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Neuroscienceand BiobehavioralReviews,Voi. 18, No. 3, pp. 385-396, 1994 Copyright1994ElsevierScienceLtd Printed in the USA. All rightsreserved 0149-7634/94 $6.00 + .00 0149-7634(94)E0001-G

Allostasis, Amygdala, and Anticipatory Angst

J A Y S C H U L K I N , t B R U C E S. M c E W E N AND PHILIP W. GOLD

Clinical Neuroendocrinology Branch, National Institute of Mental Health and Department o f Neuroendocrinology, Rockefeller University, Bethesda, MD 20892
Received 31 A u g u s t 1993 SCHULKIN, J., B. S. McEWEN AND P. W. GOLD. Aiiostasis,amygdala,and anticipatoryangst. NEUROSCI BIOBEHAV REV 18(3) 385-396, 1994.-Regions of the amygdala are involved in anticipation of negative events. Chronic anticipation of negative events leads to what we call allostatic load, or arousal pathology. Two hormones appear to be involved in arousal pathology; corticotropin-releasinghormone in the brain and giucocorticoids. We suggest that increases in corticotropin-releasinghormone, by stress or glucocorticoids, in the amygdala may have functional consequences for allostatic load. Whereas, corticotropin-releasing hormone in the parvocellular region of the paraventricular nucleus of the hypothalamus is decreased by glucocorticoids thereby under negative feedback and homeostatic control, the central nucleus of the amygdala is to some extent under positive feedback and is increased by giucocorticoids, and perhaps under allostatic control. The human and animal literature suggest that a variety of psychopathologies (e.g., melancholia) may be tied to neurohormonal signals activating regions of the amygdala. Amygdala AIlostasis Psychopathology

WE provide a framework that integrates studies in the regulation of chronic anxiety, fear, and hopelessness in animal studies, with a cluster o f analogous symptoms expressed in human clinical populations. We then provide an anatomical neurohormonal system that we hypothesize underlies these states. We tie together the fact that a cluster of psychological symptoms, (e.g., fear, anxiety, in addition to pathologies such as agitated depression, panic disorder, posttranmatic stress) while distinct and with differing mechanisms, can still result in a fixation of anticipated negative events. We argue that brain regions like the amygdala (and its associated structures) may under normal circumstance serve to regulate the internal milieu [response to internal signals like corticotropin-releasing hormone (CRH) and glucocorticoids] and integrate it with external events. Moreover, we suggest that anticipatory or allostatic mechanisms (e.g., responding to more than one signal and planning ahead, see 119,145,146) underlie such states, and that allostatic load and "arousal pathology" (too much input, chronic vigilance, conflicting signals) may contribute to the degeneration of physiological tissue and psychological adaptation (109,145,146). Additionally, we suggest that homeostatic regulation and negative feedback control of CRH by giucocorticoids (e.g., 28,108) is in contrast to the emerging evidence that CRH cell bodies in the amygdala (104,150,152) actually increase to high levels of glucocorticoids, and may be

under positive induction or allostatic control. These effects may be modest and knotted to the regulation of other neuropeptide and neurotransmitter systems, may nonetheless be activated by giucocorticoids and chronic pathology. We suggest the latter condition is tied to anticipation of adverse events and allostatic load. The logic of this paper is to define what we mean by allostasis, then review animal studies on perceived control and anticipation of adversity and the hormones of stress, and then to review the amygdala and its role in adversity. We then consider the implications that this has for a cluster of psychopathologies both in terms of homeostatic regulation and allostatic regulation, and then to suggest ways in which glucocorticoids and CRH in the amygdala may interact in magnifying the condition of adversity, stress, arousal pathology and allostatic load.

Allostasis
Allostasis can be defined as follows: the regulation o f many variables over time in maintaining stability to meet changing circumstances; Allostasis, as proposed by Sterling and Eyer, (145,146) is the regulation of the internal milieu through dynamic change in a number of hormonal and physical variables in which there is anything but a steady state. While allostasis

Requests for reprints should be addressed to Jay Schulkin, Behavioral Neuroscience Unit, Clinical Neuroendocrinology Branch, National Institute of Mental Health, Bldg. 10, 9000 Rockville Pike, Bethesda MD 20892. 385

386 is stability through change, allostatic load is the hidden price the body pays for containing the effects of arousing stimuli, and of the anticipations of negative events (109,119). Thus, we begin with stating two propositions about allostasis: First, allostatic regulation does not depend on set point responses and signals are not constant. Instead, there is constant evaluation and reevaluation of humoral and environmental signals. Second, allostatic mechanisms are tied to anticipation of needs. Behavioral adjustments are made in advance, and organismic control utilizes resources to adjust to changing anticipated demands. Behavior is driven by anticipatory and not just reactive responses. Homeostatic mechanisms, by contrast, are viewed (e.g., 17,24) as being triggered by deviations in one variable and a subsequent restorative response to correct it (food intake and a deviation of glucose levels). Homeostatic systems within limits absorb deviations from outside sources and maintain stability and sufficiency. They revolve around a certain set point that is the optimal position for a given physiological system. Thus, homeostatic regulation reflects stability of constants. But allostatic mechanisms involve the organismic control of many variables, some of which are in conflict and which may lead to allostatic load (109). Allostatic mechanisms compute tradeoffs among variables, computing many factors at once. These include many hormonal signals, which are in conflict with one another (see 106,145,146). Allostasis reflects stability through change, central coordinated effects and anticipatory responses. Physiologically, one example of allostatic load is elevated cortisol increasing insulin secretion and both hormones conjointly accelerating atherosclerosis (109). This represents physiological pathology. Allostatic load can also be cast in light of Selye's (141) conception of adaptation to stress under extreme conditions. He defined a "general adaptation syndrome." In one state that he called "resistance" (e.g., secretion of glucocorticoids), adaptation has taken hold. The other state that Selye called "exhaustion" (from perhaps chronic anxiety and fear) would include not only adrenal atrophy, but also tissue weakening such as neuronal cell loss from chronic glucocorticoid elevation (e.g., 111,135). Both states are on a continuum, and both are the consequences of elevated glucocorticoids (108,109,136). ANIMAL STUDIES ON THE LOSS OF PERCEIVEDCONTROL: FEAR, ANXIETYCOUPLEDWITH ELEVATEDGLUCOCORTICOIDS Depressed patients are often in a state of chronic expectations of negative outcomes (9), and in these respects may be considered to be under allostatic load under conditions of physiological and psychological pathology. Our hypothesis is that conditions in which there is a loss of perceived control over the environment should exaggerate normal coping responses. That is, expectations of aversive events induce anxiety and fear and can activate the hormones of stress. Prolonged activation and chronic anticipation of adversity should result in allostatic load. What experimental evidence is there in the animal literature to support models of anticipated negative events that are arousing? And what are the biological and neurohormonal mechanisms to cope with it? Curt Richter at the Phipps Clinic at John Hopkins described an animal model for what he called "hopelessness" (see his collected works, 125). He held rats until they stopped struggling or were immobile. Then he placed them in water. Rats typically swim for long periods of time. But the rats that were held drowned within minutes. Richter suggested that they experienced hopelessness, and as a consequence just gave up.

SCHULKIN, McEWEN AND GOLD They "expected failure." Perhaps the sense of being overwhelmed predominates. This kind of experience may contribute to allostatic load and arousal pathology in a susceptible organism. Within 10 yr, the language since Richter's rat studies shifted from hopelessness to "helplessness." The most popularized animal model of helplessness is that induced by uncontrollable shock. A variety of species become what investigators call "helpless" when they are placed in situations where there are uncontrollable and unpredictably aversive events, typically, shocks. They learn that their behavior does not ameliorate the situation; they eventually give up. Later, if they can perform and do something about the situation (e.g., avoid the situation by performing an operant) they give up, though they still seem anxious and fearful (see reviews, 101,140). Helpless animals lose not only the incentive to perform the task in the operant situation in which they have previously been unable to control, they also become apathetic and express decreased hunger and sex drives. They lose incentive and disengage (see reviews, 49,166). Of course disengagement may also be an adaptive response, reducing behavioral and physiological responses (84). Animals track events and draw causal relationships (34). This, we assume allows them to have some perceived control over their environment. This ability to draw causal relationships occurs when expectations are thwarted; the discrepancy can provoke learning (124). Attention is enhanced (99). But with unpredictability, learning declines and attention dissipates (124). Avoidance takes precedence over approach (91). One of the most important features in animal learning is prediction and perceived control (101,164). This is an important psychobiological adaptation-the ability to track events. This is particularly true under stress. In the laboratory, shock anticipated by a signal renders less bodily harm than unsighaled shock (e.g., gastric pathology, central catecholamine depletion, decrease in appetite). The unsignaled shock is anxiety provoking. The lack of perceived control, prediction, and demand, in addition to worry, produces a fearful state (51, 164). Many models of helplessness in the laboratory are about the loss of predictability and perceived control, anxiety and fear (101,140,163). It is a state of perpetual anticipation. This state of anticipation perhaps draws on sites in the brain in maintaining vigilance toward events that are to occur, or are expected, over both short and long periods of time. This we hypothesize may result in allostatic load and pathological arousal. Depressed or anxious people are more likely to interpret the world as menacing and to be afraid. They typically view objects as threatening or disappointing (e.g., depression, 9). Such experiences and anticipations of adverse events in individuals who have experienced a transient sense of helplessness by uncontrollable events in the laboratory, resulted in pituitary-adrenal activation (12). In both humans (12) and in rats perceived control can affect the level of glucocorticoids. For example, when footshock is predicted the level of glucocorticolds in rats or monkeys is lower overall than in yoked controls who are unable to predict the shock (80,95,96,106; though see, 102). The perceived control resulted in lower levels of the hormone (106), and reduced allostatic load. Moreover, glucocorticoids are secreted when rats are placed in novel environments and they are also secreted in rats, under acute anxiety (e.g., 102). Interestingly, rats handled extensively during neonatal development have lower circulating levels of glucocorticoid than nonhandied controls, and have greater exploration of novel environments (1 ll). Though the data are

AMYGDALA CHRONIC FEAR AND ALLOSTATIC LOAD inconsistent, without perceived control the elevation of glucocorticoids in rats or monkeys persists for longer periods of time (see 95,106). Moreover, monkeys who are fearful have higher levels of ghicocorticoids systemically than those that are not (e.g., 19,79), as do inhibited children who are also shy and fearful (76). Finally, depressed patients (e.g., 18), perhaps particularly those with agitated depression (14,48,134) have been associated with elevated cortisol. Interestingly, attempted suicide has been correlated with elevated cortisol in depressed and panic disorder patients (40). Perceived unpredictability and what might lead to arousal pathology and allostatic load reflected in hormonal levels has also been demonstrated by Sapolsky (136). Dominant male monkeys secrete less cortisol under basal conditions than subordinate monkeys (see e.g., 21 for a similar phenomenon in rats). The social stress of being lower down on the pecking order results in lower testosterone, but higher giucocorticoids. This increase in allostatic load and arousal pathology decreases the subordinate monkeys prospects in turn for successful reproduction. The elevated glucocorticoid level may reflect the uncontrollable context, though uncontrollability may not be the only difference between dominant and subordinate monkeys. Sapolsky's (136) results suggest that the loss of perceived control and the response to danger may result in elevated cortisol. Certainly fear and perhaps anxiety are tied to giucocorticoid levels in monkeys (19,79). The elevated glucocorticoid level is a biological adaptation for the subordinate male. If the animal is chronically anxious, however, then a form of arousal pathology and allostatic load may emerge. Long term exposure to high levels of giucocorticoids can result in neuronal cell loss in the hippocampus (74,111,135, but this effect depends upon length of exposure, see 108,110), in addition to the central nucleus of the amygdala (168). The central nucleus of the amygdala is one of the critical sites we will suggest that is involved in the chronic state of fear and anxiety linked perhaps to what we are calling allostatic load.
A N A T O M I C A L A N D F U N C T I O N A L STUDIES OF THE AMYGDALA

387 the largest degree of visceral projections from the solitary and parabrachial nuclei in the lower bralnstem; it projects directly to these regions in addition to other areas of the brainstem importantly involved in arousal in addition to receiving input from neocortical sites and the lateral hypothalamus (e.g., 2,89,90,139). The CEA receives sensory information from the lateral amygdala (155,156) which is a crucial site within the amygdala for fear conditioning, perhaps because of the sensory projections to this region (92). The CEA is also continuous with the bed nucleus of the stria terminalis (75; Fig. 1), a site which is derived embryologically from CEA tissue during neuronal development and thus can be called "extended amygdala" (3). This anatomical fact suggests that this region may also be an important site in the regulation of many of the same behavioral functions as regions of the amygdala. In fact, anatomically the CEA and bed nucleus are both tied to the same sites in the brain (55). They both, for example, project to the parabrachial nucleus and solitary nucleus (Fig. 2; e.g., 53,139). Functional studies demonstrate that direct electrical or chemical stimulation of the CEA and bed nucleus are known to arouse the release of hypothalamic CRH and elevate systemic circulation of ACTH and giucocorticoids (see recent reviews in 54,129). Lesions, for example, of the CEA can interfere with the release of ACTH in immobilization-induced stress (e.g., 8,129). Lesions of the CEA also decrease giucocorticoid elevation to short term immobilization-induced stress (157), specifically, the elevation of glucocorticoids in conditioned stress (129). Lateral lesions within the amygdala did not produce this effect (157). Moreover, lesions of the lateral bed nucleus (extended amygdala that contain CRH neurons and ghicocorticoid receptors) also produce the same decrement of conditioned giucocorticoid secretion to stress as lesions of the CEA (55; also see, 61,62).

DP-VP CPu

The evidence demonstrates that the amygdala is importantiy involved in expectations of adversity and that the hormones of stress are linked to amygdala function. The amygdala is encephalized hypothalamus; the amygdala is functionally involved in many of the same events as the hypothalamus (64,114,144). It is involved in appetite, drive and enjoyment (43). The amygdala is also involved in anticipated fearful and anxiety producing events and perhaps chronic arousal (94). It has been linked functionally to longterm considerations, and not simply to reactive homeostatic events (46). The activation of the amygdala is known to lead to the anticipation of fearful events (93). Regions of the amygdala can be demarcated in a number of ways. For our purposes, we want to distinguish between the basal-lateral and central-medial regions. The lateral is a funnel for all sensory information (2,92,155,156) and the centralmedial for the activation for behavioral responses (e.g., 29,81,93,138). Both regions contain nuclei which receive and process distinct sensory information (156). The central-medial is subcortical, while the lateral complex is considered more cortical presumably because of the input, or connectivity, from neocortical sites (3). The central nucleus of the amygdala (CEA), we believe, may have functional significance for allostatic regulation and perhaps for states such as melancholic depression. It receives

Core Shell ~ " ~ ~ BSTM

FIG. 1. The bed nucleus of the stria terminalis (BSTM, BSTL) and the central nucleus of the amygdala (CEA), CPu caudate putamen, DP-VP dorsal and ventral palladium, EA, extended amygdala (e.g.; BNST), 1o, lateral olfactory tract, ac anterior commisure, [Heimer and Alheid, (58)].

388

SCHULKIN, McEWEN AND GOLD

FIG. 2. An anatomical circuit that may underlie states such as melancholic depression and adversity. AC: Anterior Commission, CE: central amygdalanucleus, BST: bed nucleus of the stria terminalis, LH: lateral hypothalamus, ZI: zona incerta, PBN: parabrachial nucleus, NTS: solitarynucleus.

Other functional work has shown that the CEA, in particular, seems to play a role in conditioned arousal and attention and learning (45,68,69), and anticipatory anxiety (80). Moreover, CEA damage abolished conditioning to a fearful stimulus, without disrupting the unconditioned response (29,82,92). Interestingly, CEA lesions impair extroreceptive aversive fear conditioning without interfering with positive oral-faciai expression to intra-oral infusions of gustatory stimuli (44). In addition, CEA lesions reduced freezing behavior associated with inescapable shock or paradigms of hopelessness (50). Moreover, lesions of the CEA, and to some extent the lateral nucleus of the amygdaia, interfere with the hypoalgesic response to conditioned fearful stimuli, but not unconditioned stimuli (59,161), in addition to reducing the fear (55,60,103). These results extend earlier results that damage to this region of the amygdala reduces fear and anxiety (10). Conversely, its activation increases fear and anxiety which reflects arousal pathology and perhaps eventually aliostatic load. The activation of the CEA sets the stage for the anticipation of adversity. This suggests that allostatic regulation may be operative and arousal pathology may be one result. CORTICOTROPIN-RELEASING FACTORAND GLUCOCORTICOID REGULATIONIN HOMEOSTASISAND ALLOSTASIS The hypothaiamus is the principle site in the brain that maintains endocrine, and in many instances behavioral (vegetative) homeostasis (e.g., 144). Hypothalamic releasing hormones under negative feedback regulation and set point control strongly influence pituitary regulation of the thyroid, gonadal and adrenal axes (28). Corticotropin-releasing hormone activates corticotropin (ACTH), which then activates glucocorticoids from the adrenal glands (e.g., 125,158), and its inhibition by giucocorticoids in the parvocellular region of the paraventricular nucleus (PVN) of the hypothalamus as the hormone inhibits the response to stress and the elevation of CRH in maintaining homeostasis (e.g., 28,136). Glucocorticoids restrain CRH elevation at the level of the PVN (e.g.,

11,108), as it is well known to restrain other physiological processes (112). In other words, regulation of CRH is under negative feedback control at the level of regions of the hypothalamus. Hypothalamic disturbances in systems that regulate growth, reproduction, hunger and the regulation of the principle neuroendocrine systems are called into play during threatening situations (e.g., 30,108,112). It has been suggested by a number of investigators that the inhibition of vegetative functions and the hyperarousal are mediated through the actions of CRH, in part because intracerebroventricular administration of CRH sets into motion a coordinated series of behavioral and physiological responses such as enhanced arousal and inhibition of vegetative functions (e.g., 78,87). Along with the well known restraint on physiological processes by giucocorticoids (e.g., inflammation) and the regulation and maintenance of a variety of neuropeptides and neurotransmitters (e.g., enkephalin mRNA (20), GABA receptors (105) 5-HT receptors mRNA (22,108), some literature suggests that giucocorticoids induce positive effects, for example, upregulation of vasopressin receptors (27). Glucocorticoids induce an increase of angiotensinogen mRNA (6) in the brain which results in potentiating centraily-delivered angiotensininduced thirst (147). Glucocorticoids also induced the uptake of mineraiocorticoids in select regions of the brain and thereby potentiating mineraiocorticoid-induced sodium appetite (100, 138). More germane in the present context, glucocorticoids also facilitate amphetamine-induced self administration (122), in addition to cocaine-induced-kindiing (83). Because CRH also facilitates kindling (38,165), and CORT facilitates CRHinduced kindling (131) perhaps the giucocorticoids effects on kindling are due to the activation of extrahypothalamic CRH. Given the above, thus, while giucocorticoids restrain CRH in the paraventricular nucleus in the regulation of homeostatic regulatory functions, glucocorticoids may be facilitating CRH expression in the amygdala potentiating conditioned fear, anxiety and cautious avoidance. This formulation about the potential coordinating roles of hypothalamic and extrahypo-

AMYGDALA CHRONIC FEAR AND ALLOSTATIC LOAD thalamic CRH in mediating different components of glucocorticoids activation is one of the theoretical underpinnings of our perspective. If we are right about arousal pathology being tied to amygdala function and the hormones of stress, then both functional, anatomical and endocrine studies should support the hypothesis. There is a high density of CRH in the CEA, bed nucleus, PVN, parabrachial and solitary nucleus of the lower brainstem (e.g., 32,33,128,142), in addition to the dorsal motor nucleus and the central gray, and Barrington's nucleus adjacent to the locus coeruleus (23,52,107,137,149,150). These regions (Fig. 3) constitute part of the limbic circuit and are reciprocally connected with one another, many of which conrain both TYPE I and TYPE II corticosteroid receptor sites (30,31,108,109). Moreover, there is colocalization of CRH mRNA and glucocorticoids receptors in several of these regions (e.g., CEA, parabrachial nucleus, 70,77). In other words, they contain CRH receptors and cells and corticosteroid receptor sites, and constitute CRH fibers that are reciprocally connected with one another (e.g., 52) and are well constituted to underlie autonomic and affective responses. We now know that glucocorticoids not only decrease CRH in sites in the brain, in reducing the well known stress response, as we indicated, but can also increase CRH mRNA (104,150,162). For instance, glucocorticoid hormones increase CRH in placenta but also in magnocelhilar neurons of the PVN, while decreasing CRH production in parvocellular neurons in the paraventricular nucleus of the hypothalamus (28, 108,127,150). Thus, while vegetative or homeostatic functions such as food intake are inhibited by elevated CRF (e.g., 78), other functions such as hyperarousal are being generated (65,88). Perhaps this reflects one CRH mRNA system that regulates the pituitary adrenal axis (15,158,167) and the control of vegetative functions and another system (CEA) that regulate behavioral functions, such as fear and anxiety. Interestingly, while adrenalectomy elevates CRH mRNA in the

389 PVN, it reduces CRH mRNA in the CEA; this is reversed by corticosterone (Palkovits et al, personal communication; Makino, Gold, and Schulkin, unpublished observations). This suggests differential regulation of glucocorticoids on CRH mRNA in different neural sites (see e.g., 73). Moreover, recent evidence suggests more generally the phenomenon of differential regulation on target tissue by glucocorticoids and putative mechanisms that may be responsible for this (113). In contrast to the parvocellular region of the PVN, differing levels of glucocorticoids have been reported to induce differing changes of CRH mRNA in the CEA; in other words, the greater the degree of glucocorticoid activation of the CEA the greater the degree of CRH mRNA being synthesized (150; Fig. 4). This occurs in adrenalectomized rats treated with corticosterone (150) and in adrenally intact rats treated with high levels of corticosterone (104,162). Given the results, noted earlier, of increased fear when glucocorticoids are elevated (79,136), perhaps glucocorticoids are magnifying CRH CEA, and one result may be expectations of adversity (e.g., fear or anxiety). This finding is modest, and needs to be expanded to both measure the peptide itself, and also the receptors. Nonetheless, our hypothesis is that the activation of CEA CRH may set the context for expecting adverse events, and perhaps the induction of chronic arousal pathology over long periods of time and allostatic load. A further important relationship between the CEA and CRH has been revealed recently by Koob's laboratory (123). As measured by micro dialysis, CRH was increased in the CEA during immobilization-induced-stress (123) as is norepinephrine (117). This is a condition in which glucocorticoids are elevated (e.g., 108,110) and in which glucocorticoids may be activating CRH and other neuropeptides and neurotransmitters in the CEA and perhaps other sites in the CRH circuit in the brain (bed nucleus of the stria terminalis, parabrachial and solitary nucleus in the lower bralnstem; see also 73) in arousing anxiety and fear and the expectation of adversity.

BBS

ZI

Oe

FIG. 3. CRH sites in the brain, BBS; bed nucleus of the stria terminaiis; Ce, central nucleus of the amygdala; PVN, paraventricular nucleus of the hypothalamus; PB, parabrachiai nucleus [Gray, (52)].

390

6oo[500 < Z I:E 400

SCHULKIN, McEWEN AND GOLD

E "r" t~ (5

300
200

100
0 I I I I I I

25 50 1O0

200

400

800

Corticosterone
FIG. 4. The level of CRH mRNA and the degree of systemic corticosteronetreatment [from Swanson and Simmons, (150)].

It is also known that CRF injected imo the lateral ventricle reduces exploration and increases fear (e.g., 86,87). These effects are centrally mediated, and interference with CRH within the amygdala reduces fear (16,66,153) Additionally, while CRF antagonists ameliorate stress-induced reduction of exploration, injections of CRF into the CEA restore this effect (87). The startle reflex has been used as a model of anxiety and a measure of anticipation; CRH also facilitates startle (29). Melancholic depressed patients, in addition to anxious individuals have enhanced startle response to certain stimuli (29,56). Moreover, fear potentiated startle is reduced by antidepressants, and CRH infused into the cerebral ventricles potentiates the acoustic startle reflex (29,97,152), and is potentiated by CEA stimulation (130). Importantly, lesions of the CEA, but not paraventricnlar region of the hypothalamus abolish this response (98) and antagonists of CRH infused directly into the CEA did impair startle (13). This result indicates that the anticipatory control of behavior (as measured by startle) to central CRH is at the level of the amygdala and not the hypothalamus, and perhaps is under allostatic control. The ventral amygdalofugal pathway which interferes with the potentiation of CRH induced startle when cut (29), is rich in CRH fibers (72), and is known to be involved in other steroid and peptide-induced regulatory behaviors (4). Thus, CRH when elevated in animal studies to adverse events (e.g., 86,87) has effects reminiscent of the stress response. While it is known that CRH infused into the lateral ventricles facilitates behavioral arousal (78,86), it is not known if CRH remains elevated for longer periods under conditions of nonperceived control in animal studies. What we do know is that (a) CRH is involved in the responsiveness to aversive events and that antagonists injected into the CEA

inhibit this response (26,153); (b) stress does induce CRH (123; measured by in vivo dialysis); and (c) glucocorticoids can increase CRH mRNA (104,150,162) in brain regions involved in anxiety and fear [e.g., central nucleus of the amygdala (123; see below)], or decrease it (e.g., cells in the parvocellular region of the paraventriclular region of the hypothalamus e.g. 11,63). The increase of CRH may reflect allostatic load and amplification of the adverse signal, which is at the level of the amygdala, and the decreased level of CRH mRNA at the level of the parvocellular paraventricular region reflects homeostatic regulation. The animal literature, therefore, demonstrates the importance of the amygdala during duress that is not only influenced by the neurohormonal actions of CRH but also concentrates corticosteroid hormones, and contains CRH producing neurons. This idea does not negate the importance of the hypothalamus, but only suggests that the CEA (and perhaps the bed nucleus or extended amygdala), at the level of the forebrain, are ideally suited to underlie the chronic arousal of expectations of adversity. The fact that these regions receive the densest projection of visceral information from the brainstem and send bilateral projections to them, that they exhibit some control over hypothalamic sites, and that they receive projections from the locus coeruleus (which contains CRH e.g., 52,149) suggest their importance in arousal mechanisms. When one places the anatomy of the amygdala and its circuitry in the context of hormonal and psychological factors, it seems plausible that they are likely sites in the regulation of arousal pathology and allostatic load. Moreover, regions of the amygdala which merge into the hippocampus, contain corrico-steroid receptor sites, and project to the paraventricular hypothalamus and receive catecholaminergic input (e.g., 150). Moreover, the locus coeruleus is activated by CRH and projects to amygdala (e.g., 151,160). Importantly, CEA lesions

AMYGDALA CHRONIC FEAR AND ALLOSTATIC LOAD reduce CRH content in the locus coeruleus (85), in addition to the fact that CRF activates noradrenergic neurons (159,160). Taken together this provides more evidence that the amygdala, as the head ganglion (central-medial for processing input and the lateral region for motor output, see 93) of the autonomic nervous system along with other sites that concentrate CRH and glucocorticoids may regulate the expectations of adversity, allostatic load and perhaps a variety of psychopathologies associated with increased fear and anxiety and the sense of hopelessness (Figure 5). IMPLICATIONS Glucocorticoid activation of CRH mRNA in the amygdala may increase the level of fear and anxiety, and be another instance of a steroid and neuropeptide underlying behavior and a central motive state. This is analogous to estrogen and oxytocin inducing a readiness for lordosis, or angiotensin and aldosterone inducing a readiness to ingest sodium (e.g., 120,138). These other models are ones in which steroids and peptides work synergistically in the regulation of behavior. In the case of estrogen and oxytocin they regulate the propensity for sexual receptivity, to be responsive to events in the enviroument related to sexual contact. The two hormones when given together promote not only the arousal of sexual responsiveness, but motivated behavior; female rats, for instance, will perform operant responses to gain access to males (120). The central site of action for this response includes the lateral part of the ventromedial hypothalamic nucleus and the larger circuit that underlies this behavior has been worked out in great detail (120); in other words, estrogen activates the oxytocin system in this region which promotes sexual receptivity.

391 Similarly, the responsiveness to elevated angiotensin and adrenal steroid hormones results in a greater propensity to ingest sodium, to search for it, perform operants for sodium rewards etc (39,41,138); That is, adrenal steroid hormones induce angiotensin in brain which results in sodium ingestion. The anatomical circuit for this behavior and the peptides and steroids have been worked out to some extent, and they include nuclei in the amygdala (medial and central nuclei, 138). Our point is to suggest that glucocorticoids and CRF in at least some extrahypothalamic sites may be working synergistically resulting in expectations of adversity which can result in arousal pathology and allostatic load. CONCLUSIONS The hormones of stress, CRH, and glucocorticoids, we have suggested, arouse the sense of adversity perhaps by their actions on the amygdala. In other words, the actions of these hormones in this site set the stage for expectations of adversity. With prolonged activation the result may be pathological arousal, and allostatic load. The amygdala's known involvement in recognizing the significance of biological events and emotional memories, as well as the fact that it receives information from all neocortical sites (155,156) suggest further the importance of its involvement in integrating external events with internal humoral signals. Sites within the amygdala are well known to elicit aggressive and defensive behavior (1,42,43) and, importantly, are known to be responsive to antidepressant agents (36,37, 71,116). Elevated central CRF has been noted in the cerebral spinal

lateral basolateral

complex of amygdala centromedial amygdala (central, medial)

c~ucocomcoG ~ FIG. 5. A human brain with the amygdala emphasized. The basolateral and centromedial complex are indicated, also shown is the fact that CRH is elevated in the central region and along with elevated glucocorticoids [modified from Heimer, (58)1.

392 fluid in depression (47,67,115) schizophrenics (7) or in obsessive compulsive disorder (5). Perhaps the condition of agitated depression is one in which central CRH and systemic giucocorticoids are linked, and at least in some contexts elevated (cf. 14,18,47,115). The colocalization o f giucocorticoid receptors and CRH in the CEA (25,70) and CRH induction in this nucleus following stress (123), and increased levels of CRH mRNA in the CEA following giucocorticoid elevation (104, 150,162) provide further evidence that perhaps both hormones are participating in the expectation of adversity in this extrahypothalamic site. More evidence needs to be generated to buttress this hypothesis, and placed perhaps within the context of other neuropeptides and neurotransmitters that may be altered (108). But the animal experimental research is persuasive that the CEA is importantly involved in the response to expectancy of stressful adversity and chronic arousal and the regulation of internal and external events. The amygdaia responds to humorai signals with perceived relationships to the world and regulates internal and external events over longer periods of time (see also 46). Alterations of both homeostatic and ailostatic regulation may be a common function in fear, anxiety and hopelessness. In addition to this hyperarousai-which is analogous to the arousal of the generalized stress response that promotes avoidance and hence survival in threatening situations-there is an analogy with the stress response, that is, the inhibition of vegetative function. It is therefore the contention of this paper that giucocorticoid-CRH interactions may mediate both homeostatic and ailostatic regulation. In the parvocellular region of the PVN, it regulates vegetative functions-the inhibition of feeding, sex, etc, and in extrahypothalamic sites (CEA) CRH in synergy with hypercortisolism may be tied to allostatic functions and the anticipation of adversity. While the clinical literature from psychiatric endocrinologists has emphasized the H P A axis (CRH in the PVN activation resulting in the secretion of A C T H and subsequently glucocorticoids), the basic neuroscience has emphasized the negative feedback, and the loss of it, that results from hippocampal damage following prolonged activation of receptor sites to elevated giucocorticoids. The result is further elevation of CRH, because of the loss o f inhibitory signals (30, 74). In fact, hippocampai damage either induced by giucocorticoids, or by stress and age or by experimental manipulations can result in increased CRH in the paraventricular nucleus (e.g.,

SCHULKIN, McEWEN AND GOLD 108,136). The septal-hippocampal region is known to be involved in anxiety (51), and stress is known to impair hippocampai function (see reviews, 108,110). Therefore, it may not be surprising that regions within the hippocampus seem to have inhibitory control on paraventricular CRH; the counterregulation of stress in homeostatic regulation in response to giucocorticoids (e.g., 11,63,108,136). Interestingly, stimulation of the amygdala can increase CRH in neurons in the hippocampus that normally do not produce CRH (143) and these same sites in the hippocampus that concentrate giucocorticoids project to amygdaia (121), and to giucocorticoid receptors and CRH containing neurons in the central nucleus of the amygdaia (150,151). Our view, however, is not incompatible with a role for the hippocampus as inhibitory on hypothalamic CRH and perhaps homeostatic regulation. The positive induction of CRH in amygdala [and perhaps in other sites (e.g., bed nucleus of the stria terminaiis)] by giucocorticoids may be contributing in further arousing the experience of adversity and allostatic load or regulation. A variety of psychiatric syndromes are associated with those who are actively trying to cope with anxiety and fear. A sense of impending doom lingers everywhere. Melancholia, for example, is an organized state of anxiety in which anticipation of negative events predominates, and in which there is no clear homeostatic set point that is being regulated. In light of the recent human empirical findings using positron emission topography measuring regional blood flow that has demonstrates increased activation in amygdala in depressed patients (35), it would be of interest to determine whether this phenomenon is linked to glucocorticoid activation of CRH. In summary, we reiterate our major points: I. Allostatic load may result from chronic anxiety and fear. This is coupled to a variety of psychopathologies in which expectations of adversity predominate. II. The amygdaia is one likely site underlying this state. III. The hormones of stress (giucocorticoids and CRH) are activated during duress and may be closely linked with amygdala function during arousal pathology and allostatic load. ACKNOWLEDGEMENTS We thank our colleagues and friends, in addition to the reviewers, for their suggestions that improved the paper.

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