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What Causes Excessive Thoughts,forgetfulness,non Concentration,insomnia Along With Urine Infection?
Question: Doctor, my daughter is 19 years old and student of 2nd year MBBS. Last year she faced the problem of excessive thoughts, forgetfulness, non concentration, insomnia, irritated and frequent urine infection well before the exams. Its become more severe at the time of exams and we approached our family physician and she treated her for urine infection and prescribed anti anxiety tablet but it did not solve her problem. Later on this continued and we approach a psychiatrist and he prescribed flauxtien 20 mg a day and she responded but afterwards her behavior becomes very casual, so he reduced the tablet to 10 mg strength and stops it. Now she is facing the same problem of forgetfulness, non concentration and excessive thoughts, very reactive and tense just before her exams. She is also facing the problem of frequent constipation and mucus in the stool after stopping the flauxtien. Now she has been prescribed the tablet of 10 mg propranolol twice in the evening and she feels somewhat better but excsive thoughts are not reduced. She starts thinking on any matter and it rattles her mind. Pl inform what should we do and the treatment. Her ferritin level was 7 in the beginning and given farium Xt for thrre months and now it is 14. The B12 level is 330
Brief Answer:
Need more details.
Detailed Answer:
Hi,
Welcome to Healthcare Magic!
From the brief history you have given, I can think of two possibilities, either Obsessive Compulsive Disorder (OCD) or Bipolar Disorer or maybe both. I would like some more information to be sure.
1) Can you please let me know what was the content of her "excessive thoughts"? Was she getting the same thought again and again, which made no sense? Was she doing any activity repeatedly in spite of not wanting to do it? For example, if she had read a page, she might have been getting a thought that she hadn't read it in spite of knowing that she had read it just now and the thought makes no sense. And this thought persisted in her mind till she read the page again. Are her excessive thoughts of this kind or was she simply worrying about her exams and the excessive thoughts were just relate to the same?
2) What do you mean when you say that "she was taking things very casually and lightly"? Do you mean to say that she appeared to be overconfident and made big claims? Did she appear to be excessively cheerful? During the period she was "casual", did she sleep very less and yet appeared quite energetic?
I shall be able to help you better if you can give me more information regarding these issues. So far I can just guess that your daughter was having obsessive thoughts which caused anxiety and loss of concentration and when she was treated with fluoxetine, the obsessive thoughts reduced but she had an episode of anti-depressant induced mania or hypomania, which suggests an underlying tendency for bipolar disorder.
Best wishes.
Dr Preeti Parakh
MD Psychiatry
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
1. She recalled the past events and think about it. for example She had talked to someone mainly her class friends and recalled that conversation and think about it. She thinks that whether she had made right remarks. Whether her remarks is liked by her or him. Why he /she has said this.etc.
Also you are right that she feels that she has not read the page inspite of she has read that page just now which she says non concentration and forgetfullness. Similarily yesterday there was a exams and she written down all details in the answer sheet and in the end when teacher asked whether everybody has written all details like name , roll no. etc in the answer shett she get confused and thought that she had not written the detials and after getting the answer sheet back , she sheen it and get satisfied. Means she is not sure about her work done just before.
2. I mentioned that she was very casual during the treatment of fluaxtien that she become more cheerful and outgoing, not worrying so much and more adventurous like a childish behavoiur. She met an accident also at that time like she fell down from two wheeler got injury and got stiching in the scalp and CT scan was taken and found normal. , so doctor stopped the medicine. after that she behaves normally.
She feels the forgetfullness, non concentration and recalled the past conversatios and confusion about her act. During first year she was staying in the hostel with her roommate and after six months her friend sifted to another room and she was left alone after that she got the fear of loosing friends, confidence and such problem. Pl advise what should we do and the treatment .
Brief Answer:
Explained below.
Detailed Answer:
Hi,
From the details that you have provided, it appears that your daughter has OCD as I mentioned earlier, which responded to fluoxetine but was followed by antidepressant (fluoxetine) induced mania or hypomania.
She will need an antidepressant like fluoxetine to control the obsessional thoughts but at the same time she will also need another medicine to prevent fluoxetine induced mania. The best medicines for this are mood stabilizers like lithium and valproate, but in my opinion, considering her young age and the mildness of symptoms, we can try lighter medicines first. I have assumed that the excessive cheerfulness that she showed was mild and there was no major abnormality in the behavior. On the basis of this, I suggest that she should be given Risperidone (Sizodon) 0.5 mg at night along with Fluoxetine (Flunil/Prodep) 10 mg in the morning.
I am suggesting a lower dose of fluoxetine this time, hoping that she will respond to this dose also and the lower dose will prevent a switch to mania that occurred at the dose of 20 mg per day. But if her exams are very near and the obsessive thoughts interfering very much with her studies, then she should start 20 mg as last time. You also need to keep in mind that fluoxetine takes a few weeks to start working.
The dose of risperidone is also the lowest possible to prevent any adverse effects. If this dose is sufficient to prevent a switch to mania, it is well and good. But if you notice any increase in cheerfulness and talkativeness like last time, this dose will have to be increased or some other medicine started. In my opinion, we should wait for the situation to arise rather than starting her on a high dose from now itself. But you will need to be very watchful and observant for any changes in behavior, so that the situation is not allowed to go out of control. Risperidone may cause some stiffness in the body but that is usually seen at higher dosages. If, however, she experiences this side effect, then risperidone will have to be changed to some other medicine.
Propranolol will just lessen her anxiety a bit but will have no effect on her thoughts. She can also continue with the iron tablet but it is liable to cause constipation.
I have suggested the mildest treatment possible for her. It is possible that some dose hike or other changes may be needed. If required, you can contact me directly at
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Please feel free to ask if you need any clarifications.
Best wishes.
Dr Preeti Parakh
MD Psychiatry
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Doctor I would like o talk to you. Can I call you on telephone or mobile as we are very anxious and tense in giving the flauxtien and other tablets as she is staying in hostel. our contact no. is 0000 and request you pl provide the no. so that I can talk to you .
Thanking you
Brief Answer:
Summary of the telephonic discussion.
Detailed Answer:
Hi Mr XXXXXXX
I am just summarizing what we discussed over phone.
1) There is no major difference between Nexito (escitalopram) and Fluoxetine as far the risk of switching to a manic/hypomanic state is concerned. As far as efficacy is concerned, I expect both drugs to perform similarly or fluoxetine to provide better results. So you can choose either of the two, but my personal preference would be for fluoxetine as she responded very well to it in the past.
2) The dose of 10 mg fluoxetine every alternate day maybe tried if a delay in getting a response is not crucial. Whatever dose is given to her, one has to wait for four to six weeks before deciding whether a dose hike is needed or not because all SSRIs (like fluoxetine, Nexito) take this much time to show their response. If we start on such a low dose (the actual starting dose is 20 mg per day, not even 10 mg per day), most probably she will need a dose hike after four weeks. So it is better to start on at least 10 mg per day, though even this dose is quite low and may not be enough to control her obsessional thoughts.
3) The suggestion of adding Sizodon (risperidone) 0.5 mg at bedtime is for two reasons:
a) It has mood stabilizing action and can prevent the switch to hypomania. Even if she switches, the symptoms will be even lesser than last time as risperidone is used to treat mania/hypomania.
b) Risperidone also augments the action of Fluoxetine/Nexito. So I am hoping that with risperidone, she will get greater benefit in obsessional thoughts at a lower dosage of Fluoxetine/Nexito.
If she develops any stiffness or increase in muscle tone with risperidone, which is unlikely at this dose, we may need to shift her to any other medicine that gives the same benefits as risperidone.
4) Propranolol simply controls the physical signs of anxiety like sweating, tremors etc and has absolutely no effect on thoughts.
I hope this clears up things for you. Please feel free to ask if you need any clarifications.
Best wishes.
Dr Preeti Parakh
MD Psychiatry
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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