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A Role for the Bed Nucleus of the Stria Terminalis in Risk for Anxiety Disorders

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A Role for the Bed Nucleus of the Stria Terminalis in Risk for Anxiety Disorders Open access Review Gen Psych: first published as 10.1136/gpsych-2019-100137 on 18 December 2019. Downloaded from Extending the neurocircuitry of behavioural inhibition: a role for the bed nucleus of the stria terminalis in risk for anxiety disorders Jacqueline Clauss 1,2 To cite: Clauss J. Extending ABSTRACT diseases. Understanding the neurobiology of the neurocircuitry of Behavioural inhibition is a biologically based risk factor risk for anxiety disorders is a critical first step. behavioural inhibition: a role for anxiety disorders. Children with behavioural inhibition for the bed nucleus of the stria are shy, cautious and avoidant of new situations. Much terminalis in risk for anxiety Behavioural inhibition research on behavioural inhibition has focused on the disorders. General Psychiatry Anxiety disorders are often preceded by amygdala as an underlying neural substrate and has 2019;32:e100137. doi:10.1136/ behavioural inhibition,14–17 the tendency to gpsych-2019-100137 identified differences in amygdala function and volume; 18 however, amygdala findings have yet to lead to meaningful be shy, cautious and avoidant of novelty. Received 13 October 2019 interventions for prevention or treatment of anxiety This temperament begins in infancy as high Revised 11 November 2019 disorders. The bed nucleus of the stria terminalis (BNST) is reactivity to novelty. Infants who are highly Accepted 13 November 2019 a prime candidate to be a neural substrate of behavioural reactive to novel stimuli and distressed on inhibition, given current evidence of BNST function and separation from their mothers typically development in human research and animal models. become behaviourally inhibited children.18–20 Children with behavioural inhibition have an increased Behavioural inhibition represents the most startle response to safety cues and an increased cortisol extreme 15% on a continuum of reactivity response to social evaluative situations, both of which to novelty and many, but not all, children are mediated by the BNST. In rodents, activation of the with behavioural inhibition develop anxiety BNST underlies contextual fear responses and responses disorders later in life.15 Behaviourally inhib- to uncertain and sustained threat. Non- human primates with anxious temperament (the macaque equivalent of ited children most commonly develop social behavioural inhibition) have increased BNST activity to anxiety disorder; one meta-analysis found http://gpsych.bmj.com/ ambiguous social situations, and activity of the BNST in that 43% of behaviourally inhibited children anxious temperament is significantly heritable. Importantly, develop social anxiety disorder by late child- the BNST is sexually dimorphic and continues to develop hood or early adolescence.15 However, child- into adulthood, paralleling the development of anxiety hood behavioural inhibition also increases disorders in humans. Together, these findings suggest that risk for other anxiety disorders, including further investigation of the BNST in behavioural inhibition generalised anxiety disorder,21 22 phobias,22–24 is necessary and may lead to new avenues for the and agoraphobia.23 Childhood behavioural prevention and treatment of anxiety disorders. inhibition also increases risk for a number on October 2, 2021 by guest. Protected copyright. of other known comorbidities of anxiety disorders, including depression22 25–27 and © Author(s) (or their ANXIETY DISORDERS substance use disorders.28 29 employer(s)) 2019. Re- use Anxiety disorders are chronic,1 highly Behavioural inhibition can be observed permitted under CC BY-NC. No 2–4 30 31 commercial re- use. See rights impairing and associated with the devel- across cultures and is evolutionarily and permissions. Published by opment of comorbid mood and substance conserved across species, including earth- BMJ. use disorders.5–7 Individuals with anxiety worms, octopuses, non- human primates 1Child and Adolescent disorders rarely seek treatment (approxi- and others (for a review, see Gosling and Psychiatry, Massachusetts mately one in five individuals with an anxiety John32). Additionally, behavioural inhibition General Hospital, Boston, 33 34 Massachusetts, USA disorder seek treatment in both the USA and is heritable and has moderate stability 8 9 18 35 2Child and Adolescent China) and responses to current treatments across the lifetime; taken together, these Psychiatry, McLean Hospital, are modest at best.10 11 The estimated cost of data suggest that behavioural inhibition has a Belmont, Massachusetts, USA anxiety disorders in America alone is over biological basis. Because behavioural inhibi- 12 13 Correspondence to US$45 billion. Given this substantial soci- tion precedes the onset of anxiety disorders, Dr Jacqueline Clauss; etal burden of anxiety disorders, more work is has a known biological basis and is measur- jclauss@ partners. org needed to prevent and treat these devastating able, understanding the neurobiology of Clauss J. General Psychiatry 2019;32:e100137. doi:10.1136/gpsych-2019-100137 1 General Psychiatry Gen Psych: first published as 10.1136/gpsych-2019-100137 on 18 December 2019. Downloaded from behavioural inhibition may allow us to gain traction on there were no group differences in startle to fear cues.48 the prevention and treatment of anxiety disorders. Additionally, Schmidt et al found no temperament differ- In 1988, Dr Jerome Kagan proposed that the biolog- ences in magnitude of fear- potentiated startle in young ical bases of behavioural inhibition were hyperactivity children.41 These findings suggest that children with of the amygdala and hyper-reactivity of the sympathetic behavioural inhibition have elevated startle to safety, but nervous system; these changes led to increased reac- not fear cues, and that heightened startle to safety cues tivity to novelty.36 Physiological studies in children with may predict risk for the development of anxiety disorders. behavioural inhibition have shown that behavioural Fear- potentiated startle (ie, increased startle after seeing inhibition is associated with decreased threshold for a fearful stimulus) is thought to be mediated by the amyg- activation of the sympathetic nervous system,37 less para- dala, whereas anxiety- potentiated startle (ie, increased sympathetic input, as measured by a higher and more startle in a context that might be associated with threat) is stable (less variable) heart rate,36 38–40 and an increased thought to be mediated by the BNST.49 While safety cues sympathetic response, as measured by increased heart signal the lack of threat in these paradigms, behaviourally rate reactivity to stressors,36 41 larger pupillary diam- inhibited children may interpret the entire startle para- eter, increased laryngeal muscle tension, and increased digm as anxiety- provoking and thus have elevated startle urinary norepinephrine concentration.36 39 Cortisol and to safety cues mediated by BNST activation; however, that related hormones (ie, corticotropin- releasing hormone hypothesis has yet to be tested at this time. Consistent (CRH)) modulate these stress responses (both initiation findings of elevated startle to safety cues in behavioural of the stress response and inhibition through a negative inhibition suggest that BNST function might be altered feedback pathway)42 and much of the early research into in behavioural inhibition. the biological basis of behavioural inhibition focused on the cortisol response. Neurobiology of behavioural inhibition Several studies of the hypothalamic- pituitary- adrenal A number of recent manuscripts have reviewed the (HPA) axis response in behavioural inhibition have found neurobiological underpinnings of behavioural inhibi- 50–52 that behavioural inhibition is associated with higher tion. Inhibited temperament was initially described as cortisol concentrations at baseline and in response to the tendency to avoid and be wary of novel people, places stress. Inhibited children had significantly higher cortisol or things. As the amygdala responds to novel, fearful and 53 54 concentrations at home and in the laboratory39 41 43. salient stimuli in the environment and has efferent Pérez- Edgar et al44 found that behavioural inhibition was projections to the limbic system, sensory cortex, and brain- 53–56 associated with higher morning salivary cortisol and that stem, amygdala hyperactivity was first proposed as the 39 57 increased cortisol concentration and increased negative neurobiological basis of inhibited temperament. affect predicted more social withdrawal behaviour, a Early neuroimaging studies found that behavioural inhi- 58 50 59 precursor of social anxiety. Further investigation showed bition was associated with a faster, larger and more 58 that increased cortisol concentration in children aged sustained amygdala response to novel social stimuli. http://gpsych.bmj.com/ 4 years was significantly associated with increased social Behavioural inhibition was also associated with increased 60 61 withdrawal behaviour, specifically in boys with a history of amygdala response to newly familiar social stimuli and 62 high negative affect. High cortisol might sustain negative internal reflection about social stimuli. Consistent with affect and behavioural inhibition in boys with high nega- evidence in rodents that sustained stress and increased 63–65 tive affect early in life. Children with behavioural inhibi- cortisol activity leads to larger amygdala volume, tion may be more sensitive to social stressors, resulting in amygdala
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