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Background and objectives Modern learning theories suggest that particularly strong associative learning contributes to the etiology and maintenance of anxiety disorders, thus explaining why some individuals develop an anxiety disorder after a frightening (conditioning) event, whereas others do not. However, associative learning has rarely been investigated experimentally in specific phobias. The current study investigated associative learning in patients with flying phobia and healthy controls using a modified version of Olson and Fazio’s associative learning paradigm (Olson & Fazio, 2001). Methods Under the guise of an attention task, patients with flying phobia (n = 33), and healthy controls (n = 39) viewed a series of distracters interspersed with pairings of novel objects (counterbalanced conditioned stimuli, CSs) with frightening and pleasant stimuli (unconditioned stimuli, USs). Results After the conditioning procedure patients with flying phobia rated both CSs more frightening and showed stronger discrimination between the CSs for valence compared to healthy controls. Conclusions Our findings indicate a particularly stronger conditioning effect in flying phobia. These results contribute to the understanding of the etiology of specific phobia and may help to explain why only some individuals develop a flying phobia after an aversive event associated with flying.

Traditionally, anxiety disorders have been considered to be a learned fear response to a stimulus after a frightening experience with that stimulus (Pavlov, 1927 and Watson and Rayner, 1920). However, retrospective investigation into the learning history of fear showed that not all people experiencing fear or trauma in a given situation go on to develop a phobia, and that patients with anxiety disorders and healthy controls report a similar amount and intensity of frightening experiences with typical phobic stimuli (Lautch, 1971, Liddell and Lyons, 1978 and Rachman, 1977). With respect to flying phobia, 3 retrospective studies investigating associative learning experiences before the development of the flying phobia have been conducted so far. In interview studies, Wilhelm and Roth (1997) found that participants with flying phobia and healthy controls did not differ in the number of reported conditioning events associated with flying, and Schindler, Vriends, Michael, and Margraf (submitted for publication) found a similar pattern of results: Patients and healthy controls reported an equal number of comparable frightening events associated with flying. In a study with aircrew participants, Aitken, Lister, and Main (1981) showed that not all people who have had fearful events during flying go on to develop phobias. They found that a higher percentage of healthy controls reported having experienced a significant flying accident compared to participants with a flying phobia. In sum, the findings that healthy controls and patients with flying phobia both report aversive experiences during flying and that only patients developed a specific phobia after these incidents demonstrate, that the assumption that associative learning is an appropriate model for the development of specific phobia is doubted today. In the past decade conditioning models have experienced a renaissance, as associative learning models have become more sophisticated (Field, 2000) and findings that patients with anxiety disorders (social anxiety disorder, post-traumatic stress disorder and panic disorder) show different associative learning effects in comparison to healthy controls have been published (Blechert et al., 2007, Grillon and Morgan, 1999, Hermann et al., 2002, Michael et al., 2007, Orr et al., 2000 and Peri et al., 2000). Compared to healthy controls, patients with these anxiety disorders show either stronger discrimination between a CS paired with an aversive stimulus (e.g., electric shock, CS+) and a CS not paired (CS–) (Orr et al., 2000) or stronger CRs to both CSs, indicating stimulus generalization (Mineka & Zinbarg, 1996), or weaker inhibition of the fear response in the presence of safety signals (Davis, Falls, & Gewirtz, 2000). These results indicate that patients may have developed the disorder because of their propensity to form particular strong conditioning responses or they might reflect an epiphenomenon contributing to the maintenance of the disorder. Although specific phobias are the most common anxiety disorders (Kessler et al., 2005), to date associative learning has only been investigated in spider phobia. Schweckendiek et al. (2011) used a novel picture–picture conditioning paradigm and found that patients with spider phobia showed enhanced brain activation to a CS that was paired with phobia-relevant pictures (US) and not to CSs that were paired with non-phobic aversive USs or neutral pictures in the fear network. Regarding verbal ratings (e.g., fear, valence), patients showed higher discrimination between the CSs that were paired with phobic or non-phobic USs and neutral USs compared to healthy controls. These results show a phobia-relevant conditionabilty effect measured by brain activation and a general conditionability effect (independent from phobia-(ir)relevant USs) measured by verbal ratings. Thus indeed a stronger conditioning effect might play a role in specific phobia at least at subjective levels. In the present study we experimentally investigated associative learning effects in flying phobia, using a modified version of the associative learning paradigm of Olson and Fazio, 2001 and Olson and Fazio, 20023 for its lifelike design. As in everyday life, in which many associations will be formed between flying and mildly aversive USs (e.g., hard work life, reports of turbulent flights), this paradigm uses mildly aversive USs, namely words and pictures. Further, similar to the associations of flying in real life with pleasant (e.g., holidays, nice view, smiling crew) and frightening (e.g., strange movements in the plane, reports of flying accidents on TV) stimuli, this paradigm uses several pleasant and frightening USs. Finally, the participants view, under the guise of an attention and surveillance task, a series of random images and words (430 trials) interspersed with CS–US pairings (40 trials), making it closer to real life in the sense that associative learning always takes place within a context of many distracting stimuli. In our paradigm, neutral novel cartoon characters served as CSs. Of the 2 counterbalanced CSs 1 CS was paired with 10 different pleasant USs (CSpleas) and the other CS with 10 different frightening USs (CSfear). In a subsequent evaluation task participants rated how anxious they feel when viewing the CSs and their valence. Stronger associative learning was measured by the differentiation between CSfear and CSpleas (Orr et al., 2000) as well as generalization of the CSfear to the CSpleas (Davis et al., 2000). Recent studies have shown that increased contingency awareness in healthy participants is often correlated with stronger associative learning (Pleyers, Corneille, Luminet, & Yzerbyt, 2007). Thus, we also explored if contingency awareness of the CS–US pairings influences conditionability.

As can be seen in Table 2, the main effect for CS Type was significant for fear and valence ratings of the counterbalanced CSs (resp. F(1, 70) = 5.635, p = .020, ηp2 = 7.5% and F(1, 70) = 4.876, p = .031, ηp2 = 6.5%). The CS that was paired with frightening USs (CSfear) was rated significantly more frightening and more negative than the CS that was paired with pleasant USs (CSpleas) (see Fig. 1 for the means of the CSs in both groups), indicating successful conditioning on both rating scales. Table 2. Main and interaction effect statistics of anxiety and valence ratings after the conditioning task. Factor SS df F p η2 Anxiety ratings CS Type 2.39 1 4.88 .03 6.5% Group 15.12 1 4.08 .05 5.5% CS Type × Group .39 1 .80 >.05 1.1% Valence ratings CS Type 4.67 1 5.64 .02 7.5% Group .01 1 .00 >.05 .0% CS Type × Group 4.34 1 5.29 .02 6.5% Note. CS Type = CSpleas versus CSfear, Group = patients with flying phobia versus healthy controls. Table options Full-size image (18 K) Fig. 1. Means of conditioned stimuli (pleasant, CSpleas, and frigthening, CSfear) for both diagnostic groups (flying phobia patients vs. healthy controls, HC).