Pharmacologic treatments effective in both generalized anxiety disorder and major depressive disorder: clinical and theoretical implications

The cerebellum in fear and anxiety-related disorders

Fear and anxiety-related disorders are highly prevalent psychiatric conditions characterized by avoidant and fearful reactions towards specific stimuli or situations, which are disproportionate given the real threat such stimuli entail. These conditions comprise the most common mental disorder group. There are a high proportion of patients who fail to achieve remission and the presence of high relapse rates indicate the therapeutic options available are far from being fully efficient. Despite an increased understanding the neural circuits underlying fear and anxiety-related behaviors in the last decades, a factor that could be partially contributing to the lack of adequate therapies may be an insufficient understanding of the core features of the disorders and their associated neurobiology. Interestingly, the cerebellum shows connections with fear and anxiety-related brain areas and functional involvement in such processes, but explanations for its role in anxiety disorders are lacking. Therefore, the aims of this review are to provide an overview of the neural circuitry of fear and anxiety and its connections to the cerebellum, and of the animal studies that directly assess an involvement of the cerebellum in these processes. Then, the studies performed in patients suffering from anxiety disorders that explore the cerebellum will be discussed. Finally, we'll propose a function for the cerebellum in these disorders, which could guide future experimental approaches to the topic and lead to a better understanding of the neurobiology of anxiety-related disorders, ultimately helping to develop more effective treatments for these conditions.

How could stress lead to major depressive disorder?

Stress is associated with major depressive disorder (MDD), but the underlying mechanism remains elusive. However, some experiences, referred to as stress, may actually lead to resilience. It is thus critical first to define what type of stress may lead to MDD. Long-term potentiation (LTP) and long-term depression (LTD) are both sensitive to stress, but particularly to inescapable and not escapable stress. Thus, these are the psychological aspects of stress which contribute to the development of MDD, but by which mechanisms remains still elusive. Interestingly, the same stress may facilitate LTD and impair LTP in the CA1 region. In addition, repeated efforts are often required for learning under neutral conditions but single- or few learning trials are sufficient for forming stress-related memories. If LTP is crucial for normal learning, a combination of limited LTP and facilitated LTD appears to have higher efficiency for storing stress-related memories. Chronic psychological stress may cause a hyper-link among stress-related memories across the spatiotemporal due to shared quality of inescapability, leading to automatically negative appraisal through memory generalization mechanisms in MDD patients when encountering new distinct events which are perceived to share such similarity with previous experiences.

The history of generalized anxiety disorder as a diagnostic category

From the 19th century into the 20th century, the terms used to diagnose generalized anxiety included “pantophobia” and “anxiety neurosis.” Such terms designated paroxysmal manifestations (panic attacks) as well as interparoxysmal phenomenology (the apprehensive mental state). Also, generalized anxiety was considered one of numerous symptoms of neurasthenia, a vaguely defined illness. Generalized anxiety disorder (GAD) appeared as a diagnostic category in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, when anxiety neurosis was split into GAD and panic disorder. The distinct responses these two disorders had to imipramine therapy was one reason to distinguish between the two. Since the revised DSM-III (DSM-III-R), worry about a number of life circumstances has been gradually emphasized as the distinctive symptom of GAD. Thus, a cognitive aspect of anxiety has become the core criterion of GAD. The validity of GAD as an independent category has been questioned from DSM-III up to preparation of DSM-5. Areas of concern have included the difficulty to establish clear boundaries between GAD and (i) personality dimensions, (ii) other anxiety-spectrum disorders, and (iii) nonbipolar depression. The National Institute of Mental Health has recently proposed the Research Domain Criteria (RDoC), a framework destined to facilitate biological research into the etiology of mental symptoms. Within the RDoC framework, generalized anxiety might be studied as a dimension denominated “anxious apprehension” that would typically fit into the research domain called “negative valence systems” and the more specific construct termed “potential threat.”

Benefits of Combined Psychological and Medical Therapy for Treating an Individual With Generalized Anxiety Disorder and Post-Traumatic Stress Disorder

A patient who complained of mistaking objects in his peripheral visual field for a dog was diagnosed with Generalized Anxiety Disorder (GAD) and Post-Traumatic Stress Disorder (PTSD). He also had poor nutrition, sleep problems, somatic features, drank a considerable amount of alcohol, and exercised little. As patients with these difficulties often benefit from psychological as well as medical intervention strategies, a physician and a psychologist interviewed the patient together and developed a coordinated treatment plan. The psychologist was to work with the patient on behavioral aspects of these difficulties, although the physician treated the patient with medication. Both professionals evaluated the patient’s response to medical as well as psychological treatment strategies and reinforced the other professional’s therapeutic activities. The patient improved significantly from the combined treatment program. Although it cannot be determined, it is likely that he would not have improved as much if his treatment program had not involved both the psychologist and the physician.

The Effect of Chronic Alprazolam Intake on Memory, Attention, and Psychomotor Performance in Healthy Human Male Volunteers

Alprazolam is used as an anxiolytic drug for generalized anxiety disorder and it has been reported to produce sedation and anterograde amnesia. In the current study, we randomly divided 26 healthy male volunteers into two groups: one group taking alprazolam 0.5 mg and the other taking placebo daily for two weeks. We utilized the Cambridge Neuropsychological Test Automated Battery (CANTAB) software to assess the chronic effect of alprazolam. We selected Paired Associates Learning (PAL) and Delayed Matching to Sample (DMS) tests for memory, Rapid Visual Information Processing (RVP) for attention, and Choice Reaction Time (CRT) for psychomotor performance twice: before starting the treatment and after the completion of the treatment. We found statistically significant impairment of visual memory in one parameter of PAL and three parameters of DMS in alprazolam group. The PAL mean trial to success and total correct matching in 0-second delay, 4-second delay, and all delay situation of DMS were impaired in alprazolam group. RVP total hits after two weeks of alprazolam treatment were improved in alprazolam group. But such differences were not observed in placebo group. In our study, we found that chronic administration of alprazolam affects memory but attentive and psychomotor performance remained unaffected.

The nosologic relationship between generalized anxiety disorder and major depression

Generalized anxiety disorder (GAD) has undergone a series of revisions in its diagnostic criteria that has moved it, nosologically, away from its original affiliation with panic disorder (PD) and closer to major depressive disorder (MDD). This, together with its high comorbidity and putative shared genetic risk with MDD, has brought into question its place in future psychiatric nosology, prompting the planners of Diagnostic and Statistical Manual-V (DSM-V) and International Classification of Diseases-11 (ICD-11) to set up a workgroup tasked to better understand the relationship between GAD and MDD. This review attempts to summarize the extant data to compare GAD and MDD on a series of research validators to explore this relationship. Although insufficient data currently exist for GAD in several key validator classes, tentative conclusions can be drawn on the diagnostic status of GAD in relation to MDD. Although GAD possesses substantial overlap with MDD in the areas of genetics, childhood environment, demographics, and personality traits, this tends to hold true for other anxiety disorders (ADs) as well, with the strongest evidence for PD. Data from life events, personality disorders, biology, comorbidity, and pharmacology are mixed, showing some areas of similarity between GAD and MDD but some clear differences, again with a moderate degree of nonspecificity. Thus, although the bulk of evidence supports a close underlying relationship between them, the relatively nonspecific nature of these findings provides little more reason to question the nosologic validity of GAD in relation to MDD than that of some other anxiety disorders.

The combination of agomelatine and ritanserin exerts a synergistic interaction in passive avoidance task

Agomelatine is a potent agonist at melatonergic 1 and 2 (MT1 and MT2) receptors and an antagonist at serotonin-2C (5HT-2C) receptors. It was suggested that psychotropic effects of agomelatine is associated with its melatonergic and serotonergic effects. In this study, we aimed to evaluate the effects of agomelatine alone or in combination with ritanserin (5HT-2A/2C antagonist) on memory and learning. Male Balb-C mice (25–30 g) were used, and all drugs and saline were administrated by intraperitoneal (i.p.) route 30 min prior to evaluating retention time. Whilst agomelatine was administered at the doses of 1, 10 and 30 mg/kg, ritanserin was administered at the doses of 0.1, 1 and 10 mg/kg. To evaluate memory function, passive avoidance test was used. On the first day, acquisition time and on the second day (after 24h), retention time of mice were recorded. To evaluate the synergistic activity, only the least doses of agomelatine and ritanserine were used, that is, 1 and 0.1 mg/kg, respectively. Scopolamine (1 mg/kg) was used as a reference drug, so it was combined with drug groups. Our results show that 5HT-2A/2C receptor antagonist ritanserin (1 and 4 mg/kg, i.p.) and agomelatine (10 and 30 mg/kg, i.p.) improve memory deficit induced by scopolamine, whilst a synergistic interaction is observed between ritanserin and agomelatine (0.1 mg/kg and 1 mg/kg, i.p., respectively) when they were administered at their ineffective doses. According to our findings, we concluded that agomelatine improves memory deficit and thus improves the effect of agomelatine arises from its 5HT-2C receptor antagonist activity.

Multi-modality: a new approach for the treatment of major depressive disorder

Effective treatment with antidepressants is currently limited by factors that affect treatment compliance, including delay in onset of therapeutic effects and intolerable side-effects. Recent data suggest that use of antidepressant combinations with different mechanisms of action may be a better first-line strategy prior to augmentation with other drug classes. The rationale for this approach is that combining multiple pharmacological actions affecting multiple monoamine targets produces greater efficacy. Several new multi-modal compounds are in development and early results for the most advanced agents indicate shorter onset of therapeutic effects and improved tolerability. By modulating multiple receptors and transmitter systems, it is hoped that these new agents may also treat some of the associated symptoms of major depressive disorder, such as anxiety and cognitive dysfunction.

Alprazolam potentiates the antiaversive effect induced by the activation of 5-HT(1A) and 5-HT (2A) receptors in the rat dorsal periaqueductal gray

RATIONALE

Serotonin in the dorsal periaqueductal gray (DPAG) through the activation of 5-HT(1A) and 5-HT(2A) receptors inhibits escape, a defensive behavior associated with panic attacks. Long-term treatment with antipanic drugs that nonselectively or selectively blocks the reuptake of serotonin (e.g., imipramine and fluoxetine, respectively) enhances the inhibitory effect on escape caused by intra-DPAG injection of 5-HT(1A) and 5-HT(2A) receptor agonists. It has been proposed that these compounds exert their effect on panic by facilitating 5-HT-mediated neurotransmission in the DPAG.

OBJECTIVES

The objective of this study was to investigate whether facilitation of 5-HT neurotransmission in the DPAG is also observed after treatment with alprazolam, a pharmacologically distinct antipanic drug that acts primarily as a high potency benzodiazepine receptor agonist.

MATERIALS AND METHODS

Male Wistar rats, subchronically (3-6 days) or chronically (14-17 days) treated with alprazolam (2 and 4 mg/kg, i.p.) were intra-DPAG injected with (+/-)-8-hydroxy-2-(di-n-propylamino)tetralin hydrobromide (8-OH-DPAT), (+/-)-1-(2,5-dimethoxy-4-iodophenyl) piperazine dihydrochloride (DOI), and midazolam, respectively, 5-HT(1A), 5-HT(2A/2C), and benzodiazepine receptor agonists. The intensity of electrical current that needed to be applied to the DPAG to evoke escape behavior was measured before and after the microinjection of these agonists.

RESULTS

Intra-DPAG injection of the 5-HT agonists and midazolam increased the escape threshold in all groups of animals tested, indicating a panicolytic-like effect. The inhibitory effect of 8-OH-DPAT and DOI, but not midazolam, was significantly higher in animals receiving long-, but not short-term treatment with alprazolam.

CONCLUSIONS

Alprazolam as antidepressants compounds facilitates 5-HT(1A)- and 5-HT(2A)-receptor-mediated neurotransmission in the DPAG, implicating this effect in the mode of action of different classes of antipanic drugs.

[Pharmacological treatment of generalized anxiety disorders: rationale and limitations]

The rational use of pharmacological treatment in generalized anxiety disorders is still a matter of debate due to the uncertainties concerning the nature, diagnostic criteria and target-symptoms of this frequent and potentially invalidating disorder. If benzodiazepines may still be prescribed for a limited amount of time (i.e. 6 to 12 weeks) due to the fluctuating nature of generalized anxiety, the chronic evolution of this disorder in most patients often justifies the long-term prescription of serotoninergic (5-HT) or dual-action (5HT-NA) antidepressants and sometimes of 5HT-la partial agonists like buspirone. Imipramine, a tricyclic antidepressant was the first to demonstrate its efficacy in carefully selected patients; however, due to the side-effects of this molecule recent guidelines based on controlled clinical trials, suggest to use either serotonergic antidepressants (SSRIs) or venlafaxine as a first-line treatment of generalized anxiety disorders. Because of its pharmacological profile buspirone remains however a useful option in patients with cognitive or addictive problems, especially alcoholics. If most SSRIs have demonstrated efficacy over placebo, head to head comparisons remain limited except for escitalopram which appear better tolerated than paroxétine in this indication. More recently, an anticonvulsant, pregabaline also demonstrated its efficacy in several clinical trials but the symptomatic profile of generalized anxiety patients likely to respond to this GABA analog compared to other psychotropic treatments remain to be established. The traditional use of other psychotropic agents such as hydroxyzine, an H1 histaminergic receptor antagonist, is only supported by limited scientific data; this is also the case of sedative typical antipsychotics which benefit/risk ratio should be carefully evaluated before being prescribed to generalized anxiety patients resistant to other psychotropic agents. However, the possible use of atypical antipsychotics with a better tolerance profile than the typical ones in this indication is presently under investigation in several countries. At last it is important to realize that most clinical trials in this field only include patients with non-comorbid generalized anxiety and that their conclusion may not always be generalizable to most psychiatric patients who are usually characterized by a high rate of comorbidity. In this population the indication of specific pharmacological treatments should rely on a careful evaluation of the patients drug treatment history, of the duration, evolution and functional consequences of their symptoms and of the nature of their possible comorbidity. The treatment of resistant generalized anxiety disorders remains a question for future research but the use of imipramine or sedative antipsychotics could be an option when other treatments have failed to induce any improvement.

Generalised anxiety disorder

Generalised anxiety disorder is a persistent and common disorder, in which the patient has unfocused worry and anxiety that is not connected to recent stressful events, although it can be aggravated by certain situations. This disorder is twice as common in women than it is in men. Generalised anxiety disorder is characterised by feelings of threat, restlessness, irritability, sleep disturbance, and tension, and symptoms such as palpitations, dry mouth, and sweating. These symptoms are recognised as part of the anxiety syndrome rather than independent complaints. The symptoms overlap greatly with those of other common mental disorders and we could regard the disorder as part of a spectrum of mood and related disorders rather than an independent disorder. Generalised anxiety disorder has a relapsing course, and intervention rarely results in complete resolution of symptoms, but in the short term and medium term, effective treatments include psychological therapies, such as cognitive behavioural therapy; self-help approaches based on cognitive behavioural therapy principles; and pharmacological treatments, mainly selective serotonin reuptake inhibitors.

Anxiolytic properties of agomelatine, an antidepressant with melatoninergic and serotonergic properties: role of 5-HT2C receptor blockade

RATIONALE

The novel antidepressant agent, agomelatine, behaves as an agonist at melatonin receptors and as an antagonist at serotonin (5-HT)(2C) receptors.

OBJECTIVES

To determine whether, by virtue of its antagonist properties at 5-HT(2C) receptors, agomelatine elicits anxiolytic properties in rats.

METHODS

Employing a combined neurochemical and behavioural approach, actions of agomelatine were compared to those of melatonin, the selective 5-HT(2C) receptor antagonist, SB243,213, and the benzodiazepine, clorazepate.

RESULTS

In unfamiliar pairs of rats exposed to a novel environment, agomelatine enhanced the time devoted to active social interaction, an action mimicked by clorazepate and by SB243,213. In a Vogel conflict procedure, agomelatine likewise displayed dose-dependent anxiolytic activity with a maximal effect comparable to clorazepate, and SB243,213 was similarly active in this procedure. In a plus-maze procedure in which clorazepate significantly enhanced percentage entries into open arms, agomelatine revealed only modest activity and SB243,213 was inactive. Further, like SB243,213, and in contrast to clorazepate, agomelatine did not suppress ultrasonic vocalizations emitted by rats re-exposed to an environment associated with an aversive stimulus. Whereas clorazepate reduced dialysate levels of 5-HT and noradrenaline in hippocampus and frontal cortex of freely moving rats, agomelatine did not affect extracellular levels of 5-HT and elevated those of noradrenaline. SB243,213 acted similarly to agomelatine. Melatonin, which did not modify extracellular levels of 5-HT or noradrenaline, was ineffective in all models of anxiolytic activity. Furthermore, the selective melatonin antagonist, S22153, did not modify anxiolytic properties of agomelatine in either the social interaction or the Vogel Conflict tests.

CONCLUSIONS

In contrast to melatonin, and reflecting blockade of 5-HT(2C) receptors, agomelatine is active in several models of anxiolytic properties in rodents. The anxiolytic profile of agomelatine differs from that of benzodiazepines from which it may also be distinguished by its contrasting influence on corticolimbic monoaminergic pathways.

Prenatal exposure to diazepam and alprazolam, but not to zolpidem, affects behavioural stress reactivity in handling-naïve and handling-habituated adult male rat progeny

A gentle long-lasting handling produces persistent neurochemical and behavioural changes and attenuates the impairment in the behavioural reactivity to novelty induced by the prenatal exposure to diazepam (DZ) in adult male rat progeny. This study investigated the consequences of a late prenatal treatment with three GABA/BDZ R agonists (DZ) alprazolam (ALP) and zolpidem (ZOLP)), on different stress-related behavioural patterns, in non-handled (NH), short-lasting handled (SLH) and long-lasting handled (LLH) adult male rats exposed to forced swim test (FST), acoustic startle reflex (ASR) and Vogel test (VT). The effects on motor activity were evaluated in the open field and in the Skinner box. The seizure sensitivity to picrotoxin (PTX) was investigated as an index of the functional state of GABA/BDZ Rs. A single daily s.c. injection of DZ (1.25-2.50 mg/kg) and ALP (0.125-0.250 mg/kg) over gestational days 14-20 induced a decrease in immobility time in the FST in NH rats, no change in SLH rats and an increase in LLH rats; DZ induced an increase in the peak amplitude of the ASR in NH rats, no change in SLH rats and a reduction in LLH rats; ALP was ineffective in all groups. DZ and ALP reduced the number of punished licks in the VT in NH, SLH and LLH rats while the unpunished licks were not modified. DZ decreased locomotion and the lever pressing responses while ALP increased them. DZ and ALP increased the seizure sensitivity to PTX (2.5-4.0 mg/kg i.p.). These findings indicate a convergence on anxiety-related behaviours in the effects of prenatal exposure to DZ and ALP and a differentiation on motor activity. Long-lasting handling was able to overcompensate the increased behavioural stress reactivity induced by the prenatal exposure to DZ and ALP.

Antidepressant activity of standardized extract of Bacopa monniera in experimental models of depression in rats

Bacopa monniera Wettst. (syn. Herpestis monniera L.; Scrophulariaceae) is a commonly used Ayurvedic drug for mental disorders. The standardized extract was reported earlier to have significant anti-oxidant effect, anxiolytic activity and improve memory retention in Alzheimer's disease. Presently, the standardized methanolic extract of Bacopa monniera (bacoside A - 38.0+/-0.9) was investigated for potential antidepressant activity in rodent models of depression. The effect was compared with the standard antidepressant drug imipramine (15 mg/kg, ip). The extract when given in the dose of 20 and 40 mg/kg, orally once daily for 5 days was found to have significant antidepressant activity in forced swim and learned helplessness models of depression and was comparable to that of imipramine.

Treatment of insomnia in patients with mood disorders

Mood disorders and chronic insomnia share complex theoretical and clinical relationships. This article reviews the subjective symptoms and polysomnographic findings of subjects with mood and insomnia syndromes. The polysomnographic findings reviewed include macro-architectural and micro-architectural data. Various treatments of patients with insomnia and mood disorders will be presented, including both behavioral and pharmacological interventions.

Anxiety disorders and major depression, together or apart

This paper will discuss the relationship between anxiety and depression. We will begin with a brief historical perspective. We will then move into the twentieth century, with a focus on the 1950s, at which time the introduction of pharmacological treatment options revolutionized the field of psychiatry. The use of psychiatric medications and the observation of treatment response provided an additional means of understanding the relationship between anxiety and depression. From the late 1970s to the 1990s, it became apparent that various medications possessed wider therapeutic profiles than were previously recognized. For example, many medications were found to be efficacious in both anxiety and depressive disorders. These expanded therapeutic profiles provided additional clues to fuel our thinking about the relationship between anxiety and depression. The two major objectives of this paper are, first, to describe and formalize a process of pharmacological dissection and, second, to consider how this process might contribute to our search for a better understanding of the relationship between anxiety and depression.

Flibanserin has anxiolytic effects without locomotor side effects in the infant rat ultrasonic vocalization model of anxiety

This study compared the effects of flibanserin, a novel 5-HT(1A) agonist/5-HT(2A) antagonist; diazepam, a traditional anxiolytic; and imipramine, a traditional antidepressant, on separation-induced ultrasonic vocalizations (USVs), locomotor behaviour, negative geotaxis and body temperature of 7 - 8-day-old rat pups. Flibanserin (5, 10, 25 and 50 mg kg(-1) s.c.) reduced USVs but had no effects on locomotor behaviour or negative geotaxis. Lower doses of flibanserin (0.5, 1, 2 and 4 mg kg(-1) s.c.) had no effect on any behaviour. Diazepam (0.25, 0.5, 1 and 2 mg kg(-1) s.c.) not only reduced the USVs but also increased rolling and increased the latency of the negative geotaxic response. Imipramine (10, 15, 20 and 30 mg kg(-1) s.c.) reduced USVs, increased total locomotor activity and rolling but had no effect on negative geotaxis. None of the drugs altered body temperature. Our data showed that flibanserin is as effective in reducing the USVs as diazepam and imipramine but has a lower incidence of motor side effects. This suggests that flibanserin might be effective for the treatment of mood disturbances such as anxiety.

Mirtazapine enhances frontocortical dopaminergic and corticolimbic adrenergic, but not serotonergic, transmission by blockade of alpha2-adrenergic and serotonin2C receptors: a comparison with citalopram

Mirtazapine displayed marked affinity for cloned, human alpha2A-adrenergic (AR) receptors at which it blocked noradrenaline (NA)-induced stimulation of guanosine-5'-O-(3-[35S]thio)-triphosphate ([35S]-GTPgammaS) binding. Similarly, mirtazapine showed high affinity for cloned, human serotonin (5-HT)2C receptors at which it abolished 5-HT-induced phosphoinositide generation. Alpha2-AR antagonist properties were revealed in vivo by blockade of UK-14,304-induced antinociception, while antagonist actions at 5-HT2C receptors were demonstrated by blockade of Ro 60 0175-induced penile erections and discriminative stimulus properties. Mirtazapine showed negligible affinity for 5-HT reuptake sites, in contrast to the selective 5-HT reuptake inhibitor, citalopram. In freely moving rats, in the dorsal hippocampus, frontal cortex (FCX), nucleus accumbens and striatum, citalopram increased dialysate levels of 5-HT, but not dopamine (DA) and NA. On the contrary, mirtazapine markedly elevated dialysate levels of NA and, in FCX, DA, whereas 5-HT was not affected. Citalopram inhibited the firing rate of serotonergic neurons in dorsal raphe nucleus, but not of dopaminergic neurons in the ventral tegmental area, nor adrenergic neurons in the locus coeruleus. Mirtazapine, in contrast, enhanced the firing rate of dopaminergic and adrenergic, but not serotonergic, neurons. Following 2 weeks administration, the facilitatory influence of mirtazapine upon dialysate levels of DA and NA versus 5-HT in FCX was maintained, and the influence of citalopram upon FCX levels of 5-HT versus DA and NA was also unchanged. Moreover, citalopram still inhibited, and mirtazapine still failed to influence, dorsal raphe serotonergic neurons. In conclusion, in contrast to citalopram, mirtazapine reinforces frontocortical dopaminergic and corticolimbic adrenergic, but not serotonergic, transmission. These actions reflect antagonist properties at alpha2A-AR and 5-HT2C receptors.

The noradrenergic system in pathological anxiety: a focus on panic with relevance to generalized anxiety and phobias

Over the past three decades of psychiatric research, abnormalities in the noradrenergic system have been identified in particular anxiety disorders such as panic disorder. Simultaneously, neuroscience research on fear pathways and the stress response have delineated central functions for the noradrenergic system. This review focuses on the noradrenergic system in anxiety spectrum disorders such as panic disorder, generalized anxiety disorder, and phobias for the purpose of elucidating current conceptualizations of the pathophysiologies. Neuroanatomic pathways that are theoretically relevant in anxiogenesis are discussed and the implications for treatment reviewed.