Exposure Therapy and Counterconditioning Equally Effective for Pain-Related Fear

Counterconditioning vs Extinction

For the study (N = 50), Dr. Meulders and colleagues used a Voluntary Joystick Movement Paradigm, in which fear of movement was acquired by associating 2 of 4 joystick movements with a painful electrocutaneous stimulus.

Among participants randomized to the extinction method of fear reduction, one conditioned response was extinguished, but another was still followed by pain. In the counterconditioning group, one conditioned response was extinguished and followed by a monetary reward, while the other was followed by both pain and reward.

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“Results showed that counterconditioning effectively reduces pain-related fear, but does not produce deeper or stronger fear reduction than extinction. Adding a reward to a painful movement did [not] attenuate fear or the intensity and unpleasantness of the pain itself. Both procedures changed stimulus valence,” Dr. Meulders said.

Targeting Affective Valence May Boost Results

According to Dr. Meulders, the next step is to explore whether exposure therapy and counterconditioning differ in terms of residual negative affective valence, described as the lingering unpleasant feeling patients may have about a movement, even though they no longer avoid it from fear of bodily harm.

Accordingly, the researchers are designing a follow-up study that includes a return-of-fear phase.

“After the fear-reduction phase, half of participants in both groups will receive two unsignaled pain electrocutaneous stimulus not preceded by the painful joystick movements; the other half will not receive painful stimuli. We then will test whether fear of movement-related fear returns more in extinction group than in the counterconditioning group,” Dr. Meulders said.

“The idea is that lingering negative valence might be a pathway to relapse,” Dr. Meulders explained. “We think that changing the affective valence of feared movements might improve fear reduction and may prevent relapse.”

The study was supported by grants from the Research Foundation-Flanders, Belgium; an EFIC-Grünenthal Research Grant, and a Veni Grant provided by the Netherlands Organization for Scientific Research. The authors report no conflict of interest.


Meulders A, Karsdorp, PA, Claes, N, Vlaeyen WS. Comparing counterconditioning and extinction as methods to the reduce fear of movement-related pain.  J Pain. 2015 Oct 1. pii: S1526-5900(15)00880-9. doi: 10.1016/j.jpain.2015.09.007.