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D   The patient feels that her fear is irrational and her anxiety is needlessly excessive

Social anxiety disorder is the third most common psychiatric disorder in the United States (after major depression and alcohol dependence), yet it is often overlooked. Patients with this condition tend to be young, single, and of low socioeconomic status. It is somewhat more common in females. There are two types of social anxiety disorder: generalized (fear of many kinds of social situations) and specific (symptoms limited to public speaking, etc). The cause of the condition is not completely known, but some researchers believe it may be linked to GABA, dopamine, and/or serotonin imbalance. Treatment can include serotonin selective reuptake inhibitors such as paroxetine, benzodiazepines such as lorazepam, or beta-blockers such as propanolol.

The diagnosis is usually suspected when the patient is overly concerned about being humiliated, is very self-conscious, and has symptoms such as sweating, blushing, trembling or palpitations. Onset is often in the teen years and rarely is after age 25. Significant debility can result from avoidance, including unmet goals in education, employment, or relationships with others. These diagnostic criteria are summarized in the following table.

Summary of DSM-IV Criteria for Social Phobia

Fear of one or more social situations where there may be scrutiny by strangers

The social situation causes anxiety symptoms

The patient realizes that the fear is excessive or irrational

The social situation is avoided or endured only with distress

The symptoms cause impairment of functioning

Symptoms have lasted 6 months if the patient is under 18 years of age

The symptoms are not being caused by a pharmaceutical or another medical condition

If there is comorbidity, the fear has nothing to do with comorbidity (ie. fear of heart attack in someone with coronary disease)

The anxiety of social phobia must come from scrutiny by strangers, not in-laws. The symptoms must cause impairment of functioning, not evidenced by reported plans for marriage and high job satisfaction. The symptoms cannot be due to a medication such as caffeine or some other medical condition. The symptoms must have persisted for at least 6 months if the patient is under 18 years of age. A patient with social phobia has the insight to realize that the fear and anxiety are excessive or irrational.

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