Chapter 5 – Experimental fear 183 followed reported fear were observed, on this smaller scale of responses most differences did not reach statistical significance. This is an apparent study limitation that should be addressed in future designs. Another study limitation may have been the effectivity of the threatmanipulation. As mentioned earlier, participants in the High-threat group believed and were more frightened by the mock skin sensitivity test, compared to the Control group. However, this fear did not translate to increased fear during conditioning. It is possible that induced fear levels were not high or specific enough to translate into experienced fear during nocebo trials. However, it was not possible to increase threat levels without risking participants dropping out of the study or it seeming illogical for the researcher to continue the experiment. This is a common obstacle in experimental threat manipulations 22,30. As noted, however, the threat manipulation may not have increased fear reports due to its anticipatory and obscure nature, rather than a manipulation failure, while it is also plausible that pain may have captured participants’ attention and diverted it away from the potentiality of a threat. Finally, it is important for future studies to address whether clinically relevant extinction effects are affected by fear. For instance, reinstatement of conditioned responses (after experience with unpredictable increased pain) to the conditioned stimulus has been observed in previous studies 67–70. Reinstatement translates to clinical practice where patients may be re-exposed to exacerbated pain, even after successful treatment 70. Similarly, patients may retrieve a previously extinguished effect, upon exposure to an aversive stimulus distinct from pain, such as fear 71. Based on the results of this study, it is important to further examine whether high pain can also impact the return of learned effects on pain. It is worth noting that controlling for unwanted variability due to age differences in our sample, the generalizability of our findings to the general population is limited. Future studies may consider including broader age ranges.
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