Post-extinction conditional stimulus valence predicts reinstatement fear: relevance for long-term outcomes of exposure therapy

Examining conceptual generalisation after acquisition, extinction, and reinstatement in evaluative conditioning

In evaluative conditioning, a neutral conditional stimulus (CS) acquires the valence of a pleasant or unpleasant unconditional stimulus (US) after the CS and US are paired (acquisition). Valence acquired by the CS can generalise to other stimuli from the same category. Presenting the CS alone can reduce evaluative conditioning (extinction), but evaluations can return after the US is presented alone (reinstatement). The current research investigated whether extinction and reinstatement generalise to other category members (generalisation stimuli, GS). In Experiment 1, evaluations generalised in acquisition after conditioning with one category exemplar, but GS evaluations were unaffected by extinction and reinstatement. In Experiment 2, we aimed to enhance generalisation by presenting multiple category exemplars during conditioning. This strengthened the generalisation of evaluations in extinction but not reinstatement. In Experiment 3, conditioning with multiple exemplars caused explicit and implicit evaluations (measured using an affective priming task) to generalise in acquisition but not in extinction or reinstatement. The acquisition and extinction of US expectancy generalised in all experiments, but the reinstatement generalised in Experiment 3 only. Overall, we found partial evidence of evaluative generalisation during extinction (but not reinstatement) and demonstrated that the extinction and reinstatement of US expectancy generalises in evaluative conditioning.

Positive mood induction does not reduce return of fear: A virtual reality exposure study for public speaking anxiety

Previous laboratory work has shown that induction of positive mood prior to fear extinction decreases the negative valence of the conditional stimulus (CS) and reduces reinstatement of fear. Before translating these insights to clinical practice, it is important to test this strategy in anxious individuals. Students with a high fear of public speaking (N = 62) were randomized to either a positive mood induction, a negative mood induction, or no induction control group. All participants performed two weekly sessions of virtual reality exposure and a 1-week follow-up test including a spontaneous recovery test and reinstatement test after a social rejection (unconditional stimulus). We used self-reported fear measures and skin conductance responses. We expected that the positive group, compared to the other groups, would evaluate the CS (i.e., speaking in front of an audience) as less negative following exposure and would show less spontaneous recovery and reinstatement of fear following a social rejection. Although mood was successfully manipulated, there were no group differences in CS valence following exposure. In all conditions, VR exposure successfully reduced public speaking fear, and these effects were stable at follow-up. In contrast with expectations, the positive group showed more spontaneous recovery of CS negative valence than the negative group. To conclude, we found no evidence that positive mood induction prior to exposure optimizes exposure effects for anxious individuals.

Is disgust more resistant to extinction than fear? A meta-analytic review of laboratory paradigms

Disgust can be acquired via evaluative conditioning; a process by which a neutral stimulus (conditioned stimulus; CS) comes to be evaluated as disgusting due to its pairing with an inherently disgusting stimulus (unconditioned stimulus; US). Research has shown that conditioned disgust responses are resistant to extinction which may have implications for disorders (i.e., contamination-based obsessive-compulsive disorder, specific phobias, and post-traumatic stress disorder) in which heightened disgust has been implicated. Importantly, extinction is the primary mechanism by which exposure therapies are thought to achieve symptom reduction for these disorders. Exposure therapies were originally modeled on fear extinction, whereas disgust extinction was largely overlooked until recently. Accordingly, differences in the degree to which learned disgust and fear can be attenuated via extinction learning remains unclear. The present investigation was a meta-analysis directly comparing the degree of extinction of conditioned disgust (n = 14) and conditioned fear (n = 14) in laboratory paradigms. Extinction was operationalized as the standardized mean difference (SMD) in evaluative ratings between the CS+ (the CS paired with the US) and CS- (the unpaired CS) after extinction training. Results of a subgroup analysis indicated that disgust (SMD = 0.52) was significantly more resistant to extinction than fear (SMD = 0.37). Additionally, a series of meta-regression analyses indicated that extinction was not influenced by important study characteristics (e.g., sex, age, number of conditioning and extinction trials). The findings suggest that extinction-based approaches may be less effective at attenuating learned disgust and research is needed to better optimize treatments for disgust-related disorders.

Extinction of negative conditioned stimulus valence in human fear conditioning

Fear conditioning is a common experimental paradigm for modelling the development, and exposure-based treatment, of anxiety disorders. Measures of fear such as threat-expectancy, physiological arousal, and fear ratings typically extinguish, however feared stimuli may still be evaluated negatively (i.e. retain negative valence). This systematic review provides the first investigation of the relationship between fear conditioning methodology and extinction of negative stimulus valence. Principal findings were that type of CS (conditioned stimulus) and the CS-US pairing (i.e. specific combination of CS and unconditioned stimulus) predicted extinction outcome. Extinction of absolute negative CS valence was always achieved with shape CSs; often achieved with low fear-relevant animals as CSs, and less frequently achieved with faces as CSs - particularly neutral faces paired with a shock US. Modified extinction procedures typically achieved the same outcome as standard extinction procedures, except for partially-reinforced extinction, which was less effective than standard extinction, and positive imagery training, which was more effective than standard extinction. Further studies are warranted to evaluate the influence of fear conditioning methodology on extinction of absolute negative CS valence.

The influence of instructions on reversing the generalization of valence, US expectancy, and electrodermal responding in fear conditioning

Pairing a conditional stimulus (CS) with an aversive unconditional stimulus (US) causes negative valence and US expectancy to generalize to stimuli that are perceptually and/or conceptually similar to the CS. Past research has shown that instructing participants that the US is more likely to follow stimuli that are dissimilar to the CS reversed the generalization of US expectancy but left generalized valence unchanged. Here, we examined whether instructions about the relationship between stimuli that are perceptually similar would affect the generalization of valence. A picture of an alien (CS+) was paired with an electric stimulus, while a perceptually different alien stimulus (CS-) was presented alone. After conditioning, valence, US expectancy, and electrodermal responses generalized to different aliens that were perceptually similar (by color and shape) to the CS+ and CS-. Participants were then instructed that aliens perceptually similar to the CS+ belonged to the same group as the CS- and that aliens perceptually similar to the CS- belonged to the same group as the CS+. The instructions caused an elimination (but not a reversal) of generalized expectancy and valence but did not affect generalized electrodermal responses. This suggests that evaluations of generalization stimuli are sensitive to instructions about their relationship to the CS and that dissociations reported in the literature between valence and expectancy after instructions may occur due to the type of instruction used.

Evaluating the effects of counterconditioning, novelty-facilitated, and standard extinction on the spontaneous recovery of threat expectancy and conditioned stimulus valence

Extinction training has proved effective to diminish the expectancy of the aversive unconditioned stimulus (US). However, the negative valence of the conditioned stimulus (CS) may still stay intact. In fact, several studies have suggested that the CS negative valence may be a factor that promotes the return of fear. Our study focuses on the role of changes in the CS valence as a potential mechanism to reduce the spontaneous recovery of threat expectancies. To do that, we evaluated counterconditioning (CC), a technique aimed to reduce the CS negative valence by paring it with a positive stimulus and compared its efficacy to that of a novelty-facilitated extinction (NFE) and a standard extinction interventions. Using a 2-day protocol, participants first learned the relationship between a figure and an aversive sound, using a differential conditioning paradigm, and were then randomly assigned to one of three different groups. For the CC group, CS+ or cue A was paired with a positive US. The standard extinction group was exposed to cue A alone. For a third NFE group, cue A was followed by a neutral US. Finally, on the second day, spontaneous recovery was tested. Our findings did not provide evidence to suggest that CC could be more effective to prevent or reduce the return of threat expectancies or influence valence ratings when compared with NFE and standard extinction.

Fear Extinction as a Psychologist Views It

Fear extinction is a topic of central importance in translational neuroscience. It integrates knowledge from various disciplines, including clinical psychology, experimental psychology, psychiatry, cellular and systems neuroscience, and pharmacology. The experimental phenomenon of extinction was first discovered by Ivan P. Pavlov more than 100 years ago and still forms the basis for investigating the psychological and physiological mechanisms that drive extinction of fear. Here, I present old and new ways to think about fear conditioning and extinction from a psychologist's point of view. Extinction is a simple phenomenon with a complex machinery. Enhancing the behavioral analysis of extinction is necessary to advance research in neighboring disciplines as well and to increase our chances to develop extinction enhancers that might further improve efficacy of extinction-based therapies to treat dysfunctional fears. For that purpose, I address a number of fundamental questions in this chapter to clarify psychological viewpoints on the process of fear extinction. What is extinction? What is an association? What is fear? What can we learn from fear extinction? My goal is to reinforce critical thinking about basic assumptions underlying fear extinction and to open up new avenues for further research.

Conceptual generalisation in fear conditioning using single and multiple category exemplars as conditional stimuli - electrodermal responses and valence evaluations generalise to the broader category

Conceptual generalisation occurs when conditional responses generalise to novel stimuli from the same category. Past research demonstrates that physiological fear responses generalise across categories, however, conceptual generalisation of stimulus valence evaluations during fear conditioning has not been examined. We investigated whether conceptual generalisation, as indexed by electrodermal responses and stimulus evaluations, would occur, and differ after training with single or multiple conditional stimuli (CSs). Stimuli from two of four categories (vegetables, farm animals, clothing, and office supplies) were used as the CS+ (followed by an electric stimulus) or CS- (presented alone). Generalisation was assessed by presenting novel stimuli from the CS categories after acquisition, extinction, and reinstatement. One category exemplar was used as the CS+ and CS- in the single group, whereas three exemplars were used as the CS+ and CS- in the multiple group. Electrodermal responses generalised in acquisition and extinction but did not differ between groups. In the multiple group, CS evaluations generalised in acquisition and extinction, whereas generalisation was not evident in the single group. Training with multiple CSs also resulted in the extinction of stimulus valence. The current findings have implications for future research examining the generalisation of valence and for exposure-based treatments of anxiety.

Avoiding a feared stimulus: Modelling costly avoidance of learnt fear in a sensory preconditioning paradigm

Avoidance of learnt fear prevents the onset of a feared stimulus and the threat that follows. In anxiety-related disorders, it turns pathological given its cost and persistence in the absence of realistic threat. The current study examined the acquisition of costly avoidance of learnt fear in healthy individuals (n = 45), via a sensory preconditioning paradigm. Two neutral preconditioning stimuli (PSs) were paired with two neutral conditioned stimuli (CSs). One CS then came to predict an aversive outcome whereas the other CS came to predict safety. In test, participants engaged in stronger avoidance to the PS associated with the fear-related CS than the PS associated with the safety-related CS. Of note, executing behavioral avoidance led to missing out a competing reward, thus rendering avoidance costly. The results also provide preliminary evidence that threat anticipation and a negative change in valence play a role in driving costly avoidance of learnt fear. Future studies should examine how avoidance of learnt fear maintains pathological anxiety.

Paternal expressed emotion influences psychobiological indicators of threat and safety learning in daughters: A preliminary study

This preliminary study examined the association of children's anxiety, paternal expressed emotion (EE), and their interaction with psychophysiological indices of children's threat and safety learning. Participants included 24 father-daughter dyads. Daughters (ages 8-13 years, 100% Latina) self-reported their anxiety levels and completed a differential threat conditioning and extinction paradigm, during which psychophysiological responding was collected. Fathers completed a Five-Minute Speech Sample, from which paternal EE (i.e., criticism, emotional overinvolvement) was assessed. Anxiety-dependent associations emerged between paternal EE and individual differences in daughters' psychophysiological responding to safety signals during threat conditioning. Paternal EE was positively associated with psychophysiological responding to safety in daughters with high and mean, but not low, levels of anxiety. Although previous work suggests that chronic harsh maternal parenting is a potential risk factor for children's general threat and safety learning, these preliminary findings implicate milder forms of negative parenting behavior in fathers, particularly for highly anxious children.

Associative learning and extinction of conditioned threat predictors across sensory modalities

The formation and persistence of negative pain-related expectations by classical conditioning remain incompletely understood. We elucidated behavioural and neural correlates involved in the acquisition and extinction of negative expectations towards different threats across sensory modalities. In two complementary functional magnetic resonance imaging studies in healthy humans, differential conditioning paradigms combined interoceptive visceral pain with somatic pain (study 1) and aversive tone (study 2) as exteroceptive threats. Conditioned responses to interoceptive threat predictors were enhanced in both studies, consistently involving the insula and cingulate cortex. Interoceptive threats had a greater impact on extinction efficacy, resulting in disruption of ongoing extinction (study 1), and selective resurgence of interoceptive CS-US associations after complete extinction (study 2). In the face of multiple threats, we preferentially learn, store, and remember interoceptive danger signals. As key mediators of nocebo effects, conditioned responses may be particularly relevant to clinical conditions involving disturbed interoception and chronic visceral pain.

Does the assessment of different combinations of within-phase subjective measures influence electrodermal responding and between-phase subjective ratings during fear conditioning and extinction experiments?

The type and number of dependent measures assessed have varied between fear conditioning and extinction experiments and it remains unclear whether methodological differences influence results. Measuring skin conductance responses (SCRs) and between-phase subjective ratings between four conditions; Con condition had no within-phase ratings; US Exp condition included within-phase US expectancy ratings only; CS Eval condition included within-phase CS evaluations only and All Meas condition included both. All Meas condition exhibited larger SCRs compared to other conditions during acquisition, extinction, and return of differential responding at test. Differential SCRs did not extinguish in CS Eval and Con conditions, and CS Eval condition exhibited smaller CS- SCRs than other conditions throughout phases. US Exp condition revealed differential conditioning, successful extinction, and no return of differential SCRs. Between-phase ratings were not affected by within-phase ratings. Researchers should consider assessing different combinations of within-phase subjective ratings depending on the aims of their research.

Measuring fear: Association among different measures of fear learning

BACKGROUND AND OBJECTIVES

Fear conditioning paradigms use various measures to assess learned fear, including autonomic arousal responses like skin conductance, and self-reports of both associative (US-expectancies) and evaluative (affective ratings) learning. The present study uses a dimensional approach to examine associations among fear indices directly.

METHODS

Seventy-three participants completed a differential fear conditioning experiment, during which a neutral stimulus (CS+) was paired with an electric shock (US), while another stimulus (CS-) was never paired with the shock (partially instructed fear acquisition). Ten minutes later, both stimuli were presented without any shocks (fear extinction). Skin conductance responses and US-expectancy ratings were recorded during each phase, while self-reported negative affect was assessed for each CS at the end of extinction.

RESULTS

Results showed a positive association among US-expectancy ratings and skin conductance responses during acquisition and early extinction. US-expectancy ratings during overall extinction were positively associated with post-extinction negative affect.

LIMITATIONS

The lack of affective ratings post-acquisition may have obscured associations between associative and evaluative learning indices.

CONCLUSIONS

Results provide evidence for the expected correspondence among different indices of associative fear learning. Findings emphasize the need for incorporating both associative and evaluative learning measures in fear conditioning paradigms.

Enhancing extinction with response prevention via imagery-based counterconditioning: Results on conditioned avoidance and distress

BACKGROUND AND OBJECTIVES

Maladaptive avoidance is a core characteristic of anxiety-related disorders. Its reduction is often promoted using extinction with response prevention (ExRP) procedures, but these effects are often short-lived. Research has shown that pairing a feared stimulus with a stimulus of an incompatible valence (i.e., counterconditioning) may be effective in reducing fear. This laboratory study tested whether positive imagery during ExRP (i.e., imagery counterconditioning protocol) can also reduce avoidance.

METHODS

In the counterconditioning procedure, participants imagined a positive sound. There were four phases. First, participants were presented with squares on a computer screen of which one (CS+) was paired with an aversive sound and another (CS-) was not. Second, they learned to avoid the negative sound in the presence of the CS+, via a key press. Third, they were assigned to either the Counterconditioning (that was asked to imagine a positive sound during ExRP) or No Counterconditioning group (standard ExRP). Finally, they performed a test phase that consisted of two parts: in the first part, avoidance responses were available for each CS and in the second part, these responses were prevented.

RESULTS

The Counterconditioning intervention resulted in a short-lived reduction of distress associated with the CS+. However, groups did not differ in avoidance or distress during the test phases.

LIMITATIONS

US-expectancy ratings were collected only at the end of the experiment.

CONCLUSIONS

The results indicate that positive imagery during ExRP may be effective in reducing distress during the intervention. Explanations for the persistence of avoidance and fear are discussed.

Examining the link between positive affectivity and anxiety reactivity to social stress in individuals with and without social anxiety disorder

BACKGROUND

Positive affect (PA) attenuates negative reactivity to stress; however, this adaptive function of PA is seldom studied in psychiatric conditions characterized by more extreme forms of affective responding. We tested distinct associations of PA and negative affect (NA) with anxiety reactivity in participants with social anxiety disorder (SAD)-a condition characterized by heightened NA and diminished PA-and non-SAD control subjects.

METHOD

Adults with a principal diagnosis of SAD (n = 71) and those without a psychiatric history (n = 36) rated their PA and NA during the past week, and were exposed to a laboratory stressor wherein they delivered a video-recorded speech on a controversial topic. Anxiety reactivity was assessed in terms of anticipatory anxiety prior to the speech, and observer-rated anxiety-related behavior during the speech.

RESULTS

Across all participants, higher PA significantly predicted lower anticipatory anxiety and less anxiety-related behavior, beyond level of NA; lower NA significantly predicted attenuated anticipatory anxiety, but not anxiety-related behavior, beyond level of PA. The association between PA and stress reactivity was diminished for individuals with especially elevated NA, as well as for individuals with SAD compared to those without.

CONCLUSIONS

PA may be protective against negative reactivity to social stress; however, theoretical models and clinical applications should consider possible interactive effects of PA and NA in modulating stress reactivity.

Measuring unconditional stimulus expectancy during evaluative conditioning strengthens explicit conditional stimulus valence

During evaluative conditioning, a neutral conditional stimulus (CS) becomes pleasant or unpleasant after pairings with a positive/negative unconditional stimulus (US). Measures of US expectancy are commonly assessed during conditioning but it is unclear whether this affects evaluative learning. In Experiment 1, we examined whether the concurrent assessment of US expectancy alongside measures of CS valence would influence the acquisition, extinction, and reinstatement of explicit CS valence. Participants rated both valence and expectancy during conditioning (valence/expectancy group) or only CS valence (valence only group). Evaluative conditioning was acquired in both groups during acquisition, but its magnitude was enhanced in the valence/expectancy group. Measuring US expectancy did not influence the extinction or reinstatement of conditional valence. In Experiment 2, we confirmed the enhancement of evaluative conditioning due to concurrent measurement of US expectancy in an explicit measure, but did not find corresponding evidence in an implicit measure of conditional valence. In Experiment 3, we replicated the results using a different US expectancy scale and demonstrated that measuring CS valence multiple times throughout conditioning also strengthens conditional valence. Overall, the results suggest that the measurement of US expectancy and CS valence throughout conditioning draws attention to the contingencies and strengthens explicit evaluative learning.

Does approaching puppies and avoiding a dead cat improve the effectiveness of approach-avoidance training for changing the evaluation of feared stimuli?

BACKGROUND AND OBJECTIVES

Approach-avoidance training (AAT) is a procedure for changing people's likes and dislikes that involves executing repeated approach (e.g., pulling a joystick towards yourself) and avoidance actions (e.g., pushing a joystick away from yourself) in response to target stimuli. Typically, this leads to approached stimuli being evaluated more positively than avoided stimuli. However, the evidence that AAT can change evaluations of feared stimuli is mixed. In this preregistered study, we wanted to investigate the effectiveness of a novel version, compared to a more typical version, of AAT for changing the evaluation of fear conditioned stimuli.

METHODS

After a differential fear conditioning phase, participants (N = 80) were randomly allocated to two conditions: In the novel AAT, participants repeatedly approached one positive picture (i.e., puppies) and avoided one negative picture (i.e., a dead cat) in addition to approaching and avoiding the conditioned stimuli. Participants' evaluations of the stimuli were assessed with explicit ratings and an affective priming task.

RESULTS

We found evidence for the effectiveness of approach-avoidance training to change evaluations of fear conditioned stimuli. However, we found no evidence for the superiority of our novel version of the AAT procedure.

LIMITATIONS

The sample size of our study was quite small, limiting the statistical power to detect small effects.

CONCLUSIONS

Both a typical and an adjusted version of the AAT procedure proved successful to change conditioned negative evaluations. We compare our findings to previous studies showing limited effectiveness of the AAT procedure with feared stimuli.

Behavioral and neural processes in counterconditioning: Past and future directions

Counterconditioning refers both to the technique and putative process by which behavior is modified through a new association with a stimulus of an opposite valence. Similar to extinction, counterconditioning is considered a form of inhibition that interferes with the expression of the originally learned response without erasing it. But whereas interest in extinction continues to rise, counterconditioning has received far less attention. Here, we provide an in-depth review of counterconditioning research and detail whether counterconditioning is any more effective than extinction at preventing relapse of the originally learned behavior. We consider the clinical implications of counterconditioning, describe recent neurobiological and neuroimaging research in this area, and consider future avenues in need of further investigation.

Relapse of anxiety-related fear and avoidance: Conceptual analysis of treatment with acceptance and commitment therapy

Excessive fear and avoidance in relatively safe situations can lead to a narrowing of one's behavioral repertoire and less engagement with valued aspects of living. Ultimately, these processes can reach clinical levels, as seen in anxiety, trauma, and obsessive-compulsive disorders. Research on the basic behavioral processes underlying successful treatment with exposure therapy is growing, yet little is known about the mechanisms contributing to clinical relapse. Until recently, these mechanisms have largely been conceptualized in terms of Pavlovian return of fear, with relatively little research into operant processes. In the current paper, we briefly review translational research in anxiety disorders and the connections between fear and avoidance, focusing on recent work in the acquisition, extinction, and relapse of avoidance behavior and the generalization of this learning through arbitrary symbolic relations. We then introduce one possible treatment approach to mitigating clinical relapse, acceptance and commitment therapy (ACT), and provide a conceptual analysis for why ACT may be especially well-situated to address this issue. Finally, we end with potential directions for future research on treatment and relapse of anxiety disorders.

Reducing negative stimulus valence does not attenuate the return of fear: Two counterconditioning experiments

Exposure-based treatment for anxiety disorders is effective for many patients, but relapse is not uncommon. One predictor of the return of fear is the negative valence of fear-relevant stimuli. The aim of the current experiments was to examine whether counterconditioning with positive film clips reduces this negative stimulus valence as well as the return of fear, compared to standard extinction training and to an extinction training with non-contingent exposure to the positive film clips. Participants were 87 students in Experiment 1 (three-day paradigm), and 90 students in Experiment 2 (one-day paradigm). They first underwent a differential acquisition phase, in which one of three pictures was paired with an electric shock. They were then randomly allocated to one of the three intervention groups. Afterwards, they underwent a test phase in which pictures were presented without shock (to measure spontaneous recovery of fear), which was followed by unsignaled shocks to induce reinstatement of extinguished fear. Outcome variables were self-reported stimulus valence, shock expectancy, skin conductance, and fear-potentiated startle. In both experiments, counterconditioning decreased negative stimulus valence, relative to the other interventions, but it did not reduce spontaneous fear recovery or fear reinstatement. Overall, our findings do not support the notion that counterconditioning reduces return of fear.

The need for standards in the design of differential fear conditioning and extinction experiments in youth: A systematic review and recommendations for research on anxiety

Fear extinction studies in youth have yielded mixed results due to developmental processes and variations in design, methodology and dependent measures. This systematic review focused on studies with healthy youth between 2 and 17 years of age to identify experimental parameters of studies documenting extinction effects. Thirty-five studies met inclusion criteria and the following themes emerged (a) some studies employed parameters and task demands that are complex and require active participant involvement whereas others involved simple stimulus configurations and passive participant involvement, and (b) variation exists among dependent measures in units of measurement, timing and type of measurement. The review identified that studies using geometric shape conditioned stimuli (CS) paired with a tone unconditioned stimulus (US) (e.g., metal scraping on slate), as well as face CSs with a scream US produced the most reliable extinction effects, although the latter combination may be associated with higher drop-out than shape CSs and a tone US. The most commonly used and effective dependent measures for revealing extinction effects were skin conductance responses (SCR) and subjective ratings (SR) of CS valence, fearfulness and arousal. Fear potentiated startle (FPS) blink reflexes were also an effective but less commonly used measure. It is recommended that future studies use shape CSs and the metal scraping on slate US in studies involving children and either shape CSs and the metal scraping on slate US or face CSs paired with a scream US with adolescents. It is also recommended that US expectancy ratings and CS evaluations are assessed trial-by-trial and between-phase, and that startle-eliciting stimuli to measure startle blink reflexes are delivered on every second trial per CS so that SCR and FPS can be examined. However, further research is required to determine whether increased participant involvement due to providing trial-by-trial and between-phase ratings of the CSs and US differentially influences responding, particularly in children relative to adolescents and adults.

State-of-the-art and future directions for extinction as a translational model for fear and anxiety

Through advances in both basic and clinical scientific research, Pavlovian fear conditioning and extinction have become an exemplary translational model for understanding and treating anxiety disorders. Discoveries in associative and neurobiological mechanisms underlying extinction have informed techniques for optimizing exposure therapy that enhance the formation of inhibitory associations and their consolidation and retrieval over time and context. Strategies that enhance formation include maximizing prediction-error correction by violating expectancies, deepened extinction, occasional reinforced extinction, attentional control and removal of safety signals/behaviours. Strategies that enhance consolidation include pharmacological agonists of NMDA (i.e. d-cycloserine) and mental rehearsal. Strategies that enhance retrieval include multiple contexts, retrieval cues, and pharmacological blockade of contextual encoding. Stimulus variability and positive affect are posited to influence the formation and the retrieval of inhibitory associations. Inhibitory regulation through affect labelling is considered a complement to extinction. The translational value of extinction will be increased by more investigation of elements central to extinction itself, such as extinction generalization, and interactions with other learning processes, such as instrumental avoidance reward learning, and with other clinically relevant cognitive-emotional processes, such as self-efficacy, threat appraisal and emotion regulation, will add translational value. Moreover, framing fear extinction and related processes within a developmental context will increase their clinical relevance.This article is part of a discussion meeting issue 'Of mice and mental health: facilitating dialogue between basic and clinical neuroscientists'.

Developmental differences in aversive conditioning, extinction, and reinstatement: A study with children, adolescents, and adults

This study investigated developmental differences in aversive conditioning, extinction, and reinstatement (i.e., the recovery of conditioned aversive associations following reexposure to the unconditioned stimulus [US] post-extinction). This study examined these mechanisms in children (M_age=8.8years), adolescents (M_age=16.1years), and adults (M_age=32.3years) using differential aversive conditioning with a geometric shape conditional stimulus (CS+) paired with an aversive sound US and another shape (CS-) presented alone. Following an extinction phase in which both CSs were presented alone, half of the participants in each age group received three US exposures (reinstatement condition) and the other half did not (control condition), followed by all participants completing an extinction retest phase on the same day. Findings indicated (a) significant differences in generalizing aversive expectancies to safe stimuli during conditioning and extinction that persisted during retest in children relative to adults and adolescents, (b) significantly less positive CS reevaluations during extinction that persisted during retest in adolescents relative to adults and children, and (c) reinstatement of US expectancies to the CS+ relative to the CS- in all age groups. Results suggest important differences in stimulus safety learning in children and stimulus valence reevaluation in adolescents relative to adults.

Extinction during reconsolidation eliminates recovery of fear conditioned to fear-irrelevant and fear-relevant stimuli

Extant literature suggests that extinction training delivered during the memory reconsolidation period is superior to traditional extinction training in the reduction of fear recovery, as it targets the original fear memory trace. At present it is debated whether different types of fear memories are differentially sensitive to behavioral manipulations of reconsolidation. Here, we examined post-reconsolidation recovery of fear as a function of conditioned stimulus (CS) fear-relevance, using the unconditioned stimulus (US) to reactivate and destabilize conditioned fear memories. Participants (N = 56; 25 male; M = 24.39 years, SD = 7.71) in the US-reactivation and control group underwent differential fear conditioning to fear-relevant (spiders/snakes) and fear-irrelevant (geometric shapes) CSs on Day 1. On Day 2, participants received either reminded (US-reactivation) or non-reminded extinction training. Tests of fear recovery, conducted 24 h later, revealed recovery of differential electrodermal responding to both classes of CSs in the control group, but not in the US-reactivation group. These findings indicate that the US reactivation-extinction procedure eliminated recovery of extinguished responding not only to fear-irrelevant, but also to fear-relevant CSs. Contrasting previous reports, our findings show that post-reconsolidation recovery of conditioned responding is not a function of CS fear-relevance and that persistent reduction of fear, conditioned to fear-relevant CSs, can be achieved through behavioral manipulations of reconsolidation.

Positive valence reduces susceptibility to return of fear and enhances approach behavior

BACKGROUND AND OBJECTIVES

Although exposure therapy is highly efficacious for anxiety disorders, many individuals do not respond. Drawing from the science of fear extinction and reinstatement, the current study evaluated whether a training designed to increase valence of the feared stimulus improved the longevity of treatment outcomes.

METHODS

Participants were 61 undergraduate students with fear of spiders (>10 on Spider Phobia Questionnaire, M = 20.45, SD = 3.98) who were randomized to receive positive valence training or control training. Participants completed exposure over two days, with training conditions at the end of the first day. Tests of spontaneous recovery and reinstatement were conducted one week later.

RESULTS

Compared to control, the Positive Valence Training group demonstrated significantly less subjective fear at test of spontaneous recovery and less behavioral avoidance after reinstatement. Change in valence predicted subjective fear at spontaneous recovery and after reinstatement but did not predict behavioral avoidance after reinstatement.

LIMITATIONS

Due to the relatively small size and homogeneity of the sample, as well as the limited methods of training (i.e., film clips only) and outcome measurement (i.e., self-report and behavioral measures), current results should be interpreted with caution.

CONCLUSIONS

Adjunct positive valence training may enhance the longevity of exposure treatment.

The key role of extinction learning in anxiety disorders: behavioral strategies to enhance exposure-based treatments

PURPOSE OF REVIEW

Extinction learning is a major mechanism for fear reduction by means of exposure. Current research targets innovative strategies to enhance fear extinction and thereby optimize exposure-based treatments for anxiety disorders. This selective review updates novel behavioral strategies that may provide cutting-edge clinical implications.

RECENT FINDINGS

Recent studies provide further support for two types of enhancement strategies. Procedural enhancement strategies implemented during extinction training translate to how exposure exercises may be conducted to optimize fear extinction. These strategies mostly focus on a maximized violation of dysfunctional threat expectancies and on reducing context and stimulus specificity of extinction learning. Flanking enhancement strategies target periods before and after extinction training and inform optimal preparation and post-processing of exposure exercises. These flanking strategies focus on the enhancement of learning in general, memory (re-)consolidation, and memory retrieval.

SUMMARY

Behavioral strategies to enhance fear extinction may provide powerful clinical applications to further maximize the efficacy of exposure-based interventions. However, future replications, mechanistic examinations, and translational studies are warranted to verify long-term effects and naturalistic utility. Future directions also comprise the interplay of optimized fear extinction with (avoidance) behavior and motivational antecedents of exposure.

The effect of positive mood induction on reducing reinstatement fear: Relevance for long term outcomes of exposure therapy

While exposure therapy is effective in treating anxiety, fear can return after exposure. Return of fear can be understood through mechanisms of extinction learning. One form of return of fear is reinstatement, or, the fear that results from an unsignaled unconditional stimulus (US) presentation after extinction. Though the conditional response (CR; e.g., fear) typically reduces during extinction, the excitatory conditional stimulus (CS+) valence remains negative. The more negative the CS+ valence after the end of extinction, the greater the fear at reinstatement. The current study evaluated the degree to which positive mood induction (positive imagery training; PIT) compared to control (positive verbal training; PVT) before extinction a) decreased CS+ negative valence during extinction and b) reduced reinstatement fear. Compared to PVT, PIT a) increased positive affect, b) decreased post-extinction CS+ negative valence, and c) reduced reinstatement responding as measured by eye blink startle reflex (when shock was used at reinstatement) and self-report fear (regardless of reinstatement US type). Results suggest that increasing positive affect prior to exposure therapy could reduce relapse through reinstatement.

•

Post-extinction CS+ valence is a known predictor of reinstatement CS+ fear.

•

Pre-extinction positive mood induction increased post-extinction CS+ valence.

•

Pre-extinction positive mood induction decreased reinstatement CS+ fear.

•

Results suggest positive mood induction prior to exposure could reduce relapse in anxiety disorders.

Reappraisal facilitates extinction in healthy and socially anxious individuals

BACKGROUND AND OBJECTIVES

Cognitive behavioral therapy (CBT) combines cognitive restructuring with exposure to feared stimuli in the treatment of anxiety disorders. Due to the complexities of cognition–emotion interactions during ongoing CBT, the underlying mechanisms remain unclear, which hinders treatment optimization.

METHODS

We created a laboratory analogue by combining reappraisal, a key ingredient of cognitive restructuring, with Pavlovian conditioning, a key ingredient in behavioral treatments. The novel differential Pavlovian acquisition and extinction task featured social stimuli as conditioned and unconditioned stimuli under unregulated and reappraisal instructions.

RESULTS

Findings indicated that reappraising the conditioned stimuli attenuated acquisition (Study 1) and facilitated extinction (Study 2) of conditioned negative valence. In Study 3, highly socially anxious individuals showed deficient extinction learning relative to low socially anxious individuals but compensated for this by using reappraisal.

LIMITATIONS

Diagnostic status of participants was not assessed in structured clinical interviews.

CONCLUSIONS

Reappraisal of feared stimuli could be useful in prevention and treatment of social anxiety.