992
of postnatal Farber’s disease and were clearly higher than those in the control fetus and control postnatal tissues, particularly if the comparison is based on total lipid content; and in the liver they were clearly higher than those in the control fetus. The values for brain tissue are difficult to interpret. White-matter ceramide levels are normally much higher than grey-matter levels, and we did not attempt to separate white from grey in the fetal tissues. Furthermore, the profound maturational changes preclude meaningful comparison with postnatal tissues. The very low level of hydroxy-fattyacid-containing ceramides is in keeping with the concept8 that these are related to cerebrosides and sulpha tides, substances which normally contain a high proportion of hydroxy fatty acids and which normally are present in low concentrations until the time of myelination, which, in man, is mainly after birth. Despite this biochemical and chemical evidence that the fetus was affected with Farber’s disease, electron microscopy of the fetal tissues revealed no obvious abnormalities characteristic of the disease. In contrast, at least some of the structural abnormalities seen in the postnatal disease have also been found in fetuses with Niemann-Pick disease,9 Gaucher’s disease type 11,1° TaySachs disease," GMcgangliosidosis,12 Krabbe’s disease,13 and metachromatic leucodystrophy. 14 In the second pregnancy studied the level of ceramidase activity in amniotic cells was within the range of simultaneously assayed control amniotic cells in both centres (table I), and the fetus was judged to be unaffected. Fibroblasts from the proband, parents, and controls were reassayed with the amniotic cells (data not shown) for comparison. The patient’s amniotic cells, which were fibroblastic in appearance, were compared with fibroblast-like control amniotic cells, since some preliminary studies in Baltimore had indicated higher ceramidasespecific activities in epithelial-like cells. Thus, two epithelial strains had activities of 5-52 and 6-04 units, and one strain of mixed appearance had an activity of 4.31 units. The prediction of an unaffected fetus was confirmed by demonstration of a ceramidase level of 0.249 units in cultured fibroblasts from the newborn child (control 0-380 units; proband 0-009 units). We have noted2 that somewhat different clusters of values of cultured-cell ceramidase activities are found when assays are carried out on different occasions, and this was again evident in the present studies. The difference was most apparent in the values for the mother’s fibroblasts in the first pregnancy (0-313 units) and the second one (0-711 and 0.977 units in Baltimore and 1.72 units in London). Since simultaneously assayed control cells also gave higher activities on the latter occasion, however, evidence for her heterozygosity was obtained at each evaluation. This variability may be due in part to different batches of substrate used and different substrate-enzyme interactions.2 Until these fac-
completely understood, or until a more facile assay procedure for measuring ceramidase becomes available, both prenatal diagnosis and heterozygot detection for Farber’s disease will require simultaneous assay of several normal cell strains. tors are more
We thank Mr T. M. Coltart for the
amniocenteses,
Dr D. Turner
for carrying out the necropsy and electron microscopy on the fetus, and Mr A. W. Babarik, Mrs J. E. Baker, Miss S. Blunt, and Mr L. Jacobs for their valuable assistance. The work was supported by the Department of Health and Social Security, the Wellcome Trust, the
U.S. Public Health Service (grant no. NS 13518), and the PEW Memorial Trust. Requests for reprints should be addressed to P. F. B., Peediatric Research Unit, Guy’s Hospital Medical School, London SE 9RT. REFERENCES
Sugita M, Dulaney JT, Moser HW. Ceramidase deficiency m Farber’s disease (lipogranulomatosis). Science 1972; 178: 1100-02. 2. Dulaney JT, Milunsky A, Sidbury JB, Hobolth N, Moser HW. Diagnosis of lipogranulomatosis (Farber disease) by use of cultured fibroblasts. J Pediat 1.
1976; 89: 59-61. Dulaney JT, Moser HW. Farber disease (lipogranulomatosis). In: Glew RH, Peters SP, eds. Practical enzymology of the sphingolipidoses. New York: Alan R Liss Inc, 1977: 283-96. 4. Milunsky A, Atkins L. Prenatal diagnosis of genetic disorders. In: Milunsky A, ed. The prevention of genetic disease and mental retardation. Philadelphia: WB Saunders Company, 1975: 221. 5. Sugita M, Iwamori M, Evans J, McCluer RH, Dulaney JT, Moser HW. High performance liquid chromatography of ceramides: application to analysis 3.
of human tissues and demonstration of ceramide ease.
excess in
Farber’s dis-
J Lipid Res 1974; 15: 223-26.
6. Nonaka G, Kishimoto Y. Simultaneous determination of picomole levels of gluco- and galactocerebroside monogalactosyl diglyceride and sulfatide by high performance liquid chromatography. Biochim Biophys Acta 1979;
572: 423-31.
deficiency: Farber’s lipogranulomatosis. In: Stanbury JB, Wyngaarden JB, Fredrickson DS, eds. The metabolic basis of in-
7. Moser HW. Ceramidase
herited disease, New York: McGraw-Hill, 1978: 707. 8.
Sugita M, Connolly P, Dulaney JT, Moser HW. Fatty acid composition of free ceramides of kidney and cerebellum from a patient with Farber’s disease. Lipids 1973; 8: 410-06. 9. Schneider EL, Ellis WG, Brady RO, McCulloch JR, Epstein CJ. Prenatal Niemann-Pick disease: biochemical and histological examination of a 19-gestational week fetus. Pediat Res 1972; 6: 720-29. 10. Schneider EL, Ellis WG, Brady RO, McCulloch JR, Epstain CJ. Infantile (type II) Gaucher’s disease: in utero diagnosis and fetal pathology. J Pediat 1972; 81: 1134-39. 11. O’Brien JS, Okada S, Fillerup DL, et al. Tay-Sachs disease: prenatal diagnosis. Science 1971; 172: 61-64. 12. Lowden JA, Cutz E, Cohen PE, Rudd N, Doran TA. Prenatal diagnosis of
GM1-gangliosidosis. N Eng J Med 1973; 288: 225-28. 13. Ellis WG, Schneider EL, McCulloch JR, Suzuki K, Epstein CJ. Fetal globoid cell leukodystrophy (Krabbe disease). Pathological and biochemical examinations. Arch Neurol 1973; 29: 253-57. 14. Leroy JG, Van Elsen AF, Martin JJ, et al. Infantile metachromatic leukodystrophy: confirmation of prenatal diagnosis. N Engl J Med 1973; 288: 1365-69.
Preliminary
Communication
EFFECTS OF 1-DESAMO-8-D-ARGININE VASOPRESSIN ON BEHAVIOUR AND COGNITION IN PRIMARY AFFECTIVE DISORDER PHILIP W. GOLD HERBERT WEINGARTNER C. BALLENGER K. GOODWIN FREDERICK JAMES ROBERT M. POST Clinical Psychobiology Branch and Laboratory of Psychology and Psychopathology, National Institute of Mental Health,
Bethesda, Maryland, U.S.A. DDAVP
(1-desamino-8-d-arginine vasopressin), a synthetic analogue of vasowith pressin prolonged half-life and high antidiuretic and low pressor activity, was given in a double-blind placebo-controlled trial to four patients with major affective illness. Three of four patients showed highly significant and consistent improvements in tests designed to measure the formation, encoding, and organisation of long-term trace events in memory. Two patients also showed a significant but less consistent amelioration of other depressive symptoms during DDAVP treatment. These findings implicate central vasopressin function in the processing of information and possibly other aspects of affective illness.
Summary
993 INTRODUCTION
IN studies of
drug-free patients with bipolar affective cerebrospinal fluid levels of arginine vasopressin (AVP) (unpublished observations) and the plasma AVP response to hypertonic saline are reduced in depression when compared with that in mania.’ These data are compatible with our hypothesis that central vasopressin function may be diminished in depression and raised in mania.2 To further study the possible relation between vasopressin and affective illness, 1-desamino-8-d-arginine vasopressin (DDAVP) was given to four severely depressed patients with major illness,
we
have noted that the
affective illness admitted to the clinical research units the National Institute of Mental Health (NIMH).
at
METHODS
The patients met standard research diagnostic criteria for major affective disorder3 and had been refractory to at least two conventional somatic treatments for depression. For at least 3 weeks before and 3 weeks after DDAVP treatment, no medicines were given. Behaviour was rated twice a day under double-blind conditions by a trained nursing research team which used the revised NIMH scale for depression, anxiety, psychosis, mania, and anger.44 60-160 mg of DDAVP was given daily for 3-7 weeks intranasally by the use of a calibrated catheter. The placebo consisted of DDAVP vehicle (butanol in sterile water). During both the placebo and the active drug periods of the trial, patients had their weight and serum electrolytes recorded regularly, and their fluid intake was regulated daily to give an average of 1400 ml/24 h. In this way the double-blind nature of the study was preserved while patients were protected against DDAVP-induced water retention. Cognitive functions were assessed at least eight times during the study (before, during, and after treatment) by many procedures.5 Patients were first asked to listen to and remember standardised lists of 32 words which consisted of categories of structurally balanced or related items. The number of items recalled ("total recall") indicates the extent to which an individual organises information to be learnt6 and utilises organisation at the time of retrieval of memory. Next, subjects attempted to learn a long list of random words over the course of seven sequential recall trials.7 Only words not successfully remembered in the previous trial were presented again, but the subject was asked to recall the entire list of words including those previously retrieved. The first recall trial can be seen as a measure of short-term or immediate memory. Performance on the subsequent "prompted" trials indicates how much information has been learnt, how much has been shifted from short-term to long-term memory, and how much information can be consistently retrieved from long-term memory. This latter measure ("percent consistency of recall") is particularly useful in the evaluation of the strength and organisation of information in memory.6 RESULTS
In three of the four patients, DDAVP significantly enhanced the overall recall of learnt information. For the group, the total recall increased from 11-67 ±1-83to and "mean percent consis17.17±2.51 (p
of postnatal Farber’s disease and were clearly higher than those in the control fetus and control postnatal tissues, particularly if the comparison is based on total lipid content; and in the liver they were clearly higher than those in the control fetus. The values for brain tissue are difficult to interpret. White-matter ceramide levels are normally much higher than grey-matter levels, and we did not attempt to separate white from grey in the fetal tissues. Furthermore, the profound maturational changes preclude meaningful comparison with postnatal tissues. The very low level of hydroxy-fattyacid-containing ceramides is in keeping with the concept8 that these are related to cerebrosides and sulpha tides, substances which normally contain a high proportion of hydroxy fatty acids and which normally are present in low concentrations until the time of myelination, which, in man, is mainly after birth. Despite this biochemical and chemical evidence that the fetus was affected with Farber’s disease, electron microscopy of the fetal tissues revealed no obvious abnormalities characteristic of the disease. In contrast, at least some of the structural abnormalities seen in the postnatal disease have also been found in fetuses with Niemann-Pick disease,9 Gaucher’s disease type 11,1° TaySachs disease," GMcgangliosidosis,12 Krabbe’s disease,13 and metachromatic leucodystrophy. 14 In the second pregnancy studied the level of ceramidase activity in amniotic cells was within the range of simultaneously assayed control amniotic cells in both centres (table I), and the fetus was judged to be unaffected. Fibroblasts from the proband, parents, and controls were reassayed with the amniotic cells (data not shown) for comparison. The patient’s amniotic cells, which were fibroblastic in appearance, were compared with fibroblast-like control amniotic cells, since some preliminary studies in Baltimore had indicated higher ceramidasespecific activities in epithelial-like cells. Thus, two epithelial strains had activities of 5-52 and 6-04 units, and one strain of mixed appearance had an activity of 4.31 units. The prediction of an unaffected fetus was confirmed by demonstration of a ceramidase level of 0.249 units in cultured fibroblasts from the newborn child (control 0-380 units; proband 0-009 units). We have noted2 that somewhat different clusters of values of cultured-cell ceramidase activities are found when assays are carried out on different occasions, and this was again evident in the present studies. The difference was most apparent in the values for the mother’s fibroblasts in the first pregnancy (0-313 units) and the second one (0-711 and 0.977 units in Baltimore and 1.72 units in London). Since simultaneously assayed control cells also gave higher activities on the latter occasion, however, evidence for her heterozygosity was obtained at each evaluation. This variability may be due in part to different batches of substrate used and different substrate-enzyme interactions.2 Until these fac-
completely understood, or until a more facile assay procedure for measuring ceramidase becomes available, both prenatal diagnosis and heterozygot detection for Farber’s disease will require simultaneous assay of several normal cell strains. tors are more
We thank Mr T. M. Coltart for the
amniocenteses,
Dr D. Turner
for carrying out the necropsy and electron microscopy on the fetus, and Mr A. W. Babarik, Mrs J. E. Baker, Miss S. Blunt, and Mr L. Jacobs for their valuable assistance. The work was supported by the Department of Health and Social Security, the Wellcome Trust, the
U.S. Public Health Service (grant no. NS 13518), and the PEW Memorial Trust. Requests for reprints should be addressed to P. F. B., Peediatric Research Unit, Guy’s Hospital Medical School, London SE 9RT. REFERENCES
Sugita M, Dulaney JT, Moser HW. Ceramidase deficiency m Farber’s disease (lipogranulomatosis). Science 1972; 178: 1100-02. 2. Dulaney JT, Milunsky A, Sidbury JB, Hobolth N, Moser HW. Diagnosis of lipogranulomatosis (Farber disease) by use of cultured fibroblasts. J Pediat 1.
1976; 89: 59-61. Dulaney JT, Moser HW. Farber disease (lipogranulomatosis). In: Glew RH, Peters SP, eds. Practical enzymology of the sphingolipidoses. New York: Alan R Liss Inc, 1977: 283-96. 4. Milunsky A, Atkins L. Prenatal diagnosis of genetic disorders. In: Milunsky A, ed. The prevention of genetic disease and mental retardation. Philadelphia: WB Saunders Company, 1975: 221. 5. Sugita M, Iwamori M, Evans J, McCluer RH, Dulaney JT, Moser HW. High performance liquid chromatography of ceramides: application to analysis 3.
of human tissues and demonstration of ceramide ease.
excess in
Farber’s dis-
J Lipid Res 1974; 15: 223-26.
6. Nonaka G, Kishimoto Y. Simultaneous determination of picomole levels of gluco- and galactocerebroside monogalactosyl diglyceride and sulfatide by high performance liquid chromatography. Biochim Biophys Acta 1979;
572: 423-31.
deficiency: Farber’s lipogranulomatosis. In: Stanbury JB, Wyngaarden JB, Fredrickson DS, eds. The metabolic basis of in-
7. Moser HW. Ceramidase
herited disease, New York: McGraw-Hill, 1978: 707. 8.
Sugita M, Connolly P, Dulaney JT, Moser HW. Fatty acid composition of free ceramides of kidney and cerebellum from a patient with Farber’s disease. Lipids 1973; 8: 410-06. 9. Schneider EL, Ellis WG, Brady RO, McCulloch JR, Epstein CJ. Prenatal Niemann-Pick disease: biochemical and histological examination of a 19-gestational week fetus. Pediat Res 1972; 6: 720-29. 10. Schneider EL, Ellis WG, Brady RO, McCulloch JR, Epstain CJ. Infantile (type II) Gaucher’s disease: in utero diagnosis and fetal pathology. J Pediat 1972; 81: 1134-39. 11. O’Brien JS, Okada S, Fillerup DL, et al. Tay-Sachs disease: prenatal diagnosis. Science 1971; 172: 61-64. 12. Lowden JA, Cutz E, Cohen PE, Rudd N, Doran TA. Prenatal diagnosis of
GM1-gangliosidosis. N Eng J Med 1973; 288: 225-28. 13. Ellis WG, Schneider EL, McCulloch JR, Suzuki K, Epstein CJ. Fetal globoid cell leukodystrophy (Krabbe disease). Pathological and biochemical examinations. Arch Neurol 1973; 29: 253-57. 14. Leroy JG, Van Elsen AF, Martin JJ, et al. Infantile metachromatic leukodystrophy: confirmation of prenatal diagnosis. N Engl J Med 1973; 288: 1365-69.
Preliminary
Communication
EFFECTS OF 1-DESAMO-8-D-ARGININE VASOPRESSIN ON BEHAVIOUR AND COGNITION IN PRIMARY AFFECTIVE DISORDER PHILIP W. GOLD HERBERT WEINGARTNER C. BALLENGER K. GOODWIN FREDERICK JAMES ROBERT M. POST Clinical Psychobiology Branch and Laboratory of Psychology and Psychopathology, National Institute of Mental Health,
Bethesda, Maryland, U.S.A. DDAVP
(1-desamino-8-d-arginine vasopressin), a synthetic analogue of vasowith pressin prolonged half-life and high antidiuretic and low pressor activity, was given in a double-blind placebo-controlled trial to four patients with major affective illness. Three of four patients showed highly significant and consistent improvements in tests designed to measure the formation, encoding, and organisation of long-term trace events in memory. Two patients also showed a significant but less consistent amelioration of other depressive symptoms during DDAVP treatment. These findings implicate central vasopressin function in the processing of information and possibly other aspects of affective illness.
Summary
993 INTRODUCTION
IN studies of
drug-free patients with bipolar affective cerebrospinal fluid levels of arginine vasopressin (AVP) (unpublished observations) and the plasma AVP response to hypertonic saline are reduced in depression when compared with that in mania.’ These data are compatible with our hypothesis that central vasopressin function may be diminished in depression and raised in mania.2 To further study the possible relation between vasopressin and affective illness, 1-desamino-8-d-arginine vasopressin (DDAVP) was given to four severely depressed patients with major illness,
we
have noted that the
affective illness admitted to the clinical research units the National Institute of Mental Health (NIMH).
at
METHODS
The patients met standard research diagnostic criteria for major affective disorder3 and had been refractory to at least two conventional somatic treatments for depression. For at least 3 weeks before and 3 weeks after DDAVP treatment, no medicines were given. Behaviour was rated twice a day under double-blind conditions by a trained nursing research team which used the revised NIMH scale for depression, anxiety, psychosis, mania, and anger.44 60-160 mg of DDAVP was given daily for 3-7 weeks intranasally by the use of a calibrated catheter. The placebo consisted of DDAVP vehicle (butanol in sterile water). During both the placebo and the active drug periods of the trial, patients had their weight and serum electrolytes recorded regularly, and their fluid intake was regulated daily to give an average of 1400 ml/24 h. In this way the double-blind nature of the study was preserved while patients were protected against DDAVP-induced water retention. Cognitive functions were assessed at least eight times during the study (before, during, and after treatment) by many procedures.5 Patients were first asked to listen to and remember standardised lists of 32 words which consisted of categories of structurally balanced or related items. The number of items recalled ("total recall") indicates the extent to which an individual organises information to be learnt6 and utilises organisation at the time of retrieval of memory. Next, subjects attempted to learn a long list of random words over the course of seven sequential recall trials.7 Only words not successfully remembered in the previous trial were presented again, but the subject was asked to recall the entire list of words including those previously retrieved. The first recall trial can be seen as a measure of short-term or immediate memory. Performance on the subsequent "prompted" trials indicates how much information has been learnt, how much has been shifted from short-term to long-term memory, and how much information can be consistently retrieved from long-term memory. This latter measure ("percent consistency of recall") is particularly useful in the evaluation of the strength and organisation of information in memory.6 RESULTS
In three of the four patients, DDAVP significantly enhanced the overall recall of learnt information. For the group, the total recall increased from 11-67 ±1-83to and "mean percent consis17.17±2.51 (p
