While large numbers of studies are available on anxiety and cerebral blood flow (CBF), little is known about their relationship to extracranial (forehead) flow. The participants were 24 generalized anxiety disorder (GAD) patients and 26 normal volunteers. A randomized, between groups, repeated measures design was used to evaluate changes in cerebral blood flow. Measurements of CBF, forehead skin perfusion and ratings of anxiety and physiologic indices were made under resting conditions and during anxiety induction with epinephrine or saline infusions, given under double-blind conditions while subjects inhaled room air or 5% CO2. These subjects were divided into three groups; those with decreased anxiety, those with mild anxiety, and those with more severe anxiety increase. Subjects with severe anxiety showed least hypercarbic CBF increase (indicating cerebral vasoconstriction) and maximal increase in forehead skin perfusion. Those with minimal anxiety had most hypercarbic cerebral vasodilation and least increase in forehead skin perfusion. Forehead skin perfusion correlated positively with anxiety levels, and negatively with hypercarbic cerebral vasodilation. In animals, sympathetic activation limits hypercapnic cerebral vasodilation. Thus, the restricted hypercapnic cerebral vasodilation during severe anxiety may be mediated through cervical sympathetic fibers which innervate cerebral vessels.