Olfactory Reference Syndrome

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Excessive Concerns about Body Odors

Olfactory reference syndrome (ORS) has been defined as a psychiatric disorder involving persistent preoccupation with body odors, such as smells coming from the armpits, feet, genital area, or even bad breath (halitosis). To be diagnosed with ORS, these concerns must cause the sufferer severe distress or some difficulties in social or work functioning.

ORS does not currently fall within an existing standard psychiatric diagnostic category (that is, it is not included in the psychiatrists' manual, the DSM-IV-TR).
When compared with the existing diagnoses, ORS is perhaps most similar to body dysmorphic disorder. There also appears to be a significant overlap with social phobia and particularly the Eastern form of social anxiety known as taijin kyofusho (TKS).

Whether olfactory reference syndrome truly is a unique disorder, or merely a symptom of other psychiatric conditions, remains controversial. The main symptoms of ORS overlap with several existing disorders, so a new diagnostic category is not thought to be necessary. Nonetheless, though ORS may have overlap with existing disorders, it has also been noted that most patients with ORS tend to be young men without additional psychiatric disorders. This provides evidence that perhaps ORS is a separate disorder in its own right.

Diagnosis of Olfactory Reference Syndrome

Based on the description of the disorder in the table below, perhaps the closest related diagnosis would be body dysmorphic disorder (BDD), although by definition BDD is characterized by a preoccupation with physical features rather than body odor. On the other hand, the social anxiety and avoidance of interpersonal interaction make the disorder similar to social phobia, also called social anxiety disorder.

Criteria for Olfactory Reference Syndrome(proposed by Lochner & Stein, 2003)

  • Preoccupation with imagined body odor that persists despite reassurance.
  • At some point during the disorder, the person has recognized that the preoccupation (obsession/compulsion) is excessive or unreasonable.
  • The symptoms cause significant distress or impairment in social, occupational and/or other areas of functioning.
  • Does not occur solely during the course of another disorder (body dysmorphic disorder, hypochondriasis, social anxiety disorder, mood disorder, and obsessive-compulsive disorder.)
  • The disturbance is not due to the direct physiological effects of a substance (e.g. drug abuse or medication) or a general medical condition (e.g. hypothyroidism).

Differential Diagnoses

The tricky thing about ORS is distinguishing it from other similar disorders.
Some of the obsessive-compulsive spectrum disorders such as body dysmorphic disorder (BDD) and hypochondriasis have both obsessional and delusional variants. Given the significant overlap between ORS and BDD, one could imagine that ORS is a variation of BDD and that the diagnostic criteria of BDD should be extended to include odor. In this conceptualization, BDD might fall on a spectrum of social anxiety disorders, in which symptoms clearly lead to social anxiety and avoidance.
Hypochondriasis, on the other hand, specifically requires a preoccupation with fears of having a serious disease based on the person's misinterpretation of bodily symptoms.

Most of the symptoms reported by ORS patients meet criteria for obsessions and compulsions and patients might also be diagnosed as having obsessive-compulsive disorder. Avoidance of social situations on the basis of embarrassment associated with compulsive rituals is consistent with a diagnosis of OCD, but avoidance based primarily on embarrassment or excessive fear of humiliation and rejection (because of olfactory concerns), would suggest a different diagnosis.


Social withdrawal can also occur within the context of a major depressive episode. However, although patients with depression typically have a negative self-image and may avoid social situations, this avoidance is usually not focused on concerns about body appearance or bad breath or body odor. Where depression and such symptoms coexist, a careful history may be needed. Olfactory reference syndrome that precedes depression could be caused by olfactory concerns (and not vice versa).

Psychotic disorders, such as delusional disorder (somatic type) and schizophrenia, can cause hallucinations involving smells. If a patient believes that these thoughts and behaviors are not unreasonable or excessive, the lack of insight might qualify the symptoms as delusions. However, if insight wavers it would argue against the diagnosis of a delusional disorder. Unlike patients with schizophrenia, who would tend to believe hallucinations are being put into their mind by others, victims of ORS are able to view symptoms as originating in their own minds. However, the clinical should look for other symptoms of schizophrenia before ruling out a delusional disorder.

There are a number of medical conditions that may be associated with an unwanted odor, for example oral infections, skin conditions, and various systemic problems. The presence of these conditions must be ruled out before a diagnosis of ORS can be made. Also, obsessive and delusional thoughts about odors may be the result of neurological disorders or substances. In particular, right hemisphere brain pathology and consequent alteration of smell perception may lead to concerns about body odor. Depending on the nature of the body odor symptoms, it may be useful to do further testing, including structural brain imaging, thyroid and adrenal hormone levels, and an analysis of body fluids to determine if the odors are in fact within the normal range.

Treatment of Olfactory Reference Syndrome

The question arises whether making a diagnosis of olfactory reference syndrome rather than of one of the other disorders considered above has any treatment implications. Given ORS' close relationship with the social anxiety disorders, it would seem reasonable to consider a selective serotonin reuptake inhibitor (SSRI) and cognitive-behavioral therapy for the treatment of ORS. Although the literature on the medication management and psychotherapy of ORS is limited, it provides some support for this line of thinking. There is at least one report of successful treatment following the administration of 250 mg of clomipramine.

Source

Lochner C, Stein DJ. Olfactory Reference Syndrome: Diagnostic Criteria and Differential Diagnosis. J Postgrad Med 2003;49:328-331.

 
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