A 40-year-old male presents with a lifelong pattern of social inhibition. He reports that since childhood he has avoided social situations due to fear of negative evaluation, rarely attends social events, and has declined multiple job promotions because they would require public speaking. He describes himself as fundamentally inadequate and states he has always felt inferior to others. He has no close friends outside his family, avoids meeting new people unless certain of being liked, and views himself as socially inept and unappealing. He also experiences significant physical anxiety symptoms — trembling, sweating, and nausea — in social situations he cannot avoid.