What is the most likely diagnosis for a 21-year-old male college student experiencing brief memory loss during a public speaking assignment, with no history of traumatic brain injury, seizures, or other cognitive changes, but a long-standing fear of public speaking?

Performance Anxiety

This patient's brief memory loss during a stressful public speaking assignment is best explained by performance anxiety, not dissociative amnesia, dementia, or PTSD. 1

Clinical Reasoning

This 21-year-old demonstrates classic features of performance anxiety specific to public speaking contexts:

• Context-specific symptom expression: The memory impairment occurred exclusively during the public speaking assignment, while he provided thorough childhood history during the office visit 1
• Long-standing fear pattern: He reports always having fears of public speaking, consistent with performance anxiety rather than acute dissociative phenomena 1
• Absence of trauma: He denies any traumatic events, ruling out PTSD as a diagnosis 2
• Intact baseline function: His ability to recall detailed autobiographical information in the clinical setting demonstrates preserved memory capacity 1

Why Not the Other Diagnoses?

Dementia is definitively excluded because:

• Dementia requires cognitive impairment that interferes with ability to function at work or usual activities, represents decline from previous functioning, and is not explained by other psychiatric conditions 1
• This patient has no progressive cognitive decline, no functional impairment in daily activities, and his symptoms are entirely context-dependent 1
• His thorough recall during the office visit demonstrates intact memory systems 3

Dissociative amnesia is not appropriate because:

• Dissociative amnesia typically involves inability to recall important autobiographical information following significant trauma or overwhelming stress 2
• This patient's "memory loss" resolved immediately when context changed (office setting vs. public speaking), indicating anxiety-driven performance disruption rather than true amnesia 1
• He could recall the same information when not under performance pressure 1

PTSD is ruled out by the absence of traumatic exposure and the specific context-limited nature of symptoms 2

Understanding Performance Anxiety

Performance anxiety represents a specific subtype of social anxiety disorder where individuals experience excessive anxiety predominantly during public speaking or performance situations 1, 4. Key features include:

• High prevalence: Public speaking anxiety affects approximately one-third of community samples, with 10% experiencing marked interference with functioning 5
• Early onset: Typically begins in adolescence (50% by age 13,90% by age 20) 5
• Context-dependent expression: Symptoms manifest specifically during or in anticipation of public speaking, not across all social contexts 1
• Cognitive disruption: Anxious cognitions include fears of mind going blank (74%), being unable to continue talking (63%), and saying foolish things (59%) 5

Clinical Implications

The patient's symptom pattern reflects anxiety-driven cognitive interference rather than memory pathology. 1 During high-stress performance situations, anxiety can consume cognitive resources, leading to apparent "memory failure" that resolves when the stressor is removed 6. This is fundamentally different from organic memory disorders or dissociative states 1.

Treatment Considerations

While treatment planning was not requested, it's worth noting that performance anxiety is highly amenable to behavioral interventions, particularly exposure-based treatments 6, 4. The prognosis is generally favorable with appropriate intervention 1.

Common Pitfall

Do not mistake context-dependent cognitive disruption from performance anxiety for organic memory disorders or dissociative phenomena. 1 The key distinguishing feature is that performance anxiety produces inconsistent symptoms that vary dramatically based on context, with preserved function in non-threatening situations 1.