A 28-year-old man with panic disorder is compared to a 35-year-old woman with social phobia (social anxiety disorder). The man reports sudden, severe episodes of chest pain and dyspnea occurring unpredictably throughout the day, leading him to visit the emergency department repeatedly. The woman experiences intense fear and avoidance of public speaking and social gatherings, but her anxiety is confined to these specific situations and does not occur when she is alone. Which feature best discriminates panic disorder from social anxiety disorder?

Explanation

## Panic Disorder vs. Social Anxiety Disorder: Key Discriminator ### The Critical Distinction **Key Point:** The defining difference is the **context and predictability of anxiety onset**. - **Panic Disorder:** Attacks are **spontaneous and recurrent** — they occur unpredictably and are *not* tied to a specific social or performance context. The person may have attacks while alone, at rest, or in any situation. - **Social Anxiety Disorder (Social Phobia):** Anxiety is **situational and predictable** — it is triggered specifically by *social evaluation* (being observed, judged, or scrutinized by others) or *performance situations* (public speaking, eating in public, writing in front of others). ### Comparison Table | Feature | Panic Disorder | Social Anxiety Disorder | | --- | --- | --- | | **Trigger** | Spontaneous, unpredictable, no social context required | Triggered by social evaluation or performance | | **Context** | Can occur anywhere, anytime (alone, at home, driving) | Occurs in social/performance situations | | **Avoidance pattern** | Avoidance of places where attacks have occurred (agoraphobia) | Avoidance of social/performance situations | | **Feared outcome** | Fear of the panic attack itself (fear of fear) | Fear of negative evaluation, embarrassment, or humiliation | | **Anticipatory anxiety** | Develops secondarily (fear of next attack) | Marked before social situations | | **Autonomic symptoms** | Prominent and acute (palpitations, dyspnea, chest pain) | Present but often less severe; may include blushing, tremor | ### Clinical Pearls **Clinical Pearl:** A panic disorder patient may develop *secondary* social anxiety due to fear of having an attack in public and being unable to escape. However, the *primary* anxiety in panic disorder is not about social judgment—it is about the attack itself. **High-Yield:** On exams, the **context of onset** is the gold-standard discriminator: - **Panic Disorder:** "Attacks occur out of the blue, unpredictably." - **Social Anxiety:** "Anxiety occurs in social or performance situations." **Mnemonic: PANIC vs. SOCIAL** - **PANIC:** Unpredictable, Any time, No social context - **SOCIAL:** Situations, Observation/Evaluation, Cued, Interpersonal, Avoidance of social events, Linked to judgment [cite:DSM-5 Diagnostic Criteria for Panic Disorder and Social Anxiety Disorder]