Objective-Generalized social phobia involves fear/avoidance, specifically of social situations, whereas generalized anxiety disorder involves intrusive worry about diverse circumstances. It remains unclear the degree to which these two, often comorbid, conditions represent distinct disorders or alternative presentations of a single, core underlying pathology. Functional magnetic resonance imaging assessed the neural response to facial expressions in generalized social phobia and generalized anxiety disorder.Method-Individuals matched on age, IQ, and gender with generalized social phobia without generalized anxiety disorder (N=17), generalized anxiety disorder (N= 17), or no psychopathology (N=17) viewed neutral, fearful, and angry expressions while ostensibly making a simple gender judgment.Results-The patients with generalized social phobia without generalized anxiety disorder showed increased activation to fearful relative to neutral expressions in several regions, including the amygdala, compared to healthy individuals. This increased amygdala response related to selfreported anxiety in patients with generalized social phobia without generalized anxiety disorder. In contrast, patients with generalized anxiety disorder showed significantly less activation to fearful relative to neutral faces compared to the healthy individuals. They did show significantly increased response to angry expressions relative to healthy individuals in a lateral region of the middle frontal gyrus. This increased lateral frontal response related to self-reported anxiety in patients with generalized anxiety disorder.Conclusions-These results suggest that neural circuitry dysfunctions differ in generalized social phobia and generalized anxiety disorder.Generalized social phobia and generalized anxiety disorder are two highly prevalent, chronic, and disabling anxiety disorders (1,2) that are sometimes comorbid. Generalized social phobia involves fear/avoidance, specifically of social situations, whereas generalized anxiety disorder involves intrusive worry about a broader array of everyday life circumstances. Although both have considerable social and economic costs, disagreement exists concerning the degree to which the conditions result from a shared or unique pathophysiology. For example, high rates of comorbidity in cross-sectional and longitudinal studies suggest that the distinction between the two conditions may be relatively subtle at the descriptive level (3,4). On the other hand, data from family-based and therapeutic research suggest the two conditions can be dissociated. Specifically, such dissociation is reflected in patterns of disorder aggregation within families (5), as well as by the fact that generalized anxiety disorder, but not social phobia, responds to most tricyclic antidepressants and to buspirone (6-8). Because no brain-imaging study has directly compared the two conditions, it remains unclear whether the two disorders have dissociable neural correlates.The principal goal of the current study was to inves...

Delusions of foul body odors (often referred to as olfactory reference syndrome [ORS]) currently fall under the category of delusional disorder, somatic type (DDST), in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). We present the case of a 51-year-old man with no previous psychiatric history who presented with perceived foul odors that he delusionally attributed to trimethylaminuria (TMAU). TMAU is a rare metabolic disorder associated with foul body odors. The patient also experienced severe concurrent mood symptoms because of social isolation resulting from his delusion about his body odors. After considerable discussion of differential diagnoses, a diagnosis of DDST was ultimately made, given the patient's unrelenting nonbizarre delusions and lack of insight pertaining to his body odors. However, this case proved to be very useful in exploring the diagnostic challenges in this type of disorder and recent discussions of ORS and its proposed inclusion in the DSM-5.

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Social anxiety disorder or social phobia (SP) is defined as "the intense fear of becoming humiliated in social situations, specifically of embarrassing yourself in front of other people" (National Institute of Mental Health, 2000). It affects between 6% and 15% of the general U.S. population (1), is the third most common psychiatric disorder, and is extremely debilitating to those who have it. Individuals with SP are extremely fearful and avoid social situations (APA, 2000). The fear is caused primarily by feelings that they will be humiliated or embarrassed. The onset of SP is usually in childhood or adolescence, and the disorder occurs more often in women than in men. Many people are so affected by it that they cannot work and cannot start or maintain personal or professional relationships; in addition, an unusually high rate of comorbid depression is seen in individuals with SP. More recently, interest has focused on the development course of SP, leading to a reconceptualization of the disorder as a chronic neurodevelopment illness rather than one manifesting for the first time in adulthood (2). In recent years, our knowledge of SP has included important advances in the understanding of the epidemiology, neurobiology, and neural circuitry of SP. In this clinical synthesis, we will review the diagnosis, psychopharmacological treatment, and recent questions and controversy regarding this debilitating, yet treatable, disorder. DSM-IV-TR criteria for social anxiety disorder are listed in Table 1.