BEHAVIORTHERAPY29, 675~590, 1998

Clinical Applications of Bioinformational Theory:

Understanding Anxiety and Its Treatment
E D N A B. FOA

MICHAEL J. KOZAK
Allegheny University of the Health Sciences

This paper considers the clinical applications of the bioinformational theory of emo-
tion developed by Peter Lang and his colleagues over the past 30 years. Three aspects
of this body of work are discussed: the conceptual framework, the methods that were
developed to examine the theoretical concepts, and the empirical data that were de-
rived from these methods. The myriad contributions of bioinformational theory to
three areas of clinical application are reviewed: assessment, diagnosis, and treatment.
It is concluded that bioinformational theory has furthered our understanding of emo-
tion, especially anxiety, and that the theory's recent developments in the area of basic
neurophysiological substrata of affect hold promise for continued clinical application.

In this paper we reflect upon the clinical applications of the bioinforma-

tional theory of emotion developed by Peter Lang and his colleagues over the
past 30 years. For the purpose of this discussion, we find it illustrative to
divide this research into an earlier phase that took place in the 1960s and
1970s and a later phase, in the 1980s and 1990s. We examine here the clinical
relevance of three aspects of this body of work: the conceptual framework,
the methods that were developed to examine the theoretical concepts, and the
empirical data that were derived from these methods. In so doing, we con-
sider three types of clinical application: assessment, diagnosis, and treatment.

Early Work: 1960s and 1970s

The Conceptof Fear
Lang's earlier conceptual and empirical research was much influenced by
his interest in treatment of specific phobia, in particular systematic desensiti-

This chapter was supported in part by grants from NIMH MH45404, MH49340, and MH42178
awarded to the first author. The authors would like to thank Peter Lang and Gregory Miller for their
critical reading of an earlier draft, and Bart Brigidi for his assistance in preparing this paper.
Correspondence should be directed to Edna B. Foa, Center for the Treatment and Study of
Anxiety, Allegheny University of the Health Sciences, 3200 Henry Avenue, Philadelphia, PA
19129; (215) 842-4010; e-mail: foa@auhs.edu

675 005-7894/98/0675-069051.00/0
Copyright 1998by Associationfor Advancementof BehaviorTherapy
All rightsfor reproductionin any formreserved.
676 FOA & KOZAK

zation (Wolpe, 1952) and flooding (Marks, 1972; Stampfl & Levis, 1967).
During this phase, he construed fear as a constellation of responses in three
systems: physiological, verbal, and behavioral (Lang, 1968). Exploring the
mechanism of systematic desensitization, Lang, Melamed, and Hart (1970)
found that concordance between high autonomic arousal and self-reported
distress during fear imagery predicted good outcome of treatment. Patients
who did not show such concordance benefited less from treatment. These
results led Lang to propose that assessment of multiple response systems is
particularly important for understanding fear.
In a seminal paper on the nature of fear and its reduction via therapy, Lang
(1977) conceptualized fear as a cognitive structure that serves as a program
for escaping danger and that involves information about fear stimuli and
about fear responses. The theory emphasized the important role of informa-
tion about responses in the activation of the fear structure. In a later paper
entitled "A Bio-Informational Theory of Emotional ImageryS Lang (1979)
expanded his theoretical framework to include representations of semantic
meaning in the fear structure. The addition of the meaning concept enhanced
the relevance of the theory to clinical phenomena that are rife with semantic
meaning.
Lang's (1979) introduction of the concept of meaning provided a spring-
board for Foa and Kozak (1985, 1986) to extend the bioinformational con-
cepts into a theory of pathological anxiety and the anxiety disorders. In so
doing, they elaborated the concept of meaning to encompass semantically as
well as nonsemantically coded information about stimuli, responses, and the
relationships among them. They suggested that meaning can be coded not
only in semantic units, but also in stimulus-stimulus (S-S) and stimulus-
response (S-R) associations, and proposed that when such associations mis-
represent relationships in the world, the coded meaning is erroneous. This
view of meaning is consistent with Rescorla's (1988) conceptualization of
conditioning as involving a change in the nonsemantic meaning of the condi-
tioned stimulus. The idea that emotionally relevant meaning can be coded
nonlinguistically is also compatible with LeDoux's (1996) conclusion that
"emotional responses can occur without the involvement of the higher pro-
cessing systems of the brain, systems believed to be involved in thinking, rea-
soning, and consciousness" (p. 161).
Fear and Its Pathological Forms
As mentioned above, Lang's (1979) innovative bioinformational theory of
emotions conceptualizes fear as a cognitive structure that serves as a program
for escaping danger. By combining stimulus and response elements into a
construct of fear, it integrated information processing and biological
approaches to emotion and transcended conditioning concepts that relied on
emotional responses to "internal" stimuli. However, because the theory does
not hypothesize specific meanings associated with particular emotions, bioin-
formational theory does not inform us how to distinguish fear from other cog-
 UNDERSTANDING ANXIETY 677

nitive structures that involve response elements (Kozak & Miller, 1982). Foa
and Kozak (1986) argued that if a fear structure is a program for escaping
danger, then it must contain information about the threat associated with
stimuli and/or responses. They further suggested that a fear structure is distin-
guished from other information structures not only by response elements, but
also by certain meaning information it contains. Thus, the response programs
for running ahead of a baton-carrying competitor in a race (non-fear struc-
ture), and for running ahead of a club-carrying assailant on a racetrack (fear
structure) involve similar stimulus and response information. What distin-
guishes the fear structure is the meaning of the stimuli and responses: Only
the fear structure involves escape from threat.
The emphasis in bioinformational theory has been on physiological analy-
sis of different anxiety disorders rather than on the distinction between nor-
mal and pathological fear. Foa and Kozak (1986) focused on the concept of
meaning to develop this distinction. Most people experience fear in some cir-
cumstances, which implies the "running" of a fear program. "Normal" fear
occurs when one perceives actual threat, and such fear disappears when the
danger is removed. When does a fear become pathological? Foa and Kozak
(1986) suggested that several characteristics distinguish pathological fear.
First, fear becomes pathological when it is disruptively intense: The fear
structure involves excessive response elements, such as information about
escape and physiological responses, and these responses are resistant to mod-
ification. Second, this structure includes unrealistic elements: Some of the S-S
associations do not accurately represent the world. Third, associations
between harmless stimuli and escape or avoidance responses occur in a
pathological fear structure. Foa and Kozak (1985) further proposed that sev-
eral types of erroneous evaluations or interpretations can be evidenced in the
fear structures of individuals who exhibit pathological anxiety, only some of
which involve semantic representations. For example, most anxious individu-
als commonly conceive that their anxiety will persist forever unless they
escape the feared situation. These individuals also perceive the fear stimuli
and/or the fear responses as having extremely high potential for causing psy-
chological or physical harm.
What is the relationship between such fear structures and the anxiety disor-
ders? Several researchers have suggested that chronic disorders reflect patho-
logical cognitive structures (cf. Williams, Watts, MacLeod, & Matthews,
1988). Consistent with this view, Foa and Kozak (1985) proposed that the
various anxiety disorders can be viewed as reflecting characteristic patholog-
ical fear structures. For example, erroneous interpretations of fear responses
seem to distinguish the structure of agoraphobia from that of simple phobia.
Agoraphobics commonly construe anxiety itself to be dangerous, expecting
anxiety responses to cause physical or psychological harm. For an agorapho-
bic, stimulus elements such as supermarkets are not interpreted as intrinsi-
cally threatening. Rather, the danger is perceived to lie in the anxiety-related
sensations that they evoke. In contrast, for simple phobics, the potential harm
678 FOA & KOZAK

stems from the stimulus situation itself, such as snakes, spiders, or dogs. Fig-
ure 1 depicts a schematic model of an agoraphobic fear structure, following
Lang, Cuthbert, and Bradley (1998, p. 657).
This figure illustrates that responses such as suffocation and tachycardia, but
not stimuli such as supermarkets, are associated with the meaning of danger.
Foa and Jaycox (in press; see also Foa and Rothbaum, 1997) have sug-
gested that, like the other anxiety disorders, posttraumatic stress disorder
(PTSD) can be construed as reflecting a fear memory that contains erroneous
elements. Accordingly, the traumatic event is represented differently in the
memory of a victim who remains disturbed than in a victim who recovers.
Figure 2 illustrates a schematic model of a memory structure of a rape victim
with chronic PTSD.
First, like other pathological fear structures, it involves information about
excessive responses such as avoidance, escape, and physiological responses.
These are represented in the diamond that denotes PTSD symptoms. Second,
this structure includes erroneous S-S associations that do not accurately rep-
resent the world, such as the association between "gun" and "bald men?'
Third, the structure includes erroneous associations between harmless stimuli
such as "bald," "home," and "suburbs," and the meaning "dangerous." The
erroneous associations at the right side of the figure are also found in specific
phobics, but the number of stimulus-threat associations is hypothesized to be
particularly large in PTSD. The left side of the figure represents erroneous
associations between response elements and the meaning "incompetence;'
and those are thought to distinguish PTSD from other anxiety disorders.
In summary, bioinformational theory provided a firm conceptual founda-
tion for understanding fear as a cognitive structure, and for a rich panoply of

, °e I Indefinitely I,I n0er I

Death
I /

Attack
FIG. 1. The solid lines represent realistic associations and the dotted lines represent patho-
logical associations. The ovals represent stimulus elements, the diamonds represent response
elements, and the rectangles represent meaning elements.
 U N D E R S T A N D I N G ANXIETY 679

I Afraid J ,, J UncontroJlabJeJ~

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, , ~\ ~ymptoms~ "-. \ \ \ \ I / ,
' "- "- , \ / I ;,
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L-I C°nfused t - - I Inc°mpetentl
FIG. 2. The solid lines representrealistic associationsand the dotted lines representpatho-
logical associations.The ovals represent stimulus elements, the diamonds represent response
elements, and the rectanglesrepresent meaningelements.

derivative hypotheses. However, because it did not specifically address the

distinguishing role of meaning in fear pathology and its clinical manifesta-
tions in the various anxiety disorders, some additional theorizing about patho-
logical fear structures was required to support clinical applications. Foa and
Kozak's (1985, 1986) emotional processing theory complemented Lang's key
bioinformational concepts by: (a) providing a framework for differentiating nor-
mal and pathological fear, and (b) conceptualizing the various anxiety disorders
as involving specific fear structures that differ in the types of their erroneous
associations. Expanding the concept of meaning to encompass S-S and S-R
associations allowed emotional processing theory to accommodate the clinical
observation that perceptions of threat often occur without linguistic support.
Assessment and Diagnosis of Anxiety Disorders
Bioinformational theory has contributed significantly to the assessment of
fear and its clinical manifestations. Lang and his colleagues developed an
emotional-imagery paradigm in which subjects were trained to focus espe-
cially on either stimulus details or on response elements. They were then
assessed via scripts laden with either stimulus descriptions only or with both
stimulus and response descriptions. Subjects received low-threat, low-activity
material, called neutral scenes (e.g., sitting quietly on a sandy beach), low-
threat, high-activity material, called action scenes (e.g., riding a bicycle), and
high-threat material (e.g., confronting a poisonous snake). Several experi-
ments with this procedure were conducted by Lang and his colleagues, yield-
ing results of clinical import.
680 FOA & KOZAK

The first two experiments examined hypotheses about the nature of fear
structures. Consistent with bioinformational theory, the emphasis on response
elements in training and scripts enhanced affective engagement during imag-
ery, as indicated by self-ratings and physiological responses (Lang, Kozak,
Miller, Levin, & McLean, 1980). Two additional experiments used the imag-
ery paradigm to examine snake-phobic and socially anxious student volun-
teers (Lang, Levin, Miller, & Kozak, 1983). After response-oriented training,
both groups showed enhanced emotional reactions to scripts that included
response elements, especially when the phobic material was personally rele-
vant. Interestingly, the socially anxious subjects showed affective physiology
during imagery of the social situations, but not of snake scenes; the snake
phobics responded emotionally to both types of scenes. The relationship
between imagery ability, as measured by a Questionnaire Upon Mental Imag-
ery (QMI: Sheehan, 1967) and affective responding during imagery was also
explored via the imagery paradigm. The imagery questionnaire did not pre-
dict emotional response during imagery before training. After training, how-
ever, "good" but not "poor" imagers showed a marked increase in emotional
response during imagery (Miller et al., 1987).
As noted by Lang et al. (1998), the imagery paradigm described above was
subsequently used to investigate differences among patients with simple pho-
bias, social phobia, and agoraphobia (Cook, Melamed, Cuthbert, MacNeil, &
Lang, 1988). Patients with simple phobias showed greater cardiac and elec-
trodermal changes during imagery of their phobic material than did the other
phobic groups, especially those with agoraphobia. In addition, their scores on
an imagery questionnaire (QMI) were more related to their physiological
reactions during phobic imagery than were the QMI scores of the other two
groups. Cook et al. (1988) interpreted these results to indicate that the fear
structures of agoraphobics are less coherent than those of simple phobics. For
Lang, decreased coherence means that the "networks were less well-orga-
nized around specific cues" or that the "connections between language repre-
sentations and efferent programs may be weaker" (Lang et al., 1998, p. 667),
reflecting a view of meaning as represented linguistically in the fear struc-
ture. In their clinical application of the theory, Cook et al. tested the general
hypothesis that fearful individuals would exhibit fear to personally relevant
fear material. When differences among diagnostic groups emerged, Cook et
al. proposed that structural coherence differed among anxiety disorders, with
simple phobics having the most coherent structure and agoraphobics the
least. These findings have recently been replicated in a new Florida sample
(Lang, personal communication, 1998).
Mansueto and Foa (described in Foa, 1988) used a variant of the imagery
paradigm to examine hypothesized differences between the fear structures of
patients with simple phobia and agoraphobia. Specifically, they hypothesized
that patients with agoraphobia, but not those with simple phobia, would
exhibit fear during imagery of the idiosyncratic interoceptive cues (e.g., auto-
nomic responses) associated with fear. Patients were presented with four
types of scripts: neutral, external threat, interoceptive threat, and external-
 UNDERSTANDING ANXIETY 681

plus-interoceptive threat. The threat scripts were individualized for each sub-
ject. Figures 3 and 4 illustrate the results.
As predicted, simple phobics reported less fear and showed less skin con-
ductance for neutral and interoceptive scripts than for stimulus and combined
scripts; agoraphobics reacted more intensely to all three types of threat scripts
than to neutral scripts• Notably, the response of agoraphobics to the stimulus-
only scripts and to the stimulus-plus-interoceptive scripts seem consistent
with the clinical picture of agoraphobics, but inconsistent with the findings of
Cook et al. (1988)• One conjecture about this inconsistency is that the scripts
in the Mansueto and Foa study (described in Foa, 1988) may have been more
matched to response-elements of the study participants, and the Cook et al.
scripts more matched to stimulus elements. If, as we have hypothesized, it is
the meaning of response elements that distinguishes agoraphobic fear struc-
tures, then matching on personally relevant response elements might be espe-
cially important for fear activation.
Variants of the imagery paradigm developed by Lang and his colleagues
have contributed to the understanding of PTSD (e.g., Blanchard et al., 1996;
Orr & Pitman, 1993; Pitman, Orr, Forgue, Altman, de Jong, & Herz, 1990).
To illustrate the usefulness of this approach, we will summarize some studies
conducted by Pitman and his colleagues. In two studies assessing World War
II and Vietnam veterans with and without PTSD, those with PTSD showed
larger physiological reactions (cardiac, electrodermal, and electromyo-
graphic) to individualized combat scripts than to non-combat scripts (Orr,

5.

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Agoraphobics Simple Phobics
FIG. 3. Self-reported fear exhibited by individualswith agoraphobia and simple phobia
during imageryof scripts describingneutral,fear-relatedinteroceptiveresponses, fearedstim-
uli. and combinedfear stimuliand responses.
682 FOA & K O Z A K

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Agoraphobics Simple Phobics
Fla. 4. Spontaneous fluctuations exhibited by individuals with agoraphobia and simple
phobia during imagery of scripts describing neutral, fear-related interoceptive responses, feared
stimuli, and combined fear stimuli and responses.

Pitman, Lasko, & Herz, 1993). In another study, female survivors of child-
hood sexual abuse with current PTSD showed larger reactions during abuse-
related imagery than did survivors with past PTSD and survivors who never
had PTSD; the two latter groups did not differ from one another (Orr et al.,
1997). Diagnostic utility of the imagery paradigm is suggested by the finding
that physiological responsiveness to trauma imagery predicted PTSD diagno-
sis in Vietnam combat veterans (sensitivity: 71%; specificity: 100%; Pitman
et al., 1990).
The ease with which trauma victims can feign PTSD simply by endorsing
the relevant symptoms during a diagnostic interview has raised concern,
especially in forensic psychiatry. This issue prompted Orr and Pitman (1993)
to examine whether physiological reactivity could better discriminate indi-
viduals with and without PTSD than could self-report. They described PTSD
symptoms to veterans without PTSD and asked them to imagine individual-
ized war scripts as if they had the disorder. Group means for physiological
responding during imagery discriminated non-PTSD veterans, non-PTSD
veterans who were trying to simulate emotional reactions, and veterans with
current PTSD. However, discriminant analysis indicated the limited capacity
of this method to identify group membership accurately: specificity was 75%.
Taken together, the above-mentioned studies demonstrate the applicability
of the imagery paradigm to clinical assessment. The group differences found
in the various studies suggest that patients with anxiety disorders show
heightened reactivity when they imagine their feared material. Usually, an
 UNDERSTANDING ANXIETY 683

interview yields sufficient information for diagnosis and treatment planning,

and physiological assessment is superfluous. Sometimes, however, a patient
is unable to provide sufficient description of the fear to allow strong infer-
ences about his or her underlying fear structure. Clinician-developed hypo-
theses about the patient's fear structure might then be tested via psycho-
physiological assessment using the imagery paradigm developed by Lang
and his colleagues.
Understanding Mechanisms of Therapy
In 1977, Lang discussed the mechanisms involved in systematic desensiti-
zation, suggesting that, "the psychophysiological structure of the imagined
scenes may be a key to the emotional processing which the therapy is
designed to accomplish" (p. 863). Foa and Kozak (1985, 1986) elaborated
the concept of emotional processing, proposing that successful therapy
involves correcting the pathological aspects of fear structures, and that this
correction is the essence of emotional processing. They further proposed
that, regardless of the type of therapeutic intervention, two conditions are
required for emotional processing to occur. First, following Lang, they
argued that the fear structure needs to be activated by means of fear-relevant
information, because if the fear structure remains unaccessed, it will not be
available for modification. Second, they proposed that corrective informa-
tion incompatible with the pathological elements of the fear structure must
also be available.
Foa and Kozak (1986) identified three indicators of emotional processing
that are associated with successful outcome of exposure treatment. First,
patients who improve with therapy show fear on both physiological and self-
report measures, indicating that the fear structure has been activated (cf. Lang
et al., 1970). Second, their reactions decrease gradually upon confrontation
with feared images, objects, or situations. Third, their initial fear reaction at
each exposure session decreases across successive sessions. Several studies
point to validity of these indicators (Borkovec & Sides, 1979; Kozak, Foa, &
Steketee, 1988; Lang et al.; Watson & Marks, 1971)
More recently, patients' facial expressions have also been found to indicate
emotional processing during exposure therapy (Foa, Riggs, Massey, & Yarc-
zower, 1995). Female assault victims with PTSD were treated with imaginal
reexperiencing of the assault. Heightened facial expression of fear during
exposure predicted greater improvement with treatment. In a more recent
study, Jaycox, Foa, and Morral (in press) found that patterns of self-rated dis-
tress during imaginal reliving of the assault were indicators of emotional pro-
cessing. These results are illustrated in Figure 5.
A cluster analysis revealed three response patterns: (a) high distress in the
first session and gradual decline over the remaining sessions; (b) high distress
during the first session and no decline over sessions; (c) moderate distress dur-
ing the first session and no change over sessions. As would be predicted by
the indicators of activation and habituation, patients from the first group
684 FOA & KOZAK

90
80
> 70
-J
#) 60 nigh Engagers,
a Non-llabiluators (E/NH)
50 (N=I4)
u~
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Low Engagers,
2 30 Non-Ilabilualors (NE/NH)
(N=9)
< 20
nigh Engngers,
10
IIabituators (E/H)
0 i (N=14)
2 3 4 5 6

Sessions

FIG. 5. Average Subjective Units of Distress (SUDs) during reliving within each cluster.

improved more after treatment than did patients belonging to the other two
groups.
In summary, just as bioinformational theory provided a springboard for the
understanding of anxiety disorders and led to innovations in their assessment
and diagnosis, it also provided a foundation for understanding the therapeutic
mechanisms for modifying pathological fear. We suspect that the mecha-
nisms of emotional processing of fear that have been found to operate in
exposure therapy also underlie other effective therapeutic procedures for anx-
iety disorders: Providing information to evoke the fear structure and to cor-
rect its pathological aspects may be fundamental to emotional processing and
successful outcome.

Later Work: 1980s and 1990s

Lang's earlier work was inspired by clinical observations, primarily about
fear and its reduction via behavioral treatments. The theory of fear that grew
from these observations was developed into a theory of emotion. In the more
recent work, this development was abetted by Lang's application of a three-
dimensional approach to the analysis of linguistic meaning: valence, arousal,
and control (Mehrabian & Russell, 1974; Osgood, Suci, & Tannenbaum,
1957). Accordingly, Lang (1984) suggested that the emotional states them-
selves can be mapped along these same three dimensions and that physiolog-
ical patterns and other expressive behavior might be analyzed on the three
dimensions, just as can self-reports. Some experimental support for the three-
dimensional approach comes from a psychophysiological study of aversive
conditioning (Hodes, Cook, & Lang, 1985). In this study, slides were paired
with noise and postconditioning judgments of the slides were obtained. Con-
ditioned cardiac acceleration was associated with ratings of more negative
 U N D E R S T A N D I N G ANXIETY 685

valence, higher arousal, and lower control. Lang argued that although much
of the variance in the linguistic studies could be explained by two dimensions
(arousal and valence), " . . . the measurement of dominance has sometimes
proved crucial in making the simpler, bipolar model work. For example,
anger and fear situations were both shown to involve high arousal and low
pleasure ratings. Discrimination between them depended upon the subject's
dominance ratings, which were low in fear and high in response to the anger
context" (Lang, 1985, p. 136).
Clearly, the recent development of bioinformational theory has focused on
the architecture of brain circuits that subserve emotion (Lang et al., 1998).
The idea that emotions are action dispositions (Lang, 1977, 1979) offered a
conceptual link between hypotheses of image structures, and concern with
the primary motivational systems in the brain. Response elements in the cog-
nitive structure provide a theoretical link to primitive response systems.
Guided by the three-dimensional approach to emotions (i.e., valence,
arousal, and control), Lang and his colleagues developed a library of pictorial
stimuli for evoking emotion. The pictures represent normed variations along
the three dimensions (Center for the Study of Emotion and Attention, 1996).
These pictures, which are in the public domain and in widespread use, consti-
tute a significant advance over the widespread tradition of creating ad hoc
stimulus materials for various experiments on emotion. Additionally, they
have found significant application as emotion primers for the study of pri-
mary motivational systems via a startle paradigm. In this paradigm, subjects
are presented with cues (e.g., pictures or scripts) that vary on the dimensions
of arousal, control, and valence. Magnitude of the startle response to an
acoustic or visual probe is hypothesized to reflect the activity of primary
motivational systems (for details, see Lang et al., 1998).
For Lang and his colleagues, the startle-probe has become the favored
method of assessing emotion and has largely succeeded the imagery para-
digm from the earlier work. Perhaps because of the theory's particular inter-
est in primary motivational systems, a primitive reflex system has been
selected as an investigational tool. Lang hypothesized that activation of the
aversive system would increase startle magnitude, and that appetitive activa-
tion would decrease it (Vrana, Spence, & Lang, 1988). This hypothesis has
been supported by the finding that startle magnitude decreases, and latency
increases, from negative, neutral, through positive valences (see Lang et al.,
1998). Thus, startle magnitude can be seen as an index of affective valence
that reflects the activation of primary motivational systems.
More recently, the arousal and valence dimensions of linguistic meaning
predominated in explaining activation of primary motivational systems. In
fact, Lang's most recent description of the International Affective Picture sys-
tem mentions only the arousal and valence dimensions (1998, p. 664). The
control dimension seems to have a lesser role in the more recent work.
Although Lang (personal communication, 1998) has not revised his 1985
view that the dominance dimension is sometimes "crucial" for differentiating
686 FOA & KOZAK

certain affective states, the later work focuses particularly on arousal and
valence.
The more recent focus on arousal and valence derives from findings that
responses to a variety of emotional pictures resolve into two factors, valence
and arousal (Lang et al., 1998, p. 666 and Table 1). No control factor emerged
in this factor analysis. Lang concluded that the two factors indicate which
specific motivational system (i.e., appetitive or defensive) is being engaged,
and the intensity of such engagement. However, further attention to the con-
trol dimension might still be productive. It is possible that the pictures used in
the study may reflect a limited variety of affective states, and thus reflect a
restricted range along the control dimension, resulting in experimental insen-
sitivity to its import.
Clinical Applications of the Later Work
We have described several clinical applications of the early developments
in bioinformational theory. What about the later work? There has been some
experimental attention to applying this later work to psychopathology, espe-
cially anxiety and phobia. As is apparent from Lang et al. (1998), one line of
research investigated the hypothesis that anxious individuals show enhanced
activation of the aversive motivational system. Consistent with this hypothe-
sis, specific phobic volunteers were indeed found to show larger startle poten-
tiation by fear-related slides than did nonphobics (Harem, Cuthbert, Globisch,
& Vaitl, 1997; Sabatinelli, Bradley, Cuthbert, & Lang, 1996). Conversely, psy-
chopaths did not exhibit the usual startle potentiation by aversive pictures
(Patrick, Bradley, & Lang, 1993).
The Psychopathology of Fear and the Startle Probe
The startle probe paradigm involves both cortical (slides, text) and sub-
cortical (tone probe) stimulus processing, as well as lower-level efferent
output (blink reflex; Lang, 1998). Various paradigms that have been used to
study attention and memory processes in anxiety (see Eysenck, 1992)
involve higher-level activity for both input and output processes. If S-R
links are bidirectional in cortical and subcortical systems, stimulus infor-
mation characterized by negative valence and high arousal would be
expected to activate responses from the subcortical aversive system. How-
ever, subcortical response-information might also evoke associated stimu-
lus elements. The findings that anxious individuals show enhanced startle
potentiation by their feared material stand in intriguing juxtaposition with
the findings that anxious individuals show preferential allocation of cogni-
tive resources to threat material (Eysenck). Perhaps, then, proneness to acti-
vation of the primitive aversive motivational system supports cognitive
biases found in anxious individuals. Thus, Lang's contemporary insights
about aversive motivational systems and the findings from the startle probe
experiments may converge with results on information processing biases in
anxiety disorders.
 UNDERSTANDING ANXIETY 687

Assessment and Diagnosis of Anxiety Disorders

The startle probe paradigm has been adopted to study differences among
anxiety disorders (this study is discussed in Lang, et al., 1998). Several clini-
cal questions were addressed: Do basal startle or startle habituation distin-
guish anxiety disorders from one another? Does magnitude of startle potenti-
ation by personally relevant threat material differentiate anxiety disorders? Is
severity of general psychopathology associated with startle potentiation?
Results indicated that basal startle was higher in PTSD and panic than in spe-
cific phobics and controls, but the reverse held true for magnitude of startle
potentiation. Unexpectedly, startle potentiation did not distinguish specific
phobia and social phobia from nonphobic controls. The authors interpreted
their results to indicate an association between basal startle and severity of
psychopathology. Since correlational analyses of the association of startle
and psychopathology were not reported in the paper, this interesting hypothe-
sis awaits further exploration.
Given the theoretical thrust of the startle paradigm, it is not surprising that
startle has difficulty discriminating anxiety disorders. Indeed, the startle is an
indicator of activation of the aversive motivational system, not of the nuances
of meaning that are inherent in the diagnostic definitions of different anxiety
disorders, which are primarily defined according to the type of threat. As
noted earlier, startle's theoretical link to meaning is through valence, which
captures only one aspect of meaning. The absence of the control dimension in
the interpretation of the startle probe results necessarily uncouples this para-
digm from the uncontrollability that is conventionally hypothesized as rele-
vant to anxiety and depressive affect (Barlow, 1988; Foa, Zinbarg, & Roth-
baum, 1992; Seligman, 1975).

Fostering the Clinical Application:

Recent Developments in Bioinformational Theory
Recent developments in bioinformational theory have realized some clini-
cal application. What sort of elaboration might foster further applications? In
the area of diagnosis, the theory would need to specify what clinical diagnos-
tic observations are of interest, and how the activity of the primary motiva-
tional systems bears upon diagnostic observations. For example, one might
identify reactivity to emotional material as a diagnostic dimension of interest
that cuts across a subset of traditional diagnostic categories. One might then
hypothesize that greater reactivity is driven by higher tonic activity of the
aversive motivational system and that high reactors show more severe pathol-
ogy, irrespective of their conventionally diagnosed disorder. Such hypotheses
are testable in clinical populations and could be of great practical importance.
The efficacy of treatment, then, might be evaluated not only by reduction of
traditionally definitive symptoms, but also by whether treatment influenced
motivational system activity. Accordingly, persistence of tonic overactivity
may have implications for relapse prevention. The question of the malleabil-
688 FOA & KOZAK

ity of such overactivity via pharmacotherapy and psychotherapy would then

become a topic for study.
In the later theorizing, Lang, Bradley, and Cuthbert (1997) used the meta-
phor of strategy versus tactics to illuminate a distinction between functions of
the primary motivational systems and specific behavioral occurrences in vari-
ous contexts. Accordingly, emotion is "organized around a motivational
base" but the demands of context "'variously shape affective expression" (p.
101). Although a theoretical reduction of emotion into two primary motiva-
tional systems is useful in mapping psychological constructs onto established
physical systems, it may sacrifice the psychological resolution required to
accommodate the complex variety of clinically interesting emotional expres-
sion. Although Lang assigns the burden of this resolution to "contextual tac-
tics," explanations of these tactics have not been developed, and the contextual
determinants of phenomena of clinical importance are considered sources of
"noise" in the study of emotion (Lang et al., 1997, p. 101). Although this
might be a rather challenging enterprise, perhaps a theory of tactics must be
developed to permit greater application of Lang's later work to clinical phe-
nomena. For example, a theory of tactics would be relevant to understanding
when an aversive stimulus prompts anger and when it prompts fear.

Summary
Lang's earlier research on anxiety was motivated by problems that arose in
the clinic with the treatment of phobia. Consequently, both the theory and the
methods to test derivative hypotheses provided a natural springboard for fur-
ther theoretical and practical elaborations of clinical relevance. The later
developments in bioinformational theory have been less connected with clin-
ical phenomena. It appears that the earlier focus on clinical phenomena has
shifted toward a greater interest in more basic science, with an emphasis on
elucidating neurophysiological substrata of motivational systems. A natural
consequence of such a shift would be greater distance of new theoretical
developments from the practical realm of clinical applications. We look for-
ward to further theoretical elaboration and experimental investigation of the
relationship between the recent basic theoretical advances in bioinfor-
mational theory and the variety of emotional phenomena observed in clini-
cal contexts.

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RECEIVED: February 10, 1998

ACCEPTED: June 8, 1998