Can evolutionarily "hardwired" fear responses, e.g. for spiders and snakes, be reprogramed unconsciously in the human brain? Currently, exposure therapy is amongst the most effective treatments for anxiety disorders, but this intervention is subjectively aversive to patients, and rates of premature attrition from treatment have been reported to be as high as 70%. Here we introduce a novel method to bypass the subjective unpleasantness in conscious exposure, by directly pairing monetary reward with unconscious occurrences of decoded representations of naturally feared objects in the brain. The typical way to identify multivoxel functional magnetic resonance imaging (fMRI) representations for feared objects involves repeated presentations of the relevant images explicitly to subjects. However, for our potential treatment method to be effective in actual clinical settings, we need to decode fear representations without triggering excessively aversive reactions which may cause patients to dropout from treatments prematurely. Here we overcome this challenge by capitalizing on recent advancements in fMRI decoding techniques: We employed a method called hyperalignment to infer the relevant representations of feared objects for a designated participant based on data from other "surrogate" participants. This way the procedure completely bypasses the need for the conscious encountering of feared objects. We demonstrate that our method can lead to reliable reductions in physiological fear responses measured by skin conductance as well as amygdala hemodynamic activity. Not only do these results raise the intriguing possibility that naturally occurring fear can be "re-programmed" outside of conscious awareness, importantly they also created the rare opportunity for a psychological intervention of this nature to be tested rigorously in a double-blind placebo-controlled fashion. This may pave the way for a novel treatment method, combining the appealing rationale and proven efficacy of conventional psychotherapy with the rigor and leverage of clinical neuroscience.
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