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CHAPTER 1 12 (CR), because the patient with panic disorder expects that this predicts fainting (US). Similarly, touching a doorknob (CS) evokes distress (CR) in the patient with OCD, because it activates the representation of infection and illness (US). Exposure therapy derives its positive effects from extinction, which is the decrease in fear response (i.e., CR) to the CS, due to repeated presentations of the CS without the occurrence of the associated US (Vervliet, Craske, & Hermans, 2013). Much evidence suggests that extinction does not entail unlearning of the CS – US association, but involves new learning of an inhibitory association between the CS and the US (i.e., a CS - no US association; Bouton, 2002, 2004, 2016; Craske et al., 2014). After extinction, this inhibitory association exists alongside the original excitatory association (Bouton, 2002, 2004, 2016), see Figure 1. Figure 1. Graphical depiction of the inhibitory learning model of extinction (Vervliet et al., 2013). The circle with CS indicates the conditional stimulus and the circle with US the unconditional stimulus. The arrow indicates an excitatory association, and the line with a bar at the end an inhibitory association. Before extinction, there is an excitatory CS – US association (top panel). The CS thus evokes fear. After extinction, there is an excitatory CS – US association and an inhibitory CS – no US association (bottom panel). When the inhibitory association is active, the CS does not evoke fear. US CS Before extinction After extinction CS US