October, 1992

LETTERS TO THE EDITOR

antidepressants (3) and diazepam (4). Therefore, it is conceivable that in this case fluoxetine interfered with the metabolic degradation of chloral hydrate. It is also likely that fluoxetine, which has a high affinity to carrier protein, displaced chloral hydrate from its binding sites, causing an enhanced and prolonged drowsiness. Insomnia is the third most commonly reported side-effect of fluoxetine, and chloral hydrate is one of the safest and most commonly used hypnotic sedatives. However, the potential interaction between these two drugs should be kept in mind when they are administered together.

References I. AHFS Drug Information. Bethesda MD: American Society of Hospital Pharmacists, 1990; 28: 24. 2. AHFS Drug Information. Bethesda MD: American Society of Hospital Pharmacists, 1990; 28: 92. 3. Downs 1M, et al. Increased plasma tricyclic concentration in two patient concurrently treated with fluoxetine. J Clin Psychiatry 1989; 50: 226-227. 4. Lemberger L, Rowe i-J, et al. The effect of fluoxetine in the pharmacokinetics and psychomotor response of diazepam. Clin Pharmacol Ther 1988; 43: 412-419. S. Devarajan, M.B.,B.S. Halifax, Nova Scotia WHAT IS BEHAVIOUR THERAPY? Dear Sir: It was with great interest we read the recent article by Dr. Camenietzki (I), particularly because we believe there is insufficient information on the clinical applications of behavioural (and cognitive) techniques in the mainstream psychiatric literature. In our opinion, much of the literature over the past decade on the efficacy and detailed protocol of cognitive-behavioural therapy for the anxiety disorders has not reached the general psychiatric readership. This point is apparent in Dr. Camenietzki's admission offrustration with psychotherapy for anxiety patients over the past II years. Although we admire Dr. Camenietzki's openness in exploring behavioural techniques, we believe there are several errors in this paper which necessitate correction. Dr. Camenietzki claims relaxation training and desensitization are effective for some phobias and cites a paper on desensitization that is almost 20 years old. Recent research literature clearly indicates that in vivo exposure is superior to these types of treatments for phobic states, including agoraphobia (2,3).. Dr. Camenietzki does not recommend behaviour therapy for social phobia and instead emphasizes group psychotherapy. He does not consider cognitive-behavioural therapy for social phobia on a group basis, a procedure which has demonstrated efficacy (4,5). It should also be noted that many patients make valuable "insights" during in vivo exposure sessions and the two are not always mutually exclusive. Dr. Camenietzki talks of exposure and flooding as if they were the same techniques. In fact, in vivo exposure is not necessarily flooding. Rather than "bombarding the patient with images of pain, fear and suffering" (i.e., implosion), it is more useful for the patient to confront feared situations and symptoms in vivo, in a gradual way, according to targets that the patient sets (2,3,6,7). This approach may also result in less of the "clinical bargaining" and "fussing" that Dr. Camenietzki describes. The breathing control and correction of cognitive distortions that

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Dr. Camenietzki mentions are important components of successful therapy. However, one of the most effective cognitive-behavioural techniques for controlling anxiety involves exposing the patient to feared symptoms through such means as voluntary hyperventilation in order to reinterpret feared bodily sensations (6). This approach appears to be far more promising than desensitization for treating anxiety but is not mentioned in Dr. Camenietzki's paper. Dr. Camenietzki believes it is important to engage in clinical bargaining with the patient by making increasing demands, and claims it is essential to "fuss" over the smallest details. He cites a case where he spent 40 minutes fussing with a patient on how she would spend the first 30 seconds in a feared shopping mall. The 40 minutes may have been better spent conducting therapist-aided in vivo exposure at the particular shopping mall. In behaviour therapy the patient, rather than the therapist, should be setting goals. Further, the real goal of exposure is not to see how many subway stops a patient can travel, but to remain in the feared situation or as near to it as possible until the anxiety decreases (rather than "white knuckling" it for a short time). We also find Dr. Camenietzki's frequent analogies to the motherchild relationship to be very condescending towards the patient and may in fact foster dependence. Similarly, we also find it condescending to describe the behaviour therapist as concerned only with "graphs and diaries" while the psychotherapist maintains a "face-toface dialogue." We agree with Dr. Camenietzki's assertion that different clinical skills are emphasized in the two approaches, but despite his protestations otherwise, he has combined the roles of psychotherapist and behaviour therapist in his article (the description of fussing is a good example). This leads to confusion for the reader. A final point concerns the rationale of therapy provided to the patient. We believe the patient should always be informed that the most integral part of treatment and determinant of improvement is the regular homework of in vivo exposure. Dr. Camenietzki only reports doing this "in the heat of countertransference." Behaviour therapy has been shown to reduce the excessive health care utilization by anxiety disorder patients (8). There is a great need in the general psychiatric literature for authoritative advice from authors such as Barlow (2) and Marks (3), not an idiosyncratic paper that belittles behaviour therapy. It is unlikely that an article entitled, "A Behaviour Therapist Engages in Pharmacotherapy" (or psychoanalysis for that matter) would appear in a refereed psychiatric journal. Cognitive-behaviour therapy is not a clinical skill that can just be "picked up" along the way of clinical practice.

1.

2. 3. 4. 5. 6.

References Camenietzki S. A psychotherapist engages in behaviour therapy. Can J Psychiatry 1991; 36(7): 492-496. Barlow DH. Anxiety and its disorders: the nature and treatment of anxiety and panic. New York: Guilford Press, 1988. Marks 1M. Fears, phobias and rituals. Oxford: Oxford University Press, 1987. Mattick Rp, Peters L, Clarke Je. Exposure and cognitive restructuring for social phobia: A controlled study. Behavior Therapy 1989; 20: 3-23. Butler G. Issues in the application of cognitive and behavioral strategies to the treatment of social phobia. Clinical Psychology Review 1989; 9: 91-106. Walker JR, Norton GR, Ross CA. Panic disorder and agoraphobia: a comprehensive guide for the practitioner. Pacific Grove CA: Brooks/Cole, 1990.

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CANADIAN JOURNAL OF PSYCHIATRY

7. Barlow DH, Cerny JA. Psychological treatment of panic. New York: The Guilford Press, 1988. 8. Bowen RC, D'Arcy C, South MN, et aI. The effects of a nurse therapist conducted behavioral agoraphobic treatment program on medical utilization. Journal of Anxiety Disorders 1990; 4: 341-349. Richard P. Swinson, M.D. Brian J. Cox, M.A. Toronto, Ontario

DR. CAMENIETZKI REPLIES

Dear Sir: Swinson and Cox make it clear that they are dissatisfied with the way I use behaviour therapy with anxiety disorders. Their displeasure is so great that they seem to be chastising The Canadian Journal of Psychiatry for having published my article at all! In their scholarly search for faults in my little article, Swinson and Cox raised many worthwhile issues. I will respond first to their criticism of my frequent use of analogies to mother-child relationships in theorizing about interventions with patients. Analogizing, in my mind, is little more than an intellectual attempt to summarize observations under a meaningful umbrella. In and of itself, analogical thinking is not condescending and does not foster dependence in anyone. Only the behaviour of individuals, and not their theoretically based analogies, can belittle patients. In my case, I never share my mother-child analogies with patients in behaviour therapy because it would add little or nothing to this specific treatment process. My impression is that Swinson and Cox do not want me to share my analogies with my colleagues either. I am dangerously "idiosyncratic," it appears. I believe Swinson and Cox missed the point of my article. What I described were my frustrations with psychotherapy when treating severe anxiety disorders, and some promising findings I obtained through the use of behaviour therapy. Admittedly, I felt a bit relieved to bypass some old assumptions inherent in the psychotherapy of anxiety disorders and bring to my clinical work some fresh, innovative and useful approaches. To my surprise, I find Swinson and Cox pointing a long finger at me and defining - without a shadow of a doubt - what is behaviourally correct, what is orthodox, and what is pure. At this point in time, when the incidence of anxiety disorders is increasing exponentially, there is much need for novel approaches and experimentation with imaginative techniques, provided they are humane. My techniques and ideas are far from perfect, but there is no need to confine me to a Skinner-box of therapeutic orthodoxy. Swinson's and Cox's insistence that they know what is real behaviour therapy reminds me of the days when real treatment of agoraphobia meant interpretations of clandestine sexual impulses. Having treated severe anxiety disorders with both psychotherapy and behavioural methods, I have learned that our results are still soberingly modest. The need for promising treatment is so great that it would be unwise to dismiss any innovations and "idiosyncrasies." Shalom Camenietzki, Ph.D. Toronto, Ontario

ANTIDEPRESSANTS: WHICH TO USE FIRST?

Dear Sir, Dr. Rapp (1) has outlined some excellent reasons that "older" medications such as tricyclic and MAOI antidepressants will remain

in our psychopharmacologic armamentarium. Unfortunately, in his zeal to argue for these medications as first-line drugs in the treatment of depression, he neglects or understates several important clinical advantages of the "newer" medications. For example, I agree that significant side-effects can be reduced with the "start low, go slow" strategy, particularly with outpatients. However, as Dr. Rapp points out, that means the patient is on a minimal "therapeutic dose" for at least two weeks. With fluoxetine, patients are prescribed a therapeutic dose immediately. If! were the patient, I would want to avoid two extra weeks of being depressed. In addition, my colleagues and I assess many treatment-resistant patients in our Mood Disorders Program. Previous experience from our clinic (2) as well as a recent review of the literature (3) suggest that many of these patients have not been given even the minimal therapeutic doses of antidepressants. Psychiatrists as well as family physicians often undertreat with tricyclic and MAOI antidepressants. Again, with fluoxetine the patient is immediately getting at least a minimal therapeutic dose. Compliance with medication is also a significant problem for patients. In the same way that a single daily dosing schedule can help to improve compliance (rather than taking several doses during the day), taking a single tablet of fluoxetine rather than three to six tablets of other medication also helps compliance. Finally, we are all aware that depressed patients are at risk of committing suicide, even during active treatment. The low therapeutic index of tricyclics and MAOIs make even a one week supply a potentially fatal dose (a recommended prescribing practice for suicidal patients that is often difficult and impractical in my experience). The newer agents are clearly much safer in overdoses, and so are safer for potentially suicidal patients. In summary, the newer medications such as fluoxetine are safer in overdoses, may improve compliance and are easier to titrate to therapeutic doses. While I agree that one can never say there is a drug of choice for all patients, and that treatment needs to be tailored to the patient sitting in front of you, it seems to me that the balance is tipped in favour of the newer serotonergic antidepressants as first-line treatments for depression. References I. Rapp MS. Antidepressants: too many chokes? Can J Psychiatry 1991; 36(8): 615-616. 2. MacEwan WG, Remick RA. Treatment resistant depression: a clinical perspective. Can J Psychiatry 1988; 33(9): 788-792. 3. Guscott R, Grof P. The clinical meaning of refractory depression: a review for the clinician. Am J Psychiatry 1991; 148: 695-704. Raymond W. Lam, M.D. Vancouver, British Columbia

DR. RAPP REPLIES

Dear Sir: Dr. Lam makes some excellent points, the most important being his useful reminder that the "older" antidepressants can be fatal in surprisingly small overdoses. I cannot fault his opinion that the newer drugs be used first. Judging from the popularity of fluoxetine alone, many people agree with him. Not everyone does, however (I). There are still significant problems with fluoxetine, and I am convinced that alternatives should be considered before prescribing it routinely. It is impossible to underdose with fluoxetine, as stated, but the lag time between the administration of fluoxetine and the

What is behaviour therapy?

October, 1992 LETTERS TO THE EDITOR antidepressants (3) and diazepam (4). Therefore, it is conceivable that in this case fluoxetine interfered with...
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