142 could have been confusing to participants. In future research, nocebo suggestions can be optimized by comparing different cover stories and instructions, as these are crucial for influencing expectations. A common limitation in the learning process of extinction is the return of the conditioned response, such as fear, following the passing of time 45. The current study did not examine this effect, which is thought to result from competing learned effects and deficits in inhibitory learning and more specifically deficits in the neural regulation needed during extinction 45. Future counterconditioning experiments could shed light on whether – and under which conditions– such a reinstatement could take place following counterconditioning. Further research into the effectivity and durability of counterconditioning is necessary to establish whether this method can provide a basis for clinical interventions targeting nocebo effects. Lastly, controlling for variables in our sample such as caffeine intake and age range, or limiting our sample to higher education students may have created potential confounding variables. In future studies, it would be important to allow for more variance in the participant sample and to collect and check data related to variables such as caffeine intake, age, and education. Overall, future studies should collect and analyze manipulation check data to see whether and how different variables can influence study outcomes. The present study implemented a complete, clinically relevant model of nocebo hyperalgesia, from acquisition to attenuation. The findings reproduced prior evidence of ambiguous and variable learning being sufficient to induce nocebo hyperalgesia, and that this type of induction method may be more resistant to treatments. This study also provided evidence that counterconditioning is a powerful method for the attenuation of nocebo hyperalgesia. Counterconditioning, however, may be less potent in attenuating effects that have been induced by more ambiguous learning and should therefore undergo further assessment within ecologically valid experimental models.
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