138 Discussion The current study compared distinct and novel methods for the induction and attenuation of nocebo hyperalgesia. We demonstrated that partial reinforcement conditioning was sufficient to induce nocebo hyperalgesia, as was continuous reinforcement conditioning. Furthermore, we showed that counterconditioning is a more potent method than extinction for the attenuation of nocebo hyperalgesia. Interestingly, our results also showed that, despite pain ratings remaining consistently higher in the partial reinforcement group compared to the continuous reinforcement group during extinction, this difference did not reach significance and resistance to extinction after conditioning with partial reinforcement was not observed. Importantly, we found that while counterconditioning was sufficient to attenuate nocebo responses irrespective of induction method, nocebo hyperalgesia was significantly more resistant to counterconditioning when induced via partial, as compared to continuous reinforcement. These findings have a number of implications related to experimental models and clinical practice. The finding that conditioning with partial reinforcement is, albeit less potent than continuous reinforcement, sufficient to induce nocebo hyperalgesia, is in line with previous research by Colagiuri and colleagues 15. Reproducing these results and reaffirming the potency of the more ambiguous partial learning method has important theoretical and clinical implications. Conditioning with learning schedules that provide more variable contingencies bears a closer resemblance to what nocebo theories postulate regarding the ambiguity of learning and negative suggestions in clinical contexts 4,15. Employing a more ecologically valid paradigm can have a crucial impact on our understanding of how and why nocebo hyperalgesia may present in pain patients.
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