Psychiatry · Year 3 · from Psychiatry

Case 3: Social Anxiety Disorder

Patient Demographics

  • Age: 19 years old
  • Sex: Female
  • Occupation: College freshman

Chief Complaint

"I've skipped so many classes I might fail out. I can't handle people looking at me."

History of Present Illness

The patient is a college freshman referred by the campus counseling center after missing over half of her classes this semester. She describes intense fear and anxiety in social situations, particularly when she feels she may be observed or evaluated by others. She becomes extremely anxious in classes, especially when participation is required, fearing she will "say something stupid" and be judged negatively. She dreads being called on and will skip class rather than risk speaking in front of others. She avoids the dining hall, eating in her dorm room alone instead, because she fears others watching her eat. She has not made friends at college and spends most of her time alone in her room. She would like to join clubs and activities but the thought of meeting new people makes her feel "sick with anxiety." When forced into social situations, she experiences blushing, sweating, trembling voice, and racing heart. She reports these fears have been present since middle school and caused significant difficulties in high school, though she managed by having a small group of childhood friends. The transition to college, where she knows no one, has been overwhelming.

Mental Status Examination

Appearance: Young woman, modestly dressed, minimal eye contact, blushing, appears younger than stated age

Behavior: Timid, soft-spoken, avoids eye contact, visible discomfort being observed

Speech: Soft volume, hesitant, brief responses

Mood: "Nervous" and "embarrassed"

Affect: Anxious, constricted, embarrassed

Thought Process: Linear, goal-directed

Thought Content: Preoccupied with fear of negative evaluation, believes others notice and judge her anxiety, no suicidal ideation (denies), no homicidal ideation

Perceptions: No hallucinations

Cognition: Alert, oriented, attention and concentration intact

Insight: Good - recognizes fears are excessive

Judgment: Impaired by avoidance (missing classes, isolation)

Psychiatric Workup

Screening Tools:

  • Liebowitz Social Anxiety Scale (LSAS): 95 (severe; >60 is clinical threshold)
  • Social Phobia Inventory (SPIN): 48 (severe)
  • PHQ-9: 14 (moderate depression, likely secondary)
  • AUDIT: 8 (emerging problematic use - drinks before social events)

Review of Systems:

  • Reports drinking 3-4 drinks before any required social event "to calm down"
  • No other substance use

Diagnosis

Social Anxiety Disorder (Social Phobia), Generalized (F40.10)

DSM-5 Criteria:

  • Marked fear or anxiety about social situations where scrutiny is possible - present
  • Fear of negative evaluation (acting in embarrassing way, showing anxiety) - present
  • Social situations almost always provoke fear/anxiety - present
  • Social situations are avoided or endured with intense distress - present (avoidance prominent)
  • Fear is out of proportion to actual threat - present
  • Duration >6 months - present (since middle school)
  • Causes significant distress or impairment - present (academic failure, social isolation)
  • Not attributable to substance/medication or medical condition
  • Not better explained by another disorder

Generalized specifier: Fears include most social situations (not just performance)

Comorbidity to Address:

  • Emerging alcohol use disorder (self-medication pattern)
  • Secondary depressive symptoms

Treatment Plan

Pharmacotherapy:

  • Start sertraline 50 mg daily
  • Titrate to 100-200 mg (higher doses often needed for SAD)
  • Alternative: paroxetine, venlafaxine

Consider for performance situations (adjunct):

  • Propranolol 20-40 mg PRN, 1 hour before discrete performances (presentations)
  • Not helpful for generalized social anxiety but useful for specific events

Psychotherapy (Essential):

  • CBT for Social Anxiety Disorder
  • Cognitive restructuring targeting core beliefs about negative evaluation
  • Exposure hierarchy (gradual practice in feared social situations)
  • Social skills training if needed
  • Video feedback to correct distorted self-perception
  • Group CBT particularly effective (built-in exposure)

Exposure Hierarchy Example:

  1. Brief eye contact with stranger
  2. Asking stranger for directions
  3. Eating in dining hall at low-traffic time
  4. Answering question in small class
  5. Attending club meeting
  6. Initiating conversation with peer
  7. Class presentation

Address Alcohol Use:

  • Psychoeducation about alcohol as maintaining factor for social anxiety
  • Avoid using alcohol to cope
  • Referral to campus recovery support if use escalates

Academic Support:

  • Disability services referral for accommodations (may include reduced public speaking requirements initially)
  • Letter for medical withdrawal if needed for current semester

Follow-up:

  • Weekly initially for CBT and medication management
  • LSAS monitoring

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