will be presented with 
a series of startle probes and asked to complete the cognitive tasks while they periodically 
receive startle probes to index their anxiety across the experiment. After completing the 
cognitive tasks, subjects will be given 1 minute to prepare for a 3-minute speech that they 
will give in front of a few investigators (at least 2 IRTAs). They will be presented with 
another series of startle probes and after they will give a short speech. Finally they will 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
20
receive another series of probes, and complete a final series of questionnaires. On the 
neutral context day, subjects will watch a neutral video clip that has no relation to the 
study/speech stressor. They will complete the same cognitive tasks and receive startle 
probes throughout. They will not be required to give a speech at the end of the experiment.

Sub-study 4: Emotional Expression Multimorph task: Sub-study 4 will test 30 patients and 30 
healthy controls. The task will require one session lasting up to 2 hours. Stimuli will be pictures of 
faces exhibiting anger, disgust, fear, happiness, sadness and surprise (Ekman, 1993)..  Subjects will 
indicate which emotion the face displays. Latency and accurate response will be used as measures of 
facial emotion recognition.  The task may be slightly modified (e.g., timing, number of morphed faces, 
number of emotions) to improve sensitivity of the task to our specific goal. The cognition consent will 
be used for this study. 

Sub-study 5: Effect of anxiety on Stroop task: We have studied the effect of anxiety on the 
Stroop task in healthy adult volunteers (01-M-0185). Sub-study 5 will test 30 patients and 30 
healthy controls. The task will require one session lasting up to 2 hours. Stroop tests are used 
to study emotional distraction. In the affective Stroop task, participants say if stimuli are 
congruent or incongruent.  A visual image of either positive, negative, or neutral emotional 
content taken from the IAPS (Lang and Greenwald, 1988) is presented between the 
stimuli.  Participants experience two types of trials: task and view.  Task trials (b and c in 
figure below) involve the participant responding via button press with respect to the number of 
numbers in an array that is temporally bracketed by positive, negative or neutral images.  View 
trials (a in figure below) involve no participant response and only the display of positive, 
negative or neutral images.  Considerable work with this task has shown that task performance 
relies on the recruitment of regions implicated in top-down attention (dorsomedial and lateral 
frontal and parietal cortices); (K. S. Blair et al., 2007).  Recruitment of these regions is 
associated with a diminished amygdala response to positive or negative images (K. S. Blair et 
al., 2007).  Patients with anxiety disorders show a reduced ability to recruit dorsomedial 
prefrontal cortex during task trials and increased amygdala responses to emotional distracters 
(K. S. Blair, Vythilingam, et al., 2012; K. S. Blair et al., 2013).This task will be conducted 
during alternating periods of shock threat and safety. Some parameters of the task task (e.g. 
timing parameters of the task, organization of the safe vs threat epochs, and nature of the 
congruent/incongruent stimuli) may be modified as it fits our protocol goals, but won’t change 
the basic design. The cognition consent will be used for this study.

Sub-study 7. Active Avoidance/Stop Signal Tasks (Patients N = 40):
Participants will perform paradigms which test whether threat impacts the initiation and the 
inhibition of behavioral responses. Participants will be presented with stimuli, and will either initiate a 
response (i.e. “go”) or will inhibit their response (i.e. “stop”), based on what stimuli is presented. 
Participants will perform the stop-signal paradigm, the active avoidance of signaled threat paradigm, or a 
modified version of one of these two tasks.

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
21
Participants will perform the stop-signal paradigm during a safe condition and a threat condition that 
involves the delivery of aversive electrical stimuli. Participants will be presented with an arrow which 
points either left or right, and will be instructed to press a button with their index finger or middle finger 
based on which direction the arrow is pointing. During stop trials, a colored circle will appear behind the 
arrow and participants will be instructed to refrain from making any response. Independent stair-case 
procedures (Leotti & Wager, 2010) will be used to track performance and will determine the amount of 
time required to accurately initiate responses during “go” trials and accurately inhibit responses during 
“stop” trials. During the threat condition, one group of subjects will receive aversive electrical stimuli 
during the commission of performance errors, while another group of subjects will receive an identical 
amount of electrical stimuli regardless of performance. Stair-case procedures from the safe and threat 
conditions will be compared to determine whether processing speed of “go” and “stop” performance is 
impacted by threat.
Participants will perform a modified version of the active avoidance of signaled threat paradigm 
(Gorka, LaBar, & Hariri, 2016). Participants will hold down a computer key and will view images. The 
images will differ based on their color (low, medium, and high), and participants will always view two 
images presented one after the other. Participants will be instructed to lift their finger when seeing the 
medium-medium color combination (i.e. “go” trials), and to refrain from lifting their finger during all 
other combinations (i.e. “stop” trials). Participants will perform alternating blocks of the safe and threat 
condition, and each block will consist of a series of “go” and “stop” trials.
Participants will be instructed that following the completion of each safe block, they will be informed 
how many mistakes they made during the preceding block and will receive zero shocks regardless of their 
performance. Participants will further be instructed that following the completion of each threat block, 
they will be informed how many mistakes they made during the preceding block and will receive a single 
electric shock. We will use independent stair-case procedures to titrate task difficulty so that all 
participants are ~50% accurate during go trials. Additionally, the range of mistakes which result in a 
single electrical stimulus will be sufficiently wide that all participants will receive a single shock 
following each threat block. Participants will be told that the task becomes more difficult over time and 
that it is impossible to make zero mistakes and to avoid the shock completely, but that the duration of the 
shock is dependent on their performance and that it is possible to shorten the duration of the electrical 
stimulus by committing fewer mistakes. The duration of the electrical stimulus which participants receive 
following each threat block will vary as a function of the participant’s performance in the preceding block, 
such that larger numbers of performance errors result in an electrical stimulus of longer duration. The 
shock will not last longer than 200msec. Participants will receive electrical stimuli immediately following 
the end of each threat block.  
This research will allow us to determine whether threat preferentially impacts different types of 
performance (i.e. response initiation vs. response inhibition) and whether linking aversive outcomes to 
performance impacts the effect of threat on these behavioral phenomena. 
This study will require one session in the outpatient clinic at NIH that may last up to 3 hours.

Measures Common to all sub-studies:

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
22
Grip force measures
The strength of hand compression (i.e. grip force) will be recorded during testing to evaluate 
behavioral indices of motivation and performance. Participants will hold a hand clench 
dynamometer which will assess hand compression in units of kilogram-force (kgf). The magnitude 
of grip force will serve as a within-subject measure of motivation. Additionally, patterns of 
dynamic grip force behavior will serve as measures of fine motor skill.

Assessments
              Adverse events will be rated weekly. The primary efficacy measure will be the Clinical Global 
Impressions Scale (CGI) Improvement rating (Guy, 1976). The CGI is a well-documented outcome 
measure in studies investigating the efficacy of treatments for psychiatric disorders including social 
anxiety disorder (Liebowitz, et al., 1992), and panic disorder (Barlow, Gorman, Shear, & Woods, 2000). 
A second aspect of the CGI, the CGI Severity index, will also be administered. Clinician ratings of anxiety 
symptoms will be completed weekly. Anxiety symptoms will be rated with the Hamilton Rating Scale for 
Anxiety [HAM-A] (Hamilton, 1959). 
Research Questionnaires used in each study: In addition to using the trait portion of the STAI to 
classify healthy controls as high or low in trait anxiety, the state portion of the STAI will be administered 
prior to every experimental task (i.e., test of orienting response to innocuous stimuli, dot probe, verbal 
threat, aversive conditioning, eyeblink conditioning) to assess subjective measures of fear and anxiety that 
may influence outcome measures from experimental tasks. The remaining research measures (NEO, BDI, 
BAI, cognitive tests, etc.) are given for exploratory purposes. 
            For the purposes of screening, we use a standard set of questionnaires to assess mood and anxiety 
for subjects  including SCID, BDI-II, IDSR, HAM-D, HAM-A, and MADRS.
The non-analogue measures from these reports may be completed by the participant on the Clinical Trial 
Survey System (CTSS) online system. AIs may then collect data from the Clinical Trials Database 
(CTDB) for the purposes of this study.  Participants may enter their responses while at NIH using a 
wireless-device interface to access the NIH-intranet secure CTDB. There are no potentially actionable 
questions to be used by this system and thus the answers will not require real-time monitoring.
e.
End of Participation

Participation in the studies is expected to be completed within six months, though precise 
timing depends on the needs of the patients.  Subjects will be terminated from the protocol 
when they request to discontinue participation. Moreover, subjects requiring clinical care after 
the completion of treatment at NIH will transition to community-based clinicians. Clinical care 
will be provided in the community, outside of the current protocol.  

All subjects are seen on a regular basis by a trained clinician. Any worsening of symptoms will 
be reviewed by a panel of clinicians. This review will be designed to remove subjects from the 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
23
trial who show significant worsening, in an effort to minimize any potential adverse 
consequences of treatment.
5. STORAGE  OF DATA AND SAMPLES
We collect up to 10 saliva samples for each research participant. Saliva samples are stored in Building 49, 
Rm #B1B56. Saliva samples are discarded once cortisol levels are extracted.
.
6. ADDITIONAL CONSIDERATIONS
a.  Research with investigational drugs or devices
Acoustic startle and shock device used in this protocol are considered non-significant risk (NSR) devices 
and will only be used within published guidelines. 
  
Auditory startle does not meet criteria for a Significant Risk device as outlined Under 21 CFR 812.3(m), 
as an investigational device that: 
1. Is intended as an implant and presents a potential for serious risk to the health, safety, or welfare of a 
subject 
Response: Auditory startle is not an implantable device.
2. Is purported or represented to be for a use in supporting or sustaining human life and presents a 
potential for serious risk to the health, safety, or welfare of a subject 
Response: Auditory startle is not for use in supporting or sustaining human life. It does not present a 
potential for serious risk to the health, safety, or welfare of participants when used as described in this 
protocol. 
3. Is for a use of substantial importance in diagnosing, curing, mitigating, or treating disease, or otherwise 
preventing impairment of human health and presents a potential for serious risk to the health, safety, or 
welfare of a subject 
Response: Auditory startle, as used under this protocol is not of substantial importance in diagnosing, 
curing, mitigating, or treating disease, or otherwise preventing impairment of human health and does not 
present a potential for serious risk to the health, safety or welfare of a subject. 
4. Otherwise presents a potential for serious risk to the health, safety or welfare of a subject 
Response: Auditory startle has been in use numerous for decades and have been cleared by the FDA. 
Safety guidelines have been developed and updated allowing its dissemination to a wide range of clinical 
and non-clinical settings. The FDA has generally waived pre-IDE inquiries for auditory startle studies on 
an NSR device basis. Hence, the CNS IRB, like most US IRBs, has accepted NSR designation for auditory 
startle within these limitations. 
The shock device (electrical stimulator) does not meet criteria for a Significant Risk device as outlined 
Under 21 CFR 812.3(m), as an investigational device that: 
1. Is intended as an implant and presents a potential for serious risk to the health, safety, or welfare 
of a subject 
Response: The shock device is not an implantable device.

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
24
2. Is purported or represented to be for a use in supporting or sustaining human life and presents a 
potential for serious risk to the health, safety, or welfare of a subject 
Response: The shock device is not for use in supporting or sustaining human life. It does not present a 
potential for serious risk to the health, safety, or welfare of participants when used as described in this 
protocol. 
3. Is for a use of substantial importance in diagnosing, curing, mitigating, or treating disease, or 
otherwise preventing impairment of human health and presents a potential for serious risk to the health, 
safety, or welfare of a subject 
Response: The shock device, as used under this protocol is not of substantial importance in diagnosing, 
curing, mitigating, or treating disease, or otherwise preventing impairment of human health and does not 
present a potential for serious risk to the health, safety or welfare of a subject. 
4. Otherwise presents a potential for serious risk to the health, safety or welfare of a subject 
Response: The shock device has been in use numerous for decades and have been cleared by the FDA. 
Safety guidelines have been developed and updated allowing its dissemination to a wide range of clinical 
and non-clinical settings. The FDA has generally waived pre-IDE inquiries for shock studies on an NSR 
device basis. Hence, the CNS IRB, like most US IRBs, has accepted NSR designation for shock device 
within these limitations. 
7. RISKS AND DISCOMFORTS
a. Psychiatric Assessment: It is highly unlikely that study participants will become upset 
about the questions or interview process used in the study.  Each measure has been used 
extensively in hundreds of psychiatric patients and healthy controls without adverse effects.  
Subjects may refuse study participation at any time, and the standard interviewing and data 
collection procedures will cease, should any adverse reactions be noted.  All subjects 
completing the interviews and questionnaires will be provided with phone numbers so that 
they can have any questions answered that they feel have not been satisfactorily addressed.  
The medical investigators for this study have extensive interview experience, and they will 
determine if there is a need for clinical intervention; if necessary, arrangements for 
appropriate clinical services will be made.
b. Electric Shock. The shocks are designed to be moderately painful and to evoke anxiety. 
Based on the PI’s research 20 year experience with experiments involving the administration 
of electric shocks to both anxiety patients and healthy controls, little to no adverse reactions 
to the electric shocks are expected among patients and controls. However, in very rare 
occasions, subjects have experienced symptoms that may be related to the shock. For 
instance, a participant with a condition called “cubital tunnel syndrome,” a repetitive motion 
injury similar to carpal tunnel syndrome, indicated worsening of his syndrome over the 
months subsequent to his participation. Another participant reported pain in her arms for 
several hours after testing. The pain was no longer present the next day. It is unclear whether 
these symptoms were due to the shocks. Nevertheless, subjects with neurological symptoms 
of the wrist and arms are excluded from shock studies that use the wrist for placement of 
electrodes.

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
25
Although no adverse reactions are anticipated, clinical intervention, as delineated under 
“Emergency Treatments”, will be carried out under the supervision of Dr. Ernst in the event 
that subjects display or report distress during study procedures. 
c. Psychophysiological Recording. The psychophysiological measures that will be obtained 
are non-invasive, requiring the administration of no needles, drug, or dyes. During electrode 
placement, the possibility of skin irritation from contact with the saline electrode paste exists. 
However, this is unlikely since the salt concentration of the paste is similar to that of human 
sweat. The risk is equivalent to that of an EEG recording. Because the PI’s past studies in 
anxiety patients and controls using virtually identical recording procedures have resulted in 
little discomfort to participants, no adverse reactions to such procedures are expected.
d. Auditory Startle Stimulus. Loud sounds can cause hearing problems, but the auditory 
stimuli that will be used in the startle studies are safe (i.e., there is no danger of hearing 
impairment). This is because of the physical characteristics of the startle sound (40-ms 
duration, 102-dB white noise) are within the safe range. Auditory startling sounds of much 
higher intensities and longer duration (500 ms) are frequently used in startle studies (Hawk & 
Cook, 2000; Lipp & Siddle, 1998)(Hawk & Cook, 2000; Lipp & Siddle, 1998). Forty-
ms/102dB sounds are well below the recommended limits stated in the documentation of 
various safety regulations. For example, the Occupational Safety & Health Administration 
(OSHA) recommends that exposure to impulsive or impact noise should not exceed 140 dB 
peak SPL. The National Institute on deafness and other Communication disorders (NIDCD) 
website recommends no more than 15 min unprotected exposure at 100 dB. Finally, we use 
white noise, which are safer than pure tones.
e. Air Puff. The air puff is very intense and mildly unpleasant, but harmless. There is no 
known risk event associated with the air-puff
f. Experimental Procedures.  A series of procedures designed to minimize risk will be 
applied to participants in this protocol. Both patients and healthy controls will undergo a 
sample shock procedure before any experiments involving electric shock are run to assess 
each individual’s reaction to the shock, to adjust the shock to a level that is well tolerated, 
and to give the participant a chance to withdraw from the study if they so wish. An additional 
procedure is the observation of participants by way of a non-recording video camera and 
two-way audio telecom throughout testing. Participants are instructed to signal the 
experimenter through the video camera or by calling the experimenter’s name at any point 
during the experiment if they wish to end the experiment or if they wish to speak with the 
experimenter for any reason. Upon completion of testing procedures for a given visit, 
patients with a psychiatric disorder are evaluated by Dr. Ernst to assess for any adverse 
reactions to experimental procedures. Hence, any problems that stem from these procedures 
will also be detected and treated in a timely manner.  
g. Delayed Treatment. Although anxiety and mood patients will not be taken off any 
medication for the purposes of this study, we will only include those patients who are not 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
26
currently taking psychotropic medications.  The only exception to this is the bipolar 
depressed patients.  These individuals, because of the risks associated with mood 
destabilization, will be permitted to continue taking either Depakote or lithium carbonate as 
mood stabilizers.  Nonetheless, patients included in this study may be at risk of symptom 
worsening because of the absence of other psychopharmacologic treatment. If patients 
choose to enroll in the study despite this risk, their symptoms will be monitored by medical 
staff.  If symptoms worsen and are deemed by our medical staff to be a threat to the patient’s 
welfare, the patient will be discontinued from the study and receive brief treatment by our 
medical staff while referral efforts to community care are underway.  
h. Emotional Pictures. The emotional pictures will be selected from a set of standardized 
stimuli that are frequently used in psychophysiological and brain imaging studies of 
emotions (Lang et al. 1988). Because the intensity of these pictures might make some people 
uncomfortable, their contents will be fully described to the subjects before participation in 
the study. The participants will be reminded that they may stop looking at the pictures at any 
time.
i.
Grip force measures: This measure is not expected to increase risks in human subjects. 
 
8. SUBJECT SAFETY MONITORING 

Subject monitoring will be conducted by the Principal investigator, Monique Ernst, MD, Ph.D.

All patients will be monitored at each visit for their participation for signs of discomfort or desire 
to discontinue the protocol. Specifically, they are in constant view of the research staff during the 
experiment.  They are instructed to wave at the (non-recording) camera or else to call the 
researcher if they wish to stop the experiment.  The researcher is within earshot of the participant 
at all times.  The participants will also be explicitly told during the consenting procedure as well as 
after the sample shock procedure that it is their right to discontinue the study at any time.

Criteria for Withdrawal: If a patient experiences clinically significant worsening, displays any 
suicidal ideation or active plans of suicide, reports adverse reactions to the experiment at any point 
during the study, appears to be in distress at any point during the procedures, or demonstrates 
adverse responses by way of the  post-experimental assessment of adverse events, the patient will 
meet with Dr.Ernst or Dr. Zarate, or their clinical staff, who will assess the patient’s suitability for 
continuation in the study and will administer appropriate psychiatric treatment. If the psychiatrist 
determines that continuation is clinically counter-indicated, the patient will be removed from the 
protocol but will receive treatment at the NIH under the care of Dr. Ernst or Dr. Zarate until 
appropriate, long-term psychiatric care is arranged. The reasons for patients’ discontinuation from 
the study will be logged and changes to procedures necessary to prevent future adverse reactions 
will be made.

Role of Medical Doctors: The medical advisory investigator for this study, Dr. Monique Ernst, 
will serve as the primary treating psychiatrist for anxiety patients enrolled in this protocol. Dr. 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
27
Ernst’s role will include serving as the intervening psychiatrist in the event of adverse reactions or 
symptom worsening as well as delivering short-term treatment (1-2 months, not to exceed 3 
months) to anxiety patients upon their completion of the protocol. Additionally, Dr. Ernst will 
complete the initial psychiatric evaluation (described below) and will be on call for subjects along 
with other psychiatrists on the child anxiety on-call schedule to allow 24-7 on call coverage for 
patients in this protocol. In the event that participating patients experience symptom worsening 
while off-campus, they will call the child anxiety on-call schedule. When Dr. Ernst is the on call-
physician, he will provide the psychiatric treatment for this patient. Otherwise, the on-call 
physician at the time the patient calls will intervene and provide the necessary care.  Dr. Zarate and 
his associates in his program will serve as the primary treating psychiatrists for depressed patients 
in this protocol.  Dr. Zarate or a clinician in his group will be the primary treating physicians. They 
will intervene in the event of adverse reactions or symptom worsening and will as deliver 
appropriate treatment.

Healthy Controls: Throughout experimental procedures, psychiatrically healthy subjects will be 
monitored by both a non-recording video camera and by a two-way audio telecom. Procedures will 
be stopped for any subject who asks to stop any procedure at any point.  Subjects will be asked if 
they wish to continue with other phases of the study.  Procedures will also be stopped for any 
subject who exhibits signs of distress during any phase of the study.  At this point, subjects will be 
interviewed to confirm that they are in fact in distress and psychiatric intervention will follow 
when necessary. Subjects will be asked if they wish to continue with other phases of the study. 

Psychiatric Patients: Mood patients accepted into this protocol will have been thoroughly 
screened and assessed for inclusion/exclusion criteria by clinicians of the Experimental Therapeutics 
& Pathophysiology Branch of NIMH. For English speaking bipolar depressed patients, Dr. Zarate and his 
team will be responsible for screening evaluations, the experiments and clinical assessments during each 
visit.  
o
Monitoring during the experimental sessions is conducted by a research assistant under the 
supervision of a physician from this branch.  Like healthy controls, patients will be monitored via 
non-recording camera and two-way audio telecom throughout experimental procedures. 
o
All patients with anxiety psychiatric disorders will be provided with Dr. Ernst’s pager number as 
well as other phone numbers for emergency psychiatric coverage, 24-hours/day.  Patients with 
mood disorders will be provided with Dr. Zarate’s or one of his physician’s pager number as well 
as other phone numbers for emergency psychiatric coverage, 24-hours/day.
o
Patients will be monitored by way of multiple clinical assessments. The clinical assessments by the 
psychiatrist addresses not only the primary (mood) diagnosis, but also any allowed comorbid 
conditions with which the patient suffers.  Symptom severity of both the primary and comorbid 
conditions is monitored and interventions provided by medical staff as deemed medically necessary

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
28
 Below is a table delineating all scheduled clinical assessments for patients during each visit.
       * Only includes scheduled assessments and does not include        
          assessments/interventions to be administered in the case of adverse events.
       **1 week interval between visits. 

Initial Psychiatric Evaluation: At the outset of screening, patients will meet with Dr. 
Ernst or Dr. Zarate for an initial psychiatric assessment. During this evaluation, the 
psychiatrists will assess the patients’ suitability for this study based on the patient’s 
psychiatric/medical history as well as the patient’s current symptom profile. Patients 
participating in studies 1 and 2 will be informed that the study is not designed to treat 
their psychiatric disorder/s and that their condition may worsen while participating in this 
study. Additionally, patients will be reminded that psychopharmacologic and 
psychotherapeutic treatment options for anxiety and mood disorders are available in 
clinical practice outside of the NIH and delaying such treatment may have adverse effects 
on their mental health.

Study Phase: If, during the course of the study, a subject’s condition deteriorates to the 
point where emergency treatment is needed, the subject will be removed from the 
protocol. At this point or any other point where subjects are removed from the study for 
non-emergent reasons, clinical care will be provided by staff, under the direction of Drs. 
Ernst or Zarate. This care will continue until the case has been successfully stabilized, 
through the use of standard clinical practice in the treatment of anxiety and mood 
disorders.  If patients require in-patient care, they will be hospitalized in one of the 
NIMH inpatient units. 
Session**
Time
Type of Assessment
Clinical Staff
upon arrival
Initial psychiatric evaluation
Dr. Pine
upon arrival
SCID
credential staff clinician
upon arrival
Assessment of symptom severity(C-MARS) credential staff clinician
end of session
Assessment of adverse reactions
Dr. Pine
upon arrival
Assessment of symptom severity(C-MARS) credential staff clinician
end of session
Assessment of adverse reactions
Dr. Pine
upon arrival
Assessment of symptom severity(C-MARS) credential staff clinician
end of session
Post-exp. psychiatric assessment 
Dr. Pine
Schedule of Clinical Assessments for Patients*
2
1
3

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
29

Clinical Care After Treatment: Following the completion of the study, psychiatric patient 
participants in the anxiety protocol will receive short term psychiatric treatment lasting 1-2 
months (not to exceed 3 months) under the care of Drs. Ernst and the adult anxiety program 
staff. The total amount of time that out-of-study care will be provided is expected to vary, 
given the diverse clinical needs of patients. Ideally, the team will provide care for between 
one and two months in most cases. However, efforts to transition care to the community will 
intensify after two months and the study team will make every effort to ensure that no more 
than 3 months of treatment are provided.   Similarly, the depressed patients will receive care 
as outlined above under the direction of Dr. Zarate and the mood disorders program staff.  
The time line of care as detailed above will be followed for these patients as well.  
9. OUTCOME MEASURES 
a.
Primary outcome measures: Primarily, we are interested in exploring the affective, cognitive 
and behavioral of our study’s dependent measures. The primary outcome measures will be the 
startle reflex and performance on cognitive tasks. 
b.
Secondary outcome measures: These measures include psychophysiological measures other 
than startle (e.g., skin conductance) and state and trait questionnaires. 
10. STASTISTICAL ANALYSIS
The overall target N for the protocol is 663 healthy controls and 608 patients.  Participants who drop out 
will be replaced.  Participants may participate in more than one sub-study. 

Sub-study 1
o
Analysis of data/study outcomes: Startle amplitude during the verbal threat procedure 
will be averaged over cue and no cue (ITI) periods within conditions. There will be 
separate analyses for anxiety disorders and mood disorders. The data will be submitted to a 
Group (GAD, SAD, panic disorder, control or MDD, bipolar, control) x Condition (P, N, 
U) x Cue (cue, ITI) ANOVA. If this interaction is significant, within-group simple-effects 
comparing startle amplitudes during the ITI of predictable versus unpredictable conditions 
will be compared for all groups separately. Larger startle magnitudes in the unpredictable 
versus predictable condition suggest heightened sensitivity to unpredictability. Between 
group contrasts will also be computed to compare difference scores (i.e., differences 
between startle magnitudes during unpredictable and predictable conditions) across groups. 
In our pilot and published studies, we obtained the lowest effect size (f=0.30) for 
contextual fear (anxiety-potentiated startle). 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
30
o
Power analysis: We set power at .80 and experiment-wise, two-tailed alpha at 0.05. Based 
on these parameters, we will need 18 subjects per group. Assuming a 15 % unusable data 
rate due to lack of startle response or equipment failure, approximately 22 subjects per 
group will be recruited for a total of 110 patients and 44 healthy controls. 

Sub-study 2
o
Analysis of data/study outcomes: Startle amplitude will be averaged over conditions 
(safe, threat) and WM load (View, 1, 2, 3). There will be separate analyses for anxiety 
disorders and mood disorders. The data will be submitted to a Group (GAD, SAD, panic, 
controls or MDD, bipolar, controls) x condition (safe, threat) x WM load (1-back, 2,-back, 
3-back). 
o
Power analysis: Based on our published study in healthy controls (Vytal et al, in press), 
where we found a 2-way interaction between condition and WM load with an effect size of 
η2=0.20, we estimate that we will need 20 subjects per group. Given a rate of 15% of 
unusable data, approximately 23 subjects per group will be recruited for a total of 
approximately 115 patients and 46 healthy controls. We will also need approximately 40 
healthy controls to pilot various versions of the tasks for a total of 86 controls.  

Sub-study 3
o
Analysis of data/study outcomes: patients will be tested twice, before and after the 8-
week treatment, while controls will be also tested twice, 8 weeks apart. Startle amplitude 
and performance will be averaged over conditions (safe, threat) and WM load (view, 1, 2, 3 
for startle and 1, 2, 3 for performance). These data will be submitted to omnibus Group 
(patients, controls) x condition (safe, threat) x WM load (view, 1-back, 2-back, 3-back for 
startle and 1-back, 2-back, 3-back for performance) x Time (first session, second session) 
ANOVAs.  However, the analysis will focus on the 3-back condition, where greater group 
differences are expected.  Changes in fear-potentiated startle and differential performance 
(threat minus safe) in the 3-back condition from session 1 to session 2 will be compared 
between the two groups. Secondary measures will be subjected to multiple-regression 
analyses. For all such analyses, questionnaire scores will serve as predictor variables and 
different experimental outcomes will serve as dependent variables. Analyses will regress 
questionnaire scores dependent measures of interest: 1) anxiety-potentiated scores, 2) WM 
scores, and 3) attentional-bias scores. In so doing, we will be able to assess the combined 
and unique contributions of questionnaire scores to the variability in dependent measures.
o
Power analysis: We estimate that we will need 30 subjects per group. Given a rate of 
25% of unusable data or non-completers, approximately 38 controls and 38 patients will be 
recruited.
11. HUMAN SUBJECT PROTECTIONS 
a. Subject selection

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
31
i. Statement of equitability: 
The race distribution of the samples studied in this project will be similar to that of the greater 
Washington DC metropolitan area, and will include representation from all minorities excepting 
American Indians, who we have much less opportunity to study. Because the NIMH is located in a 
suburban area in which African-Americans may be under-represented, if at any point the race 
composition of subjects recruited during the proposed imaging study fails to reflect the race 
distribution of the larger geographic area, we will intentionally emphasize recruitment of subjects 
from more urban areas through collaborations being formed with Howard University. While we 
have not found significant race effects on the clinical or psychobiological parameters assessed, we 
will continue to perform secondary analyses to explore potential effects of race on these domains. 
We exclude non-English speakers since not all the instruments and test we use are translated and 
validated in Spanish or other languages. 
We expect to enter about equal number of females and males in the study. Pregnant females will be 
excluded because the effects of shock are unknown on a developing fetus.  The upper limit for age 
range of 50 years is set to achieve greater homogeneity in our sample and thereby reduce the 
variability of the startle reflex, which tend to decrease with increased in age. This is necessary to 
increase the signal to noise ratio and the sensitivity of our study to detect differences between 
conditions.
ii. Rationale for selection if not equitable
N/A
b. Justification for inclusion/ exclusion of children

In order to elicit anxiety responses similar to those occurring in anxiety disorders it is important 
that out stressor is highly unpleasant. We thus chose to use electric shock as the stressor. Though 
shock stressors are well tolerated by adults (and used frequently in the literature to assess stress 
reactions in healthy and disordered individuals), such methods may be inappropriate for children. 
We will not enter children under age 18 because of ethical concerns about exposing them to threat 
of shock. Moreover, concerns regarding the legal inability to provide informed consent before age 
18 (and the consequent dependence on parental decision) preclude inclusion of subjects under age 
18.
c.
Justification for inclusion of other vulnerable subjects, e.g. cognitively impaired, pregnant, mentally 
ill 
We exclude patients with cognitive impairment as they would be unable to self-administer the 
necessary test instruments.  Subjects with other Axis I disorders other than mood and anxiety 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
32
disorders because of the confounding effects of other psychiatric disorders. Pregnant women are 
excluded because the effects of MRI and shocks on the fetus are not known.
d.  Justification of sensitive procedures (use of placebo, medication withdrawal, provocative testing)

Electric shocks are used as the stressor in this study. Our use of electric shocks stems from our 
experience that electric shocks are among the most efficient ways to induce anxiety in the 
laboratory setting and to detect patients control differences. 
e.
Safeguards for vulnerable populations e.g. DPA, pregnancy testing, contraception use, ethics consult, 
HSPU involvement

We assess pregnancy via urine test within 24 hours of any testing and exclude all participants who 
are pregnant.

Protections for NIH employees, staff and family members participating in this study include 1) 
assuring that the participation or refusal to participate will have no effect, either beneficial or 
adverse, on the subject’s employment or position at the NIH, 2) giving employees and staff who 
are interested in participating the “NIH Information Sheet on Employee Research Participation” 
prior to obtaining consent, and 3) assuring that there will be no direct solicitation of employees or 
staff. This study collects sensitive information (e.g. drug and alcohol use, specific medical 
diagnoses). The PI will train study staff regarding obtaining and handling potentially sensitive and 
private information about NIH employees, staff and family members through staff discussions and 
written branch/section procedures.  Prior to enrollment, potential participants will be informed 
that sensitive information (e.g. drug and alcohol use, specific medical diagnoses) will be in the 
participant’s NIH medical record.
12. ANTICIPATED BENEFIT

The experimental procedures involved in this study provide no direct benefit but are likely 
to yield generalizable knowledge about the psychophysiology of anxiety in health and 
disorder. Results from this study may help others with similar diagnoses in the future by 
facilitating the development of more effective assessment and intervention strategies for 
anxiety disorders.

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
33
14. CONSENT DOCUMENTS AND PROCESS
a. Designation of those obtaining consent

Study investigators designated as able to obtain consent listed in KSP form, will obtain 
informed consent. Consent for NIH employees, staff and family members will not be obtained by 
coworkers.
b. Consent procedures
All participants will receive a verbal explanation in terms suited to their comprehension of 
the purposes, procedures and potential risks of the study and of their rights as research 
participants. Participants will have the opportunity to carefully review the written consent 
form and ask questions regarding this study prior to signing. 
Prior to commencement of the experiments, all participants will have been fully informed 
and will be consented under protocol 03-M-0093. There will be two separate consents, one 
for controls, and one for anxiety volunteers. 

Telehealth Consent Procedures: Under certain circumstances, there may be a need to obtain 
telephone or telehealth consent for this study using NIH-approved platforms.  Under these 
circumstances, the individual will be sent a copy of the consent form. After the document is 
reviewed, an AI authorized to obtain consent will contact the individual and review the 
procedures and risks.  The participant and the investigator will sign their respective copies, and 
the former will return their copy to the investigator.  One copy each of the signed consent form 
will be placed in the Medical Record, retained by the investigator, and returned to the participant 
or parent/guardian. Proper documentation will be made in CRIS.
Informed consent for the study will be obtained in-person or via Telehealth prior to any tests. 
The consent forms include a checklist that includes all procedures outlined in the protocol. 
Prior to consenting, all procedures subjects will experience will be marked so that the 
participant understands exactly what they will be doing. If a subject returns to do a different 
task within the same protocol, they will be re-consented with appropriate procedures marked
During the consent process, participants will be reminded that their participation is voluntary 
and that they may discontinue their participation at any time without jeopardizing their 
continuing medical care at this institution, or losing benefits they would otherwise be 
entitled to. Patients will be informed that they will be provided with treatment 
recommendations, short-term treatment, and referrals to other treatment providers should 
they decide to withdraw from the study. All subjects will also be informed that Drs. Ernst or 
Zarate, or other psychiatrists acting for them, will have the right to withdraw them from the 
study at any time for clinical reasons or if they have failed to follow instructions. 
Importantly, patients will be informed that upon completion of the study they will be 
provided with continued short-term treatment for their psychiatric disorder at no cost at the 
NIH for up to two months after which they will be referred to an appropriate psychiatric 
team for long-term treatment. 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
34
All subjects who will participate in studies 1 and 2 (that do not involve CBT) will be 
informed that no immediate personal medical or psychiatric benefits will be derived from 
participation. It will be explained that these experiments are designed to gain information 
that will lead to better understandings of the associations between brain function and anxiety 
arousal that will potentially benefit individuals with anxiety disorders in the future, but that 
the results will not be helpful for indicating current treatment, diagnosis, or prognosis. 
Subjects will be informed of all potential risks of participation during the consenting process. 
Of note, patients with anxiety and/or mood disorders will be told that the study is not 
designed to treat their psychiatric disorder/s and that their condition may worsen while 
participating in this study. 
Additionally, patients participating in studies 1 and 2 will be reminded that 
psychopharmacologic and psychotherapeutic treatment options for anxiety and mood 
disorders are available in clinical practice outside of the NIH and delaying such treatment 
may have adverse effects on their mental health. During the consent process, anxiety 
patients will be told that Dr. Ernst will be assigned to them as their primary psychiatrist 
should they participate in the study and that they will be given Dr. Ernst’s pager number as 
well as other methods for contacting NIMH psychiatrists 24 hours a day, 7 days a week. The 
same procedure applies to depressed patients, who will be provided with Dr. Zarate’s 
contact information.
c.
Consent documents

All consent forms include the required elements

Consent documents submitted with this protocol include: Control, Patient, and Cognition
15. DATA AND SAFETY MONITORING
a.
Data and Safety monitor: 
This protocol will be monitored by an independent safety monitor, Dr. Pedro Martinez. 
 
b. Data and Safety monitoring plan: 
The PI will prepare a report on data and safety parameters for the Independent Monitor  annually.  
The Independent monitor will provide a written monitoring report to be submitted to the IRB at the 
time of continuing review. 
c.
Criteria for stopping the study or suspending enrollment or procedures:  
The study will be stopped or suspended for any potentially related serious adverse event.  The 
Principal Investigator, Independent Monitor, and IRB will determine if changes are needed for the 
research to continue or if it will be closed. Any changes required as conditions for resuming the 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
35
research must be submitted as an amendment and IRB-approved before the changes can be 
implemented.
16.  QUALITY ASSURANCE

Quality assurance monitor
Quality assurance will be monitored by the PI and research team and the NIMH Office of 
Regulatory Oversight (ORO).

Quality assurance plan
ORO monitors intramural research studies to ensure compliance with GCP, organizational policies and 
regulations.  Audit frequency is determined by the ORO SOP based on the study level of risk.  Results of 
ORO audits are provided to the PI, The Clinical Director and the CNS IRB.  This study will undergo 
audits at least once every three years and for cause.
17. ADVERSE EVENT AND UNANTICIPATED PROBLEM REPORTING
Reportable events for this protocol will be tracked and reported in compliance with Policy 801.
18. ALTERNATIVES TO PARTICIPATION

There are antianxiety medications that may be prescribed by family doctors as well as psychiatrists 
that could alleviate the anxiety symptoms experienced.  Some of these treatments are 
benzodiazepines (alprazolam, e.g.) and some SSRIs (lexapro, e.g.).  Cognitive behavioral therapy 
(CBT) is also readily available by therapists in the community as a treatment of choice for anxiety 
symptoms.  Those who agree to participate in this research will be advised of these alternatives to 
research participation.  
19.
PRIVACY
All research activities will be conducted in as private a setting as possible. 
20. CONFIDENTIALITY
a. For research data and investigator medical records.
Every necessary step will be taken to prevent identification of study participants or violations of 
confidentiality of the data. Paper data are stored in locked cabinets within locked closets/rooms. Electronic 
data are encrypted and cannot be accessed without obtaining a password. All data are reviewed as they are 
obtained.  Information will be stored using a confidential code and data will be treated only as groups.  All 

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
36
data entered into a database will appear only in coded form.  Members of the research team will have 
access to these coded data.  Only staff directly involved in the care of each subject will have access to 
clinical documents that contain identifying information.  This will include the study PI, the study 
psychiatrist, clinical staff, and research assistants.  This study collects sensitive medical information. The 
PI will train study staff regarding obtaining and handling potentially sensitive and private information 
about NIH employees, staff and family members through staff discussions and written branch/section 
procedures.
b. For stored samples
Saliva samples are labeled with subject number only.  No identifying information appears on the 
tube.  Cross-referenced records are stored separately.  
c. Special precautions
N/A
21. CONFLICT OF INTEREST/ TECHNOLOGY TRANSFER
a.
Distribution of NIH Guidelines 

NIH guidelines on conflict of interest have been distributed to all investigators.
b. Conflicts of interest 

There are no conflicts-of-interest to report.
c.
Role of a commercial company or sponsor

N/A
22.  TECHNOLOGY TRANSFER
N/A
23. RESEARCH AND TRAVEL COMPENSATION 

Which populations will be paid and which will not: All volunteers will be compensated for time 
and research-related inconveniences.

Amount of compensation: Subjects will be given compensation for their participation in the study based 
on NIH standards for time devoted to research projects based on the following schedule. All participants 
will be compensated  $150 for completing the study. Subjects may receive an extra $20 for the 
optional Telehealth consenting visit. Payment will be sent after each visit. The total compensation 
for a study visit will be $150 or $170 for a study visit and Telehealth consenting visit. 

Travel compensation: No travel compensation will be given to participants in this protocol.

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
37

NIH employees or staff who participate during work hours must have permission from their 
supervisor. NIH employees or staff must either participate outside of work hours or take leave in 
order to receive compensation.

24.  REFERENCES
Airaksinen, E., Larsson, M., & Forsell, Y. (2005). Neuropsychological functions in anxiety disorders 
in population-based samples: Evidence of episodic memory dysfunction. Journal of 
Psychiatric Research, 39, 207–214.
Al-Kubaisy, T., Marks, I.M., Logsdail, S., Marks, M.P., & K., L. (1992). Role of exposure homework in 
phobia reduction: A controlled study. Behavior Therapy, 23, 599-621.
Barlow, D.H. (1988). Anxiety and its disorders: the nature and treatment of anxiety and panic. New York: 
Guilford Press.
Barlow, D.H., Gorman, J.M., Shear, M.K., & Woods, S.W. (2000). Cognitive-behavioral therapy, 
imipramine, or their combination for panic disorder: A randomized controlled trial. Journal of the 
American Medical Association, 283, , 2529–2536.
Beck, A.T., & Steer, R.A. (1987). BDI: Beck Depression Inventory. New York: The Psychological 
Corporation, Harcourt Brace Jovanovich, Inc.
Bishop, S.J. (2008). Neural Mechanisms Underlying Selective Attention to Threat. Annals of the New 
York Academy of Sciences, 1129, 141-152.
Blanchard, Caroline D., Hynd, A. L., Minke, K. A., Minemoto, T., & Blanchard, R. J. (2001). Human 
defensive behaviors to threat scenarios show parallels to fear- and anxiety-related defense patterns 
of non-human mammals. Neuroscience & Biobehavioral Reviews, 25(7–8), 761–770. 
https://doi.org/10.1016/S0149-7634(01)00056-2
Borg, G. (1998). Borg's Perceived Exertion and Pain Scales. Human Kinetics 1.
Borg, G. A. (1982). Psychophysical bases of perceived exertion. Medicine & Science in Sports & 
Exercise, 14(5), 377–381.
Butler, G., Cullington, A., Munby, M., Amies, P.l., & Gelder, M. (1984). Exposure and anxiety 
management in the treatment of social phobia. Journal of Consulting and Clinical Psychology, 2, 
642-650.
Chen, K. Y., Acra, S. A., Majchrzak, K., Donahue, C. L., Baker, L., Clemens, L., et al. (2003). Predicting 
Energy Expenditure of Physical Activity Using Hip- and Wrist-Worn Accelerometers. Diabetes 
Technology & Therapeutics, 5(6), 1023–1033. http://doi.org/10.1089/152091503322641088
Costa, P.T., & McCrae, R.R. (1992). Revised NEO Personality Inventory (NEO-PI-R) and NEO Five 
Factor Inventory (NEO-FFI) professional manual. Odessa, Fl: Psychological Assessment 
Resources.
Davis, J. A., & Convertino, V. A. (1975). A comparison of heart rate methods for predicting endurance 
training intensity. Medicine and Science in Sports, 7(4), 295–298.
Davis, M., Walker, D.L., Miles, L., & Grillon, C. (2010). Phasic vs sustained fear in rats and humans: role 
of the extended amygdala in fear vs. anxiety. Neuropsychopharmacol, 35, 105-135.

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
38
Deacon, B. J. & Abramowitz, J. S. (2004), Cognitive and behavioral treatments for anxiety disorders: A 
review of meta-analytic findings. Journal of Clinical Psychology, 60, 429–441. 
Ensari, I., Greenlee, T. A., Motl, R. W., & Petruzzello, S. J. (2015). META-ANALYSIS OF ACUTE 
EXERCISE EFFECTS ON STATE ANXIETY: AN UPDATE OF RANDOMIZED 
CONTROLLED TRIALS OVER THE PAST 25 YEARS. Depression and Anxiety, n/a–n/a. 
http://doi.org/10.1002/da.22370
Eysenck, M.W., & Calvo, M.G. (1992). Anxiety and performance: the processing efficiency theory. 
Cognition and Emotion, 6, 409-434.
Eysenck, M.W., Derakshan, N., Santos, R., & Calvo, M.G. (2007). Anxiety and cognitive performance: 
attentional control theory. Emotion, 7, 336-353.
Fletcher, G. F., Balady, G. J., Amsterdam, E. A., Chaitman, B., Eckel, R., Fleg, J., et al. (2001). Exercise 
Standards for Testing and Training. Circulation (Vol. 104, pp. 1694–1740).
Frijda, N. H. (2009). Emotion experience and its varieties. Emotion Review, 1(3), 264–271.
Gorka, A. X., LaBar, K. S., & Hariri, A. R. (2016). Variability in emotional responsiveness and coping 
style during active avoidance as a window onto psychological vulnerability to stress. Physiology & 
Behavior, 158, 90–99. https://doi.org/10.1016/j.physbeh.2016.02.036
Grillon, C. (2002). Associative learning deficits increase symptoms of anxiety in humans. Biological 
Psychiatry, 51, 851-858.
Grillon, C., Ameli, R., Goddard, A., Woods, S., & Davis, M. (1994). Baseline and fear-potentiated startle 
in panic disorder patients. Biological Psychiatry, 35, 431-439.
Grillon, C., & Davis, M. (1997). Fear-potentiated startle conditioning in humans: explicit and contextual 
cue conditioning following paired vs. unpaired training. Psychophysiology, 34, 451-458.
Grillon, C., and Davis, M. (2007). Effects of stress and shock anticipation on prepulse inhibition of the 
startle reflex. Psychophysiology 34, 511–517.
Grillon, C., Lissek, S., Pine, D.S., McDowell, D., & Levenson, J. (2007). Reduction of trace but not delay 
eyeblink conditioning in panic disorder. Am J Psychiatry, 164, 283-289.
Grillon, C., Lissek, S., Rabin, S., McDowell, D., Dvir, S., & Pine, D.S. (2008). Increased anxiety during 
anticipation of unpredictable but not predictable aversive stimuli as a psychophysiologic marker of 
panic disorder. Am J Psychiatry, 165, 898-904.
Grillon, C., & Morgan, C.A. (1999). Fear-potentiated startle conditioning to explicit and contextual cues 
in Gulf war veterans with posttraumatic stress disorder. Journal of Abnormal Psychology, 108, 
134-142.
Grillon, C., Morgan, C.A., Davis, M., & Southwick, S.M. (1998). Effects of experimental context and 
explicit threat cues on acoustic startle in Vietnam veterans with posttraumatic stress disorder. 
Biological Psychiatry, 44, 1027-1036.
Grillon, C., Pine, D.S., Lissek, S., Rabin, S., Bonne, O., & Vythilingam, M. (2009). Increased anxiety 
during anticipation of unpredictable aversive stimuli in posttraumatic stress disorder but not in 
generalized anxiety disorder. Biol Psychiatry, 66, 47-53.
Guy, W. (1976). ECDEU Assessment for Psychopharmacology, Revised Edition. Rockville, MD.
Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 
32, 50-55.
Hawk, L.W., & Cook, E.W. (2000). Independence of valence modulation and prepulse inhibition of 
startle. Psychophysiology., 37, 5-12.

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
39
Heimberg, R.G. (2002). Cognitive-behavioral therapy for social anxiety disorder: current status and future 
directions. Biological Psychiatry, 51, 101-108.
Karvonen, J., & Vuorimaa, T. (1988). Heart rate and exercise intensity during sports activities. Practical 
application. Sports Medicine (Auckland, N.Z.), 5(5), 303–311.
Leotti, L. A., & Wager, T. D. (2010). Motivational influences on response inhibition measures. Journal of 
Experimental Psychology: Human Perception and Performance, 36(2), 430.
Levenson, R. W. (1994). Human emotion: A functional view. The Nature of Emotion: Fundamental 
Questions, 123–126.
Liebowitz, M.R., Schneier, F.R., Campeas, R., Hollander, E., Hatterer, J., Fyer, A., Gorman, J.M., Papp, 
L., Davies, S., Gully, R., & Klein, D.F. (1992). Phenelzine vs atenolol in social phobia: a placebo-
control led comparison. Archives of General Psychiatry, 49, 290–300.
Linden, M., Zubraegel, D., Baer, T., Franke, U., & Schlattmann, P. (2005). Efficacy of Cognitive 
Behaviour Therapy in Generalized Anxiety Disorders. Psychotherapy and psychosomatics, 74, 36-
42.
Lipp, O., & Siddle, D. (1998). The effects of prepulse-blink reflex trial repetition and prepulse change on 
blink reflex modification at short and long lead intervals. Biological Psychology, 47, 45-63.
Lissek, S., Levenson, J., Biggs, A., Johnson, L.L., Ameli, R., Pine, D.S., & Grillon, C. (2008). Social 
anxiety disorder is associated with elevated fear-conditioning to socially relevant unconditioned 
stimuli. Am J Psychiatry, 165, 124-132.
Lissek, S., Rabin, S., Heller, R.E., Lukenbaugh, D., Geraci, M., Pine, D.S., & Grillon, C. (2010). 
Overgeneralization of conditioned fear as a pathogenic marker of panic disorder. Am J Psychiatry, 
167, 47-55.
Marks, I.M., & Mathews, A.M. (1979). Brief standard self-rating for phobic patients. Behav Res & Ther, 
17, 263-267.
McTeague, L.M., Lang, P.J., Laplante, M.-C., Cuthbert, B.N., Strauss, C.C., & Bradley, M.M. (2009). 
Fearful imagery in social phobia: generalization, comorbidity, and physiological reactivity. 
Biological Psychiatry, 65, 374-382.
Meyer, T.J., Miller, M.L., Metzger, R.L., & Borkovec, T.D. (1990). Development and validation of the 
Penn State Worry Questionnaire. Behav Res Ther, 28, 487-495.
Newman, S.G., Trabert, W., & Roth, W.T. (1994). Does behavioral treatment of social phobia lead to 
cognitive changes? Behavior Therapy, 25, 503-517.
Otto, M.W., & Deveney, C. (2005). Cognitive-behavioral therapy and the treatment of panic disorder: 
efficacy and strategies. The Journal of clinical psychiatry, 66, 28-32.
Peterson, R.A., & Reiss, S. (1992). Anxiety Sensitivity Index Manual (2nd Edition). Worthington, OH: 
International Diagnostic Systems.
Robinson, O. J., Krimsky, M., & Grillon, C. (2013). The impact of induced anxiety on response inhibition. 
Frontiers in Human Neuroscience, 7, 69. https://doi.org/10.3389/fnhum.2013.00069
Robinson, O.J., Overstreet, C., Letkiewicz, A.M., & Grillon , C. (in press). Depressed mood enhances 
anxiety to unpredictable threat. Psychol Med.
Shackman, A. J., Sarinopoulos, I., Maxwell, J. S., Pizzagalli, D. A., Lavric, A., & Davidson, R. J. (2006). 
Anxiety selectively disrupts visuospatial working memory. Emotion, 6, 40–61. 
Smallwood, J., Davies, J. B., Heim, D., Finnigan, F., Sudberry, M., O'Connor, R., et al. (2004). Subjective 
experience and the attentional lapse: task engagement and disengagement during sustained 
attention. Conscious. Cogn. 13, 657–690.

Title: Predictability and Aversive Expectancies in Anxiety and Depressive Disorders
10/04/2021
03-M-0093
40
Spielberger, C.D. (1983). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting 
Psychologist Press.
Sztajzel, J. (2004). Heart Rate Variability. Swiss Med Wkly, 134, 514–522.
Turner, S.M., Beidel, D.C., Colley, M.R., Woody, S.R., & Messer, S.C. (1994). A multicomponent 
behavioral treatment for social phobia: Social effectiveness therapy. Behavioral Research and 
Therapy, 32, 381-390.
Verbruggen, F., & Logan, G. D. (2008). Response inhibition in the stop-signal paradigm. Trends in 
Cognitive Sciences, 12(11), 418–424. https://doi.org/10.1016/j.tics.2008.07.005
Vytal, K., Cornwell, B., Arkin, N., & Grillon, C. (in press). Describing the interplay between anxiety and 
cognition: From impaired performance under low cognitive load to reduced anxiety under high 
load. Psychophysiology.
Vytal, K.E., Cornwell, B.R., Arkin, N.E., Letkiewicz, A.M., and Grillon C. (2013). The complex 
interaction between anxiety and cognition: Insight from spatial and verbal working memory. 
Front. Hum. Neurosci. 7:93. doi: 10.3389/fnhum.2013.00093.
Watson, D., Clark, L.A., & Tellegen, A. (1988). Development and validation of brief measures of positive 
and negative affect:  the PANAS scales. Journal of Personality and Social Psychology, 54, 1063-
1070.
Yerkes, R.M., & Dodson, J.D. (1908). The relationship of strength of stimulus to rapidity of habit-
formation. Journal of Comparative and Neurological Psychology, 18, 459-482.