What is the most appropriate initial approach for managing a patient presenting with symptoms of anxiety and fear of social or performance situations, who reports feeling 'on edge' and having worries about multiple concerns, and is seeking a note to avoid public speaking at work due to self-reported post-traumatic stress disorder (PTSD) symptoms?

Educate the Patient on the Correct Diagnosis

The most appropriate initial approach is to educate the patient on the difference between PTSD and social anxiety disorder, as accurate diagnosis is essential before any treatment can be initiated. 1

Why This Patient Does Not Have PTSD

This patient's presentation is inconsistent with PTSD and instead clearly meets criteria for social anxiety disorder:

• PTSD requires exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence 2
• This patient's "trauma" is embarrassment from a college presentation—not a qualifying traumatic event
• The patient explicitly denies core PTSD symptoms: no hypervigilance, no emotional numbing, no depersonalization, no derealization 2
• Their "flashbacks" are simply embarrassing memories, not intrusive re-experiencing of trauma 2
• Symptoms have been present their "whole life" rather than developing after a specific traumatic event 1

Why This Is Social Anxiety Disorder

The clinical presentation precisely matches social anxiety disorder criteria:

• Marked fear of social situations involving scrutiny by others (public speaking, work performance, social situations) 1
• Fear that anxiety symptoms will be negatively evaluated (embarrassment concern) 1
• Panic attack during public speaking in college demonstrates the performance-limited subtype 1
• Social situations are avoided or endured with intense anxiety (seeking work accommodation) 1
• Lifelong duration (median onset age 13 years, with 75% occurring between ages 8-15) 1
• Causes clinically significant impairment in occupational functioning (cannot give work presentations) 1

Why Education Must Come First

Providing inappropriate accommodations or starting treatment for the wrong diagnosis would be harmful:

• Writing a work excuse letter reinforces avoidance behavior, which is the core maintaining factor in social anxiety disorder 1
• Starting "PTSD medication" would be treating a non-existent condition and delay appropriate care
• Immediate immersion therapy without proper psychoeducation and graduated exposure would be premature and potentially traumatizing 1

The Correct Initial Approach

Begin with psychoeducation about social anxiety disorder:

• Explain that social anxiety disorder is characterized by persistent fear of social situations where scrutiny may occur, lasting typically 6 months or more 1
• Clarify that avoidance (like seeking work accommodations) perpetuates the disorder rather than treating it 1
• Discuss that social anxiety disorder is highly treatable with specific interventions 3, 4

After Education: Evidence-Based Treatment Options

Once the patient understands their correct diagnosis, offer:

First-line psychotherapy:

• Individual CBT specifically designed for social anxiety disorder (Clark and Wells model or Heimberg model) delivered by a skilled therapist over approximately 12 sessions 1
• CBT includes cognitive restructuring, gradual exposure to feared social situations, and relapse prevention 1
• Individual therapy is preferred over group therapy due to superior clinical effectiveness 1

First-line pharmacotherapy:

• SSRIs (escitalopram, paroxetine, or sertraline) are evidence-based options 1, 4
• SNRIs (venlafaxine) are also effective 4
• Treatment choice should consider patient preference and availability 1

Combined approach:

• Combination of SSRI with CBT demonstrates superior efficacy compared to medication monotherapy 5

Critical Pitfall to Avoid

Do not enable avoidance behavior. Writing a letter to excuse the patient from public speaking would:

• Reinforce the maladaptive coping strategy of avoidance 1
• Worsen long-term outcomes and quality of life 3
• Prevent the patient from engaging in exposure therapy, which is the most effective treatment component 1, 4