Case Study
Case presentation
A 26-year-old woman presented with symptoms of intense fear and discomfort in social situations
She experienced sudden bouts of sweating, trembling, and increased heart rate during triggering episodes followed by severe blushing
Medical history
- Suffered from sudden bouts of sweating, trembling, and increased heart rate during triggering episodes, followed by severe blushing since last 6 months
- Was fearful while interacting with authoritative figures and of being judged by others
- Avoided networking events and presentations at work
Family psychiatric history :
- Depression in paternal uncle
- Restrictive upbringing by parents
Physical examination
| Height | 161 cm |
| Weight | 60 kg |
| Blood pressure | 122/80 mm/Hg |
| Pulse | 74 beats/minute |
All vital parameters were within the normal range.
Investigations
Routine blood tests, electrocardiogram, chest radiograph, and head CT showed normal findings.
Mental status examination
- Beck Depression Inventory (BDI): 25 (moderate depressive symptoms)
- Beck Anxiety Inventory (BIA): 16 (moderate anxiety symptoms)
- Social Interaction Anxiety Scale (SIAS): 55 (social anxiety disorder)
- Liebowitz Social Anxiety Scale (LSAS) 60 (moderate social anxiety disorder)
Confirmed diagnosis: Social anxiety disorder
Management: Combination of Clonazepam (0.5 mg) + Escitalopram oxalate (10 mg) once-daily for 8 weeks
Follow-up
At 8 weeks:
- Interacted with colleagues without fear or anxiety
- Actively engaged in conversations with colleagues and family
- Was advised to not self-medicate in case of rebound episodes
- Was assessed for withdrawal symptoms after treatment discontinuation
| At 4 weeks (Visit 1) | At 8 weeks (Visit 2) | |
| BDI | 10 | 2 |
| BIA | 7 | 0 |
| SIAS | 21 | 7 |
| LSAS | 35 | 20 |
Discussion
- Social anxiety disorder can be treated with selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines.1
- Clonazepam is approved by the Food and Drug Administration (FDA) for anxiety disorders.2
- Escitalopram is approved for major depressive disorder (MDD) and general anxiety disorder (GAD).2
- Benzodiazepines as add-on therapy to antidepressants are more effective in the management of depression-associated anxiety and sleep disturbances initially till the action of SSRIs begins.3
- The use of benzodiazepine antagonists (Flumazenil), oxazolidinones (Linezolid), monoamine oxidase inhibitors (Phenelzine) among other drugs is not recommended during concommitant therapy with Clonazepam 4 and Escitalopram.5
- Further, alcohol intake during treatment with Clonazepam is not recommended in order to prevent potential drug-food interactions.4
Conclusion
The combination of Clonazepam and Escitalopram provided rapid relief from symptoms of social anxiety and has a faster onset of action with better control of depression-associated anxiety symptoms compared to monotherapy.
References:
- 1. Social anxiety disorder. Available from: https://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-shyness. Accessed on 15th April 2024.
- Iyer SS, Singal R, Mitra S, et al. Safety and efficacy of Placida® (fixed dose combination of flupentixol 0.5 mg + melitracen 10 mg) in comparison to escitalopram 10 mg + clonazepam 0.5 mg in patients with comorbid anxiety and depression: a randomized, double blind, double dummy, parallel group clinical trial. Int J Clin Trials. 2023;10(4):318-24.
- Dar SA, Bhat BA, Jan MM. Addition of benzodiazepines to selective serotonin reuptake inhibitors to optimize treatment of depression: a hospital based study. Int J Res Med Sci. 2018;6(6):2081.
- Clonazepam. Available from: https://www.mayoclinic.org/drugs-supplements/clonazepam-oral-route/side-effects/drg-20072102?p=1. Accessed on 15th April 2024.
- Escitalopram. Available from: https://www.mayoclinic.org/drugs-supplements/escitalopram-oral-route/precautions/drg-20063707?p=1. Accessed on 15th April 2024.
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