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Frasier RM, Starski PA, de Oliveira Sergio T, Grippo AJ, Hopf FW. Sex differences in heart rate variability measures that predict alcohol drinking in rats. Addict Biol 2024; 29:e13387. [PMID: 38502109 PMCID: PMC11061848 DOI: 10.1111/adb.13387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/23/2024] [Accepted: 02/13/2024] [Indexed: 03/20/2024]
Abstract
Problem alcohol drinking continues to be a substantial cost and burden. In addition, alcohol consumption in women has increased in recent decades, and women can have greater alcohol problems and comorbidities. Thus, there is a significant need for novel therapeutics to enhance sex-specific, individualized treatment. Heart rate (HR) and HR variability (HRV) are of broad interest because they may be both biomarkers for and drivers of pathological states. HRV reflects the dynamic balance between sympathetic (SNS, 'fight or flight') and parasympathetic (PNS, 'rest and digest') systems. Evidence from human studies suggest PNS predominance in women and SNS in men during autonomic regulation, indicating the possibility of sex differences in risk factors and physiological drivers of problem drinking. To better understand the association between HRV sex differences and alcohol drinking, we examined whether alcohol consumption levels correlated with time domain HRV measures (SDNN and rMSSD) at baseline, at alcohol drinking onset, and across 10 min of drinking, in adult female and male Wistar rats. In particular, we compared both HRV and HR measures under alcohol-only and compulsion-like conditions (alcohol + 10 mg/L quinine), because compulsion can often be a significant barrier to treatment of alcohol misuse. Importantly, previous work supports the possibility that different HRV measures could be interpreted to reflect PNS versus SNS influences. Here, we show that females with higher putative PNS indicators at baseline and at drinking onset had greater alcohol consumption. In contrast, male intake levels related to increased potential SNS measures at drinking onset. Once alcohol was consumed, HR predicted intake level in females, perhaps a pharmacological effect of alcohol. However, HRV changes were greater during compulsion-like intake versus alcohol-only, suggesting HRV changes (reduced SNS in females, reduced PNS and increased HR in males) specifically related to aversion-resistant intake. We find novel and likely clinically relevant autonomic differences associated with biological sex and alcohol drinking, suggesting that different autonomic mechanisms may promote differing aspects of female and male alcohol consumption.
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Affiliation(s)
- Raizel M. Frasier
- Department of PsychiatryIndiana University School of MedicineIndianapolisIndianaUSA
- Medical Scientist Training ProgramIndiana University School of MedicineIndianapolisIndianaUSA
| | - Phillip A. Starski
- Department of PsychiatryIndiana University School of MedicineIndianapolisIndianaUSA
| | | | - Angela J. Grippo
- Department of PsychologyNorthern Illinois UniversityDeKalbIllinoisUSA
| | - F. Woodward Hopf
- Department of PsychiatryIndiana University School of MedicineIndianapolisIndianaUSA
- Stark Neurosciences Research InstituteIndiana UniversityIndianapolisIndianaUSA
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Grippo AJ, Akinbo OI, Amidei A, Wardwell J, Normann MC, Ciosek S, Kovalev D. Maladaptive cardiac and behavioral reactivity to repeated vicarious stress exposure in socially bonded male prairie vole siblings. Auton Neurosci 2024; 251:103145. [PMID: 38194740 PMCID: PMC10843770 DOI: 10.1016/j.autneu.2023.103145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/11/2024]
Abstract
Behaviors, emotions, and cardiovascular functions are influenced by stress. But these detrimental effects are not exclusive to an individual that directly experiences stress. Stress is also experienced vicariously through observation of another individual undergoing stress. The current study used the strong social bonds in socially monogamous prairie voles to determine effects of repeated vicarious stress on cardiac and behavioral outcomes. Male prairie voles were exposed to either a 5-minute open field chamber alone [separate (control)] or while concurrently witnessing their sibling undergo a tail-suspension stressor [concurrent (experimental)], repeated across 4 sessions. Cardiac responses in animals in the open field were evaluated for heart rate and heart rate variability prior to, during, and after each test session, and behaviors were evaluated for motion, exploration, stress reactivity, and anxiety-relevant behaviors during each test session. The concurrent condition (versus separate) displayed increased heart rate and reduced heart rate variability during repeated test sessions, and impaired recovery of these parameters following the test sessions. The pattern of disturbances suggests that both increased sympathetic and reduced parasympathetic influence contributed to the cardiac responses. Animals in the concurrent condition (versus separate) displayed disrupted rearing, grooming, and motion; reduced duration of center section exploration; and increased freezing responses across repeated test sessions. Collectively, cardiac and behavioral stress reactivity are increased as a function of vicarious stress in prairie voles, which are evident across repeated experiences of stress. These results inform our understanding of the experience of vicarious stress in social species, including humans.
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Affiliation(s)
- Angela J Grippo
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA.
| | - Oreoluwa I Akinbo
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Alex Amidei
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Joshua Wardwell
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Marigny C Normann
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Sarah Ciosek
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Dmitry Kovalev
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
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Frasier RM, De Oliveira Sergio T, Starski PA, Grippo AJ, Hopf FW. Heart rate variability measures indicating sex differences in autonomic regulation during anxiety-like behavior in rats. Front Psychiatry 2023; 14:1244389. [PMID: 38025424 PMCID: PMC10644002 DOI: 10.3389/fpsyt.2023.1244389] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Mental health conditions remain a substantial and costly challenge to society, especially in women since they have nearly twice the prevalence of anxiety disorders. However, critical mechanisms underlying sex differences remain incompletely understood. Measures of cardiac function, including heart rate (HR) and HR variability (HRV), reflect balance between sympathetic (SNS) and parasympathetic (PNS) systems and are potential biomarkers for pathological states. Methods To better understand sex differences in anxiety-related autonomic mechanisms, we examined HR/HRV telemetry in food-restricted adult rats during novelty suppression of feeding (NSF), with conflict between food under bright light in the arena center. To assess HRV, we calculated the SDNN (reflective of both SNS and PNS contribution) and rMSSD (reflective of PNS contribution) and compared these metrics to behaviors within the anxiety task. Results Females had greater HR and lower SNS indicators at baseline, as in humans. Further, females (but not males) with higher basal HR carried this state into NSF, delaying first approach to center. In contrast, males with lower SNS measures approached and spent more time in the brightly-lit center. Further, females with lower SNS indicators consumed significantly more food. In males, a high-SNS subpopulation consumed no food. Among consumers, males with greater SNS ate more food. Discussion Together, these are congruent with human findings suggesting women engage PNS more, and men SNS more. Our previous behavior-only work also observed female differences from males during initial movement and food intake. Thus, high basal SNS in females reduced behavior early in NSF, while subsequent reduced SNS allowed greater food intake. In males, lower SNS increased engagement with arena center, but greater SNS predicted higher consumption. Our findings show novel and likely clinically relevant sex differences in HRV-behavior relationships.
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Affiliation(s)
- Raizel M. Frasier
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
- Medical Scientist Training Program, Indiana University School of Medicine, Indianapolis, IN, United States
| | | | - Phillip A. Starski
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Angela J. Grippo
- Department of Psychology, Northern Illinois University, DeKalb, IL, United States
| | - F. Woodward Hopf
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
- Stark Neurosciences Research Institute, Indiana University, Indianapolis, IN, United States
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Kitano K, Yamagishi A, Horie K, Nishimori K, Sato N. Helping behavior in prairie voles: A model of empathy and the importance of oxytocin. iScience 2022; 25:103991. [PMID: 35310938 PMCID: PMC8931361 DOI: 10.1016/j.isci.2022.103991] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/15/2022] [Accepted: 02/23/2022] [Indexed: 11/29/2022] Open
Abstract
Several studies suggest that rodents show empathic responses and helping behavior toward others. We examined whether prairie voles would help conspecifics who were soaked in water by opening a door to a safe area. Door-opening latency decreased as task sessions progressed. Female and male voles stayed close to the soaked voles' side at equal rates and opened the door with similar latencies. When the conspecific was not soaked in water, the door-opening latency did not decrease. This suggests that the distress of the conspecific is necessary for learning to open the door and that the door-opening performed by prairie voles corresponds to helping behavior. Additionally, we examined the helping behavior in prairie voles in which oxytocin receptors were genetically knocked out. Oxytocin receptor knockout voles demonstrated less learning of the door-opening behavior and less interest in soaked conspecifics. This suggests that oxytocin is important for the emergence of helping behavior. Prairie voles demonstrated helping behavior toward a cagemate in distress There was no difference in helping behavior depending on the helper’s sex Learning of the helping behavior was prevented when cagemates were not in distress Oxytocin receptor knockout prairie voles demonstrated less helping behavior
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Affiliation(s)
- Kota Kitano
- Department of Psychological Sciences, Kwansei Gakuin University, 1-1-155, Uegahara, Nishinomiya, Hyogo 662-8501, Japan
| | - Atsuhito Yamagishi
- Department of Psychological Sciences, Kwansei Gakuin University, 1-1-155, Uegahara, Nishinomiya, Hyogo 662-8501, Japan
| | - Kengo Horie
- Silvio O. Conte Center for Oxytocin and Social Cognition, Center for Translational Social Neuroscience, Yerkes National Primate Research Center, Emory University, 954 Gatewood Road, Atlanta, GA 30329, USA
| | - Katsuhiko Nishimori
- Department of Obesity and Inflammation Research, Fukushima Medical University, Fukushima, Fukushima 960-1295, Japan
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University, Fukushima, Fukushima 960-1295, Japan
| | - Nobuya Sato
- Department of Psychological Sciences, Kwansei Gakuin University, 1-1-155, Uegahara, Nishinomiya, Hyogo 662-8501, Japan
- Corresponding author
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Leal PEDPT, da Silva AA, Rocha-Gomes A, Riul TR, Cunha RA, Reichetzeder C, Villela DC. High-Salt Diet in the Pre- and Postweaning Periods Leads to Amygdala Oxidative Stress and Changes in Locomotion and Anxiety-Like Behaviors of Male Wistar Rats. Front Behav Neurosci 2022; 15:779080. [PMID: 35058757 PMCID: PMC8763963 DOI: 10.3389/fnbeh.2021.779080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022] Open
Abstract
High-salt (HS) diets have recently been linked to oxidative stress in the brain, a fact that may be a precursor to behavioral changes, such as those involving anxiety-like behavior. However, to the best of our knowledge, no study has evaluated the amygdala redox status after consuming a HS diet in the pre- or postweaning periods. This study aimed to evaluate the amygdala redox status and anxiety-like behaviors in adulthood, after inclusion of HS diet in two periods: preconception, gestation, and lactation (preweaning); and only after weaning (postweaning). Initially, 18 females and 9 male Wistar rats received a standard (n = 9 females and 4 males) or a HS diet (n = 9 females and 5 males) for 120 days. After mating, females continued to receive the aforementioned diets during gestation and lactation. Weaning occurred at 21-day-old Wistar rats and the male offspring were subdivided: control-control (C-C)—offspring of standard diet fed dams who received a standard diet after weaning (n = 9–11), control-HS (C-HS)—offspring of standard diet fed dams who received a HS diet after weaning (n = 9–11), HS-C—offspring of HS diet fed dams who received a standard diet after weaning (n = 9–11), and HS-HS—offspring of HS diet fed dams who received a HS diet after weaning (n = 9–11). At adulthood, the male offspring performed the elevated plus maze and open field tests. At 152-day-old Wistar rats, the offspring were euthanized and the amygdala was removed for redox state analysis. The HS-HS group showed higher locomotion and rearing frequency in the open field test. These results indicate that this group developed hyperactivity. The C-HS group had a higher ratio of entries and time spent in the open arms of the elevated plus maze test in addition to a higher head-dipping frequency. These results suggest less anxiety-like behaviors. In the analysis of the redox state, less activity of antioxidant enzymes and higher levels of the thiobarbituric acid reactive substances (TBARS) in the amygdala were shown in the amygdala of animals that received a high-salt diet regardless of the period (pre- or postweaning). In conclusion, the high-salt diet promoted hyperactivity when administered in the pre- and postweaning periods. In animals that received only in the postweaning period, the addition of salt induced a reduction in anxiety-like behaviors. Also, regardless of the period, salt provided amygdala oxidative stress, which may be linked to the observed behaviors.
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Affiliation(s)
- Pedro Ernesto de Pinho Tavares Leal
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
- Laboratório de Nutrição Experimental – LabNutrex, Departamento de Nutrição, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Alexandre Alves da Silva
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
- Laboratório de Nutrição Experimental – LabNutrex, Departamento de Nutrição, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Arthur Rocha-Gomes
- Laboratório de Nutrição Experimental – LabNutrex, Departamento de Nutrição, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Tania Regina Riul
- Laboratório de Nutrição Experimental – LabNutrex, Departamento de Nutrição, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
- Programa de Pós-Graduação em Ciências da Nutrição, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Rennan Augusto Cunha
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Christoph Reichetzeder
- Department of Nutritional Toxicology, Institute of Nutritional Science, University of Potsdam, Potsdam, Germany
- Christoph Reichetzeder,
| | - Daniel Campos Villela
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
- *Correspondence: Daniel Campos Villela,
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Affective empathy and prosocial behavior in rodents. Curr Opin Neurobiol 2021; 68:181-189. [PMID: 34091136 DOI: 10.1016/j.conb.2021.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 12/30/2022]
Abstract
Empathy is an essential function for humans as social animals. Emotional contagion, the basic form of afffective empathy, comprises the cognitive process of perceiving and sharing the affective state of others. The observational fear assay, an animal model of emotional contagion, has enabled researchers to undertake molecular, cellular, and circuit mechanism of this behavior. Such studies have revealed that observational fear is mediated through neural circuits involved in processing the affective dimension of direct pain experiences. A mouse can also respond to milder social stimuli induced by either positive or negative emotional changes in another mouse, which seems not dependent on the affective pain circuits. Further studies should explore how different neural circuits contribute to integrating different dimensions of affective empathy.
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Normann MC, Cox M, Akinbo OI, Watanasriyakul WT, Kovalev D, Ciosek S, Miller T, Grippo AJ. Differential paraventricular nucleus activation and behavioral responses to social isolation in prairie voles following environmental enrichment with and without physical exercise. Soc Neurosci 2021; 16:375-390. [PMID: 33947321 DOI: 10.1080/17470919.2021.1926320] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Social stressors produce neurobiological and emotional consequences in social species. Environmental interventions, such as environmental enrichment and exercise, may modulate physiological and behavioral stress responses. The present study investigated the benefits of environmental enrichment and exercise against social stress in the socially monogamous prairie vole. Female prairie voles remained paired with a sibling (control) or were isolated from a sibling for 4 weeks. The isolated groups were assigned to isolated sedentary, isolated with environmental enrichment, or isolated with both enrichment and exercise conditions. Behaviors related to depression, anxiety, and sociality were investigated using the forced swim test (FST), elevated plus maze (EPM), and a social crowding stressor (SCS), respectively. cFos expression was evaluated in stress-related circuitry following the SCS. Both enrichment and enrichment with exercise protected against depression-relevant behaviors in the FST and social behavioral disruptions in the SCS, but only enrichment with exercise protected against anxiety-related behaviors in the EPM and altered cFos expression in the hypothalamic paraventricular nucleus in isolated prairie voles. Enrichment may improve emotion-related and social behaviors, however physical exercise may be an important component of environmental strategies for protecting against anxiety-related behaviors and reducing neural activation as a function of social stress.
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Affiliation(s)
- Marigny C Normann
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Miranda Cox
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Oreoluwa I Akinbo
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | | | - Dmitry Kovalev
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Sarah Ciosek
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Thomas Miller
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Angela J Grippo
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
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Grippo AJ, McNeal N, Normann MC, Colburn W, Dagner A, Woodbury M. Behavioral and neuroendocrine consequences of disrupting a long-term monogamous social bond in aging prairie voles. Stress 2021; 24:239-250. [PMID: 32820956 PMCID: PMC7914264 DOI: 10.1080/10253890.2020.1812058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 08/14/2020] [Indexed: 12/13/2022] Open
Abstract
Social support from a spouse, long-term partner, or someone who provides emotional or instrumental support may protect against consequences of aging, including mediating behavioral stress reactivity and altering neurobiological process that underlie short-term stress responses. Therefore, long-term social bonding may have behavioral and neurobiological benefits. The socially monogamous prairie vole provides a valuable experimental model for investigating the benefits of long-term social bonds on short-term stress reactivity in aging animals, given their unique social structure of forming enduring opposite-sex bonds, living in family groups, and bi-parental rearing strategies. Male-female pairs of long-term, cohabitating prairie voles were investigated for short-term behavioral and neuroendocrine stress reactivity following either long-term social pairing (control), or a period of social isolation. In Experiment 1, social isolation was associated with altered behavioral reactivity to an acute swim stressor, and greater neural activation in the hypothalamic paraventricular nucleus, as well as specifically the parvocellular region, following the swim stressor (vs. control). In Experiment 2, social isolation was associated with greater corticosterone reactivity following an acute restraint stressor (vs. control). No sex differences were observed. Exploratory correlation and subgroup analyses revealed systematic relationships among various demographic variables (such as age of the subjects, amount of time the pair cohabitated together, and number of litters the pair reared together) and the behavioral and neuroendocrine outcome measures. These findings may inform our understanding of the benefits of long-term social bonding on modulating short-term behavioral and neuroendocrine responses to stress.LAY SUMMARYReceiving social support from a long-term spouse or partner, or having a strong support network from friends, may have important health benefits as people age. In aging monogamous prairie voles, social isolation from a long-term social partner disrupted behaviors and short-term stress responses, whereas living with a long-term partner protected against these disruptions. This research is important for our understanding of the benefits of social support on stress responses as we age.
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Affiliation(s)
- Angela J Grippo
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Neal McNeal
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Marigny C Normann
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - William Colburn
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Ashley Dagner
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
| | - Matthew Woodbury
- Department of Psychology, Northern Illinois University, DeKalb, IL, USA
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Sullivan RM, Opendak M. Neurobiology of Infant Fear and Anxiety: Impacts of Delayed Amygdala Development and Attachment Figure Quality. Biol Psychiatry 2021; 89:641-650. [PMID: 33109337 PMCID: PMC7914291 DOI: 10.1016/j.biopsych.2020.08.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/16/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022]
Abstract
Anxiety disorders are the most common form of mental illness and are more likely to emerge during childhood compared with most other psychiatric disorders. While research on children is the gold standard for understanding the behavioral expression of anxiety and its neural circuitry, the ethical and technical limitations in exploring neural underpinnings limit our understanding of the child's developing brain. Instead, we must rely on animal models to build strong methodological bridges for bidirectional translation to child development research. Using the caregiver-infant context, we review the rodent literature on early-life fear development to characterize developmental transitions in amygdala function underlying age-specific behavioral transitions. We then describe how this system can be perturbed by early-life adversity, including reduced efficacy of the caregiver as a safe haven. We suggest that greater integration of clinically informed animal research enhances bidirectional translation to permit new approaches to therapeutics for children with early onset anxiety disorders.
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Affiliation(s)
- Regina M. Sullivan
- Emotional Brain Institute, Nathan Kline Institute, New York, NY USA,Child & Adolescent Psychiatry, New York University Langone Medical Center, New York, NY USA
| | - Maya Opendak
- Emotional Brain Institute, Nathan Kline Institute, New York, NY USA,Child & Adolescent Psychiatry, New York University Langone Medical Center, New York, NY USA
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