What are possible differential diagnoses for a 13-year-old patient experiencing anxiety and avoidance behaviors in social situations, particularly in classes and when meeting new peers, with symptoms including nervousness, heart palpitations, shortness of breath (SOB), shakiness, and sweating?

Differential Diagnoses for a 13-Year-Old with Social Anxiety Symptoms

The three most likely differential diagnoses for this patient are: (1) Social Anxiety Disorder, (2) Generalized Anxiety Disorder, and (3) Panic Disorder. 1, 2

Primary Diagnosis: Social Anxiety Disorder

Social Anxiety Disorder is the most likely diagnosis given this patient's specific pattern of fear and avoidance in social situations where he may be negatively evaluated by peers and teachers. 1

Key Supporting Features:

• Fear triggered specifically by social evaluation situations - being called on by teachers and meeting unfamiliar teens 1
• Avoidance of social situations with unfamiliar peers despite maintaining friendships 1
• Physical symptoms during performance situations including heart palpitations, shortness of breath, shakiness, and sweating when answering questions in class 1
• Age of onset at 13 years matches the median age of onset for social anxiety disorder, with 75% of cases occurring between ages 8-15 1
• Maintained functioning - continues attending school and maintaining good grades, which is consistent with social anxiety disorder where patients often continue functioning despite significant distress 1

Diagnostic Criteria Alignment:

The patient meets DSM-5 criteria for social anxiety disorder: persistent fear (2 months duration) of social situations where scrutiny may occur, exposure provokes anxiety with physical symptoms, avoidance behaviors present, and symptoms cause distress but not complete functional impairment. 1

Second Differential: Generalized Anxiety Disorder

Generalized Anxiety Disorder must be considered if the patient's worry extends beyond social situations to multiple domains. 1, 2, 3

Distinguishing Features to Assess:

• Worry content and breadth - GAD involves excessive, uncontrollable worry about numerous everyday situations (school performance, family, health, future events), not just social evaluation 2, 3
• Free-floating anxiety - GAD patients experience pervasive tension "on edge" across multiple contexts, not situation-specific 3
• Physical symptoms - while both disorders share autonomic symptoms, GAD typically presents with more chronic muscle tension, fatigue, concentration difficulties, and sleep disturbance 1, 3

Why This May Not Be GAD:

The patient's anxiety appears situation-specific (classes without friends, meeting new teens) rather than generalized across multiple life domains, and symptoms are triggered by social evaluation rather than being free-floating. 1, 3

Third Differential: Panic Disorder

Panic Disorder should be ruled out given the presence of panic-like symptoms (palpitations, shortness of breath, shakiness, sweating). 1, 2

Critical Distinguishing Features:

• Trigger pattern - Panic disorder involves recurrent unexpected panic attacks that occur spontaneously without clear triggers 1, 2
• Fear of panic itself - Panic disorder patients develop persistent concern about having additional attacks and their consequences 1
• Agoraphobic avoidance - Panic disorder with agoraphobia involves fear of situations where escape might be difficult (crowds, enclosed spaces, public transportation) 1

Why This May Not Be Panic Disorder:

This patient's symptoms are consistently triggered by social evaluation situations rather than occurring unexpectedly, and his avoidance is specific to unfamiliar social contexts rather than situations where escape would be difficult. 1

Important Differential Considerations to Exclude

Medical Conditions:

Before confirming any anxiety disorder diagnosis, rule out medical conditions that mimic anxiety: 2, 4

• Hyperthyroidism - check thyroid function tests 2, 4
• Hypoglycemia - assess glucose levels and diabetes screening 2, 4
• Cardiac arrhythmias - consider if palpitations are prominent 4
• Caffeine excess - quantify caffeine intake from energy drinks, coffee, tea 4

Other Psychiatric Conditions to Consider:

• Selective Mutism - characterized by absence of speech in specific social situations despite speaking at home; however, this patient is speaking (though anxiously) when called upon 1
• Specific Phobia - would involve fear of a specific object or situation rather than social evaluation 1
• Separation Anxiety Disorder - involves fear of separation from attachment figures, not social evaluation 1
• Autism Spectrum Disorder - social difficulties stem from impaired social communication rather than fear of negative evaluation 1
• Avoidant Personality Disorder - represents a more pervasive pattern but may overlap with generalized social anxiety disorder; however, personality disorder diagnosis is typically deferred in adolescents 5

Comorbidity Considerations

Assess for comorbid conditions that frequently co-occur with anxiety disorders: 2, 4, 6

• Major Depressive Disorder - present in approximately one-third of patients with social anxiety disorder 1, 6
• Other anxiety disorders - patients often have multiple anxiety disorders simultaneously 1, 6
• Substance use - adolescents may use alcohol or substances to self-medicate social anxiety 1, 6

Clinical Pitfalls to Avoid

Common Diagnostic Errors:

• Dismissing symptoms as "normal teenage shyness" - the presence of physical symptoms, avoidance behaviors, and distress indicates pathological anxiety requiring intervention 1, 7
• Focusing only on physical symptoms - providers may pursue cardiac or pulmonary workup without recognizing the anxiety disorder 7, 8
• Missing social anxiety when panic symptoms are present - the situational triggers distinguish social anxiety from panic disorder 1, 5
• Overlooking functional impairment - this patient maintains grades and attendance, but the internal distress and avoidance of social opportunities represent significant impairment in adolescent development 1

Assessment Priorities:

• Detailed trigger analysis - map exactly when symptoms occur (only in social evaluation contexts vs. multiple situations vs. unexpectedly) 1, 3
• Avoidance patterns - social anxiety involves avoiding social scrutiny, GAD involves worry without specific avoidance, panic disorder involves avoiding situations where panic might occur 1, 5, 3
• Developmental impact - assess how symptoms affect peer relationships, academic participation, and social skill development 1