Deipnophobia: A Case of Social Anxiety Masquerading as Eating Issues

Prim Care Companion CNS Disord 2022;24(2):21cr02987

To cite: Das A, Holland J, Flynn V, et al. Deipnophobia: a case of social anxiety masquerading as eating issues. Prim Care Companion CNS Disord. 2022;24(2):21cr02987.
To share: https://doi.org/10.4088/PCC.21cr02987

© Copyright 2022 Physicians Postgraduate Press, Inc.

^aDepartment of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
*Corresponding author: Aparna Das, MD, 4301 West Markham St, Little Rock, AR 72205 (ad.mamc.1510@gmail.com).

Deipnophobia is a type of social anxiety disorder wherein the individual feels anxious while dining in public or engaging in dinner conversations.^1,2 Social anxiety disorder is common in the general population, with a lifetime prevalence of around 12%.³ However, the exact prevalence of deipnophobia is unknown. We report the case of a patient who had a variant of deipnophobia.

Case Report

A 23-year-old White woman presented to the clinic with complaints of loss of appetite and eating problems. She reported that whenever she would go out to dine with her boyfriend, the moment her boyfriend finished his food and started looking at her, she would have panic attacks. Gradually, these symptoms progressed to involve panic attacks when eating at home with her boyfriend. She denied having anxiety when eating meals by herself. She denied living with her boyfriend, but they would often meet at each other’s houses to watch movies or dine together. She reported a healthy relationship with her boyfriend. Her past medical history revealed that as a child, she had undiagnosed gastrointestinal issues for a long time. She described her parents as accusatory and dismissive of her concerns. In middle school, she was diagnosed with lactose intolerance. She started using dairy-free products with subsequent relief of symptoms. She remained symptom free until high school when she got into an abusive relationship. She reported that she was physically, verbally, and emotionally abused by her then boyfriend. She denied being body shamed or any beratement related to her eating habits or weight. At that time, she started having difficulty eating in the cafeteria in front of other kids and started avoiding eating there. After some time, the abusive relationship ended, and she became more comfortable eating in front of others. Around 4 years ago, she started having panic attacks related to eating out with another previous boyfriend and anxiety like the current presentation. These episodes of anxiety surrounding eating in public occurred in the context of being in a relationship. She denied any depressive symptoms. She reported that her body mass index (BMI) was always in the normal range throughout her life and that her current BMI was 24 kg/m². She denied symptoms suggestive of another eating disorder, body image issues, or obsessive thoughts. Her family history was strongly positive for anxiety on her maternal side.

For medication management, selective serotonin reuptake inhibitors (eg, sertraline or fluoxetine) were offered. The patient, however, opted for a trial of venlafaxine due to her family members’ reporting a positive response to venlafaxine for anxiety. She was started on venlafaxine 75 mg/d and engaged in therapy. After 12 weeks, she denied any concerns of social anxiety and had full participation in social eating events with her boyfriend. The long-term medication plan involved continuation of venlafaxine for 6 months and then tapering and discontinuing the medication. During the entire period of management, she was longitudinally followed and had multiple follow-up visits. She was also seen around 1 month after discontinuation of medication for a final follow-up visit and reported that she was symptom free.

Discussion

This case is interesting for 2 reasons: (1) highly selective presentation and (2) social anxiety masquerading as eating issues. The patient did not have a typical presentation of social anxiety of eating in public or in front of strangers, but her rather selective social anxiety occurred after her boyfriend finished eating his meal and started looking at her. This anxiety started while dining out and progressed to the point that it also started occurring at home. There was no anxiety if her boyfriend continued eating and both finished at the same time. The underlying fears in the patient’s case were related to embarrassment, being judged, and losing control.⁴ It is important to inquire about underlying thoughts, as this can help differentiate social anxiety disorder from eating disorders wherein the hesitancy of eating is due to fear related to body image issues.⁴ Eating disorders and social anxiety disorder are also highly comorbid, and both should be screened for during evaluation.^4,5 This case also reinforces the role of genetic and environmental factors⁶ in the genesis of social anxiety. Biologically, the patient was predisposed to anxiety, as she reported anxiety on her maternal side. Environmental factors like parental invalidation, lactose intolerance as a child, and negative psychological experiences due to an abusive partner as a teenager led to the emergence of anxiety. The coronavirus disease 2019 pandemic is another factor that could have led to potential worsening of anxiety.⁷ Looking at the neurobiology of the disorder, brain areas such as the amygdala, insula, and striatum; serotonergic and dopaminergic system dysfunction; and adrenergic activation are implicated in the causation of social anxiety.⁸ Treatment involves medication management with antidepressants, propranolol, and therapy.⁸

In conclusion, untreated social anxiety disorder can be debilitating and may interfere with functioning. It is important to screen for other psychiatric illnesses that may mimic or coexist with it. Prompt recognition and management can lead to better outcomes.

Published online: April 7, 2022.
Relevant financial relationships: None.
Funding/support: None.
Patient consent: Consent was received from the patient to publish the case report, and information has been de-identified to protect anonymity.