Seasonal Affective Disorder Training

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					LETfERS              TO        THE      EDITOR

         peridot          binding      in guinea        pig     brain        membranes.            Proc      Nail     Acad      Seasonal Affective                     Disorder            and       the Photic                 Sneeze
         Sci USA              1984;    81:5618-5621                                                                             Response

                                                              DOUGLAS                 W. HOFFMAN,                     M.D.          SIR: Seasonal        affective        disorder     is a condition         usually      char-
                                                                                            Hanover,                  N.H.      acterized       by recurrent          episodes       of depression         in the fall and
                                                                                                                                winter     alternating        with nondepressed               or hypomanic             periods
                                                                                                                                in the spring         and summer             (1). It appears       responsive         to treat-
                                                                                                                                ment with bright            artificial        light, although        neither     the patho-
Bipolar Affective                      Disorder         and         Heterozygous
                                                                                                                                physiology        of the disorder            nor the antidepressant             mechanism
                                                                                                                                of phototherapy                  is well understood.                        However,                 Wehr        et al. (2)
    SIR: Several     years                  ago Joffe              et al. (1)             reported      a possible              have shown        that photothenapy          probably     works   through                                                    the
association      between                     thalassemia                 minor               (heterozygous         3-           eye rather     than the skin. It has been hypothesized                  that                                                sea-
                                                                                                                                sonal affective       changes   are associated        with a heightened                                                     vul-
thalassemia)        and affective          illness in members           of a limited
                                                                                                                                nerability    to fluctuations       in environmental        light (1).
pedigree.     In another        preliminary       study Scherer and Eberle (2)
                                                                                                                                   To the best of my knowledge     (personal   communication
found that patients            with both depressive           disorder    and heter-
                                                                                                                                from D.A. Oren and N.E. Rosenthal,     Aug. 24, 1988), no one
ozygous      3-thalassemia          may show some peculiarities             in symp-
                                                                                                                                has yet           noted    the analogy         between       this vulnerability                                          and
toms. We have performed                  hemoglobin       electrophoresis      in 180
                                                                                                                                another          phenomenon        involving       heightened       sensitivity                                     to fluc-
consecutive        psychiatric        outpatients      given diagnoses        accord-
                                                                                                                                tuations          in environmental         light, namely,        the so-called                                       photic
ing to             the        Research      Diagnostic         Criteria.                         The    prevalence
                                                                                                                                (or solar)           sneeze       reflex.          This     is the tendency                         to sneeze            when
(1 7.8%)                 of    hetemozygous          3-thatassemia                             (hemoglobin         A2
                                                                                                                                suddenly       exposed         to bright     light,    a trait probably             influenced
more than 3.2%)        in the overall sample was within the range
                                                                                                                                by genetic          factors       (3). Everett         (3) hypothesized                that      the
found    in the general       population        in southern       Sardinia     (3).
                                                                                                                                photic      sneeze      reflex      may be due to hypersensitivity                         of the
However,       a trend for a greater        prevalence      was found in bi-
                                                                                                                                parasympathetic              nervous       system.        Dilsaver        and Majchrzak
polar    (including     manic     schizoaffective)        patients       (22.4%)                                                (4), noting       that depression           may involve            supersensitivity             of a
than in unipolar       patients      (9.1%).      Moreover,       patients     suf-
                                                                                                                                central      muscarinic          mechanism,          found       evidence         that      bright
fening        from             schizoaffective                disorder             with      a bipolar              course      light subsensitizes            central    muscarinic          function        in rats. These
showed             a significantly                 higher          proportion              of the hematolog-                    preliminary         data suggest         that there        may be a similar               under-
ical     disorder              than     patients        with         other         affective           disorders         (14    lying       chotinergic               mechanism              in      the      photic               sneeze        response
of 45, or 31.1%,                       versus   17 of 126, or 13.5%;   p<O.Ol).     We                                          and       the    sensitivity           of the        CNS          to bright             light         generally.
are now extending                        the original  sample and studying      the nd-                                                I believe      that      further        research            to test this heuristic                          hypoth-
atives       of our            probands.           A false         association              due    to population                esis      is merited.           For       example,            do      individuals                    who        show         the
stratification   will be excluded       if cosegregation       within                                                 pedi-     photic     sneeze            response-probably                          about      20%                 of the general
grees is found.                                                                                                                 population-also                    show      seasonal                 fluctuations                    in mood?      Are
    Whatever    the genetic relationship        between    affective                                                disor-      there       fast     and       slow         loops         by which                bright           light      affects        the
der and hetemozygous        3-thalassemia        (false association,                                                   epi-     CNS-the              former           represented            by      the photic               sneeze           reflex,       the
static       genetic            interactions,           linkage              disequilibrium,                 direct       ef-   latter      by vulnerability                  to seasonal              affective             disorder?             Is there
fect),   we would       like to suggest        the use of this easily                                                           a common       pattern                      of inheritance                   for these                     hypothesized
diagnosable    condition     in linkage     studies   of affective disor-                                                       loops? Provided       that                  large numbers                   of individuals                     are tested,
dens, since the 3-globin       gene cluster       can be regarded     as a                                                      we should             be able to answer                     these          questions               with        fairly      sim-
polymorphic     locus in certain     populations      and can help clar-                                                        pie tests     and             questionnaires.                  An          association                  between              the
ify the status of genetic linkage between bipolar illness and                                                                   photic    sneeze             response       and           seasonal           affective               disorder            could
chromosome       1 1 (4, 5).                                                                                                    have       important            therapeutic                implications.

                                                                                                                                  1. Rosenthal              NE, Sack            DA, Gillin JC, et at: Seasonal    affective
  1. Joffe RT, Horvath           Z, Tarvydas       I: Bipolar affective disorder     and                                             disorder:             a description         of the syndrome  and preliminary       find-
     thalassemia        minor (letter). Am J Psychiatry           1986; 143:933                                                          ings with      tight therapy.      Arch     Gen                   Psychiatry               1984;  41:72-80
  2. Scheren     J, Eberte E: Major affective disorder              and heterozygous                                              2.     Wehr      TA, Skwerer         RG, Jacobsen                         FM,      et      al:      Eye versus    skin
     beta-thatassaemia.           Psychopharmacology          (Suppl) 1988; 96:145                                                       phototherapy         of seasonal       affective                    disorder.              Am J Psychiatry
  3. Siniscalco     M, Bernini L, Filippi G, et at: Population              genetics of                                                  1987; 144:753-757
     haemoglobin          variants,     thatassaemia       and gtucose-6-phosphate                                                3.     Everett      HC:    Sneezing     in response                        to     tight.         Neurotogy             1964;
         dehydrogenase                 deficiency,          with      particular           reference         to the     ma-              14:483-490
         lana hypothesis.  Bull WHO      1966; 34:379-393                                                                         4. Ditsaver             SC, Majchrzak              MJ:      Bright         artificial            light     subsensitizes
 4.      Egetand JA, Gerhard    5, Pauls DL, et at: Bipolar affective                                                 disor-             a central        muscaninic          mechanism.              Life        Sci    1987;         41:2607-26                14
         ders linked to DNA markers      on chromosome     1 1. Nature                                                1987;
         325:783-787                                                                                                                                                                                                    RONALD                 PIES, M.D.
  S.     Ketsoe JR. Ginns El, Egeland      JA, et at: Re-evaluation     of the                                                                                                                                                             Boston,   Mass.
         linkage relationship  between  chromosome    1 1 p loci and the gene
         for bipolar affective disorder  in the Old Order Amish. Nature
         1989; 342:238-243                                                                                                      The       Sham        of Treatment

                                                                                   A. BOCCHETTA,                      M.D.          SIR:        A recent     lecture  on the pharmacotherapy           of schizo-
                                                                                   M. DEL ZOMPO,                      M.D.      phrenia           by an outstanding         expert consisted     of lengthy,      te-
                                                                                             Cagliari,                 Italy    dious,          and repetitious      presentations     of slides   showing      the

1094                                                                                                                                                                   Am      ]     Psychiatry                   147:8, August                          1990
                                                                                                                                                                                        LETTERS            TO THE            EDITOR

significant         differences     between     psychoactive      drugs      and pla-                                                                                  REFERENCES
cebos      and also between           clozapine     and earlier    antipsychotics.
                                                                                                                           1. CummingsJL:                  Neuropsychiatry:            the paradigm              shift.    Psychiatric
These       data were based          on symptom        and behavioral         changes
                                                                                                                              Times, January                1990, pp 41-43
assessed        reliably      in a double-blind       manner    and subjected         to                                   2.    Peabody       FW:        The   Care     of the     Patient.     Cambridge,               Mass,     Har-
rigorous             statistical         methods.            The      symptoms              and     behaviors                 yard University   Press, 1927
thus measured            were not presented,            implying        that everybody                                     3. Tumulty     PA: What is a clinician                      and     what       does      he do?        N EngI
knows       what     symptoms            and behaviors        patients       with schizo-                                     J Med 1970; 283:20-27
phrenia       manifest.                                                                                                    4. Enget GL: The care of the patient:                         art or science?           Johns      Hopkins
    This simplistic         presentation        of complex       conditions        and pro-                                   MedJ    1977; 140:222-225
cesses    may be a caricature,               but it is symptomatic              of the neu-                                S. Moht PC, LomaxJ,       Tasman     A, et                   at: Psychotherapy      training  for
ropsychiatnic           paradigm          (1) and     current       psychiatric       treat-                                  the psychiatrist  of the future. Am                        J Psychiatry     1990; 147:7-13
ment,        whose            nature       and      length         are increasingly               dictated          by
                                                                                                                                                                                               STEPHEN              FLECK,          M.D.
public       or private           third-party           payers,        by utilization          review
                                                                                                                                                                                                     New            Haven,         Conn.
bodies,        and by the unfortunate                        tendency          (borrowed          from
internal        medicine)          to treat       diseases        instead      of patients.        This
has been         the unwelcome                 aspect       of the so-called              remedical-
                                                                                                                         Comments             on Task           Force      Report         on Psychiatric                  Residency
ization       of psychiatry,            because        medicine           has abandoned            Pea-
body’s       injunction          that “the care of the patient                       lies in caring
                                                                                                                             SIR: It was with genuine         sadness     that I read the recent         joint
for the patient”               (2) or, to quote               a latter-day         colleague         em-
                                                                                                                         position    paper  from the Association             for Academic       Psychiatry
phasizing         that communication                     is the main tool of the physi-
                                                                                                                         and the American        Association       of Directors      of Psychiatry        Res-
cian, “What              the scalpel         is to the surgeon,               words        are to the
                                                                                                                         idency    Training     entitled     “Psychotherapy           Training      for the
clinician”          (3). Communication-exploring                                a person’s         feel-
                                                                                                                         Psychiatrist          of    the Future”           (1). Except          for the references,                   the
ings and thought                processes-can               also be “scientific”              (4), but
                                                                                                                         suggested     thrust     for the future     seemed     no                     different          from     what
currently,         on wards          and in clinics,           students       and residents           are
                                                                                                                         could     have been written          30 years ago.
taught       to put symptoms                   and behavioral                manifestations           to-
                                                                                                                            Although        a letter   is certainly      not the                      forum      to debate     the
gether into a cluster that fits one or another                                  DSM-III-R            def-
                                                                                                                         adequacy      of any theory        of personality       or                     psychotherapy,        it is
inition,      and by implication                 they come to believe                 that this tells
                                                                                                                         important       for psychiatry         to realize   that                      these     debates   exist.
them       what       treatment,         and.particularty                what     medication,           to
                                                                                                                         To      mandate            the    primacy         of the        psychodynamic                     approach
                                                                                                                         and to assert            that other           views       of psychotherapy                  are subspe-
      The         excellent          publication             of the      joint       task      force       of the
                                                                                                                         cialties     rather        than alternatives                is to limit diversity.
Association             for Academic     Psychiatry                       and the            American          As-
                                                                                                                              Viewing        transference             and countertransference                      as central         to
sociation            of Directors    of Psychiatry                       Residency            Training          (5)
                                                                                                                         the understanding                 of all patient-therapist                  interactions            does as
concerning   psychotherapy                            training         in the future              did not ad-            great a disservice               to the understanding                    of other          positions         as
dress (it was not charged                  to do so) the essence             of psychiatric
                                                                                                                         would        mandating             that the psychodynamic                          theory       of trans-
education,         which      is to learn about         people,       about     personality
                                                                                                                         ference        be understood               only as an example                     of response            gen-
development             and      structure       and  their      deviations,         none      of
                                                                                                                         eratization.          Choosing           long-term           expressive          psychotherapy               as
which       can be apprehended                  by categorizing          symptoms,           but
                                                                                                                         paradigmatic             and the best way to learn about                               psychopathol-
which       requires       psychotherapeutic            engagement            over time.        It
                                                                                                                         ogy dangerously                narrows           the choices          of future          psychiatrists.
takes      more      than     3 weeks        to learn    about       and understand              a
                                                                                                                              Stating       that even supportive                       psychotherapy               needs       to be
severely      psychotic         patient     and gather       data from families             and
                                                                                                                         psychodynamically                     informed            to be performed                    adequately
others.                                                                                                                  ignores        the major           contributions               of Carl Rogers,                the client-
    There      are intangible            impediments        to interpersonal            thera-
                                                                                                                         centered         approach,           and a different              conception            of human           na-
peutic engagement                        with psychotic      patients.                  It is more com-
                                                                                                                         ture that is not based                   on conflict.           Asserting         that psychother-
fontable  to subdue                       a patient’s   excitement                     and unwelcome
                                                                                                                         apy must             be understood                  in a developmental                      perspective
behavior             chemically            than      to engage           that     uncooperative                and
                                                                                                                         distorts        the contributions                  of the rational-emotive                        and the
possibly            dangerous            patient.      Medication               may be indicated                but
                                                                                                                         strategic-systemic                positions,          as two prominent                   examples.
should            not     be prolonged                without           efforts       to communicate
                                                                                                                              There       is insufficient            space       to mention            each of the many
with     the person     who    is so fearsomely         disturbed,      although
                                                                                                                         arguable          points       in the article,              but the points               I have        made
ultimately      the patient    may benefit        from medication          mainte-
                                                                                                                         should        not be construed                    as suggesting             that      the psychody-
nance.     The ease of dispensing         drugs-which,          by implication,
                                                                                                                         namic        viewpoint            is without             value       or that          psychotherapy
may be believed          to be “specific”       because     we have different
pharmaceuticals         for schizophrenic         and depressed      patients-                                           should       not be a prominent                       aspect       in the training              of future
leads to forgoing    psychosocial                                and psychotherapeutic       en-                         psychiatrists.            A return           to the positions               that existed             over a
gagement.  Such treatment       may                            seem efficient and cost-effec-                            generation           ago does not equip                    new psychiatrists                to compete
tive in the short                      run,   but      it is not         so in the long     run,                    as   as psychotherapists                  with more            broadly       trained         mental       health
indicated  by our                    enormous          readmission          rates, and treatment                         professionals             in other          disciplines.          To view           the teaching             of
and      education             suffer.       It is more        expensive             to allow          sufficient        other      major       schools         of psychotherapy                 as obscuring              the task
time        and      bring      to bear       appropriate             professional            resources         for      and diffusing            the effort          seems       to slight       the intellectual              capa-
all inpatients                than     to discharge            them      as soon            as their      behav-         bilities     of psychiatric               residents         and imply            that they cannot
ior will permit it. Thus,    this problem      becomes     a societal                                         one,       handle       a diversity           of views.
but it is our responsibility       as professionals       to educate                                            the             An old maxim               states,     “If your       only     tool      is a hammer,               then
public  and be advocates      for resources     for comprehensive                                              and       every      problem       is a nail.”   The decision        to elevate                               the psy-
early treatment      of our patients,                         treating   them as persons with                            chodynamic           approach      to a central   position     could                              lead psy-
complex     problems     rather than                          as containers   of malfunction-                            chiatnists       in training    to obtain     a hammer       and be                               forced   to
ing     machinery.                                                                                                       compete           equipped          with      a poorly      stocked          toolbox.            A mandate

Am       ]    Psychiatry                 I 47:8,      August            1990                                                                                                                                                       1095

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