The functional anatomy, neurochemistry, and pharmacology of anxiety

The functional anatomy of anxiety involves amygdala-based neurocircuits wit h critical reciprocal connections to the medial prefrontal cortex. Traumati c experiences leave emotional imprints involving the amygdala, with facilit ated fear-conditioned associations involving declarative memory traces. Avo idance conditioning is an additional component. An understanding of the fun ctional anatomy of anxiety allows for a new perspective on the various anxi ety disorders. The neurotransmitters involved in these circuits are reviewe d for their relevance to the pharmacologic choices in the treatment of anxi ety. Potent serotonin reuptake inhibitors appear to have superior efficacy in many of the anxiety disorders, with indications that norepinephrine reup take inhibitors have an advantage in severe forms of major depression. Medi cations with dual effects-blocking reuptake of both serotonin and norepinep hrine (e.g., clomipramine and venlafaxine XR)-have superior benefits in ach ieving remission in major depression and GAD. These medications may also of fer a faster onset of action and theoretically superior benefits in patient s with comorbid anxiety disorder and major depression.