Evidence-Based Reviews

How to help patients with olfactory reference syndrome

Current Psychiatry. 2007 March;6(3):49-65

References

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Functional impairment. Individuals with ORS often avoid other people or believe that others avoid them.¹² They are typically embarrassed and worried that others will be offended by the smell. They may:

avoid activities such as dating
break off engagements
refuse to travel
move to another town
become housebound.^3,7,10,12

Patients may change jobs repeatedly or avoid school or work³ because of shame and embarrassment, a belief that other people talk about the supposed odor, or the patient’s excessive preoccupations and time-consuming repetitive and safety behaviors.^5,13,14

The distress and impaired functioning may lead to psychiatric hospitalization, depression, suicidal ideation, suicide attempts, and completed suicide.^7,10,12,15 Pryse-Phillips studied 36 patients with ORS and reported:

nearly one-half (43%) experienced “suicidal ideas or action”
2 (5.6%) committed suicide.³

Illness course. Most authors suggest that ORS is usually chronic, persisting for years if not decades, with possible worsening over time if patients do not receive appropriate treatment.^11,15 In a 2-year follow-up study,³ ORS symptoms persisted relatively unchanged in 10 of 11 patients.

Some authors have questioned whether ORS can transform into schizophrenia, but others have found little evidence for this.^3,6

Psychiatric comorbidity. Depression is mentioned most often in the literature.^12,13 In Pryse-Phillips’ 36 ORS patients (who did not have a “primary” depressive disorder), depression symptoms tended to be severe.³ The depression generally is considered secondary to ORS, although Pryse-Phillips evaluated 50 additional patients with ORS symptoms whom she considered to have a “primary” depressive disorder.³ Other psychiatric comorbidities include bipolar disorder, personality disorder, schizophrenia, hypochondriasis, alcohol and/or drug abuse, obsessive-compulsive disorder (OCD), and body dysmorphic disorder.^3,7,15 In a study of 200 individuals with body dysmorphic disorder, 8 had comorbid ORS.¹⁶

Diagnosing ORS

Clinical clues to ORS (Table 1) probably are not present in all patients and some are not specific to ORS. They appear to be common features of the illness, however, and may alert you to its presence. Our clinical impression is that many patients with ORS are secretive about their symptoms because they are ashamed of them. Thus, you need to be alert to clues and specifically inquire about ORS symptoms to detect its presence.

Criteria. DSM-IV-TR and ICD-10 lack specific diagnostic criteria for ORS, instead applying criteria for delusional disorder. One problem with this approach is that delusional disorder criteria specify that any co-occurring mood symptoms must be brief relative to the duration of the delusional periods. This requirement may not be valid when applied to ORS.

In our experience, some patients have protracted depressive symptoms that appear secondary to “primary” ORS symptoms, and another diagnosis—such as psychotic depression—does not appear to account for their symptoms.

We propose working diagnostic criteria for ORS (Table 2), which are similar to those proposed by Lochner and Stein¹⁷ and require empiric validation. Suggested questions for the patient interview (Table 3) can help you identify and diagnose ORS.

Differential diagnosis. Keep in mind that a false belief that one emits a bad smell may be a symptom of schizophrenia, and this would trump an ORS diagnosis if other schizophrenia symptoms are present. Some patients with severe depression may believe they smell bad as part of a nihilistic delusional belief system (such as in Cotard’s syndrome—nihilistic delusions in severe depression).

Whether to conceptualize a false belief about body odor as a symptom of depression or as ORS with comorbid or secondary depression may be unclear from case to case.

Table 1

Clinical clues to the presence of olfactory reference syndrome

Referential thinking. Interpreting actions of others—such as opening a window, moving away, putting a hand to their nose, or making comments related to odors—as evidence that the person smells offensive
Excessive attempts to ‘disguise’ the smell, such as washing routines, clothes changing, clothes laundering, or using abundant perfume, deodorant, mouthwash, mints, or other forms of camouflage
Other excessive and repetitive behaviors, such as checking for or asking other people for reassurance about the odor
Social anxiety or avoidance of social activities, relationships, work, school, or other daily activities
Requests for treatment for the perceived odor from dentists, gastroenterologists, proctologists, or other nonpsychiatric physicians despite a negative medical workup

Table 2

Working diagnostic criteria for olfactory reference syndrome

A.	Persistent false belief that one emits a malodorous smell; this belief may encompass a range of insight and does not have to be delusional
B.	The belief is time-consuming and preoccupies the individual for at least 1 hour per day
C.	The belief causes clinically significant distress or results in significant impairment in social, occupational, or other important areas of functioning
D.	The belief is not better accounted for by another mental disorder or a general medical condition