Evidence-Based Reviews

How to help patients with olfactory reference syndrome

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

References

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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.

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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.

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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.

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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.

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

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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).

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Clinicians using other first-generation antipsychotics (trifluoperazine, thioridazine, and chlorpromazine) reported a positive response in only 2 of 19 cases (11%).^12,22

Combination therapy. Ten of 17 cases (59%) of ORS responded to combined treatment with an antidepressant and an antipsychotic.^2,12

Other somatic treatments. Several reports found benzodiazepine monotherapy lacked efficacy, as was the case for electroconvulsive therapy.^12,15 One report noted an unsuccessful outcome with leucotomy and a partial response with bilateral partial division of the thalamo-frontal tract.¹⁵

Psychosocial treatment. All reports of psychosocial therapies are single cases or small series, and none used a control intervention.^2,7,14

Behavioral treatment has been efficacious, although patients require months to years to habituate. Several reports totalling 14 patients describe behavioral treatment over weeks to months.^7,23 These treatments involved exposure to avoided social situations and response prevention, which consisted of refraining from repetitive or camouflaging behaviors such as showering, visits to the toilet, or deodorant use. Gomez-Perez and colleagues²³ noted that exposure therapy was less effective for ORS than for social phobia or OCD.

One report described a patient with flatulence concerns who responded to a paradoxical intention consisting of instructions to emit gas as soon as it was experienced; at 1-year follow-up, her symptoms had not recurred.²⁴

Psychodynamic interventions show no benefit for ORS symptoms.

Treatment summary

Ms. A became increasingly despondent and depressed. She eventually sought the help of her family doctor, who referred her to a psychiatrist. With a combination of a serotonergic antidepressant (escitalopram, 40 mg/d), a low-dose atypical antipsychotic (quetiapine, 50 mg at night), and cognitive-behavioral therapy, she started to re-engage in daily activities. During 6 months of treatment, the intensity of her belief about having body odor abated.

Limited data support the use of SRI monotherapy or an SRI plus an antipsychotic. Using SRI monotherapy for delusional patients may sound counterintuitive, but this approach appears efficacious for patients with delusional body dysmorphic disorder, which has similarities to ORS.^17,25,26

Clinically, we have found the use of atypical antipsychotics as an adjunct to SRIs to be helpful, although this strategy has not been subjected to clinical trials. Pimozide alone or in combination with an antidepressant also appears promising, as does exposure and response prevention. Do not combine pimozide with clomipramine because of the risk of cardiac toxicity.

Related resources

Phillips KA, Gunderson C, Gruber U, Castle DJ. Delusions of body malodour: the olfactory reference syndrome. In: Brewer W, Castle D, Pantelis C. Olfaction and the brain. Cambridge, UK: Cambridge University Press; 2006:334-53.
Pryse-Phillips W. An olfactory reference syndrome. Acta Psychiatr Scand 1971;47:484-509.

Drug brand names

Chlorpromazine • Thorazine
Clomipramine • Anafranil
Escitalopram • Lexapro
Pimozide • Orap
Quetiapine • Seroquel
Thioridazine • Mellaril
Trifluoperazine • Stelazine

Disclosure

Dr. Phillips receives research support from the National Institute of Mental Health, the Food and Drug Administration, UCB Pharma, and Forest Pharmaceuticals.

Dr. Castle receives research support from Janssen-Cilag; is a consultant to Eli Lilly and Company., Bristol-Myers Squibb, and Lundbeck; and is a speaker for Eli Lilly and Co., sanofi-aventis, Bristol-Myers Squibb, Janssen-Cilag, Lundbeck, and Organon.

Acknowledgment

The authors would like to thank Craig Gunderson, MD, and Uschi Gruber, MB, for their assistance with a literature search on olfactory reference syndrome.