Psychiatry · Year 2 · from Psychiatry
Case 3: Social Anxiety Disorder - Performance Type
Patient Presentation
Demographics: 26-year-old male
Chief Complaint: "I can't give presentations at work. I think I'm going to have to quit my job."
History of Present Illness: A 26-year-old software engineer presents with severe anxiety specifically related to public speaking and presentations. He was recently promoted and his new role requires monthly presentations to his team of 15 people. During his first required presentation 2 months ago, he experienced severe anxiety with trembling hands (visible to others), quavering voice, blushing, and mental blanking. He reports intense fear that others noticed his anxiety and judged him as incompetent. He has since avoided three scheduled presentations by calling in sick, and he worries constantly about upcoming presentations for weeks in advance. He does not have significant anxiety in other social situations - he is comfortable in one-on-one conversations, can eat in public without difficulty, and has a close group of friends. He has always been a "nervous public speaker" but managed to avoid presentations throughout school and his previous job.
Mental Status Examination:
- Appearance: Well-groomed, appropriate
- Behavior: Calm when discussing non-presentation topics, becomes visibly anxious when discussing presentations
- Mood: "Anxious about work"
- Affect: Anxious when discussing feared situations, otherwise euthymic
- Thought content: Fear of negative evaluation specifically related to performance; no broader social fears
- Insight: Good - recognizes fear is excessive
Workup:
- Liebowitz Social Anxiety Scale: Elevated scores specifically in performance situations; social interaction scores within normal limits
- PHQ-9: Score 6 (minimal depressive symptoms)
Diagnosis: Social Anxiety Disorder, performance only specifier
Treatment:
- Discussed that performance-only social anxiety is often amenable to multiple treatment approaches
- Propranolol 20-40 mg prescribed for as-needed use 30-60 minutes before presentations (beta-blocker for peripheral manifestations)
- Psychoeducation about the anxiety-performance cycle
- Referral for CBT with focus on:
- Cognitive restructuring (testing predictions about negative evaluation)
- Gradual exposure starting with small groups, progressing to larger audiences
- Video feedback to correct distorted self-perception
- Attention training to focus outward rather than on self-monitoring
- Practiced presentation in therapy with video recording
- Video review demonstrated anxiety was far less visible than patient perceived
- At 4-week follow-up: Successfully completed presentation using propranolol and exposure techniques
- Plan to gradually reduce reliance on propranolol as confidence builds through repeated exposures
Clinical Pearl: The "performance only" specifier applies when social anxiety is restricted to public speaking or performing. This presentation is distinct from generalized social anxiety disorder where fears extend across social interactions. Performance-only social anxiety often responds well to beta-blockers (propranolol, atenolol) for as-needed use, which block the peripheral manifestations of anxiety without cognitive effects. Video feedback is a powerful CBT technique demonstrating that visible signs of anxiety are typically far less noticeable to others than the patient perceives.
Clinical Image
Image Description: Functional MRI showing amygdala hyperactivation in anxiety disorders. The amygdala, highlighted in the temporal lobe, shows increased activation in response to threat stimuli in patients with anxiety disorders compared to healthy controls.
Attribution: Brain imaging demonstrating neural basis of anxiety disorders. Educational use. Image adapted from neuroscience literature on amygdala function in anxiety.
Image Source: Wikimedia Commons - Search for "amygdala fMRI" or "anxiety brain imaging"