A 28-year-old woman comes to the office due to panic attacks. She was promoted at work 7 months ago and has experienced severe anxiety, trembling, sweating, chest tightness, and shortness of breath when giving presentations or meeting new clients. The patient says, "I have been anxious around people since I was a teenager, but it is getting worse. It's very embarrassing. I know everyone can see that I'm extremely nervous in meetings and will think I'm incompetent. I'm afraid I'll make a fool of myself. The last time I had to speak, I became so anxious that I couldn't breathe and almost passed out." The patient is becoming increasingly concerned that she will lose her job, which is resulting in poor sleep. She drinks 2-3 glasses of wine on weekends and does not use illicit substances. Physical examination is unremarkable. On mental status examination, she is visibly anxious throughout the interview and avoids eye contact with the physician. Which of the following is the most likely diagnosis in this patient?
Differential diagnosis of DSM-5 anxiety disorders | |
Social anxiety disorder | Anxiety restricted to social & performance situations, fear of scrutiny & embarrassment |
Panic disorder | Recurrent, unexpected panic attacks |
Specific phobia | Excessive anxiety about a specific object or situation (phobic stimulus) |
Generalized anxiety disorder | Chronic multiple worries, anxiety, tension |
This patient's severe anxiety related to fears of negative evaluation and embarrassment in social and performance situations is consistent with social anxiety disorder (SAD). Her history suggests that she has been socially anxious since adolescence and that the demands of her new job have exacerbated her condition. Her persistent anxiety and poor eye contact during interaction with the physician are also characteristic of the disorder. According to DSM-5, patients whose symptoms occur only in performance-related situations are specified as having the performance-only subtype of SAD.
SAD related to discrete performance situations may be mistaken for a specific phobia. When fears are related to being publically scrutinized, embarrassed, or negatively judged in a social context (as in this patient), the appropriate diagnosis is SAD. Having a specific phobia is characterized by the fear of a specific object or situation (eg, flying, heights, animals) rather than the fear of negative evaluation in a social situation (Choice E).
(Choice A) Generalized anxiety disorder is characterized by multiple, uncontrollable worries (eg, health, finances, relationships, family) whereas this patient's anxiety is restricted to fears of negative evaluation in social and performance situations and its potential consequences (eg, losing her job).
(Choice B) SAD may present with panic symptoms triggered by a feared social situation. However, to make a diagnosis of panic disorder, unexpected panic attacks are required with the fear related to the panic symptoms themselves. This patient's panic symptoms are always triggered by a fear of embarrassment and humiliation in social and performance situations.
(Choice D) In somatic symptom disorder, patients have excessive anxiety that is focused around physical symptoms. In contrast, this patient's physical symptoms are manifestations of the severe anxiety she feels in social situations.
Educational objective:
Social anxiety disorder (SAD) is characterized by a fear of social situations and anxiety about embarrassment. In the performance-only subtype, anxiety occurs only in performance-related situations. SAD should be differentiated from panic disorder (unexpected panic attacks) and specific phobia (stimulus not related to social anxiety).