Question: Hello Doctor. I am 43-year-old male, working as medical typist sitting on the computer 10 hours per day. from Tamil nadu XXXXXXX
1. I am suffering from sleep difficulty. I only get sleep when I take alprazolam 0.5 mg and mirtazapine 7.5 mg at nighttime (for the last 3 years). Occasionaly, I take Ativan 1-2 mg also once in a month. In the morning times, I feel sleepy and tired and not active. I am always anxious and get hesitation and face difficulty to talk to new people and when I go to any office like ticket booking and banks. Because of that shyness and hesitation, my voice is shaky and everybody looks at me why I am talking like this.
2. I also feel depressed and low I am having trouble speaking like a shivering and nervous voice like old people. On ENT consultation, they ruled out physical cause in the vocal cords and throat and they say, it is psychological issue. I had previous psychological treatment before 10 years for the same problem and had treatment with alprazolam 0.25 three times/day for 4 months. Voice improved but after this treatment was stopped, the voice started shaking again.

My other physical problems include hypertension for the last 13 years (I am on enalapril 10 mg morning, 5 mg night; losartan potassium 100 mg morning, 50 mg night, atorvastatin 5 mg at night). I also had asthma which is now cured. I had taken (romilast) Montelukast for 3 years

Kindly let me know what can be done about this. How to get sleep naturally? Will my voice be okay? Do I have to be on drugs life long for these problems if I get treated?

I noted your reply. I also went through the website http://www.excelatlife.com/articles/anxiety50/page2.htm. I went through an exercise called Willoughby Personality Scale. I scored 58 and the results said I have above average social anxiety. Since we have only 2 days left for followup, I am coming now with followup questions. I will go through the rest of the site and exercises slowly.

1. For your question on how long I have been medical typist, I have been working for the last 15 years as medical typist. I have worked around 4 years in the night shifts (that was 5 years back). I tried yoga for around 4 months regularly, but I used to get severe asthma (now a days I am relieved of that). Yoga did not improve my voice.

I also tried early morning meditations – in fact, deep relaxation audios of Alpha Subbulakshmi Bandhayan (negative thoughts removal), Dr. XXXXXXX of KMCH XXXXXXX for around 3-4 months and found some improvement in mood, better than yoga, but it did not give complete relief of clarity of shaking of voice / sleep.

I understand from your views and guidance on the website that there are few exercises and self-help exercises that I should follow. Now I have 2 problems,

1.     Is that of voice tremulousness and
2.     Not getting sleep without alprazolam and mirtazapine as mentioned earlier.

I think for voice, I should carry on with relaxation exercises and exercises mentioned in the http://www.excelatlife.com/. I also started playing, taking good diet, and exercising.

Now the important problem is my sleep which is dependent on medications. Now, I am sleeping with the medications that were prescribed 3 years ago by a MD psychiatrist. but I am not sure, if I am going on the right path. I feel so bad when I go to bed during nighttime. I go to bed at 1030 and keep thinking on when sleep will come to me. Till 11 or 1130 I keep thinking that I try to sleep without medicines, and after that, I take the pills. Then I wake up late in the morning like 830. This is not a correct routine. I want to get up early in the morning and sleep early like 930 immediately when I go to bed.

My home situation is bad, joint family, one noisy kid, one psychiatrist-treated shouting brother, and my wife quarrelling with mother most of the times in same kitchen. We have only 3 rooms to live. In the midst of all this noise and quarrels, I try multitasking work, doing some other job part time like stock market apart from medical typing. I used to get also tension type of headaches when I get sudden stress during market hours above the eyebrows.

One successful method I found out myself was, whenever I go out of town, like a picnic or tour away from my home situation, I get better quality sleep with half dose or cutting one of the pills of alprazolam or mirtazapine. I get better quality deeper sleep even at my home when I return from these picnics. I cannot picnic most of the time, due to busy work schedule but I discovered this improvement accidentally after touring 2-3 times to nearby towns.

Now, my question is,
1. I am in a dilemma whether I should be visiting a psychiatrist again for sleep medications or should I take the same medications early like 7 o clock. Is there any successful way to stop the sleep medications and get natural sleep? If at all I have to follow a different medication, what medications do you suggest (please suggest medications that are nonaddictive). You said, I had become used to anxit medication, and since that was stopped I might get reactions in the body. What other alternatives are there to cure the reactions. What form of rigorous physical exercises I should do specifically.

Sir,

I must thank you very much for your suggestions. Thanks for the blessings too.

All the points you told me are very good. Affirmative. I must spend some time to laugh like watching comedy movie. I am going to buy a TV immediately. Yesterday I bought one set of shuttle cork bat and started playing, it felt good and pleasurable after working.

Regarding the voice, as you told, it does not become serious within home surroundings. Sometimes, i stammer at home also, but with family members, my voice is generally okay. It bothers me very much when I go to banks, public places while buying something, talking to bank officials, or persons in authority, paying EB bills. I also could not speak at all in a team meeting when I worked in BPO company. Words were not at all coming out and the Team leader had to ask questions to me to bring out the answers out while other team members were talking spontaneously. In such places only I am getting embarassed. I am otherwise good in writing, but the stammering and stuttering occurs in speaking in such places.

As you said, I need to stop worrying that there is this problem and stop imagining a time frame, but before I am cured, I need to take these anti-anxiety pills when I visit few offices. In fact, I m working now in a home based work model because I fear that I wont be able to talk in supervisory posts in company setup. Even if I take anxit medication, there is some stammering. I dont know what dose should be taken. I took 0.25 to 0.5 mg of Alprazolam before such occasions. I want to know if I should use the pill only at the time of such situations or regularly daily. Can you suggest? I will call around 1.15 noon today.