A review on the effects of verbal instructions in human fear conditioning: Empirical findings, theoretical considerations, and future directions

Contingency Reversal in Conditioned Fear Learning: The Moderated Mediation Model of Intolerance of Uncertainty and Instruction

Objective

The study aimed to examine the roles of anxiety and intolerance of uncertainty (IU) in conditioned fear learning under an uncertain context induced by the contingency reversal of the association between the conditioned stimulus and the unconditioned stimulus (CS-US).

Methods

The study sample comprised 53 participants, randomly divided into two groups: a non-instruction group and an instruction group. The experimental procedure encompassed five stages: pre-acquisition, acquisition, generalization, reversal acquisition, and reversal generalization. Our study primarily focused on analyzing a moderated mediation model.

Results

In the instructed group, we observed that the reversed fear generalization response was directly influenced by the pre-reversal fear generalization response, while also being indirectly mediated by the IU factor. However, in the non-instructed group, we did not find a significant mediating effect of IU. Moreover, we noted that the mediation of IU was contingent on the instructional information. It is noteworthy that anxiety did not exhibit a discernible role in conditioned fear within the uncertainty condition in our study.

Conclusion

The findings provide novel insights into fear-related phenomena, emphasizing the intricate interplay between individual traits and fear generalization under conditions of uncertainty. They contribute to understanding the mechanisms of emotional and cognitive interactions in uncertain conditions.

Mental threat rehearsal increases fear generalization

BACKGROUND AND OBJECTIVES

Fear generalization to harmless stimuli characterizes anxiety-related disorders, but much remains unknown about its determinants. Based on studies showing that mental imagery of threat can increase conditioned fear responding, we tested whether it also facilitates fear generalization, and whether threat inflation moderates this effect.

METHODS

In a fear conditioning study, 120 participants first completed an acquisition phase, in which one of two pictures was followed by an aversive sound (human scream). Then, the sound was presented 11 times at an increasing (threat inflation) or constant volume (no threat inflation). Finally, a generalization stimulus was presented, and some participants were asked to imagine the last sound (threat rehearsal) and others were not (no threat rehearsal).

RESULTS

Bayesian informative hypotheses tests indicated that imagery-based threat rehearsal increased generalization of threat expectancy, and, combined with threat inflation, it also resulted in stronger generalized distress.

LIMITATIONS

due to the absence of a test phase, it is unclear whether our effects would transfer to other GSs and whether they would persist beyond the manipulation phase.

CONCLUSIONS

Mental imagery of threat may put individuals at risk for fear generalization. Future studies should examine whether modulating imagery may prevent clinical anxiety.

Observational learning of threat-related attentional bias

Attentional bias to threat has been almost exclusively examined after participants experienced repeated pairings between a conditioned stimulus (CS) and an aversive unconditioned stimulus (US). This study aimed to determine whether threat-related attentional capture can result from observational learning, when participants acquire knowledge of the aversive qualities of a stimulus without themselves experiencing aversive outcomes. Non-clinical young-adult participants (N = 38) first watched a video of an individual (the demonstrator) performing a Pavlovian conditioning task in which one colour was paired with shock (CS+) and another colour was neutral (CS-). They then carried out visual search for a shape-defined target. Oculomotor measures evidenced an attentional bias toward the CS+ colour, suggesting that threat-related attentional capture can ensue from observational learning. Exploratory analyses also revealed that this effect was positively correlated with empathy for the demonstrator. Our findings extend empirical and theoretical knowledge about threat-driven attention and provide valuable insights to better understand the formation of anxiety disorders.

Resolving the Delusion Paradox

BACKGROUND AND HYPOTHESIS

The neurocomputational framework of predictive processing (PP) provides a promising approach to explaining delusions, a key symptom of psychotic disorders. According to PP, the brain makes inferences about the world by weighing prior beliefs against the available sensory data. Mismatches between prior beliefs and sensory data result in prediction errors that may update the brain's model of the world. Psychosis has been associated with reduced weighting of priors relative to the sensory data. However, delusional beliefs are highly resistant to change, suggesting increased rather than decreased weighting of priors. We propose that this "delusion paradox" can be resolved within a hierarchical PP model: Reduced weighting of prior beliefs at low hierarchical levels may be compensated by an increased influence of higher-order beliefs represented at high hierarchical levels, including delusional beliefs. This may sculpt perceptual processing into conformity with delusions and foster their resistance to contradictory evidence.

STUDY DESIGN

We review several lines of experimental evidence on low- and high-level processes, and their neurocognitive underpinnings in delusion-related phenotypes and link them to predicted processing.

STUDY RESULTS

The reviewed evidence supports the notion of decreased weighting of low-level priors and increased weighting of high-level priors, in both delusional and delusion-prone individuals. Moreover, we highlight the role of prefrontal cortex as a neural basis for the increased weighting of high-level prior beliefs and discuss possible clinical implications of the proposed hierarchical predictive-processing model.

CONCLUSIONS

Our review suggests the delusion paradox can be resolved within a hierarchical PP model.

Incidental learning of faces during threat: No evidence for enhanced physiological responses to former threat identities

Remembering an unfamiliar person and the contextual conditions of that encounter is important for adaptive future behavior, especially in a potentially dangerous situation. Initiating defensive behavior in the presence of former dangerous circumstances can be crucial. Recent studies showed selective electrocortical processing of faces that were previously seen in a threat context compared to a safety context, however, this was not reflected in conscious recognition performance. Here, we investigated whether previously seen threat-faces, that could not be remembered, were capable to activate defensive psychophysiological response systems. During an encoding phase, 50 participants with low to moderate levels of anxiety viewed 40 face pictures with neutral expressions (6 s each), without an explicit learning instruction (incidental learning task). Each half of the faces were presented with contextual background colors that signaled either threat-of-shock or safety. In the recognition phase, all old and additional new faces (total of 60) were presented intermixed without context information. Participants had to decide whether a face was new or had been presented previously in a threatening or a safe context. Results show moderate face recognition independent of context conditions. Startle reflex and skin conductance responses (SCR) were more pronounced for threat compared to safety during encoding. For SCR, this differentiation was enhanced with higher levels of depression and anxiety. There were no differential startle reflex or SCR effects during recognition. From a clinical perspective, these findings do not support the notion that perceptual biases and physiological arousal directly relate to threat-associated identity recognition deficits in healthy and clinical participants with anxiety and trauma-related disorders.

Let's play pretend: Towards effective modelling in experimental psycho(patho)logy

BACKGROUND AND OBJECTIVES

Models are omnipresent in science. We introduce a novel framework to achieve more effective modelling practices in general psychology and experimental psychopathology.

METHOD

We analyze three types of models that are common in psychology: laboratory models, computational models, and cognitive models. We then evaluate two common ways to assess the translational value of models (phenomenological similarity and deep similarity) as well as an arguably underappreciated way (functional similarity). Functional similarity is based on an assessment of whether variables (e.g., the administration of a pharmacological substance) have a similar effect (a) in the model (e.g., in a fear conditioning procedure) and (b) on the real-life target phenomenon (e.g., on real-life anxiety complaints).

CONCLUSIONS

We argue that the assessment of functional similarity is a powerful tool to assess the translational value of models in the field of experimental psychopathology and beyond.

Effects of Experiencing CS-US Pairings on Instructed Fear Reversal

Fear learning allows us to identify and anticipate aversive events and adapt our behavior accordingly. This is often thought to rely on associative learning mechanisms where an initially neutral conditioned stimulus (CS) is repeatedly paired with an aversive unconditioned stimulus (US), eventually leading to the CS also being perceived as aversive and threatening. Importantly, however, humans also show verbal fear learning. Namely, they have the ability to change their responses to stimuli rapidly through verbal instructions about CS-US pairings. Past research on the link between experience-based and verbal fear learning indicated that verbal instructions about a reversal of CS-US pairings can fully override the effects of previously experienced CS-US pairings, as measured through fear ratings, skin conductance, and fear-potentiated startle. However, it remains an open question whether such instructions can also annul learned CS representations in the brain. Here, we used a fear reversal paradigm (female and male participants) in conjunction with representational similarity analysis of fMRI data to test whether verbal instructions fully override the effects of experienced CS-US pairings in fear-related brain regions or not. Previous research suggests that only the right amygdala should show lingering representations of previously experienced threat ("pavlovian trace"). Unexpectedly, we found evidence for the residual effect of prior CS-US experience to be much more widespread than anticipated, in the amygdala but also cortical regions like the dorsal anterior cingulate or dorsolateral prefrontal cortex. This finding shines a new light on the interaction of different fear learning mechanisms, at times with unexpected consequences.SIGNIFICANCE STATEMENT Humans are able to learn about aversive stimuli both from experience (i.e., repeated pairings of conditioned stimulus (CS) and unconditioned stimulus (US; pavlovian conditioning), and from verbal instructions about stimulus pairings. Understanding how experience-based and verbal learning processes interact is key for understanding the cognitive and neural underpinnings of fear learning. We tested whether prior aversive experiences (CS-US pairings) affected subsequent verbal learning, searching for lingering threat signals after verbal instructions reversed a CS from being threatening to being safe. While past research suggested such threat signals can only be found in the amygdala, we found evidence to be much more widespread, including the medial and lateral PFC. This highlights how experience-based and verbal learning processes interact to support adaptive behavior.

Fear Learning in Genital Pain: Toward a Biopsychosocial, Ecologically Valid Research and Treatment Model

Although fear learning mechanisms are implicated in the development, maintenance, exacerbation, and reduction of genital pain, systematic research on how fear of genital pain emerges, spreads, persists, and reemerges after treatment is lacking. This paper provides an overview of the literature on pain-related fear, integrates the ideas on learning and sexual arousal responding, and specifies the pathways through which compromised learning may contribute to the development and persistence of genital pain. In order to refine theories of genital pain and optimize treatments, we need to adopt a biopsychosocial framework to pain-related fear learning and uncover potential moderators that shape individual trajectories. This involves examining the role of physiological processes, subjective experiences, as well as partner and relational cues in fear acquisition, excessive generalization and impaired safety learning, extinction of fear, counterconditioning, and return of fear. Recent methodological advances in fear conditioning and sex research are promising to enable more symptom-specific and ecologically valid experimental paradigms.

Social learning and the adaptiveness of expressing and perceiving fearfulness

The fearful ape hypothesis revolves around our ability to express and perceive fearfulness. Here, we address these abilities from a social learning perspective which casts fearfulness in a slightly different light. Our commentary argues that any theory that characterizes a (human) social signal as being adaptive, needs to address the role of social learning as an alternative candidate explanation.

Consensus design of a calibration experiment for human fear conditioning

Fear conditioning is a widely used laboratory model to investigate learning, memory, and psychopathology across species. The quantification of learning in this paradigm is heterogeneous in humans and psychometric properties of different quantification methods can be difficult to establish. To overcome this obstacle, calibration is a standard metrological procedure in which well-defined values of a latent variable are generated in an established experimental paradigm. These intended values then serve as validity criterion to rank methods. Here, we develop a calibration protocol for human fear conditioning. Based on a literature review, series of workshops, and survey of N = 96 experts, we propose a calibration experiment and settings for 25 design variables to calibrate the measurement of fear conditioning. Design variables were chosen to be as theory-free as possible and allow wide applicability in different experimental contexts. Besides establishing a specific calibration procedure, the general calibration process we outline may serve as a blueprint for calibration efforts in other subfields of behavioral neuroscience that need measurement refinement.

Classical conditioning of faciliatory paired-pulse TMS

In this proof-of-concept study, we questioned whether the influence of TMS on cortical excitability can be applied to classical conditioning. More specifically, we investigated whether the faciliatory influence of paired-pulse TMS on the excitability of the human motor cortex can be transferred to a simultaneously presented auditory stimulus through conditioning. During the conditioning phase, 75 healthy young participants received 170 faciliatory paired TMS pulses (1st pulse at 95% resting motor threshold, 2nd at 130%, interstimulus interval 12 ms), always presented simultaneously with one out of two acoustic stimuli. In the test phase, 20 min later, we pseudorandomly applied 100 single TMS pulses (at 130% MT), 50 paired with the conditioned tone-50 paired with a control tone. Using the Wilcoxon-Signed Rank test, we found significantly enhanced median amplitudes of motor evoked potentials (MEPs) paired with the conditioned tone as compared to the control tone, suggesting successful conditioning (p = 0.031, responder rate 55%, small effect size of r = - 0.248). The same comparison in only those participants with a paired-pulse amplitude < 2 mV in the conditioning phase, increased the responder rate to 61% (n = 38) and effect size to moderate (r = - 0.389). If we considered only those participants with a median paired-pulse amplitude < 1 mV, responder rate increased further to 79% (n = 14) and effect size to r = - 0.727 (i.e., large effect). These findings suggest increasingly stronger conditioning effects for smaller MEP amplitudes during paired-pulse TMS conditioning. These proof-of-concept findings extend the scope of classical conditioning to faciliatory paired-pulse TMS.

Understanding clinical fear and anxiety through the lens of human fear conditioning

Fear is an adaptive emotion that mobilizes defensive resources upon confrontation with danger. However, fear becomes maladaptive and can give rise to the development of clinical anxiety when it exceeds the degree of threat, generalizes broadly across stimuli and contexts, persists after the danger is gone or promotes excessive avoidance behaviour. Pavlovian fear conditioning has been the prime research instrument that has led to substantial progress in understanding the multi-faceted psychological and neurobiological mechanisms of fear in past decades. In this Perspective, we suggest that fruitful use of Pavlovian fear conditioning as a laboratory model of clinical anxiety requires moving beyond the study of fear acquisition to associated fear conditioning phenomena: fear extinction, generalization of conditioned fear and fearful avoidance. Understanding individual differences in each of these phenomena, not only in isolation but also in how they interact, will further strengthen the external validity of the fear conditioning model as a tool with which to study maladaptive fear as it manifests in clinical anxiety.

Instructions and experiential learning have similar impacts on pain and pain-related brain responses but produce dissociations in value-based reversal learning

Recent data suggest that interactions between systems involved in higher order knowledge and associative learning drive responses during value-based learning. However, it is unknown how these systems impact subjective responses, such as pain. We tested how instructions and reversal learning influence pain and pain-evoked brain activation. Healthy volunteers (n=40) were either instructed about contingencies between cues and aversive outcomes or learned through experience in a paradigm where contingencies reversed three times. We measured predictive cue effects on pain and heat-evoked brain responses using functional magnetic resonance imaging. Predictive cues dynamically modulated pain perception as contingencies changed, regardless of whether participants received contingency instructions. Heat-evoked responses in the insula, anterior cingulate, and other regions updated as contingencies changed, and responses in the prefrontal cortex mediated dynamic cue effects on pain, whereas responses in the brainstem’s rostroventral medulla (RVM) were shaped by initial contingencies throughout the task. Quantitative modeling revealed that expected value was shaped purely by instructions in the Instructed Group, whereas expected value updated dynamically in the Uninstructed Group as a function of error-based learning. These differences were accompanied by dissociations in the neural correlates of value-based learning in the rostral anterior cingulate, thalamus, and posterior insula, among other regions. These results show how predictions dynamically impact subjective pain. Moreover, imaging data delineate three types of networks involved in pain generation and value-based learning: those that respond to initial contingencies, those that update dynamically during feedback-driven learning as contingencies change, and those that are sensitive to instruction. Together, these findings provide multiple points of entry for therapies designs to impact pain.

Sometimes I feel the fear of uncertainty: How intolerance of uncertainty and trait anxiety impact fear acquisition, extinction and the return of fear

It is hypothesized that the ability to discriminate between threat and safety is impaired in individuals with high dispositional negativity, resulting in maladaptive behavior. A large body of research investigated differential learning during fear conditioning and extinction protocols depending on individual differences in intolerance of uncertainty (IU) and trait anxiety (TA), two closely-related dimensions of dispositional negativity, with heterogenous results. These might be due to varying degrees of induced threat/safety uncertainty. Here, we compared two groups with high vs. low IU/TA during periods of low (instructed fear acquisition) and high levels of uncertainty (delayed non-instructed extinction training and reinstatement). Dependent variables comprised subjective (US expectancy, valence, arousal), psychophysiological (skin conductance response, SCR, and startle blink), and neural (fMRI BOLD) measures of threat responding. During fear acquisition, we found strong threat/safety discrimination for both groups. During early extinction (high uncertainty), the low IU/TA group showed an increased physiological response to the safety signal, resulting in a lack of CS discrimination. In contrast, the high IU/TA group showed strong initial threat/safety discrimination in physiology, lacking discriminative learning on startle, and reduced neural activation in regions linked to threat/safety processing throughout extinction training indicating sustained but non-adaptive and rigid responding. Similar neural patterns were found after the reinstatement test. Taken together, we provide evidence that high dispositional negativity, as indicated here by IU and TA, is associated with greater responding to threat cues during the beginning of delayed extinction, and, thus, demonstrates altered learning patterns under changing environments.

Validación cognitiva de un protocolo instruccional de reexperimentación emocional en adultos víctimas de violencia política en Colombia

La reexperimentación emocional (re) permite dar sentido a hechos traumáticos o estresantes mediante un proceso dirigido por instrucciones verbales o escritas, y por ello puede generar beneficios en el bienestar psicológico y la salud física autoinformada. El objetivo del presente estudio fue evaluar la comprensión de tres tipos de instrucciones experimentales (re tradicional, re con claves de aceptación y compromiso, y re psicosocial) y una instrucción para el grupo control (re trivial), mediante técnicas de validación cognitiva (pruebas centradas en el significado y verbalización de pensamiento) en personas expuestas a hechos de violencia política en Colombia. Para ello, se desarrolló un estudio de tipo cualitativo con corte instrumental, en el que se entrevistó a 42 colombianos víctimas de violencia política, en su mayoría mujeres, elegidos con un muestro por conveniencia. Las entrevistas fueron transcritas y codificadas mediante un análisis categorial mixto que tomó como referente procedimientos del Movimiento de Aspectos Cognitivos de la Metodología de Encuestas. Como resultado, los participantes comprendieron de manera diferencial las instrucciones dadas en cada protocolo, enfocándose en aspectos como el contexto sociopolítico en el caso del protocolo psicosocial, y en respuestas asociadas a la aceptación en el protocolo con claves de aceptación y compromiso. Se identificaron dificultades en la comprensión de algunas secciones de los protocolos, las cuales fueron ajustadas. Finalmente, se enfatiza la importancia de implementar técnicas de validación cognitiva para verificar la comprensión de instrucciones, protocolos o instrumentos, dado que el desempeño de los participantes y la calidad de las medidas de las intervenciones pueden verse afectados por la comprensión e interpretación de las instrucciones propuestas.

Investigating the Role of Perceived Information Overload on COVID-19 Fear: A Moderation Role of Fake News Related to COVID-19

During crises and uncertain situations such as the coronavirus disease 2019 (COVID-19) pandemic, social media plays a key function because it allows people to seek and share news, as well as personal views and ideas with each other in real time globally. Past research has highlighted the implications of social media during disease outbreaks; nevertheless, this study refers to the possible negative effects of social media usage by individuals in the developing country during the COVID-19 epidemic lockdown. Specifically, this study investigates the COVID-19 fear using the survey data collected from a developing country. In total, 880 entries were used to analyze the COVID-19 fear using the AMOS software. Findings indicated that information-seeking and sharing behavior of individuals on social media has a significant impact on perceived COVID-19 information overload. Perceived COVID-19 information overload has a positive impact on COVID-19 fear. In addition, fake news related to COVID-19 strengthens the relationship between perceived COVID-19 information overload and COVID-19 fear. The implication and limitations of the study are also discussed in the final section of the study.

Enhanced Instructed Fear Learning in Delusion-Proneness

Psychosis is associated with distorted perceptions and deficient bottom-up learning such as classical fear conditioning. This has been interpreted as reflecting imprecise priors in low-level predictive coding systems. Paradoxically, overly strong beliefs, such as overvalued beliefs and delusions, are also present in psychosis-associated states. In line with this, research has suggested that patients with psychosis and associated phenotypes rely more on high-order priors to interpret perceptual input. In this behavioural and fMRI study we studied two types of fear learning, i.e., instructed fear learning mediated by verbal suggestions about fear contingencies and classical fear conditioning mediated by low level associative learning, in delusion proneness—a trait in healthy individuals linked to psychotic disorders. Subjects were shown four faces out of which two were coupled with an aversive stimulation (CS+) while two were not (CS-) in a fear conditioning procedure. Before the conditioning, subjects were informed about the contingencies for two of the faces of each type, while no information was given for the two other faces. We could thereby study the effect of both classical fear conditioning and instructed fear learning. Our main outcome variable was evaluative rating of the faces. Simultaneously, fMRI-measurements were performed to study underlying mechanisms. We postulated that instructed fear learning, measured with evaluative ratings, is stronger in psychosis-related phenotypes, in contrast to classical fear conditioning that has repeatedly been shown to be weaker in these groups. In line with our hypothesis, we observed significantly larger instructed fear learning on a behavioural level in delusion-prone individuals (n = 20) compared to non-delusion-prone subjects (n = 23; n = 20 in fMRI study). Instructed fear learning was associated with a bilateral activation of lateral orbitofrontal cortex that did not differ significantly between groups. However, delusion-prone subjects showed a stronger functional connectivity between right lateral orbitofrontal cortex and regions processing fear and pain. Our results suggest that psychosis-related states are associated with a strong instructed fear learning in addition to previously reported weak classical fear conditioning. Given the similarity between nocebo paradigms and instructed fear learning, our results also have an impact on understanding why nocebo effects differ between individuals.

The social learning of threat and safety in the family: Parent-to-child transmission of social fears via verbal information

Parental verbal threat (vs. safety) information regarding the social world may impact a child's fear responses, evident in subjective, behavioral, cognitive, and physiological indices of fear. In this study, primary caregivers provided standardized verbal threat or safety information to their child (N = 68, M = 5.27 years; 34 girls) regarding two strangers in the lab. Following this manipulation, children reported fear beliefs for each stranger. Physiological and behavioral reactions were recorded as children engaged with the two strangers (who were blind to their characterization) in a social interaction task. Child attention to the strangers was measured in a visual search task. Parents also reported their own, and their child's, social anxiety symptoms. Children reported more fear for the stranger paired with threat information, but no significant differences were found in observed child fear, attention, or heart rate. Higher social anxiety symptoms on the side of the parents and the children exacerbated the effect of parental verbal threat on observed fear. Our findings reveal a causal influence of parental verbal threat information only for child-reported fear and highlight the need to further refine the conditions under which acquired fear beliefs persist and generalize to behavior/physiology or get overruled by nonaversive real-life encounters.

Learning via instructions about observations: exploring similarities and differences with learning via actual observations

Our behaviour toward stimuli can be influenced by observing how another person (a model) interacts with those stimuli. We investigated whether mere instructions about a model's interactions with stimuli (i.e. instructions about observations) are sufficient to alter evaluative and fear responses and whether these changes are similar in magnitude to those resulting from actually observing the interactions. In Experiments 1 (n = 268) and 2 (n = 260), participants either observed or read about a model reacting positively or negatively to stimuli. Evaluations of those stimuli were then assessed via ratings and a personalized implicit association test. In Experiments 3 (n = 60) and 4 (n = 190), we assessed participants' fear toward stimuli after observing or reading about a model displaying distress in the presence of those stimuli. While the results consistently indicated that instructions about observations induced behavioural changes, they were mixed with regard to whether instructions were as powerful in changing behaviour as observations. We discuss whether learning via observations and via instructions may be mediated by similar or different processes, how they might differ in their suitability for conveying certain types of information, and how their relative effectiveness may depend on the information to be transmitted.

The mere sight of loved ones does not inhibit psychophysiological defense mechanisms when threatened

Looking at pictures of loved ones, such as one's romantic partner or good friends, has been shown to alleviate the experience of pain and reduce defensive reactions. However, little is known about such modulatory effects on threat and safety learning and the psychophysiological processes involved. Here, we explored the hypothesis that beloved faces serve as implicit safety cues and attenuate the expression of fear responses and/or accelerate extinction learning in a threatening context. Thirty-two participants viewed pictures of their loved ones (romantic partner, parents, and best friend) as well as of unknown individuals within contextual background colors indicating threat-of-shock or safety. Focusing on the extinction of non-reinforced threat associations (no shocks were given), the experiment was repeated on two more test days while the defensive startle-EMG, SCR, and threat ratings were obtained. Results confirmed pronounced defensive responding to instructed threat-of-shock relative to safety context (e.g., threat-enhanced startle reflex and SCR). Moreover, threat-potentiated startle response slowly declined across test days indicating passive extinction learning in the absence of shocks. Importantly, neither a main effect of face category (loved vs. unknown) nor a significant interaction with threat/safety instructions was observed. Thus, a long-term learning history of beneficial relations (e.g., with supportive parents) did not interfere with verbal threat learning and aversive apprehensions. These findings reflect the effects of worries and apprehensions that persist despite the repeated experience of safety and the pictorial presence of loved ones. How to counter such aversive expectations is key to changing mal-adaptive behaviors (e.g., avoidance or stockpiling), biased risk perceptions, and stereotypes.

A Current Learning Theory Approach to the Etiology and Course of Anxiety and Related Disorders

The authors describe how contemporary learning theory and research provide the basis for models of the etiology and maintenance of anxiety and related disorders. They argue that contemporary learning theory accounts for much of the complexity associated with individual differences in the development and course of these disorders. These insights from modern research on learning overcome the limitations of earlier behavioral approaches, which were overly simplistic and have been justifiably criticized. The authors show how considerations of early learning histories and temperamental vulnerabilities affect the short- and long-term likelihood that experiences with stressful events will lead to the development of anxiety disorders. They also discuss how contextual variables during and after stressful learning experiences influence the maintenance of anxiety disorder symptoms. Thus, contemporary learning models provide a rich and nuanced understanding of the etiology and course of anxiety and related disorders. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Association of Fear of COVID-19 and Health Literacy Among the General Public in Saudi Arabia: A Cross-Sectional Assessment

Objective

This study aims to determine the level of fear of coronavirus disease—2019 (COVID-19) among the general public in Saudi Arabia and the association of its scores with their level of health literacy.

Methods

A descriptive cross-sectional study was conducted among the general population in Saudi Arabia from April 2020 to May 2020. A three-part online self-reported survey was used to assess the participants' demographic characteristics, fear of COVID-19 of the participants, and levels of health literacy.

Results

Of the 848 participants, 56.8% were in the age group of 25–34, 45.6% were females, and 57.1% had a bachelor's degree. The total mean score of the fear of COVID-19 scale of the participants was FCoV-19: mean ± SD = 19.60 ± 7.33 and the health literacy was HL index: mean ± SD = 27.57 ± 11.05. There was a significant difference in the scores of fear of COVID-19 scale in terms of age (F = 2.442, p = 0.050), representing that those aged 45 and above had higher mean fear scores than the younger participants. The analysis revealed that an increased level of fear of COVID-19 was associated with older age (B = 1.87; p = 0.020), being unemployed (B = 0.76; p = 0.023), with no formal education (B = 0.89; p = 0.001), and low level of health literacy (B = 0.02; p = 0.021).

Conclusion

The study shows an above-average level of fear of COVID-19 of the general public in Saudi Arabia and its association with a low level of functional health literacy. Timely and comprehensive health interventions should be promoted to enhance the level of health literacy and further reduce the level of fear of COVID-19 in the community.

Rating expectations can slow aversive reversal learning

The process of learning allows organisms to develop predictions about outcomes in the environment, and learning is sensitive to both simple associations and higher order knowledge. However, it is unknown whether consciously attending to expectations shapes the learning process itself. Here, we directly tested whether rating expectations shapes arousal during classical conditioning. Participants performed an aversive learning paradigm wherein one image (CS+) was paired with shock on 50% of trials, while a second image (CS-) was never paired with shock. Halfway through the task, contingencies reversed. One group of participants rated the probability of upcoming shock on each trial, while the other group made no online ratings. We measured skin conductance response (SCR) evoked in response to the CS and used traditional analyses as well as quantitative models of reinforcement learning to test whether rating expectations influenced arousal and aversive reversal learning. Participants who provided online expectancy ratings displayed slower learning based on a hybrid model of adaptive learning and reduced reversal of SCR relative to those who did not rate expectations. Mediation analysis revealed that the effect of associative learning on SCR could be fully explained through its effects on subjective expectancy within the group who provided ratings. This suggests that the act of rating expectations reduces the speed of learning, likely through changes in attention, and that expectations directly influence arousal. Our findings indicate that higher order expectancy judgments can alter associative learning.

The (shared) features of fear: Toward the source of human fear responding

Little is known about why people behave the way they do in threatening situations. Some theories invoke a transfer of responses from unconditioned stimuli (US) to conditioned stimuli (CS), but this principle goes astray because responses to the US and CS can differ substantially. The idea that we introduce here is that the pattern of responses to a newly established CS does not come from the US but (at least partly) transfers from how one (learned to) respond(s) to previously encountered stimuli with threat value. So, we conceptualize threat value as a stimulus feature that allows responses to transfer between stimuli that share this feature (in the same way as, for example, overlap in color or shape can support transfer). In contrast to prevailing views, this new perspective focuses on the relation between the CS and already established threat signals rather than on the relation between the CS and the US. We discuss how this shared features perspective on human fear responding can inspire future directions in both the laboratory and clinical practice.

Does an unconditioned stimulus memory devaluation procedure decrease disgust memories and conditioned disgust? Results of two laboratory studies

Research has demonstrated that disgust can be installed through classical conditioning by pairing neutral conditioned stimuli (CSs) with disgusting unconditioned stimuli (USs). Disgust has been argued to play an important role in maintaining fear-related disorders. This maintaining role may be explained by conditioned disgust being less sensitive to extinction (i.e., experiencing the CS in the absence of the US). Promising alternatives to extinction training are procedures that focus on the devaluation of US memory representations. In the current study, we investigated whether such devaluation procedures can be successful to counter conditioned disgust. We conducted two laboratory studies (N = 120 and N = 51) in which disgust was conditioned using audio-visual USs. Memory representations of the USs were devalued by having participants recall these USs while they performed a taxing eye-movement task or executed one of several control tasks. The results showed successful conditioned disgust acquisition. However, no strong evidence was obtained that an US memory devaluation procedure modulates disgust memory and diminishes conditioned disgust as indicated by subjective, behavioral, or psychophysiological measures. We discuss the relevance of our results for methodological improvements regarding US memory devaluation procedures and disgust conditioning.

The role of intolerance of uncertainty in classical threat conditioning: Recent developments and directions for future research

Intolerance of uncertainty (IU), the tendency to find uncertainty aversive, is an important transdiagnostic dimension in mental health disorders. Over the last decade, there has been a surge of research on the role of IU in classical threat conditioning procedures, which serve as analogues to the development, treatment, and relapse of anxiety, obsessive-compulsive, and trauma- and stressor-related disorders. This review provides an overview of the existing literature on IU in classical threat conditioning procedures. The review integrates findings based on the shared or discrete parameters of uncertainty embedded within classical threat conditioning procedures. Under periods of unexpected uncertainty, where threat and safety contingencies change, high IU, over other self-reported measures of anxiety, is specifically associated with poorer threat extinction learning and retention, as well as overgeneralisation. Under periods of estimation and expected uncertainty, where the parameters of uncertainty are being learned or have been learned, such as threat acquisition training and avoidance learning, the findings are mixed for IU. These findings provide evidence that individual differences in IU play a significant role in maintaining learned fear and anxiety, particularly under volatile environments. Recommendations for future research are outlined, with discussion focusing on how parameters of uncertainty can be better defined to capture how IU is involved in the maintenance of learned fear and anxiety. Such work will be crucial for understanding the role of IU in neurobiological models of uncertainty-based maintenance of fear and anxiety and inform translational work aiming to improve the diagnosis and treatment of relevant psychopathology.

Deleting "fear" from "fear extinction": Estimating the individual extinction rate via non-aversive conditioning

Individual differences in extinction learning have attracted ample attention of researchers and are under investigation as a marker for the onset of anxiety disorders and treatment response. Unfortunately, the common paradigm for obtaining the extinction rate, which entails aversive stimulus pairings, is subject to practical limitations. Therefore, the present study assessed whether the use of an aversive stimulus is actually needed to get a good estimate of the extinction rate. A total of 161 undergraduate students completed a conditioning task with both an aversive and a non-aversive stimulus. Using latent class growth analysis (LCGA), distinct trajectories, representing normal and stunted extinction learning, were identified for both these stimulus types. Participants' membership in these classes largely overlapped for aversive and non-aversive stimulus pairings and respective extinction indices were significantly correlated. Thereby, findings suggest that the use of a non-aversive stimulus could suffice for successfully capturing individual differences in extinction learning. However, future studies are needed to confirm that conditioning with a non-aversive stimulus may serve to predict clinically relevant outcomes.

COVID-19 information overload and generation Z's social media discontinuance intention during the pandemic lockdown

While previous research highlights the benefits of social media in times of a pandemic, this research focuses on the potential dark side of social media use among Generation Z (Gen Z) in the UK during the COVID-19 pandemic lockdown between March and May 2020. The study reveals that COVID-19 information overload through social media had a negative impact on Gen Z social media users' psychological well-being. Moreover, perceived information overload heightened both social media fatigue and fear of COVID-19, which, in turn, increased users' social media discontinuance intention. In addition, considering that social media is the predominant method of maintaining connectivity with others for Gen Z users during the lockdown, the fear of missing out (FoMO) buffered the impact of social media fatigue and fear of COVID-19 on Gen Z users' social media discontinuance intention. Our research adds a hitherto underexplored perspective to the impact of the COVID-19 pandemic on young people's mental health. We offer a series of practical suggestions for social media users, social media platform providers, and health officials, institutions, and organizations in the effective and sustainable use of social media during the global COVID-19 pandemic and in the post-pandemic time.

Verbal threat learning does not spare loved ones

Significant others provide individuals with a sense of safety and security. However, the mechanisms that underlie attachment-induced safety are hardly understood. Recent research has shown beneficial effects when viewing pictures of the romantic partner, leading to reduced pain experience and defensive responding. Building upon this, we examined the inhibitory capacity of loved face pictures on fear learning in an instructed threat paradigm. Pictures of loved familiar or unknown individuals served as signals for either threat of electric shocks or safety, while a broad set of psychophysiological measures was recorded. We assumed that a long-term learning history of beneficial relations interferes with social threat learning. Nevertheless, results yielded a typical pattern of physiological defense activation towards threat cues, regardless of whether threat was signaled by an unknown or a loved face. These findings call into question the notion that pictures of loved individuals are shielded against becoming threat cues, with implications for attachment and trauma research.

Phenotyping mental health: Age, community size, and depression differently modulate COVID-19-related fear and generalized anxiety

INTRODUCTION

When the first COVID-19 infections were reported in Germany, fear and anxiety spread faster than the pandemic itself. While moderate amounts of fear of a COVID-19 infection may be functional, generalized anxiety and the potentially resulting distress and psychopathology may possibly be detrimental to people's health. Authorities need to avoid a countrywide panic, on the one hand, but foster a realistic awareness of the actual threat, on the other hand.

OBJECTIVES

The current cross-sectional study aimed to investigate psychological reactions in response to the real or perceived infection threats. In particular, the analysis should reveal whether COVID-19-related fear and generalized anxiety in times of COVID-19 have distinct correlates.

METHODS

A nationwide study was conducted from March 10th to May 4th 2020 in Germany (n = 15,308; 10,824 women, 4433 men, 51 other). Generalized anxiety was assessed using the GAD-7, while COVID-19-related fear was measured using a self-generated item. Both outcome variables were entered into linear regression models. Demographic information, depressive symptoms, trust in governmental interventions, subjective level of information regarding COVID-19 and media use were used to predict generalized anxiety and COVID-19-related fear.

RESULTS

The data revealed distinct correlates of COVID-19-related fear and generalized anxiety. Although COVID-19-related fear and generalized anxiety had overlapping predictors, such as neuroticism, they most prominently differed in age distribution and direction of an urban-rural disparity: generalized anxiety decreases with age, but COVID-19-related fear is most pronounced in elderly participants. Generalized anxiety is also more prevalent in rural communities, but COVID-19-related fear is elevated in metropoles. Furthermore, the presence of a risk disease increases COVID-19-related fear, but not generalized anxiety.

CONCLUSION

These results suggest that COVID-19-related fear is often justified considering the individual risk of infection or complication due to infection. Some of the characteristics that predict COVID-19-related fear leave generalized anxiety unaffected or show divergent predictive directions. The present findings hint toward two related, but discriminant constructs.

Human fear conditioning is moderated by stimulus contingency instructions

Recent research findings indicate that human fear conditioning is affected by instructions, particularly those concerning the contingency between the conditioned stimulus (CS) and the unconditioned stimulus (US). However, whether or not such instructions were provided to participants often remains unsaid in fear conditioning studies. In the current study (N = 102), we investigated whether conditioned fear acquisition depends on CS-US contingency instructions. Participants were randomly assigned to one of three groups. The first group was instructed about the precise CS-US contingency before conditioning. The second group was instructed to discover the CS-US contingency. The third group did not receive any contingency instructions. We found facilitated fear acquisition (using skin conductance and startle) and increased contingency awareness in the first and second group compared to the third group. Furthermore, contingency reversal instructions immediately reversed conditioned responses. Based on these results, we advise to systematically report the contingency instructions used in fear conditioning research.

Learning dynamics of electrophysiological brain signals during human fear conditioning

Electrophysiological studies in rodents allow recording neural activity during threats with high temporal and spatial precision. Although fMRI has helped translate insights about the anatomy of underlying brain circuits to humans, the temporal dynamics of neural fear processes remain opaque and require EEG. To date, studies on electrophysiological brain signals in humans have helped to elucidate underlying perceptual and attentional processes, but have widely ignored how fear memory traces evolve over time. The low signal-to-noise ratio of EEG demands aggregations across high numbers of trials, which will wash out transient neurobiological processes that are induced by learning and prone to habituation. Here, our goal was to unravel the plasticity and temporal emergence of EEG responses during fear conditioning. To this end, we developed a new sequential-set fear conditioning paradigm that comprises three successive acquisition and extinction phases, each with a novel CS+/CS- set. Each set consists of two different neutral faces on different background colors which serve as CS+ and CS-, respectively. Thereby, this design provides sufficient trials for EEG analyses while tripling the relative amount of trials that tap into more transient neurobiological processes. Consistent with prior studies on ERP components, data-driven topographic EEG analyses revealed that ERP amplitudes were potentiated during time periods from 33-60 ms, 108-200 ms, and 468-820 ms indicating that fear conditioning prioritizes early sensory processing in the brain, but also facilitates neural responding during later attentional and evaluative stages. Importantly, averaging across the three CS+/CS- sets allowed us to probe the temporal evolution of neural processes: Responses during each of the three time windows gradually increased from early to late fear conditioning, while long-latency (460-730 ms) electrocortical responses diminished throughout fear extinction. Our novel paradigm demonstrates how short-, mid-, and long-latency EEG responses change during fear conditioning and extinction, findings that enlighten the learning curve of neurophysiological responses to threat in humans.

Behavioral and Physiological Evidence Challenges the Automatic Acquisition of Evaluations

Dual-learning theories of evaluations posit that evaluations can be automatically (i.e., efficiently, unconsciously, uncontrollably, and involuntarily) acquired. They also often assume the existence of evaluative-learning processes that are impervious to verbal information. In this article, we explain that recent research challenges both assertions for three categories of measures: explicit evaluative measures, implicit evaluative measures, and physiological measures of fear. In doing so, we also question the widespread assumption that implicit (i.e., typically behavioral and physiological) compared with explicit (i.e., self-reported) evaluative measures are indicative of the way evaluations are acquired. In the second part of the article, we discuss the practical implications of these recent findings.

Sinking In: The Peripheral Baldwinisation of Human Cognition

The Baldwin effect is a hypothetical process in which a learned response to environmental change evolves a genetic basis. Modelling has shown that the Baldwin effect offers a plausible and elegant explanation for the emergence of complex behavioural traits, but there is little direct empirical evidence for its occurrence. We highlight experimental evidence of the Baldwin effect and argue that it acts preferentially on peripheral rather than on central cognitive processes. Careful scrutiny of research on taste-aversion and fear learning, language, and imitation indicates that their efficiency depends on adaptively specialised input and output processes: analogues of scanner and printer interfaces that feed information to core inference processes and structure their behavioural expression.

Induction of conditioned avoidance via mental imagery

There is a growing interest on how mental imagery may be involved in the onset and maintenance of anxiety-related disorders. Here, we used an experimental design to investigate whether a key symptom across anxiety-related disorders, namely avoidance, can be induced via mental imagery. Healthy participants first learned that one neutral stimulus (A) was associated with a mild electric shock and two other neutral stimuli (B and C) were not. They then learned to cancel the shock when A was presented, by pressing a button on a keyboard ('behavioral avoidance'). Next, they were asked to imagine that stimulus B was followed by the shock (i.e., without actual B or shock presentations; Experiment 1; N = 66) or they were shown B and asked to imagine the shock (i.e., without actual shock presentations; Experiment 2; N = 60). Finally, in the test phase, they were shown each of the three stimuli (without the shock) and given the opportunity to make the avoidance response. Results showed that participants tended to avoid B in the test phase in Experiment 1, even though it had never been presented with the shock but not in Experiment 2. We discuss how the findings may explain the acquisition of avoidance in the presentation of innocuousstimuli across anxiety-related disorders.

Negative reinforcement rate and persistent avoidance following response-prevention extinction

Persistent avoidance may be influenced by prior negative reinforcement rate (i.e., how effective the response is at controlling threat). In clinical settings, the effectiveness of extinction-based methods for treating anxiety-related avoidance may be impacted by prior reinforcement rate. Here, we conducted a laboratory-based treatment study to investigate the persistence of avoidance following response-prevention extinction (RPE) when prior avoidance had been differentially effective at cancelling shock. Participants in three negative reinforcement rate groups (100%, 50%, and 0%) completed a validated avoidance conditioning paradigm involving Pavlovian fear extinction, RPE, and re-extinction phases. It was hypothesised that partially reinforced avoidance would lead to diminished resistance to fear extinction following response prevention, compared to continuously- or never-reinforced avoidance. Persistent avoidance was related to prior negative reinforcement rate, with higher rates more resistant to extinction. These findings illustrate the role of reinforcement rate in the persistence of avoidance and may aid understanding of treatment relapse.

Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020

Fear is an adaptive response in the presence of danger. However, when threat is uncertain and continuous, as in the current coronavirus disease (COVID-19) pandemic, fear can become chronic and burdensome. To identify predictors of fear of the coronavirus, we conducted an online survey (N = 439) three days after the World Health Organization declared the coronavirus outbreak a pandemic (i.e., between March 14 and 17, 2020). Fear of the coronavirus was assessed with the newly developed Fear of the Coronavirus Questionnaire (FCQ) consisting of eight questions pertaining to different dimensions of fear (e.g., subjective worry, safety behaviors, preferential attention), and an open-ended question. The predictors included psychological vulnerability factors (i.e., intolerance of uncertainty, worry, and health anxiety), media exposure, and personal relevance (i.e., personal health, risk for loved ones, and risk control). We found four predictors for the FCQ in a simultaneous regression analysis: health anxiety, regular media use, social media use, and risks for loved ones (R² = .37). Furthermore, 16 different topics of concern were identified based participants' open-ended responses, including the health of loved ones, health care systems overload, and economic consequences. We discuss the relevance of our findings for managing people's fear of the coronavirus.

Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020

Fear is an adaptive response in the presence of danger. However, when threat is uncertain and continuous, as in the current coronavirus disease (COVID-19) pandemic, fear can become chronic and burdensome. To identify predictors of fear of the coronavirus, we conducted an online survey (N = 439) three days after the World Health Organization declared the coronavirus outbreak a pandemic (i.e., between March 14 and 17, 2020). Fear of the coronavirus was assessed with the newly developed Fear of the Coronavirus Questionnaire (FCQ) consisting of eight questions pertaining to different dimensions of fear (e.g., subjective worry, safety behaviors, preferential attention), and an open-ended question. The predictors included psychological vulnerability factors (i.e., intolerance of uncertainty, worry, and health anxiety), media exposure, and personal relevance (i.e., personal health, risk for loved ones, and risk control). We found four predictors for the FCQ in a simultaneous regression analysis: health anxiety, regular media use, social media use, and risks for loved ones (R² = .37). Furthermore, 16 different topics of concern were identified based participants' open-ended responses, including the health of loved ones, health care systems overload, and economic consequences. We discuss the relevance of our findings for managing people's fear of the coronavirus.

The Impact of Intolerance of Uncertainty and Cognitive Behavioural Instructions on Safety Learning

Background

Difficulty updating threat associations to safe associations has been observed in individuals who score high in self-reported Intolerance of Uncertainty (IU). Here we sought to determine whether an instruction based on fundamental principles of Cognitive Behavioural Therapy could promote safety learning in individuals with higher levels of IU, whilst controlling for self-reported trait anxiety (STICSA).

Methods

We measured skin conductance response, pupil dilation and expectancy ratings during an associative threat learning task in which participants either received a cognitive behavioural instruction or no instruction prior to threat extinction (n = 92).

Results

Analyses revealed that both self-reported IU and STICSA similarly predicted differences in skin conductance response. Only individuals with lower IU/STICSA in the cognitive behavioural instruction condition displayed successful safety learning via skin conductance response.

Conclusions

These initial results provide some insight into how simple cognitive behavioural instructions combined with exposure are applied differently in individuals with varying levels of self-reported anxiety. The results further our understanding of the role of basic cognitive behavioural principles and self-reported anxiety in safety learning.

Behavioral Conceptualization and Treatment of Chronic Pain

Pain is considered a hardwired signal of bodily disturbance belonging to a basic motivational system that urges the individual to act and to restore the body's integrity, rather than just a sensory and emotional experience. Given its eminent survival value, pain is a strong motivator for learning. Response to repeated pain increases when harm risks are high (sensitization) and decreases in the absence of such risks (habituation). Discovering relations between pain and other events provides the possibility to predict (Pavlovian conditioning) and control (operant conditioning) harmful events. Avoidance is adaptive in the short term but paradoxically may have detrimental long-term effects. Pain and pain-related responses compete with other demands in the environment. Exposure-based treatments share the aim of facilitating or restoring the pursuit of individual valued life goals in the face of persistent pain, and further improvements in pain treatment may require a paradigm shift toward more personalized approaches.

Facilitating translational science in anxiety disorders by adjusting extinction training in the laboratory to exposure-based therapy procedures

Extinction learning is suggested to be a central mechanism during exposure-based cognitive behavioral psychotherapy. A positive association between the patients' pretreatment extinction learning performance and treatment outcome would corroborate the hypothesis. Indeed, there is first correlational evidence between reduced extinction learning and therapy efficacy. However, the results of these association studies may be hampered by extinction-training protocols that do not match treatment procedures. Therefore, we developed an extinction-training protocol highly tailored to the procedure of exposure therapy and tested it in two samples of 46 subjects in total. By using instructed fear acquisition training, including a consolidation period overnight, we wanted to ensure that the conditioned fear response was well established prior to extinction training, which is the case in patients with anxiety disorders prior to treatment. Moreover, the extinction learning process was analyzed on multiple response levels, comprising unconditioned stimulus (US) expectancy ratings, autonomic responses, defensive brain stem reflexes, and neural activation using functional magnetic resonance imaging. Using this protocol, we found robust fear conditioning and slow-speed extinction learning. We also observed within-group heterogeneity in extinction learning, albeit a stable fear response at the beginning of the extinction training. Finally, we found discordance between different response systems, suggesting that multiple processes are involved in extinction learning. The paradigm presented here might help to ameliorate the association between extinction learning performance assessed in the laboratory and therapy outcomes and thus facilitate translational science in anxiety disorders.

Effects of verbal instructions and physical threat removal prior to extinction training on the return of conditioned fear

Instructions given prior to extinction training facilitate the extinction of conditioned skin conductance (SCRs) and fear-potentiated startle responses (FPSs) and serve as laboratory models for cognitive interventions implemented in exposure-based treatments of pathological anxiety. Here, we investigated how instructions given prior to extinction training, with or without the additional removal of the electrode used to deliver the unconditioned stimulus (US), affect the return of fear assessed 24 hours later. We replicated previous instruction effects on extinction and added that the additional removal of the US electrode slightly enhanced facilitating effects on the extinction of conditioned FPSs. In contrast, extinction instructions hardly affected the return of conditioned fear responses. These findings suggest that instruction effects observed during extinction training do not extent to tests of return of fear 24 hours later which serve as laboratory models of relapse and improvement stability of exposure-based treatments.