How to Help Patients with Olfactory Reference Syndrome Delusion of Body Odor Causes Shame, Social Isolation

CP_0307_Phillips.FinalREV 2/16/07 12:06 PM Page 49 How to help patients with olfactory reference syndrome Delusion of body odor causes shame, social isolation Katharine A. Phillips, MD Professor of psychiatry and human behavior Brown Medical School ® Dowden Health Media Providence, RI David J. Castle, MDCopyright St. Vincent's Hospital For personal use only The University of Melbourne Australia s. A, a 21-year-old M teacher, recalled always having been “sensi- tive,” but when she started her first job at age 19 she began to believe that she emitted an offensive odor. She experienced thoughts that she passed offensive fla- tus, her breath had a fecal odor, and people noticed © 2007 Smithsonian Institution/Corbis and were offended. Gradually Ms. A became more convinced of Patients with olfactory reference syndrome (ORS) these distressing beliefs and began to think that falsely believe they emit an offensive body odor. she permeated fecal odor through her skin. She Prominent referential thinking—believing that also became sure that colleagues were talking other people perceive the odor—also is common. about her and that they complained about her To introduce you to ORS, we discuss its clinical “disgusting” smell. diagnosis and treatment based on our review of VOL. 6, NO. 3 / MARCH 2007 49 For mass reproduction, content licensing and permissions contact Dowden Health Media. CP_0307_Phillips.FinalREV 2/16/07 12:06 PM Page 50 Olfactory reference syndrome Box 1 ings. She tried to keep meeting room doors Patient troubled by ‘a very bad odor open and believed that colleagues held their ... which came from his own person’ hands to their noses to “protect” themselves from her odor. Olfactory reference syndrome (ORS) has been described around the world for more than a ORS symptoms are most often reported as begin- century. In 1891, Potts described a delusional ning when patients are in their mid 20s, 50-year-old man who “had been troubled for the although some reports suggest onset during past three months with smelling a very bad odor, puberty or adolescence.4 In clinical series, the which he likened to that of a ‘back-house,’ and ratio of men to women is approximately 2:1. which came from his own person. [He believed] this smell was so very strong that other men Preoccupation. Individuals with ORS are preoccu- objected to working with him….” pied with the belief that they emit an unpleasant or 1,2,5-9 Despite its long history, the syndrome’s offensive body odor (Box 1), most commonly: prevalence is not well-established. ORS probably • flatulence, fecal, or anal odors is underdiagnosed and more common than • general body odor generally recognized: • halitosis • In a tertiary psychiatry unit in London, 0.5% • genital odors.1-3 of 2,000 patients who were not systematically Other perceived odors include sweat, armpit screened for ORS spontaneously reported ORS odor, sperm, urine, and malodorous hands and symptoms. feet.1-3 Occasionally, the imagined odor resembles • In a self-report survey of 2,481 students in nonbodily smells, such as ammonia or detergent. Japan, 2.1% had been concerned with emitting The odor is perceived to emanate from corre- a strange bodily odor during the past year. sponding body areas, such as the anus, skin, • In a study in a dental clinic in Japan, the mouth, rectum, genitalia, feet, nose, or axillae. majority of patients with a primary complaint Although most reports suggest that patients of halitosis actually had “imaginary halitosis” (another term for ORS). focus on one odor, some describe being concerned about several smells simultaneously or different Source: References 1,2,5–9 odors over time.10,11 Referential thinking. As the syndrome’s name several hundred cases, including the largest implies, many ORS patients have delusions of ref- reported series of patients with ORS.1-4 erence, falsely believing that other people perceive the odor.3 They misinterpret the behavior of CLINICAL FEATURES OF ORS others, assuming it is a reaction to how the Ms. A quit her job and felt confident enough to patient smells (Box 2, page 52).2,3 work again only when she performed a 2-hour They may misperceive comments (such as, daily cleansing routine, doused herself in per- “It’s stuffy in here”), receiving perfume or soap as fume, and placed an incontinence pad in her a gift, or behaviors such as people sniffing, touch- underwear. Despite these precautions, she still ing or rubbing their nose, clearing their throat, thought her colleagues avoided her. opening a window to get fresh air, putting a She always averted her mouth when speak- newspaper in front of their face, or looking or ing, held her hand in front of her mouth, and sat moving toward or away from the patient.1,3,5,7 far from others and close to the door in meet- Because they are ashamed, embarrassed, and continued on page 52 50 VOL. 6, NO. 3 / MARCH 2007 CP_0307_Phillips.FinalREV 2/16/07 12:06 PM Page 52 Olfactory reference syndrome continued from page 50 Box 2 Patients may change jobs repeatedly or avoid 3 Delusion, hallucination, or both? school or work because of shame and embarrass- ment, a belief that other people talk about the DSM-IV-TR classifies olfactory reference syndrome supposed odor, or the patient’s excessive preoccu- (ORS) as a delusional disorder, somatic type pations and time-consuming repetitive and safe- (the modern equivalent of monosymptomatic ty behaviors.5,13,14 hypochondriacal psychosis). ORS also is The distress and impaired functioning may mentioned in the text on social anxiety disorder. lead to psychiatric hospitalization, depression, ORS may not be diagnosed if: suicidal ideation, suicide attempts, and complet- • criterion A for schizophrenia has ever been met ed suicide.7,10,12,15 Pryse-Phillips studied 36 pa- • or if symptoms are due to the direct physiologic tients with ORS and reported: effects of a substance or a general medical • nearly one-half (43%) experienced “suicidal condition, such as a brain tumor or temporal lobe epilepsy. ideas or action” • 2 (5.6%) committed suicide.3 Many patients report being able to smell the Illness course. imagined odor, suggesting that they experience Most authors suggest that ORS is an olfactory hallucination. Pryse-Phillips described usually chronic, persisting for years if not the olfactory hallucinations of her 36 ORS case decades, with possible worsening over time if patients as “a real and immediate perception... patients do not receive appropriate treatment.11,15 often perceived in the absence of other odors.” In a 2-year follow-up study,3 ORS symptoms per- ORS generally is regarded as delusional, with sisted relatively unchanged in 10 of 11 patients. possible secondary illusional misinterpretations Some authors have questioned whether ORS and referential thinking. ORS beliefs usually can transform into schizophrenia, but others have appear to be of delusional intensity, although found little evidence for this.3,6 some patients may have some—although limited —insight (that is, overvalued ideation). Psychiatric comorbidity. Depression is mentioned most often in the literature.12,13 In Pryse-Phillips’ Source: References 2 and 3 36 ORS patients (who did not have a “primary” depressive disorder), depression symptoms tend- ed to be severe.3 The depression generally is con- concerned about offending others with their odor,13 sidered secondary to ORS, although Pryse- many patients engage in repetitive and “safety” Phillips evaluated 50 additional patients with behaviors intended to check, eliminate, or camou- ORS symptoms whom she considered to have a flage the supposed odor (Box 3, page 55).1,3,7,12,14 “primary” depressive disorder.3 Other psychiatric Functional impairment. Individuals with ORS comorbidities include bipolar disorder, personali- often avoid other people or believe that others ty disorder, schizophrenia, hypochondriasis, alco- avoid them.12 They are typically embarrassed and hol and/or drug abuse, obsessive-compulsive dis- worried that others will be offended by the smell. order (OCD), and body dysmorphic disorder.3,7,15 They may: In a study of 200 individuals with body dysmor- • avoid activities such as dating phic disorder, 8 had comorbid ORS.16 • break off engagements • refuse to travel DIAGNOSING ORS • move to another town Clinical clues to ORS (Table 1, page 60) probably • become housebound.3,7,10,12 are not present in all patients and some are not continued on page 55 52 VOL. 6, NO. 3 / MARCH 2007 CP_0307_Phillips.Final 2/14/07 1:40 PM Page 55 continued from page 52 specific to ORS. They appear to be common fea- Box 3 tures of the illness, however, and may alert you to ‘Safety’ and avoidance behaviors its presence. Our clinical impression is that many seen in olfactory reference syndrome patients with ORS are secretive about their symptoms because they are ashamed of them. Thus, you Excessive showering or washing are among need to be alert to clues and specifically inquire the repetitive, ritualistic or “safety” behaviors about ORS symptoms to detect its presence. many patients with ORS engage in to check, Criteria. DSM-IV-TR and ICD-10 lack specific eliminate, or camouflage supposed odor. Frequent diagnostic criteria for ORS, instead applying cri- clothes changing or laundering also is common. teria for delusional disorder. One problem with Camouflaging attempts may include excessive use of deodorant, soap, cologne, powder, mints, this approach is that delusional disorder criteria mouthwash, or toothpaste; wearing layers specify that any co-occurring mood symptoms of clothing; or smoking. must be brief relative to the duration of the delu- Many patients frequently check for the odor sional periods. This requirement may not be valid or its source (such as trying to smell their own when applied to ORS.

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