268 Facilitatory mechanisms are able to amplify the pain experience 39 through a long-range integrative process involving specific aspects of learning that encode and consolidate beliefs and expectations about previously experienced stimuli. Yet, different forms of biobehavioral modulation can influence pain via distinct systems 40 and many variables related to cognitive and emotional factors may further influence nocebo effects. It is noteworthy that in our nocebo meta-analysis presented in chapter 2, the studies examined did not generally report exact measures of certain key learning characteristics. For example, measures of baseline learning ability in distinct domains, such as the verbal or visual learning measures we obtained in chapter 7, can be helpful in pinpointing subprocesses of learning that are crucial for nocebo responding. Accordingly, direct physiological and behavioral measures of fear, when measured across studies, may hold the potential of better explaining under which conditions learned nocebo responses are augmented. While experimental studies most often measure anxiety levels, in chapter 3 we showed that anxiety cannot reliably be shown to impact nocebo responses, as measured neurochemically and via imaging techniques. It is thus possible that, in accordance with our results in chapters 5, 6, and 7, integrative cognitive learning mechanisms function in collaboration with affective learning, despite these latter emotional factors being somewhat neglected in nocebo studies. More precise measures of learning and memory could indeed show a moderating effect on nocebo magnitudes and help explain these effects across the nocebo literature – an important objective for future research. A potential cooperation of cognitive and fear-specific learning mechanisms Fear seems to play a significant role in nocebo hyperalgesia, and our work has added to the understanding of how affective learning may
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