ArticleLiterature Review

Why Behavior Change is Difficult to Sustain

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Abstract

Unhealthy behavior is responsible for much human disease, and a common goal of contemporary preventive medicine is therefore to encourage behavior change. However, while behavior change often seems easy in the short run, it can be difficult to sustain. This article provides a selective review of research from the basic learning and behavior laboratory that provides some insight into why. The research suggests that methods used to create behavior change (including extinction, counterconditioning, punishment, reinforcement of alternative behavior, and abstinence reinforcement) tend to inhibit, rather than erase, the original behavior. Importantly, the inhibition, and thus behavior change more generally, is often specific to the "context" in which it is learned. In support of this view, the article discusses a number of lapse and relapse phenomena that occur after behavior has been changed (renewal, spontaneous recovery, reinstatement, rapid reacquisition, and resurgence). The findings suggest that changing a behavior can be an inherently unstable and unsteady process; frequent lapses and relapse should be expected to occur. In the long run, behavior-change therapies might benefit from paying attention to the context in which behavior change occurs.

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... Extinction learning reduces excessive food cue reactivity and unhealthy eating, but the reduction or extinction of food cue reactivity does not erase its original learning; it is not simply the unlearning, forgetting, replacement, or erasing of previously learned associations between cues and unhealthy eating (Bouton, 2014). Memories of previously learned associations last forever, it is important that they become less powerful and are not activated first. ...
... Inhibitory learning implies that the old and extant associations are quite easy to reactivate and thus remain a weakness for a long time to come. Spontaneous recovery, renewal, reinstatement, and rapid reacquisition after extinction demonstrate that a relapse can happen quickly (Bouton, 2014). With the passing of time after extinction, the original responding to the cue (food cue reactivity) can return which is called spontaneous recovery. ...
... Studies show that the newly learned inhibitory associations ("the cue predicts that I will not eat") are strongly context dependent (Bouton, 2014). So, if cravings extinguish during exposure sessions in a treatment room, there is a good chance that the food cravings will return when one is in the original unhealthy eating context, like home (renewal). ...
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Article
Adopting a healthier lifestyle includes replacing long-standing unhealthy eating habits with new healthier ones and maintaining these newly acquired healthy eating habits. A permanent behavior change appears to be difficult to maintain, which may follow from some basic learning processes. In the last decades, a lot was learned about the learning mechanisms that promote relapse into old behaviours. Taking these learning processes into consideration, a new exposure intervention was developed to combat several forms of unhealthy eating. Exposure is a powerful strategy to change behaviours and cognitions. This theoretical article briefly discusses some fundamental learning processes that may be involved in unhealthy eating habits and shows how the exposure intervention can be applied to promote healthier eating and long-term behavioral change at all ages.
... The process of behavior change is well-studied. Yet, sustained behavior change remains challenging to intervene effectively on (Bouton 2014). While behavior change is recognized by experts as being a complex process involving dynamic and stochastic factors that span the psychological, social and physical domains, popular misconceptions are that changing one's behavior requires no more than 'common sense' or a good marketing campaign, and that most people will rationally process relevant knowledge and information (Kelly and Barker 2016). ...
Chapter
The field of consumer health informatics (CHI) is constantly evolving. The literature that supports CHI includes a broad scope of expertise and disciplines, which makes discovering relevant literature a challenge. Through a library and information science lens, we provide foundational familiarity with the structures of information discovery systems and considerations that impact the discovery of CHI literature. We outline the steps included in the design and execution phases of a CHI-related literature search. We also provide an example search using wearable technologies and a case in point that illustrates how terminologies differ across databases. We describe the importance of operationalizing elements of a research question and strategically combining search terms in a query to enhance the findability of CHI literature. The reader will gain a database-agnostic understanding of the structures and factors relevant to the retrieval of CHI literature, which should be particularly useful as the field of CHI and the tools for retrieving literature continuously change.
... Nudging has been criticized for offering a limited platform on which long lasting and sustainable behavioral change may be based (Mols et al., 2015), but this is not unique for nudging interventions since behavioral change is, in general, difficult to sustain (Bouton, 2014). That nudging is a simple, less costly, and easy to administer intervention that can work in the short term might be enough in itself. ...
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Article
Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010–December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.
... An overview of evidence about the impact of interventions on positive parenting practices in the past 20 years revealed only small effect sizes, i.e., at 0.10 on average (Supplee & Duggan, 2019). More generally, previous research has also shown that it is difficult for people to change health-related behaviors (Kelly & Barker, 2016) and sustain behavior changes (Bouton, 2014), even though the importance of health is undeniable for most of people. Another potential explanation lies in the way ethnic-racial socialization was measured. ...
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Article
Emerging research from the United States indicates that people with an East Asian background experience COVID-19-related racial discrimination. There is some (although not consistent) evidence that these discrimination experiences can in turn have psychological and behavioral consequences, such as strengthening one’s ethnic identity and influencing parents’ ethnic-racial socialization practices. The current study presents a unique natural experiment examining self-reported perceived discrimination experiences, ethnic identity, and ethnic-racial socialization among 80 Chinese immigrant mothers in the Netherlands before and after the COVID-19 outbreak (39 mothers recruited before the start of the COVID-19 pandemic and 41 during). The main findings from our exploratory analyses indicated an impact of the pandemic with higher (subtle) discrimination and stronger ethnic identity among Chinese immigrant mothers living in the Netherlands, highlighting how personal experiences related to intergroup processes have changed as a result of the COVID-19 crisis in the European context.
... Evidence of the public health and economic benefits of physical activity is prompting governments around the world to develop policies to increase the population physical activity [11] . However, studies have shown that the changing of behaviour is a gradual process and each stage requires different set of supports [12] . According to studies conducted by the WHO in several states, public action to promote physical activity is further complicated by the need to address multiple determinants [13] . ...
... En los últimos años, varios autores han resaltado la importancia del condicionamiento instrumental en el establecimiento de conductas no deseadas como el abuso de sustancias, comer en exceso, entre otras (e.g., Bernal et al., 2014;Bouton 2014;Podlesnik & Kelley, 2015). Por lo tanto, se ha sugerido que la investigación de la extinción de conductas instrumentales puede esclarecerlos mecanismos que subyacen a dichas conductas (Boutonetal., 2012). ...
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Los esfuerzos por construir espacios escolares saludables, implica conexiones compasivas, respetuosas y amorosas frente a todos los conflictos que afectan a la comunidad estudiantil, todo aquello que fragmenta y daña debe ser analizado, desafiado y restaurado en el aula. Los programas que atienden la convivencia pacífica dentro de las instituciones educativa resultan buenos pero insuficientes para poder encarar el problema de la violencia en las escuelas en particular y en nuestras sociedades en general.
... Renewal may occur across a range of context changes that could be highly detectable or quite subtle to practitioners. The broad definition of context in the literature includes even modest features of the environment (e.g., lighting in a room, individuals and furniture present), which is indicative of the generality of renewal across various stimulus conditions (Bouton, 2014;Podlesnik et al., 2017). Examples from basic research of subtle "context" changes include visual (e.g., colored lights), olfactory (e.g., lemon scent vs. vanilla scent), and auditory cues, to name a few (Bouton et al., 2011;Craig et al., 2019;Podlesnik et al., 2017). ...
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Article
Individuals who engage in problem behavior receive treatment services in various settings, such as their homes, schools, and clinics. These individuals are also likely to experience treatment provision from various practitioners, such as therapists, teachers, and caregivers. Changes in the treatment setting or intervention agent (i.e., context) can cause renewal of problem behavior. Renewal is the form of relapse that occurs when a previously eliminated behavior returns due to a change in context. Practitioners should know six things about renewal to improve clinical practice: (1) generality of renewal; (2) potential for renewal even when alternative reinforcement is available; (3) similarity between renewal testing procedures and situations that practitioners commonly encounter; (4) close relationship between renewal and the generalization of behavior change; (5) distinction between renewal and another form of relapse (i.e., resurgence); and (6) potential mitigation strategies. Practitioners should prepare for renewal during context changes when working with their clients, especially during changes to the treatment setting or intervention agent.
... This is somewhat surprising since the treatment protocol places a strong emphasis on the identification of values and afterwards, valued behaviours were followed up and encouraged each session (valuable activity of the week). Nonetheless, it might be possible that this was still not sufficient to elicit behavioural change, which has proven to be complex (Bouton, 2014). Another explanation could be found in the instrument used for the measurement of valued behaviour, the VLQ. ...
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Article
Patients with acquired brain injury (ABI) often experience symptoms of anxiety and depression. Until now, evidence-based treatment is scarce. This study aimed to investigate the effectiveness of Acceptance and Commitment Therapy (ACT) for patients with ABI. To evaluate the effect of ACT for people with ABI, a non-concurrent multiple baseline design across four cases was used. Participants were randomly assigned to a baseline period, followed by treatment and then follow-up phases. Anxiety and depressive symptoms were repeatedly measured. During six measurement moments over a year, participants filled in questionnaires measuring anxiety, depression, stress, participation, quality of life, and ACT-related processes. Randomization tests and NAP scores were used to calculate the level of change across phases. Clinically significant change was defined with the Reliable Change Index. Three out of four participants showed medium to large decreases in anxiety and depressive symptoms (NAP = 0.85 till 0.99). Furthermore, participants showed improvements regarding stress, cognitive fusion, and quality of life. There were no improvements regarding psychological flexibility, value-driven behaviour, or social participation. This study shows that ACT is possibly an effective treatment option for people experiencing ABI-related anxiety and depression symptoms. Replication with single case or large scale group studies is needed to confirm these findings.
... This means that the improvement of hygiene practices in the dibiterie is not affected by the variable factors of production, such as materials and consumables for hygiene. Moreover, the training has significantly reduced the total bacterial load in phase 3 but not in phase 2. Therefore, the training did not significantly improve the overall hygiene and especially the personal hygiene at the phase 2 because it is very difficult to suddenly change traditional behaviours which are often very rooted in habits [8,29,30]. Indeed, phase 2 allowed the dibiteries to gain experience implementing the messages of the training intervention. This time was therefore not sufficient for the effective adoption of the messages and innovations promoted. ...
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Article
Background: Rapid urbanisation in Sub-Saharan African cities such as Dakar, Senegal, leads to proliferation of informal braised meat restaurants known as "dibiteries". Dibiteries do not often comply with minimal hygiene and food safety standards. The primary objective of this study was to assess the effectiveness and cost of a good hygiene practice intervention, identify factors that incentivize hygiene improvement and how that impacts on dibiteries' income. Methods: A randomized controlled trial was carried out in Dakar dibiteries. The 120 random samples of braised meat were collected in three phases: (i) one-month pre-intervention, (ii) 2 months post-intervention, (iii) 10 months post-intervention. The trial comprised four groups of 10 dibiteries each: (a) (control) received no intervention, (b) a standardized training module, (c) a hygiene kit, (d) a training module and hygiene kit. Laboratory analysis of samples determined the total aerobic mesophilic flora (TAMF), thermotolerant coliforms (TC) and Staphylococcus aureus (SA). A questionnaire-based survey and focus group discussion were used to identify pre-intervention hygiene practices, and socioeconomic determinants of hygiene management in dibiteries post-intervention, respectively. Results: Samples were found to be contaminated with TAMF, TC and SA. In phase 1, 27 and 13% of the samples contained TC and SA, respectively. In phase 2, no significant improvement of contamination rates was seen. In phase 3, microbiological quality of samples was significantly improved, with only 11.5% showing contamination with any of the bacterial species analysed (p < 0.1). Compared to the control group, only samples from dibiteries in group (b) had significantly reduced bacterial load in phase 3. The cost of intervention and hygiene improvement was estimated at 67 FCFA ($ 0.12) and 41 FCFA ($ 0.07) / day respectively and did not significantly impact on dibiterie profitability. Incentives to sustainably implement good hygiene practices were mainly linked to access to secure long-term workspaces. Conclusion: This intervention may have worked, but globally the results are mixed and not quite significant. However, continuous training in good hygiene practice and access to secure and sustainable infrastructure for dibiterie restaurants are the incentives necessary to achieve sustainable investments and behavioural change. We recommend further intervention refinement and testing other factors for promoting the adoption of good hygiene practices in the dibiteries in relation to consumers health risk.
... It is not only difficult to motivate a person to change daily habits but necessary to think about how to maintain the new habits and avoid a relapse. Bouton [16] explained that new behaviour is difficult to sustain because it does not automatically erase old behaviour (habits), and many factors or contexts could influence people to regress to old behaviours. Therefore, this present study suggests that a person needs self-motivation to sustain the changed habits of daily life. ...
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Article
Background The proportion of the older Thai population is increasing rapidly. Lifestyle may impact active ageing in later life. Interventions that empower older Thai adults to initiate and carry out lifestyle changes are needed. This study applied the Plan-Do-Study-Act (PDSA) cycle, a tool for improving lifestyle changes, with the aim of exploring interactions among older Thai adults when participating in group activities. Method Focused ethnography was used based on participant observations, field notes and video recordings of 15 older Thai adults aged 62–78 years. Results Older Thai adults faced difficulties at the beginning since they were unfamiliar with initiating and carrying out lifestyle changes according to the PDSA concept. This provided a learning opportunity enabling older Thai adults to reach their individual goals of lifestyle change. Conclusions The PDSA cycle has the potential to empower older adults in group contexts to promote lifestyle changes related to active ageing.
... Changing behaviour can prevent or relieve health conditions, but change in the long-term tends to be difficult (Bouton, 2014). As stated previously, health coaching applications with ECAs can support users in this process. ...
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Article
Introduction Embodied Conversational Agents (ECAs) can be included in health coaching applications as virtual coaches. The engagement with these virtual coaches could be improved by presenting users with tailored coaching dialogues. In this article, we investigate if the suggestion of an automatically tailored topic by an ECA leads to higher engagement by the user and thus longer sessions of interaction. Methods A Micro-Randomized Trial (MRT) was conducted in which two types of interaction with an ECA were compared: (a) the coach suggests a relevant topic to discuss, and (b) the coach asks the user to select a topic from a set of options. Every time the user would interact with the ECA, one of those conditions would be randomly selected. Participants interacted in their daily life with the ECA that was part of a multi-agent health coaching application for 4–8 weeks. Results In two rounds, 82 participants interacted with the micro-randomized coach a total of 1011 times. Interactions in which the coach took the initiative were found to be of equal length as interactions in which the user was allowed to choose the topic, and the acceptance of topic suggestions was high (71.1% overall, 75.8% for coaching topics). Conclusion Tailoring coaching conversations with ECAs by letting the coach automatically suggest a topic that is tailored to the user is perceived as a natural variation in the flow of interaction. Future research could focus on improving the novel coaching engine component that supports the topic selection process for these suggestions or on investigating how the amount of initiative and coaching approach by the ECA could be tailored.
... friends, family, spouse), and the abundance of unhealthy food advertisements shown in the media (Mazzola et al., 2019;Shahsanai et al., 2019). Given the barriers to and difficulty of changing eating behaviours (Bouton, 2014), people are often drawn to "quick fixes" to lose weight (Thomas et al., 2008). ...
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Article
Background: A fad diet is a broad term used to describe dieting methods that recommend altering the intake of macronutrients to specific proportions or instruct people to intake or avoid particular foods, often with the goal of rapid weight loss. Previous literature reviews report social influence impacts general diet behaviour, but have yet to examine fad diets, specifically. Therefore, the purpose of this systematic review was to synthesize literature related to social influence on an individual's fad diet use and understand the sociocultural factors related to diet use. Methods: Using PRISMA guidelines, Medline, PsycInfo, Embase, CINAHL, and CENTRAL databases were searched to identify articles investigating the impact of social on fad diet use. Covidence was used to manage the review process and Garrard's Matrix Method was used to extract data from reviewed articles (n = 13). Results: A majority of reviewed studies examined interpersonal influence (62%) and reported social influence impacting a variety of fad diet behaviours (92%). Interpersonal and media influence were highlighted as motivating factors for adopting unhealthy dieting methods (54%), and studies showed interpersonal support impacted adoption and maintenance of fad diet use (23%). Also, social norms were reported to influence unhealthy weight control behaviours (15%). Discussion: This review revealed social influence is associated with the adoption, adherence, and termination of fad diets. The prevalence of fad diets in society and the lack of research on this topic warrants further examination of factors related to fad diets use and the spread among interpersonal networks.
... Harting et al. (2006), for example, reported a waning in the decrease of fat intake at 18 months compared to 4 months. Recurrence of unhealthy behaviours should be anticipated in lifestyle interventions, since the patterns are not forgotten, but rather inhibited (Bouton, 2014). A healthy lifestyle is not an end-point you achieve, but a process with ups and downs, requiring continuous efforts. ...
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Article
This study aimed to systematically review the use of clinical prediction models (CPMs) in personalised lifestyle interventions for the prevention of cardiovascular disease. We searched PubMed and PsycInfo for articles describing relevant studies published up to August 1, 2021. These were supplemented with items retrieved via screening references of citations and cited by references. In total, 32 studies were included. Nineteen different CPMs were used to guide the intervention. Most frequently, a version of the Framingham risk score was used. The CPM was used to inform the intensity of the intervention in five studies (16%), and the intervention’s type in 31 studies (97%). The CPM was supplemented with relative risk estimates for additional risk factors in three studies (9%), and relative risk estimates for intervention effects in four (13%). In addition to the estimated risk, the personalisation was determined using criteria based on univariable risk factors in 18 studies (56%), a lifestyle score in three (9%), and a physical examination index in one (3%). We noted insufficient detail in reporting regarding the CPM’s use in 20 studies (63%). In 15 studies (47%), the primary outcome was a CPM estimate. A statistically significant effect favouring the intervention to the comparator arm was reported in four out of eight analyses (50%), and a statistically significant improvement compared to baseline in five out of seven analyses (71%). Due to the design of the included studies, the effect of the use of CPMs is still unclear. Therefore, we see a need for future research.
... Indeed, the benefits of behavioural changes are complex, dynamic and could be cumulative. 42,43 These findings provide us with a better understanding that accurate information and education about perceived benefits are necessary to promote active responses among survivors of stroke and facilitate healthy behaviours. 7 Accurate information about warning signs, onset of symptoms and other disease-related information should be provided, and proper education to raise awareness of the benefits of healthy behaviours to prevent stroke recurrence may be more appealing and acceptable to stroke survivors with multiple recurrences. ...
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Article
Aims: To understand how survivors of stroke perceive secondary prevention and explore their perceived barriers and facilitators using the Theoretical Domains Framework. Design: A qualitative descriptive study. Methods: Nineteen survivors of stroke from three hospitals were recruited and interviewed from April 2019 to April 2020. The data were analysed deductively and inductively by content analysis strategies. Results: Three main themes of perception of secondary prevention were identified, these being active treatment-seeking, attention to taking medications and negative attitude towards lifestyle changes. Using deductive analysis, eight domains of the Theoretical Domains Framework were reported to be relevant in the secondary prevention behaviour of survivors of stroke that mapped to five 'barrier' domains (i.e. knowledge, physical skills, beliefs about capability, beliefs about consequences and optimism) as well as six 'facilitator' domains (i.e. knowledge, interpersonal skills, beliefs about capability, intention, emotion and social influences). Using inductive analysis we identified two additional important factors not falling in the domains of the Theoretical Domains Framework. These comprised female spouses' support and patients' economic autonomy, both of which could be classified as a facilitator or barrier. Conclusion: Survivors of stroke perceive seeking treatment and using preventive medication as more important than modifying lifestyle behaviours. Knowledge and insight into the barriers and facilitators of secondary prevention in this specific context provides a theoretical and practical basis for the design of future secondary prevention interventions. Impact: Stroke survivors' perceptions of secondary prevention, barriers and facilitators were explored in the context of a developing country. These findings highlight the need to better communicate the importance of improving lifestyle modification and medication adherence, and provide evidence for designing relevant interventions for stroke management in the community.
... People with diabetes are typically advised to engage in several self-management behaviors to improve their health outcomes, including healthy dieting and exercise-this is known to require personalized educational material and multitudes of data on suitable foods and types of exercise. Yet, sustained, long-term behavior change remains challenging [11]. A possible solution involves using agile development to quickly prototype mobile apps, with the direct involvement of patient end-users, to design a mobile app that is personalized to their requirements and needs. ...
Chapter
Modern smartphones offer advanced sensing, connectivity, and processing capabilities for data acquisition, processing, and generation: but it can be difficult and costly to develop mobile research apps that leverage these features. Nevertheless, in life sciences and other scientific domains, there often exists a need to develop advanced mobile apps that go beyond simple questionnaires: ranging from sensor data collection and processing to self-management tools for chronic patients in healthcare. We present Punya, an open source, web-based platform based on MIT App Inventor that simplifies building Linked Data-enabled, advanced mobile apps that exploit smartphone capabilities. We posit that its integration with Linked Data facilitates the development of complex application and business rules, communication with heterogeneous online services, and interaction with the Internet of Things (IoT) data sources using the smartphone hardware. To that end, Punya includes an embedded semantic rule engine, integration with GraphQL and SPARQL to access remote graph data, and support for IoT devices using Bluetooth Low Energy and Linked Data Platform Constrained Application Protocol (LDP-CoAP). Moreover, Punya supports generating Linked Data descriptions of collected data. The platform includes built-in tutorials to quickly build apps using these different technologies. In this paper, we present a short discussion of the Punya platform, its current adoption that includes over 500 active users as well as the larger app-building MIT App Inventor community of which it is a part, and future development directions that would greatly benefit Semantic Web and Linked Data application developers as well as researchers who leverage Linked Open Data resources for their research.
... While adapting to such healthy behaviors can help prevent the onset of many diseases [16], behavior changes are challenging to sustain long-term [17]. It has been shown that breathing training apps have very low long-term adherence, even though the number of installations is high [18]. ...
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Article
Background: Slow-paced breathing has been shown to be positively associated with psychological and physiological health. In practice, however, there is little long-term engagement with breathing training, as shown by the usage statistics of breathing training apps. New research suggests that gameful smartphone-delivered breathing training may address this challenge. Objective: This study assesses the impact of breathing training, guided by a gameful visualization, on perceived experiential and instrumental values and the intention to engage in such training. Methods: A between-subject online experiment with 170 participants was conducted, and one-way multiple analysis of variance and two-tailed t test analyses were used to test for any difference in intrinsic experiential value, perceived effectiveness, and the intention to engage in either a breathing training with a gameful or a nongameful guidance visualization. Moreover, prior experience in gaming and meditation practices were assessed as moderator variables for a preliminary analysis. Results: The intrinsic experiential value for the gameful visualization was found to be significantly higher compared to the nongameful visualization (P=.001), but there was no difference in either perceived effectiveness (P=.50) or the intention to engage (P=.44). The preliminary analysis of the influence of meditation and gaming experience on the outcomes indicates that people with more meditation experience yielded higher intrinsic experiential values from using the gameful visualization than people with no or little meditation experience (P=.03). This analysis did not find any additional evidence of gaming time or meditation experience impacting the outcomes. Conclusions: The gameful visualization was found to increase the intrinsic experiential value of the breathing training without decreasing the perceived effectiveness. However, there were no differences in intentions to engage in both breathing training conditions. Furthermore, gaming and meditation experiences seem to have no or only a small positive moderating effect on the relationship between the gameful visualization and the intrinsic experiential value. Future longitudinal field studies are required to assess the impact of gameful breathing training on actual behavior, that is, long-term engagement and outcomes.
Article
Background: There is increasing interest in the potential role of eHealth interventions to support self-management in people with musculoskeletal disorders (MSDs). The COVID-19 pandemic appears to have been a significant catalyst for the implementation of eHealth modalities into routine practice, providing a unique opportunity for real-world evaluation of this underutilized method of delivering physiotherapy. Objective: To explore the perceptions of eHealth-mediated supported self-management from the perspective of people with MSDs and physiotherapists who work in this clinical area. Methods: A qualitative interpretive descriptive approach was used. Semi-structured telephone interviews with 13 musculoskeletal physiotherapists and 13 people with musculoskeletal disorders were undertaken. Transcripts were analyzed using reflexive thematic analysis. Results: Three main themes were identified: 1) Flexibility within a blended care model; 2) eHealth as a facilitator of self-management support; and 3) Technology: Getting it right. Participants expressed concerns about assessment and diagnosis, establishing a therapeutic relationship and felt eHealth should be reserved for follow-up purposes. There was a consistent view expressed that eHealth could facilitate aspects of self-management support. A lack of resources and suboptimal user experience remains a challenge. Conclusions: eHealth-mediated self-management support interventions were broadly acceptably, predominately as a follow-up option.
Chapter
Despite recent advances in digital health solutions and machine learning, personal health applications that aim to modify health behaviors are still limited in their ability to offer more personalized decision support. Moreover, while many personal health applications cater to general health and well-being, there remains a significant opportunity to increase the clinical relevance of the insights being generated. This chapter describes the motivation for, and illustrative applications of, semantic technologies for enabling clinically relevant personal health applications. We present two use cases that demonstrate how semantic web technologies, in combination with machine learning and data mining methods, can be used to provide personalized insights to support behaviors that are consistent with nutritional guidelines for people with diabetes.KeywordsSemantic webKnowledge graphsArtificial intelligencePersonal healthHealth behaviorDiabetes self-managementConsumer healthDecision support systems
Chapter
An overview of the automatisms that regulate perceptual-judgment processes indicate that it is best to distinguish between a spontaneous and a deliberate change. Deliberate or voluntary change mechanisms require deliberate processes and precise actions that lead to a new equilibrium. Voluntary behavior changes according to perspective. Voluntary change mechanisms are not properly incentivized. I will show how innovations systemically incentivizing voluntary behavior changes are more consistent and sustainable than so-called disruptive technological innovations. I believe that this answers the central question, that is, who has to pay for the costs to educate consumers and make them more choice-savvy. Creative solutions to reward virtuous behavior and new habits have started to surface in recent years. The mismatch between the intention of following a plan and the actual ability to carry it through requires mitigating strategies. Compared to others, proximity strategies have so far yielded the first successes.
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The purpose of this paper is to explore how social influence (SI), which is disaggregated into subjective norms (SN), social image (SIM), and social identity (SID), predicts perceived usefulness (PU), perceived pleasure (PP), and continuance intention (CI) toward sports and fitness applications. The underlying context is the socialization and gamification of exercise during the Covid-19 pandemic. Based on the theory of SI and the technology acceptance model, a theoretical framework was built where PU and PP mediate the influence of SI on CI, and proposed hypotheses were tested. The responses of 296 Keep users (a popular sports and fitness application in China) to a questionnaire survey were analyzed. SN and SIM were found to have significant positive effects on SID; SID has significant positive effects on PU and PP; both PU and PP have significant positive effects on the CI of users; SID and PU positively and significantly mediate the relationship between SN/SIM and CI; PU positively and significantly mediates the SID-CI relationship. However, the role of PP in mediating the influence of SI on CI is non-significant. This paper deepens the current understanding of the mechanisms that influence the relationship between SI and CI under the context of socialization and gamification services.
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Various studies demonstrated that extinction training taking place shortly after the activation of the acquired fear could weaken the conditioned fear. The procedure is called post-retrieval extinction (PRE). However, from the time it emerged, it has suffered from inconsistencies in the ability of researchers to replicate the seemingly established effects. Extant literature implies that conditioned fear might be differentially sensitive to the nature of conditioned stimuli (CS) used. The aim of the present study, therefore, is threefold. First, we aimed to replicate Schiller et al. (Nature, 463, 49–53. 2010) procedure in which the PRE had produced positive results with arbitrary CSs only. Also, we examined the PRE as a function of CS type (ecological-fear-relevant (images of spider and snake) vs. arbitrary (images of yellow and blue circles)). Finally, we aimed to investigate the long-term effects of the PRE (i.e., 24 h, 15 d, and 3 mo). The study consisted of acquisition, re-activation and extinction, and re-extinction phases. Dependent measure was the recovery of fear responses as indexed by the skin conductance responses (SCRs) and arousal ratings of the participants at the last trial of the extinction and the first trial of the re-extinction. All groups showed significant acquisition and extinction patterns, compared to the other two groups (i.e., 6 h after the activating CS and without an activating stimulus) only the group that undertook extinction trials 10 min after the activating CS showed a sustained extinction. Thus, our findings provided further evidence for the robustness of the PRE paradigm in preventing the recovery of extinguished fears behaviorally, both with ecological and arbitrary stimuli.
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Describes technological methods and tools for objective and quantitative assessment of quality of life (QoL) Appraises technology-enabled methods for incorporating QoL measurements in medicine Highlights the success factors for adoption and scaling of technology-enabled methods
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The present study investigates the effectiveness of a novel, consumer‐informed, family training for youth suicide prevention. Research suggests family members play a key role in reducing suicide risk for their children. However, family members often do not possess the necessary knowledge, confidence, and skills needed to intervene with a suicidal youth. Family members (N = 582) participated in the It's Time to Talk About It: Family Training for Youth Suicide Prevention (ITT‐FT) and completed pretest and posttest measures. Additionally, 158 family members completed a 6‐month follow‐up evaluation. Results indicated significant improvements in knowledge, effective attitudes, perceived behavioral control, social norms, and intentions immediately after the training. Knowledge and perceived behavioral control were sustained at follow‐up. Participants identifying as Hispanic/Latinx exhibited greater decreases in stigma related to help‐seeking. Those who had a family history of mental health treatment experienced a greater increase in social norms related to other families seeking help. Findings underline the importance of implementing a family‐focused program aimed at improving training outcomes such as knowledge, confidence, and intentions—key constructs associated with behavior change. Improvement in several domains following the training highlight the critical role family members can play in reducing youth suicide risk.
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Pain is experienced either due to a physical condition, where it represents associated with actual or potential tissue damage, or due to a psychological situation, implying mental suffering, mental torment. Acute pain lasts for a limited amount of time and is provoked by a specific cause, while chronic pain is a long-term condition that drastically decreases quality of life and may affect patients absent from any biological cause. Chronic pain can affect cognitive functions (e.g., reasoning ability, attention, working memory), mood, sleep quality, sexual functions, and overall mental health. Generally, chronic pain therapy requires a multidisciplinary and complex approach. This chapter proposes a system called iSenseYourPain that continuously assesses chronic pain by leveraging ubiquitous sensor-based behavior assessment techniques. Based on findings from previous research and focusing on qualitative and quantitative assessment of patients’ behavior over time, the iSenseYourPain system is designed to automatically collect data from ubiquitous and everyday smart devices and identify pain-based behavior changes (e.g., changes in sleep duration and social interactions). It facilitates the providing of immediate assistance for pain and discomfort reduction by informing relatives and medical staff of the likelihood of potentially critical health situations. The overall goal of the iSenseYourPain system is to identify pain-related behavior changes in an accurate and timely manner in order to support patients and physicians, allowing the latter to have constant and accurate data on the patient’s condition.
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Similar to the concept of general well-being for individuals and societies, researchers have proposed various approaches to the concepts of personal beliefs and quality of life (QoL). In this chapter, QoL is discussed from an individual, subjective, cognitive and behavioral perspective with a focus on personal beliefs. More specifically, we present stress management as an endeavor in which yoga and personal beliefs can be applied to improve QoL. Stress management is recognized as a major health factor influencing an individual’s QoL. Empowered behavior to manage stress is discussed using a four-step model (involving thoughts, beliefs, emotions and behavior), that describes how human behavior is shaped by habits formed through individual experiences that unconsciously influence one’s thoughts, belief systems and emotions. Interventions such as yoga and meditation lead practitioners to question and alter thoughts in ways that can lead to improvements in QoL. Studies have indicated that when yoga and meditation are practiced regularly, the body implements stress-reducing processes automatically and unconsciously when a stressful situation arises. Therefore, this chapter contributes to the literature by demonstrating how yoga and meditation intervene in the mechanisms by which thoughts, beliefs and feelings shape behavior, as have been detailed in recent studies. In addition to the implementation of yoga and meditation, the possible use of technology and other tools for the quantitative assessment of states as a means of facilitating self-empowered behavior is discussed.
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In the WHO definition of Quality of Life, the environmental domain includes a subdomain called Opportunities for acquiring new information and skills . The information landscape has drastically changed over the past three decades, and now offers opportunities for acquiring information to almost everybody at any time, as the more recent technologies penetrated worldwide. It is thus worth evaluating if and how this change is reflected into the specific subdomain at stake and into the way it is measured. Before and while the information revolution was happening, the subdomain has been classically measured by giving as much attention to the accessibility of information as to the capability of acquiring it . We argue that these two components do not have the same weight nowadays, and that measurements should reflect this conceptual consideration. The more accessible information is indeed also often becoming overwhelming, and it is calling for an improved ability to appraise it. Technologies can help not just measuring the capability to appraise this information, but first and foremost they could build on individually acquired data to make the information more tailored to the user. This is done in other domains than health, and specifically in the marketing field, which has been already an inspiration for the health communication field and could contribute to advancements in the health behavioral domain. Therefore, after discussing how the concept of health literacy could inform the conceptual refinement of the subdomain at stake, this chapter will focus on how personal Internet-enabled technologies could contribute to its measurement in real-time, helping healthcare institutions and policy-makers to make health information more tailored and more accessible to the users.
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Daily behaviors influence an individual’s health and, in turn, all the domains of their quality of life (QoL). Accurately quantifying these behaviors may allow individuals to improve their overall awareness of these behaviors, make necessary habit changes, and receive more individualized treatment approaches. Currently, self-reported patient-reported outcomes (PROs) are the most common means of assessing daily behaviors. However, this method has multiple limitations, including the infrequency of collection, its subjective nature, its reliance on memory recall, and the influence of social norms. In comparison with PROs, using personalized and miniaturized technological innovations, including smartphones, mobile applications, and wearables, can enable the continuous assessment of daily life behaviors that contribute to or result from an individual’s QoL in a more accurate and timely manner. These technologies have the potential to transform the current state of quantifying QoL, allowing for improved research and the implementation of more individualized approaches to prevention and treatment. This chapter thus presents potential areas of future research and development opened by the use of these technologies in the field of QoL.
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Transportation has been recently recognized as a key element in the study of individual Quality of Life (QoL). However, relatively little is known about the interconnectedness between various transport dimensions and wellbeing measures. In scoping the existing literature, the chapter identifies studies reporting on a link between one of the seven transport indicators (mobility, affordability, accessibility, connectivity, externality, travel needs, and attitudes) and QoL. Based on the scoping review, a conceptual framework (TRAWEL) was deductively developed to understand wellbeing measures in five broader dimensions of transportation: transportation infrastructure, the built environment, and transport externalities at a societal level, travel and time use, and travel satisfaction at the individual level. Furthermore, the data requirements for accurate quantification and the possible study groups of interest are also discussed. The chapter concludes by summarizing the key points of the framework and by highlighting policy implications and areas for future research.
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Sleep is critical for a healthy, engaged and satisfying life. A large proportion of our lives is spent asleep, and a large proportion of our housing, resources, expenditure, and attention are dedicated to it. Good sleep strongly predicts better outcomes across a very broad range of life-long health, social, and industrial indices. Poor sleep has very significant and costly impacts upon physical and mental health (including metabolic health, depression, and anxiety), learning and education outcomes, and work-related outcomes (including stress, absenteeism, safety and performance). The social importance of good sleep can be seen in robust associations between sleep and loneliness, isolation, perceived social support, family and interpersonal relationships, and broader community participation and engagement. The availability and power of new sleep tracking devices mean that access and opportunity for satisfactory, satisfying, and sufficient sleep could be greatly increased. In this Chapter, we discuss the importance of sleep for quality of life and the limitations of existing monitoring technologies. We then introduce new tracking technologies and consider their benefits as well as potential pitfalls.
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Personal interactions are an important element of an individual’s health and life quality in the long term. As the site of many interpersonal interactions has been moved to the digital domain, human society has never been more intertwined. The digital footprints of interpersonal interactions can be quantified and measured via smartphones and wearables, providing more objective, quantitative, and accurate measurements. This chapter focuses on quantifying personal relationships in the context of quality of life, specifically focusing on novel technology-based quantification solutions. It first analyzes traditional qualitative quality of life measures based on subjective self-reporting that include measures of personal relationships, specifically the WHOQOL-BREF, WHOQOL-100, RAND-36, KIDSCREEN-27, SWLS, and Beach Center FQOL, as well as other non-validated measures. The chapter then proposes novel technological solutions for data gathering and analysis by introducing the concept of digital item representation, a process that leverages personal datasets originating from smartphones and wearables. The chapter also discusses issues relating to users’ privacy that influence the acceptance of such everyday technologies as well as the quality of data collected in the long term.
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Energy and fatigue carry important implications for vitality and overall quality of life. Lacking energy and experiencing fatigue can be both burdensome as well as adaptive. This chapter first classifies energy and fatigue and then reviews their measurement. This chapter closes with opportunities for future directions. Energy and fatigue are present under varying conditions including in daily performance, during and after acute physical or mental strain (capacity), and in the context of chronic conditions. Energy and fatigue have been measured both subjectively and objectively. Subjective outcomes can be derived from self-reported scales and prompts; objective outcomes may be derived from performance and capacity tasks and technology-reported physiological, biological, and behavioural markers. The scales and tasks employed to measure energy have been traditionally validated but may lack daily life context and ecological validity. Prompts and behavioural monitoring methods are emerging as promising alternatives. Energy and fatigue have also been routinely monitored for specific diseases and occupations. However, fewer studies monitor healthy individuals through consumer technology in daily life contexts. More research is needed for an objective, unobtrusive, longitudinal, and contextual measurement of energy and fatigue in the healthy general population, in service of improving health, wellbeing, and quality of life.
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This chapter provides an overview of the evidence linking mobility to quality of life (QoL). The findings showed that the operationalization of QoL varied across studies covering measures of physical or mental health, general health perception, life satisfaction, participation, illness intrusiveness, health-related QoL (HRQL) and global quality of life. These outcomes are sometimes single items or uni-dimensional constructs and sometimes profile measures, rendering the interpretation of findings in our context difficult. This complexity led to a revelation that one could think of QOL of the person differently from the QoL of the body. QoL of the person is best reflected through global QOL measures including those of life satisfaction whereas QoL of the body is reflected in outcomes related to aspects of function including physical, emotional, or psychological impairments, activity limitations and participation restrictions. This chapter will focus on the general construct of mobility, which is considered an activity limitation, and on the causes of limited mobility, impairments of structures and functions needed for mobility. A distinction is made between the between the person’s QoL and the body’s QoL. While the person’s QOL is best self-expressed, the body’s QOL could be monitored in real-time with the assistance of a growing portfolio of personal, wearable technologies. The chapter ends with thoughts about how QoL of the body, and especially mobility, could be monitored and what that future may look like.
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Sexual activity is an important facet of social functioning and quality of life (QoL) reflected in its inclusion in the World Health Organization’s generic, 26-item, quality of life instrument, the WHOQOL-BREF, in the item “how satisfied are you with your sex life?” Several instruments designed to assess sexual activity, function or QoL have been developed, varying in their scope, measurement properties, and applicability to certain populations. Evidence from literature reviews of instruments was synthesized to (a) identify generic self-administered instruments, which have been developed for research or clinical practice in adults and (b) to investigate their scope, psychometric properties, and applicability. We then considered these methods together with emerging Quality of Life Technologies. In total, 110 instruments were identified via nine reviews and 31 generic instruments were retained. There was a good evidence of the instruments’ internal consistency and reliability, but limited evidence of their responsiveness to change. While 31 instruments provide an adequate assessment of function/sexual QoL, fitting with COSMIN guidance, their scope varied and only three of these were developed since the revision of the definition of sexual dysfunction in 2013. Computerized self-reported measures may facilitate data collection yet were rarely discussed by authors. This meta-review has compiled evidence on generic instruments that can improve the collection of data on sexual function/QoL in research and clinical practice. We also discuss the emerging use of applications, connected wearables and devices that may provide another less invasive avenue for the assessment of sexual function/QoL at the individual and population level.
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Mobile network connectivity enables individuals to use various Internet-based applications and is nowadays an integral part of the physical environment. More specifically, this connectivity shapes individuals’ modes of gathering information and their communication capabilities. In turn, this impacts the individual’s decision-making and, in the long term, may influence their health and quality of life (QoL). This chapter focuses on longitudinal modeling of the availability of mobile connectivity such as Wi-Fi and 3G or 4G for individuals living in the Geneva area (Switzerland). We analyze connectivity over 5 years (2015–2020) based on data collected from 110 mQoL (mobile QoL) Living Lab participants. The participants are from three different cohorts corresponding to distinct data collection periods (2015–2017, 2018–2019, 2020). We derive four features that quantify an individual’s connectivity level: the network access technology (Wi-Fi or cellular), signal strength, the overall data consumption (upload and download), and the participants’ mobility patterns while connected. We also compare the connectivity levels of the three cohorts over time. Our findings reflect the relations between mobile connectivity and the smartphone network activity of the mQoL study cohorts during their daily activities, which may impact their QoL. We summarize the results and conclude this chapter by exploring the different QoL technologies and services enabled by mobile connectivity. However, the effects of connectivity on specific QoL domains, such as psychological aspects (i.e., positive/negative feelings) or social relationships, should be investigated further.
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An essential objective of preventive healthcare is to assess the lifestyle of citizens and identify those with health risk behaviors long time before they develop a lifestyle-related disease. In spite of lasting attempts to support preventive healthcare services in reaching individuals at risk through information campaigns, systematic health check programs, and more recently, data-driven approaches, citizens remain at a distance to the preventive healthcare services. The purpose of this chapter is to investigate the reasons for this distance between citizens and preventive care offers and the potential of quantified-self technologies for decreasing this. The analysis shows that while data-driven approaches to lifestyle assessment do assist preventive care services in screening a large population, they do not solve the fundamental challenge; that citizens are often challenged in relating to the risk assessment and in the consequences of their current behaviors on a long timescale. Based on these findings, two design implications are elicited to guide design of systems based on quantified-self to support early assessment and improvement of potentially unhealthy lifestyle, potentially improving health and quality of life in the long term.
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This chapter will discuss the usage of more objective and unobtrusive ways technology can be used to assess leisure activities. It is well known that leisure activities are positively correlated with measures of quality of life and subjective well-being. How we spend our free time has a great deal of influence on how we subjectively assess the quality of our lives. One aspect of our leisure time, which is gaining more and more interest, is the use of smartphones and wearables. According to global statistics, almost half of the global population spends more than 5 h a day using their smartphones. The use of technology has a profound effect on the way we spend our lives, socialize and entertain. Because our use of technology leaves a massive amount of digital data, we are now able to search for patterns of digital behaviour and use them as proxies or predictors for real life behaviours, bypassing or complementing self-reports and subjective measures. Our discussion revolves around several aspects of technology and leisure time. First, how technology use relates to leisure activities and what alternative unobtrusive measures could be developed to measure or predict leisure activities. Second, we will discuss the positive and negative aspects of technology use.
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Educational efforts and achievement in an individual’s youth influence their life-long social status and quality of life. Historically, higher education’s teaching relied on passive learning of hour’s long monologues delivered in person. This system puts in clear disadvantage and reduces the quality of life of many students who cannot attend lectures or keep up with the pace of learning. Fortunately, the current technology-led paradigm shift in undergraduate teaching and learning, addresses these challenges. Here we investigated: (1) what are the current assessment methods for cognitive state, memory and learning in healthy populations? (2) What types of platforms and tools offer alternative ways of learning and interacting in classrooms?; How can these platforms (3) support assessment of students’ cognitive state and learning process? and (4) support students with specific needs? To answer (1), we conducted scoping review on the current instruments and scales.; for (2) we interviewed digital learners, researchers, and faculty and created a list of platforms and tools, which were further analyzed to answer the last questions. We found that digital tools allow students to: (a) access course material remotely, (b) engage with classmates in groups/forums (c) work collaboratively on shared documents and (d) provide feedback and communicate anonymously with classmates and lecturers during and/or after lectures. We show that, while learning platforms and tools can adapt learning to the students’ abilities, learners and lectures require additional training/paradigm shift to fully benefit. We present results and discuss design implications for technologies, which, could boost learning and attainment of educational goals, particularly for “non-traditional” learners.
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An individual’s financial resources are directly related to their ability to meet current and future needs. Higher levels of financial assets and lower debt have been found to be positively associated with financial satisfaction. On the other hand, inadequate financial resources can lead to financial strain and financial distress. According to the WHOQOL theoretical model, financial resources refer to a person’s view of how his/her financial resources, the extent to which these resources meet the needs for a healthy and comfortable lifestyle, and what the person can afford or cannot afford which might affect quality of life. Few studies have addressed the impact of financial resources and financial burden on quality of life and the role of QoL technology-enabled tools for measuring and managing financial resource and improving quality of life. This chapter reviews the literature about (1) the effects of financial resources and financial burden on treatment outcomes and overall quality of life; (2) the state-of-art tools for measuring financial resources by individuals and financial and health professionals; (3) the evaluation of Web-based interventions for enhancing financial resource management; and (4) the behavioral and technology-related factors for successful adoption of QoL technology-enabled methods and financial resource management tools for improving individual life satisfaction and financial well-being.
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This chapter will detail how the advent of the internet and smartphones has fundamentally transformed the nature of social support and its effects on quality of life and health. Technological change has altered: (1) The ways in which we assess social support, (2) The perception and effects of social support. First, we will examine how recent technological innovations have allowed for more detailed, objective, and accurate assessments of social support. Digital technology has enabled us to go beyond simple self-report measures to assess social support and quality of life in unprecedented ways. By leveraging big data across several accessible technological platforms, researchers can begin to understand how social support processes unfold in real time and the myriad ways technology can be used to measure meaningful aspects of social support. In the second section, we will discuss how the concept of social support has changed in the age of digital communication. We will focus on how the presence and use of technological devices influences face-to-face interactions, online groups, and family dynamics. Taken together, this chapter will recognize the changes in social assessment afforded by technology and consider several important areas in which technological tools have transformed social support.
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Activities of Daily Living (ADL) has become a clinical de facto instrument to assess older people’s daily functional status living independently at home. This chapter focuses on a ‘smart home environment’ that contributes to the individual’s QoL and leverages a novel objective ADL assessment technology embedded in the home. This objective ADL (OADL) assessment is achieved through fusing data from simple, non-intrusive, always-on, wireless sensors placed in a home environment. To evaluate the OADL in older people, we conducted a 10-month pilot study with five eligible participants between 79 and 88 years old. In each participant’s home, we installed a smart home system. We presented OADL assessment to participants daily through a tablet app for self-management and caregivers through a web portal for decision-making. We then compare the similarity between OADL assessment and traditional self-reported Barthel ADL from participants. Initial study results demonstrated the great potential of the OADL as an effective daily functional status index and management instrument for caregivers to support beloved ones remotely and enable timely and early interventions when necessary. This chapter presents state of art in that domain and reflects on other design implications for a home environment, facilitating better health and life quality in the long term.
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Artificial Intelligence (AI) paves the way for many innovations and undoubtedly impacts individuals’ quality of life (QoL). It is also a risk factor, especially when it comes to personal safety and security. In today’s world, however, every person has a role to play in identifying and managing the risks of using AI, not only the AI experts. The first essential step in identifying those risks is to know individuals’ attitudes and motivations regarding the use of AI and the behaviors and practices of AI use (or non-use) they engage in. In 2016 and 2017, we surveyed 1000 bachelor’s and master’s students from various academic departments in Western Switzerland. We aimed to explore their current attitudes and motivations and outline scenarios for possible futures focusing on AI, security, safety, and QoL in Switzerland. This chapter summarizes the survey results and discusses individuals’ behaviors and interactions in the context of the identified scenarios. Based on the scenarios, we attempted to determine how businesses and governments in the present might seize future opportunities offered by AI while also addressing some of the implications of AI for individuals’ QoL. Our research results may serve as starting points to enrich discussion concerning AI and QoL and help individuals, along with businesses and governments, make better decisions in an increasingly connected world.
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Fitness technology, including trackers and smartphone applications (apps), has become increasingly popular for measuring and encouraging physical activity in recent years. Physical activity is closely linked with health and well-being; however, many Americans do not engage in regular exercise. This trend of inactivity increases with age and can interfere with an individual’s capacity to work. The benefits of physical activity and fitness extend beyond job performance and physical aspects of work capacity and include longer life and enhanced quality of life. This literature review addresses the question: How does the use of self-management QoL technologies affect work capacity and reported quality of life? It examines (1) the factors associated with variations in work capacity and quality of life; (2) the state-of-art of personalized, miniaturized computing QoL technologies for measuring and improving physical activity and fitness levels; (3) the use of activity trackers to quantify work capacity; and (4) strategies to enhance use of Web-based tools and fitness technology for behavioral change, health management, and rehabilitation interventions for the self-management of work capacity and enhancement of health-related quality of life across the lifespan. This chapter concludes with recommendations for future development of tools for the assessment and improvement of working capacity.
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Quality of life (QoL) refers to an individual’s well-being including their physical and psychological health, social relationships, and environmental domains. Current assessments of QoL are mostly qualitative and infrequent, following a self-reported approach. However, the recent widespread availability of personalized and miniaturized technological innovations, including mobile devices and applications, has enabled the continuous assessment of daily life behaviors that contribute to or result from the individual’s QoL. The continuous assessment of behaviors facilitates an enhanced understanding of an individual’s short-term as well as long-term health and QoL. This chapter outlines the World Health Organization Quality of Life (WHOQOL, and specifically the WHOQOL-BREF) instrument, which provides a way to categorize the behaviors and aspects of daily life that contribute to an individual’s QoL. As a result, the WHOQOL-BREF presented here serves as the organizational method for this book. Additionally, this chapter presents 71 technology-enabled daily life assessment studies conducted by “quantified-selfers” across the span of the last 6 years, and draws lessons learned by the community. Overall, this chapter illustrates how technology-enabled assessments of an individual’s daily life behaviors and QoL can complement current self-reported QoL assessments. Following this, each chapter within this book elaborates on technology-enabled assessments of a specific dimension of an individual’s QoL.
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Quality of life (QoL) is a subjective term often determined by various aspects of living, such as personal well-being, health, family, and safety. QoL is challenging to capture objectively but can be anticipated through a person’s emotional state; especially positive emotions indicate an increased QoL and may be a potential indicator for other QoL aspects (such as health, safety). Affective computing is the study of technologies that can quantitatively assess human emotions from external clues. It can leverage different modalities including facial expression, physiological responses, or smartphone usage patterns and correlate them with the person’s life quality assessments. Smartphones are emerging as a main modality, mostly because of their ubiquitous availability and use throughout daily life activities. They include a plethora of onboard sensors (e.g., accelerometer, gyroscope, GPS) and can sense different user activities passively (e.g., mobility, app usage history). This chapter presents a research study (here referred to as the TapSense study) that focuses on assessing the individual’s emotional state from the smartphone usage patterns. In this TapSense study, the keyboard interaction of n = 22 participants was unobtrusively monitored for 3 weeks to determine the users’ emotional state (i.e., happy, sad, stressed, relaxed) using a personalized machine learning model. TapSense can assess emotions with an average AUCROC of 78%(±7% std). We summarize the findings and reflect upon these in the context of the potential developments within affective computing at large, in the long term, indicating a person’s quality of life.
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Self-esteem, a person’s overall evaluation that she is valued and accepted vs. devalued and rejected by others, is crucial for people quality of life. As such, self-esteem has been central in the social-psychological literature since the late eighteenth century. However, its relevance is coupled with lack of agreement on how self-esteem is best conceived and assessed. Here we review definitions and measures of self-esteem in relation to quality of life in order (a) to understand how self-esteem has been defined, operationalized and assessed, and (b) to clarify which facets of self-esteem have been overlooked and need further study. Although we found multiple definitions of self-esteem, which led to a series of measures ranging from single item to multi-dimensional measures of state, trait and contingent self-esteem, the motivational component of self-esteem and its in-context behavioral correlates have yet to be operationalized. What follows, is that whether people think, feel, or behave in particular ways is caused by, concomitant with, or causes self-esteem, is still not understood. Because self-esteem is an emotionally laden system monitoring one’s relational value to others, we suggest that future research could use new technology-based research methods and eventually grasp real-time self-report and behavioral assessment of self-esteem. This appears a promising approach to overcome the limitations of self-esteem’s current theorizations and operationalizations. Thus, a new line of research considering the momentary experience of self-esteem, its behavioral components and its social context, could potentially unveil novel processes and mechanisms linking self-esteem and quality of life that have yet to be discovered and understood.
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Activities of Daily Living (ADLs) refers to the fundamental skills required to care for one-self and live independently and includes dressing, feeding, personal hygiene, continence and transferring. Assessing ADLs is therefore essential, especially for vulnerable population who may need assistance in performing these activities. As current validated scales to measure ADLs capacity are often dependent of an informant or a caregiver and are mainly performed in the controlled settings of the hospital, using technology-enabled tools could benefit individual’s health in terms of disease prevention and treatment but would also enhance individual’s quality of life and independence. This chapter presents 4 standard validated scales for ADLs and the current research activities on the use of technologies to assess one’s ability to perform ADLs, mainly indoor-outdoor mobility and nutrition. A nutrition assessment use case through a conversational agent is presented in the second part of the chapter. Future opportunities for technology-enabled ADL assessment are discussed.
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Introduction We know little about what youth with opioid use disorders (OUD) think about outpatient substance use treatment and 12-step meetings following discharge from residential substance use treatment. This study explores youths' preferences between intensive outpatient treatment (IOP) and community-based 12-step groups. Method The study recruited youth (n = 35) from a larger randomized trial (N = 288) that examined the effectiveness of extended-release naltrexone versus treatment-as-usual. This study asked the youth to participate in semi-structured qualitative interviews at baseline, 3 months, and 6 months post-residential treatment discharge. Qualitative interviews probed youths' key decision points during the six-months following residential treatment for OUD, including medication and counseling, and 12-step continuation in the community. Results Qualitative analyses revealed three overarching themes related to youths' preferences for either IOP or 12-step meetings: structure of recovery support, mechanisms of accountability, and relationships. Conclusion Despite varying preferences, this analysis highlights the complexity of benefits that youth report receiving from each approach. Research has yet to determine the degree to which these approaches are complementary or supplementary for this population.
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Introduction: Oral mucositis is a common debilitating complication of cancer treatments, particularly chemotherapy and radiation. Objectives: The purpose of this study was to improve oral mucositis prevention and control among cancer patients through the implementation of best practice guidelines in a tertiary referral center in Northern Iran. Methods: A clinical audit design was utilized in this implementation project. A preimplementation audit was conducted against nine best practice criteria for the prevention and treatment of oral mucositis among new cases of cancer patients in November and December 2019. Fifty cancer patients and 20 nurses participated in this phase of the clinical audit. The next step included a facilitated multidisciplinary focus group identifying targeted strategies and implementing them, completed in late December 2019. A postimplementation audit was then conducted on another 50 cancer patients and the same 20 nurses in January and early February 2020. The project utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice software. Results: The preimplementation audit revealed gaps between the current practice and best practice across eight of the nine criteria. After implementing the targeted strategies, the outcomes improved across most of the criteria in the follow-up audit: 80% increase was observed in compliance of staff education, 100% increase in providing standard oral hygiene protocol in place, 64% increase in carrying out a dental examination and conducting initial oral cavity examination, and also 34% increase in conducting of ongoing oral cavity examination by a dentist, and finally 100% increase in providing preventive and therapeutic oral care regimens in place and oral pain assessment using a validated tool. Conclusion: The results of this project indicate that clinical auditing is an effective approach to the assessment of evidence-based care practices for oral mucositis among new cancer patients. Evidence-based oral mucositis management among cancer patients can be achieved by educating the patients and nursing staff using the newest guidelines and dentists' comprehensive dental and oral hygiene examinations.
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This chapter reviews research on the effectiveness of incentives in general health promotion, and in interventions for smoking and other drug addictions in particular. Consistent with basic principles of learning and reinforcement, and from a behavioral economic perspective, it finds that (1) incentives are effective in encouraging smoking cessation and other health behaviors; (2) incentives are effective while in place but not after they are terminated; and (3) nonsmoking may be encouraged by increasing the availability of reinforcing activities that substitute for the reinforcement from nicotine. Incentives may be especially effective when smoking cessation is a priority for a specific period of time, such as during pregnancy. Incentive programs appear to influence otherwise "hard-to-reach" groups. The impact of incentives is enhanced when implemented in the context of broader programs promoting smoking cessation, and incentives applied to populations may be cost efficient by achieving modest effects for large numbers of individuals. Basic principles of reinforcement and the use of incentives understood within a behavioral economic framework should continue to inform publichealth interventions and may lead to new insights into effective approaches for influencing health behavior.
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Three experiments demonstrated, and examined the mechanisms that underlie, the renewal of extinguished discriminated operant behavior. In Experiment 1, rats were trained to perform 1 response (lever press or chain pull) in the presence of one discriminative stimulus (S; light or tone) in Context A, and to perform the other response in the presence of the other S in Context B. Next, each of the original S/response combinations was extinguished in the alternate context. When the S/response combinations were tested back in the context in which they had been trained, responding in the presence of S returned (an ABA renewal effect was observed). This renewal could not be due to differential context-reinforcer associations, suggesting instead that the extinction context inhibits either the response and/or the effectiveness of the S. Consistent with the latter mechanism, in Experiment 2, ABA renewal was still observed when both the extinction and renewal contexts inhibited the same response. However, in Experiment 3, previous extinction of the response in the renewing context (occasioned by a different S) reduced AAB renewal more than did extinction of the different response. Taken together, the results suggest at least 2 mechanisms of renewal after instrumental extinction. First, extinction performance is at least partly controlled by a direct inhibitory association that is formed between the context and the response. Second, in the discriminated operant procedure, extinction performance can sometimes be partly controlled by a reduction in the effectiveness of the S in the extinction context. Renewal of discriminated operant behavior can be produced by a release from either of these forms of inhibition. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
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After a relatively small amount of training, instrumental behavior is thought to be an action under the control of the motivational status of its goal or reinforcer. After more extended training, behavior can become habitual and insensitive to changes in reinforcer value. Recently, instrumental responding has been shown to weaken when tested outside of the training context. The present experiments compared the sensitivity of instrumental responding in rats with a context switch after training procedures that might differentially generate actions or habits. In Experiment 1, lever pressing was decremented in a new context after either short, medium, or long periods of training on either random-ratio or yoked random-interval reinforcement schedules. Experiment 2 found that more minimally trained responding was also sensitive to a context switch. Moreover, Experiment 3 showed that when the goal-directed component of responding was removed by devaluing the reinforcer, the residual responding that remained was still sensitive to the change of context. Goal-directed responding, in contrast, transferred across contexts. Experiment 4 then found that after extensive training, a habit that was insensitive to reinforcer devaluation was still decremented by a context switch. Overall, the results suggest that a context switch primarily influences instrumental habit rather than action. In addition, even a response that has received relatively minimal training may have a habit component that is insensitive to reinforcer devaluation but sensitive to the effects of a context switch.
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Two experiments with rats explored renewal effects in operant conditioning preparations. When pressing a lever was trained in one context and then extinguished in a second context, the responding was renewed by returning to the original context (ABA renewal) in Experiment 1. This finding was replicated in Experiment 2 with discriminative operant performance signaled by a localized light cue. In spite of the successful demonstration of ABA renewal effect in these experiments, AAB renewal was detected in neither experiment: When the responses had been extinguished in the context of acquisition, testing the rats in a second context did not renew the responses. The demonstration of ABA renewal but no AAB renewal suggests that extinction in another context and/or a return to the original context are critical for renewal of extinguished operant performance.
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A common treatment for operant problem behavior is alternative reinforcement. When alternative reinforcement is removed or reduced, however, resurgence of the target behavior can occur. Shahan and Sweeney (2011) developed a quantitative model of resurgence based on behavioral momentum theory that suggests higher rates of alternative reinforcement result in faster response elimination and greater resurgence when removed, whereas lower rates of alternative reinforcement result in slower response elimination but are followed by less resurgence. Thus, the present study was designed to examine whether faster target response elimination and less resurgence could be achieved by beginning with a high rate of alternative reinforcement and gradually thinning it such that a low rate is ultimately removed during a simulated treatment lapse. Results showed that high rates of alternative reinforcement were more effective than low or thinning rates at target response suppression but resulted in resurgence when discontinued. Low and thinning rates, on the other hand, were less effective at response suppression but target responding did not increase when alternative reinforcement was discontinued. The quantitative model cannot currently account for the finding that lower-rate alternative reinforcement may not effectively disrupt behavior relative to an extinction only control. Relative advantages of high, low, thinning, or no alternative reinforcement are discussed with respect to suppression of target response rate during treatment, resurgence when alternative reinforcement is removed, and alternative response persistence, while taking into account differences between this animal model and modern applied behavior analytic treatments.
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Prior research has demonstrated renewal, which is the ability of contextual cues to modulate excitatory responding to a Pavlovian conditioned stimulus (CS). In the present research, conditioned lick suppression in rats was used to examine similar contextual modulation of Pavlovian conditioned inhibition. After Pavlovian conditioned inhibition training with a CS in one context, subjects were exposed to pairings of the CS with an unconditioned stimulus (US) either in the same or in a second context. Results indicated that, when the CS was paired with the US in the second context, the CS retained its inhibitory control over behavior, provided that testing occurred in the context used for inhibition training. However, when the CS-US pairings occurred in the inhibition training context, the CS subsequently proved to be excitatory regardless of where testing occurred. These observations indicate that conditioned inhibition is subject to renewal.
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Reinstatement after counterconditioning was examined in three experiments with rats. The rats received CS-shock pairings in Phase 1 and then CS-food pairings in Phase 2. When unsignaled shock was presented after appetitive conditioning, fear performance to the CS replaced food performance. This reinstatement effect depended on initial pairings of the CS and shock in Phase 1. It also depended on shock exposure occurring in the test context. The results parallel previous data obtained after extinction. Counterconditioning and extinction yield several parallel effects (spontaneous recovery, renewal, and now reinstatement) which suggest that Phase 2 does not destroy the learning acquired in Phase 1.
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Drug addiction can be a chronic problem. Abstinence reinforcement can initiate drug abstinence, but as with other treatments many patients relapse after the intervention ends. Abstinence reinforcement can be maintained to promote long-term drug abstinence, but practical means of implementing long-term abstinence reinforcement are needed. We reviewed 8 clinical trials conducted in Baltimore, MD from 1996 through 2010 that evaluated the therapeutic workplace as a vehicle for maintaining reinforcement for the treatment of drug addiction. The therapeutic workplace uses employment-based reinforcement in which employees must provide objective evidence of drug abstinence or medication adherence to work and earn wages. Employment-based reinforcement can initiate (3 of 4 studies) and maintain (2 studies) cocaine abstinence in methadone patients, although relapse can occur even after long-term exposure to abstinence reinforcement (1 study). Employment-based reinforcement can also promote abstinence from alcohol in homeless alcohol dependent adults (1 study), and maintain adherence to extended-release naltrexone in opioid dependent adults (2 studies). Treatments should seek to promote life-long effects in patients. Therapeutic reinforcement may need to be maintained indefinitely to prevent relapse. Workplaces could be effective vehicles for the maintenance of therapeutic reinforcement contingencies for drug abstinence and adherence to addiction medications.
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Drug use and relapse involve learned associations between drug-associated environmental cues and drug effects. Extinction procedures in the clinic can suppress conditioned responses to drug cues, but the extinguished responses typically reemerge after exposure to the drug itself (reinstatement), the drug-associated environment (renewal), or the passage of time (spontaneous recovery). We describe a memory retrieval-extinction procedure that decreases conditioned drug effects and drug seeking in rat models of relapse, and drug craving in abstinent heroin addicts. In rats, daily retrieval of drug-associated memories 10 minutes or 1 hour but not 6 hours before extinction sessions attenuated drug-induced reinstatement, spontaneous recovery, and renewal of conditioned drug effects and drug seeking. In heroin addicts, retrieval of drug-associated memories 10 minutes before extinction sessions attenuated cue-induced heroin craving 1, 30, and 180 days later. The memory retrieval-extinction procedure is a promising nonpharmacological method for decreasing drug craving and relapse during abstinence.
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Two experiments examined the susceptibility of excitation and inhibition to contextual change when the conditioned stimulus (CS) was ambiguous using an appetitive conditioning paradigm. In Experiment 1, excitation to a CS was lost with a context switch when inhibition had been learned to the CS in a prior feature-negative (FN) discrimination. Control groups that had received either more or less excitatory conditioning in the absence of inhibitory pretraining showed no loss. In Experiment 2 inhibition was lost with a context switch in a group that had received excitatory and then inhibitory conditioning with the CS. No loss was observed in a group that had not received excitatory pretraining. The results suggest that contexts are especially likely to control performance to ambiguous CSs when they can modulate the second of two learned associations. Results are discussed in terms of their implications for occasion setting and modern conditioning theory.
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Pavlovian conditioning models have influenced the development of cue exposure treatments for drug abuse. However, poor maintenance of extinction performance (renewal) after treatment is a common problem. A treatment-analogue experiment tested the role of context in renewal, as well as a potential strategy for reducing renewal. Seventy-eight social drinkers completed extinction trials to reduce saliva and urge reactivity to alcohol cues and were randomly assigned to a renewal test in either the same context as extinction, a different context, or the different context containing a cue from the extinction context (E-cue). As predicted, the different context produced greater renewal than the same context and renewal was attenuated when the E-cue was present. These results offer preliminary evidence for the context dependence of extinction to alcohol cues and for the use of an extinction cue to improve the generalizability of exposure therapies.
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Five appetitive conditioning experiments with rats examined the ability of extinction cues (ECs) to reduce spontaneous recovery after extinction procedures that varied the temporal relation between the ECs and the conditioned stimulus (CS) and included presentations of additional events (e.g. other stimuli correlated with extinction, CSs, and the US). In extinction, two different ECs were presented either closely in time before (i.e. recent to), or more distant (i.e. remote) from a nonreinforced CS. Both recent and remote ECs reduced spontaneous recovery to the CS when present during testing (Experiments 1-4). Each EC reduced recovery despite the addition during extinction of a second EC and CS (Experiments 1, 3, and 1), and the US (Experiment 3). Experiments 4 and 5 investigated the recent and remote ECs' tendency to control a serial occasion setting discrimination involving the target CS under explicit training conditions. Neither EC gained such discriminative control. Possible explanations of the results are discussed, including configural learning, occasion setting, and contextual cue control.
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Four conditioned suppression experiments examined the influence of contextual stimuli on the rat's fear of an extinguished conditioned stimulus (CS). When rats received pairings of a CS with shock in one context and then extinction of the CS in another context, fear of the CS was renewed when the CS was returned to and tested in the original context (Experiments 1 and 3). No such renewal was obtained when the CS was tested in a second context after extinction had occurred in the conditioning context (Experiment 4). In Experiment 2, shocks presented following extinction reinstated fear of the CS, but only if they were presented in the context in which the CS was tested. In each experiment, the associative properties of the contexts were independently assessed. Contextual excitation was assessed primarily with context-preference tests in which the rats chose to sit in either the target context or an adjoining side compartment. Contextual inhibition was assessed with summation tests. Although reinstatement was correlated with demonstrable contextual excitation present during testing, the renewal effect was not. Moreover, there was no evidence that contextual inhibition developed during extinction. The results suggest that fear of an extinguished CS can be affected by the excitatory strength of the context but that independently demonstrable contextual excitation or inhibition is not necessary for contexts to control that fear.
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When conditioning and extinction are conducted in different contexts, a return to the conditioning context causes a renewal of conditioned responding. The results of 4 experiments with rats in an appetitive conditioning preparation suggest that renewal results from a failure to retrieve extinction outside the extinction context. Presentation of a cue from extinction during renewal testing attenuated the renewal effect; attenuation depended on the cue's correlation with extinction. On its own, the cue did not elicit responding, suggesting it was not a conditioned excitor; it also failed tests for conditioned inhibition. The authors propose that it worked by retrieving a memory of extinction. The findings parallel previous results with spontaneous recovery and are thus consistent with the view that renewal and spontaneous recovery result from a common mechanism.
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In four experiments utilizing an appetitive conditioning preparation, reacquisition of conditioned responding was found to occur both rapidly and slowly following extinction. In Experiment 1, acquisition of responding to a tone that had been conditioned and extinguished occurred more rapidly than acquisition in either a group that received equivalent exposure to the food unconditioned stimulus or a 'rest' control group that received only exposure to the apparatus in the first two phases. However, reacquisition was impaired relative to acquisition in a 'learning-experienced' group that had previously received conditioning and extinction with a different stimulus. Experiments 2 and 3 produced similar results, but also found that high responding during reacquisition was confined to trials that followed reinforced, rather than nonreinforced, trials. Experiment 4, in which very few initial conditioning trials were used, produced reacquisition that was slow compared with both learning-experienced and rest controls. The results are consistent with a role for sequential learning: Reacquisition is rapid when animals have learned that reinforced trials signal other reinforced trials.
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Extinction is the decrease in strength of a learned behavior when the conditioned stimulus is presented without the unconditioned stimulus (in Pavlovian learning), or when the behavior is no longer reinforced (in operant or instrumental learning). This chapter reviews the behavioral literature on extinction. The first section reviews several relapse phenomena, such as the renewal effect, which suggest that extinction does not destroy original learning, but instead involves new context-dependent learning. The second section reviews theoretical explanations of the cause of extinction. The final section reviews behavioral and pharmacological ways of optimizing extinction learning and decreasing the likelihood of relapse.
Chapter
Pavlovian phenomena have long served as models for the etiology, treatment, and relapse from treatment of diverse disorders (e.g., phobias, addictions). Here, the chapter briefly reviews Pavlovian conditioning models of anxiety disorders, experimental extinction models of exposure therapy, and recovery from extinction models of relapse following exposure therapy. It then focuses on how research on experimental extinction has led to the development of specific behavioral techniques to reduce recovery from extinction and hence relapse from exposure therapy. These techniques include conducting extinction treatment in multiple contexts, giving a massive amount of extinction, increasing the time between extinction trials and between extinction sessions, administering extinction in the presence of a second excitor, and testing in the presence of a retrieval cue from extinction. It is concluded that these behavioral techniques, all of which were discovered in the experimental laboratory, are potent and important tools to be considered by psychotherapists trying to make their patients less susceptible to relapse.
Article
Three experiments examined the role of context in punishment learning. In Experiment 1, rats were trained to lever press for food in Context A and then punished for responding in Context B (by presenting response-contingent footshock). Punishment led to complete suppression of the response. However, when responding was tested (in extinction) in Contexts A and B, a strong renewal of responding occurred in Context A. In Experiment 2, renewal also occurred when initial reinforcement occurred in Context A, punishment occurred in Context B, and testing occurred in a new context (Context C). In both experiments, behavioral suppression and renewal were not observed in groups that received noncontingent (yoked) footshocks in Context B. In Experiment 3, 2 responses (lever press and chain pull) were separately reinforced in Contexts A and B and then punished in the opposite context. Although the procedure equated the contexts on their association with reinforcement and punishment, renewal of each response was observed when it was tested in its nonpunished context. The contexts also influenced response choice. Overall, the results suggest that punishment is specific to the context in which it is learned, and establish that its context-specificity does not depend on a simple association between the context and shock. Like extinction, punishment may involve learning to inhibit a specific response in a specific context. Implications for theories of punishment and for understanding the cessation of problematic operant behavior (e.g., drug abuse) are discussed. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
Article
The retrieval of extinction memories is dependent on contextual cues associated with extinction training. Various forms of response restoration after extinction, such as renewal, reinstatement, and spontaneous recovery, can be viewed as failures to retrieve an extinction memory. It follows that provision of a cue to aid retrieval of the extinction memory should attenuate response restoration or relapse after extinction. Six experiments studied the impact of an extinction retrieval cue (E-cue) on restoration of extinguished alcohol seeking in rats. Rats were trained to respond for alcoholic beer and this responding was then extinguished. Extinction training was accompanied by noncontingent presentations of a 60-s auditory stimulus that served as an E-cue. Presentations of the E-cue on test attenuated ABA renewal of alcohol seeking (Experiment 1) whereas an equally familiar cue from training had no effect (Experiment 2). Presentations of the E-cue had no effect on the reacquisition of alcohol seeking (Experiment 3). The same effects on ABA renewal (Experiments 4 and 6) and reacquisition (Experiment 5) were observed when the E-cue was trained in a response contingent manner during extinction. Taken together these findings show that presentations of an E-cue are able to attenuate the renewal but not reacquisition of alcohol seeking and are interpreted with reference to Bouton's model of extinction (Bouton, 1994a, 1994b, 2004). (PsycINFO Database Record (c) 2014 APA, all rights reserved).
Article
In resurgence, an extinguished instrumental behavior (R1) recovers when a behavior that has replaced it (R2) is also extinguished. The phenomenon may be relevant to understanding relapse that can occur after the termination of "contingency management" treatments, in which an unwanted behavior (e.g., substance abuse) is reduced by reinforcing an alternative behavior. When reinforcement is discontinued, the unwanted behavior might resurge. However, unlike most resurgence experiments, contingency management treatments also introduce a negative contingency, in which reinforcers are not delivered unless the client has abstained from the unwanted behavior. In two experiments with rats, we therefore examined the effects of adding a negative "abstinence" contingency to the resurgence design. During response elimination, R2 was not reinforced unless R1 had not been emitted for a minimum period of time (45, 90, or 135 s). In both experiments, adding such a contingency to simple R1 extinction reduced, but did not eliminate, resurgence. In Experiment 2, we found the same effect in a yoked group that could earn reinforcers for R2 at the same points in time as the negative-contingency group, but without the requirement to abstain from R1. Thus, the negative contingency per se did not contribute to the reduction in resurgence. These results suggest that the contingency reduced resurgence by making reinforcers more difficult to earn and more widely spaced in time. This could have allowed the animal to learn that R1 was extinguished in the "context" of infrequent reinforcement-a context more like that of resurgence testing. The results are thus consistent with a contextual (renewal) account of resurgence. The method might provide a better model of relapse after termination of a contingency management treatment.
Article
Previous research has suggested that changing the context after instrumental (operant) conditioning can weaken the strength of the operant response. That result contrasts with the results of studies of Pavlovian conditioning, in which a context switch often does not affect the response elicited by a conditioned stimulus. To begin to make the methods more similar, Experiments 1-3 tested the effects of a context switch in rats on a discriminated operant response (R; lever pressing or chain pulling) that had been reinforced only in the presence of a 30-s discriminative stimulus (S; tone or light). As in Pavlovian conditioning, responses and reinforcers became confined to presentations of the S during training. However, in Experiment 1, after training in Context A, a switch to Context B caused a decrement in responding during S. In Experiment 2, a switch to Context B likewise decreased responding in S when Context B was equally familiar, equally associated with reinforcement, or equally associated with the training of a discriminated operant (a different R reinforced in a different S). However, there was no decrement if Context B had been associated with the same response that was trained in Context A (Experiments 2 and 3). The effectiveness of S transferred across contexts, whereas the strength of the response did not. Experiment 4 found that a continuously reinforced response was also disrupted by context change when the same response manipulandum was used in both training and testing. Overall, the results suggest that the context can have a robust general role in the control of operant behavior. Mechanisms of contextual control are discussed. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Article
Traditionally, discrimination has been understood as an active process, and a technology of its procedures has been developed and practiced extensively. Generalization, by contrast, has been considered the natural result of failing to practice a discrimination technology adequately, and thus has remained a passive concept almost devoid of a technology. But, generalization is equally deserving of an active conceptualization and technology. This review summarizes the structure of the generalization literature and its implicit embryonic technology, categorizing studies designed to assess or program generalization according to nine general headings: Train and Hope; Sequential Modification; Introduce to Natural Maintaining Contingencies; Train Sufficient Exemplars; Train Loosely; Use Indiscriminable Contingencies; Program Common Stimuli; Mediate Generalization; and Train “To Generalize”.
Article
In this article I review research and theory on the "interference paradigms" in Pavlovian learning. In these situations (e.g., extinction, counterconditioning, and latent inhibition), a conditioned stimulus (CS) is associated with different unconditioned stimuli (USs) or outcomes in different phases of the experiment; retroactive interference, proactive interference, or both are often observed. In all of the paradigms, contextual stimuli influence performance, and when information is available, so does the passage of time. Memories of both phases are retained, and performance may depend on which is retrieved. Despite the similarity of the paradigms, conditioning theories tend to explain them with separate mechanisms. They also do not provide an adequate account of the context's role, fail to predict the effects of time, and overemphasize the role of learning or storage deficits. By accepting 4 propositions about animal memory (i.e., contextual stimuli guide retrieval, time is a context, different memories are differentially dependent on context, and interference occurs at performance output), a memory retrieval framework can provide an integrated account of context, time, and performance in the various paradigms.
Article
Four experiments with rats examined renewal of extinguished instrumental behavior when the reinforcement histories of the contexts were equated by giving complementary training and extinction of a different response (lever press and chain pull) in each context. In Experiments 1 through 3, renewal occurred when the response was tested in the acquisition context (ABA) or outside the extinction context (AAB and ABC). Further, in Experiments 1 through 3, when both responses were simultaneously available, there was a clear preference for the response that was not in its extinction context. In Experiment 4, renewal was not reduced when testing occurred in a context that had been associated with extinction of the other instrumental response. The experimental designs rule out differential context-reinforcer associations being the only contributing mechanism of renewal, and also raise questions about configural and occasion-setting accounts. The results are consistent with the idea that during extinction an inhibitory association is formed between the context and the response. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Article
In resurgence, an operant behavior that has undergone extinction can return ("resurge") when a second operant that has replaced it itself undergoes extinction. The phenomenon may provide insight into relapse that may occur after incentive or contingency management therapies in humans. Three experiments with rats examined the impact of several variables on the strength of the resurgence effect. In each, pressing one lever (L1) was first reinforced and then extinguished while pressing a second, alternative, lever (L2) was now reinforced. When L2 responding was then itself extinguished, L1 responses resurged. Experiment 1 found that resurgence was especially strong after an extensive amount of L1 training (12 as opposed to 4 training sessions) and after L1 was reinforced on a random ratio schedule as opposed to a variable interval schedule that was matched on reinforcement rate. Experiment 2 found that after 12 initial sessions of L1 training, 4, 12, or 36 sessions of Phase 2 each allowed substantial (and apparently equivalent) resurgence. Experiment 3 found no effect of changing the identity of the reinforcer (from grain pellet to sucrose pellet or sucrose to grain) on the amount of resurgence. The results suggest that resurgence can be robust; in the natural world, an operant behavior with an extensive reinforcement history may still resurge after extensive incentive-based therapy. The results are discussed in terms of current explanations of the resurgence effect.
Article
Examined, in 5 conditioned suppression experiments, the influence of summation between fear of the CS and the context in experimental paradigms in which the rat is exposed to UCSs following conditioning or extinction. Context-preference tests assessed contextual fear. In Exps I–III with 88 female Wistar rats, the inflation paradigm, in which fear of a CS paired with a weak UCS is enhanced by exposure to intense UCS alone, was investigated. Results show that the contextual fear that was present when the target CS was tested was reduced by presenting the intense UCSs in a different context, by exposing Ss to the context following their presentation, and by signaling the intense UCSs with a 2nd CS. In Exp IV with 32 female Wistar rats, UCS exposures following conditioning or extinction both produced contextual fear, but only fear of the extinguished CS was reinstated by that fear. In Exp V with 32 female Wistar rats, identical amounts of contextual fear reinstated fear of an extinguished CS, but not a nonextinguished CS, when the 2 types of CSs were arranged to evoke comparable amounts of fear prior to testing. It is suggested that contextual fear plays a role in the reinstatement paradigm but not in the inflation paradigm. (33 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Examined the course of extinction of 1 behavior as a function of the presence and subsequent absence of reinforcement for alternative behavior. 4 experiments were conducted, using a total of 102 male hooded rats in 3 experiments and 30 adult White Carneaux pigeons in the 4th. Major findings are: (a) Topography and reinforcement schedule for alternative behavior had little differential effect. (b) High-frequency reinforcement of alternative behavior increased suppressive effects of extinction, and low-frequency reinforcement did not. (c) Reinforced alternative behavior maintained for a relatively long period decreased subsequent recovery of the original response programed for extinction, resulting in a substantial saving in total number of extinction responses. (d) Temporary reinforcement of alternative behavior produced more permanent suppression in the context of simple extinction than in the context of SD (change in stimulus) periods in discrimination learning. (17 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
extinction, the loss of responding that occurs when a conditioned stimulus (CS) is presented repeatedly without the unconditioned stimulus (US) following conditioning, is a basic fact of learning and a basic tool in behavior therapy the research to be reviewed in this chapter suggests that even after fairly prolonged extinction procedures, extinguished fear stimuli can still evoke substantial fear under the right conditions / have suggested that extinction does not cause unlearning, but instead gives the CS a second, and therefore "ambiguous," meaning / the meaning of the stimulus, and the response it currently evokes, may depend fundamentally on its current context the first part of this chapter reviews some of the evidence that supports this view of context and extinction / the research involves experiments investigating the rat's fear of tone and light conditioned stimuli associated with mild footshock / "contexts" were usually provided by the boxes or apparatuses in which the rat was exposed to these events the second part of the chapter surveys a wider range of stimuli that can function as contexts, including drug states, emotional states, and time / suggest that extinction performance may inherently depend on where, when, and under what conditions the fear stimulus is encountered / fear can easily recur after extinction because extinction fundamentally involves learning about the context (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
When conditioning and extinction are conducted in different contexts, a return to the conditioning context causes a renewal of conditioned responding. The results of 4 experiments with rats in an appetitive conditioning preparation suggest that renewal results from a failure to retrieve extinction outside the extinction context. Presentation of a cue from extinction during renewal testing attenuated the renewal effect; attenuation depended on the cue's correlation with extinction. On its own, the cue did not elicit responding, suggesting it was not a conditioned excitor; it also failed tests for conditioned inhibition. The authors propose that it worked by retrieving a memory of extinction. The findings parallel previous results with spontaneous recovery and are thus consistent with the view that renewal and spontaneous recovery result from a common mechanism. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Five conditioned suppression experiments with rats explored retention interval and context effects in discrimination reversal learning. In the discrimination phase, a tone (T) was paired with shock, and a houselight-off stimulus (L) was presented alone; in the reversal phase, T was extinguished and L was paired with shock. Discrimination training made L a latent inhibitor but not a conditioned inhibitor. A 28-day delay after the reversal caused spontaneous recovery to T but had no effect on L. A context switch before the reversal caused more rapid conditioning to L but did not affect extinction to T. A return to the original context after the reversal had occurred in a different context renewed suppression to T and latent inhibition to L; contextual control was strong 21 days later. Tests in a neutral context indicated that each training context controlled performance to T and L. A memory retrieval framework may begin to integrate the effects of context and time. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Background: Rat studies have demonstrated that exposure to environments associated with alcohol intake reinstates alcohol seeking after extinction of alcohol-reinforced responding in a different context. However, extinction is limited as an abstinence model, because humans typically abstain because of negative consequences associated with excessive drinking. It is currently unknown whether alcohol-associated contexts can provoke relapse to alcohol seeking after alcohol-taking behavior is suppressed by adverse consequences in a different context. Methods: Alcohol-preferring P rats were first given home-cage access to 20% ethanol. Next, they were trained to self-administer 20% ethanol in one context (context A). Subsequently, all rats continued to self-administer alcohol in a different context (context B). For one group, 50% of alcohol-reinforced responses were punished by mild footshock; two other groups either received noncontingent shocks or no shock. A fourth group was given extinction training in context B. All rats were then tested for relapse to alcohol seeking under extinction conditions in contexts A and B. Results: In Context B, alcohol-taking behavior was suppressed by contingent shock (punishment) and extinction training but not by noncontingent shock. In Context A, relapse to alcohol seeking was reliably observed in the punished and extinction groups; a context switch had no effect on alcohol seeking in the no-shock or noncontingent shock groups. Conclusions: Our data indicate that punishment-induced suppression of alcohol-taking behavior is context-dependent. We propose that our procedure can be used to explore mechanisms of context-induced relapse to alcohol seeking after alcohol-taking behavior is suppressed by adverse consequences.
Article
Three experiments with rats examined the effects of thinning the rate of reinforcement for the alternative behavior in the resurgence paradigm. In all experiments, pressing one lever (L1) was first reinforced and then extinguished while pressing a second alternative lever (L2) was then reinforced. When L2 responding was then extinguished, L1 responses "resurged." Resurgence was always observed when L2 was reinforced on an unchanging reinforcement schedule during Phase 2. However, other rats received systematic decreases in the rate of L2 reinforcement before extinction of L2 began. Such a "thinning" procedure was predicted to reduce final resurgence by associating L1 extinction with longer and longer periods without a reinforcer. The procedure did reduce the resurgence effect observed when L2 was put on extinction (Experiment 3). However, in each experiment, thinned groups also returned to L1 responding, and continued to make L1 responses, while the reinforcement schedule for L2 was being thinned. Fine-grained analysis of behavior in time suggested that this early resurgence was not due to adventitious reinforcement of L1, occasion setting of L1 by reinforcer presentation, or the entrainment of L1 as a schedule-induced interim behavior. The results are overall consistent with the hypothesis that resurgence is a renewal effect in which extinguished L1 responding recovers when the context provided by the L2 reinforcement schedule is changed. Challenges for this view are also discussed.
Article
Three experiments with rat subjects examined the effects of contextual stimuli on performance in appetitive conditioning. A 10-sec tone conditioned stimulus (CS) was paired with a food-pellet unconditioned stimulus (US); conditioning was indexed by the observation of headjerking, a response of the rat to auditory stimuli associated with food. In Experiment 1, a context switch following initial conditioning did not affect conditioned responding to the tone; however, when the response was extinguished in the different context, a return to the original conditioning context “renewed” extinguished responding. These results were replicated in Experiments 2 and 3 after equating exposure to the two contexts (Experiment 2) and massing the conditioning and extinction trials (Experiment 3). The results of Experiment 1 also demonstrated that separate exposure to the US following extinction reinstates extinguished responding to the tone; this effect was further shown to depend at least partly on presenting the US in the context in which testing is to occur (Experiments 2 and 3). Overall, the results are consistent with previous data from aversive conditioning procedures. In either appetitive or aversive conditioning, the context may be especially important in affecting performance after extinction.
Article
In two experiments with rat subjects, we examined the effects of a retention interval on performance in two conditioning paradigms in which a conditioned stimulus (CS) was associated with different unconditioned stimuli (USs) in successive phases of the experiment- Experiment 1 was designed to examine aversive-appetitive transfer, in which the CS is associated with shock and then food; Experiment 2 was designed to examine appetitive-aversive transfer, in which the CS is associated with food and then shock. Aversive and appetitive conditioned responses (freezing and head-jerk responding, respectively) were scored from videotape. In both experiments, a 28-day retention interval following the end of Phase 2 caused a recovery of the Phase 1 response and a resuppression of the Phase 2 response. The results suggest that the original association is not destroyed when the CS is associated with a new US in Phase 2. They also suggest that both retroactive and proactive interference effects may result-from interference with performance output rather than a disruption or loss of what is learned during or stored from the target phase.
Article
In four experiments utilizing an appetitive conditioning preparation, reacquisition of conditioned responding was found to occur both rapidly and slowly following extinction. In Experiment 1, acquisition of responding to a tone that had been conditioned and extinguished occurred more rapidly than acquisition in either a group that received equivalent exposure to the food unconditioned stimulus or a “rest” control group that received only exposure to the apparatus in the first two phases. However, reacquisition was impaired relative to acquisition in a “learning-experienced” group that had previously received conditioning and extinction with a different stimulus. Experiments 2 and 3 produced similar results, but also found that high responding during reacquisition was confined to trials that followed reinforced, rather than nonreinforced, trials. Experiment 4, in which very few initial conditioning trials were used, produced reacquisition that was slow compared with both learning-experienced and rest controls. The results are consistent with a role for sequential learning: Reacquisition is rapid when animals have learned that reinforced trials signal other reinforced trials.
Article
Effects on the extinction of GABAergic drug, chlordiazepoxide (CDP), and glutamatergic drug, D: -cycloserine (DCS), in C57BL/6 mice were compared. Following a palatability test (Experiment 1), Experiments 2-6 involved food-reinforced lever press training followed by extinction sessions at 1- or 4-day intervals. The effects of drugs were examined. Experiment 7 involved a two-lever task. CDP did not affect food palatability (Experiment 1), but facilitated extinction when administered prior to extinction sessions via intracerebral (Experiment 2) or peripheral administration at 1-day (Experiments 3-7) or 4-day intervals (Experiment 6). Reducing the amount of training prior to extinction reduced the delay in the effect of CDP typically seen, and CDP had a larger effect in early sessions on mice that had received less training (Experiment 3). There was some evidence that CDP could be blocked by flumazenil (Experiment 4), and CDP withdrawal reversed extinction facilitation (Experiments 5 and 7). With 4-day intervals, DCS administered immediately following extinction sessions, or pre-session CDP, facilitated extinction with 48-trial sessions (experiment 6B). With six-trial sessions, the co-administration of post-session DCS enhanced facilitation produced by pre-session CDP (experiment 6A). Finally, CDP facilitated extinction in a dose-related fashion following training on a two-lever food-reinforced task (Experiment 7). The findings are consistent with the hypotheses that two neurotransmitter systems have different roles in operant extinction and that glutamatergic systems are involved in extinction learning and GABAergic systems involved in the expression of that learning. This parallels findings with extinction following Pavlovian conditioning, which has been more extensively investigated.
Article
Rats received 15 pairings of a CS and shock in one context, and then a series of CS-alone trials in a second context. Even though this extinction procedure produced a complete loss of conditioned suppression, when the animals were returned to the site of original conditioning, suppression was renewed to a level comparable to that of animals that had not undergone extinction. Controls indicated that the renewed suppression was not due solely to pseudoconditioning, suggesting that the CS-US association had survived extinction. Renewed suppression was also demonstrated in a third context that was never associated with shock. Loss of suppression did not necessarily depend upon inhibitory conditioning of the extinction context. The data suggest that extinction of conditioned fear is specific to the context in which it occurs. They also suggest the possibility that animals might discriminate episodes in which a CS is reinforced and nonreinforced independently of the excitatory or inhibitory status of cues, like contextual stimuli, that are coincidentally present during those episodes.
Article
Two appetitive conditioning experiments with rats examined reacquisition after conditioned responding was eliminated by either extinction or by a partial reinforcement procedure in which reinforced trials were occasionally presented among many nonreinforced trials. In Experiment 1, reacquisition to a conditional stimulus (CS) that had been conditioned and extinguished was more rapid than acquisition in a group that had received no prior conditioning. However, the addition of occasional reinforced trials to extinction slowed this rapid reacquisition effect. Experiment 2 replicated the result and showed that a procedure in which the CS and the unconditional stimulus (US) were unpaired in extinction interfered even further with reacquisition. The results suggest that rapid reacquisition is ordinarily produced when reinforced trials provide a contextual cue that can renew responding by signaling other acquisition trials (Ricker & Bouton, 1996). The effects of partial reinforcement in extinction are surprising from several theoretical perspectives and have useful clinical implications.
Article
Renewal of operant performance formerly eliminated by omission or noncontingency training was explored in two experiments with rats. When pressing a lever was trained with food reinforcement in one context (A) and then eliminated in a second context (B), responding was renewed by returning the rats to the original context (A). This ABA renewal effect was demonstrated in Experiment 1 when the elimination training was an omission procedure (delivery of food for withholding responding) and in Experiment 2 when it was a noncontingency procedure (delivery of food irrespective of responding). Because omission training (differential reinforcement of other behavior) and noncontingency training have been used in applied settings as effective procedures to reduce undesired human behaviors, the clinical implications of our findings for the relapse of undesirable behavior were discussed.
Article
Three experiments with rat subjects examined the effects of contextual stimuli on performance in Pavlovian aversive-to-appetitive and appetitive-to-aversive transfer. A 30-s tone conditioned stimulus (CS) was first paired with either a shock or food pellet unconditioned stimulus (US) in one phase and then paired with the other US in a subsequent phase. Aversive and appetitive conditioning were indexed by the observation of freezing and headjerking, respectively. In aversive-appetitive transfer (Experiment 1), a context switch following Phase 1 aversive conditioning reduced the retarded appetitive conditioning ordinarily observed in Phase 2. In addition, a return to the Phase 1 context after completion of Phase 2 caused renewed Phase 1 responding and decreased Phase 2 responding. In appetitive-aversive transfer (Experiments 2 and 3), a context switch following Phase 1 appetitive conditioning had no effect because neither positive nor negative transfer with Phase 2 aversive conditioning was observed in this situation. However, a return to the Phase 1 conditioning context after completion of Phase 2 caused renewed Phase 1 responding at 1- and 28-day retention intervals (Experiment 2). These results are consistent with a role for context as a retrieval cue for memories corresponding to different phases. This view is discussed along with more traditional associative perspectives on contextual control.
Article
Conditioning and extinction of fear have traditionally been viewed as two independent learning processes for encoding representations of contexts or cues (conditioned stimuli, CS), aversive events (unconditioned stimuli, US), and their relationship. Based on the analysis of protein kinase signaling patterns in neurons of the fear circuit, we propose that fear and extinction are best conceptualized as emotional states triggered by a single CS representation with two opposing values: aversive and non-aversive. These values are conferred by the presence or absence of the US and encoded by distinct sets of kinase signaling pathways and their downstream targets. Modulating specific protein kinases thus has the potential to modify emotional states, and hence, may emerge as a promising treatment for anxiety disorders.