This week, we are sharing another USMLE® Step 1-style practice question to test your knowledge of medical topics. Today’s case involves a 25-year-old woman who has concerns about being socially withdrawn and has been avoiding social events at her job. Past medical history is noncontributory. Which of the following is the most likely diagnosis? Can you figure it out?
A 25-year-old woman comes to the physician due to concerns about being socially withdrawn. The patient tells the physician she has been avoiding any social events at her job. She adds that although she likes to go out and meet new people at her work, she fears that she will be embarrassed and they will judge her negatively. She also declined a promotion at this job 6 months ago because she thought she would have to talk to more people in both virtual and in-person meetings; she was concerned that she would feel embarrassed if she “said the wrong thing.” She is able to sleep 8 hours every night and has no trouble falling asleep. She has no history of alcohol or substance dependence. Past medical history is noncontributory. Which of the following is the most likely diagnosis?
A. Social anxiety disorderB. Performance anxiety
C. Generalized anxiety disorder
D. Agoraphobia
E. Specific phobia
Scroll down to find the answer!
The correct answer to today’s USMLE® Step 1 Question is…
A. Social anxiety disorder
Before we get to the Main Explanation, let’s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
The incorrect answers to today’s USMLE® Step 1 Question are…
B. Performance anxiety
Incorrect: Performance anxiety is a subtype of social anxiety which is confined to situations where public performance of some kind is required (e.g. public speaking). However, this patient’s anxiety is related to all social events and not confined to performance, making social anxiety disorder the more likely the diagnosis.
C. Generalized anxiety disorder
Incorrect: Patients with generalized anxiety disorder have anxiety and stress related to a multitude of topics. This patient’s anxiety is limited to social and public activities (including virtual meetings), making social anxiety disorder the more likely the diagnosis.
D. Agoraphobia
Incorrect: Agoraphobia is characterized by excessive worry or anxiety in closed or crowded places from which escape might be difficult. This patient’s anxiety is more with social and public activities (including virtual meetings), making social anxiety disorder the more likely the diagnosis.
E. Specific phobia
Incorrect: A specific phobia is an anxiety disorder characterized by excessive fear and worry about a specific object or place. This patient’s anxiety about social events is due to the fear of being negatively judged or embarrassed, making social anxiety disorder the more likely diagnosis.
Main Explanation
This patient is experiencing intense anxiety related to social activities and the fear of embarrassment or negative judgement from others participating in the activities; this stress is having a significant impact on her life (e.g., declining the promotion, avoiding social activities at work). The most likely diagnosis is social anxiety disorder.
Social anxiety disorder is characterized by excessive worry and anxiety about being embarrassed or judged when engaging in social activities. It is one of the most common anxiety disorders, and it is more commonly diagnosed in females than males. The fear and anxiety in social anxiety disorder is only seen in relation to social events, where the patient feels that they could be exposed to negative judgment by others. This anxiety often leads to some degree of impairment in the patient’s life (e.g., avoidance of social events, turning down opportunities).
The DSM-V diagnostic criteria for social anxiety disorder is as follows:
- Excessive fear or worry about one or more social situations where the patient could be exposed to scrutiny or negative judgment by others.
- The social events provoke excessive worry and anxiety.
- The anxiety is out of proportion to the real threat posed by the social situation.
- The social situations are either endured with intense fear and worry, or they are avoided completely.
- Duration for ≥ 6 months
- The presentation is not better explained by substance use or another mental or physical disorder.
The treatment for social anxiety disorder includes both medication and psychotherapy. The selective serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine and the selective norepinephrine serotonin reuptake inhibitor (SNRI) venlafaxine are all very effective and can be used as first-line treatment. Cognitive behavioral therapy is also effective. Although medical treatment can demonstrate faster effects, CBT has been shown to be more effective in managing social anxiety in the long term.
The performance subtype of social anxiety is specific to situations where the patient has to present or perform in front of others. The patient’s fear of being embarrassed or judged is limited to these instances of performance, while other social situations are tolerated as normal. The performance subtype can be managed with as-needed beta-blockers (e.g. propranolol) or benzodiazepines. Beta-blockers are preferred due to lower risk of dependence, especially in patients with a history of substance use disorders.
Major Takeaway
Social anxiety disorder is characterized by excessive anxiety about social events due to the fear of being negatively judged or embarrassed. Treatment involves a combination of medication (e.g. SSRIs) and cognitive behavioral therapy.
References
Rose GM, Tadi P. Social Anxiety Disorder. [Updated 2020 Nov 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555890/ Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 16, DSM-IV to DSM-5 Social Phobia/Social Anxiety Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t12/ _________________________
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The United States Medical Licensing Examination (USMLE®) is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). Osmosis is not affiliated with NBME nor FSMB.
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