Journal of Anxiety Disorders 41 (2016) 521

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

Fear of the unknown: One fear to rule them all?

R. Nicholas Carleton
Anxiety and Illness Behaviours Laboratory, Department of Psychology, University of Regina, Regina, SK, Canada

a r t i c l e i n f o a b s t r a c t

Article history: The current review and synthesis was designed to provocatively develop and evaluate the proposition that
Received 17 February 2016 fear of the unknown may be a, or possibly the, fundamental fear (Carleton, 2016) underlying anxiety and
Received in revised form 26 March 2016 therein neuroticism. Identifying fundamental transdiagnostic elements is a priority for clinical theory and
Accepted 26 March 2016
practice. Historical criteria for identifying fundamental components of anxiety are described and revised
Available online 29 March 2016
criteria are offered. The revised criteria are based on logical rhetorical arguments using a constituent
reductionist postpositivist approach supported by the available empirical data. The revised criteria are
Keywords:
then used to assess several fears posited as fundamental, including fear of the unknown. The review and
Fear of the unknown
Intolerance of uncertainty
synthesis concludes with brief recommendations for future theoretical discourse as well as clinical and
Anxiety non-clinical research.
Neuroticism 2016 The Author. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
Fundamental fears license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction 1.1. Determining anxiety

One fear to rule them all, one fear to nd them, one fear to bring
them all and in the black box bind them. The pastiche of Tolkiens
text (1954) represents an ideal place to begin a review and synthe-
sis designed to provocatively develop and evaluate the proposition
that fear of the unknown may be a, or possibly the, fundamental
fear underlying anxiety and therein neuroticism (Carleton, 2016;
p. 39). Fear of the unknown (FOTU) will be dened herein as, an
individuals propensity to experience fear caused by the perceived
absence of information at any level of consciousness or point of pro-
cessing; relatedly, intolerance of uncertainty (IU) will be dened
as, an individuals dispositional incapacity to endure the aver-
sive response triggered by the perceived absence of salient, key,
or sufcient information, and sustained by the associated percep-
tion of uncertainty. (Carleton, 2016; p. 31). The paper begins with
a brief historical overview of anxiety determinants and hierarchical
models for anxiety and fear. The original criteria for fundamental
fears are presented as foundations for contemporary revisions. The
revised criteria are then used to assess several fears posited as fun-
damental, including fear of the unknown. The paper concludes with
brief recommendations for future theoretical discourse as well as
clinical and non-clinical research.
E-mail address: Nick.Carleton@uregina.ca
Psychologists have sought fundamental determinants of cog-
nitions, behaviours, personalities, and pathologies since Wundt.
Contemporary textbooks describe psychology as a science dedi-
cated to understanding the multiple determinants of cognitions,
behaviours, and emotions (e.g., Gerrig, Zimbardo, Desmarais, &
Ivanco, 2011; Lilienfeld et al., 2015). Many psychologists rely on
a constituent reductionist postpositivist philosophy of science in
such efforts; oversimplied, the approach identies increasingly
fundamental components of a construct (i.e., constituent reduc-
tionism), without ignoring the emergent properties, and while
accepting an underlying reality that can be measured or understood
by progressive but imperfect approximations (i.e., postpositivism).
Identifying fundamental components has broadly beneted many
scientic elds (e.g., chemistry, biology, physics). Such practices
t well with structuralism and functionalism (Munger, 2003), and
Gestalt researchers acknowledge progressive reductionism as ben-
ecial, caveating costs to understanding complex whole systems
(Humphrey, 1924a, 1924b). Accordingly, many psychologists have
applied similar practices to understanding and modifying cogni-
tions, emotions, and behaviours.
Theorists from Freud (Breuer & Freud, 1974; Freud, 1924), to
Spielberger (1975), to Barlow (2000, 2002), have suggested individ-
ual differences make some people more likely to experience fear or
anxiety. The tendency to respond with fear or to experience perva-
sive anxiety was called neuroticism by Freud and trait anxiety by
Spielberger. Spielberger (1972) described anxiety as psychobio-
logical (p.489) and extremely complex and involve[ing] a number
of different measurable components (Spielberger, 1975; p. 139).

http://dx.doi.org/10.1016/j.janxdis.2016.03.011
0887-6185/ 2016 The Author. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
6 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521
He posited an interaction between exposure to stressors, appraisals
of stressors (in line with Scherer, 2009), and a recursive interac-
tivity between experiences of state and trait anxiety (in line with
Scherer & Brosch, 2009). Spielberger (1975) further suggested com-
ponents of anxiety should be independently conceptualized and
operationally measured as critical variables in a state-trait theory
of anxiety (p. 139). In other words, anxiety was not fundamental1
unto itself, and Spielberger underscored the differentiation of state
and trait anxiety was only the beginning of understanding anxiety.
Theorists have since supported a constituent reductionist post-
positivist approach to understanding trait anxiety (Barlow, Ellard,
Sauer-Zavala, Bullis, & Carl, 2014; Barlow, Sauer-Zavala, Carl, Bullis,
& Ellard, 2014; Brown & Barlow, 2009; Cuijpers et al., 2010; Lahey,
2009), particularly when used synonymously with constructs like
neuroticism (Ormel, Rosmalen, & Farmer, 2004). Such synonymous
usage has led prominent theorists to argue the functional equiva-
lency of several constructs related to trait anxiety. For example,
Kagan and Snidman (2004) clarify that inhibited and uninhibited
to the unfamiliar temperament categories refer to introverted and
extraverted, respectively. Barlow and colleagues (Barlow, Sauer-
Zavala et al., 2014) argue the same two categories respectively
refer to trait anxiety and negative affect, as well as positive affect.
Clark and Beck (2010) argued trait anxiety is . . .so closely related
to negative emotionality (i.e., Neuroticism or Negative Affect) that
the two are considered almost synonymous (p.104). If (1) neu-
roticism by any name is a higher-order biopsychosocial construct
that is facilitated by fear of potentially recurring aversive experi-
ences (Barlow, 2000); (2) fear is distinguished from anxiety by being
present-oriented and relatively certain, rather than future-oriented
and relatively uncertain (Barlow, 2000); (3) prolic anxiety denes
neuroticism (Barlow, Sauer-Zavala et al., 2014); and (4) fear is the
basic cognitive process underlying all anxiety disorders (Clark &
Beck, 2010, p. 29), then a hierarchical structure identifying increas-
ingly fundamental fears offers several potential advantages; for
example, informing and being informed by psychological theories
of evolution, emotion, cognition, development, personality, and
decision-making.
2. Hierarchical models of fears
Initial hierarchical models for neuroticism, fears, and phobias
were based on evidence from researching learning. That evidence
underscored neuroticism as learned and, therein, governed by
the laws of learning (Eysenck, 1966). Following that premise,
Rachman (1977) posited a fear acquisition model that implicated
conditioning, vicarious exposure (i.e., observational learning), and
information transmission (i.e., didactics), which accumulated sig-
nicant support (e.g., Muris, Merckelbach, de Jong, & Ollendick,
2002; Rachman, 1991).
Contemporary fear acquisition models (see for review, Armeld,
2006; Coelho & Purkis, 2009; Mallan, Lipp, & Cochrane, 2013)
assume cognitive or emotional factors underlie fear responses
(Coelho & Purkis, 2009); however, interactions between naturally
selected predispositions and environmental variables remain crit-
ical for fear acquisition (Coelho & Purkis, 2009; p. 343). In line
with contemporary appraisal models of emotion (Moors, 2009),
there may be evolutionarily-supported fears prepared or inherited
(i.e., requiring little or no learning) based on biological substrates.
Those fears, in conjunction with environmental inuences (e.g.,
direct or indirect learning), might explain all fear acquisition and,
therein, neuroticism. That said, arguments for cohesive sets of stim-
uli as biologically prepared (e.g., snakes, spiders) are supported by
1
serving as, or being an essential part of, a foundation or basis; basic; underlying
(fundamental, n.d.).
some evidence (e.g., Cook & Mineka, 1989; Ohman & Mineka, 2001;
Poulton & Menzies, 2002b; Waters, Lipp, & Randhawa, 2011), but
confounded by others.
Certain fears, such as the fear of spiders, are frequently referred
to as biologically prepared. However, only approximately 200
species of spiders worldwide can cause severe human envenom-
ing, out of the more than 30,000 species of spiders (Diaz, 2004).
The contrary is true of mushrooms, which are usually viewed
as not biologically relevant to fear. Nevertheless, some mush-
rooms, such as the Amanita phalloides, are one of the toxic agents
most responsible for fatal cases in Poland (Kotwica & Czerczak,
2007), and unintentional poisoning with plants is common in
small children (Eddleston & Persson, 2003). Approximately 100
species of poisonous mushrooms have been identied in the
United States alone (Lincoff & Mitchel, 1977), which makes it
reasonable to suspect that mushrooms have posed a greater
threat to the survival of the human species than have spiders
and snakes combined (Delprato, 1980). (Coelho & Purkis, 2009,
p. 342)
The challenge may be partially resolved by considering whether
the cohesive stimuli sets are biologically prepared, or the elements
therein. Fear of snakes has been argued as innate for primates
(e.g., Hebb, 1949); however, 6-month-old infants show no fear of
snakes because the fear has not yet been learned (Kagan & Snidman,
2004); in contrast, 4-month-old infants broadly demonstrate fear
responses to unfamiliar stimuli (Kagan & Snidman, 2004). Snakes
may become more likely to produce fear because, relative to other
more frequently encountered stimuli, snakes have unfamiliar skin,
body shape, and movement patterns (Kagan & Snidman, 2004), all
of which speaks more to a biological preparedness for unknowns
(Carleton, 2016), or other elements of the stimulus, than to the
cohesive stimulus itself. There are also more unknowns associ-
ated with encountering a snake than a mushroom, not the least of
which being the snake moves quickly whereas the mushroom does
nota potentially critical element underscored in looming models
(Riskind, 1997).
Recent research comparing responses to snakes and owers
demonstrated that novelty (i.e., the unknown; Carleton, 2016)
was the key element for activation of the amygdala, with no evi-
dence of a novelty by stimulus interaction (Balderston, Schultz, &
Helmstetter, 2013); however, neurological responses subsequent
to the amygdala (e.g., hippocampal responses) did evidence per-
ception of the snake as more threatening. As such, appraisals of
associated cuesknowns and unknownscan dramatically inu-
ence fear (Carleton, 2016). For example, a planned encounter with
a snake secured behind glass might be less fear provoking than
being told your meal contains mushrooms of ambiguous origin.
Similarly, as recently synthesized by Carleton (2016), theorists have
argued that appraised elements, context, and the relative number
of unknowns, may be the critical determinants of an emotional
response.
For example, what is it that water phobic individuals react to?
Clearly it is not water per se as they likely seek water to drink, to
bathe in, and to nourish their plants. Is it deep water? If so, how
deep is deep enough? Or is it water in which they might drown,
or in which they might not be able to negotiate their way to
safety? These later two possibilities sound rather like cognitive
processes at work. At least for adults, it appears that such reac-
tions are somehow bound up with perception and cognition of
certain stimulus elements. (Kleinknecht, 2002; p. 162)
Contemporary fear acquisition models argue fear and anxiety
involves context, appraisal, learning, scaffolding, or generalization
of stimuli and responses (Coelho & Purkis, 2009); nevertheless,
 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521
since Spielberger (1972) and Rachman (1977), fears described
as effectively unconditioned have been posited and referred to
as basic, evolutionarily-supported, fundamental, inherent, innate,
non-associative, predisposed, or prepared. There is evidence sup-
porting such fears (Poulton & Menzies, 2002b) as congruent with
learning models (Poulton & Menzies, 2002a). There are theorists
who argue that unequivocal and denitive evidence for any fear
as unlearned is impossible (e.g., Muris et al., 2002; Rachman,
1991); however, others argue for nearly innate fears (e.g., Mineka
& Ohman, 2002), and still others argue that models of emotion
and anxiety explicitly posit at least one category of stimuli, the
unknown, as innately facilitating a fear response (see for review,
Carleton, 2016).
3. The original fundamental fears
In 1991, Reiss explicated a logical, constituent reductionist, post
positivist method for identifying key cognitive elements of anxiety,
which he called fundamental fears. Reiss (1991) used a variant of
the downward arrow technique to argue:
Fundamental fears provide reasons for fearing a wide range of
stimuli, whereas ordinary fears do not have this characteristic.
For example, consider the rational relationships among three
different fears: (a) the fear of snakes; (b) the fear of heights;
and (c) the fear of anxiety. Fears of snakes and heights are ratio-
nally unrelated to one another in the sense that having one of
the fears is not a reason for having the other fear. It makes no
sense for a person to say, I am afraid of heights because I am
afraid of snakes. On the other hand, the fear of anxiety is ratio-
nally related to the fear of snakes and heights. A rational person
might say, I am afraid of snakes and heights because I am afraid
I would have a panic attack if I encountered those stimuli. A
person who is unusually afraid of (or sensitive to) the possibil-
ity of a panic attack holds a reason for potentially fearing snakes,
heights, or any other situation that might be expected to lead to
panic. (Reiss, 1991, p. 147)
Reiss revised theor (Reiss, 1997) posited a hierarchical structure
that placed anxiety sensitivity (AS), the fear of negative evaluation
(FNE), and the fear of injury later labelled illness/injury sensitivity
(IIS; Taylor, 1993) as fundamental2 elements underlying all fears
and therein neuroticism.
AS, the propensity to catastrophically appraise the symptoms
or sensations related to anxiety (e.g., palpitations, trembling),
describes fearing potential consequences associated with anxiety
sensations (Taylor, 1999), and several symptom prole mod-
els incorporate AS as critical (Olatunji, Broman-Fulks, Bergman,
Green, & Zlomke, 2010). FNE describes fearing negative evalua-
tions (Heimberg, Brozovich, & Rapee, 2010; Leary, 1983) and is
a hallmark of social anxiety (Heimberg et al., 2010). IIS describes
fearing physical harm and the associated consequences (Carleton,
Asmundson, & Taylor, 2005; Reiss, Peterson, Gursky, & McNally,
1986; Taylor, 1993). IIS relates to specic phobias (e.g., spiders;
Page, 1994), pain-related anxiety (Vancleef, Peters, Roelofs, &
Asmundson, 2006), chronic pain (Thibodeau, Fetzner, Carleton,
Kachur, & Asmundson, 2013; Verbunt et al., 2003), and disability
(Carleton, Abrams, Kachur, & Asmundson, 2009, Carleton, Abrams,
Kachur, & Asmundson, 2010).
Reiss (1991) approach to identifying fundamental fears was
summarized by Taylor (1993): Reiss (1991), and personal com-
munication, June 1991) used two criteria to dene these fears as
fundamental; (1) they are fears of inherently noxious [aversive]
2
Paralleling Spielbergers (1972) use of the term fundamental.
7
stimuli, and (2) other, common fears can be logically reduced to
them (p. 289). Taylor implied fundamental fears cannot require
a priori learning (i.e., an unconditioned stimulus and an uncon-
ditioned response), should underlie more common fears and
anxieties, and should not be rationally related to other fears (Taylor,
1993). Neither inherent3 nor noxious4 were dened by Reiss (1991)
or Taylor (1993), implying the dictionary denitions, and Reiss
(1991) argued AS, FNE, and IIS were inherent. Accordingly, neuroti-
cism would result from learned fears facilitated by inherent AS, FNE,
and IIS. The supposition accords with notions that neuroticism is
not an explanatory concept in the aetiology of psychopathology,
since it measures a persons characteristic level of distress over
a protracted period of time (Ormel et al., 2004; p. 906), as well
as Clark and Becks (2010) notions that fear, then, is the basic
cognitive process underlying all anxiety disorders (p. 29).
Each of AS, FNE, and IIS appears at least partially distinct
from each other (e.g., Carleton, Thibodeau, Osborne, Taylor, &
Asmundson, 2014; Taylor, 1993) and neuroticism (e.g., Cornwell,
Johnson, Berardi, & Grillon, 2006; Muris, Vlaeyen, & Meesters, 2001;
Thibodeau, Carleton, Collimore, & Asmundson, 2012; Vancleef et al.,
2006); however, the intercorrelations range from 0.24 to 0.76, indi-
cating important shared variance (e.g., Carleton, Thibodeau et al.,
2014; Thibodeau et al., 2012). Each has also demonstrated theo-
retical and predictive utility beyond neuroticism for common fears
(Heimberg et al., 2010; Olatunji et al., 2010; Thibodeau, Fetzner
et al., 2013). More importantly, reductions in one (e.g., AS), can
reduce common fears (Boswell, Thompson-Hollands, Farchione,
& Barlow, 2013), even when related more to another fundamen-
tal fear. For example, interoceptive exposure reduces AS, but also
social anxiety (Collimore & Asmundson, 2014; Dixon, Kemp, Farrell,
Blakey, & Deacon, 2015), which appears more related to FNE
(Heimberg et al., 2010).
4. Revisiting the criteria for fundamental fears
The criteria introduced by Reiss (1991) and Taylor (1993) pro-
vide a solid foundation for identifying fundamental fears that can
be expanded in at least two ways. First, by integrating requirements
from contemporary emotion theories (Mulligan & Scherer, 2012).
Second, by integrating subsequent criteria proffered for identify-
ing fundamental fears or elements in psychological constructs as
identied from a brief literature review.
The review was not intended to be exhaustive and comprehen-
sive. Instead, English articles in Thomson Reuters Web of Science
Core Collection database that referenced Taylor (1993), 55 in total,
were reviewed for critiques or revisions to the criteria; however,
none were identied. The same database was searched for English
psychology or psychiatry articles titled with the phrase innate
fear or non-associated fear, which have also been used to describe
fundamental fears. The result was 35 articles, one of which ref-
erenced Poulton and Menzies (2002a,b) criteria for such fears.
Poulton and Menzies article had been cited 20 times, none of
which proffered revisions to their criteria. The same database was
searched for the term fundamental as a title in English psy-
chology or psychiatry review articles published since 1993. There
were 30 results. Among those, one article provided a set of criteria
for identifying fundamental elements of a psychological construct
(i.e., Anderson, Hildreth, & Howland, 2015), which was based on
a second article from the same result set (Baumeister &Leary,
1995). There were two additional articles that offered principles for
3
existing in someone or something as a permanent and inseparable element,
quality, or attribute; intrinsic (inherent, n.d.); i.e., require little or no learning.
4
harmful or injurious to health or physical well-being; unpleasant(noxious,
n.d.); i.e., aversive.
8 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521

Table 1
Example supporting evidence for fundamental fear criteria.

Preliminary Strong Stronger Very Strong

2 Broad theoretical
congruence across
psychological disciplines
3 Logical thought
experiments
4 Descriptive statistics
indicating normative
distributions
5 Logical thought
experiments
6 Logical thought
experiments
7 Logical thought
experiments
8 Factor analytic evidence
that indicates robust
independence from other
constructs at comparable
levels
Developmentally early Species with similar Genotypic heritability and
reports of fear following neurobiological substrates stimulus-specic biological
stimulus exposure experience fear following substrates
stimulus exposure
Cross-sectional heritability Longitudinal heritability Experimental research
and developmental and developmental with human and
research research non-human animals
encountering the
candidate fear
Taxometric analyses Discriminant Experimental heritability
indicating a continuous epidemiological research research across species
latent structure for pathologies
Qualitative research with Cross-sectional research Prospective research
samples reporting diverse assessing for changes in manipulating the fear and
fear intensities higher-order variables assessing subsequent
based on lower-order changes in higher-order
variables variables
Qualitative and quantitative research using downward Prospective research
arrow techniques with samples having diverse fears manipulating higher-order
and fear intensities fear(s), but not the
fundamental fear, and
evidencing absent change
in the fundamental fear
Cross-sectional correlation Prospective longitudinal research assessing variance
and regression analyses accounted for by experimental manipulations to the
fundamental fear
Manipulating a fear and nding evidence that a Lesioning studies
similarly lower-ordered fear was minimally impacted demonstrating dedicated
biological substrates for a
single, discrete,
fundamental fear

identifying traits (McAdams & Pals, 2006) or fundamental causal
agents (Gottfredson, 2004); however, all were congruent with
Anderson et al. (2015) criteria, which were derived from an exten-
sive review of what constitutes fundamentality for motivation;
therefore, Baumeister and Learys (1995) criteria per Anderson et al.
(2015), as well as criteria from Poulton and Menzies (2002a) were
integrated with Reiss (1991) and Taylors (1993) criteria. Accord-
ingly, increasingly fundamental (i.e., lower-order) fears should be
as follows, with examples of supporting evidence in Table 1.
4.1. Criterion One
Fundamental fears should be emotions. Following Mulligan and
Scherers (2012) denition, a fundamental fear is (1) time limited,
(2) triggered by at least one appraisal, (3) guided by at least one
appraisal, (4) contains bodily changes (e.g., arousal) that are felt,
and (5) involves a perceptual or intellectual episode. A percept in
and of itself is not an emotion; therefore, sensations (e.g., noci-
ception) and reexes (e.g., startle) are not emotions (Leventhal &
Scherer, 1987; Moors, 2009); however, a stimulus (perceived pre-
consciously or consciously), sensation, or reex that results in an
inherent appraisal that triggers an emotion of fear (Mulligan &
Scherer, 2012) would meet Criterion One. Emotions are experi-
enced on continua of intensities (e.g., Fox, 2008; Lang, 1995; Lang,
Bradley, & Cuthbert, 1998a, Lang, Bradley, & Cuthbert, 1998b; Lang,
Bradley, Fitzsimmons et al., 1998; Scherer, 2005); as such, per
Carleton (2016), fear will refer to a continuum ranging from low
(e.g., dislike, bother) to moderate (e.g., fearful) to high (e.g., terror).
McNaughton, 2003; Gray, 1976) or analogue thereof because the
stimulus is inherently appraised as aversive; herein, inherent
describes responses requiring little or no a priori learning (i.e., con-
ditioning or observation) and aversive describes an actually or
potentially tissue-damaging event (Loeser & Treede, 2008; p. 475).
4.3. Criterion Three
Fundamental fears should be evolutionarily supported such
that the fear produced by the stimulus would have a logically-
defensible selection bias. An evolutionary selection bias dovetails
with Criterion Two. Normative phenotypic levels should provide
logically supported evolutionary individual and group level advan-
tages, with extreme phenotypic levels advantaging the group. For
example, normative IIS would be evolutionarily supported at the
individual level. Extremely high IIS for a group subset might mit-
igate group risk; in contrast, extremely low IIS for a group subset
might facilitate protection from predators.
4.4. Criterion four
Fundamental fears should be continuously and normally dis-
tributed in the population. An inherent fear would be biologically
supported with an underlying genetic basis (i.e., Criteria Two
and Three). The fear should be present at some level in most
healthy individuals, with pathology and/or group-specic advan-
tages rather than individual advantages occurring at extremes (i.e.,
the tails of the distribution).

4.2. Criterion Two 4.5. Criterion Five

Fundamental fears should be responses to stimuli inherently A fundamental fear should be a logical reduction of higher-order
appraised as aversive. The stimulus should (nearly) automati- constructs (e.g., common fear- and anxiety-related constructs;
cally activate the Behavioural Inhibition System (BIS; Gray & personality constructs, such as trait anxiety, neuroticism, neurotic
 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521
temperament, negative affectivity; disorder-related symptoms).
For example, high neuroticism > fearing unemployment > fears of
insufcient resources > fears of starvation > fears of physical harm;
fearing unemployment (relatively higher-order) would contribute
to heightened neuroticism, but be driven by fear of physical harm
(relatively lower-order fear; increasingly fundamental). Fearing
unemployment logically requires substantial a priori learning, the
elements of which can then be logically reduced to include a
relationship between employment, access to food, and avoiding
physical harm.
4.6. Criterion Six
Fundamental fears should be non-derivative (i.e., logically
irreducible). As fears become increasingly fundamental (i.e., lower-
order; non-derivative), fewer a priori determinants should be
required. For example, What is fear-inducing about being unem-
ployed? might be followed by, What is fear-inducing about not
being paid? At some point the iterative downward arrow logical
reduction process should produce a logical tautologically expressed
rhetorically as, I fear it because I fear it. Criteria Two, Three,
Five, and Six are related because higher-order constructs would
necessarily be learned derivations of lower-order fears, whereas a
non-derivative fear should be inherent and tautological. Fears that
are part of an irreducible cyclical tautology (e.g., I fear X because of
Y, and I fear Y because of X, but neither X nor Y are feared because of
an irreducible Z) could also be argued as non-derivative and therein
potentially fundamental.
4.7. Criterion Seven
Fundamental fears should be able to account for variance in
higher-order constructs; as such, fundamental fears should be
increasingly correlated with increasingly proximal higher-order
constructs (i.e., requiring fewer downward arrow iterations). For
example, if public performance fears can be readily reduced to
FNE, the constructs should be highly correlated. Other variables
might still be important (e.g., fear of being injured by an angry
mob), but would have lower correlations. The fear should also be
correlated with increasingly distal higher-order constructs (e.g.,
neuroticism); however, the relationship should become smaller
as contributions from other lower-order elements are included
or accounted for. Changes to lower-order constructs should also
produce diffuse changes in related higher-order constructs. For
example, rather than targeting public speaking, giving a perfor-
mance, or blushing, therapists could target FNE, broadly reducing
all related higher-order fears (Barlow, Ellard et al., 2011; Barlow,
Farchione et al., 2011); that said, FNE might be targeted using expo-
sures involving those higher-order fears (Heimberg & Becker, 2002;
Heimberg, Becker, Goldnger, & Vermilyea, 1985; Heimberg et al.,
2010; Hofmann, 2007).
4.8. Criterion Eight
A fundamental fear should be factorially distinct. Paralleling
Criterion Seven, Criterion Eight provides more than logical or
rhetorical evidence of Criteria Five and Six.
5. Reassessing the original fundamental fears
AS, FNE, and IIS appear important, inuential, and lower-order
constructs that contribute to higher-order constructs (e.g., neuroti-
cism; psychopathological symptoms); however, whether they are
fundamental remains debatable. Since Reiss (1991) publication at
least three additional fears have been posited as potentially funda-
mental: fear of death (Iverach, Menzies, & Menzies, 2014), fear of
9
pain (Carleton, Abrams, Asmundson, Antony, & McCabe, 2009), and
FOTU (Carleton, 2012, 2016). What follows is neither an exhaustive
discussion of each fear, nor intended to discount the importance of
any fear. Instead, the discourse is intended to provocatively argue
the relative fundamentality of FOTU.
There appears to be initial evidence that AS, FNE, and IIS meet
criteria One, Four, Five, Seven, and Eight. Each appears to be an emo-
tion. Moreover, moderately intense AS, FNE, and IIS, would facilitate
self-care, mitigate inappropriate risk-taking, and support the devel-
opment of social networks (Buss, 1990); however, too much would
be paralyzing and too little would be self-destructive. Having
a group subset with higher than average fears might facilitate
appropriate group-level safety behaviours (e.g., avoiding danger-
ous locations) and group cohesion (e.g., encouraging pro-social
behaviours). In contrast, having a group subset with lower than
average fears might facilitate protection from predators (e.g., mem-
bers willing and able to risk individual harm to protect the group).
Each appears to be a logical reduction of higher-order constructs.
AS appears to be a logical reduction of anxiety and, therein, most
if not all anxiety disorders (Taylor, 1999). AS accounts for variance
in higher-order constructs (Naragon-Gainey, 2010; Olatunji et al.,
2010; Smits, Berry, Tart, & Powers, 2008; Taylor, 1999), including
neuroticism (Calkins et al., 2009; Olatunji & Wolitzky-Taylor, 2009;
Schmidt et al., 2010; Schmidt & Mallott, 2006; Taylor, 1999), and
has dimensions that appear continuously distributed in the popu-
lation (Asmundson, Weeks, Carleton, Thibodeau, & Fetzner, 2011;
Bernstein, Zvolensky, Norton et al., 2007; Bernstein, Zvolensky,
Stewart, & Comeau, 2007). FNE is the hallmark logical reduction
of social anxiety and accounts for variance in the higher-order con-
struct (e.g., Heimberg et al., 2010); furthermore, the latent structure
of FNE and social anxiety appears continuous (Weeks, Carleton,
Asmundson, McCabe, & Antony, 2010; Weeks, Norton, & Heimberg,
2009). IIS appears to be a logical reduction of harm-related phobias
(e.g., health anxiety) and accounts for variance in related higher-
order constructs (Asmundson, Abramowitz, Richter, & Whedon,
2010; Thibodeau, Fetzner et al., 2013); the latent structure of IIS
remains to be assessed. Each appears at least partially factorially
distinct (Carleton, Thibodeau et al., 2014; Taylor, 1993).
Despite Reiss (1991) original contention, AS, FNE, and IIS do not
appear to meet Criterion Two or Criterion Six. None appear to be
fearful emotional responses to stimuli that are necessarily inher-
ently appraised as aversive. Individuals may yet be predisposed to
or prepared for such fears, but each appears to require a priori learn-
ing. In addition, none appear to be necessarily non-derivative (i.e.,
logically irreducible) because they can be logically reduced to one
or more other component fears, or appear to be dependent on a
moderator (e.g., another fear).
5.1. Not necessarily inherent
AS appears to require a priori learning about potential con-
sequences for the sensations (Taylor, 1993, 1999). For example,
elevated heart rate, palpitations, and shortness of breath are not
inherently aversive; instead, some people actively seek such sen-
sations by engaging in higher-risk behaviours for entertainment
(e.g., movies, sky diving; Allison et al., 2012; Rooney, Benson,
& Hennessy, 2012) or due to problematic behaviours (e.g., sub-
stance use, gambling; Comeau, Stewart, & Loba, 2001; Hittner &
Swickert, 2006; Schmidt, Mussel, & Hewig, 2013). The sensations
do not become aversive, facilitating AS, without (1) an anticipated
consequential threat that would have required learning (i.e., not
inherent); (2) fear of some potential consequential threat (e.g.,
heart palpitations may precede a heart attack; Carleton, 2012;
Carleton, Norton, & Asmundson, 2007; Fergus & Bardeen, 2013;
Taylor, 1999); or (3) fear because of insufcient certainty of safety
(Carleton, 2012, 2016). The stimuli would not be appraised as
10 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521
threatening without a priori learning that such stimuli can precede
aversive consequences, FOTU acting as a moderator, or FOTU acti-
vating the BIS (Carleton, 2016). An evolutionary argument for AS
preparedness could be made (e.g., mitigating injury and illness);
however, effective interventions (e.g., pharmaceuticals to mitigate
heart attacks) supporting the benets for early reactions to such
sensations (e.g., racing heart) are relatively recent.
FNE may also require a priori learning. For example, the complex
rules associated with even relatively simple and common social
interactions are not universal (e.g., eye contact; Akechi et al., 2013).
Rules for conversations and overt behaviours are even more com-
plex. Learning the social rules alone is not sufcient to produce
FNE. The consequences for violating those social rules (i.e., garner-
ing negative evaluation) must also be learned, directly or indirectly;
however, FNE could be moderated by FOTU. That said, an evolution-
ary argument for FNE preparedness may be particularly defensible.
Cooperative group membership would offer a substantial evolu-
tionary advantages (e.g., Ackerman, Huang, & Bargh, 2012) and FNE
may have reduced the risk of critical group membership breaches
(Baumeister & Leary, 1995; Haselton & Nettle, 2006).
IIS also appears to require a priori learning. For example, a person
could be born having not experienced (i.e., exposure), witnessed
(i.e., vicarious exposure), or understood (i.e., didactic exposure; e.g.,
taught about Type I diabetes) injury or illness. Until such learn-
ing occurred there would be no way to know that injury or illness
existed, much less that they can be aversive and should be feared;
however, IIS could be moderated by FOTU. Again, an evolutionary
argument for IIS preparedness could be made (e.g., reducing the
probability of death before sexual maturity); however, such general
fears become conated with mechanisms (e.g., predators), intensi-
ties (e.g., a laceration vs. a bruise; a common cold vs. tuberculosis),
or nociception. Fearing illness as inherent on the basis of an evo-
lutionary argument would be particularly challenging. Our ability
to identify illness with our primary senses (e.g., visual assessment)
is relatively poor except for advanced stages of some illnesses (e.g.,
small pox) and our understanding of illness as typically induced by
other agents (e.g., bacteria, virus, genetics) is very recent.
Despite their importance, the evidence does not appear to
support AS, FNE, or IIS as being denitively inherent. All three
appear to require another fear or substantial learning contingent
on expectations of aversive consequencesspecic, non-specic, or
unknownwhich then become the focus of fear, rather than the AS
sensations, the negative evaluation, the actual illness or injury.
5.2. Arguably derivative (i.e., not necessarily logically irreducible)
AS subsumes fearful responses to somatic, cognitive, and social
categories of interoceptive stimuli based on the belief that the
sensations have adverse consequences such as death, insanity, or
social rejection (Reiss & McNally, 1985) (Taylor et al., 2007; p.
177). Example descriptions can be drawn from the Anxiety Sen-
sitivity Index 3 (Taylor et al., 2007): When I feel pain in my chest,
I worry that Im going to have a heart attack (Somatic); When my
thoughts seem to speed up, I worry that I might be going crazy
(Cognitive); When I begin to sweat in a social situation, I fear peo-
ple will think negatively of me (Social). The description of AS and
the exemplar items appears to suggest the fear is logically reducible
to at least one other fear (e.g., heart attack; psychopathology;
negative evaluation). Furthermore, insufcient certainty regard-
ing the pending consequences appears critical (Carleton, Sharpe,
& Asmundson, 2007).
FNE refers to apprehension about others evaluations, distress
over their negative evaluations, avoidance of evaluative situations,
and the expectation that others would evaluate oneself negatively
(Watson & Friend, 1969; p. 449). Example descriptions can be
drawn from the Brief Fear of Negative Evaluation Scale (Rodebaugh
et al., 2004; Weeks et al., 2005): I am frequently afraid of other peo-
ple noticing my shortcomings; I am afraid that other people will
nd fault with me. Negative evaluation could well lead to physi-
cal harm in modern or historical societies (Ackerman et al., 2012)
through being physically attacked or ostracized. Social dimensions
of AS (e.g., fearing blushing or sweating), are related to social
anxiety (Carleton, Collimore, & Asmundson, 2010; Rector, Szacun-
Shimizu, & Leybman, 2007; Taylor et al., 2007), possibly because
they can compromise status (Seyfarth & Cheney, 2012). A related
construct, fear of positive evaluation (FPE; Weeks, Heimberg,
Rodebaugh, & Norton, 2008), also appears important and distinct
(Weeks, Jakatdar, & Heimberg, 2010; Whiting et al., 2014). Exam-
ple descriptions can be drawn from the Fear of Positive Evaluation
Scale (Weeks, Heimberg, & Rodebaugh, 2008): I am uncomfort-
able exhibiting my talents to others, even when I think my talents
will impress them. FPE has not been posited as fundamental, but
therein appears to have strengths and limitations similar to FNE.
IIS subsumes fearful responses to becoming ill or injured
(Carleton et al., 2005). Example descriptions can be drawn from
the Illness/Injury Sensitivity Index-Revised (Carleton, Park, &
Asmundson, 2006): I am frightened of being injured (Injury);
The thought of physical illness scares me (Illness). The breadth
may be problematic because objective indications of tissue damage
(e.g., unexplained bruises) may be dismissed as non-threatening;
similarly, evidence of infection (e.g., a virus screen) may be asso-
ciated with no threatening symptoms. Conversely, persons can
report experiencing substantial symptoms indicating tissue dam-
age or infection, with no objective indications of either (Asmundson
& Carleton, 2008). There would also be considerable difculty in
disentangling IIS from fears of the causal mechanism (e.g., preda-
tion) and aversive sensations (e.g., dizziness, pain). Accordingly, IIS
may be logically reducible to AS, fear of pain (Carleton, Abrams,
Asmundson et al., 2009), FNE (Carleton & Asmundson, 2012), or
FOTU (Carleton, 2012, 2016).
Each of AS, FNE, and IIS appears well-supported as lower-order
relative to common fears, higher-order factors, and psychopatholo-
gies; however, sensations (e.g., chest pain), negative evaluations
(e.g., by a competitor with insufcient agency for retribution), or
injuries and illnesses (e.g., a trivial scratch) sufciently known to
be inconsequential are unlikely to be feared; instead, sufcient
certainty of safety can make anxiety-related sensations appeti-
tive, rather than aversive, negative evaluations empowering, and
soreness from minor post-workout injuries invigorating. By con-
trast, pending sufcient certainty of aversive consequences, the fear
could refer to a consequence and only tangentially to AS, FNE, or
IIS (Carleton, 2012; Carleton, Sharpe et al., 2007). In the absence
of sufcient certainty, responses appear to depend signicantly on
individual responses to unknowns (Carleton, 2012, 2016). In any
case, AS, FNE, and IIS, appear reexively related and reducible to
fears of death, pain, or unknowns; therefore, despite being lower-
order and critical, none appear denitively fundamental.
5.3. Fear of death as fundamental
Benjamin Franklin is often referenced as saying nothing can be
said to be certain, except death and taxes. Death is the conclu-
sion of the process that is dying. Fearing death is not evidenced by
reexes to preserve life (e.g., breathing, Moro5 ), because reexes
are not emotions (Leventhal & Scherer, 1987; Moors, 2009; Moors,
Ellsworth, Scherer, & Frijda, 2013). Reexes could be appraised per-
cepts causally associated with fear pending appropriate learning
(Mulligan & Scherer, 2012); however, reexes would not evidence
5
An infant reex of adduction and then exion of the arms, triggered by a per-
ception of falling (Zafeiriou, 2004).
 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521
fear of death as inherent any more than salivation evidences fear
of starvation as inherent. For example, Moro following a sudden
drop could cause fear of vestibular motor sensations associated
with falling or fear of pain after impact; conversely, it could cause
joy if caught repeatedly being caught by a parent was perceived as
certain.
A person who fears death may not fear death, per se, instead fear-
ing (1) the process of dying, which is reducible to other fears (e.g.,
AS, FNE, IIS, fear of pain); (2) that death will be unpleasant (e.g., the
afterlife may be painful); (3) unknowns about death (e.g., death may
or may not involve an afterlife), making the unknown the object of
fear; or (4) the concept of oblivion, an unequivocal unknown, which
requires substantial a priori learning. Neither dying nor death are
inherent concepts; both must be learned (Balk, 2010). Absence
of fear of death among children under ten [years of age] is in
keeping with Anthonys study reported in The Childs Discovery of
Death (Anthony, 1940) (Bowlby, 1973, p.117). As detailed in Car-
letons review (Carleton, 2016), children fear unknowns, darkness,
and snakesamong other thingslong before demonstrating under-
standing or fear of death (Bowlby, 1973; Kagan & Snidman, 2004).
Furthermore, death is not necessarily aversive or avoided. Many
religions posit death as involving a fantastic and appetitive after-
life (Segal, 2010). Where the afterlife is potentially appetitive, any
associated fear must result from (1) insufcient certainty in the
promise of that appetitive afterlife or (2) the process of dying as a
transition to that afterlife. Notional development of an appetitive
afterlife may have been to cope with unknowns related to death.
For this fear of death is indeed the pretence of wisdom, and not real
wisdom, being the appearance of knowing the unknown; since no
one knows whether death, which they in their fear apprehend to be
the greatest evil, may not be the greatest good (Socrates, 399 BC).
In any case, fear of death, while arguably pervasive and poignant,
does not appear fundamental.
5.4. Fear of pain as fundamental
Haruki Murakami claimed Pain is inevitable. Suffering is
optional (Murakami, 2009; p.vii); relatedly, fear of pain may be
fundamental (Carleton, 2012; Carleton, Abrams, Asmundson et al.,
2009). Pain is a sensory and emotional experience associated with
perceived or potential tissue damage (Loeser & Treede, 2008; p.
475). Nociception is the neuronal processing of noxious stimuli,
beginning with the activation of nociceptors (Loeser & Treede,
2008; p. 475). Nociception is inherently aversive (Pear, 2014; Rolls,
2013), but evolutionarily derivative for mitigating injury and death
(Broom, 2001; Fields, 2006) and not necessarily fear provoking
(Asmundson & Carleton, 2008; Carleton & Asmundson, 2012). Noci-
ception is neither an emotion (Leventhal & Scherer, 1987; Moors,
2009) nor synonymous with the subjective and complex experi-
ence of pain, which involves nociception, appraisals, attributions
of meaning (Asmundson, Norton, & Norton, 1999; International
Association for the Study of Pain, 1986; Loeser & Treede, 2008;
Melzack & Katz, 2004). The distinction complicates assessing fear
of pain as fundamental because fear of pain typically refers to the
experience of pain rather than nociception (Asmundson & Carleton,
2008; Carleton & Asmundson, 2012).
Nociception evokes appraisals that may produce the experience
of pain (Asmundson & Wright, 2004) and is not required to experi-
ence pain (e.g., phantom limb pain; Diers, Christmann, Koeppe, Ruf,
& Flor, 2010; Melzack, 1990). Fear of pain references the unpleasant
sensory and emotional experience that may be associated with the
nociception, but is the result of substantial and complex learning
based on attributions of meaning to nociception (Asmundson et al.,
1999; International Association for the Study of Pain, 1986; Melzack
& Katz, 2004), making it neither inherent nor non-derivative.
Nociception might be aversive but not fear-provoking if the fol-
11
lowing are certain: (1) short length; (2) manageable intensity; (3)
no consequential sequelae (e.g. not harmful); or (4) consequen-
tial sequelae are appetitive (e.g., goal completion; pleasure). For
example, consuming spicy foods, long-distance running, or elective
skin puncturing may be sought because the nociception is consid-
ered certainly short and consequentially pleasurable. In contrast,
uncertainty regarding the duration, intensity, and injuriousness
associated with nociception could dramatically increase fear and
anxiety. Increased FOTU appears to increase fear of pain in response
to nociception (Helsen, Goubert, & Vlaeyen, 2013), therein sup-
porting FOTU as a critical moderator or determinant for fear and
anxiety-related nociception.
Despite the aforementioned challenges to fear of pain as
fundamental, it appears normally and continuously distributed
(Asmundson & Carleton, 2008; Asmundson, Vlaeyen, & Crombez,
2004). Fear of pain is also a logical reduction of pain-related anx-
iety (Carleton & Asmundson, 2009; Powell, Honey, & Symbaluk,
2012), which accounts for variance in higher-order constructs (e.g.,
chronic pain; Carleton & Asmundson, 2012) and appears ubiqui-
tous (Carleton, Abrams, Asmundson et al., 2009). Pain-related fear
and anxiety are related, but factorially distinct from each other
(Carleton & Asmundson, 2009), and from AS, IIS, and FNE (Carleton,
Abrams, Asmundson et al., 2009; Carleton, Thibodeau et al., 2014);
however, meta-analytic results support a robust relationship with
AS such that pain-related fear and anxiety may be derivatives of,
or reexively related to, AS (Ocanez, McHugh, & Otto, 2010). In any
case, fear of pain appears well-supported as a lower-order construct
that meets some criteria for being fundamental; however, fear of
pain requires learned appraisals and attributions, and appears log-
ically reducible, or reexively related, to AS, IIS, FNE, death, and
FOTU. As such, fear of pain, while critically important, may not be
fundamental.
6. Fear of the unknown
6.1. Inherent
Perhaps the earliest direct written reference to FOTU as the
fundamental fear came from Lovecraft in 1927: The oldest and
strongest emotion of mankind is fear, and the oldest and strongest
kind of fear is fear of the unknown (as cited in Joshi & Schultz,
2001; p. 255). The quote remains relevant, with colloquialisms ref-
erencing not knowing as the worst part of distressing situations.
FOTU tautologically does not require a priori learning; indeed, the
rst thing that could be feared would be the perceived absence of
information at any level of consciousness (Carleton, 2016; p. 31).
All other fears appear to require learning involving the perceived
presence of perceived or recalled information (Bandura, 1965, 1971;
Mowrer, 1947; Muris et al., 2002; Pinker, 1997; Powell et al., 2012;
Skinner, 1953).
Broad theoretical congruence across psychological disciplines
suggests unknowns are inherently appraised as aversive (e.g., emo-
tion, development, attachment, neurobiology; see for review and
synthesis, Carleton, 2016). Contemporary emotion theories place
checks for unknowns at the earliest stage of emotion processing
(i.e., low-level neural substrates), underscore pervasive inuences
thereafter (e.g., conceptual cortical areas; Mulligan & Scherer,
2012; Scherer, 2009, 2013), and implicate aggregate responses
to unknowns as dening affective dispositions (Scherer & Brosch,
2009). Models of attachment and temperament explicitly discuss
FOTU as inherent and intrinsic to the development of neuroticism
(e.g., Ainsworth & Bell, 1970; Bowlby, 1973; Colonnesi et al., 2011;
Degnan & Fox, 2007; Kagan & Snidman, 2004; Lewis-Morrarty et al.,
2016, in press; Madigan, Atkinson, Laurin, & Benoit, 2013; Moehler
et al., 2008). Finally, the Uncertainty and Anticipation Model of Anx-
12 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521
iety (UAMA; Grupe & Nitschke, 2013) posits negative interactions
with uncertainty as facilitating maladaptive responses including
inated estimates of threat cost improbability, hypervigilance,
division safety learning, behavioural and cognitive avoidance and
heightened reactivity to threat uncertainty (Grupe & Nitschke,
2013; p. 490).
Neurobiological researchers have emphasized FOTU as a cor-
nerstone for BIS activation and therein fear and anxiety (Bach &
Dolan, 2012; Gray & McNaughton, 2003; Grupe & Nitschke, 2013;
Herry et al., 2007; Jackson, Nelson, & Proudt, 2015; Kagan &
Snidman, 2004; Nelson, Kessel, Jackson, & Hajcak, 2016; Thayer,
Ahs, Fredrikson, Sollers, & Wager, 2012). A recent meta-analysis
evidenced unknowns as increasing heart rate variability and acti-
vation of the amygdala and ventromedial prefrontal cortex (Thayer
et al., 2012). There is also distinct neural encoding (including sum-
mary statistic-type representations) of uncertainty [that] occurs in
distinct neural systems (Bach & Dolan, 2012, p. 572). Furthermore,
the earliest cognitive processing of stimuli automatically classies
a stimulus as threatening or not based on knowns and unknowns
(Bradley, Mogg, Millar, & White, 1995; Cisler & Koster, 2010;
Mathews & MacLeod, 1994, 2005; McNally, 1995), with unknown
stimuli consistently categorized as threatening. Unknowns incre-
mentally activate the BIS (Gray & McNaughton, 2003), increase
error-related negativity based on event-related potentials (Jackson,
Nelson, & Hajcak, 2016; Jackson et al., 2015), potentiate star-
tle (Nelson & Shankman, 2011), and produce sustained amygdala
and hippocampal increases (Herry et al., 2007; Jackson et al.,
2015).
6.2. Evolutionarily supported
FOTU logically ts within evolutionary psychology models
(e.g., Buss, 1995). Indeed, there appears to be substantial theo-
retical and neurobiological evidence supporting the evolutionary
basis of FOTU (Brosschot, Verkuil, & Thayer, 2016). Enough fear
to approach unknowns with caution (i.e., treating unknowns as
potential threats) would be adaptive, so long as the intensity
did not compromise survival activities (e.g., seeking food, shel-
ter, mates; Carleton, 2012). Accordingly, evolution should have
produced a selection bias for assessing unknowns as likely threat-
ening and therein BIS activating (Bach & Dolan, 2012; Brosschot
et al., 2016; Cosmides & Tooby, 1996; Cosmides, 1989; Gigerenzer,
1991; Thayer et al., 2012), but still potentially benecial (Gray &
McNaughton, 2003). That bias appears well reected in neurobi-
ology, temperament, and development research (Brosschot et al.,
2016; Carleton, 2016).
Given the evolutionary advantage associated with the assump-
tion of threat, the view that we and others have proposed is
that the default response to uncertainty, novelty, and threat
is the sympathoexcitatory preparation for action commonly
known as the ght or ight response (Herry et al., 2007; Thayer
& Lane, 2009). This default threat response may be related to
the well-known negativity bias, a phenomenon that describes
the tendency to prioritize negative information over positive
(Cacioppo, Gardner, & Berntson, 1999). From an evolutionary
perspective this represents a system that errs on the side of
cautionwhen in doubt prepare for the worstthus maximiz-
ing survival and adaptive responses (LeDoux, 1996). (Thayer
et al., 2012, p. 749)
Humans and closely related non-human animals (e.g., bono-
bos) prefer certainty to risk (Kacelnik & Bateson, 1996; Tversky
& Kahneman, 1981), but adapt based on learning history (e.g.,
the aggregate of encounters with unknowns) and situational vari-
ables (e.g., the relative number of knowns and unknowns; Gilby
& Wrangham, 2007; Heilbronner, Rosati, Stevens, Hare, & Hauser,
2008; Stevens et al., 2005 Stevens, Rosati, Ross, & Hauser, 2005).
Non-human primate infants initially respond to unknowns with
fear and anxiety, but rapidly habituate in the absence of aversive
consequences (Kalin & Shelton, 1989; Kalin, Shelton, & Takahashi,
1991; Timmermans, Vochteloo, Vossen, Rder, & Duijghuisen,
1994). In non-primate mammals, unknown objects evoking fear
are at rst avoided, increasing the immediate safety of the ani-
mal. However, if the level of fear is low or when it subsides with
time or gained distance, animals start active exploration of the
[unknown] object, territory, or context that evoked their anxiety or
fear and information gathered in the process of exploration allows
them to adapt to the novelty or environmental changes (Pisula
et al., 2012; p. 145; Timmermans et al., 1994). Wild animals treat
unknowns as more aversive than animals raised in the relative
safety of laboratories (Tanas & Pisula, 2011). There is also substan-
tial evidence that responses to unknowns vary based on genetic
variation (Flagel, Waselus, Clinton, Watson, & Akil, 2014), with early
exposure to reliable environments impacting phenotype (Weaver
et al., 2004). For example, Tang and colleagues experimentally evi-
denced neonate rats as initially responding to unknowns with fear
(Akers et al., 2008; Tang, Akers, Reeb, Romeo, & McEwen, 2006;
Tang, Reeb-Sutherland, Romeo, & McEwen, 2012). The same stud-
ies demonstrated attenuation of the responses for the duration
of their lifespan through repeated brief exposures to unknowns
during early development. The attenuation was maximized when
the neonates had a mother with high levels of self-stress regula-
tion who, most importantly, provided reliable care. Poor self-stress
regulation in the mother or unreliable provision of care produced
neonates with higher FOTU; nevertheless, the exposures robustly
attenuated those responses.
6.3. Continuously and normally distributed
Undergraduate and community sample data suggests FOTU
is generally normally distributed with a slight positive skew
(e.g., Boelen & Reijntjes, 2009; Boelen, Vrinssen, & van Tulder,
2010; Carleton, Gosselin, & Asmundson, 2010; Carleton, Mulvogue
et al., 2012; Carleton, Norton et al., 2007; Whiting et al., 2014).
There is currently only one taxometric assessment involving FOTU
(Carleton, Weeks et al., 2012). The study used a large unselected
sample and three distinct taxometric procedures to assess latency.
The results evidenced FOTU, as measured by IU, appears contin-
uously distributed (Carleton, Weeks et al., 2012), but additional
research is needed; for example, assessments with data from clin-
ical samples.
6.4. Logical reduction of higher-Order constructs
The rst explicit suggestion that FOTU may be the most basic
component of pathological anxiety and a fundamental compo-
nent of all anxiety disorders (Carleton, Sharpe et al., 2007; p.
2314) was published in 2007. Carletons (2012) summary proposi-
tion of the subsequent evidence was that FOTU, most prominently
demonstrated by IU, represents a logically necessary . . . transdi-
agnostic dispositional risk factor for clinically signicant anxiety
and depression (p. 943). Carleton (2016) reviewed and synthe-
sized literature spanning contemporary models of emotion and
neuroticism, including behavioural inhibition, neurobiology, and
temperament, focusing on the role of unknowns. The result was
evidence that responses to unknowns represent a pervasive logical
reduction of several higher-order constructs, including neuroti-
cism. Accordingly, there appears to be substantial support for the
notion that FOTU is a logical reduction of higher-order constructs.
In line with contemporary theories (Barlow, Ellard, Sauer-Zavala,
Bullis, & Carl, 2014; Carleton, 2016; Clark & Beck, 2010; Gray &
McNaughton, 2003), a person does not report having several fears
 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521
because they have high levels of neuroticism (Carleton, 2016); a
person currently reports high levels of neuroticism because they
are fearful of unknowns in a variety of contexts, as well as having
several other fears.
6.5. Non-Derivative (i.e., logically irreducible)
Each of AS, FNE, and IIS, as well as fears of death and pain, can
be logically reduced to another feared element (e.g., being anxious
about illness for fear of being negatively evaluated), form reex-
ively circular tautologies with each other, or are dependent on
FOTU. In contrast, the current logical, rhetorical, and biological evi-
dence suggests FOTU is non-derivative. The unknown itself has
long been considered potentially threatening (e.g, Dugas, Letarte,
Rhaume, Freeston, & Ladouceur, 1995; Epstein, 1972; Freeston,
Rhaume, Letarte, Dugas, & Ladouceur, 1994). Unknowns exacer-
bate fear (e.g., Dugas, Hedayati et al., 2005; Gray & McNaughton,
2003; Grupe & Nitschke, 2013; Hock & Krohne, 2004) and that
fear moderates responses to ambiguous stimuli (e.g., Hedayati,
Dugas, Buhr, & Francis, 2003, November). As FOTU increases, people
become more likely to accept negative consequences than toler-
ate uncertainty (e.g., Buhr & Dugas, 2002; Ghosh, 1997; Rassin
& Muris, 2005). The appraisal models of emotion (Moors et al.,
2013; Scherer, 2009), contemporary anxiety models (Barlow, Ellard
et al., 2014; Clark & Beck, 2010; Gray & McNaughton, 2003), and
the developmental literature (Ainsworth, Blehar, Waters, & Wall,
1978; Bowlby, 1973, 1989; Kagan & Snidman, 2004) all place fearful
responses to unknowns as the cornerstone of anxiety and non-
derivative (Carleton, 2016).
Consider a person who reports FOTU because it might lead to
an aversive outcome feared because of AS, FNE, IIS, fear of death, or
fear of pain. Irrespective of the feared aversive outcome, the logi-
cal reduction process leads to asking what about that outcome is
problematic. For example, Im afraid of the unknown because I do
not know if I will have a heart attack. If I have a heart attack I might
die. If I die my deity might judge me negatively and punish me
painfully. Im afraid to experience such pain because I dont know
how long or intense it will be. Im afraid because I dont know. The
iterative process of deriving fear-evoking elements appears to end,
tautologically, with FOTU.
6.6. Accounts for higher-order variance
Initial clinical research into FOTU, typically reected by IU, has
focused on worry and generalized anxiety disorder (GAD; Dugas
et al., 1995; Dugas, Marchand, & Ladouceur, 2005; Freeston et al.,
1994; Ladouceur et al., 1999). Freeston et al. postulated a causal
relationship between IU and worry as constituents of GAD. Despite
initial focus on worry and GAD, there is now overwhelming evi-
dence that FOTU, most commonly measured as IU, represents a
broad transdiagnostic construct accounting for variance in several
higher-order constructs (see for review, Carleton, 2012, 2016; Hong
& Cheung, 2015).
Fearing the unknown, as most commonly reected by IU, has
accounted for statistically signicant variance in symptoms of panic
disorder (Buhr & Dugas, 2009; Carleton, Duranceau et al., 2014;
Carleton, Fetzner, Hackl, & McEvoy, 2013), social anxiety disorder
(Boelen & Reijntjes, 2009; Boelen et al., 2010; Carleton, Collimore
et al., 2010; Khawaja & McMahon, 2011; Teale Sapach, Carleton,
Mulvogue, Weeks, & Heimberg, 2015; Whiting et al., 2014),
obsessive compulsive disorder (Grayson, 2010; Jacoby, Fabricant,
Leonard, Riemann, & Abramowitz, 2013; Khawaja & McMahon,
2011; Lind & Boschen, 2009; Tolin, Abramowitz, Brigidi, & Foa,
2003), posttraumatic stress disorder (Banducci, Bujarski, Bonn-
Miller, Patel, & Connolly, 2016; Boelen, 2010; Boelen, Reijntjes, &
Smid, 2016; Fetzner, Horswill, Boelen, & Carleton, 2013; Oglesby,
13
Boffa, Short, Raines, & Schmidt, 2016; Otis, Keane, & Kerns, 2003;
White & Gumley, 2009), substance use (Banducci et al., 2016),
health anxiety (Boelen & Carleton, 2012; Fergus & Bardeen, 2013;
Fergus & Valentiner, 2011; Fergus, 2013; Kurita, Garon, Stanton,
& Meyerowitz, 2013; Wright, 2016), separation anxiety (Boelen,
Reijntjes, & Carleton, 2014), and eating disorders (Konstantellou
& Reynolds, 2010; Renjan, McEvoy, Handley, & Fursland, 2016;
Sternheim, Startup, & Schmidt, 2011). FOTU has also been asso-
ciated with depression (Boelen et al., 2016; Meeten, Dash, Scarlet,
& Davey, 2012; Miranda, Fontes, & Marroquin, 2008; Miranda &
Mennin, 2007; Nelson, Shankman, & Proudt, 2014; Yook, Kim, Suh,
& Lee, 2010), anger (Dugas, 2016; Fracalanza, Koerner, Deschenes,
& Dugas, 2014), and personality disorder symptoms (Berenbaum,
Bredemeier, & Thompson, 2008; Fergus & Rowatt, 2014).
There have been several broad studies, including meta-analyses,
supporting FOTU, reected by IU, as a transdiagnostic factor that
appears generally comparable across psychopathologies (Boswell
et al., 2013; Carleton, Mulvogue et al., 2012; Freeston, 2016;
Freeston et al., 2016; Gentes & Ruscio, 2011; Mahoney & McEvoy,
2012c; McEvoy & Erceg-Hurn, 2016; McEvoy & Mahoney, 2013;
Norr et al., 2013). Furthermore, response patterns based on
multigroup conrmatory factor analyses with questions assessing
FOTU appear invariant across sex (ps = 0.06 to 0.43), while being
signicantly different when comparing clinical samples to com-
munity (p < 0.01) and undergraduate (p < 0.01) samples (Carleton,
Mulvogue et al., 2012).
FOTU predicts variance in higher-order constructs in longitu-
dinal genetic twin research. For example, AS increases in children
and adults as a function of exposure to stressful events (particu-
larly those that are uncontrollable and unpredictable i.e., unknown;
Carleton, 2016) (Zavos, Gregory, & Eley, 2012, p. 205). There is
also evidence suggesting FOTU appears transdiagnostic in chil-
dren and adolescents (Freeston et al., 2016; Wright, 2016). FOTU
has also accounted for variance beyond AS (Boelen & Reijntjes,
2009; Carleton, Collimore et al., 2010; Carleton, Sharpe et al., 2007;
Dugas, Gosselin, & Landouceur, 2001), fear of anxiety (Buhr & Dugas,
2009), metabeliefs (de Bruin, Rassin, & Muris, 2007; Dugas et al.,
2007), disorder-specic IU (Thibodeau et al., 2015), positive and
negative affectivity (Carleton, Collimore et al., 2010; Thibodeau
et al., 2012), and neuroticism (Boelen & Reijntjes, 2009; Mahoney
& McEvoy, 2012b). That said, neuroticism is not an explanatory
concept in the aetiology of psychopathology, since it measures a
persons characteristic level of distress over a protracted period
of time (Ormel et al., 2004; p. 906). Hierarchical linear regres-
sion entry order recommendations suggest the most fundamental
(i.e., lowest-order) construct or the temporally earliest construct
should be accounted for rst, with increasingly higher-order or
temporally distal constructs entered thereafter (Petrocelli, 2003).
As such, controlling for neuroticism or analogues thereof before
controlling for the lower-order determinants (e.g., fundamental
fears) of such higher-order constructs may be suboptimal; nev-
ertheless, such assessments have stringently demonstrated that
FOTU, as most commonly reected by IU, accounts for variance in
critical higher-order constructs.
Intentional and targeted reductions in FOTU, as reected by
IU, have produced reductions in higher-order constructs. Per-
haps the earliest and most recognized treatment protocol for
reducing FOTU was designed by Dugas and Ladouceur (Dugas &
Ladouceur, 2000; Ladouceur, Dugas et al., 2000). The treatment is
specic to IU and effective for reducing GAD symptoms (Dugas &
Ladouceur, 2000; Dugas & Robichaud, 2007; Ladouceur, Dugas et al.,
2000), but also produces changes within increasingly higher-order
constructs, such as worry or neuroticism (Buhr & Dugas, 2009;
Dugas, Laugesen, & Bukowski, 2012; Ladouceur, Dugas et al., 2000;
Ladouceur, Gosselin, & Dugas, 2000). As such, the evidence supports
GAD as the phenotypic expression of high levels of neuroticism
14 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521
(Barlow, Ellard et al., 2014, p.488) and reducing FOTU may be a
lynchpin for reducing neuroticism (Carleton, 2012, 2016).
Dugas and Ladouceurs (2000) treatment protocol is the most
established and prolic; however, there are alternatives. For
example, a metacognitive therapy (van der Heiden, Muris, &
van der Molen, 2012) has substantially reduced IU and symp-
toms in patients with GAD (ds = 0.94 to 2.39). Further, Dugas
and Ladouceurs delineated treatment (Dugas & Robichaud, 2007)
formed the basis for adaptations beyond GAD. Reductions in
IU appear to reduce obsessive compulsive disorder symptoms
(Grayson, 2010; Wilhelm & Steketee, 2006); more recently, Hewitt
and colleagues (Hewitt, Egan, & Rees, 2009) used Dugas and
Robichauds (2007) IU section to reduce social anxiety symptoms
in a case study (i.e., reliable change index scores > 1.96). Similarly,
Mahoney and McEvoy (Mahoney & McEvoy, 2012a) provided a
7-week cognitive behavioural group therapy (CBGT) for persons
with social anxiety disorder. The therapy included learning to tol-
erate uncertainty before, during, and after social situations was
emphasized during treatment and integrated into core skills (p.
851). Reductions in IU (r2 = 0.57) predicted subsequent reductions
in depression (r2 = 0.37) and social anxiety symptoms (r2 = 0.61),
implicating a causal relationship. Boswell et al. (2013) also sup-
ported Carletons (Carleton, 2012, 2016) proposition that FOTU
represents a critical transdiagnostic factor with evidence from the
Unied Protocol for the Transdiagnostic Treatment of Emotional
Disorders (Barlow, Ellard et al., 2011). The Unied Protocol includes
an exposure element focused on interactions with unknowns.
Patients with various disorders received the treatment in a 16-
week randomized control trial wherein symptoms fell (i.e., Hedges
g = 0.52 to 1.11; Farchione et al., 2012). Most recently, changes
in IU have been associated with reductions in repetitive negative
thinking (d = 1.25), depression (d = 1.09), social anxiety symptoms
(d = 1.65 to 2.18), and GAD symptoms (d = 2.20; McEvoy & Erceg-
Hurn, 2016), further underscoring the transdiagnostic importance
of FOTU.
Hong and Cheung (Hong & Cheung, 2015) further evidenced
FOTU as a common factor for treating anxiety and mood disor-
ders with a 73 article meta-analytic assessment of vulnerabilities
for depression and anxiety. The meta-analyses examined rela-
tionships between six cognitive vulnerabilities associated with
depression (i.e., pessimistic inferential style, dysfunctional atti-
tudes, and ruminative style) and anxiety (i.e., anxiety sensitivity,
IU, and fear of negative evaluation) (p.1). Their results supported
FOTU as accounting for substantial variance in higher-order con-
structs (rs = 0.45 to 0.57) and underscored the primacy of FOTU as
a vulnerability with the highest core factor loading of 0.81. First,
IU had the strongest factor loadingimplying that a fundamental
fear of the unknown (Carleton, 2012) may feature heavily in this
common core. This element of unknown may encompass external
environmental uncertainties and threats and an individuals inter-
nally oriented uncertainty about his or her own resources to deal
with such threats (Hong & Cheung, 2015; p.13).
FOTU, as commonly reected by IU, also accounts for higher-
order variance outside of other fears and anxiety. For example,
FOTU accounts for substantial variance in explicit behavioural
tasks (rs = 0.20 to 0.43; Jacoby, Abramowitz, Buck, & Fabricant,
2014; Jacoby, Abramowitz, Reuman, & Blakey, 2016; Ladouceur,
Talbot, & Dugas, 1997), implicit behavioural tasks (part r = 0.78;
Thibodeau, Carleton, Gomez-Perez, & Asmundson, 2013), and hap-
tics (d = 0.53; van Horen & Mussweiler, 2014), while interacting
with behaviour and threat perception (partial 2 = 0.06; Reuman,
Jacoby, Fabricant, Herring, & Abramowitz, 2015). FOTU has also
been implicitly studied in the literature on decision making and risk
(see, for example, Bammer & Smithson, 2008; Jaeger, Renn, Rosa, &
Webler, 2010; Luhmann, Ishida, & Hajcak, 2011). As a consequence,
FOTU appears to have practical utility for predicting and modify-
ing transdiagnostic symptoms, individual differences, measurable
behaviours, and decisions.
6.7. Factorially distinct
Research exploring FOTU, as reected by IU, as factorially
independent from other constructs has been conducted with the
Intolerance of Uncertainty short form (i.e., IUS-12; Carleton, Norton
et al., 2007). The available results have provided robust support that
FOTU is factorially distinct. The rst such study supporting facto-
rial independence was conducted by (Carleton, Sharpe et al., 2007)
using undergraduate data. There have been two subsequent pub-
lications investigating different aspects of factorial independence
for FOTU (Carleton, Thibodeau, Osborne, & Asmundson, 2012;
Carleton, Thibodeau et al., 2014). The publications used a large
sample of undergraduates and community members who provided
responses to measures of anxiety sensitivity, fear of injury or illness,
fear of negative evaluation, fear of pain, and FOTU as measured by
IU; nevertheless, independent replications appear well-warranted.
6.8. General summary
Based on the criteria for fundamental fears, AS, FNE, IIS, and
fear of death do not appear to qualify as fundamental. Fear of
pain might yet be argued as fundamental, but appears necessarily
moderated by FOTU. In any case, there appears to be substan-
tive evidence supporting FOTU as meeting the revised criteria for
being a fundamental fear. The theoretical process followed a poten-
tially defensible constituent reductionist postpositivist approach
wherein FOTU met stringent propositional requirements that have
been developing for more than two decades (e.g., Anderson et al.,
2015; Baumeister & Leary, 1995; Carleton, Thibodeau et al., 2014;
Reiss, 1991; Taylor, 1993). Specically, FOTU appears (1) to be
an emotion; (2) inherent; (3) logically evolutionarily supported;
(4) continuously and normally distributed in the population;
(5) a logical reduction of higher-order constructs; (6) logically
non-derivative and irreducible; (7) able to account for variance
in higher-order constructs; and (8) factorially distinct. As such,
FOTU appears to be defensibly referred to as a fundamental fear
(Bach & Dolan, 2012; Carleton, 2012, 2016; Hong & Cheung,
2015). Accordingly, using FOTU as a foundation for a constituent
reductionist postpositivist approach to researching anxiety-related
psychopathology appears potentially appropriate per recent calls
for identifying key underlying factors for neuroticism (Barlow,
Sauer-Zavala et al., 2014; Brown & Barlow, 2009; Cuijpers et al.,
2010; Lahey, 2009).
7. The undiscovered countryimplications and future
directions
Assuming acceptance of the postulates herein and before (e.g.,
Bach & Dolan, 2012; Carleton, 2012, 2016; Hong & Cheung, 2015;
Thayer et al., 2012), substantial research remains to be conducted.
The extant literature base does not yet include direct empiri-
cal assessments of FOTU. Instead, such assessments have been
made using related constructs including uncertainty, ambiguity,
and novelty. Even then, much of the research has been based
on cross-sectional designs with self-report as the primary depen-
dent variable of interest. Future research should work towards
experimental, longitudinal designs with multimodal dependent
variables. A more comprehensive description of research limi-
tations and future directions is available from Shihata, McEvoy,
Mullan, and Carleton this issue. Furthermore, additional research
can and should be conducted to test how well FOTU meets each of
the propositional requirements (i.e., the eight criteria) for identify-
ing a fundamental fear. There appears to be sufcient preliminary
 R.N. Carleton / Journal of Anxiety Disorders 41 (2016) 521
support, but each of the criteria included initial recommendations
for producing stronger evidence to support a fear as fundamental
(see Table 1).
Despite the substantial neurobiological evidence (e.g.,
Balderston et al., 2013; Brosschot et al., 2016; Gray & McNaughton,
2003), much more remains to be conducted (see Brosschot et al.,
2016; Grupe & Nitschke, 2013). Research exploring how FOTU
interacts with automatic (Balderston et al., 2013; Cisler & Koster,
2010; Leyro, Zvolensky, & Bernstein, 2010; Mathews & MacLeod,
1994, 2005) and elaborated (Grenier, Barrette, & Ladouceur, 2005)
processing also appears well-warranted (Fergus, Bardeen, & Wu,
2013). Human research could also be augmented by animal studies
exploring FOTU (e.g., Herry et al., 2007; Mishra, Logue, Abiola, &
Cade, 2011).
The research to date has also focused primarily on anxiety
and related disorders, with less research exploring depression
(e.g., Nelson et al., 2014; Yook et al., 2010); however, FOTU may
impact all psychopathology as well as normative emotions and
decision-making (Bach & Dolan, 2012; Carleton, 2012, 2016; Hong
& Cheung, 2015). As such, researchers should further explore the
inuence of fearing the unknown on depression, somatic disorders
(e.g., chronic pain; Carleton & Asmundson, 2012), eating disor-
ders (Konstantellou & Reynolds, 2010; Sternheim et al., 2011), and
personality disorders (Berenbaum et al., 2008; Fergus & Rowatt,
2014), as well as supporting normative and healthy responses.
There may also be important differences in the impact of chronic
small unknowns (e.g., those associated with daily hassles) and one
or more major unknowns (e.g., whether a person will pass a critical
exam).
Explicit integration of FOTU into progressive updates of estab-
lished models for psychopathologies (e.g., the shared vulnerability
model; Asmundson, Coons, Taylor, & Katz, 2002) remains to be
considered. Research needs to be conducted exploring associated
neurological processes, memory, and self-awareness. There is also
research to be done exploring interventions transdiagnostic and
otherwise for FOTU, building on the seminal theory by Dugas
and Ladouceur (2000), Freeston et al. (1994), Ladouceur, Dugas
et al. (2000), as well as recent research and theory from Barlow,
Sauer-Zavala et al. (2014), Boswell et al. (2013), Einstein (2014),
Mahoney and McEvoy (2012a), and McEvoy and Erceg-Hurn (2016).
For example, FOTU or associated constructs (e.g., IU) could be made
explicit, rather than implicit, components of psychoeducation and
explicit targets for exposures. The inevitability of unknowns can
also be addressed, and patients can be provided tools to better
manage interactions with unknowns (e.g., cognitive restructuring,
improved probability assessments, mindfulness, acceptance).
The current review and synthesis extends previous ones in sev-
eral ways (Bach & Dolan, 2012; Carleton, 2012, 2016; Hong &
Cheung, 2015). First, a thorough rationale has been offered for iden-
tifying fundamental fears. Second, direct progressive comparisons
have now been made with other candidate constructs. Third, the
available empirical research supporting FOTU, much using IU, as
meeting the criteria for a fundamental fear has been reviewed.
Overall, the result is a robust theoretical foundation, replete with
preliminary direct experimental evidence and references to exten-
sive indirect experimental evidence with IU, for exploring FOTU
as a fundamental fear underlying anxiety and neuroticism. In sum,
FOTU may also be the fundamental fear a fear that rules all other
fears, brings them together producing anxiety, and binds them,
facilitating anxiety and neuroticism.
Acknowledgements
R. N. Carletons research is supported by the Canadian Institutes
of Health Research through a New Investigator Salary Award (FRN:
15
13666). Open Access for this publication was provided by the Uni-
versity of Regina Presidents Publication Fund. Special thanks to the
many colleagues and students across the world who contributed
their time in debating the issues presented or the details of the pre-
sentation, with particular thanks in alphabetical order to Gordon J.
G. Asmundson, Gioia Bottesi, Michel J. Dugas, Sophie Duranceau,
Amber J. Fletcher, Mark H. Freeston, Richard G. Heimberg, Michael
J. Horacki, Naomi Koerner, Craig Melhoff, Sandeep Mishra, Peter M.
McEvoy, Donald Sharpe, Sarah Shihata, & Justin W. Weeks.
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