Diagnosis: Social Anxiety Disorder (Social Phobia)
This woman has social anxiety disorder, not GAD, agoraphobia, or depression, because her anxiety is specifically triggered by social situations involving potential scrutiny (presentations, parties) rather than being pervasive across multiple life domains, and she maintains normal functioning in non-social contexts. 1
Key Diagnostic Features Supporting Social Anxiety Disorder
Situation-specific anxiety: The fear is limited to social or performance situations where scrutiny may occur (presentations, parties), which is the hallmark of social anxiety disorder 1, 2
Preserved baseline functioning: Normal sleep, appetite, and ability to enjoy solitary activities (reading) argue strongly against GAD or depression 3
Absence of generalized worry: GAD requires excessive, uncontrollable worry about multiple life domains (work, health, finances, relationships) that extends beyond any single concern 3. This patient's symptoms are confined to social performance situations 1
Not agoraphobia: Agoraphobia involves fear of situations where escape might be difficult or help unavailable (crowds, public transportation, open spaces), not fear of social scrutiny itself 2
Not depression: The preserved appetite, normal sleep, and maintained interest in activities (reading) exclude major depressive disorder 3
Diagnostic Confirmation
Use the Mini-SPIN screening tool (cutoff ≥6 points), which demonstrates 89% sensitivity and 90% specificity for social anxiety disorder in primary care 4, 5
Confirm diagnosis using DSM criteria: marked fear of social situations lasting ≥6 months, with avoidance or endurance with intense anxiety, causing clinically significant impairment 1, 2
Treatment Recommendations
First-line treatment should be individual CBT specifically designed for social anxiety disorder, delivered over approximately 12 sessions by a skilled therapist. 1
Psychotherapy (Preferred Initial Treatment)
Cognitive-behavioral therapy includes cognitive restructuring, gradual exposure to feared social situations, and relapse prevention 1
CBT is preferred over group therapy due to superior clinical effectiveness for social anxiety disorder 1
Pharmacotherapy (First-Line Options)
SSRIs are the evidence-based first-line medications: paroxetine, sertraline, or escitalopram 1, 2, 6
Paroxetine is FDA-approved for social anxiety disorder at doses of 20-60 mg/day 2
Sertraline is FDA-approved for social anxiety disorder at doses of 50-200 mg/day 6
For moderate to severe presentations, combined psychotherapy and pharmacotherapy is often recommended 5
Critical Pitfalls to Avoid
Do not provide work excuse letters or accommodations that reinforce avoidance, as avoidance is the core maintaining factor in social anxiety disorder 1
Do not start treatment for GAD or depression without proper differential diagnosis, as this delays appropriate care and can be harmful 1
Do not attempt immediate immersion therapy without proper psychoeducation and graduated exposure, as this can be premature and potentially traumatizing 1