Vervliet Craske Hermans 2013

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/236088922
Fear Extinction and Relapse: State of the Art
Article in Annual Review of Clinical Psychology · March 2013

DOI: 10.1146/annurev-clinpsy-050212-185542 · Source: PubMed
CITATIONS READS
524 5,489
3 authors, including:
Bram Vervliet
KU Leuven
157 PUBLICATIONS 8,752 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
NWO VIDI project: When the good gets bad…and sticks! Understanding and challenging (the spreading of) pain-related avoidance behavior View
project
Joint PhD project on virtual reality exposure in socially anxious individuals View project
All content following this page was uploaded by Bram Vervliet on 02 June 2014.
The user has requested enhancement of the downloaded file.

CP09CH08-Vervliet ARI 24 February 2013 11:56
ANNUAL
REVIEWS Further Fear Extinction and Relapse:
Click here for quick links to
Annual Reviews content online,
including:
State of the Art
• Other articles in this volume
• Top cited articles Bram Vervliet,1 Michelle G. Craske,2
Annu. Rev. Clin. Psychol. 2013.9:215-248. Downloaded from www.annualreviews.org
• Top downloaded articles

• Our comprehensive search and Dirk Hermans1
1
Department of Psychology, University of Leuven, Leuven 3000, Belgium;
email: bram.vervliet@ppw.kuleuven.be, dirk.hermans@ppw.kuleuven.be
2
Department of Psychology, University of California, Los Angeles, California 90095-1563;
by 94.227.112.104 on 03/31/13. For personal use only.
email: mgcraske@ucla.edu
Annu. Rev. Clin. Psychol. 2013. 9:215–48 Keywords

The Annual Review of Clinical Psychology is online at Pavlovian conditioning, learning theory, memory retrieval, anxiety
http://clinpsy.annualreviews.org
treatment, translational research, relapse prevention
This article’s doi:
10.1146/annurev-clinpsy-050212-185542 Abstract
Copyright c 2013 by Annual Reviews. Exposure-based treatments for clinical anxiety generally are very effective,
All rights reserved
but relapse is not uncommon. Likewise, laboratory studies have shown that
conditioned fears are easy to extinguish, but they recover easily. This analogy
is striking, and numerous fear extinction studies have been published that
highlight the processes responsible for the extinction and return of acquired
fears. This review examines and integrates the most important results from
animal and human work. Overall, the results suggest that fear extinction is
relatively easy to “learn” but difficult to “remember.” It follows that treat-
ments will benefit from an enhanced focus on the long-term retrieval of fear
extinction. We review the available studies on the prevention of return of
fear and the prospects of weakening fear memories forever. We show that
the behavioral principles outlined in learning theory provide a continuous
inspiration for preclinical (neurobiological) and clinical research on the ex-
tinction and return of fear.
215
Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
RETURN OF FEAR IN CLINICAL PRACTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
RETURN OF FEAR IN CLINICAL ANALOGUE STUDIES:
ROLE OF CONTEXT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Extinguished Fears Can Return with a Change of External Context . . . . . . . . . . . . . . . 220
Extinguished Fears Can Return with a Change of Internal State . . . . . . . . . . . . . . . . . . . 220
RETURN OF FEAR IN THE LABORATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Renewal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Spontaneous Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Reinstatement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
THE LEARNING THEORY PERSPECTIVE ON FEAR CONDITIONING
AND EXTINCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

Fear Conditioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Deviant Fear Conditioning in Anxious Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Mechanisms of Extinction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
THE DEVELOPMENT OF THE RETRIEVAL MODEL

OF EXTINCTION IN RATS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
What We Learned from Reinstatement Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
What We Learned from Renewal Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
The Retrieval Model of Extinction and Return of Fear . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
The Neurological Model of Extinction and Return of Fear . . . . . . . . . . . . . . . . . . . . . . . 227
Multiple Pathways to Return of Fear?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
PRECLINICAL HUMAN STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Reinstatement in Human Fear Conditioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Renewal in Human Fear Conditioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Spontaneous Recovery in Human Fear Conditioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
ROADS TO RELAPSE PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Preventing Relapse by Strengthening the Extinction Memory . . . . . . . . . . . . . . . . . . . . . 235
Preventing Relapse By Weakening the Fear Memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
FUTURE RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
What Constitutes a Context? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Individual Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Extinction Versus Reconsolidation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Time Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Return Versus Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Retrieval Versus New Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
INTRODUCTION
Behavior therapy originated with Wolpe’s (1958) systematic application of basic learning prin-
ciples to the treatment of fear (systematic desensitization; see Eelen & Vervliet 2006). Over the
years, behavior therapy has maintained a preferential relationship with fundamental learning the-
ory. However, the cognitive revolution in psychology in the 1970s and 1980s sparked strong
216 Vervliet · Craske · Hermans

Extinction of de Extinction of de Clinical trials of

Extinction of de Extinction of pre-
novo conditioned novo conditioned exposure-based
novo conditioned existing fears in
fears in healthy fears in anxious treatments of
fears in animals anxious individuals
humans individuals anxiety
Figure 1
The different steps in the translational research program on fear extinction. Fear extinction in animals represents the most fundamental
preclinical research line (extreme left); clinical trials of exposure-based treatments in anxious patients represent the most applied
research line (extreme right). Preclinical research in healthy humans verifies animal findings in the human species. Preclinical research
in anxious individuals verifies the relevance of the studied processes for clinical anxiety. Clinical analogue studies that target extinction
of preexisting fears in anxious individuals can test the application of fundamental principles in real-world fears with selected treatment
components. Clinical trials evaluate the added efficacy of adjustments to treatment packages. The arrows indicate a continuous
influence between the different steps, in both directions.
criticisms against the traditional learning theory perspective on fear and anxiety disorders. Ac-
cordingly, fundamental learning research contributed less to (cognitive-) behavioral therapy that
emerged in the 1980s. The backlash against traditional learning theory failed to take account
of important theoretical developments within the field of learning theory (Mineka & Zinbarg
2006, Rescorla 1986). The recent rise of (affective) neuroscience research has reinstalled interest
in learning theory as a framework for preclinical animal models of psychopathology. The fear
domain has once again pioneered this new evolution. The domain is an excellent example of
successful translational research, in which preclinical and clinical research programs mutually re-
inforce each other (see Figure 1 and sidebar Translating Research Findings From the Laboratory
to the Clinical Setting and Back). The focus on fear also bolsters connections among learning
theory, clinical psychology, psychiatry, affective neuroscience, pharmacology, and genetics. As we
argue in this review, this cross-fertilization is in large part due to the elegance and simplicity of
the Pavlovian fear-conditioning procedure that has been adopted widely for the study of fear and Clinical research:
anxiety. applied research that
Prevention of relapse is a common theme in the renewed research program on fear. Effective evaluates interventions
(and moderating
pharmacological and psychotherapeutic treatments for anxiety have existed for quite some time
factors) in the clinical
(see, e.g., meta-analyses by Eddy et al. 2004, Hofmann & Smits 2008, Mitte 2005). The most setting
effective psychotherapies share exposure techniques as a key ingredient. This involves repeatedly
Return of fear: an
exposing the anxious client to the situations that elicit fear. Typically, this leads to reductions of increase of the fear
fear over repeated exposures. Exposure-based therapy is very successful in reducing fear levels index from the end of
in anxiety patients, as is pharmacotherapy. Despite these successes, however, these therapies also the last treatment
share a common weakness: poor retention of fear reduction in the long-term. Treatment efficacy session to a follow-up
test
studies have shown that successful fear reductions are sometimes short-lived and followed by a
return of fear symptoms that can culminate in a full-blown relapse (see, e.g., Eddy et al. 2004).
www.annualreviews.org • Fear Extinction and Relapse 217

TRANSLATING RESEARCH FINDINGS FROM THE LABORATORY TO THE

CLINICAL SETTING AND BACK
Translational research encompasses all research that combines laboratory with more applied research methodolo-
gies. Clinical research feeds into basic laboratory research by formulating current questions and problems in clinical
practice; basic laboratory research feeds into clinical research by revealing underlying mechanisms and suggesting
novel intervention techniques. The success of translational research depends in large part on the validity of the
experimental model used to mimic the disorder in the laboratory. In the fear domain, the translation can be verified
at different steps. The Pavlovian conditioning model can be applied in nonhuman animals, healthy individuals, and
anxious individuals. Extinction (exposure) can be investigated with de novo conditioned fears or with preexisting
fears in anxious individuals. Each step has added values and limitations; the combination of the different steps
constitutes the strength of the translational research program.
The current challenge is not to achieve fear reduction, but rather to maintain it over time. Relapse
prevention has become the major focus of fear extinction research, as it is for addiction and
depression research.
Return of fear is a widespread phenomenon. It occurs with clinical anxiety that has been treated,
but it also occurs with experimentally induced fears in the laboratory. Fears can be easily created
through a Pavlovian conditioning procedure, in which an innocuous stimulus (e.g., a green light)
is systematically followed by an aversive stimulus (e.g., an electrical shock). This typically results in
Extinction: the conditional fear reactions to the light (e.g., freezing in rats). In conditioning terms, the innocuous
gradual decay of
stimulus is called the conditional stimulus (CS), the aversive stimulus is the unconditional stimulus
conditioned responses
due to repeated (US), and the fear reaction the conditional response (CR).
presentations of the As in exposure-based treatments, repeated presentations of the light CS in the absence of
CS without the the aversive shock US typically leads to a gradual reduction of the fear CR. This is called the
associated US extinction effect. One of the most basic findings on extinction is that extinguished responses can
Pavlovian reoccur (Pavlov 1927). In the case of fear conditioning, this provides a preclinical laboratory model
conditioning: a for the return of fear. Clinical and preclinical research complement each other. Clinical studies can
learning phenomenon
record conditions under which return of fear occurs, examine individual differences in the return of
that occurs when
pairings of two stimuli fear, and test treatment adjustments to prevent the return of fear. The advantage of this research is
cause a change in the its direct applicability (no translational gap). The disadvantages are the constraints upon studying
behavioral reaction to the underlying mechanisms (due to time limitations), ethical considerations (e.g., brain lesioning),
either stimulus lack of control over etiology and potentially confounding factors, and so on. Preclinical laboratory
Conditional stimulus research can recreate the etiological factors believed to underlie the development of anxiety and
(CS): a stimulus that examine the phenomenon of interest in a highly controlled way. The main disadvantage is the
elicits a reaction
gap with clinical practice and the uncertainty about whether the revealed mechanisms are actually
conditional upon its
previous pairings with relevant to clinical phenomenology. A combination of clinical and preclinical research is needed
another stimulus to advance our understanding of disorders and to improve existing treatments. Return of fear
Conditional provides a textbook example of how this combination can lead to scientific and practical progress.
response (CR): the Of particular interest in the return of fear domain is the significant contribution from Pavlovian
reaction elicited by a fear-conditioning research in healthy humans. Fears can be created in healthy individuals with the
conditional stimulus same basic procedure as in animals: repeated pairings of an innocuous with an aversive stimulus.
that has been paired
Most measures of fear differ from rat studies (subjective ratings, skin conductance), but some
with an unconditional
stimulus are highly similar (the fear-potentiated startle reflex). The preclinical human model can translate
animal findings to the human species, and it permits the study of processes that are clinically
very relevant but difficult to research in rat models (e.g., cognitive processes). The disadvantage

is the ethical constraint on the types of experimental manipulations that can be used (e.g., brain
lesioning, traumatic experiences). Human fear conditioning bridges the gap between preclinical
animal research and clinical patient research.
Unconditional
The main theme of this review is that extinction and return of fear are intimately connected. stimulus (US):
Return of fear is at the core of extinction; any theory of extinction will have to explain return a stimulus that
of fear and vice versa. We give a selective overview of the preclinical rat studies, preclinical elicits a reaction
human studies, and clinical studies that have shaped our understanding of fear extinction and unconditionally
(independent of
the conditions under which fears return. The main guide throughout this review is learning
pairings with other
theory. This approach provides a continuous source of inspiration for new developments in the stimuli)
field of fear extinction and return. Learning theories of extinction have inspired the search for
Fear conditioning: a
conditions of return of fear, and observations of return of fear have prompted new theoretical Pavlovian conditioning
developments. These developments have had a major influence on affective neuroscience research procedure with an
into fear extinction and on clinical research into exposure treatment. The integration of learning aversive stimulus as
theory, affective neuroscience, and clinical psychology has also sparked the development of an US and fear measures
as dependent variables
innovative treatment paradigm that relies on behavioral-pharmacological interactions to produce
(CR)
sustainable fear reduction. We discuss this paradigm shift when reviewing the empirical status of
Preclinical research:
prevention-of-return strategies.
fundamental
A major challenge in translational research is to connect fundamental research findings to laboratory research
clinically relevant phenomena. Sometimes the connection can be found on the procedural level, and that investigates
at other times the connection is primarily on a conceptual level. We aim to show that most theory- processes with clinical
inspired research on return of fear can be connected to clinical practice, even if the connection relevance, using an
experimental model of
seems remote at first sight. For that purpose, we refer to a relatively simple example of phobic fear
the disorder
(although the same principles apply to panic disorder, social anxiety disorder, and posttraumatic
stress disorder):
Bob experienced a panic attack inside an elevator. As a consequence, he became fearful of elevators
and avoided elevators whenever possible. Bob’s therapist proposed a cognitive-behavioral treatment
strategy based on repeated exposures to elevators. After a few sessions, Bob was able to use elevators
with minimal discomfort and no longer avoided them. Both the therapist and Bob were very satisfied
with these results and concluded that further treatment was not necessary. A few months later, Bob
experienced some moments of fear inside elevators again, and his tendency to avoid them was renewed.
Subsequently, Bob experienced a full-blown relapse of his anxiety disorder.
This very return of fear is the primary target of this review.
RETURN OF FEAR IN CLINICAL PRACTICE

The return of fear was first documented as the reemergence of fear following systematic desen-
sitization (Rachman 1966). Typically, the level of fear is assessed during behavioral avoidance
tests at pre- and posttreatment and at a follow-up assessment weeks to months later. The client is
asked to gradually approach his/her feared object as closely as possible and to report the level of
fear at each step. Concurrently, psychophysiological indices of anxiety can be measured (e.g., skin
conductance, heart rate). The routine observation is fear reduction from pre- to posttreatment as-
sessment. Return of fear is defined by an increase of fear from posttreatment to follow-up. Return
of fear has been specifically studied following exposure therapy for specific phobias, obsessive-
compulsive disorder, agoraphobia, and performance anxieties. In the existing literature, estimates
of return of fear range from 19% to 62% (see review by Craske & Mystkowski 2006). Other
studies report rates of relapse more broadly by indexing recurrence of panic attacks or overall

ratings of clinical severity. For example 23% to 27% of patients with panic disorder reportedly
relapse (Brown & Barlow 1995, Fava et al. 2001) following exposure-based therapies. It is clear
that return of fear after successful treatment is not uncommon and that it poses a serious challenge
to the long-term outcome of existing (exposure-based) treatments.
RETURN OF FEAR IN CLINICAL ANALOGUE STUDIES:

ROLE OF CONTEXT
Return of fear puts serious limitations on the long-term outcome of (exposure-based) anxiety
treatments. An important research target is to reveal the conditions that can trigger return of
fear. Clinical observations provide little information because of the lack of experimental control.
Clinical analogue studies that take an experimental approach are more informative. These stud-
ies often use a simplified version of cognitive behavioral therapy interventions (focusing on the
exposure ingredient) and experimentally examine specific manipulations between posttreatment
and follow-up. Within this line of research, the role of context in the return of fear is the most
systematically investigated feature.
Extinguished Fears Can Return with a Change of External Context

Five exposure studies (total of 285 fearful participants) have shown that posttreatment fear is
higher when assessments occur in a context different from the treatment context. Rodriguez
et al. (1999) exposed spider-fearful college students to two spiders during a one-session exposure
protocol. Assessments at two-week follow-up revealed a significant return of fear in a different
context (presentation of the same spiders in a different room with an experimenter who differed
from the therapist), as indicated by number of steps completed on a behavioral avoidance test and
associated heart rate (although subjective fear ratings did not indicate return of fear). Using very
similar designs and spider-fearful samples, Mineka et al. (1999) and Mystkowski et al. (2002, 2006)
found significant return of self-reported fear, but not heart rate, during a behavioral avoidance test.
In a public speaking–anxious sample, Culver et al. (2011) found return of self-reported fear and
heart rate at a two-week follow-up test in a context different from treatment. All studies contained
control conditions with fear assessments in the treatment context, which elicited no return of fear.
Extinguished Fears Can Return with a Change of Internal State

Contexts can also include the internal state (i.e., arousal) of an individual. A study with 43 spider-
fearful individuals showed that incongruent internal states during treatment and follow-up can
produce a return of fear (Mystkowski et al. 2003). Internal states were manipulated by the ingestion
of caffeine or placebo. Groups that had received the same ingestion before treatment and test
showed sustained fear reduction; groups that had received different ingestions showed a significant
return of self-reported fear.
These clinical analogue studies demonstrate the important role of internal and external contexts
in the return of fear after exposure treatment. But what exactly is the role of the context here?
What does it tell us about the mechanism of exposure and return of fear? How can we neutralize
the detrimental effect of context changes and improve long-term extinction? Such questions are
difficult to answer using clinical studies alone, but preclinical laboratory research on the extinction
and return of fear has been extremely instrumental.

a Contextual renewal of extinguished fears

Fear conditioning Fear extinction Fear test
(tone-shock) (tone-nothing) (tone-alone)
Fear
Fear
Fear
Trials [context A] Trials [context B] [Context B] [Context A/C]
b Spontaneous recovery of extinguished fears


Fear
Fear
Fear
Trials Trials Immediate Delayed
c Reinstatement of extinguished fears

Fear
Fear
Fear
Trials Trials
Shocks
Figure 2
The different procedures used to trigger the return of fear in the laboratory.
RETURN OF FEAR IN THE LABORATORY

It has long been known that extinction is fragile and that extinguished conditional responses
return easily (Pavlov 1927). This is now also documented in the domain of fear conditioning.
Three procedures have been used to trigger the return of fear in the laboratory (see Figure 2).
One includes explicit context changes, whereas the other two do not.
Renewal
Figure 2a refers to the observation of return of fear when tests occur in a context different from
extinction (in rat research, the context is usually the experiment cage). In ABA renewal, fear
conditioning occurs in context A, extinction in context B, followed by test of the extinguished CS
in context A again. In ABC renewal, the stimulus is tested in a novel context C. In AAB renewal,

conditioning and extinction both occur in context A, followed by a test of the stimulus in a novel
context B (Bouton 2002).
Spontaneous Recovery
Figure 2b refers to the observation that a time interval after extinction can produce fear recovery
to the extinguished CS. The amount of fear recovery in rats is proportional to the length of the
extinction-test time interval, with a complete recovery after 14 days (Quirk 2002).
Reinstatement
Figure 2c refers to the observation that unsignaled presentations of the aversive event can produce
fear recovery to the extinguished CS (Rescorla & Heth 1975).
Bob’s fears may have extinguished through exposures to the elevator in the therapist’s office building,
but they reemerge when he enters an elevator in a different building (renewal). Bob’s fears may also
reemerge when he has not been inside an elevator for some time (spontaneous recovery). Or Bob’s fear
of elevators may reemerge after he experiences an out-of-the-blue panic attack unrelated to elevators
(reinstatement).
Observations of return of fear show that extinction/exposure does not simply erase the fear.
Any theory of extinction should explain (a) how fears can extinguish without erasure and (b)
how posttreatment manipulations can elicit the return of extinguished fears. The learning theory
perspective has proven to be a very successful framework in the behavioral analysis of extinction
and the development of extinction theories.
THE LEARNING THEORY PERSPECTIVE ON FEAR CONDITIONING

AND EXTINCTION
A theory of return of fear implies a theory of extinction, which is itself based on a theory of how
fears are acquired in the first place.
Fear Conditioning
A light that systematically precedes a shock elicits fear. Standard learning theory states that the
light-shock experiences leave a memory trace that consists of three components: a mental repre-
sentation of the light CS, a mental representation of the shock US, and an association between
these two representations. Future perceptions of the light will activate its representation and, by
virtue of the CS-US association, also the US representation. This activation of the US repre-
sentation produces the conditional fear reactions and can be understood as “the light signals the
shock” or “the light retrieves the memory of the shock.” The CS-US association is a hypothetical
construct that is held responsible for the conditional fear response.
The fear response is a reaction pattern unique to the CS. It is not a lingering reaction to a
past traumatic event (shock US) but rather the emotional component of the anticipation of a
reoccurrence of that event. Fear is always future oriented. The adaptive nature of fear is such that
it urges organisms to take action and prepare for upcoming danger (Lang et al. 2000).
The strength of the conditional fear reaction is determined by two variables: the strength of
the CS-US association and the intensity of the US memory. From a cognitive perspective, this
corresponds to a probability × intensity estimation. A stimulus that signals high probability of
an intense threat will elicit strong fear. Low probability and/or weak threat will produce less fear.

ANXIOUS INDIVIDUALS SHOW DEVIANT PATTERNS OF FEAR CONDITIONING
Examining the behavior of anxious individuals in the Pavlovian fear-conditioning model has generated interesting
hypotheses about the deviant processes in anxiety. First, anxious individuals may suffer from heightened fear re-
activity to dangerous stimuli. Second, anxious individuals may suffer from impaired extinction learning and, more
broadly, safety learning. Third, anxious individuals may suffer from overgeneralization of acquired fears to non-
dangerous stimuli. Finally, anxious individuals may suffer from a failure to associate specific stimuli to the aversive
event (unconditional stimulus), resulting in chronic threat perception and anxiety. Results consistent with all of
these hypotheses have been found; an important question is whether there is an underlying unifying mechanism.
Bob’s level of fear is determined by (a) an explicit/implicit estimation of the chance of another panic
attack inside an elevator (with higher estimations relating to a stronger elevator-panic association) and
(b) an explicit/implicit estimation of the hazard of panic attacks (with higher hazard estimations relating
to more intense representations of panic and its consequences).
Deviant Fear Conditioning in Anxious Individuals

Pavlovian fear conditioning in itself is an adaptive mechanism. Learning to fear certain signals
can be crucial for survival. Examining the behaviors of anxious individuals in a standard fear-
conditioning procedure can shed light on the deviant processes in irrational anxiety: Where does
the mechanism go wrong (see sidebar Anxious Individuals Show Deviant Patterns of Fear Con-
ditioning)? A meta-analysis on fear-conditioning studies showed that individuals with an anxiety
disorder continue to react fearfully to stimuli that no longer signal danger (i.e., weakened fear
extinction; Lissek et al. 2005). This has been further supported by more recent studies with panic
disorder patients (Michael et al. 2007), posttraumatic stress disorder (PTSD) patients (Blechert
et al. 2007; Milad et al. 2007, 2009), and children with anxiety disorders (Craske et al. 2008). Fear
extinction deficits also correlate with symptom severity in PTSD (Norrholm et al. 2011).
Impaired fear extinction is also present in individuals at risk for anxiety disorders, suggesting
that it is an important etiological factor. Children from parents with anxiety disorders showed
slower fear extinction than healthy control children exhibited (Craske et al. 2008). Impairments
in conditioned fear extinction predicted 31% of the variance of PTSD development in firefighter
recruits (Guthrie & Bryant 2006; for comparable results in soldiers deployed in Afghanistan, see
Lommen et al. 2013). Individuals with subclinical levels of anxiety (high scorers on a trait-anxiety
questionnaire; another risk factor for clinically severe anxiety) show a deviant pattern of neural
correlates during fear extinction, consistent with the pattern seen in clinically anxious samples
(Sehlmeyer et al. 2011).
It is of crucial importance to understand the mechanisms that underlie fear extinction and how
extinction can be improved. Standard learning theory provides different possibilities concerning
the mechanisms of extinction.
Mechanisms of Extinction
Reduction of the fear response may simply reflect the destruction of the underlying CS-US as-
sociation (e.g., Rescorla & Wagner 1972). Without that association, confrontations with the CS
will no longer activate the memory of the aversive US and hence elicit no fear. The CS returns
to a neutral state, as if no conditioning experience has taken place. In our example, to Bob the
elevator is just an elevator again. Second, the association may remain intact, but the memory of

the US may become devalued instead. Repeated CS presentations activate the US memory over
and over again, without experiencing its aversive impact any more. If this induces a devaluation of
the US memory, CS-based retrieval of this less aversive US memory will elicit less fear (Rescorla
& Heth 1975). In our example, elevators may still activate Bob’s memory of the panic attack, but
this memory is not so frightening any more. Third, the extinction trials may leave the CS-US
association and the US memory intact and induce a (temporary) deactivation of the US memory
instead. The temporary deactivation inhibits the previously conditioned fear response (extinction).
This deactivating mechanism is commonly conceptualized as the learning of an inhibitory associ-
ation (as opposed to the normal excitatory CS-US association). According to this view, extinction
can be seen as the development of an inhibitory CS-US association that counteracts the previ-
ously formed excitatory CS-US association (Bouton 1993). The excitatory association activates
the US memory, but the inhibitory association serves to deactivate it (e.g., by augmenting the
activation threshold of that memory). The net effect will be the absence of fear to the CS (i.e.,
extinction). In our example, Bob may have associated elevators with the absence of panic attacks,
which deactivates the fear arousing memory of the panic attack.
The destruction of the CS-US association provides the most favorable outcome, with no threat
of return of fear (erasure). Devaluation of the US memory reduces fear, but the intact CS-US
association leaves the possibility for the return of fear should the US memory regain its original
intensity. The suppression of the CS-US association runs the risk of return of fear in the event
that the suppressing source (inhibitory CS-US association) weakens.
THE DEVELOPMENT OF THE RETRIEVAL MODEL

OF EXTINCTION IN RATS
The research of Mark Bouton and others on renewal and reinstatement has greatly shaped our
understanding of extinction and relapse and has culminated in the retrieval model of extinction.
In order to fully explicate the specifics of this model, we discuss the rat conditioning studies that
stimulated its development.
What We Learned from Reinstatement Studies

Reinstatement through US revaluation. Extinction may rely on the progressive devaluation of
the US memory (the devaluation hypothesis, described above). In that case, US-alone presentations
during reinstatement testing would reintensify the US representation and thereby produce a return
of fear to the associated CS (Rescorla & Heth 1975). However, Bouton & Bolles (1979a) showed
that reinstatement of fear is a context-dependent phenomenon, a finding that is difficult to align
with the US revaluation hypothesis. Rats that had received unsignaled shocks in a context different
from extinction (a separate cage with distinctive features) failed to show the reinstatement effect
when they were exposed to the CS in the extinction context again. Together with the renewal
phenomenon, this finding points to the important role of context in the return of fear.
Reinstatement exceeds contextual fear, but depends on it. It is conceivable (and often demon-
strated) that unsignaled shocks induce a general fear of the entire context that surrounds the subject
(Grillon 2002). Nevertheless, the amount of reinstated fear to the CS typically exceeds the amount
of fear elicited by the test context. This shows that the fear increase is a genuine return of the
fear-eliciting properties of the CS rather than a reflection of newly conditioned contextual fear.
On the other hand, an additional experiment showed that contextual fear is the primary trigger for
the return of CS fear. Rats that received lengthy exposure to the test context after the unsignaled

shocks displayed less reinstatement of CS fear as compared to rats that were exposed to an unre-
lated context (Bouton & Bolles 1979a). Arguably, the lengthy context exposure extinguished fear
of the context before the CS was presented. In sum, reinstated fear to the CS goes above and
beyond contextual fear, but also depends on it. As we discuss below, Bouton (2002) proposed that
the newly formed context-US association retrieves the CS-US association from memory.
Reinstatement depends on a context-CS association. Various learning models hypothesize

that presenting a CS in a specific context establishes a context-CS association in memory (e.g.,
sometimes-opponent process theory; Wagner 1981). Conditioning to the context can then produce
conditioned responding to the CS as well, mediated by the context-CS association. Accordingly,
Westbrook et al. (2002) also found a return of fear of the CS when the unsignaled shocks were
administered in the extinction context and tests occurred in a different context. Arguably, the
CS becomes associated with the context in extinction; later context-US conditioning will then
produce fear of the CS (mediated conditioning). This explanation of reinstatement emphasizes

the importance of new learning rather than retrieval.
The set of basic reinstatement findings suggests that the experience of an out-of-the-blue panic attack
will reevoke Bob’s fears of elevators (a) if he is still in a state of heightened anxiety/arousal when having
to enter an elevator or (b) if he experienced the attack in a context that he associates with elevators
(e.g., an office building). In general, one could say that the unsignaled panic attack evokes a general
uncertainty about when and where attacks will recur. Because elevators have been associated with panic
in the past, they are odds-on predictors of future attacks for Bob.
What We Learned from Renewal Studies

Renewal through contextual fear. The contextual fear mechanism of reinstatement could also
underlie the ABA-renewal phenomenon. A return to the conditioning context A may reelicit some
contextual fear, which would then reinstate fear of the CS. However, closer inspection of the
renewal phenomenon rules out this explanation. First, researchers have observed ABA renewal in
the absence of any detectable fear of conditioning context A (Bouton & Bolles 1979b, Bouton &
King 1983). Second, renewal is also observed when the CS is tested in a novel context C that is
presumably neutral (ABC renewal).
Renewal through stimulus generalization. Stimuli may elicit different percepts in distinct
contexts. For instance, a yellow line may appear more orange against a red background. Also, con-
texts and stimuli may merge into a unitary representation, forming a Gestalt, before entering the
conditioning process (configural learning theories; e.g., Pearce 1987). In a renewal experiment,
the extinction CS may be perceived as different from the acquisition CS. It is well known that
conditional responses generalize on the basis of perceptual similarity (Pavlov 1927). On the first
extinction trial in a different context, the CS will evoke the conditional response partly (general-
ization decrement). As a consequence, only a part of the conditional response (and US association)
is submitted to extinction. When the original acquisition CS is presented at test (in ABA renewal),
the nonextinguished part of the conditional response (and US association) will be activated, leading
to return of fear (see Vervliet et al. 2004, 2005). This will also happen in ABC renewal, because
the nonextinguished part can generalize to CS in context C. A simple test of this mechanism,
however, is to observe whether there is indeed a response decrement on the first trial of ex-
tinction. Bouton and his colleagues have repeatedly reported that there is no detectable decre-
ment in the conditional response from the last CS acquisition trial in context A to the first CS

extinction trial in context B (Bouton 1994). This stands in sharp contrast to the large increase of the
conditional response when the CS is presented in the renewal test context. Hence, a simple gener-
alization explanation is not sufficient. The data seem to point to the more complex and surprising
hypothesis of an intrinsic asymmetry in the generalization of acquisition and the generalization
of extinction. This was not anticipated by standard learning theory.
Renewal through contextual inhibition. CS-alone extinction trials may promote learning that
the entire extinction context is safe (conceptualized as the formation of an inhibitory context–US
association). This novel contextual meaning prevents fear reactions to the CS, although the CS-US
association remains intact. By implication, presenting the CS in another context should recover the
fear reaction (renewal). This contextual inhibition hypothesis was tested by assessing whether the
extinction context of the CS would reduce fear reactions to other separately conditioned stimuli
as well. Thus, rats were conditioned to a light and a tone in context A, followed by extinction
of the light in context B. During tests of the tone in context B, rats showed no decrease in fear
responding (Bouton & King 1983). Hence, in contrast to the contextual inhibition hypothesis,
there was no evidence of general inhibitory/safety learning about the extinction context. This
shows that extinction is specific to both context and stimulus.
The set of renewal results suggests that a fear of elevators may reemerge in Bob when he has to enter
an elevator in a context different from exposure treatment, even when this novel context is itself not
anxiety provoking. In addition, the fragility of the fear-extinction effect is not necessarily due to a failure
of eliciting the full fear in treatment or because Bob feels safe in the therapy context (e.g., because of the
presence of the therapist). Even in the absence of these extinction-preventing factors, the long-term
fear-extinction effect remains delicate.
The Retrieval Model of Extinction and Return of Fear

Bouton and colleagues proposed that extinction learning is based on the formation of a second,
inhibitory CS-US association that coexists with the earlier formed excitatory association. When
the inhibitory association is active, the expression of the CS-US association is suppressed (the CS
evokes no fear). When the inhibitory association is inactive, the CS-US association is expressed
(the CS evokes fear again). The data show that the activity of inhibitory associations depends
on the context in which the CS is presented. Bouton and colleagues proposed that activation of
the inhibitory association requires the concurrent presence of both the CS and the extinction
context. Graphically, this is represented by an extra representation node that receives input from
both the context and the CS, and which is connected (through an inhibitory association) with
the US representation (see Figure 3). The extra node functions as an AND gate so that both
the extinction context and the CS need to be present before the inhibition is active. The most
important aspect of this model is that the excitatory CS-US association does not involve such
an AND gate and is therefore independent from the context (in accordance with the observed
asymmetry between the generalization of acquisition and the generalization of extinction).
This model can also be applied to spontaneous recovery if time is considered as a context as
well. External and internal contexts dynamically develop over time so that the context at the time
of extinction is most likely to differ from the context at a long-term test. The extinction memory is
more difficult to retrieve in this new context than the conditioning memory, leading to spontaneous
recovery of fear. Reinstatement is also accounted for from a retrieval viewpoint. The unsignaled
US presentations in a test for reinstatement produce conditioning with the context (context-US
association). This novel association retrieves the earlier CS-US association, producing recovered
fear responses to the CS.

CS US Memory after conditioning
CS US Memory after extinction
CX
Figure 3
A graphical representation of the retrieval model of extinction. The memory after extinction is more
complex than the memory after conditioning. Circles indicate memory representations of stimuli (CS,
conditional stimulus; US, unconditional stimulus; CX, context); arrows indicate an excitatory association; the
line with a bar at the end represents an inhibitory association.
The representation of the retrieval model of extinction is rather abstract, but Mark Bouton
has proposed several ways to interpret this more meaningfully. First, by connecting it to the
occasion-setting literature, it becomes clear that the extinction context actually signals when the
CS-US inhibitory association is valid. The AND gate can be seen as a hierarchical node through
which the context connects to the (inhibitory) association between the CS and the US. The
context “sets the occasion” for the inhibitory association. Second, extinction turns a CS into an
ambiguous stimulus with two opposing meanings. The excitatory association provides a “danger”
meaning, whereas the inhibitory association provides a “safety” meaning. From this perspective,
the extinction context disambiguates the meaning of the CS by delineating the occasions when
the CS is safe. Finally, the model can be viewed from a memory-retrieval perspective. Some
memories are weak and easily “forgotten” in the sense that more retrieval cues are needed in
order to remember them fully. Often, contexts provide potent retrieval cues in this regard. The
data seem to suggest that extinction memories (CS-US inhibition) are weak and easily forgotten
outside of the extinction context. In other words, the extinction context functions as a potent
retrieval cue for the extinction memory that is otherwise easily forgotten (hence, return of fear
outside of the extinction context). Original excitatory fear memories, on the other hand, are easily
activated and do not depend on contextual retrieval cues. From this perspective, the link between
the context representation and the AND gate node is conceptualized as a retrieval link of the
inhibitory CS-US association (the extinction memory). The extinction context acts to retrieve the
extinction memory, thereby signaling when the CS-US inhibitory association is valid and hence
disambiguating the dangerous-safe CS. In our example, the treatment context may act to retrieve
the fear extinction memory, thereby signaling when the elevator–no panic association is valid and
hence disambiguating dangerous-safe elevators to Bob. An important implication is that the long-
term success of extinction will depend on the retrievability of the extinction memory (Bouton
2002, Craske et al. 2012). This concurs with the clinical perspective that the achievement of fear
extinction (i.e., fear reduction over the course of exposure therapy) is not the major challenge, but
rather the sustainability of obtained extinction effects (i.e., prevention of return of fear).
The Neurological Model of Extinction and Return of Fear

The neurobiological basis of (conditioned) fear extinction has been well mapped (Quirk & Milad
2012). The amygdala plays a central role in the conditioning of fear reactions. Sensory information
about the CS and the US is transmitted from the thalamus to the basolateral nucleus of the
amygdala. The plasticity in that center forms the basis of the CS-US association, and connections

to the central nucleus of the amygdala, with its own connections to brainstem regions, serve the
expression of fear. Other regions that are implicated in fear are the dorsal anterior cingulate
cortex (presumably related to threat anticipation) and the insular cortex (presumably related to
interoception, awareness, and sensitivity to visceral activity). Fear extinction relies on activity
of the amygdala, hippocampus, and ventromedial prefrontal cortex (vmPFC) in concert. The
hippocampus is known for its role in computing a unitary representation of complex stimuli, such
as contexts. The vmPFC has connections to the intercalated cells of the amygdala, which serve
an inhibitory (gamma-aminobutyric acid–mediated) function. It is believed that the hippocampus
provides the contextual information and signals when the vmPFC should activate the inhibitory
influence in the amygdala, resulting in inhibition of the fear reaction. If the CS is encountered
within the extinction context, this extinction network is activated and the fear reaction is inhibited.
If the CS is encountered outside of the extinction context, this extinction network is not activated
and fear is expressed. Interestingly, the available research supports a much more consistent role
for the hippocampal-vmPFC network in extinction recall (e.g., 24 hours later) than during initial
extinction learning (Milad & Quirk 2002, Quirk et al. 2000). This suggests that the network is
particularly important for the retrieval of the extinction memory. It is clear that the neurological
model of extinction maps well onto the behavioral retrieval model of extinction (Quirk & Milad
2012).
Multiple Pathways to Return of Fear?

Rodent studies on the extinction and return of fear are mostly in line with the retrieval model of
extinction. Alternative explanations based on standard learning theory have been systematically
discarded. However, phenomena and their underlying mechanisms may vary depending on proce-
dural parameters, species, subject samples, and individual variables. Some studies have replicated
critical results in appetitive and instrumental conditioning in rats, showing generalizability of the
retrieval model of extinction (Bouton 2002). Nevertheless, there is no a priori reason to expect that
extinction and return of fear are subsumed by the same mechanism in humans (or other animal
species and procedures). Even within the human species, there may be differences between healthy
and clinical samples, or other individual variables may exist. Moreover, return of fear may rely
on a combination of different mechanisms that operate at the same time (e.g., part of the return
of fear reflects contextual inhibition, the other part reflects context-specific CS inhibition). This
may have implications for the implementation of strategies to prevent return of fear, but little is
known in this regard. The extinction and the return of fear remain a complex issue, even though
the retrieval model is the major guideline for experimental research.
PRECLINICAL HUMAN STUDIES

The memory retrieval model of extinction is exclusively based on rat conditioning research. Al-
though the model provides an interesting perspective on clinical fear extinction and relapse, there
is obviously a large translational gap between conditioned rats and anxious patients. Testing the
translation on several intermediate steps can bridge that gap. One important step consists of fear-
conditioning studies in healthy human individuals.1 The advantage of this type of paradigm is the
1
A major advantage of the Pavlovian fear-conditioning procedure is that it can be similarly applied in animals and humans. But
a number of procedural differences exist that may be important. First, due to ethical constraints, the participant individually
selects an intensity of the aversive US regarded as “uncomfortable, but not painful” at the start of the experiment. Such
mildly unpleasant USs may produce only weak fear reactions. Second, the fear measures often differ from those in animal

high level of experimental control (fear conditioning) and the absence of a cross-species transla-
tion problem. Hence, the establishment of return of fear and testing the underlying mechanism in
nonclinical human participants provides crucial information about the applicability of the memory
retrieval model of extinction to clinical anxiety and treatment.
Reinstatement in Human Fear Conditioning

Reinstatement has long been established in animal fear-conditioning research (Rescorla & Heth
1975), but demonstrations in humans are more recent. There are now 15 published studies on fear
reinstatement with a total of 742 participants, comprising a variety of USs (loud noise, electrical
shock, air blast to the throat), CSs (neutral pictures, lights, fear-relevant pictures), and fear mea-
sures (skin conductance, fear-potentiated startle, subjective ratings of fear and threat expectancy).
Together, these studies establish the robustness of the reinstatement procedure to elicit return of
fear in preclinical research in humans. They also reveal important aspects of the fear-reinstatement
mechanism in humans.
Reinstatement is context dependent in humans. LaBar & Phelps (2005) tested whether hu-
man fear reinstatement is influenced by contextual changes, as in rats (Bouton & Bolles 1979a).
Following conditioning and extinction in one context, participants received unsignaled USs ei-
ther in the same or in a novel context (a different room). Final tests of the extinguished CS always
occurred in the extinction context. As expected, reinstatement was observed only in the group
that received no context changes. This suggests a common mechanism between human and rat
conditioning studies. In addition, two amnesic patients with hippocampal damage failed to show
reinstatement in the same context (LaBar & Phelps 2005). This supports the hypothesis that the
hippocampus is implicated in the processing of contexts and the production of return of fear (Quirk
& Milad 2012).
Reinstatement can occur with various timings after acquisition and extinction. In rodent
studies, the phases of acquisition, extinction, and recovery test are typically distributed over sep-
arate days. In contrast, in human studies these phases are often combined in a single session
(mostly for practical reasons). Due to these time differences, the rodent studies may rely more
on long-term memory processes with possible implications for the reinstatement mechanism.
Nevertheless, human fear reinstatement has been shown with a 24-hour or 48-hour time interval
between conditioning and extinction reinstatement, or with the three phases distributed over three
separate days (Kindt & Soeter 2013, Kindt et al. 2009, Norrholm et al. 2006, Schiller et al. 2009,
Soeter & Kindt 2011). In addition, Kindt et al. (2009) and Schiller et al. (2009) showed successful
reinstatement when participants were retested one month and one year later, respectively. This
supports the generalizability of the reinstatement findings between rodent and human preclinical
research.
Reinstatement produces a return of attentional biases. Anxiety patients often show an at-
tentional bias for threat-related material (Bar-Haim et al. 2007). Attention to threat stimuli is a
first step in the production of a fear reaction. This bias may be a causal or maintaining factor
of anxiety symptomatology (MacLeod et al. 2002). Such cognitive biases are difficult to model
conditioning experiments. The only exception is the fear-potentiated startle reflex, although efforts are being made to translate
a measure of freezing to humans. Third, human studies mostly use visual stimuli, whereas animal studies mostly use auditive
stimuli as CSs. Finally, the timing of CS, US, intertrial intervals, and intersession intervals differs greatly. These differences
should be taken into account when comparing results from animal and human experiments.

in rodents. Preclinical human research has shown that fear-conditioned stimuli elicit an atten-
tional bias similar to the bias seen in anxious patients. Furthermore, this attentional bias decreases
through extinction and returns at a reinstatement test (Dirikx et al. 2004, Hermans et al. 2005,
Van Damme et al. 2006). Together, these data suggest that return of fear can be accompanied by
a return of attentional biases, which may further exacerbate fear reactivity.
Reinstatement is larger to negatively valenced stimuli. Human participants typically evaluate

fear-conditioned stimuli as negative (rated on a positive-negative scale). Conditioned negative
valence is more difficult to extinguish than conditioned fear reactions (Vansteenwegen et al. 2006).
Unextinguished negative valence may provide a vulnerability factor for return of fear. Dirikx
et al. (2004, 2007) and Hermans et al. (2005) found a significant correlation between the rated
negativity of the CS after extinction and the amount of return of fear in a subsequent test for
reinstatement. The authors proposed a mechanism for reinstatement, based on the assumption that
fear represents a combination of negative valence and arousal (Lang et al. 1990). They speculated
that the reinstating USs induce general arousal that can recombine with the residual negative
valence of the CS and produce return of fear. This hypothesis awaits further experimentation, but
it has the advantage that it can predict individual differences in reinstatement based on end-of-
extinction performance (unextinguished negative valence).
Reinstatement is not always stimulus specific in human fear conditioning. Human fear-
conditioning studies routinely include a nonconditioned control stimulus. This is a stimulus
(termed the CS-) that is presented equally as often as the CS+ but is never paired with the
US. The conditional fear response is defined as the differential reaction to the CS+ and CS-, as
their only difference is the association with the US. It follows that the reinstatement of fear should
be specific to the CS+. However, a number of studies have observed equally strong increases of
fear responding to the CS- as well (Dirikx et al. 2009, Kull et al. 2012, Sokol & Lovibond 2012).
This seems to contradict the view of reinstatement as a return of fear phenomenon, as there was
no prior fear to the CS-. Moreover, it is unclear why some studies find differential reinstatement to
the CS+ and not to the CS- whereas others do not. One interesting observation is that participants
with higher levels of self-reported trait anxiety showed more fear of the CS- at reinstatement test
(Kindt et al. 2009, Soeter & Kindt 2010). This suggests that return of fear is a widespread, normal
phenomenon, but anxious individuals may show nonspecific levels of return of fear that augment
the risk for relapse. Some studies may have unknowingly recruited more anxious participants than
others, leading to more or less differential reinstatement.
There are two candidate mechanisms for the relationship between trait anxiety and nondiffer-
ential reinstatement. First, anxious individuals have a propensity for fear generalization (Lissek
et al. 2010). Consequently, fear of the CS- may reflect generalization from the returned fear to
the CS+. Second, anxious individuals have a propensity to fear the entire experimental context
(Grillon 2002). Consequently, the reinstating USs may induce a higher level of contextual fear so
that any stimulus presented in that context will induce fear (Sokol & Lovibond 2012).
Reinstatement can be triggered by other aversive stimuli. Most studies on reinstatement

have used the exact same US as used during acquisition to elicit return of fear. However, little
is known about the boundary conditions of the reinstating US. Sokol & Lovibond (2012) tested
the degree to which other aversive stimuli produce return of fear after extinction. They found
increased fear to the CS+ regardless of whether the same US or a different aversive stimulus was
used (for similar findings in rats, see Rescorla & Heth 1975). Importantly, participants who had
received administrations of the different aversive stimulus expected this stimulus to follow the CS

at test (rather than the original US). This has significant implications for the retrieval model of
extinction, as it suggests that not all aspects of the US are crucial for retrieval. Rather, the newly
learned contextual fear (context fear) retrieves the old CS fear, regardless of the fear-inducing US.
New fears can trigger old fears.
Reinstatement in preclinical human research: Conclusion. Human studies on fear reinstate-

ment have shown that the effect is context dependent, occurs primarily in response to CSs with
unextinguished negative valence, and is triggered by other aversive stimuli as well. Together,
these data suggest that any stimulus that induces arousal in the test context can trigger return of
fear, particularly to CSs with unextinguished negative valence. The clinical implication would be
that any stressful life event that induces fear or arousal is able to revive old fears that have been
extinguished through exposures.
The results on attentional biases show that reinstatement may elicit a return not only of the
fear symptoms themselves but also of their maintaining factors. Finally, the return of fear may
easily spill over to other stimuli that are not related to the threat, particularly in individuals with
high trait anxiety. The clinical implication is that, if left untreated, the return of fear through
reinstatement is very likely to spread out and trigger a full-blown relapse. Accordingly, a clinical
study found that unextinguished negative valence at posttreatment predicted individual levels of
return of fear (Vasey et al. 2012).
Bob’s fear of elevators may return after stressful life events other than panic attacks (e.g., marital
problems). In addition, Bob’s vulnerability for relapse may increase if he continues to dislike elevators
after treatment. The return of fear can be accompanied by an increased attention toward escape routes,
phone boxes, alarm buttons, elevator movements, etc., which probably hinders reextinction of fear.
The return of fear may also extend to other situations that previously were not associated with the
panic attacks (riding in cars, trains, buses). This suggests that each relapse episode contains the risk of
exacerbating the symptomatology.
Renewal in Human Fear Conditioning

Around the same time that the fear reinstatement effect was established in human fear condition-
ing, researchers also demonstrated the contextual renewal effect. To recapitulate, renewal occurs
when shifting the surrounding context between extinction and test produces a return of fear to the
extinguished CS. Renewal has attracted more interest than reinstatement, resulting in 24 published
studies with a total of 1,248 participants. The phenomenon has now been demonstrated with a va-
riety of USs (loud noise, electrical shock, negative International Affective Picture System images),
a variety of CSs (neutral pictures, lights, fear-relevant pictures), fear measures (skin conductance,
fear-potentiated startle, subjective ratings of threat expectancy, fMRI brain scanning), a variety of
contexts (different rooms, different central lightings in the same room, pictures of rooms, virtual
reality contexts, background sounds), and different participant samples (healthy individuals, anx-
ious patients). Together, these studies establish the robustness of the renewal procedure to elicit
return of fear in preclinical research in humans. In addition, the studies reveal important aspects
of the fear renewal mechanism in humans.
ABA renewal is independent of contextual fear. One potential mechanism for ABA renewal is
based on the assumption that the context A may acquire a certain level of conditional fear during
the conditioning phase (see section What We Learned from Renewal Studies). Returning to that
context will reactivate a general fear response. Tests of the CS in that context will then result

in the recording of fear, not because fear of the CS has returned, but because the entire context
elicits fear. Alvarez et al. (2007) observed that the conditioning context A elicited more fear than
the extinction context B, which is in line with the hypothesis above. However, the level of fear of
context A did not correlate with the level of fear of the extinguished CS tested in that context.
Although this is a statistical null finding, it suggests that the renewal of fear to the extinguished
CS is independent of the amount of fear elicited by the test context (cf. rodent findings; Bouton
& King 1983).
ABC renewal occurs but is weaker than ABA renewal. A more stringent test of the influence
of fear of the test context on renewal is to assess the extinguished CS in a neutral context C (ABC
renewal). Effting & Kindt (2007) found an increase of fear to the extinguished CS in a novel
context C, but less so when compared to ABA renewal. Also, the ABC renewal displayed an equal
increase to the CS- (nondifferential return of fear), whereas the ABA renewal was specific to the
CS+ (differential return of fear). Neumann & Kitlertsirivatana (2010) also observed weaker ABC
renewal compared to ABA renewal, but this time the return of fear was differential in both renewal
procedures. Many procedural differences exist between the two studies, and it is not possible to
identify the crucial parameter for differential versus nondifferential ABC renewal.
Milad et al. (2005a) and Neumann & Kitlertsirivatana (2010) observed complete ABA renewal,
as compared with another CS in the test context that had never been extinguished. These studies
suggest that ABA renewal may in general lead to a maximal return of fear, whereas ABC renewal
leads to a submaximal return of fear (cf. rodent studies; Harris et al. 2000). Based on results in
rodents, one would expect even smaller renewal effects within an AAB renewal procedure (Thomas
et al. 2003). Unfortunately, there are no reports of AAB renewal in human fear conditioning.
ABA renewal does not depend (entirely) on inhibition of the extinction context. Renewal
can result from general inhibition (safety) learning during extinction. Instead of learning that the
CS is no longer followed by the US (CS-US inhibition), participants can learn that the US never
occurs in the extinction context B (context-US inhibition). Testing the CS in a different context
will remove this contextual inhibition and produce renewal of fear to the CS (see section What
We Learned from Renewal Studies). Milad et al. (2007) fear conditioned two stimuli during the
acquisition phase (CS1 and CS2). Next, CS1 was extinguished in context B, whereas CS2 was
not. On the next day, CS2 elicited more fear in context B than CS1. This shows that the fear-
extinction effect to CS1 is not entirely due to inhibition by context B. Arguably, the extinction
context B is not a general signal of safety (conditioned inhibitor) but rather acts specifically on the
conditioned-and-extinguished CS1.
ABA renewal can occur with various timings after acquisition and extinction. Whereas
most human studies combine the phases of acquisition, extinction, and renewal test in one session,
some have separated phases or days. Studies from the Milad laboratory routinely investigate ABA
renewal effects with acquisition and extinction occurring in one session, followed by renewal tests
in both contexts 24 hours later (Milad et al. 2005a; see also Kalisch et al. 2006). The ABA results
in this procedure confirm that the context specificity of fear extinction is present with long-term
memory mechanisms as well. There is at present no study that has distributed the three phases
over separate days (cf. rodent studies). Importantly, Zeidan et al. (2011) have shown that the ABA
renewal effect is stable over time when the procedure is conducted three times with 12 weeks
between each testing. This shows the reliability of the ABA renewal procedure and supports its
potential for diagnostic purposes and the screening of novel intervention methods.

ABA renewal is stronger with fear-relevant stimuli and contexts. Fear extinction is delayed
when fear-relevant pictures (e.g., spiders and snakes) are used as conditional stimuli instead of
geometric figures (for a review, see Öhman & Mineka 2001). This may reflect a different extinction
mechanism and hence a different renewal mechanism. In two studies, Neumann & Longbottom
(2008) observed contextual renewal with fear-relevant stimuli. Together with the reinstatement
results by Kindt et al. (2009), Soeter & Kindt (2010, 2011), and Kindt & Soeter (2013), these
findings show that return of fear occurs with fear-relevant stimuli as well, despite their slower
extinction rate.
Interestingly, the size of the renewal effect depended on an interaction between the fear-
relevance of the CSs and the naturalistic context in which it was tested (picture of indoor office or
outdoor bush). The mechanism of this interaction is not yet clear and merits further research.
Fear conditioning is not entirely context free in humans. A major tenet of the retrieval theory
of extinction is that conditioning memories are much easier to retrieve than extinction memories,
with the latter requiring input from contextual retrieval cues. Indeed, Bouton and colleagues
routinely observed no decrement in fear responding to the CS when it is first presented in the
extinction context B. This contrast with the clear effect of the context change after extinction
provided the impetus for much of the return of fear research. Most human studies have not
tested the fear decrement after acquisition, and from those that tested it, the majority reported a
statistically significant fear decrement (reviewed by Vervliet et al. 2013). This observation casts
doubts on the exact mechanism underlying renewal in human fear conditioning.
ABC renewal elicits more ambiguity than ABA renewal. Bouton formulated his retrieval
model of extinction in terms of ambiguity. That is, extinction turns a CS into an ambiguous
stimulus (with both an excitatory and inhibitory association); the context serves to disambiguate
the current meaning of the CS (activating the inhibitory association or not). In humans, the
latency to provide a rating of the current status of the CS has been interpreted as a measure
of CS ambiguity (Lissek et al. 2008). Using an ABA- and ABC-renewal procedure, Neumann
& Kitlertsirivatana (2010) found that the latency increased for any stimulus whenever a context
changed (after acquisition as well as extinction). However, the latency was highest for the CS+
when presented in the novel test context C. This suggests that the ambiguity is low in a test for
ABA renewal but higher in a test for ABC renewal.
Renewal can be triggered by changes in perceptual features of the CS. Vervliet et al. (2004,
2005) found that conditional fear generalizes easily to a stimulus that shares common features
with the CS, whereas fear extinction with this stimulus does not generalize back to the CS. This
return of fear demonstrates ABA renewal with stimulus changes rather than context changes. Fear
extinction with the CS itself did generalize to the other stimulus (i.e., no AAB renewal).
Extinction recruits activity of the hippocampus and vmPFC in concert. In a study by Milad
et al. (2007; see above), participants were tested in an MRI scanner during all phases of the ex-
periment. Day 2 testing in the extinction context (B) revealed augmented activity in two loci of
the vmPFC and the hippocampus during the extinguished stimulus. Moreover, a positive corre-
lation was found between activity in these areas and the strength of extinction recall as measured
by skin conductance. This pattern of brain activity is similar to what has been found in rodents
and supports the neurological theory that fear acquisition is based on amygdala activity and that
(the recall of) extinction additionally recruits activity of the vmPFC and the hippocampus in con-
cert to inhibit amygdala activity (and hence inhibit fear). Arguably, the hippocampus forms a

unitary representation of the extinction context (which is often a diffuse set of background cues),
and the vmPFC is the inhibitory agent that activates the inhibitory parts of the amygdala, the
intercalated cells (Quirk & Milad 2012). Further in line with this account, Milad et al. (2005b)
reported that thickness of the vmPFC correlated with the level of extinction (skin conductance)
when participants viewed the CS+ in the extinction context.
Kalisch et al. (2006) found very similar results in a similar design. Acquisition and extinction
learning phases occurred in separate contexts on Day 1; tests were conducted in both contexts
on Day 2 (the acquisition context test phases started with an unsignaled shock, which is akin to a
reinstatement procedure). Again, the extinguished CS elicited augmented activity in the vmPFC
and the (anterior) hippocampus in the extinction context. In line with the neurological theory of
extinction recall, the vmPFC and the hippocampus correlated positively in the extinction context
but not in the acquisition context.
Renewal in preclinical human research: Conclusion. Preclinical research in humans has now
widely demonstrated that conditioned fears can return with a change of context after extinction.
ABA renewal can elicit a complete return of fear and is generally larger than ABC renewal. In line
with the retrieval model of extinction, ABA renewal is not related to the level of fear elicited by test
context A, and the extinction effect is not (or at least not entirely) due to general inhibition/safety
learning to context B. This suggests that extinction is based on the development of context-specific
CS inhibition (Bouton 2002). However, stimulus generalization is not ruled out as an alternative
explanation, and some additional critical tests are lacking to fully validate the retrieval model of
extinction in human fear conditioning (see Vervliet et al. 2013).
Brain scanning studies with fMRI techniques have revealed a remarkable similarity with the
neurocircuitry revealed in rodent brain lesion research. The fear extinction network requires
concerted activity in the hippocampus, vmPFC and the amygdala. This supports the translation
between preclinical rodent and human studies.
Human studies have also revealed additional information relevant to the renewal mechanism.
First, the type of CSs and contexts used is not trivial. Certain matches between CSs and contexts
produce stronger renewal effects than others. There is no current theory that explains these effects.
Second, the ambiguity of the conditioned-and-extinguished CS is relatively low when presented in
the conditioning context A. The prior learning history with context A may directly disambiguate
the meaning of the CS. The ambiguity is higher when the conditioned-and-extinguished CS is
tested in a novel context C. We have seen that the renewal effect is lower in context C as compared
to A. This may suggest that the novel context C is not as good a disambiguating agent as the
conditioning context A. Possibly, the renewal effect in C is more malleable than in A, which would
provide more opportunity for renewal prevention in ABC renewal as compared to ABA renewal.
The results suggest that return of Bob’s fear may be stronger to the original elevator where he experi-
enced the panic attack as compared to a similar elevator in another building. The latter may elicit more
ambiguity (comprising both danger and safety properties). Interestingly, anxious individuals tend to
interpret ambiguous situations as dangerous, which is possibly a marker for anxiety pathology (Lissek
et al. 2006). In addition, some buildings (contexts) may trigger more fear of elevators than others (e.g.,
high buildings, old buildings, hotels, places far away from home). These factors may modulate the
occurrence and intensity of return of fear.
Spontaneous Recovery in Human Fear Conditioning

Spontaneous recovery occurs when a time interval between the last CS extinction trial and the first
CS test trial produces a return of conditioned responding (Pavlov 1927). This phenomenon has

received less attention in human research, but at least five studies with a total of 471 healthy human
participants have established the basic effect (Guastella et al. 2007; Huff et al. 2009; Norrholm et al.
2008; Schiller et al. 2008, 2009). These studies included different fear measures (fear-potentiated
startle reflex, skin conductance, subjective ratings of threat expectancy), different types of CSs
(neutral lights and pictures, fear-relevant pictures), and different types of USs (electrical shock,
airblast to the throat). The time interval between extinction and test varied between 24 hours and
94 hours. No study has systematically tested a dose-dependent relationship between extinction-test
interval and the amount of spontaneous recovery (cf. rodent research; Quirk 2002).
ROADS TO RELAPSE PREVENTION

Return of fear is now widely established in rodent and human preclinical research. In the clinical
setting, return of fear jeopardizes the long-term efficacy of exposure-based treatments of anxiety. A
return of fear can trigger a full-blown relapse of the anxiety disorder. Preventing the return of fear
seems to be a major route toward the prevention of relapse of anxiety disorders. The behavioral
and neurological analysis of the extinction and return of fear have provided the impetus for a
variety of prevention strategies that have been put to test.
Preventing Relapse by Strengthening the Extinction Memory

Arguably, return of fear results from a failure to activate/retrieve the extinction memory. Strategies
to enhance the strength and retrievability of extinction memories may prevent return of fear.
Massive extinction prevents relapse in rats. Augmenting the number of extinction trials may
strengthen the extinction memory and weaken the return of fear. Denniston et al. (2003) found
almost no ABA and ABC renewal when the extinction trials exceeded the acquisition trials with a
multiplication factor of 100. However, no human studies have evaluated the number of exposure
trials with respect to offsetting context renewal, spontaneous recovery, or reinstatement.
Compound extinction prevents relapse in rats but produces unfavorable results in humans.
Associative learning models hypothesize that extinction learning is driven by error reduction. Early
in extinction, the CS produces a prediction error by signaling a US that no longer occurs. Inhibition
learning reduces this error. Based on this hypothesis, augmenting the prediction error should
lead to stronger inhibition learning and maybe stronger memory formation. Using rats, Thomas
et al. (2003) combined three fear-conditioned stimuli in extinction as a means of augmenting the
prediction error. As expected, extinction proceeded faster to this compound stimulus, and ABA-
renewal tests revealed weaker return of fear to the individual stimuli (as compared to individually
extinguished stimuli). Along the same lines, Rescorla (2006) found that combining individual
and compound trials in extinction produces less spontaneous recovery and reinstatement of the
conditioned fear responses.
To date, there have been no prevention studies with compound extinction trials in humans.
However, Lovibond et al. (2000) and Vervliet et al. (2007) found deleterious effects of a compound
extinction procedure on the extinction effect itself. Tests with the individual stimuli revealed intact
levels of fear. The mixed individual-compound extinction procedure awaits further experimenta-
tion in humans.
Extinction retrieval cues may prevent relapse in humans, but the exact conditions are un-
clear. The retrieval view on extinction implies that facilitating the retrieval of extinction memories
will prevent the return of fear. Brooks & Bouton (1994) proposed that random presentations of

an extra stimulus during the entire extinction phase would provide this stimulus the ability to
retrieve the extinction memory (possibly through a stimulus-context association). They provided
the proof of principle of this method in an appetitive conditioning preparation in rats. Three hu-
man fear-conditioning studies have now shown beneficial effects of retrieval cues on the prevention
of ABA renewal (Dibbets et al. 2008, Dibbets & Maes 2011, Vansteenwegen et al. 2006). Extra
tests in the Dibbets studies suggested that the retrieval cue turned into a safety signal (in contrast
to Brooks & Bouton 1994). That is, the retrieval cue also reduced fear of separately conditioned
stimuli. In addition, fear returned when the conditioned-and-extinguished CS was presented in
its own extinction context but in the absence of the retrieval cue. This is an unfavorable outcome,
as it is counterproductive in clinical practice to create dependence on safety signals (breaking
such dependence is often a primary goal of treatment). More research is needed to outline the
procedural conditions to produce a benign retrieval cue versus a malignant safety cue.
A clinical study found only a very weak effect of retrieval cues on the return of fear after exposure
treatment (of public speaking anxiety; Culver et al. 2011). It is clear that even though retrieval
cues may be beneficial for the prevention of return of fear, we need much more information about
the conditions for success.
Mental reinstatement prevents relapse in humans. Rather than presenting a cue to retrieve
the extinction memory, one can just ask human participants to mentally reinstate the treatment
episode (Mystkowski et al. 2006). This strategy produced a clear reduction of contextual renewal
of fear in an exposure treatment study with spider-anxious individuals. This provides a proof of
principle that memory retrieval can prevent return of fear. It remains to be seen how nonverbal
retrieval cues can assume this function.
Multiple contexts extinction can prevent relapse in rats and humans, under some condi-
tions. Extinction is typically specific to the context in which learning took place. Conducting
extinction in multiple contexts would obviously expand the number of contexts capable of pro-
ducing the extinction effect. This method has proven successful to reduce and even abolish ABC
renewal in rodent and human fear conditioning (Bandarian Balooch et al. 2012, Gunther et al.
1998). An analogous clinical study showed the same effect in spider-fearful individuals who were
exposed to videotaped spiders against different background contexts (Vansteenwegen et al. 2007).
However, a rat conditioning study comprising three experiments and a human conditioning
study comprising two experiments failed to find a reducing effect on ABA or ABC renewal (Bouton
et al. 2006, Neumann et al. 2007). The exact reasons for this discrepancy are unclear, but two
additional studies have revealed specific conditions that modulate the effects of multiple contexts
extinction. One rat conditioning study found a beneficial effect of multiple contexts extinction on
ABA renewal only with extensive extinction training (the number of acquisition trials multiplied
by 15; Thomas et al. 2009). One human conditioning study found that multiple contexts extinction
abolished ABC renewal when the extinction contexts were similar to the test context (Bandarian
Balooch & Neumann 2011). Finally, the rat study by Gunther et al. (1998) also showed that
multiple contexts extinction failed to reduce renewal when fear conditioning had occurred in the
same number of contexts.
Internal states can also function as context. Kircanski et al. (2012) and Culver et al. (2012)
found that greater variability in terms of fear levels throughout exposure (i.e., repeated increases
following decreases in minute to minute anxiety levels) is a positive predictor of follow-up outcomes
in contaminant anxiety and public speaking anxiety. Arguably, the variability of fear levels produced
multiple internal contexts during extinction, thereby enhancing the retrievability of extinction in
the long-term. These correlational studies need further experimental examination.

Multiple stimulus extinction prevents relapse in humans. Preclinical human studies found
that fear extinction is difficult to generalize over stimuli (Vervliet et al. 2004, 2005). A clinical ana-
logue study showed return of fear in spider-fearful individuals when a novel spider was presented at
test, except when the individuals had been exposed to a variety of spiders during treatment (Rowe
& Craske 1998); however, another study of contaminant anxiety showed trends only (Kircanski
et al. 2012). Hence, the multiple contexts extinction effects may also apply to multiple stimulus
extinction procedures.
US devaluation reduces fear but prevents return only in humans, not in rats. An alternative
way to reduce fear is by devaluing the US. One straightforward way is to present the aversive US
over and over again, until the unconditional reaction habituates. Storvse et al. (2010) showed that
this successfully reduces conditional fear in rats. However, this fear-reduction effect still shows
return of fear (spontaneous recovery, reinstatement, renewal). Dibbets et al. (2012) added imagery
rescripting (i.e., imagining more control over the aversive effects of the US) to the extinction phase
of a typical ABA-renewal design in order to devalue the US (pictures of aversive scenes in this
case). They found a reduced ABA-renewal effect, mediated by the US-devaluation effects.
The cognitive enhancer d-cycloserine boosts fear extinction and prevents some forms of
relapse, but caution is warranted. Fear-conditioning studies in rats have identified the critical
receptor mechanisms that are involved in fear extinction. Most interestingly, infusing a blocking
drug of specific glutamate receptors in the amygdala during or shortly after extinction weakened
the long-term extinction effect (on a separate drug-free test; Falls et al. 1992). Conversely, infusing
an enhancing drug of those receptors strengthened the long-term extinction effect (on a separate
drug-free test; Walker et al. 2002). D-cycloserine, as the drug is called, is a cognitive enhancer with
a favorable clinical profile, having been used as a first-generation antibiotic. Later studies showed
that D-cycloserine is primarily involved in the consolidation of the newly formed extinction mem-
ory, because postextinction administrations produced the same effect (up to four-hour intervals;
Richardson et al. 2004). D-cycloserine also reduced fear of a separately conditioned stimulus, and
it prevented reinstatement (Richardson et al. 2004). However, D-cycloserine leaves renewal and
rapid reacquisition intact (Ledgerwood et al. 2005, Woods & Bouton 2006). Based on this pattern
of results, Woods & Bouton (2006) and Vervliet (2008) concluded that D-cycloserine most likely
promotes contextual inhibition (safety). Enhanced contextual inhibition would still show renewal,
but reinstatement would be weaker (as the reinstating USs may not be able to overcome the in-
hibition and produce the contextual fear needed to retrieve the CS fear). Enhanced contextual
inhibition would also reduce fear to other conditioned stimuli presented in that context. More
research is needed to pinpoint the exact mechanism.
D-cycloserine has been shown to augment fear-extinction effects in exposure treatment as well.
For example, Ressler et al. (2004) showed that administering D-cycloserine prior to two exposure
sessions in height-phobic individuals produced better extinction effects in the long term. Adminis-
tering D-cycloserine in combination with interoceptive exposure for patients with panic disorder
has also resulted in a greater reduction in symptom severity and a greater likelihood of achieving
a change in clinical status at posttreatment and one-month follow-up compared to exposure plus
placebo (Otto et al. 2010). Similar results have been found in socially phobic samples (at both post-
treatment and one-month follow-up; Hofmann et al. 2006), and some evidence suggests a benefit
of combining D-cycloserine with exposure and response prevention for obsessive-compulsive dis-
order for anxiety symptoms at midtreatment and depressive symptoms at posttreatment (Wilhelm
et al. 2008). In a meta-analysis of the efficacy of D-cycloserine for anxiety disorders, reported effect
sizes were d = 0.90 at posttreatment and d = 0.40 at follow-up when collapsing across animal,

nonclinical human, and clinical human samples; in human clinical samples only, the effect sizes
were d = 0.60 at posttreatment and 0.47 at follow-up.
A rat conditioning study showed that D-cycloserine can also increase fear of the CS in the long
term if administered prior to a single trial of the CS instead of a full series of extinction trials.
Arguably, the single trial merely retrieved the fear memory, and D-cycloserine strengthened
this fear memory through a process called reconsolidation (see below). Likewise, Kalisch et al.
(2008) added D-cycloserine to fear acquisition in humans and found an increased fear effect on a
drug-free test. In addition, there are a number of null findings in human fear-extinction studies
(Guastella et al. 2007, Klumpers et al. 2012). The only successful effect of D-cycloserine on fear
reduction in human conditioning comes from a study by Kuriyama et al. (2011), but they used a
contingency-reversal procedure rather than a standard fear-extinction procedure.
A number of other cognitive enhancers are now being examined for their effects of conditioned
fear extinction and exposure treatment, with varying degrees of success (for an overview, see
Hofmann et al. 2011).
Human and animal preclinical findings suggest that Bob may become more resilient against relapse (a)
when he is massively exposed to elevators, (b) when exposures in the elevator are compounded with
other threatening situations (e.g., hyperventilation), (c) when Bob can retrieve the (safety) treatment
memory in case of renewed fear experiences (e.g., via treatment reminder cues), (d ) when exposures
took place in multiple different contexts or with multiple types of elevators, (e) when the threatening
meaning of panic attacks is reduced directly (e.g., by exposures to bodily sensations), or ( f ) when a
cognitive enhancer augmented the consolidation of the fear extinction memory during the exposure
sessions.
Preventing Relapse By Weakening the Fear Memory

Most studies have focused on strengthening the extinction learning and memory in order to prevent
return of fear. However, even a strong extinction memory leaves the original fear memory intact
and thereby presents the continuous risk for a return of fear. Researchers have more recently
turned toward interventions that might weaken the fear memory directly.
Immediate extinction can prevent relapse in rats but produces mixed results in rats and
humans. Pavlov (1927) reported that recently conditioned salivary reflexes extinguished more
easily than more remotely conditioned salivary reflexes. Myers et al. (2006) showed that immediate
fear extinction in rats (up to one hour after conditioning) produced durable fear extinction that
was resistant to return of fear procedures. The authors argued that immediate extinction interferes
with the consolidation of the CS-US association in memory, thereby weakening the fear memory
itself. However, more rat conditioning studies have found the opposite result: more return of fear
after immediate extinction (e.g., Maren & Chang 2007, Woods & Bouton 2006). Two human
studies in this regard have produced either inconclusive results (Norrholm et al. 2008) or typical
levels of return of fear 24 hours after immediate extinction (Schiller et al. 2008). A third human
study showed more spontaneous recovery of fear and more prolonged renewal after immediate
versus delayed extinction (Huff et al. 2009).
Reconsolidation treatments can prevent relapse in rats and humans, but results are mixed.
Retrieving already stored memories induces a process of reconsolidation (Nader et al. 2000). Once
retrieved, the memory has to be rewritten into long-term memory, which requires neurochemical
(de novo protein synthesis) processes in the brain. This gives rise to the fascinating possibility of
changing memories post factum, during the reconsolidation time window upon retrieval.

Debiec & LeDoux (2004) infused a beta adrenergic blocking agent (propranolol) into the
brain after rats received a single retrieval trial of the CS (which was previously fear conditioned).
When propranolol was infused shortly after the retrieval trial (up to four hours), it produced
long-term fear reduction effects that were resistant to reinstatement. Propranolol has a favorable
clinical profile, as it is widely used for the treatment of hypertension. Its effects on fear memory
reconsolidation are highly promising from an anxiety treatment perspective. A number of studies
from the Kindt laboratory have replicated these findings in human fear-conditioning studies (Kindt
et al. 2009; Soeter & Kindt 2010, 2011). Interestingly, whereas the physiological correlate of fear
was erased (fear-potentiated startle reflex), the declarative memory of the CS-US contingency
was intact. Two preliminary clinical studies found beneficial effects of the addition of propranolol
to memory retrieval in posttraumatic stress disorder (Brunet et al. 2008, 2011). Of note, other
experimental studies have shown that propranolol can weaken extinction when it is added to a full-
extinction phase (in rats, Mueller et al. 2008; in humans effect was only on declarative memory,
Bos et al. 2012). This is a potentially harmful side effect of the drug when it is to be applied in
exposure-based treatments of anxiety.
Monfils et al. (2009) found that administering fear-extinction trials within the reconsolidation
time window of a CS can weaken the fear memory directly. Rats that received a retrieval trial prior
to extinction showed no return of fear with tests of spontaneous recovery, renewal, reinstatement,
and reacquisition. The effect was found only with retrieval-extinction intervals up to ten minutes or
one hour (not with six or twenty-four hours). Arguably, the CS extinction experiences that occur
within the reconsolidation time window update the fear memory rather than form a separate
extinction memory. These results were replicated in a separate rat study that also revealed central
components of the neurobiological mechanism underlying this extinction-induced erasure of fear
memories (Clem & Huganir 2010). Three human fear-conditioning studies showed highly similar
behavioral results (Argen et al. 2012, Oyarzun et al. 2012, Schiller et al. 2009). However, other
studies showed either no effect of the retrieval extinction procedure (in humans, Kindt & Soeter
2013 and Soeter & Kindt 2011; in mice, Ishii et al. 2012) or a significant increase of fear (in rats,
Chan et al. 2010). These divergent results show that the conditions under which retrieval extinction
produces desirable results are currently unknown. More experimental and clinical research is under
way.
Human and animal preclinical findings suggest that Bob’s fear of elevators may never return if the
elevator-panic association is erased from memory. There is little experimental support for the idea that
immediate exposures to elevators after the traumatic panic attack prevent the development of the fear
memory and symptomatology. On the other hand, the memory may be malleable afterward, when a
brief exposure to an elevator reactivates Bob’s memory. In this time window, the fear memory may be
weakened by the administration of beta blockers or by the administration of multiple safety/extinction
experiences through a typical exposure procedure.
FUTURE RESEARCH
We have a fairly good view of the mechanisms of fear extinction and return, but important questions
remain unanswered. We selectively highlight questions below.
What Constitutes a Context?

The important role of context in extinction is indisputable, but what constitutes a context in the
experimental situation, and what are the relevant contexts in clinical practice? There are three

main approaches to defining context. From a perceptual viewpoint, the context is a complex, diffuse
constellation of background cues that surrounds the subject and/or the CS (Rudy 2009). From a
temporal viewpoint, the context is a long-lasting stimulus that extends from before to after the
CS (Grillon 2002). From a functional viewpoint, the context is an occasion setter or a retrieval
cue: It signals or retrieves the current meaning of discrete stimuli that are presented within that
context (Bouton 2002). These different definitions subserve different research lines on contextual
learning that have been largely separated. Furthermore, different levels of contexts co-occur in
clinical practice. Contexts can be very local (e.g., the room of exposure treatment) or very global
(e.g., the ten years of living in a certain city). Learning will be more general when it is attached to a
global context or more specific when it is attached to a local context. Engaging local versus global
contexts in learning and memory can provide novel ways to obtain persistent fear extinction.
Individual Differences
We have replicated findings on the ways in which rats and humans behave on average in extinc-
tion and return of fear experiments. However, individual differences with regard to extinction
and return of fear are of high interest for several reasons. First, they may serve as an endopheno-
type for genetic research into anxiety (Lonsdorf et al. 2009) and other biological factors (gonadal
hormones, Lebron-Milad & Milad 2012; resting state metabolism of the brain, Linnman et al.
2012). Second, they may serve as a biomarker for identifying individuals with an anxiety disorder
or at risk for developing an anxiety disorder ( Jovanovic et al. 2010). Third, they may serve as a
prospective moderator for exposure treatment outcomes. Ideally, the individual results (behav-
ioral or neurological) in an extinction and return of fear experiment may provide information to
guide tailoring of exposure treatment to the needs of the individual client. Tests of the underlying
behavioral and/or neural mechanism may point to certain interventions. For example, if return of
fear is driven by stimulus generalization, interventions that are aimed at changing the generaliza-
tion process could be most efficient (e.g., through modification of attentional processes). If return
of fear is driven by contextual inhibition (safety) learning, then blocking safety learning would be
a target of treatment. If return of fear is driven by context-specific CS inhibition, then flexible
retrieval of the extinction memory may be the primary target of treatment.
Extinction Versus Reconsolidation

The reconsolidation-extinction boundaries remain unclear. Some interventions are beneficial
when they occur in the reconsolidation time window but malignant when they occur in the extinc-
tion learning window and vice versa. Reconsolidation is triggered by retrieval of the fear memory,
but surely all extinction learning starts with retrieval of the fear memory. We need procedures that
discriminate more precisely between these two processes. Also, in clinical practice, most clients
will retrieve their fear memories to a certain degree whenever they enter treatment sessions. The
question is what type, degree, or frequency of retrieval opens the reconsolidation window and
provides the opportunity to update the underlying memories.
Time Factors
Time factors have been relatively understudied in Pavlovian conditioning research, but the mem-
ory (re)consolidation approach has reemphasized their crucial role in retrieval, extinction, and
recovery (Monfils et al. 2009, Myers et al. 2006). Other time factors that may play an impor-
tant role are the duration of the intertrial intervals in extinction and the duration of the CS

presentations during extinction. To date, clinical and preclinical studies have produced mixed re-
sults in this regard (Cain et al. 2003, Prenoveau et al. 2013, Rowe & Craske 1998, Tsao & Craske
2000). It is clear that time factors play an important role in extinction learning and retention, but
very little is known about their exact effects. We need more research to design exposure programs
with optimal within- and between-session scheduling.
Return Versus Relapse

Finally, return of fear is only a precursor for relapse (a return of the full symptomatology of the
anxiety disorders). Not all clients who experience return of fear are likely to relapse fully. In fact,
return of fear may serve an important function by providing an opportunity to further practice the
skills and self-exposure taught in treatment. How and when return of fear culminates in relapse
is unknown. Rigid avoidance patterns are probably the most important symptom of most anxiety
disorders. Avoidance is related to fear, but this relationship is highly complex (Mineka 1979).
Pre-clinical and clinical research examining the conditions under which return of fear triggers a
return of the avoidance patterns will provide an important addition to the current state of fear
extinction and return research.
Retrieval Versus New Learning

Some reinstatement findings are difficult to reconcile with a pure retrieval view. Reinstatement
can reflect mediated conditioning through context-CS associations, and it can occur with a novel
aversive stimulus as well (Sokol & Lovibond 2012, Westbrook et al. 2002). Reinstatement may also
reflect newly produced arousal that recombines with remaining negative CS valence (Hermans
et al. 2005). The relative weight of new learning versus retrieval in reinstatement is a subject for
further research. Such research will further delineate the conditions that may elicit return of fear
in clinical practice and guide further development and testing of prevention techniques within the
reinstatement model.
CONCLUSION
Insight into the behavioral and neural mechanisms of fear extinction and its return has progressed
immensely. These advances are largely due to concurrent research efforts in clinical and preclinical
studies in humans and nonhuman animals. The translational impact among different domains
is enhanced by the simplicity and elegance of the Pavlovian conditioning model of anxiety.
Novel insights have also resulted in the testing of prevention strategies, with varying degrees
of success. To date, most strategies (behavioral and behavioral-pharmacological) have produced
mixed results. We need more research to delineate the exact conditions that produce long-term
extinction success and to tailor specific prevention strategies to the needs of the individual patient.
We expect that a continuation of the concerted efforts in this translational domain will lead to
more breakthroughs soon.
SUMMARY POINTS
1. Fear extinction represents an excellent example of successful translational research.
2. Return of fear remains an important problem for the long-term efficacy of exposure-based
treatments of anxiety.

3. Relapse prevention is a major focus in the domain of fear research.

4. Learning theory remains an important source of inspiration for psychological and neu-
rological research into fear extinction and return.
5. Extinction is relatively easy to “learn” but difficult to “remember.”
6. Laboratory-based prevention research has yielded promising but mixed results.
7. Neurobiological research has inspired novel ways to prevent the return of fear, by weak-
ening the fear memory itself.
8. Multiple pathways can lead to return of fear.
DISCLOSURE STATEMENT
M.G. Craske is a member of the Scientific Advisory Board of the Anxiety Disorders Association of
America. The authors are not aware of any further affiliations, memberships, funding, or financial
holdings that might be perceived as affecting the objectivity of this review.
ACKNOWLEDGMENTS
We thank Dr. Debora Vansteenwegen for stimulating discussions concerning several topics cov-
ered in this review. Preparation of this manuscript was supported by the Center for Excellence on
Generalization Research (GRIP∗ TT; KU Leuven grant PF/10/005).
LITERATURE CITED
Agren T, Engman J, Frick A, Björkstrand J, Larsson E, et al. 2012. Disruption of reconsolidation erases a fear
memory trace in the human amygdala. Science 337:1550–52
Alvarez RP, Johnson L, Grillon C. 2007. Contextual-specificity of short-delay extinction in humans: renewal
of fear-potentiated startle in a virtual environment. Learn. Mem. 14:247–53
Bandarian Balooch S, Neumann DL. 2011. Effects of multiple contexts and context similarity on the renewal
of extinguished conditioned behaviour in an ABA design with humans. Learn. Motiv. 42:53–63
Bandarian Balooch S, Neumann D, Boschen MJ. 2012. Extinction treatment in multiple contexts attenuates
ABC renewal in humans. Behav. Res. Ther. 50:604–9
Bar-Haim Y, Lamy D, Pergamin L, Bakermans-Kranenburg MJ, van IJzendoorn MH. 2007. Threat-related
attentional bias in anxious and non-anxious individuals: a meta-analytic study. Psychol. Bull. 133:1–24
Blechert J, Michael T, Vriends N, Margraf J, Wilhelm FH. 2007. Fear conditioning in posttraumatic stress
disorder: evidence for delayed extinction of autonomic, experiential, and behavioural responses. Behav.
Res. Ther. 45:2019–33
Bos MG, Beckers T, Kindt M. 2012. The effects of noradrenergic blockade on extinction in humans.
Biol. Psychol. 89:598–605
Bouton ME. 1993. Context, time and memory retrieval in the interference paradigms of Pavlovian learning.
Psychol. Bull. 114:80–99
Bouton ME. 1994. Conditioning, remembering, and forgetting. J. Exp. Psychol.: Anim. Behav. Process. 20:219–
31
Bouton ME. 2002. Context, ambiguity, and unlearning: sources of relapse after behavioral extinction. Biol.
Psychiatry 52:976–86
Bouton ME, Bolles RC. 1979a. Role of conditioned contextual stimuli in reinstatement of extinguished fear.
J. Exp. Psychol.: Anim. Behav. Process. 5:368–78
Bouton ME, Bolles RC. 1979b. Contextual control of the extinction of conditioned fear. Learn. Motiv. 10:445–
66

Bouton ME, Garcia-Guttierez A, Zilski J, Moody EW. 2006. Extinction in multiple contexts does not neces-
sarily make extinction less vulnerable to relapse. Behav. Res. Ther. 44:983–94
Bouton ME, King DA. 1983. Contextual control of the extinction of conditioned fear: tests for the associative
value of the context. J. Exp. Psychol.: Anim. Behav. Process. 9:248–65
Brooks DC, Bouton ME. 1994. A retrieval cue for extinction attenuates response recovery (renewal) caused
by a return to the conditioning context. J. Exp. Psychol.: Anim. Behav. Process. 20:366–79
Brown TA, Barlow DH. 1995. Long-term outcome in cognitive-behavioral treatment of panic disorder: clinical
predictors and alternative strategies for assessment. J. Consult. Clin. Psychol. 63:754–65
Brunet A, Orr SP, Tremblay J, Robertson K, Nader K, Pitman RK. 2008. Effects of post-retrieval propranolol
on psychophysiologic responding during subsequent script-driven traumatic imagery in post-traumatic
stress disorder. J. Psychiatr. Res. 42:503–6
Brunet A, Poundja J, Tremblay J, Bui E, Thomas E, et al. 2011. Trauma reactivation under the influence of pro-
pranolol decreases posttraumatic stress symptoms and disorder: 3 open-label trials. J. Clin. Psychopharm.
31:547–50
Cain CK, Blouin AM, Barad M. 2003. Temporally massed CS presentations generate more fear extinction
than spaced presentations. J. Exp. Psychol.: Anim. Behav. Process. 29:323–33
Chan WYM, Leung HT, Westbrook RF, McNally GP. 2010. Effects of recent exposure to a conditioned
stimulus on extinction of Pavlovian fear conditioning. Learn. Mem. 17:512–21
Clem RL, Huganir RL. 2010. Calcium-permeable AMPA receptor dynamics mediate fear memory erasure.
Science 330:1198–12
Craske MG, Liao B, Brown L, Vervliet B. 2012. Role of inhibition in exposure therapy. J. Exp. Psychopathol.
3:322–45
Craske MG, Mystkowski JL. 2006. Exposure therapy and extinction: clinical studies. In Fear and Learning:
From Basic Processes to Clinical Implications, ed. MG Craske, D Hermans, D Vansteenwegen, pp. 217–33.
Washington, DC: Am. Psychiatr. Assoc.
Craske MG, Waters AM, Bergman RL, Naliboff B, Lipp OV, et al. 2008. Is aversive learning a marker of risk
for anxiety disorders in children? Behav. Res. Ther. 46:954–67
Culver NC, Stoyanova M, Craske MG. 2011. Clinical relevance of retrieval cues for attenuating context
renewal of fear. J. Anxiety Disord. 25:284–92
Culver NC, Stoyanova M, Craske MG. 2012. Emotional variability and sustained arousal during exposure.
J. Behav. Ther. Exp. Psychiatry 43:787–93
Debiec J, LeDoux JE. 2004. Disruption of reconsolidation but not consolidation of auditory fear conditioning
by noradrenergic blockade in the amygdala. Neuroscience 129:267–72
Denniston JC, Chang RC, Miller RR. 2003. Massive extinction treatment attenuates the renewal effect. Learn.
Motiv. 34:68–86
Dibbets P, Havermans R, Arntz A. 2008. All we need is a cue to remember: the effect of an extinction cue on
renewal. Behav. Res. Ther. 46:1070–77
Dibbets P, Maes JR. 2011. The effect of an extinction cue on ABA-renewal: Does valence matter? Learn.
Motiv. 42:133–44
Dibbets P, Poort H, Arntz A. 2012. Adding imagery rescripting during extinction leads to less ABA renewal.
J. Behav. Ther. Exp. Psychiatry 43:614–24
Dirikx T, Hermans D, Vansteenwegen D, Baeyens F, Eelen P. 2004. Reinstatement of extinguished condi-
tioned responses and negative stimulus valence as a pathway to return of fear in humans. Learn. Mem.
11:549–54
Dirikx T, Hermans D, Vansteenwegen D, Baeyens F, Eelen P. 2007. Reinstatement of conditioned responses
in human differential conditioning. J. Behav. Ther. Exp. Psychiatry 38:237–51
Dirikx T, Vansteenwegen D, Eelen P, Hermans D. 2009. Non-differential return of fear in humans after a
reinstatement procedure. Acta Psychol. 130:175–82
Eddy KT, Dutra L, Bradley R, Westen D. 2004. A multidimensional meta-analysis of psychotherapy and
pharmacotherapy for obsessive-compulsive disorder. Clin. Psychol. Rev. 24:1011–30
Eelen P, Vervliet B. 2006. Conditioning and anxiety: an historical perspective. In Fear and Learning: From
Basic Processes to Clinical Implications, ed. M Craske, D Hermans, D Vansteenwegen. Washington, DC:
Am. Psychol. Assoc.

Effting M, Kindt M. 2007. Contextual renewal of human fear associations in a renewal paradigm. Behav. Res.
Ther. 45:2002–18
Falls WA, Miserendino MJD, Davis M. 1992. Extinction of fear-potentiated startle: blockade by infusion of
an NMDA antagonist into the amygdala. J. Neurosci. 12:854–63
Fava GA, Rafanelli C, Grandi S, Conti S, Ruini C, et al. 2001. Long-term outcome of panic disorder with
agoraphobia treated by exposure. Psychol. Med. 31:891–98
Grillon C. 2002. Startle reactivity and anxiety disorders: aversive conditioning, context, and neurobiology.
Biol. Psychiatry 52:958–75
Guastella AJ, Lovibond PF, Dadds MR, Mitchell P, Richardson R. 2007. A randomized controlled trial of the
effect of D-cycloserine on extinction and fear conditioning in humans. Behav. Res. Ther. 45:663–72
Gunther LM, Denniston JC, Miller RR. 1998. Conducting exposure treatment in multiple contexts can prevent
relapse. Behav. Res. Ther. 36:75–91
Guthrie RM, Bryant RA. 2006. Extinction learning before trauma and subsequent posttraumatic stress. Psy-
chosom. Med. 68:307–11
Harris JA, Jones ML, Bailey GK, Westbrook RF. 2000. Contextual control over conditioned responding in
an extinction paradigm. J. Exp. Psychol.: Anim. Behav. Process. 26:174–85
Hermans D, Dirikx T, Vansteenwegen D, Baeyens F, Van den Bergh O, Eelen P. 2005. Reinstatement of fear
responses in human aversive conditioning. Behav. Res. Ther. 43:533–51
Hofmann SG, Meuret AE, Smits JA, Simon NM, Pollack MH, et al. 2006. Augmentation of exposure therapy
with D-cycloserine for social anxiety disorder. Arch. Gen. Psychiatry 63:298–304
Hofmann SG, Smits JAJ. 2008. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of
randomized placebo-controlled trials. J. Clin. Psychiatry 69:621–32
Hofmann SG, Smits JAJ, Asnaani A, Gutner CA, Otto MW. 2011. Cognitive enhancers for anxiety disorders.
Pharmacol. Biochem. Behav. 99:275–84
Huff NC, Hernandez JA, Blanding NQ, La Bar KS. 2009. Delayed extinction attenuates conditioned fear
renewal and spontaneous recovery in humans. Behav. Neurosci. 123:834–43
Ishii D, Matsuzawa D, Matsuda S, Tomizawa H, Sutoh C, Shimizu E. 2012. No erasure effect of retrieval-
extinction trial on fear memory in the hippocampus-independent and dependent paradigms. Neurosci.
Lett. 523:76–81
Jovanovic T, Norrholm SD, Blanding NQ, Davis M, Duncan E, et al. 2010. Impaired fear inhibition is a
biomarker of PTSD but not depression. Depress. Anxiety 27:244–51
Kalisch R, Korenfeld E, Stephan KS, Weiskopf N, Seymour B, Dolan RJ. 2006. Context-dependent human
extinction memory is mediated by a ventromedial prefrontal and hippocampal network. J. Neurosci.
26:9503–11
Kalisch R, Holt B, Petrovic P, De Martino B, Kloppel S, et al. 2008. The NMDA agonist D-cycloserine
facilitates fear memory consolidation in humans. Cereb. Cortex 19:187–96
Kindt M, Soeter M. 2013. Reconsolidation in a human fear conditioning study: a test of extinction as updating
mechanism. Biol. Psychol. 92(1):43–50
Kindt M, Soeter M, Vervliet B. 2009. Beyond extinction: erasing human fear responses and preventing the
return of fear. Nat. Neurosci. 12(3):256–58
Kircanski K, Mortazavi A, Castriotta N, Baker AS, Mystkowski JL, et al. 2012. Challenges to the traditional
exposure paradigm: variability in exposure therapy for contamination fears. J. Behav. Ther. Exp. Psychiatry
43:745–51
Klumpers F, Denys D, Kenemans JL, Grillon C, van der Aart J, Baas MP. 2012. Testing the effects of delta9-
THC and D-cycloserine on extinction of conditioned fear in humans. J. Psychopharmacol. 26:471–78
Kull S, Müller BH, Blechert J, Wilhelm FH, Michael T. 2012. Reinstatement of fear in humans: autonomic
and experiential responses in a differential conditioning paradigm. Acta Psychol. 140:43–49
Kuriyama K, Honma M, Soshi T, Fuji T, Kim Y. 2011. Effect of D-cycloserine and valproic acid on the ex-
tinction of reinstated fear-conditioned responses and habituation of fear conditioning in healthy humans:
a randomized controlled trial. Psychopharmacology 218:589–97
LaBar K, Phelps EA. 2005. Reinstatement of conditioned fear in humans is context dependent and impaired
in amnesia. Behav. Neurosci. 119:677–86

Lang PJ, Bradley MM, Cuthbert BN. 1990. Emotion, attention, and the startle reflex. Psychol. Bull. 97:377–95
Lang PJ, Davis M, Ohman A. 2000. Fear and anxiety: animal models and human cognitive psychophysiology.
J. Affect. Disord. 61:137–59
Lebron-Milad K, Milad MR. 2012. Sex differences, gonadal hormones and the fear extinction network: im-
plications for anxiety disorders. Biol. Mood Anxiety Disord. 2:3
Ledgerwood L, Richardson R, Cranney J. 2005. D-cycloserine facilitates extinction of learned fear: effects on
reacquisition and generalized extinction. Biol. Psychiatry 57:841–47
Linnman C, Zeidan MA, Furtak SC, Pitman RK, Quirk GJ, Milad MR. 2012. Resting amygdala and me-
dial prefrontal metabolism predicts functional activation of the fear extinction circuit. Am. J. Psychiatry
169:415–23
Lissek S, Biggs AL, Rabin SJ, Cornwell BR, Alvarez RP, et al. 2008. Generalization of conditioned fear-
potentiated startle in humans: experimental validation and clinical relevance. Behav. Res. Ther. 46:678–87
Lissek S, Pine DS, Grillon C. 2006. The strong situation: a potential impediment to studying the psychobiology
and pharmacology of anxiety disorders. Biol. Psychol. 72:265–70
Lissek S, Powers AS, McClure EB, Phelps EA, Woldehawariat G, et al. 2005. Classical fear conditioning in
the anxiety disorders: a meta-analysis. Behav. Res. Ther. 43:1391–424
Lissek S, Rabin S, Heller RE, Lukenbaugh D, Geraci M, et al. 2010. Overgeneralization of conditioned fear
as a pathogenic marker of panic disorder. Am. J. Psychiatry 167:47–55
Lommen MJJ, Engelhard IM, Sijbrandij M, van den Hout MA, Hermans D. 2013. Pre-trauma individual
differences in extinction learning predict posttraumatic stress. Behav. Res. Ther. 51:63–67
Lonsdorf TB, Weike AI, Nikamo P, Schalling M, Hamm AO, Öhman A. 2009. Genetic gating of human
fear learning and extinction: possible implications for gene-environment interaction in anxiety disorder.
Psychol. Sci. 20:198–206
Lovibond PF, Davis NR, O’Flaherty AS. 2000. Protection from extinction in human fear conditioning.
Behav. Res. Ther. 38:967–83
MacLeod C, Rutherford E, Campbell L, Ebsworthy G, Holker L. 2002. Selective attention and emotional
vulnerability: assessing the causal basis of their association through the experimental manipulation of
attentional bias. J. Abnorm. Psychol. 111:107–23
Maren S, Chang C. 2007. Recent fear is resistant to extinction. Proc. Natl. Acad. Sci. USA 103:18020–25
Michael T, Blechert J, Vriends N, Margraf J, Wilhelm FH. 2007. Fear conditioning in panic disorder: enhanced
resistance to extinction. J. Abnorm. Psychol. 116:612–17
Milad MR, Orr SP, Pitman RK, Rauch SL. 2005a. Context modulation of memory for fear extinction in
humans. Psychophysiology 42:456–64
Milad MR, Pitman RK, Ellis CB, Gold AL, Shin LM, et al. 2009. Neurobiological basis of failure to recall
extinction memory in posttraumatic stress disorder. Biol. Psychiatry 66:1075–82
Milad MR, Quinn BT, Pitman RK, Orr SP, Fischl B, Rauch SL. 2005b. Thickness of ventromedial prefrontal
cortex in humans is correlated with extinction memory. Proc. Natl. Acad. Sci. USA 102:10706–11
Milad MR, Quirk GJ. 2002. Neurons in medial prefrontal cortex signal memory for fear extinction. Nature
420:70–74
Milad MR, Wright CI, Orr SP, Pitman RK, Quirk GJ, Rauch SL. 2007. Recall of fear extinction in humans
activates the ventromedial prefrontal cortex and hippocampus in concert. Biol. Psychiatry 62:446–54
Mineka S. 1979. The role of fear in theories of avoidance learning, flooding, and extinction. Psychol. Bull.
86:985–1010
Mineka S, Mystkowski JL, Hladek D, Rodriguez BI. 1999. The effects of changing contexts on return of fear
following exposure therapy for spider fear. J. Consult. Clin. Psychol. 67:599–604
Mineka S, Zinbarg R. 2006. A contemporary learning theory perspective on the etiology of anxiety disorders:
It’s not what you thought it was. Am. Psychol. 61:10–26
Mitte K. 2005. A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and
without agoraphobia. J. Affect. Disord. 88:27–45
Monfils M, Cowansage K, Klann E, LeDoux J. 2009. Extinction-reconsolidation boundaries: key to persistent
attenuation of fear memories. Science 324:951–55
Mueller D, Porter JT, Quirk G. 2008. Noradrenergic signaling in infralimbic cortex increase cell excitability
and strengthens memory for fear extinction. J. Neurosci. 28:369–75

Myers KM, Ressler KJ, Davis M. 2006. Different mechanisms of fear extinction dependent on length of time
since fear acquisition. Learn. Mem. 13(2):216–23
Mystkowski JL, Craske MG, Echiverri AM. 2002. Treatment context and return of fear in spider phobia.
Behav. Ther. 33:399–416
Mystkowski JL, Craske MG, Echiverri AM, Labus JS. 2006. Mental reinstatement of context and return of
fear in spider-anxious individuals. Behav. Ther. 37:49–60
Mystkowski JL, Mineka S, Vernon LL, Zinbarg RE. 2003. Changes in caffeine states enhance return of fear
in spider phobia. J. Consult. Clin. Psychol. 71:243–50
Nader K, Schafe GE, LeDoux JE. 2000. Fear memories require protein synthesis in the amygdala for recon-
solidation after retrieval. Nature 406:722–26
Neumann DL, Kitlertsirivatana E. 2010. Exposure to a novel context after extinction causes a renewal of
extinguished conditioned responses: implications for the treatment of fear. Behav. Res. Ther. 48:565–70
Neumann DL, Lipp OV, Cory SE. 2007. Conducting extinction in multiple contexts does not necessarily
attenuate the renewal of shock expectancy in a fear-conditioning procedure with humans. Behav. Res.
Ther. 45:385–94
Neumann DL, Longbottom PL. 2008. The renewal of extinguished conditioned fear with fear-relevant and
fear-irrelevant stimuli by a context change after extinction. Behav. Res. Ther. 46:188–206
Norrholm SD, Jovanovic T, Olin IW, Sands LA, Karapanou I, et al. 2011. Fear extinction in traumatized
civilians with posttraumatic stress disorder: relation to symptom severity. Biol. Psychiatry 69:556–63
Norrholm SD, Jovanovic T, Vervliet B, Myers K, Davis M, et al. 2006. Conditioned fear extinction and
reinstatement in a human fear potentiated startle paradigm. Learn. Mem. 13:681–85
Norrholm SD, Vervliet B, Jovanovic T, Boshoven W, Myers KM, et al. 2008. Timing of extinction relative
to acquisition: a parametric analysis of fear extinction in humans. Behav. Neurosci. 122(5):1016–30
Öhman A, Mineka S. 2001. Fears, phobias, and preparedness: toward an evolved module of fear and fear
learning. Psychol. Rev. 108(3):483–522
Otto MW, Tolin DF, Simon NM, Pearlson GD, Basden S, et al. 2010. Efficacy of D-cycloserine for enhancing
responses to cognitive-behavior therapy for panic disorder. Biol. Psychiatry 67:365–70
Oyarzun JP, Lopez-Barroso D, Fuentemilla L, Cucurell D, Pedraza C, et al. 2012. Updating fearful memories
with extinction training during reconsolidation: a human study using auditory aversive stimuli. PLoS ONE
7(6):e38849
Pavlov IP. 1927. Conditioned Reflexes. London: Oxford Univ. Press
Pearce JM. 1987. A model for stimulus generalization in Pavlovian conditioning. Psychol. Rev. 94:61–73
Prenoveau JM, Craske MG, Liao B, Ornitz EM. 2012. Human fear conditioning and extinction: Timing is
everything. . . or is it? Biol. Psychol. In press
Quirk GJ. 2002. Memory for extinction of conditioned fear is long-lasting and persists following spontaneous
recovery. Learn. Mem. 9:402–7
Quirk GJ, Milad MR. 2012. Fear extinction as a model for translational neuroscience: ten years of progress.
Annu. Rev. Psychol. 63:129–51
Quirk GJ, Russo GK, Barron JL, Lebron K. 2000. The role of ventromedial prefrontal cortex in the recovery
of extinguished fear. J. Neurosci. 20:6225–31
Rachman S. 1966. Studies in desensitization III: speed of generalization. Behav. Res. Ther. 4:7–15
Rescorla RA. 1986. Pavlovian conditioning: It’s not what you think it is. Am. Psychol. 43:151–60
Rescorla RA. 2006. Deepened extinction from compound stimulus presentation. J. Exp. Psychol.: Anim. Behav.
Process. 32:135–44
Rescorla RA, Heth D. 1975. Reinstatement of fear to an extinguished conditioned stimulus. J. Exp. Psychol.:
Anim. Behav. Process. 104:88–96
Rescorla RA, Wagner AR. 1972. A theory of Pavlovian conditioning: variations in the effectiveness of rein-
forcement and nonreinforcement. In Classical Conditioning II, ed. AH Black, WF Prokasy, pp. 64–99. New
York: Appleton-Century-Crofts
Ressler KJ, Rothbaum BO, Tannenbaum L, Anderson P, Graap K, et al. 2004. Cognitive enhancers as adjuncts
to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Arch. Gen.
Psychiatry 61:1136–44

Richardson R, Ledgerwood L, Cranney J. 2004. Facilitation of fear extinction by D-cycloserine: theoretical

and clinical implications. Learn. Mem. 11:510–16
Rodriguez BI, Craske MG, Mineka S, Hladek D. 1999. Context-specificity of relapse: effects of therapist and
environmental context on return of fear. Behav. Res. Ther. 37:845–62
Rowe MK, Craske MG. 1998. Effects of varied-stimulus exposure training on fear reduction and return of
fear. Behav. Res. Ther. 36:719–34
Rudy JW. 2009. Context representations, context functions, and the parahippocampal-hippocampal system.
Learn. Mem. 16:573–85
Schiller D, Cain CK, Curley NG, Schwartz JS, Stern SA, et al. 2008. Evidence for recovery of fear following
immediate extinction in rats and humans. Learn. Mem. 15:394–402
Schiller D, Monfils M, Raio CM, Johnson DC, LeDoux JE. 2009. Preventing the return of fear in humans
using reconsolidation update mechanisms. Nature 463:49–53
Sehlmeyer C, Dannlowski U, Schöning S, Kugel H, Pyka M, et al. 2011. Neural correlates of trait anxiety in
fear extinction. Psychol. Med. 41:789–98
Soeter M, Kindt M. 2010. Dissociating response systems: erasing fear from memory. Neurobiol. Learn. Mem.
94:30–41
Soeter M, Kindt M. 2011. Disrupting reconsolidation: pharmacological and behavioral manipulations. Learn.
Mem. 18:357–66
Sokol N, Lovibond PF. 2012. Cross-US reinstatement of human conditioned fear: return of old fears or
emergence of new ones? Behav. Res. Ther. 50:313–22
Storvse AB, McNally GP, Richardson R. 2010. US habituation, like CS extinction, produces a decrement in
conditioned fear that is NMDA dependent and subject to renewal and reinstatement. Neurobiol. Learn.
Mem. 93:463–71
Thomas BL, Larsen N, Ayres JJB. 2003. Role of context similarity in ABA, ABC, and AAB renewal paradigms:
implications for theories of renewal and for treating human phobias. Learn. Motiv. 34:410–36
Thomas BL, Vurbic D, Novak C. 2009. Extensive extinction in multiple contexts eliminates the renewal of
conditioned fears in rats. Learn. Motiv. 40:147–59
Tsao JCI, Craske MG. 2000. Timing of treatment and return of fear: effects of massed, uniform-, and
expanding-spaced exposure schedules. Behav. Ther. 31:479–97
Van Damme S, Crombez G, Hermans D, Koster EHW, Eccleston C. 2006. The role of extinction and
reinstatement in attentional bias to threat: a conditioning approach. Behav. Res. Ther. 44:1555–63
Vansteenwegen D, Vervliet B, Hermans D, Baeyens F, Van den Bergh O. 2007. The repeated confrontation
with videotapes of spiders in multiple contexts attenuates renewal of fear in spider anxious students. Behav.
Res. Ther. 45:1169–79
Vansteenwegen D, Vervliet B, Hermans D, Beckers T, Baeyens F, Eelen P. 2006. Stronger renewal in human
fear conditioning when tested with an acquisition retrieval cue than with an extinction retrieval cue. Behav.
Res. Ther. 44:1717–25
Vasey MW, Harbaugh CN, Buffington AG, Jones CR, Fazio RH. 2012. Predicting return of fear following
exposure therapy with an implicit measure of attitudes. Behav. Res. Ther. 50:767–74
Vervliet B. 2008. Learning and memory in conditioned fear extinction: effects of D-cycloserine. Acta Psychol.
127:601–13
Vervliet B, Baeyens F, Van den Bergh O, Hermans D. 2013. Extinction, generalization, and return of fear: a
critical review of renewal research in humans. Biol. Psychol. 92(1):51–58
Vervliet B, Vansteenwegen D, Baeyens F, Hermans D, Eelen P. 2005. Return of fear in a human differential
conditioning paradigm caused by a stimulus change after extinction. Behav. Res. Ther. 43(3):357–71
Vervliet B, Vansteenwegen D, Eelen P. 2004. Generalization of extinguished skin conductance responding in
human fear conditioning. Learn. Mem. 11:555–58
Vervliet B, Vansteenwegen D, Hermans D, Eelen P. 2007. Concurrent excitors limit the extinction of condi-
tioned fear in humans. Behav. Res. Ther. 45:375–83
Wagner AR. 1981. SOP: a model of automatic memory processing in animal behavior. In Information Processing
in Animals: Memory Mechanisms, ed. NE Spear, RR Miller, pp. 5–47. Hillsdale, NJ: Erlbaum

Walker DL, Ressler KJ, Lu K, Davis M. 2002. Facilitation of conditioned fear extinction by systemic ad-
ministrator or intra-amygdala infusions of D-cycloserine as assessed with fear-potentiated startle in rats.
J. Neurosci. 22(6):2343–51
Westbrook RF, Iordanova M, McNally G, Richardson R, Harris JA. 2002. Reinstatement of fear to an extin-
guished conditioned stimulus: two roles for context. J. Exp. Psychol.: Anim. Behav. Process. 28:97–110
Wilhelm S, Buhlmann U, Tolin DF, Meunier SA, Pearlson GD, et al. 2008. Augmentation of behavior therapy
with D-cycloserine for obsessive-compulsive disorder. Am. J. Psychiatry 165:335–41
Wolpe I. 1958. Psychotherapy by Reciprocal Inhibition. Stanford, CA: Stanford Univ. Press
Woods AM, Bouton ME. 2006. D-cycloserine facilitates extinction but does not eliminate renewal of the
conditioned emotional response. Behav. Neurosci. 120:1159–62
Zeidan MA, Lebron-Milad K, Thompson-Hollands J, Im JJ, Dougherty DD, et al. 2011. Test-retest reliability
during fear acquisition and fear extinction in humans. CNS Neurosci. Ther. 18:313–17

CP09-FrontMatter ARI 9 March 2013 1:0
Annual Review of
Clinical Psychology
Volume 9, 2013
Contents
Evidence-Based Psychological Treatments: An Update

and a Way Forward
David H. Barlow, Jacqueline R. Bullis, Jonathan S. Comer,
and Amantia A. Ametaj p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1

Quitting Drugs: Quantitative and Qualitative Features
Gene M. Heyman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p29
Integrative Data Analysis in Clinical Psychology Research

Andrea M. Hussong, Patrick J. Curran, and Daniel J. Bauer p p p p p p p p p p p p p p p p p p p p p p p p p p p p61
Network Analysis: An Integrative Approach to the Structure
of Psychopathology
Denny Borsboom and Angélique O.J. Cramer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p91
Principles Underlying the Use of Multiple Informants’ Reports
Andres De Los Reyes, Sarah A. Thomas, Kimberly L. Goodman,
and Shannon M.A. Kundey p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 123
Ambulatory Assessment
Timothy J. Trull and Ulrich Ebner-Priemer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 151
Endophenotypes in Psychopathology Research: Where Do We Stand?
Gregory A. Miller and Brigitte Rockstroh p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 177
Fear Extinction and Relapse: State of the Art
Bram Vervliet, Michelle G. Craske, and Dirk Hermans p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 215
Social Anxiety and Social Anxiety Disorder
Amanda S. Morrison and Richard G. Heimberg p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 249
Worry and Generalized Anxiety Disorder: A Review and
Theoretical Synthesis of Evidence on Nature, Etiology,
Mechanisms, and Treatment
Michelle G. Newman, Sandra J. Llera, Thane M. Erickson, Amy Przeworski,
and Louis G. Castonguay p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 275
Dissociative Disorders in DSM-5
David Spiegel, Roberto Lewis-Fernández, Ruth Lanius, Eric Vermetten,
Daphne Simeon, and Matthew Friedman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 299
viii
Depression and Cardiovascular Disorders

Mary A. Whooley and Jonathan M. Wong p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 327
Interpersonal Processes in Depression
Jennifer L. Hames, Christopher R. Hagan, and Thomas E. Joiner p p p p p p p p p p p p p p p p p p p p p 355
Postpartum Depression: Current Status and Future Directions
Michael W. O’Hara and Jennifer E. McCabe p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 379
Emotion Deficits in People with Schizophrenia
Ann M. Kring and Ori Elis p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 409
Cognitive Interventions Targeting Brain Plasticity in the Prodromal
and Early Phases of Schizophrenia
Melissa Fisher, Rachel Loewy, Kate Hardy, Danielle Schlosser,

and Sophia Vinogradov p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 435
Psychosocial Treatments for Schizophrenia
Kim T. Mueser, Frances Deavers, David L. Penn, and Jeffrey E. Cassisi p p p p p p p p p p p p p p 465
Stability and Change in Personality Disorders

Leslie C. Morey and Christopher J. Hopwood p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 499
The Relationship Between Personality Disorders and Axis I
Psychopathology: Deconstructing Comorbidity
Paul S. Links and Rahel Eynan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 529
Revisiting the Relationship Between Autism and Schizophrenia:
Toward an Integrated Neurobiology
Nina de Lacy and Bryan H. King p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 555
The Genetics of Eating Disorders
Sara E. Trace, Jessica H. Baker, Eva Peñas-Lledó, and Cynthia M. Bulik p p p p p p p p p p p p p 589
Neuroimaging and Other Biomarkers for Alzheimer’s Disease:
The Changing Landscape of Early Detection
Shannon L. Risacher and Andrew J. Saykin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 621
How Can We Use Our Knowledge of Alcohol-Tobacco Interactions
to Reduce Alcohol Use?
Sherry A. McKee and Andrea H. Weinberger p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 649
Interventions for Tobacco Smoking
Tanya R. Schlam and Timothy B. Baker p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 675
Neurotoxic Effects of Alcohol in Adolescence
Joanna Jacobus and Susan F. Tapert p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 703
Socioeconomic Status and Health: Mediating and Moderating Factors
Edith Chen and Gregory E. Miller p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 723
Contents ix
School Bullying: Development and Some Important Challenges

Dan Olweus p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 751
The Manufacture of Recovery
Joel Tupper Braslow p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 781
Indexes
Cumulative Index of Contributing Authors, Volumes 1–9 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 811

Cumulative Index of Articles Titles, Volumes 1–9 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 815
Errata
An online log of corrections to Annual Review of Clinical Psychology articles may be

found at http://clinpsy.annualreviews.org
x Contents
View publication stats

Vervliet Craske Hermans 2013

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Vervliet Craske Hermans 2013

Uploaded by

Copyright:

Available Formats

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

Fear Extinction and Relapse: State of the Art

Article in Annual Review of Clinical Psychology · March 2013

The user has requested enhancement of the downloaded file.

• Top downloaded articles

Annu. Rev. Clin. Psychol. 2013. 9:215–48 Keywords

AND EXTINCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

THE DEVELOPMENT OF THE RETRIEVAL MODEL

216 Vervliet · Craske · Hermans

Extinction of de Extinction of de Clinical trials of

www.annualreviews.org • Fear Extinction and Relapse 217

TRANSLATING RESEARCH FINDINGS FROM THE LABORATORY TO THE

218 Vervliet · Craske · Hermans

This very return of fear is the primary target of this review.

RETURN OF FEAR IN CLINICAL PRACTICE

www.annualreviews.org • Fear Extinction and Relapse 219

RETURN OF FEAR IN CLINICAL ANALOGUE STUDIES:

Extinguished Fears Can Return with a Change of External Context

Extinguished Fears Can Return with a Change of Internal State

220 Vervliet · Craske · Hermans

a Contextual renewal of extinguished fears

b Spontaneous recovery of extinguished fears

Fear conditioning Fear extinction Fear test

Trials Trials Immediate Delayed

c Reinstatement of extinguished fears

RETURN OF FEAR IN THE LABORATORY

www.annualreviews.org • Fear Extinction and Relapse 221

THE LEARNING THEORY PERSPECTIVE ON FEAR CONDITIONING

222 Vervliet · Craske · Hermans

ANXIOUS INDIVIDUALS SHOW DEVIANT PATTERNS OF FEAR CONDITIONING

Deviant Fear Conditioning in Anxious Individuals

www.annualreviews.org • Fear Extinction and Relapse 223

THE DEVELOPMENT OF THE RETRIEVAL MODEL

What We Learned from Reinstatement Studies

224 Vervliet · Craske · Hermans

Reinstatement depends on a context-CS association. Various learning models hypothesize

produce fear of the CS (mediated conditioning). This explanation of reinstatement emphasizes

What We Learned from Renewal Studies

www.annualreviews.org • Fear Extinction and Relapse 225

The Retrieval Model of Extinction and Return of Fear

226 Vervliet · Craske · Hermans

CS US Memory after conditioning

CS US Memory after extinction

The Neurological Model of Extinction and Return of Fear

www.annualreviews.org • Fear Extinction and Relapse 227

Multiple Pathways to Return of Fear?

PRECLINICAL HUMAN STUDIES

228 Vervliet · Craske · Hermans

Reinstatement in Human Fear Conditioning

www.annualreviews.org • Fear Extinction and Relapse 229

Reinstatement is larger to negatively valenced stimuli. Human participants typically evaluate

extinction performance (unextinguished negative valence).

Reinstatement can be triggered by other aversive stimuli. Most studies on reinstatement

230 Vervliet · Craske · Hermans

Reinstatement in preclinical human research: Conclusion. Human studies on fear reinstate-

Renewal in Human Fear Conditioning

www.annualreviews.org • Fear Extinction and Relapse 231

232 Vervliet · Craske · Hermans

www.annualreviews.org • Fear Extinction and Relapse 233

Spontaneous Recovery in Human Fear Conditioning

234 Vervliet · Craske · Hermans

ROADS TO RELAPSE PREVENTION

Preventing Relapse by Strengthening the Extinction Memory