Intensive Auditory Comprehension Treatment for People with Severe Aphasia

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Intensive Auditory Comprehension Treatment for People with Severe Aphasia:
Outcomes and Use of Self-Directed Strategies

A dissertation proposal submitted to the
Division of Graduate Education and Research
Of the University of Cincinnati

in partial fulfillment of the requirements of the degree of

DOCTOR OF PHILOSOPHY
In the Department of Communication Sciences and Disorders
In the College of Allied Health Sciences

Dissertation Committee: Aimee Dietz, Ph D., chair Lisa Kelchner, Ph.D. Robin Thomas, Ph.D. Pete Scheifele, Ph.D

2012 by
Kelly Knollman-Porter

Intensive Auditory Comprehension Treatment

Abstract

The purpose of this study was to determine the efficacy of an intensive (2 hours/day, 5 days/week for 3 weeks) treatment protocol on individuals with severe, chronic speech perception or auditory comprehension deficits associated with aphasia. Two experiments were implemented to examine this purpose. Experiment I: Single Word Comprehension Approach (SWCA) established the effectiveness of an intensive treatment protocol on single word auditory comprehension (n = 6). Alternatively, Experiment II: Speech Perception Approach (SPA) examined the outcomes of an intensive treatment protocol on speech perception in individuals with profound global aphasia (n = 2). The researcher employed an ABA single subject design for both experiments, and examined the following variables: (1) changes in single word comprehension (SWCA) or speech perception (SPA); (2) the number of self-initiated requests for repetition and lip-reading cues; (3) the effectiveness of repetition and lip-reading cues; (4) the indirect effects of the protocols on verbal expression (SWCA – naming; SPA – repetition; Both – narrative skills); (5) and generalization to functional communication environments. Results revealed that all participants enrolled in the SWCA or SPA exhibited a lack of awareness regarding their comprehension impairment at the onset of treatment. Despite this reduced awareness, 7 of the 8 demonstrated a large effect on either single word comprehension or speech perception. A generalization effect to untrained stimuli was also exhibited by these participants. The use of repetition successfully improved speech perception and single word comprehension in all participants; however lip-reading was beneficial in only 1 of the 8 participants. An indirect effect on verbal expression naming ability was demonstrated by 5 of the 6 SWCA participants; this effect was not observed in the SPA participants. Carryover of these skills to functional communication situations was reported by one of the eight caregivers. These finding suggest that

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Intensive Auditory Comprehension Treatment

individuals with severe to profound, deficits have the potential for continued improvements in speech perception or auditory comprehension, even in the chronic stages of recovery. However, caregiver involvement, use of personally relevant stimuli and rehabilitation protocols designed to increase self-awareness of speech perception and single word comprehension impairments may be a crucial link to generalization of communication gains to functional situations with this population.

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Intensive Auditory Comprehension Treatment

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Intensive Auditory Comprehension Treatment

Acknowledgements

This work is dedicated to the men and women with aphasia who have willingly and openly allowed me to be a part of their lives. Without hesitation, they have been my true teachers. These individuals and their families have not only demonstrated to me the unique, complex world of aphasia, but more so, the true meaning of perseverance, dedication, and strength. They have and continue to inspire and challenge me as a clinician, researcher and as a human being.

I would also like to specifically thank my mentor, Dr. Lisa Kelchner, who has been and continues to be a role model for me in the field. Her passion and depth of knowledge are astounding. Even with these skills, she consistently displays humility and grace; never demeaning or critical. Words cannot thank her enough for the many years of training, advice, and guidance she has provided me over the past 15 years.

Three years ago, I had the pleasure of meeting Dr. Aimee Dietz. Little did I know at the time, she would play such a crucial role in the success of my program. Even through pregnancy and the birth of her beautiful son, she continued to challenge and encourage me to develop my skills as a clinical researcher. She supported me in my belief that clinical research, while time intensive, can make a difference in the lives of individuals with aphasia. My sincere thanks goes to her for the many hours of editing and guidance provided through this journey.

I will forever be indebted to my parents, Don and Doris Knollman. From a very young age, they instilled in me the importance of education, integrity, and hard work. During every stage in my life, they have been a constant source of assistance and encouragement. I thank them

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Intensive Auditory Comprehension Treatment

for standing in the gap while I chased yet another dream. I couldn’t ask for a better Mom and

Dad.
In addition, one of my greatest blessings are my children. Both Anna and Eric have been a constant support for me along this long journey. More than once, they used my own words against me when the more challenging phases of the Ph.D. program arose. It was a joy to watch them grow and mature through this process. It is my hope, that through my experiences they can realize that with persistence and dedication anything in life is possible.

Finally, over twenty years ago, God brought an amazing man into my life. Never have I known anyone as self-sacrificing and supportive as my husband, Randy Porter. He was my midnight tech support, statistics and excel tutor, my cheerleader and my counselor when the challenges of the program became overwhelming. Without hesitation, he is the best thing that ever happened to me. I love him very much and am forever grateful for his never ceasing, unconditional support.

This dissertation is truly not my own; and could not have been initiated or completed without the support of many other wonderful individuals. To the following I am also thankful: Dr. Pete Scheifele, Dr. Robin Thomas, Miami University Aphasia Support Group members and their families, my wonderful colleagues at Miami University, my students, and my church family.

“We are like clay jars in which this treasure is stored. The real power comes from God and not from us.” 2 Corinthians 4:7

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Intensive Auditory Comprehension Treatment

Table of Contents
List of Tables List of Figures Chapter 1

xvii xx

  • Introduction
  • 1

  • 5
  • Purpose of the Investigation

Chapter 2

  • Review of the Literature
  • 7

  • 7
  • Normal Comprehension: The Process

Acoustic phonetic analysis Phonological processing Lexical semantic system
889

  • Speech Perception/Auditory Comprehension Deficits Associated with Aphasia
  • 10

The Influence of Short-Term Working Memory on Comprehension
Short-term working memory: Normal Comprehension Short-term working memory: Comprehension in aphasia
11 11 12

  • Self-Awareness
  • 13

  • 14
  • Self-Awareness in Aphasia

  • Assessment of Comprehension Deficits in Aphasia
  • 18

  • 19
  • Assessment of short-term working memory and comprehension

Therapeutic Management of Comprehension Deficits in Aphasia
Intensity of treatment
20 22 23 24
Utilization of repetition cues Utilization of lip-reading cues

  • Research Questions and Research Hypothesis: Experiment I - SWCA
  • 25

  • 27
  • Research Questions and Research Hypothesis: Experiment II – SPA

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Intensive Auditory Comprehension Treatment

Chapter 3

  • Methods
  • 29

  • 31
  • Participants

  • Setting
  • 34

34 34
Design Screening and Cognitive-Linguistic Assessment Materials

  • Equipment
  • 34

34 35
Audio and video equipment Audiometer

  • Screening
  • 35

35 35 35 36 36
Social and medical history survey Hearing screening Visual acuity screening Response screening Comprehension severity screening

Cognitive-Linguistic Assessment
Phonological processing
36 36 37 37 37
Semantic processing Working memory Non-linguistic cognitive assessment tools

Screening and Cognitive-Linguistic Assessment Procedures
Video recording protocol
38 38

  • Screening
  • 38

38 38 39 39 40 40
Medical and social history survey Hearing screening Visual acuity screening Response screening Comprehension severity screening Neuroimaging

  • Cognitive-Linguistic Assessment
  • 40

  • 41
  • Measurement of phonological processing and working memory

Measurement of semantic comprehension and working memory 43

  • Non-linguistic cognitive assessment protocol
  • 44

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Intensive Auditory Comprehension Treatment

Assessment of Experimental Complexity Stimuli Materials
Experiment I: SWCA assessment materials Experiment II: SPA assessment materials
Assessment of Experimental Stimuli Complexity Procedures
Experiment I: SWCA assessment procedures Experiment II: SPA assessment procedures
Experimental Materials
44 44 46 46 47 50 53
Experiment I: SWCA
Equipment
53 53 53 54
Single word comprehension stimuli Verbal naming stimuli

  • Experiment II: SPA
  • 54

54 55
Speech perception stimuli Verbal repetition stimuli

Common experimental materials
Audio and video equipment Picture description
55 55 55 55 55
Communication history survey Frustration/fatigue monitoring

  • Experimental Procedures
  • 55

Experiment I: SWCA
SWCA baseline phase
Single word comprehension Verbal naming measures
SWCA treatment phase SWCA probe data
56 56 56 56 56 59

  • 59
  • SWCA maintenance phase

Experiment II: SPA
SPA baseline phase
Speech perception
60 60 60 60 61 62
Verbal repetition measures
SPA treatment phase SPA probe data

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Intensive Auditory Comprehension Treatment

  • SPA maintenance phase
  • 62

Common experimental procedures
Picture description
62 62 63 63
Communication history survey Frustration/fatigue monitoring

  • Independent and Dependent Variables
  • 63

63 64 65 66 66
Experiment I: SWCA independent and dependent variables Experiment II: SPA independent and dependent variables
Research Fidelity Analyses Ethical Issues

Chapter 4

  • Results
  • 68

68 68
Single Word Comprehension Study
Participant T.G.

  • Single word comprehension – Response to intervention
  • 69

69 70 71
Trained stimuli Untrained stimuli Comprehension error patterns

Self-initiated requests for cues
Repetition
72 72

  • 73
  • Lip-reading

  • Comprehension accuracy following cues
  • 73

73 75
Repetition Lip-reading

Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
75 75 76 77

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Intensive Auditory Comprehension Treatment

  • Generalization to functional communication environments
  • 78

  • 81
  • Participant B.G.

  • Single word comprehension – Response to intervention
  • 81

82 82 83
Trained stimuli Untrained stimuli Comprehension error patterns

Self-initiated requests for cues
Repetition
84 84

  • 85
  • Lip-reading

  • Comprehension accuracy following cues
  • 86

86 87
Repetition Lip-reading

Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
88 88 89 91

  • Generalization to functional communication environments
  • 92

  • 93
  • Participant T.O.

Single word comprehension – Response to intervention
Trained stimuli
93 94 94 95
Untrained stimuli Comprehension error patterns

Self-initiated requests for cues
Repetition
96 96

  • 97
  • Lip-reading

  • Comprehension accuracy following cues
  • 98

98 99
Repetition Lip-reading

Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
99 99 100 102

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Intensive Auditory Comprehension Treatment

Generalization to functional communication environments
Participant B.D.
Single word comprehension – Response to intervention
103 105 105 105 106 107
Trained stimuli Untrained stimuli Comprehension error patterns

Self-initiated requests for cues
Repetition
108 108

  • 109
  • Lip-reading

  • Comprehension accuracy following cues
  • 110

110 111
Repetition Lip-reading

Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
112 112 114 115

  • Generalization to functional communication environments
  • 116

  • 119
  • Participant D.W.

Single word comprehension – Response to intervention
Trained stimuli
120 120 120 121
Untrained stimuli Comprehension error patterns

Self-initiated requests for cues
Repetition
122 122

  • 123
  • Lip-reading

  • Comprehension accuracy following cues
  • 124

124 125
Repetition Lip-reading

Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
126 126 128 129

  • 130
  • Generalization to functional communication environments

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Intensive Auditory Comprehension Treatment

  • Participant R.K.
  • 133

  • Single word comprehension – Response to intervention
  • 133

134 134 135
Trained stimuli Untrained stimuli Comprehension error patterns

Self-initiated requests for cues
Repetition
136 136

  • 137
  • Lip-reading

  • Comprehension accuracy following cues
  • 138

138 139
Repetition Lip-reading

Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
140 140 141 142

  • Generalization to functional communication environments
  • 143

  • 146
  • Experiment I: SWCA – Summary of results

Research Question 1 Research Question 2 Research Question 3 Research Question 4 Research Question 5 Research Question 6 Research Question 7 Research Question 8
146 147 148 148 149 150 151 151

Speech Perception Study
Participant T.L.
Speech perception – Response to intervention
152 152 153 153 153 154
Trained stimuli Untrained stimuli Speech perception error patterns

Self-initiated requests for cues
Repetition
156 156

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Intensive Auditory Comprehension Treatment

  • Lip-reading
  • 156

  • Speech perception accuracy following cues
  • 157

157 158
Repetition Lip-reading

Verbal Expression – Indirect treatment effects
Repetition of trained speech perception stimuli Repetition of untrained speech perception stimuli Picture description
158 158 159 160

  • Generalization to functional communication environments
  • 161

  • 164
  • Participant E.R.

Speech perception – Response to intervention
Trained stimuli
165 165 165 166
Untrained stimuli Speech perception error patterns

Self-initiated requests for cues
Repetition
167 167

  • 168
  • Lip-reading

  • Speech perception accuracy following cues
  • 169

169 170
Repetition Lip-reading

Verbal Expression – Indirect treatment effects
Repetition of trained speech perception stimuli Repetition of untrained speech perception stimuli Picture description
171 171 172 173

  • Generalization to functional communication environments
  • 174

  • 177
  • Experiment I: SPA – Summary of results

Research Question 1 Research Question 2 Research Question 3 Research Question 4 Research Question 5 Research Question 6 Research Question 7 Research Question 8
177 178 178 178 179 179 180 180

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Intensive Auditory Comprehension Treatment

Chapter 5

  • Discussion
  • 181

  • 181
  • Experiment I: SWCA – Major Outcomes

  • Response to intervention
  • 182

185 185 188 191 192
Effectiveness of self-initiated requests for cues
Repetition Lip-reading
Verbal expression: Indirect treatment effects Generalization to functional communication environments

  • Experiment II: SPA – Major Outcomes
  • 195

  • Response to intervention
  • 196

197 200 201
Effectiveness of self-initiated requests for cues Verbal expression: Indirect treatment effects Generalization to functional communication environments

  • Limitations and Direction for Future Research
  • 202

Intensity of the treatment protocol Neurologic correlates Utilization of lip-reading cues Indirect impact on verbal expression Functional relevance of treatment stimuli Functional communication
202 203 204 205 206 206

  • 208
  • Were the outcomes worth the effort?

  • Conclusions
  • 210

211 225 228 229 230 231

References

Appendix A. Inclusion/Exclusion Criteria Appendix B. Hearing Screening Appendix C. Visual Acuity Screening Appendix D. Response Screening Appendix E. Lexical Analysis SWCA

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Intensive Auditory Comprehension Treatment

  • Appendix F. Experimental Stimuli Complexity Assessment SWCA High Frequency
  • 233

Appendix G. Experimental Stimuli Complexity Assessment SWCA Medium Frequency 235 Appendix H. Experimental Stimuli Complexity Assessment SWCA Low Frequency Appendix I. Experimental Stimuli Complexity Assessment SPA CV Appendix J. Experimental Stimuli Complexity Assessment SPA CVC Appendix K. Experimental Stimuli Complexity Assessment SPA CCVC Appendix L. Baseline and Probe SWCA High Frequency Version A Appendix M. Baseline and Probe SWCA High Frequency Version B Appendix N. Baseline and Probe SWCA Medium Frequency Version A Appendix O. Baseline and Probe SWCA Medium Frequency Version B Appendix P. Baseline and Probe SWCA Low Frequency Version A Appendix Q. Baseline and Probe SWCA Low Frequency Version B Appendix R. Treatment SWCA High Frequency
237 239 242 244 246 248 250 252 254 256 258 263 267 271 273 275 277 279 283 287 288
Appendix S. Treatment SWCA Medium Frequency Appendix T. Treatment SWCA Low Frequency Appendix U. Baseline and Probe SPA - CV Version A Appendix V. Baseline and Probe SPA - CV Version B Appendix W. Baseline and Probe SPA - CVC Version A Appendix X. Baseline and Probe SPA - CVC Version B Appendix Y. Treatment SPA – CV Stimuli Appendix Z. Communication History Survey Appendix AA. Fatigue/Frustration Scale Appendix BB. Frustration Form

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  • Classical and Instrumental Conditioning

    Classical and Instrumental Conditioning

    Classical and Instrumental Conditioning Lecture 8 1 Basic Procedure for Classical Conditioning CS US (Bell) (Meat Powder) CR UR (Salivation) (Salivation) 2 Major Phenomena of Classical Conditioning • Acquisition – CR to CS Reinforced by US – Response Gains Strength • Magnitude of CR • Probability of CR 3 Acquisition: Trial 1 CS Bell Food US Drops of CR Saliva Time 4 Acquisition: Trial 5 CS Bell Food US Drops of CR Saliva Time 5 Acquisition: Trial 10 CS Bell Food US Drops of CR Saliva Time 6 Acquisition of a Conditioned Response CS ==> US 1 0.8 Positive 0.6 Acceleration Negative Acceleration 0.4 Probability Probability of CR 0.2 The “Sigmoidal” (S-Shaped) Learning Curve is Also Known as an Ogive 0 1 2 3 4 5 6 7 8 9 10 11 12 Trials 7 Two Shapes to the Learning Curve Naïve Organism/ Experienced Organism/ Complex Behavior Simple Behavior Response Strength Response Strength 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Trials Trials 8 Major Phenomena of Classical Conditioning • Acquisition • Extinction – No Reinforcement – Response Loses Strength 9 Extinction: Trial 1 CS Bell Food US Drops of CR Saliva Time 10 Extinction: Trial 5 CS Bell Food US Drops of CR Saliva Time 11 Extinction: Trial 10 CS Bell Food US Drops of CR Saliva Time 12 Extinction of a Conditioned Response CS ==> No US 1 0.8 0.6 0.4 Probability Probability of CR 0.2 0 1 2 3 4 5 6 7 8 9 10 11 12 Trials 13 Major Phenomena of Classical Conditioning • Acquisition • Extinction • Spontaneous Recovery – Rest After Extinction – Retest CS alone 14 Spontaneous
  • Spontaneous Recovery ƒ Stimulus Generalization/ Discrimination

    Spontaneous Recovery ƒ Stimulus Generalization/ Discrimination

    Module 18 Classical Conditioning (cont’d) Processes of Conditioning Acquisition Extinction Spontaneous Recovery Stimulus Generalization/ Discrimination Spontaneous recovery The re-emergence of an extinguished CR after a period of rest Classical Conditioning Generalization tendency for stimuli similar to CS to elicit similar responses Can be adaptive- as children taught to fear moving cars on street to respond similarly to trucks and motorcycles on the street Discrimination in classical conditioning, the learned ability to distinguish between a CS and other stimuli that do not signal a US E.g., fear pitbulls but not golden retrievers Lightning but not flashing disco lights Updating Pavlov’s understanding Role of mental processes Thought/expectation of the CS-US link matters for conditioning Consistent link between the CS and US matters Role of biological dispositions Each species’ biological dispositions prepare it to learn the associations that enhance its survival Taste aversion (rather than sight) in rats - they are biologically prepared to learn associations between the taste of a particular food and the onset of an illness, but not between sights and sounds and an illness. Classical Conditioning: Key Points CC prepares us for significant events by identifying events that commonly predict them Can explain a wide range of behavior Advertising, food aversion, phobias Focuses on naturally occurring responses Not under voluntary control Any naturally occurring behavior (or response) can be conditioned to neutral stimulus Eye blink — bell Sexual arousal — perfume How far does the power of CC spread? Pictures rates as similar / neutral by a group of judges Then these faces were presented to a new group – each picture was paired with either a pleasant, neutral, or unpleasant odor.
  • Context-Dependent Extinction Learning Emerging from Raw

    Context-Dependent Extinction Learning Emerging from Raw

    www.nature.com/scientificreports OPEN Context‑dependent extinction learning emerging from raw sensory inputs: a reinforcement learning approach Thomas Walther1, Nicolas Diekmann1, Sandhiya Vijayabaskaran1, José R. Donoso1, Denise Manahan‑Vaughan2, Laurenz Wiskott1 & Sen Cheng1* The context‑dependence of extinction learning has been well studied and requires the hippocampus. However, the underlying neural mechanisms are still poorly understood. Using memory‑driven reinforcement learning and deep neural networks, we developed a model that learns to navigate autonomously in biologically realistic virtual reality environments based on raw camera inputs alone. Neither is context represented explicitly in our model, nor is context change signaled. We fnd that memory‑intact agents learn distinct context representations, and develop ABA renewal, whereas memory‑impaired agents do not. These fndings reproduce the behavior of control and hippocampal animals, respectively. We therefore propose that the role of the hippocampus in the context‑ dependence of extinction learning might stem from its function in episodic‑like memory and not in context‑representation per se. We conclude that context‑dependence can emerge from raw visual inputs. Treatment of anxiety disorders by exposure therapy is ofen followed by unwanted renewal of the seemingly extinguished fear. A better understanding of the cognitive and neural mechanisms governing extinction learn- ing and fear renewal is therefore needed to develop novel therapies. Te study of extinction learning goes back to Ivan Pavlov’s research on classical conditioning 1. Pavlov and his colleagues discovered that the conditioned response (CR) to a neutral conditioned stimulus (CS) diminishes over time, if the CS is presented repeatedly without reinforcement by an unconditioned stimulus (US).
  • Compound Stimulus Extinction Reduces Spontaneous Recovery in Humans

    Compound Stimulus Extinction Reduces Spontaneous Recovery in Humans

    Downloaded from learnmem.cshlp.org on August 16, 2017 - Published by Cold Spring Harbor Laboratory Press Brief Communication Compound stimulus extinction reduces spontaneous recovery in humans Cesar A.O. Coelho,1,2 Joseph E. Dunsmoor,1 and Elizabeth A. Phelps1,3 1Department of Psychology, New York University, New York, New York 10003, USA; 2Departamento de Psicobiologia, Universidade Federal de Sa˜o Paulo, Sa˜o Paulo, Sa˜o Paulo 04023062, Brazil; 3Emotional Brain Institute, Nathan Kline Institute for Psychiatric Research, Orangeburg, New York 10962, USA Fear-related behaviors are prone to relapse following extinction. We tested in humans a compound extinction design (“deepened extinction”) shown in animal studies to reduce post-extinction fear recovery. Adult subjects underwent fear conditioning to a visual and an auditory conditioned stimulus (CSA and CSB, respectively) separately paired with an electric shock. The target CS (CSA) was extinguished alone followed by compound presentations of the extinguished CSA and non- extinguished CSB. Recovery of conditioned skin conductance responses to CSA was reduced 24 h after compound extinc- tion, as compared with a group who received an equal number of extinction trials to the CSA alone. The inability to control or regulate emotional expression in the Experiments in rats have demonstrated the effectiveness of face of nonthreatening stimuli is a hallmark of many anxiety dis- deepened extinction in reducing post-extinction fear recovery orders. A growing body of clinical translational research is begin- (Rescorla 2006; Leung et al. 2012; McConnell et al. 2013), recovery ning to characterize abnormalities associated with the control of of lever press responding (Janak and Corbit 2011) and recovery of fear expression in anxiety disorders by utilizing fear conditioning cocaine seeking (Kearns et al.