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Q. Though my reports are fine, I still exhibit fear for so many things. Why?

Answered by
Dr. Kumarshri Shriniwas Saraswat
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Aug 25, 2016 and last reviewed on: Jul 17, 2020

Hi doctor,

I am a 46 year old male. My health is good since my childhood. I am a pure vegetarian. I do not smoke or drink alcohol. I have completed my PhD in plant biotechnology. My mother died when I was 10 due to heart problems. My father died a year back and he was healthy except minor hypertension. I have three brothers and three sisters, who are all healthy. I fear for a crowd, water, claustrophobia and height since childhood and about health recently. I think about my parents and worry a lot.

I was very good in studies, very polite, soft spoken and a bit shy. I did not like to get married after seeing my father’s second marriage. Most of my life has been spent alone. Before 16 years, I got an offer to work in abroad. I went there and returned back after a month due to unknown anxiety. I wanted to go back, but had severe panic and anxiety problems, unknown fear of health, travel risks, etc. I felt as if I was going mad and getting worst diseases.

My physician checked and referred me to a psychiatrist. He gave me 25 mg Clofranil, 10 mg Nitrosun and a digestive tonic. I was sleeping the whole day. Within a week, I felt confidence and courage. But, I started getting severe leg pain, especially during the night and later I came to know that Clofranil has to be started with a low dosage and I was given a higher dose. Within a month, I was fine and started to travel. I enjoyed my travel by air, bus and train. After one month, I stopped the medication abruptly. I got headache and some panic attacks for a week and then I was fine.For nearly 10 years I was normal. Then, six years before, I met with financial crisis due to loss in my business. I got depressed and returned back to my native. Now, I wanted to go back, but I could not get into the flight. All my previous symptoms are coming back. I fear to travel even by bus. Recently, I had a checkup and everything is fine including thyroids. I received treatment from different doctors and had different medicines that include Sizodon, Clonazepam, Clofranil, Propranolol, Fluvoxamine, Trazolan, Serenace, Petril, Etizolam, etc. I have tried ayurveda and homeopathy treatment too, but of no use. In my experience with the above medicines, I found Clofranil and Nitrosun gave me better results. Please help with my condition.

#

Hello,

Welcome to icliniq.com.

  • I have gone through your detailed history. Your primary complaints are of multiple phobias, including agoraphobia. It is quite evident from other details that you are physically healthy and the problems are of psychological origin.
  • Now, coming to your medicine history, I have a few observations and suggestions and they are as follows.
  • Phobias are to be treated with a combination of medicines and a type of behavior therapy known as systematic desensitization.
  • In phobia, there is an association between fear and a neutral stimulus like height, closed space, traveling, etc. This association needs to be broken in the treatment.
  • Systematic desensitization is a step by step breaking of this association. It involves learning to relax in the presence of progressively increasing anxiety provoking situations. It is a complete therapy in itself. It is provided by psychologists and rarely psychiatrists.
  • Systematic desensitization is the gold standard in the treatment of phobias. When done along with medication, it shows excellent results.
  • I would advice you to seek a good psychologist at your place who has experience with systematic desensitization. This is the likely reason why you are not improving with medicines, because no such therapy is done alongside in your case.
  • Given your past history of response, I would suggest reconsidering Clomipramine and gradually pushing the dose to 75 mg or higher, if needed and tolerated.
  • Nitrosun (Nitrazepam) can be taken along with it if you have sleep issues. Also, give the medicine enough time to act. Changing medicines frequently is not going to help. Proper dose and enough time will give you satisfactory results.
  • I would suggest you discuss these options with your treating doctor and plan your future treatment.

Probable diagnosis:

Multiple phobias.

Regarding follow up:

For further doubts consult a psychiatrist online.---> https://www.icliniq.com/ask-a-doctor-online/psychiatrist

Thank you doctor,

Should I consult a psychiatrist here for prescription?

#

Hi,

Welcome back to icliniq.com.

  • Yes, you should consult a psychiatrist at your place, show my answer and get the prescription.

For further information consult a psychiatrist online --> https://www.icliniq.com/ask-a-doctor-online/psychiatrist

Thank you doctor,

How long should I continue the prescription?

#

Hi,

Welcome back to icliniq.com.

  • The starting dose of Clomipramine is 25 mg and Nitrosun is 5 mg. You get the prescription for 15 days and you can follow up after 15 days.

Revert back after 15 days to a psychiatrist online --> https://www.icliniq.com/ask-a-doctor-online/psychiatrist

Thank you doctor,

Should I take both the tablets at night?

#

Hello,

Welcome back to icliniq.com.

  • Yes, both the tablets have to be taken at night time. Take care.

Revert back after 15 days to a psychiatrist online --> https://www.icliniq.com/ask-a-doctor-online/psychiatrist

Dr Namaskar. Am taking medicines (clofranil 25 & nitrosun 5 / day @ night) regularly. Am not having any side effects now a days. Am yet to find a psychologist in my area for desensitization. My medicines are getting over in 2 days. Kindly advice me the next course of medication. Please send the prescription otherwise i couldnt get these medicines.
Thanks and regards
Dr Pandia rajan
# Hello Mr. Pandia.

I'll send the prescription by evening. I plan to make clofranil dose to 50 mg along with nitrazepam 5 mg.

Regards,
Dr Kumarshri saraswat.
Dr Namaskar. Am taking medicines (clonil 50 & nitrosun 5 / day @ night) regularly. Thank you so much. Am getting positive results (almost 30% improved). My medicines are getting over in 5 days, since i order through medplus online they need 3-4 days to deliver. Kindly advice me the next course of medication. If you are increasing the dose is it possible to split it into morning & night? Is it possible to take some nitrosun in the morning? I am not much busy i can sleep in the day time too, just for speedy recovery!!. Please send the prescription otherwise i couldnt get these medicines.
Thanks and regards
Dr Pandia rajan
# Hello Mr pandia, it is good to know that you are doing well.
I'll be increasing dose to 75 mg of sustained release clomipramine. It is to be taken at night time only.
Nitro sun is also to be taken only at night. Taking it in morning might worsen your illness. I'll send you the prescription by evening.

Regards,
Dr Kumarshri saraswat.
Dear Dr thank you so much, the payment window was not coming, so am paying now, sorry!!
# Hello Mr. Rajan
No problem.

Take care.
Dr K. saraswat.
Dr namaskar. I had already paid yesterday itself. Am waiting for your prescription. Please send ASAP.
Thanks
Pandia rajan
# Hello,
Am sorry for the delay. It's not about the payment but I forgot sending the prescription. I have sent it now to icliniq and you should receive it soon.
Regards,
Dr Kumarshri saraswat
Dear Dr sir
am getting improved day by day. Though it is slow but am seeing the progress (upto 50%). Currently am taking clonil 75 SR (0-0-1) and Nitrosun 5 (0-0-1). Am not seeing any side effects except dry mouth and slow urination. Am getting good sleep, walking into crowds, standing on que, boarding crowded bus, enclosed spaces (like a/c train compartments) etc. Only thing am yet to try is airplane!! kindly advise me the next course of medication with a prescription. Is it advisable to increase the dosage of Nitrosun?
Regards
# Hello Mr.pandia Rajan,
It is good to know that you are doing well with proper and regular treatment.
Gradual and steady improvement is the goal.
I would recommend continuing on the current dose.
Nitrosun is ok at 5mg.

I'll send a fresh prescription by evening.
Regards,
Dr Kumarshri saraswat.
Thank you so much. Just want to know whether common analgesic tablets viz. coldact (Chlorpheniramine maleate+Phenylephrine) or paracetamol can be taken with clonil & nitrosun?
# Hello Mr pandia,

They can be safely taken with your medicines.
Regards,
Dr Kumarshri saraswat.
Dear Dr sir
Namaskar. Am getting improved day by day. Though it is slow but am seeing the progress (upto 60%). I have tried crowded places and A/c trains, am feeling comfortable except very minimal anxiety feelings. Am yet to try air travel, though am anxious about it!!

Currently am taking clonil 75 SR (0-0-1) and Nitrosun 5 (0-0-1). Am not seeing any side effects except dry mouth and slow urination. Am getting good sleep. kindly advise me the next course of medication with a prescription.
Thanks and Regards
Pandia rajan
# Hello Mr pandia,
Good to hear that you are doing well currently.
I will send you a repeat prescription for 20 days in the evening . In the meanwhile, it would be nice if you can get an ecg done and upload the image. I will consider adjusting medicine doses after that.

Regards,
Dr Kumarshri saraswat.
Dear Dr,
Namaskar. Please find attached my ecg pic., my BP is 130/85 (checked in the eve, before taking medicines). Before starting your medication i checked my sugar level it was normal. I have not yet received the prescription!
Regards
# Hello Mr pandia Rajan,
I'll be increasing dose of clonil to 100 mg and send a fresh prescription by evening.
Regards,
Dr Kumarshri saraswat.
Dear Dr namaskar. I am feeling better than before (70%). Kindly advise me the next course of medication. Thanks a lot!
Regards
Pandia rajan
# Hello Mr pandia Rajan,

It is good to know that you are doing well with your current medications.

I would like to continue your current medications. I hope to see more improvement with passing time.

I'll be able to send your prescription by tomorrow evening only as I am traveling currently.

Regards,
Dr Kumarshri saraswat.
Dear Dr, namaskar. Am continuing the current medicines as per your advice. Am not seeing any significant improvement after increasing the clofranil to 100 mg. Kindly advise me the next course of medicines. Thanks a lot
Regards
Pandia rajan
# Hello Mr pandia,

I need to know how well are you since starting the medicines.
Also, what are your current complaints in which you seek improvement?

Regards,
Dr Kumarshri saraswat.
Dear Dr. I was mentioning about anxiety related to travel, enclosed spaces, crowd etc. I was advised with 75 mg clofranil sr and 5 mg nitrosun. I had improved up to 70%. Last month you increased the dose to 100 mg clofrani but am not seeing further improvements! Kindly advise the next course of medicines. Regards
# Hello Mr pandia Rajan,

In this scenario, we will continue dose at 75 mg and i will add another medicine to reduce the anxiety.
I'll send a fresh prescription tomorrow morning for the same.

Regards,
Dr Kumarshri saraswat.
Good evening Dr. This is to remind you for my prescription!
Regards
# Hello Mr pandia Rajan,
I remember your prescription but I am stuck in travel. I will email it before 8.00pm max.

My apologies for the delay.

Regards,
Dr Kumarshri saraswat.
Dear Dr namaskar, happy Shankranthi. Am improving day by day slowly, thank you so much. Am continuing the medicines as per your advice. I just want to know how long should I continue these medicines? What are the possible side effects?

Is there any SOS medicines for anticipatory anxiety?( To be used during travels).

Is it effective if I consult a psycologist online?
Regards
# Hello Mr. Pandia Rajan,
It is good to know that you are doing well and improving gradually.

I'll answer your questions one by one :-

1)As your illness is chronic (17 years) and you were suffering from the symptoms till just a few months ago, you will need treatment for a long duration.
How many years will you need medication cannot be answered now. It is when you are doing well and completely alright without a single symptom, and you remain like this for 2 years, then we can think of quitting medicines.

2)side effects become important only if you experience them. There are no permanent or dangerous side effects as such.

3)you can take tablet rivotril 0.5mg for anticipatory anxiety and traveling.

4)yes ,if you find a good psychologist who is expert in treating anxiety disorders, then yes, it will be helpful.

Regards,
Dr kumarshri saraswat.
Dr thank you so much for the quick reply. Please send me the prescription including rivotril.
Tx & regards
# Hello,I'll send you the prescription by tomorrow.

Regards,
Dr kumarshri saraswat.
Dr namaskar. I have been taking medicines as advised. My anxiety level is maintained around 70%. Am having high constipation. More over am waking up in the midnight and staying awake for at least 1 hour & sleeping again. I feel drowsy in the morning, feeling not slept well. Kindly advise.
Regards
# Hello,
I am sending you a modified prescription which will take care of anxiety and sleep issues.
For constipation, i will recommend Sat isabgol powder to be taken at night with lukewarm water.

Regards,
Dr kumarshri saraswat.
Dr namaskar. Am improving slowly & steadily. Should I continue the same medicines?

I was happened to meet one of my friend"s friend who is a psychiatrist, well qualified & experienced. He recommended
1. Propranolol 10 = 1-1-1
2. Desvenlafaxine. = 0-0-1
3. Fluoxetine. = 1-0-0
4. Clonozepam =0-0-1

Kindly advise me the advantages & dis advantages of the above medicines.
Thanks & Regards
# Hello Mr. Pandia Rajan,

There are no advantages or disadvantages of medicines.
The question is which medicines are most suitable for your condition.

I believe that the current combination of medicines that you are on is most likely to benefit you in present and future.
Your improvement with the medicines is remarkable (more than expected for the severity of your disease)

I think experimenting with random medicines that some doctor has suggested is going to worsen and complicate your disease in the long term.

Regards,
Dr kumarshri saraswat.
Dear sir Thank you so much for the advice. I am happy with your treatment so I continue the same.

Hope I have to continue the same medicines as advised before. Clonil Sr 75, nitrosun 5 & stalopam 10. Each one at night.
Regards
# Hello Mr pandia Rajan,
Yes, you need to continue the same medicines
I'll send a prescription for the same soon.
Regards,
Dr kumarshri saraswat.
Dr namaskar. The progress is slow & steady. Kindly advise me the medicines. Regards
# Hello mr.rajan,
if the progress is slow and steady on the current medicines,then there is no need to change medicines.
continue the same medicines as previous.

Regards,
dr.k.saraswat
Dear Dr namaskar. I have progress upto 80% and maintaining. My sleep is ok though with some minor disturbance. Kindly advise the medication.
Regards
# Hello Mr. Pandia Rajan,
If you are doing good on current medicines, then I would recommend continuing them.
Giving extra medication just for sleep is not recommended as it might cause /worsen depression.
Do let me know if you need a prescription.

Regards,
Dr kumarshri saraswat.
Dr namaskar. My progress is getting maintained at the same level of around 80%. Kindly advise me the next course of medicines.
Regards
# Hello, as you have substantial progress till now and are doing good, then I would recommend continuing the same medicines for another month.
Regards,
Dr kumarshri saraswat.
Thanks a lot. The payment didn't go thru, am paying now.
Regards
# Hello Mr pandia Rajan,
That is alright.
Regards,
Dr kumarshri saraswat

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