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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., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background and Objectives: Cognitive models of social anxiety disorder (SAD) emphasize anticipatory processing as a prominent maintaining factor occurring before social-evaluative events. While anticipatory processing is a maladaptive process, the cognitive mechanisms that underlie ineffective control of attention are still unclear. The present study tested predictions derived from attentional control theory in a sample of undergraduate students high and low on social anxiety symptoms., Methods: Participants were randomly assigned to either engage in anticipatory processing prior to a threat of a speech task or a control condition with no social evaluative threat. After completing a series of questionnaires, participants performed pro-saccades and antisaccades in response to peripherally presented facial expressions presented in either single-task or mixed-task blocks., Results: Correct antisaccade latencies were longer than correct pro-saccade latencies in-line with attentional control theory. High socially anxious individuals who anticipated did not exhibit impairment on the inhibition and shifting functions compared to high socially anxious individuals who did not anticipate or low socially anxious individuals in either the anticipatory or control condition. Low socially anxious individuals who anticipated exhibited shorter antisaccade latencies and a switch benefit compared to low socially anxious individuals in the control condition., Limitations: The study used an analogue sample; however findings from analogue samples are generally consistent with clinical samples., Conclusions: The findings suggest that social threat induced anticipatory processing facilitates executive functioning for low socially anxious individuals when anticipating a social-evaluative situation., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background and Objectives: Research has demonstrated that after exposure treatment, re-exposure to a previously feared stimulus outside of the treatment context can result in renewal of fear. The current study investigated whether conducting exposure treatment in multiple real-life contexts can attenuate renewal of fear., Methods: Forty-six moderate to high spider fearful individuals were randomly allocated to groups that received exposure treatment in either one context or three contexts. Follow-up testing was conducted one week and four weeks after exposure in the treatment context or a novel context., Results: Renewal of fear was found for the single extinction context group when exposed to the feared object in a novel context with self-report of fear, heart rate, and behavioural avoidance. However, renewal of fear was attenuated for the multiple extinction context group., Limitations: The sample included moderate to high spider fearful participants rather than clients with spider phobia, potentially limiting the generalisability of the findings to clinical populations., Conclusions: Using multiple extinction contexts in combination with other methods of attenuating renewal (e.g., context similarity) may provide a means to reduce the risk of renewal of fear., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Renewal has been implicated as one of the underlying mechanisms in return of fear following exposure therapy. ABC renewal is clinically more relevant than ABA renewal and yet it is a weaker form of renewal, suggesting that conducting extinction treatment in multiple contexts may be sufficient to attenuate ABC renewal. Using self-reported expectancy of shock and startle blink responses the current study examined the effects of conducting extinction treatment in multiple contexts on ABC fear renewal. Participants (N = 68) received conditional stimulus (CS) and unconditional stimulus (US) pairings in one context (A) followed by extinction treatment (CS presentations alone) in either one other context (B) or three other contexts (BCD). Non-reinforced test trials in a novel context (E) resulted in renewal of extinguished conditioned behaviour for those who received extinction in only one context. However, renewal was attenuated for those who received extinction treatment in three contexts. No renewal was found for the control group that received the test trial in the same context as during extinction. Suggestions are provided for clinicians seeking to prevent or attenuate return of fear following exposure therapy., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Renewal gives an experimental model for the relapse of fear symptoms following exposure therapy. While renewal of extinguished fear in humans has been observed following a return to the original context in which fear was acquired (ABA design), it has been more difficult to show upon presentation of a novel context (ABC design). The present experiment used a particularly strong context manipulation in a fear conditioning procedure. Context was manipulated by using large photographs of real environments taken from various angles and was present throughout the entire experiment. A renewal of cognitive expectancy was found in both ABA and ABC renewal designs, although it was larger in the former than in the latter. Response times in making the expectancy judgments increased when there was a change to a new context. The results demonstrate consistency in fear renewal effects between human and animal studies and suggest that relapse following exposure therapy via renewal remains a danger when people encounter a previously feared object in a novel context., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Although it is well documented that fear responses develop following aversive Pavlovian conditioning, it is unclear whether fear learning also manifests in the form of attentional biases for fear-related stimuli. Boschen, Parker, and Neumann (Boschen, M. J., Parker, I., & Neumann, D. L. (2007). Changes in implicit associations do not occur simultaneously to Pavlovian conditioning of physiological anxiety responses. Journal of Anxiety Disorders, 21, 788-803.) showed that despite the acquisition of differential skin conductance conditioned responses to angry faces paired (CS+) and unpaired (CS-) with an aversive shock, development of implicit associations was not subsequently observed on the Implicit Association Test. In the present study, participants (N=76) were assigned either to a Shock or NoShock group and completed a similar aversive Pavlovian conditioning procedure with angry face CS+ and CS- stimuli. Participants next completed a visual probe task in which the angry face CS+ and CS- stimuli were paired with angry face control stimuli and neutral faces. Results confirmed that differential fear conditioning was observed in the Shock group but not in the NoShock group, and that the Shock group subsequently showed a selective attentional bias for the angry face CS+ compared with the CS- and control stimuli during the visual probe task. The findings confirm the interplay between learning-based mechanisms and cognitive processes, such as attentional biases, in models of fear acquisition and have implications for treatment of the anxiety disorders.

Despite the existence of effective interventions for anxiety disorders, relapse--or the return of fear--presents a significant problem for patients and clinicians in the longer term. The present paper draws on the experimental and clinical behavioural literature, reviewing the mechanisms by which the return of fear can occur. The aim of the paper was to generate a list of treatment recommendations for clinicians aimed at reducing relapse in successfully treated anxiety disorders. Clinical and experimental literature on the mechanisms of renewal, reinstatement, spontaneous recovery and reacquisition are reviewed. These are linked with the clinical and experimental literature on the return of fear in successfully treated anxiety. A list of recommendations to assist in reducing the probability of relapse in successfully treated anxiety is presented. This list includes methods for use in behavioural (exposure) treatment of anxiety disorders that aim to enhance clinical outcomes. Despite the significant problem of relapse in successfully treated anxiety, there are methods available to reduce the probability of relapse through return of fear. Clinicians engaging in treatment of anxiety disorders should be mindful of these methods to ensure optimal patient outcome.

The acquisition, extinction, and subsequent recovery of conditioned fear can be influenced by the nature of the conditional stimulus (CS) and the context in which the CS is presented. The combined effects of these factors were examined in a differential fear-conditioning procedure with humans. Fear-relevant or fear-irrelevant CSs were followed by a shock unconditional stimulus (US) during acquisition and presented alone during extinction. The CSs were images presented upon different background contexts. Half the participants received the same context during acquisition and extinction and the remaining received different contexts. All participants received test trials in the same context as acquisition. In Experiment 1 (N=64), a renewal of shock expectancy and skin conductance responses was found during test for fear-relevant and fear-irrelevant CSs when extinction was given in a different context. In Experiment 2 (N=72), renewal for fear-relevant stimuli was enhanced when acquisition and test was given in an indoor office context and extinction in an outdoor bush context. The opposite context configuration produced the strongest renewal for fear-irrelevant stimuli. The return of extinguished conditioned fear can occur to fear-relevant stimuli that are commonly associated with clinical fears and its strength may be enhanced when the stimuli are encountered in certain contexts after extinction.

The renewal of Pavlovian-conditioned responses may provide a model for the relapse of fear following extinction-based treatments for anxiety disorders. Renewal can be observed if conditional stimulus (CS) and unconditional stimulus (US) pairings are given in one context, extinction trials of CS presentations in a second context, prior to test trials of CS presentations in the original acquisition context (ABA renewal). We examined ABA renewal in humans by using a fear-conditioning procedure with an unpleasant shock US. A renewal of rated shock expectancy was demonstrated with this procedure. Conducting extinction treatment in multiple contexts was expected to attenuate the renewal effect. However, the renewal of shock expectancy persisted when extinction treatment was given across three or five different contexts. With the current renewal design, learning task, and measure of conditioned behaviour, extinction treatment does not appear to readily generalise to the test context. The use of multiple extinction treatments in a clinical setting may not necessarily reduce the likelihood of relapse via a renewal effect.

The ABA renewal procedure involves pairing a conditional stimulus (CS) and an unconditional stimulus (US) in one context (A), presenting extinction trials of the CS alone in a second context (B), and nonreinforced test trials of the CS in the acquisition context (A). The renewal of extinguished conditioned behaviour is observed during test. The current study tested the effects of multiple extinction contexts and context similarity in attenuating renewal. Participants (N = 99) took part in a fear conditioning ABA renewal procedure. Using a measure of self-reported expectancy of the US, ABA renewal was observed when a single extinction context that was dissimilar to the test context was used. Renewal was attenuated, though still present, when extinction occurred in multiple dissimilar extinction contexts or in a single extinction context that was similar to the test context. Renewal was completely abolished when multiple extinction contexts that were similar to the test context were combined. Multiple extinction contexts and context similarity act additively in their effect on attenuating renewal. The results are discussed in relation to the design of exposure therapy programs that seek to reduce relapse that can occur via renewal. (Contains 2 figures and 2 tables.)

Abstract: The ABA renewal procedure involves pairing a conditional stimulus (CS) and an unconditional stimulus (US) in one context (A), presenting extinction trials of the CS alone in a second context (B), and nonreinforced test trials of the CS in the acquisition context (A). The renewal of extinguished conditioned behaviour is observed during test. The current study tested the effects of multiple extinction contexts and context similarity in attenuating renewal. Participants (N =99) took part in a fear conditioning ABA renewal procedure. Using a measure of self-reported expectancy of the US, ABA renewal was observed when a single extinction context that was dissimilar to the test context was used. Renewal was attenuated, though still present, when extinction occurred in multiple dissimilar extinction contexts or in a single extinction context that was similar to the test context. Renewal was completely abolished when multiple extinction contexts that were similar to the test context were combined. Multiple extinction contexts and context similarity act additively in their effect on attenuating renewal. The results are discussed in relation to the design of exposure therapy programs that seek to reduce relapse that can occur via renewal. [ABSTRACT FROM AUTHOR]

Pavlovian conditioning is a form of associative learning shown to contribute to the development and reduction of clinical anxiety and fear, and more recently, intergroup anxiety and fear. The current review provides a synthesis of the literature on associative learning of fear toward outgroups. Findings are reviewed that outline how fear toward the outgroup, relative to the ingroup, can be preferentially learnt and is resistant to extinction‐based techniques. Novel future research directions for intergroup anxiety are then identified based upon previous research on clinical anxiety. It is proposed that processes known to enhance the extinction of specific phobia should be investigated with social stimuli. Specifically, it is argued that exploring cognitive factors during extinction and conducting extinction in multiple contexts may provide new avenues to pursue intergroup harmony through reduced intergroup anxiety. The review concludes by suggesting innovative research designs are needed to validate an associative learning account of fear toward outgroups outside of experimental settings. [ABSTRACT FROM AUTHOR]

The return of fear following exposure therapy suggests that extinction does not result in a permanent unlearning of the association between a conditional stimulus (CS) and an unconditional stimulus (US). One proposed mechanism of return of fear is ABA renewal in which a CS is paired with a US in context A, presented alone in context B, and followed by test trials in context A. The current study examined the effects of extended extinction and multiple extinction contexts on ABA renewal in 121 first year psychology students. Using a fear conditioning procedure, renewal of shock expectancy during test was observed when extinction was presented for 12 extinction trials in a single context. In addition, renewal was attenuated when extinction was extended to 36 extinction trials or conducted in multiple contexts with 12 extinction trials. Combining extended extinction with multiple contexts resulted in the greatest attenuation of renewal. The results suggest that prolonged exposure treatment in multiple contexts may enhance the cross-contextual generalizability of extinction learning and reduce the likelihood of renewal of fear. [ABSTRACT FROM AUTHOR]

Reinstatement of fear is a proposed mechanism for return of fear following exposure therapy. A standard reinstatement procedure in the laboratory involves a conditional stimulus (CS) paired with an unconditional stimulus (US) during acquisition (i.e., CS+), and a CS paired without an US (CS-) during acquisition. In extinction the CS + and CS- are presented alone, then the US is presented without the CS in reinstatement, and followed by test trials of the CS. The current study examined whether reinstatement of fear can be triggered by a CS that was previously paired with the US (i.e., unextinguished CS) and reduced by extinction to the CSextinguished and CSunextinguished but not the CS- in a sample of first year psychology students (expectancy data N = 93; heart rate data N = 73). A differential aversive conditioning procedure presented within a virtual reality environment was used to examine reinstatement of the US expectancy and conditioned heart rate responses. As predicted, presentation of an unextinguished CS reinstated fear of a second previously extinguished CS. Moreover, conducting extinction with multiple stimuli attenuated this reinstatement of fear as indexed by self-report and heart rate measures. The present results suggest that therapy should include exposure to multiple stimuli to reduce the likelihood of reinstatement of fear. [ABSTRACT FROM AUTHOR]