Evidence-Based Reviews

How to help patients with olfactory reference syndrome

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

References

1. Iwu CO, Akpata O. Delusional halitosis. Review of the literature and analysis of 32 cases. Br Dent J 1989;167:294-6.

2. Osman AA. Monosymptomatic hypochondriacal psychosis in developing countries. Br J Psychiatry 1991;159:428-31.

3. Pryse-Phillips W. An olfactory reference syndrome. Acta Psychiatr Scand 1971;47:484-509.

4. Yamada M, Shigemoto T, Kashiwamura K, et al. Fear of emitting bad odors. Bull Yamaguchi Med Sch 1977;24:141-61.

5. Potts CS. Two cases of hallucination of smell. University of Pennsylvania Medical Magazine 1891;226.-

6. Forte FS. Olfactory hallucinations as a proctologic manifestation of early schizophrenia. Am J Surg 1952;84:620-2.

7. Marks I, Mishan J. Dysmorphophobic avoidance with disturbed bodily perception: a pilot study of exposure therapy. Br J Psychiatry 1988;152:674-8.

8. Kasahara Y, Kenji S. Ereuthophobia and allied conditions: a contribution toward the psychopathological and cross-cultural study of a borderline state. In: Arieti S, ed. The world biennial of psychiatry in psychotherapy. New York, NY: Basic Books, 1971.

9. Iwakura M, Yasuno Y, Shimura M, Sakamoto S. Clinical characteristics of halitosis: differences in two patient groups with primary and secondary complaints of halitosis. J Dent Res 1994;73:1568-74.

10. Johanson E. Mild paranoia. Acta Psychiatr Scand 1964;40:13-4.

11. Sutton RL. Bromidrosiphobia. JAMA 1919;72:1267-8.

12. Malasi TH, El-Hilu SR, Mirza IA, Fakhr El-Islam M. Olfactory delusional syndrome with various aetiologies. Br J Psychiatry 1990;156:256-60.

13. Alvarez WC. Practical leads to puzzling diagnoses. Philadelphia, PA: JB Lippincott; 1958.

14. Brotman AW, Jenike MA. Monosymptomatic hypochondriasis treated with tricyclic antidepressants. Am J Psychiatry 1984;141:1608-9.

15. Videbech T. Chronic olfactory paranoid syndromes. Acta Psychiatr Scand 1966;42:183-213.

16. Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosom 2005;46:317-32.

17. Lochner C, Stein DJ. Olfactory reference syndrome: diagnostic criteria and differential diagnosis. J Postgrad Med 2003;49:328-31.

18. Dominguez RA, Puig A. Olfactory reference syndrome responds to clomipramine but not fluoxetine: a case report. J Clin Psychiatry 1997;58:497-8.

19. Ross CA, Siddiqui AR, Matas M. DSM-III. Problems in diagnosis of paranoia and obsessive-compulsive disorder. Can J Psychiatry 1987;32:146-8.

20. Ulzen TPM. Pimozide-responsive monosymptomatic hypochondriacal psychosis in an adolescent. Can J Psychiatry 1993;38:153-4.

21. Riding J, Munro A. Pimozide in the treatment of monosymptomatic hypochondriacal psychosis. Acta Psychiatr Scand 1975;52:23-30.

22. Kong SG, Tan KH. Monosymptomatic hypochondriacal psychosis: a report of 3 cases. Singapore Med J 1984;25:432-5.

23. Gomen-Perez JD, Marks IM, Gutierrez-Fisac JL. Dysmorphophobia: clinical features and outcome with behavior therapy. Eur Psychiatry 1994;9:229-35.

24. Milan MA, Kolko DJ. Paradoxical intention in the treatment of obsessional flatulence ruminations. J Behav Ther Exp Psychiatry 1982;13:167-72.

25. Phillips KA. The broken mirror: understanding and treating body dysmorphic disorder. New York, NY: Oxford University Press; 1996 (revised and expanded edition, 2005; Japanese edition, 1999).

26. Marks IM. Fears, phobias, and rituals. Oxford, UK: Oxford University Press; 1987.

Table 3

Diagnosing ORS: Suggested questions for patient interview

Do you have concerns about the way you smell (your body odor)? Do you believe that other people think you smell bad? How much time do you spend each day thinking about your body odor? Does your concern about how you smell upset you a lot? Does your concern about the way you smell interfere with daily activities, such as your job, relationships, school work, or socializing? (Ask the patient about multiple and specific areas of functioning.) Are there situations that you avoid (or wish you could avoid) because of the way you think you smell?

Do you have concerns about the way you smell (your body odor)?
Do you believe that other people think you smell bad?
How much time do you spend each day thinking about your body odor?
Does your concern about how you smell upset you a lot?
Does your concern about the way you smell interfere with daily activities, such as your job, relationships, school work, or socializing? (Ask the patient about multiple and specific areas of functioning.)
Are there situations that you avoid (or wish you could avoid) because of the way you think you smell?

Treatment-seeking behavior

Ms. A consulted several proctologists and a dentist but was not convinced by their reassurance and continued to believe she “stank.” Her relationship with her boyfriend suffered because she continually asked for reassurance about how she smelled and avoided sexual intercourse because of her odor concerns.

Eventually she confronted her boss about her belief that her coworkers were complaining about her smell. Despite reassurance that she didn’t smell bad, she left her job.

Box 3

‘Safety’ and avoidance behaviors seen in olfactory reference syndrome

Excessive showering or washing are among the repetitive, ritualistic or “safety” behaviors many patients with ORS engage in to check, eliminate, or camouflage supposed odor. Frequent clothes changing or laundering also is common.

Camouflaging attempts may include excessive use of deodorant, soap, cologne, powder, mints, mouthwash, or toothpaste; wearing layers of clothing; or smoking.

Many patients frequently check for the odor or its source (such as trying to smell their own breath or checking the anal area for seepage). Some patients use the toilet excessively or eat a special diet to try to minimize the smell. Others repeatedly seek reassurance about how they smell.

Avoidance behaviors are common and include sitting far from other people, moving as little as possible to avoid spreading the supposed odor, or averting the head or covering the mouth.

Source: References 1,3,7,12, and 14

Medical, surgical, and dental interventions. Because individuals with ORS believe they have a physical problem, many seek evaluation and treatment from nonpsychiatric physicians or dentists.^1,2,12 Seeking a cure for perceived halitosis, they may consult dentists, general surgeons, or ear, nose, and throat specialists. For perceived anal odors, they may consult proctologists, surgeons, or gastroenterologists. Some patients have multiple medical workups.

Convincing patients such as Ms. A of the falsity of their beliefs can be difficult,¹ and some succeed in having medical procedures or surgery, such as excision of tonsils or axillary glands.^3,7,12 To our knowledge, controlled prospective studies of nonpsychiatric treatments have not been done, but it appears that such treatments usually are ineffective.^1,3,6,9

Psychiatric interventions. Convincing patients with ORS to obtain mental health treatment can be difficult.^2,6 Patients with delusional halitosis “would rather go in search of a ‘better dentist’ than go to a psychiatrist.”¹

To get patients to accept psychiatric treatment, we suggest an approach similar to that recommended for body dysmorphic disorder. It may be helpful, for example, to focus on the distress and disability caused by the odor preoccupation, rather than on whether the patient actually smells bad.

Medication and psychotherapy

Limited evidence. The ORS treatment literature is very limited, consisting largely of case reports and small case series. To our knowledge, no controlled treatment trials have been done, no treatments have been compared head to head, and most studies did not use standardized measurements of psychopathology.

Published data therefore must be interpreted cautiously. Some medication reports used relatively low doses and short treatment durations (although what constitutes an adequate therapeutic trial for ORS is not known). Psychotherapy reports often did not specify details of the intervention or the number and duration of sessions. It is not known whether adding a cognitive component to behavioral therapy enhances efficacy, and the combination of psychotherapy and medication has not been studied systematically. More methodologically rigorous treatment studies are needed.

Because of space limitations, we cite representative case reports in the following section of this treatment review, rather than all of the cases found in our literature search.

Antidepressants. Although most ORS patients are delusional, serotonin reuptake inhibitor (SRI) monotherapy has been reported to be efficacious in 10 of 15 cases (67%). Most of these patients received clomipramine.¹⁸ In reports of non-SRI antidepressants, 6 of 15 cases (43%) responded. Some patients’ symptoms responded to an antidepressant after failing to respond to antipsychotic treatment.¹⁹

Antipsychotics. Pimozide is the most studied medication for ORS, with 15 of 31 cases (48%) responding.^2,20 In a series of 12 patients, pimozide responders received 2 to 4 mg/d, except for one patient who needed 6 mg/d.²¹ Patients usually responded within 1 to 4 weeks (an average time to response was not reported). In 2 of these cases, ORS symptoms recurred after pimozide was discontinued and then remitted again after it was restarted.²¹ In another report,² 7 of 14 patients (50%) responded to pimozide.