Preventing the Return of Fear Using Reconsolidation Update Mechanisms Depends on the Met-Allele of the Brain Derived Neurotrophic Factor Val66Met Polymorphism

Memory Reconsolidation Updating in Substance Addiction: Applications, Mechanisms, and Future Prospects for Clinical Therapeutics

Persistent and maladaptive drug-related memories represent a key component in drug addiction. Converging evidence from both preclinical and clinical studies has demonstrated the potential efficacy of the memory reconsolidation updating procedure (MRUP), a non-pharmacological strategy intertwining two distinct memory processes: reconsolidation and extinction-alternatively termed "the memory retrieval-extinction procedure". This procedure presents a promising approach to attenuate, if not erase, entrenched drug memories and prevent relapse. The present review delineates the applications, molecular underpinnings, and operational boundaries of MRUP in the context of various forms of substance dependence. Furthermore, we critically examine the methodological limitations of MRUP, postulating potential refinement to optimize its therapeutic efficacy. In addition, we also look at the potential integration of MRUP and neurostimulation treatments in the domain of substance addiction. Overall, existing studies underscore the significant potential of MRUP, suggesting that interventions predicated on it could herald a promising avenue to enhance clinical outcomes in substance addiction therapy.

Carbon Dioxide Reactivity Differentially Predicts Fear Expression After Extinction and Retrieval-Extinction in Rats

Background

Cues present during a traumatic event may result in persistent fear responses. These responses can be attenuated through extinction learning, a core component of exposure therapy. Exposure/extinction is effective for some people, but not all. We recently demonstrated that carbon dioxide (CO2) reactivity predicts fear extinction memory and orexin activation and that orexin activation predicts fear extinction memory, which suggests that a CO2 challenge may enable identification of whether an individual is a good candidate for an extinction-based approach. Another method to attenuate conditioned responses, retrieval-extinction, renders the original associative memory labile via distinct neural mechanisms. The purpose of the current study was to examine whether we could replicate previous findings that retrieval-extinction is more effective than extinction at preventing the return of fear and that CO2 reactivity predicts fear memory after extinction. We also examined whether CO2 reactivity predicts fear memory after retrieval-extinction.

Methods

Male rats first underwent a CO2 challenge and fear conditioning and were assigned to receive either standard extinction (n = 28) or retrieval-extinction (n = 28). Then, they underwent a long-term memory (LTM) test and a reinstatement test.

Results

We found that retrieval-extinction resulted in lower freezing during extinction, LTM, and reinstatement than standard extinction. Using the best subset approach to linear regression, we found that CO2 reactivity predicted LTM after extinction and also predicted LTM after retrieval-extinction, although to a lesser degree.

Conclusions

CO2 reactivity could be used as a screening tool to determine whether an individual may be a good candidate for an extinction-based therapeutic approach.

Interaction of Brain-derived Neurotrophic Factor, Exercise, and Fear Extinction: Implications for Post-traumatic Stress Disorder

Brain-Derived Neurotrophic Factor (BDNF) plays an important role in brain development, neural plasticity, and learning and memory. The Val66Met single-nucleotide polymorphism is a common genetic variant that results in deficient activity-dependent release of BDNF. This polymorphism and its impact on fear conditioning and extinction, as well as on symptoms of post-traumatic stress disorder (PTSD), have been of increasing research interest over the last two decades. More recently, it has been demonstrated that regular physical activity may ameliorate impairments in fear extinction and alleviate symptoms in individuals with PTSD via an action on BDNF levels and that there are differential responses to exercise between the Val66Met genotypes. This narrative literature review first describes the theoretical underpinnings of the development and persistence of intrusive and hypervigilance symptoms commonly seen in PTSD and their treatment. It then discusses recent literature on the involvement of BDNF and the Val66Met polymorphism in fear conditioning and extinction and its involvement in PTSD diagnosis and severity. Finally, it investigates research on the impact of physical activity on BDNF secretion, the differences between the Val66Met genotypes, and the effect on fear extinction learning and memory and symptoms of PTSD.

Cognitive neuroscience perspective on memory: overview and summary

This paper explores memory from a cognitive neuroscience perspective and examines associated neural mechanisms. It examines the different types of memory: working, declarative, and non-declarative, and the brain regions involved in each type. The paper highlights the role of different brain regions, such as the prefrontal cortex in working memory and the hippocampus in declarative memory. The paper also examines the mechanisms that underlie the formation and consolidation of memory, including the importance of sleep in the consolidation of memory and the role of the hippocampus in linking new memories to existing cognitive schemata. The paper highlights two types of memory consolidation processes: cellular consolidation and system consolidation. Cellular consolidation is the process of stabilizing information by strengthening synaptic connections. System consolidation models suggest that memories are initially stored in the hippocampus and are gradually consolidated into the neocortex over time. The consolidation process involves a hippocampal-neocortical binding process incorporating newly acquired information into existing cognitive schemata. The paper highlights the role of the medial temporal lobe and its involvement in autobiographical memory. Further, the paper discusses the relationship between episodic and semantic memory and the role of the hippocampus. Finally, the paper underscores the need for further research into the neurobiological mechanisms underlying non-declarative memory, particularly conditioning. Overall, the paper provides a comprehensive overview from a cognitive neuroscience perspective of the different processes involved in memory consolidation of different types of memory.

Reconsolidation and Fear Extinction: An Update

Fear memories can be updated behaviorally by delivering extinction trials during the reconsolidation window, which results in a persistent attenuation of fear memories (Monfils et al., Science 324:951-955, 2009). This safe and non-invasive paradigm, termed retrieval-extinction (or post-retrieval extinction), has also been found to be successful at preventing the return of fear in healthy fear conditioned humans (Schiller et al., Nature 463:49-53, 2010), and in the time since its discovery, there has been an explosion of research on the use of retrieval-extinction in fear memories in humans and other animals, some of which have found a long-term reduction in conditioned responding, and some who have not. These discrepant findings have raised concerns as to whether retrieval-extinction really results in updating of the original fear memory, or if it simply enhances extinction. We will first review the progress made on elucidating the cellular mechanisms underlying the fear attenuating effects of retrieval-extinction and how they differ from traditional extinction. Special attention will be paid to the molecular events necessary for retrieval-extinction to successfully occur and how these reconsolidated memories are represented in the brain. Next, we will examine the parameters that determine whether or not a memory will be updated via extinction during the reconsolidation window (also known as boundary conditions). These boundary conditions will also be discussed as possible explanations for discrepant findings of the retrieval-extinction effect. Then we will examine the factors that can determine whether an individual's fears will successfully be attenuated by retrieval-extinction. These individual differences include genetics, age, and psychopathology. Finally, we will discuss recent attempts to bring the retrieval-extinction paradigm from the bench to the bedside for the behavioral treatment of anxiety and trauma disorders.

Valproate Adjuvant Cognitive Behavioral Therapy in Panic Disorder Patients With Comorbid Bipolar Disorder: Case Series and Review of the Literature

Anxiety disorders are the most common comorbid psychiatric disorders in patients with bipolar disorder. Managing anxiety symptoms in comorbid conditions is challenging and has received little research interest. The findings from preclinical research on fear conditioning, an animal model of anxiety disorder, have suggested that memory reconsolidation updating (exposure-based therapy) combined with valproate might facilitate the amelioration of fear memories. Here, three cases of successful amelioration of agoraphobia and panic symptoms through valproate adjuvant therapy for cognitive behavioral therapy in patients who failed to respond to two to three consecutive standard pharmacotherapy trials over several years are described. To the best of the author's knowledge, this is the first attempt to combine CBT with valproate in patients with panic disorder, agoraphobia, and comorbid bipolar disorder. Additionally, the background preclinical research on this combination therapy based on the reconsolidation-updating mechanism, the inhibition of histone deacetylase 2, and critical period reopening, off-label use of valproate in panic disorder, plasticity-augmented psychotherapy, and how to combine valproate with CBT is discussed.

The influence of dispositional cognitive reappraisal and expressive suppression on post-retrieval and standard extinction

Individual differences in the ability to habitually regulate emotion may impact the efficacy of fear memory extinction. The aim of this study was to assess the relationship between dispositional cognitive reappraisal and expressive suppression with post-retrieval and standard extinction. Fear memory and extinction were measured with the recovery of skin conductance responses. We also examined the relationship between a temporal feature of electrodermal responding (half-recovery time) and each of the emotion regulation strategies. University students (N = 80) underwent a three-day fear conditioning procedure using a within-subject design consisting of acquisition on day one, post-retrieval extinction and standard extinction on day two, and recovery test on day three. Individual difference data on self-reported levels of cognitive reappraisal, expressive suppression, trait anxiety, and depression were collected. We did not detect a relationship between the two emotion regulation strategies measured in this study and acquisition or extinction. We found, however, that increased dispositional use of cognitive reappraisal was associated with lower spontaneous recovery to both the post-retrieval extinction and standard extinction stimulus after controlling for age, trait anxiety, and depression. There were no associations between expressive suppression and conditioned responses. We also observed patterns of faster dissipation of arousal for reappraisal and slower for suppression to the conditioned stimulus during extinction training, which may represent the unique influence of each emotion strategy on the regulation of fear. We conclude greater daily use of cognitive reappraisal, but not expressive suppression, associates with extinction retention after receiving both standard and post-retrieval extinction.

Behavioral phenotyping of a rat model of the BDNF Val66Met polymorphism reveals selective impairment of fear memory

The common brain-derived neurotrophic factor (BDNF) Val66Met polymorphism is associated with reduced activity-dependent BDNF release and increased risk for anxiety disorders and PTSD. Here we behaviorally phenotyped a novel Val66Met rat model with an equivalent valine to methionine substitution in the rat Bdnf gene (Val68Met). In a three-day fear conditioning protocol of fear learning and extinction, adult rats with the Met/Met genotype demonstrated impaired fear memory compared to Val/Met rats and Val/Val controls, with no genotype differences in fear learning or extinction. This deficit in fear memory occurred irrespective of the sex of the animals and was not seen in adolescence (4 weeks of age). There were no changes in open-field locomotor activity or anxiety measured in the elevated plus maze (EPM) nor in other types of memory measured using the novel-object recognition test or Y-maze. BDNF exon VI expression in the dorsal hippocampus was higher and BDNF protein level in the ventral hippocampus was lower in female Val/Met rats than female Val/Val rats, with no other genotype differences, including in total BDNF, BDNF long, or BDNF IV mRNA. These data suggest a specific role for the BDNF Met/Met genotype in fear memory in rats. Further studies are required to investigate gene-environment interactions in this novel animal model.

Deficit of Inhibition as a Marker of Neuroplasticity (DEFINE Study) in Rehabilitation: A Longitudinal Cohort Study Protocol

Background: Brain plasticity is an intrinsic property of the nervous system, which is modified during its lifetime. This is one mechanism of recuperation after injuries with an important role in rehabilitation. Evidence suggests that injuries in the nervous system disturb the stability between inhibition and excitability essential for the recuperation process of neuroplasticity. However, the mechanisms involved in this balance are not completely understood and, besides the advancement in the field, the knowledge has had a low impact on the rehabilitation practice. Therefore, the understanding of the relationship between biomarkers and functional disability may help to optimize and individualize treatments and build consistent studies in the future.

Methods: This cohort study, the deficit of inhibition as a marker of neuroplasticity study, will follow four groups (stroke, spinal cord injury, limb amputation, and osteoarthritis) to understand the neuroplasticity mechanisms involved in motor rehabilitation. We will recruit 500 subjects (including 100 age- and sex-matched controls). A battery of neurophysiological assessments, transcranial magnetic stimulation, electroencephalography, functional near-infrared spectroscopy, and magnetic resonance imaging, is going to be used to assess plasticity on the motor cortex before and after rehabilitation. One of the main hypotheses in this cohort is that the level of intracortical inhibition is related to functional deficits. We expect to develop a better understanding of the neuroplasticity mechanisms involved in the rehabilitation, and we expect to build neurophysiological “transdiagnostic” biomarkers, especially the markers of inhibition, which will have great relevance in the scientific and therapeutic improvement in rehabilitation. The relationship between neurophysiological and clinical outcomes will be analyzed using linear and logistic regression models.

Discussion: By evaluating the reliability of electroencephalography, functional near-infrared spectroscopy, transcranial magnetic stimulation, and magnetic resonance imaging measures as possible biomarkers for neurologic rehabilitation in different neurologic disorders, this study will aid in the understanding of brain plasticity mechanisms in rehabilitation, allowing more effective approaches and screening methods to take place.

No persistent attenuation of fear memories in humans: A registered replication of the reactivation-extinction effect

It has been proposed that memory retrieval can destabilize consolidated memories, after which they need to be reconsolidated in order to be retained. The presentation of relevant information during memory reconsolidation could then result in the modification of a destabilized memory trace, by allowing the memory trace to be updated before being reconsolidated. In line with this idea, Schiller et al. (2010) have demonstrated that memory retrieval shortly before extinction training can prevent the later recovery of conditioned fear responding that is observed after regular extinction training. Those findings have been the subject of considerable controversy, due in part to theoretical reasons but also due to a number of failures to obtain similar results in conceptual replication attempts. Here, we report the results of a highly powered, direct, independent replication of the critical conditions of Schiller et al. (2010, Experiment 1). Due to misrepresentation of the exclusion criteria in the original Schiller et al. (2010) report, data collection was considerably delayed. When we eventually managed to attain our pre-registered sample size, we found that we could not observe any benefit of reactivation-extinction over regular extinction training in preventing recovery of conditioned fear. The results of the present study, along with the mixed findings in the literature and the misreporting in Schiller et al. (2010), give cause to question whether there is robust evidence that reactivation-extinction prevents the return of fear in humans.

Role of prelimbic cortex PKC and PKMζ in fear memory reconsolidation and persistence following reactivation

The persistence of newly acquired memories is supported by the activity of PKMζ, an atypical isoform of protein kinase C (PKC). Whether the activity of conventional and atypical PKC isoforms contributes to reactivated memories to persist is still unknown. Similarly, whether memory reactivation is a prerequisite for interventions to be able to change memory persistence is scarcely investigated. Based on the above, we examined the role of conventional and atypical PKC isoforms in the prelimbic cortex in reconsolidation and persistence of a reactivated contextual fear memory in male Wistar rats. It is shown that (i) inhibiting the PKC activity with chelerythrine or the PKMζ activity with ZIP impaired the persistence of a reactivated memory for at least 21 days; (ii) ZIP given immediately after memory reactivation affected neither the reconsolidation nor the persistence process. In contrast, when given 1 h later, it impaired the memory persistence; (iii) chelerythrine given immediately after memory reactivation impaired the reconsolidation; (iv) omitting memory reactivation prevented the chelerythrine- and ZIP-induced effects: (v) the ZIP action is independent of the time elapsed between its administration and the initial memory test. The results indicate that prelimbic cortex PKC and PKMζ are involved in memory reconsolidation and persistence.

Memory Retrieval-Extinction Combined With Virtual Reality Reducing Drug Craving for Methamphetamine: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Relapse, often precipitated by drug-associated cues that evoke craving, is a key problem in the treatment of methamphetamine use disorder (MUD). Drug-associated memories play a major role in the maintenance of relapse. Extinction training is a common method for decreasing drug craving by suppressing drug-associated memories. However, the effects are often not permanent, which is evident in form of spontaneous recovery or renewal of cue-elicited responses. Based on memory reconsolidation theory, the retrieval-extinction (R-E) paradigm may be more effective in decreasing spontaneous recovery or renewal responses than extinction. After the original memory reactivated to a labile state, extinction will be introduced within the reconsolidation window, thereby updating drug-associated memories. However, there are still some controversial results, which suggest that the reactivation of drug-associated memories and the 10 min-6 h of limited time window are two main elements in the R-E protocol. Virtual reality (VR) is supposed to promote memory reactivation by providing vivid drug-related stimuli when compared with movies.

OBJECTIVE

The aim of this study is to examine the effectiveness of R-E training combined with VR on reducing spontaneous recovery or renewal of cue-elicited responses, in comparison to extinction, R-E training provided outside the time window of 6 h and R-E training retrieved using videos, in methamphetamine abusers.

METHODS

The study is a parallel matched controlled study including 95 participants with MUD. Participants will be randomly assigned to either a R-10 min-E group (methamphetamine-related cues retrieval in VR followed by extinction after 10 min) or a NR-10 min-E group (neutral cues retrieval in VR followed by extinction after 10 min) or a R-6 h-E group (methamphetamine-related cues retrieval in VR followed by extinction after 6 h) or a RV-10 min-E group (methamphetamine-related cues retrieval in videos followed by extinction after 10 min). Cue-evoked craving and reactivity will be assessed at pre-test and at 1 day, 1 week, 1 month, and 6-month post-tests.

DISCUSSION

To our knowledge, this study will probably be the first study to examine the efficacy of R-E training combined with VR to reduce cue-evoked responses in people with MUD. This innovative non-pharmacological intervention targeting drug-associated memories may provide significant clinical implications for reducing relapse, providing the study confirms its efficacy.

CLINICAL TRIAL REGISTRATION

The trial is registered with Chinese Clinical Trial Registry at 17 October 2018, number: ChiCTR1800018899, URL: http://www.chictr.org.cn/showproj.aspx?proj=30854.

Fear expression is suppressed by tyrosine administration

Animal studies have demonstrated that catecholamines regulate several aspects of fear conditioning. In humans, however, pharmacological manipulations of the catecholaminergic system have been scarce, and their primary focus has been to interfering with catecholaminergic activity after fear acquisition or expression had taken place, using L-Dopa, primarily, as catecholaminergic precursor. Here, we sought to determine if putative increases in presynaptic dopamine and norepinephrine by tyrosine administered before conditioning could affect fear expression. Electrodermal activity (EDA) of 46 healthy participants (24 placebo, 22 tyrosine) was measured in an instructed fear task. Results showed that tyrosine abolished fear expression compared to placebo. Importantly, tyrosine did not affect EDA responses to the aversive stimulus (UCS) or alter participants’ mood. Therefore, the effect of tyrosine on fear expression cannot be attributed to these factors. Taken together, these findings provide evidence that the catecholaminergic system influences fear expression in humans.

On the Involvement of BDNF Signaling in Memory Reconsolidation

When retrieval occurs concomitantly with novelty detection, mismatch perception or reactivation of conflicting information, consolidated memories can enter into a labile state, and to persist, must be restabilized through a protein synthesis-dependent reconsolidation process during which their strength and content can be modified. Extensive literature implicates brain-derived neurotrophic factor (BDNF), a key regulator of synaptogenesis and synaptic plasticity, in the acquisition, consolidation and extinction of several memory types. However, the participation of BDNF in memory reconsolidation has been less studied. In this review, we discuss recent reports supporting the involvement of BDNF signaling in reactivation-induced memory updating.

A review of boundary conditions and variables involved in the prevention of return of fear after post-retrieval extinction

Experimental evidence suggests that the return of fear may be prevented by post-retrieval extinction (PRE), a procedure consisting of extinction training after the presentation of a retrieval cue. However, attempts to replicate these findings have yielded mixed results, with some studies showing diminished fear responses after PRE, whereas others show no effect on the return of fear following this procedure. The discrepancies across studies have been interpreted as evidence that there might be conditions under which PRE is not effective (boundary conditions), but these variables have yet to be fully described. We aimed to provide an overview of PRE in humans. We briefly present the theory and research that originated post-retrieval procedures with a focus on the experimental setup used in human studies. We continue with a compilation of possible experimental boundary conditions along with some questions for future research.

Exploring the boundaries of post-retrieval extinction in healthy and anxious individuals

Over a dozen studies have examined the efficacy of post-retrieval extinction (PRE) in healthy adults in the fear conditioning laboratory, with a recent meta-analysis reporting an overall small-moderate effect on attenuating the return of fear compared to standard extinction. The current study was designed to extend PRE effects to a mixed sample of healthy and anxious individuals, explore potential moderators, and examine the benefit of PRE for a memory conditioned over multiple days. Healthy (n = 49) and anxious (n = 43) adults received either one day of acquisition followed by PRE, one day of acquisition followed by extinction, or three days of acquisition followed by PRE. Comparing participants who received one day of acquisition followed by PRE or extinction, no significant effect of PRE was observed on differential skin conductance response reinstatement or reactivity to the conditioned stimulus alone. Anxiety symptoms did not moderate outcomes. There was no difference in return of fear for anxious participants who received three days of acquisition followed by PRE versus one day of acquisition followed by PRE. These results further highlight the variability of findings in the PRE literature and need for further examination of individual difference factors that may moderate PRE effects.

Who is studied in de novo fear conditioning paradigms? An examination of demographic and stimulus characteristics predicting fear learning

A common challenge in fear conditioning studies is that a relatively large proportion of individuals fail to acquire a differential conditioned skin conductance response (SCR). Researchers have identified demographic factors associated with poorer fear learning and explored the use of different fear conditioning paradigms across various populations. However, few studies have strategically aimed to enhance acquisition by manipulating the unconditioned stimulus (UCS). In the current manuscript, we examined whether demographic factors predicted failure to condition (n = 274) and explored whether modifications to the UCS enhanced fear learning (n = 143). Results indicated that race, but not age, education, or gender, predicted failure to condition. Stepwise logistic regression demonstrated that race was the most influential of these predictors; African Americans were less likely to acquire a conditioned SCR, compared to non-African Americans. Also, use of a compound UCS (i.e., electric shock combined with a scream noise) led to nearly double the rate of acquisition of a conditioned SCR. Hence, use of a compound UCS may provide a way to reduce the number of excluded individuals in studies of fear-conditioned SCR and thereby improve the representativeness of research samples.

A Prediction Error-driven Retrieval Procedure for Destabilizing and Rewriting Maladaptive Reward Memories in Hazardous Drinkers

Maladaptive reward memories (MRMs) can become unstable following retrieval under certain conditions, allowing their modification by subsequent new learning. However, robust (well-rehearsed) and chronologically old MRMs, such as those underlying substance use disorders, do not destabilize easily when retrieved. A key determinate of memory destabilization during retrieval is prediction error (PE). We describe a retrieval procedure for alcohol MRMs in hazardous drinkers that specifically aims to maximize the generation of PE and therefore the likelihood of MRM destabilization. The procedure requires explicitly generating the expectancy of alcohol consumption and then violating this expectancy (withholding alcohol) following the presentation of a brief set of prototypical alcohol cue images (retrieval + PE). Control procedures involve presenting the same cue images, but allow alcohol to be consumed, generating minimal PE (retrieval-no PE) or generate PE without retrieval of alcohol MRMs, by presenting orange juice cues (no retrieval + PE). Subsequently, we describe a multisensory disgust-based counterconditioning procedure to probe MRM destabilization by re-writing alcohol cue-reward associations prior to reconsolidation. This procedure pairs alcohol cues with images invoking pathogen disgust and an extremely bitter-tasting solution (denatonium benzoate), generating gustatory disgust. Following retrieval + PE, but not no retrieval + PE or retrieval-no PE, counterconditioning produces evidence of MRM rewriting as indexed by lasting reductions in alcohol cue valuation, attentional capture, and alcohol craving.

An Update on Memory Reconsolidation Updating

The reactivation of a stored memory in the brain can make the memory transiently labile. During the time it takes for the memory to restabilize (reconsolidate) the memory can either be reduced by an amnesic agent or enhanced by memory enhancers. The change in memory expression is related to changes in the brain correlates of long-term memory. Many have suggested that such retrieval-induced plasticity is ideally placed to enable memories to be updated with new information. This hypothesis has been tested experimentally, with a translational perspective, by attempts to update maladaptive memories to reduce their problematic impact. We review here progress on reconsolidation updating studies, highlighting their translational exploitation and addressing recent challenges to the reconsolidation field.

Effect of a Brief Memory Updating Intervention on Smoking Behavior: A Randomized Clinical Trial

IMPORTANCE

Recent research on addiction-related memory processes suggests that protracted extinction training following brief cue-elicited memory retrieval (ie, retrieval-extinction [R-E] training) can attenuate/eradicate the ability of cues to elicit learned behaviors. One study reported that cue-elicited craving among detoxified heroin addicts was substantially attenuated following R-E training and through 6-month follow-up.

OBJECTIVE

To build on these impressive findings by examining whether R-E training could attenuate smoking-related craving and behavior.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, mixed-design, human laboratory randomized clinical trial took place between December 2013 and September 2015. Participants were recruited in Charleston, South Carolina. Study sessions took place at the Medical University of South Carolina. The participants were 168 screened volunteer smokers, of whom 88 were randomized; 72 of these 88 participants (81.8%) attended all the follow-up sessions through 1 month. The primary eligibility criteria were current nicotine dependence (DSM criteria), smoking 10 or more cigarettes per day, and a willingness to attempt smoking cessation.

INTERVENTIONS

Participants were randomly assigned to receive either smoking-related memory retrieval followed by extinction training (the R-E group) or nonsmoking-related retrieval followed by extinction training (the NR-E group).

MAIN OUTCOMES AND MEASURES

Primary outcomes were cue-elicited craving and physiological responding to familiar and novel cues in the R-E group vs the NR-E group over a 1-month follow-up period. Secondary outcomes were smoking-related behaviors.

RESULTS

A total of 44 participants were randomly assigned to the R-E group (mean age, 48.3 years; 72.7% male); a total of 44 participants were randomly assigned to the NR-E group, with 43 attending at least 1 training session (mean age, 46.7 years; 55.8% male). The mean craving response to both familiar and novel smoking cues was significantly lower for participants in the R-E group than for participants in the NR-E group at 1-month follow-up (for both cue types: t1225 = 2.1, P = .04, d = 0.44, and Δ = 0.47 [95% CI, 0.04-0.90]). The mean numbers of cigarettes smoked per day at 2 weeks and 1-month were significantly lower for the R-E group than for the NR-E group (treatment main effect: F1,68 = 5.4, P = .02, d = 0.50, and Δ = 2.4 [95% CI, 0.4-4.5]). Significant differences in physiological responses, urine cotinine level, number of days abstinent, lapse, and relapse were not observed between groups (all between P = .06 and .75).

CONCLUSIONS AND RELEVANCE

Retrieval-extinction training substantially attenuated craving to both familiar and novel smoking cues and reduced the number of cigarettes smoked per day by participants 1 month after treatment relative to extinction training alone. Between-group differences were not observed for physiological responses, cotinine level, number of days abstinent, relapse, or lapse. In summary, R-E training is a brief behavioral treatment that targets smoking-related memories and has the potential to enhance relapse prevention.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02154685.