Life Sciences, Vol. 33, pp.

19-29 Pergamon Press

Printed in the U.S.A.

YOHIMBINE INDUCED ANXIETY AND INCREASEDNORADRENERGICFUNCTION IN HUMANS:

EFFECTS OF DIAZEPAM AND CLONIDINE

Dennis S. Charney, M.D.; George R. Heninger, M.D.; D.Eugene Redmond, J r . , M.D.

Yale University School of Medicine, Connecticut Mental Health Center, 34 Park

Street, New Haven, CT 06508

(Received in final form April 18, 1983)

Summary

Yohimbine (30 mg) produced s i g n i f i c a n t increases in subjective

anxiety, autonomic symptoms, blood pressure, and plasma 3-methoxy-4-
hydroxy-phenylethyleneglycol (MHPG) in ten healthy subjects. The effects
of pretreatment with diazpam (I0 rag) or clonidine (5 ug/kg) on these
yohimbine induced changes was examined. Both diazepam and clonidine
s i g n i f i c a n t l y antagonized yohimbine-induced anxiety, but only clonidine
s i g n i f i c a n t l y attenuated the yohimbine induced increases in plasma
MHPG, blood pressure, and autonomic symptoms. When given alone,
clonidine s i g n i f i c a n t l y decreased plasma MHPG and blood pressure,
whereas diazepam did not. These findings indicate that: (I) nor-
adrenergic hyperactivity may be a factor in the production of some
anxiety states; (2) the anti-anxiety effects of clonidine appear to
result from i t s actions on receptors which decrease noradrenergic
a c t i v i t y ; (3) di azepam reverses yohimbi ne-i nduced anxiety wi thout
effects on several physiological or biochemical indicators of
noradrenergic a c t i v i t y in humans.

Despite the considerable prevalence and morbidity of human anxiety dis-

orders, few c l i n i c a l studies have investigated specific neurobiological mecha-
nisms of different anti-anxiety treatments. During the past decade, advances
in basic neuroscience have led to several hypotheses regarding the etiology
and treatment of anxiety. Roles for brain norepinephrine, endogenous opioids,
endogenous benzodiazepines, purines, and gamma-aminobutyric acid (GABA) have
been proposed based on p r e - c l i n i c a l studies (1-5). The primary purpose of
the present investigation was to assess the r e l i a b i l i t y and magnitude of
yohimbine-induced increases in anxiety and noradrenergic function in healthy
human subjects and to evaluate the effects of two drugs with antianxiety
actions (diazepam and clonidine) on the yohimbine-induced changes. Since
yohimbine, clonidine, and diazepam have been shown to a l t e r some aspect of
noradrenergic function via actions on biochemically and neurophysiological ly
characterized receptors, the relative effects of these drugs (alone or in
combination) should provide data relevant to t h e i r possible mechanisms of
acti on.

I t has been suggested that o v e r a c t i v i t y of brain noradrenergic systems is

related to the production of some forms of anxiety and that the therapeutic
mode of action of anti-anxiety drugs is to decrease noradrenergic function
(1). Data from a variety of investigations using different experimental
paradigms provide support for this hypothesis. Electrical or pharmacological
activation of the major norepinephrine nucleus, the locus coeruleus (LC), pro-
duce physiological, behavioral, and biochemical effects in monkeys which are
similar to naturally occurring anxiety (1,6). Opposite effects are produced
by LC lesions in monkeys (1). Yohimbine, which increases locus coeruleus and

0024-3205/83 $3.00 + .00

Copyright (c) 1983 Pergamon Press Ltd.
20 Yohimbine-induced Anxiety in Humans Vol. 33, No. i, 1983

central noradrenergic a c t i v i t y by blocking alpha-2 adrenergic autoreceptors,

produces an anxiety state in humans (7). In contrast, clonidine, which
decreases LC function and central noradrenergic a c t i v i t y by a c t i v a t i n g alpha-
2 adrenergic autoreceptors, appears to have some a n t i - a n x i e t y properties in
anxious subjects (8-10). Abrupt discontinuation of opiates, antidepressant
drugs, and clonidine have been associated with anxiety states and an increase
in noradrenergic turnover as r e f l e c t e d by changes in plasma 3-methoxy-4-
hydroxyphenylethyleneglycol (MHPG) (11-13). Increases in anxiety and the
occurrence of panic attacks have been shown to correlate highly with increases
in plasma MHPG in agoraphobic patients (14).

In the present investigation the e f f e c t of yohimbine to increase norepin-

ephrine (NE) turnover and produce anxiety (7,15-17) was used as an experiment-
al "model" of human anxiety that may relate to dysfunction of the brain
noradrenergic system. The e f f e c t s of clonidine and diazepam on yohimbine-in-
duced anxiety and increases in noradrenergic a c t i v i t y were studied in
healthy human subjects. Plasma free MHPG concentrations were used as an index
of central NE turnover because this major metabolite of brain NE (18,19) con-
t r i b u t e s s u b s t a n t i a l l y to the plasma pool (20) and r e f l e c t s MHPG concentration
in brain under a variety of circumstances (21). Changes in blood pressure and
autonomic symptoms were also measured as signs of noradrenergic a c t i v i t y .

Methods

Subjects:

The subjects were six males (38 + 13) and four females (37 + 6) who gave
t h e i r w r i t t e n informed consent for t h e i r p a r t i c i p a t i o n in t h i s study which
had been approved by the Human Investigation Committee at the Yale University
School of Medicine. All subjects were found to be free of s i g n i f i c a n t medical
problems on the basis of a complete medical and neurological evaluation in-
cluding electrocardiogram, electroencephalogram, chest X-ray, and laboratory
tests of renal, hepatic, pancreatic, hematologic, and thyroid function. The
subjects were determined to be free of mental disorder on the basis of a
structured psychiatric interview. All subjects were non-obese and had not
taken any drugs for at least one month p r i o r to the study.

Procedure:

The study was conducted on the Clinical Research Unit of the Connecticut
Mental Health Center. The subjects were not hospitalized and arrived at the
research unit by 8:00 AM of each test day. Prior to the f i r s t test day each
subject came to the research unit for an interview and physical exam, and to
become familiar with the setting in which the study would take place. They
were instructed to adhere to a vanillylmandelic acid exclusion diet for three
days prior to each test day.

The subjects participated in the following test days during which they
received the following drugs by mouth: (a) placebo (b) yohimbine 30 mg (c)
diazepam 10 mg (d) clonidine 5 ug/kg (e) diazepam 10 mg and yohimbine 30 m9
and (f) clonidine 5 ug/kg and yohimbine 30 mg. The diazepam or clonidine,
when administered with yohimbine, were given 15 minutes prior to the yohimbine
dose. With the small number of subjects i t was not possible to balance for
order effects. However the sequence of the test days was not uniform among
the subjects. The time interval between test days ranged from one to three
weeks.

For each test day, subjects fasted overnight for 10 hours and remained in
the fasting state during the t e s t day until approximately 3:00 PM. They were
Vol. 33, No. I, 1983 Yohimbine-induced Anxiety in Humans 21

supine with t h e i r heads elevated during most of the six-hour test day. They
stood to micturate and to permit recording of t h e i r standing blood pressure
and pulse. They were not permitted to sleep. Blood was sampled from an
intravenous cannula in a forearm vein that was kept patent with a normal
saline solution. Blood samples were obtained for plasma free MHPG at 15, and
0.5 minutes p r i o r to the medication dose and at 120,180,240 and 300 minutes
a f t e r the yohimbine dose. S i t t i n g and standing blood pressure and pulse were
measured in the usual c l i n i c a l fashion with a mercury sphygmomanometer at
baseline and every 60 minutes up to 240 minutes following the dose.

Behavioral ratings were administered once during the baseline period and
every 60 minutes following the medication dose. Visual analogue scales
completed by the subject were used to evaluate the change of i0 d i f f e r e n t mood
states (Happy, Sad, Drowsy, Anxious, I r r i t a b l e , Energetic, Calm, Fearful, High,
Mellow). The scales were scored in millimeters (mm) from the l e f t hand side
of a 100 mm line to a perpendicular mark made by the subject at the point
corresponding to his feeling state at that time. Therefore the score could
range from 0 (not at a l l ) to 100 (most ever). The subjects also completed a
12 item physical symptoms scale (PSS) designed to measure the severity of
somatic symptoms commonly associated with states of increased noradrenergic
function. Each of the following symptoms were rated on a 4 point scale (0 =
not at a l l , 3 = severe): nausea, urinary frequency, p e r s p i r a t i o n , p a l p i t a -
t i o n s , restlessness, anorexia, tremulousness, p i l o e r e c t i o n , hot and cold
flashes, lacrimation, rhinorrhea and muscle aches. The subjects, research
nurse, and laboratory s t a f f were blind to the composition and sequence of the
medication doses.

Biochemical Methods:

The blood samples for MHPGwere kept on ice, a maximum of one hour, be-
fore separation of plasma in a r e f r i g e r a t e d centrifuge. Each sample yielded
three ml aliquots of plasma. Sodium metabisulfite (0.5 mg) and deuterated
I~IPG (200 ng) were added to each plasma aliquot f o r MHPG determination. The
plasma specimens were then frozen at -70 degrees C until assay. Preparation
of the sample was carried out according to a modified version of the method
of Dekirmenjian and Maas (22). Quantitation of the plasma free MHPGwas
carried out by selected ion monitoring, as described elsewhere (23), using a
Finnegan Model 3200 quadruple mass spectrometer equipped with a Finnegan Model
9500 gas chromatographic i n l e t system. (Finnegan Corp., Sunnyvale, CA). In
order to reduce variance, plasma specimens were assayed in duplicate, and the
mean of the two values was taken as the value. I f the two samples d i f f e r e d by
more than 25%, a t h i r d aliquot was assayed in a s i m i l a r fashion. The mean of
the two closest determinations was used as the f i n a l value.

Data Anal~sis:

The e f f e c t s of diazepam, yohimbine, clonidine, and the two combinations

in comparison to placebo on the biochemical, behavioral, and blood pressure
variables were examined by an analysis of variance with repeated measures
(ANOVA). Variables in which a s i g n i f i c a n t overall drug e f f e c t was i d e n t i f i e d
(p < 0.05) were f u r t h e r evaluated by ANOVA's comparing the effects between two
of the relevant pairs of t e s t days. These ANOVA's included e i t h e r all time
points (e.g. blood pressure) or with certain variables the baseline values and
the time point where peak effects were observed (e.g. autonomic symptoms).
S i g n i f i c a n t interactions (p <0.05) were also examined with paired t tests
(two t a i l e d ) to analyze the effects of the d i f f e r e n t drugs across time.
22 Yohimbine-induced Anxiety in Humans Vol. 33, No. I, 1983

Results

Effects of Diazepam and Clo.nidine Pre.treatment On Yohimbine Induced Anxiety

Yohimbine produced an increase in the visual analogue scale of anxiety.

This e f f e c t was completely antagonized by both diazepam and clonidine pre-
treatment. The ANOVA comparing placebo and yohimbine administration revealed
a s i g n i f i c a n t drug and time of sampling i n t e r a c t i o n on the visual analogue
scale of anxiety (F=4.72; df=6,54; p < 0.001). S e l f reported anxiety was
increased 60 (p < 0.02) and 120 (p < 0.05) minutes following the yohimbine
dose in comparison to placebo. ANOVA's revealed s i g n i f i c a n t differences be-
tween the e f f e c t s of yohimbine alone and the diazepam-yohimbine (F=3.68; df =
5,40; p < 0.01) and the clonidine-yohimbine (F=4.29; df=5,40; p < 0.01) com-
binations on s e l f reported anxiety. In addition, at no time point was anxiety
s i g n i f i c a n t l y increased following diazepam-yohimbine or clonidine-yohimbine
administration in comparison to placebo (See figure I ) .

16
~ Plocebo
E] Yohlmblne
0 Dlozepclm

~
A 12 • Clonidirle
E 0 Diozepgrn-Yohlmbine
E e -Yohimbine
>-
i- 8
bJ
x
Z

,L l ; l l
0 60 120 180 24.0

drug MINUTES
given

Fig. 1
The second arrow ndicates the time of
administration of yohimbine, diazepam, or
clonidine alone, and the f i r s t arrow indicates
time of pre-treatment with diazepam or clonidine
in combination with yohimbine. Anxiety was
measured by a visual analog scale ranging from 0
to 100 mm. Each point represents the mean of 10
subjects. (See t e x t f o r d e t a i l s ) .

Effects of Diazepam and Clonidine Pretreatment on Yohimbine-lnduced Increase

in Plasma Free MHPG

Yohimbine induced robust increases in plasma free MHPG. This increase

was s i g n i f i c a n t l y attenuated by clonidine, but not diazepam, pretreatment.
The ANOVA assessing the e f f e c t s of yohimbine and placebo on plasma free MHPG
~evealed a s i g n i f i c a n t drug and time of sampling i n t e r a c t i o n (F=16.28; d f = l , 9 ;
p <0.005). Clonidine pretreatment antagonized the yohimbine-induced increase
in plasma free MHPG in comparison with placebo, r e s u l t i n g in an i n s i g n i f i c a n t
drug and time of sampling i n t e r a c t i o n . This was also i l l u s t r a t e d by the ANOVA
which revealed a s i g n i f i c a n t drug and time of sampling i n t e r a c t i o n between the
effects of yohimbine alone and the yohimbine-clonidine combination on plasma
free MHPG (F=8.8; df=l,9p p < 0.02).
Vol. 33, No. i, 1983 Yohimbine-induced Anxiety in Humans 23

In contrast to clonidine, diazepam pretreatment did not a l t e r the yohim-

bine induced increases in plasma free MHPG. The ANOVA comparing the effect
of the diazepam-yohimbine combination and placebo on plasma free MHPGdemon-
strated a significant drug and time of sampling interaction (F=17.8; df=l,9;
p < 0.005) similar in magnitude to that observed for yohimbine alone. In
addition, an ANOVA also revealed no significant drug and time of sampling
interaction between the effects of yohimbine alone and the diazepam-yohimbine
combination on plasma free MHPG. When given alone, clonidine, but not diaze-
pam, had a significant drug and time of sampling interaction on plasma free
tIHPG in comparison to placebo (F=22.1; df=l,9; p < 0.002).

The time course of the effects of placebo, yohimbine, clonidine, diazepam

and the clonidine-yohimbine and diazepam-yohimbine combinations on plasma free
MHPG are i l l u s t r a t e d in Figure 2. Yohimbine, in comparison to placebo,
resulted in s i g n i f i c a n t increases in plasma free MHPG 120,180,240, and 300
minutes following the dose (p<O.Ol). Clonidine pretreatment s i g n i f i c a n t l y
attenuated the yohimbine induced increases in plasma free MHPG240 (p 0.02)
and 300 (p<O.Ol) minutes following the dose. In contrast, s i m i l a r pretreat-
ment with diazepam failed to attenuate the yohimbine induced increases in
plasma free MHPG at any of the time points. Clonidine, when administered
alone, s i g n i f i c a n t l y decreased plasma free MHPG 120 (p<O.Ol), 180 (p< .005),
240 (p<O.O05), and 300 (p<O.O01) minutes following the dose. Diazepam did
not s i g n i f i c a n t l y a l t e r plasma free M~PG at any of the time points. These
findings are summarized in Table i.

140

~. 13o
"r

120

0.

~ I10
..1
W

,T, t00
Z

90

v,,Placebo
o Yohimbine BO I / 1 I I J

0 Diozepam 0 60 120 180 240 300

tt
• Clonidine drug MINUTES
0 Diazeparn-Yohimbine given
• Clonidine-Yohimbine

Fig. 2
Changes in mean plasma free MHPG (expressed
as percentage of mean baseline plasma free
I~4PG) following oral doses of placebo,
yohimbine, diazepam, clonidine, and diazepam-
yoh i mbi ne and cl oni di ne-yoh i mbi ne combi nations.
24 Yohimbine-induced Anxiety in Humans Vol. 33, No. I, 1983

TABLE I.
The Effect of Yohimbine, Diazepam, and a Diazepam-Yohimbine
and a Clonidine-Yohimbine Combination on Plasma MHPG
Mean MHPG + SD (ng/ml)*
Basel i ne- P1acebo-
Peak Drug
Treatment Basel i ne Peak Di ffe ren ce Di fference
Placebo 3.9 + 1.1 4.2 + 1.01 0.3 + 0.3
Yohimbine 3.9 + 1.0 5.2 + 1.32 1.3 + 0.83 1.0 + 0.8
Diazepam 3.7 + 1.0 4.0 + 1.1 0.3 + 0.5 0.0 + 0.5
Clonidine 3.7 + 0.6 3.4 + 0.51 -0.3 + 0.43 -0.6 + 0.4
Di azepam-
Yohimbine 3.5 + 0.6 4.8 + 0.82 1.3 + 0.63 1.0 + 0.7
Clonidine-
Yohi mbi ne 3.5 + 0.6 4.2 + 0.71 0.7 + 0.74 0.4 + 0.9
*'indicates mean of plasma free MHPGconcentrations of samples drawn 15 and 0.5
min. before drug doses (Baseline) and samples drawn 3,4 and 5 hours following
the doses (Peak). mall comparisons by paired t~test (two t a i l e d ) : Ip< 0.02
baseline vs peak, Lp< 0.001 baseline vs peak,-°p< 0.01 baseline peak d i f f e r -
ence placebo vs yohimbige, placebo vs clonidine, and placebo vs diazepam-
yohimbine combination, ~p< 0.05 baseline peak difference clonidine-yohimbine
combination vs yohimbine and clonidine-yohimbine vs diazepam-yohimbine combin-
ation.

Effects o f Diazepam and Clonidine Pretreatment on Yohimbine-lnduced Chan~es in

Autonomic Function and Blood Pressure

Autonomic symptoms:

Yohimbine produced an increase i n several autonomic symptoms on the PSS

which were blocked more by pretreatment w i t h c l o n i d i n e than by diazepam. The
ANOVA's o f the PSS symptoms f o l l o w i n g yohimbine and placebo revealed s i g n i f i -
cant drug and time of sampling i n t e r a c t i o n s f o r p e r s p i r a t i o n ( F = 7 . 8 2 ; d f = l , 9 ;
p< 0 . 0 2 ) , u r i n a r y frequency (F=8.24; d f = l , 9 ; p< 0 . 0 2 ) , p i l o e r e c t i o n (F=5.22;
d f = l , 9 ; p< 0 . 0 5 ) , and hot and cold flashes (F=5.33; d f = l , 9 ; p< 0 . 0 5 ) . Urinary
frequency and hot and cold flashes were s i g n i f i c a n t l y increased 60 minutes
f o l l o w i n g the yohimbine dose. P e r s p i r a t i o n and p i l o e r e c t i o n were s i g n i f i c a n t -
l y increased 120 (p< 0.05) minutes f o l l o w i n g the yohimbine dose.

C l o n i d i n e pretreatment antagonized the yohimbine e f f e c t s on a l l PSS

symptoms except f o r u r i n a r y frequency. ANOVA's of the PSS symptoms comparing
the e f f e c t s o f placebo and the c l o n i d i n e - y o h i m b i n e combination revealed a
s i g n i f i c a n t drug and time o f sampling i n t e r a c t i o n only f o r u r i n a r y frequency
(F=6.82; d f = l , 8 ; p< 0 . 0 5 ) . Diazepam pretreatment had more v a r i a b l e e f f e c t s on
the a b i l i t y o f yohimbine to induce these symptoms. The ANOVA's of the PSS
symptoms comparing the e f f e c t s o f placebo and the diazepam-yohimbine combina-
t i o n revealed s i g n i f i c a n t drug and time o f sampling f o r u r i n a r y frequency
(F=12.5; df=1,9; p <0.01) and p i l o e r e c t i o n (F=21.O; d f = l , 9 ; p< 0.005). Urin-
ary frequency and p i l o e r e c t i o n were s i g n f i c a n t l y increased 60 minutes (p<O.05)
f o l l o w i n g diazepam-yohimbine treatment. C l o n i d i n e and diazepam, when given
alone, had no s i g n i f i c a n t e f f e c t s on PSS symptoms in comparison to placebo.

On the mood states rated by the v i s u a l analogue scales, yohimbine had

s i g n i f i c a n t e f f e c t s only on a n x i e t y (see above). Diazepam and c l o n i d i n e had
Vol. 33, No. i, 1983 Yohimbine-induced Anxiety in Humans 25

s i g n i f i c a n t effects on the scale for drowsiness. The ANOVA of the effects of

diazepam and clonidine, respectively, on drowsiness compared to placebo re-
vealed s i g n i f i c a n t drug and time of sampling interactions (F=4.38; df:6,48;
p< 0.001; F=6.55; df=6,42; p< 0.001). Diazepam resulted in a s i g n i f i c a n t
increase in drowsiness 60 minutes (p< 0.01) following the dose. Clonidine
resulted in s i g n i f i c a n t increases in drowsiness 60 (p< 0.002), 120 (p< 0.001),
180 (p< 0.01), and 240 (p< 0.05) minutes following the dose. These effects
were s i g n i f i c a n t l y antagonized by concommitant yohimbine administration.
ANOVA's revealed s i g n i f i c a n t differences between the effects of clonidine
alone and the clonidine-yohimbine combination (F=2.91; df=6,42; p< 0.02) and
the effects of diazepam alone and the diazepam-yohimbine combination (F=2.58;
df=6,42; p<0.05) on s e l f reported drowsiness. In addition, at no time point
was drowsiness s i g n i f i c a n t l y increased following clonidine-yohimbine or
diazepam-yohimbine administration in comparison to placebo.
Blood Pressure:

Yohimbine produced s i g n i f i c a n t increases in s i t t i n g and standing s y s t o l i c

blood pressures. These increases were blocked by clonidine, but not diazepam,
pretreatment (see Table 2). The ANOVA's of the effect of yohimbine and place-
bo on heart rate, d i a s t o l i c blood pressure, and s y s t o l i c blood pressure re-
vealed s i g n i f i c a n t drug and time of sampling interactions for s i t t i n g (F=2.69;
df=4,32; p<0.05) and standing (F=8.26; df=4,36; p<0.001) s y s t o l i c blood
pressure. Yohimbine produced s i g n i f i c a n t increases in s i t t i n g and standing
s y s t o l i c blood pressure, respectively, 60 (p<O.O01; p<O.O01), 120 (p<0.001;
p<0.001), 180 (p<0.05; p<0.01), and 240 (p<0.05; p<0.05) minutes follow-
ing the dose.

The effect of yohimbine on s y s t o l i c blood pressure was completely antag-

onized by clonidine pretreatment. The ANOVAof the effect of clonidine-yohim-
bine administration on s i t t i n g and standing systolic blood pressures in
comparison to placebo revealed no s i g n i f i c a n t drug and time of sampling i n t e r -
actions. In addition, ANOVA's demonstrated a s i g n i f i c a n t drug effect between
~ohimbine alone and the clonidine-yohimbine combination on both sitting (F=
8.22; df=l,8; p<0.01) and standing (F=156.2; df=1,8; p<.001) systolic
blood pressure. Whenindividual time points were considered, clonidine-yohim-
bine administration resulted in significant decreases in sitting systolic
(p<0.05), standing systolic (p<0.01) sitting diastolic (p <0.05) and stand-
ing diastolic (p<0.05) blood pressures 60 minutes following the dose.

In contrast to clonidine, diazepam had no effect on the yohimbine-induced

increases on s i t t i n g and standing systolic blood pressure. Combined diazepam
and yohimbine administration, like yohimbine given alone, produced s i g n i f i c a n t
dose and time of sampling interactions for s i t t i n g (F=2.61; df=4,32; p<0.05)
and standing (F=6.64; df=4,32; p<O.001) s y s t o l i c blood pressures. In addition
ANOVA's revealed no s i g n i f i c a n t difference between the effects of yohimbine
alone and combined yohimbine-diazepam administration on s y s t o l i c blood press-
ure. There were no s i g n i f i c a n t differences between s y s t o l i c blood pressures
obtained following yohimbine alone or combined diazepam-yohimbine administra-
tion at any of the time points studied.
26 Yohimbine-induced Anxiety in Humans Vol. 33, No. 1, 1983

TABLE I I .

The Effect of Yohimbine, Diazepam, Clonidine and Diazepam-Yohimbine

and Clonidine-Yohimbine on Standing Systolic Blood Pressure (mm Hg ~SD)

Minutes a f t e r Dose
Treatment Baseline* 60 120 180 240

Placebo 117 + 8 115 + 11 114 + 9 118 + 7 119 + 8

Yohimbine 115 + 10 132 + 123 128 + 153 124 + 142 125 + 171

Diazepam 120 ~ 9 117 ~ 14 117 ~ 13 117 ~ 15 121 ~ 14

Clonidine 123 + 7 109 + 142 90 + 20 3 89 + 173 90 + 143

Di azepam &
Yohimbine 113 + 12 126 + 92 131 + 112 125 + 142 123 + 142

Cloni dine &

Yohimbine 119 + 10 110 + 132 112 + 14 110 + 18 II0 + 18

*indicates mean s y s t o l i c blood pressure determined 15 and 0.5 minutes

~ pr i o<0.05
r to
dose. All comparisons are paired t_ tests (two t a i l e d ) :
from baseline, Cp <0.01 from baseline, ~p <0.001 from baseline.

Clonidine, when given alone, resulted in highly s i g n i f i c a n t drug and time

of sampling interactions for both s i t t i n g and standing d i a s t o l i c and s y s t o l i c
blood pressures (p <0.001). S i g n i f i c a n t decreases in these blood pressures
were observed 60,120,180, and 240 minutes following the dose (p <0.001).
Clonidine also had a s i g n i f i c a n t drug and time of sampling i n t e r a c t i o n on
s i t t i n g heart rate (p<0.001) with s i g n i f i c a n t decreases occurring 120,180,
and 2'40 (p <0.001) minutes following the dose. Diazepam had no s i g n i f i c a n t
effects on blood pressure or heart rate.

Comment

The finding that yohimbine induces subjective anxiety and increases

plasma MHPG is consistent with a previous i n v e s t i g a t i o n using a lower dose of
yohimbine (17) and supports the hypothesis r e l a t i n g increased brain noradre-
nergic a c t i v i t y to some anxiety states ( I ) . Clonidine, as previously reported
(24,25) induced s i g n i f i c a n t decreases in plasma MHPG and blood pressure. The
observation that clonidine s i g n i f i c a n t l y antagonized yohimbine-induced
anxiety, increases in blood pressure, autonomic symptoms, and NE turnover is
consistent with previous animal investigations (26,27) and supports the hypo-
thesis that the a n t i - a n x i e t y actions of clonidine occur via i t s a b i l i t y to
reduce noradrenergic function by stimulating alpha-2 adrenergic autoreceptors
(1,24,25).

Diazepam, in contrast to clonidine, did not a l t e r plasma MHPG levels or

blood pressure. In addition, while diazepam did antagonize yohimbine-induced
anxiety, i t did not block the yohimbine-induced increases in plasma MHPG,
blood pressure, and autonomic symptoms. The lack of an e f f e c t of diazepam on
plasma MHPG is not surprising considering that high doses (10 mg/kg) of benzo-
diazepines were required to reduce baseline NE turnover or stress induced
increases in NE turnover in rodents (28-31). The results are not consistent
with reports that low doses of diazepam and chlordiazepoxide decreased spon-
taneous single unit a c t i v i t y in the LC in rats a f t e r intravenous (32) or
Vol. 33, No. i, 1983 Yohimbine-induced Anxiety in Humans 27

microiontophoretic administration (33). In addition the i n a b i l i t y of diazepam

to antagonize yohimbine-induced increases in plasma MHPG in the present study
contradicts one investigation in laboratory rats which noted that diazepam
attenuated the yohimbine-induced increase in norepinephrine turnover (31),
although this study also used high (10 mg/kg) doses of diazepam. These
studies raise the question of whether doses of diazepam greater than I0 mg
given to human subjects would reduce the rise in norepinephrine turnover
caused by yohimbine. The results of the present investigation are similar to
a previous human study which noted that chlordiazepoxide reduced yohimbine-
induced anxiety but not i t s a b i l i t y to increase blood pressure (34).

The findings of this investigation support the notion that diazepam and
clonidine reduce yohimbine-induced anxiety by different mechanisms. At the
receptor level diazepam is presumed to act at brain GABA and benzodiazepine
receptors (2-4), whereas clonidine acts at separate alpha-2 receptors. These
receptors have been shown to coexist in some brain regions suggesting that
those regions are involved in the anti-anxiety or anti-fear effects of
diverse compounds such as clonidine, diazepam, and morphine, each of which
has a similar effect in that region via a separate receptor site ( I ) . One
would predict that clonidine, which acts at the identical receptor as yohim-
bine, ought to reverse yohimbine's effects exactly. The fact that diazepam
does not reverse either the increase in plasma MHPGor autonomic and blood
ressure changes induced by yohimbine suggests the following p o s s i b i l i t i e s :
I1) that diazepam acts at a site "downstream" from noradrenergic neurons; (2)
that diazepam does not act on the medullary centers which are thought to
mediate the blood pressure and autonomic effects of clonidine (and yohimbine);
(3) that plasma MHPG under the conditions studied is not s u f f i c i e n t l y sensi-
tive to measure changes in brain norepinephrine turnover; or (4) that the
single unit effects of diazepam noted in rodents do not occur in humans at
standard c l i n i c a l doses.

The interpretation of the findings of this study are based on the assump-
tion that yohimbine induces anxiety via i t s a b i l i t y to block alpha-2 adrener-
gic autoreceptors and thereby increase noradrenergic neuronal impulse flow.
I t should be noted however, that yohimbine has also been shown to have effects
on dopamine (35) and serotonin (36,37) function in the brain. I t is possible,
although unlikely, that the effects of clonidine and diazepam pretreatment on
the yuhimbine induced increases in anxiety, autonomic symptoms, blood pressure
and plasma MHPG are due to actions on these systems.

The previous reports that yohimbine w i l l produce an anxiety-like state in

subjects with psychiatric illness has been extended to include normal subjects
and this state is shown to be reversed by clonidine. The subjective aspect of
this yohimbine-induced anxiety is also reversed by the widely used benzodiaze-
pine, diazepam. The present study f a i l s to c l a r i f y the mechanism by which
diazepam interacts with an anxiety state apparently induced by an increase in
noradrenergic a c t i v i t y . The further delineation of how these and other
similar compounds interact with each other and with anxiety may have implica-
tions regarding the mechanisms and etiology of different anxiety disorders
suggested by descriptive (38-40), treatment (40,41), prognostic (38,42), and
genetic 43-45) studies.

Acknowleagements

This research was supported in part by the State of Connecticut, USPHS

Grants MH-25642, MH-14276, MH-30929, and MH-18949. DER is the recipient of
USPHS RSCDA DA-O0075. K. Hafstad, S. Capelli, D.H. Landis, B. Reynolds, S.
Giddings, A. Smith, and H. Meidtke provided expert nursing and technical
assistance. Patty Burzynski typed the manuscript.
28 Yohimbine-induced Anxiety in Humans Vol. 33, No. ], 1983

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