Olfactory reference syndrome
Olfactory reference syndrome (ORS) is a psychiatric condition in which there is a persistent false belief and preoccupation with the idea of emitting abnormal body odors which the patient thinks are foul and offensive to other individuals.[1][2] People with this condition often misinterpret others' behaviors, e.g. sniffing, touching their nose or opening a window, as being referential to an unpleasant body odor which in reality is non-existent and cannot be detected by other people.[3]
This disorder is often accompanied by
Signs and symptoms
The onset of ORS may be sudden, where it usually follows after a precipitating event, or gradual.[1]
Odor complaint
The defining feature of ORS is excessive thoughts of having offensive body odor(s) which are detectable to others. The individual may report that the odor comes from: the nose and/or mouth, i.e.
Although all individuals with ORS believe they have an odor, in some cases the individual reports they cannot perceive the odor themselves. In the latter cases, the belief arises via misinterpretation of the behavior of others or with the rationale that a disorder of smell which prevents self detection of the odor (i.e.
Some distinguish delusional and non-delusional forms of ORS. In the delusional type, there is complete conviction that the odor is real. In the non-delusional type, the individual is capable of some insight into the condition, and can recognize that the odor might not be real, and that their level of concern is excessive.[5] Others argue that reported cases of ORS present a spectrum of different levels of insight.[2] Since sometimes the core belief of ORS is not of delusional intensity, it is argued that considering the condition as a form of delusional disorder, as seems to occur in the DSM, is inappropriate.[2] In one review, in 57% of cases the beliefs were fixed, held with complete conviction, and the individual could not be reassured that the odor was non existent. In 43% of cases the individual held the beliefs with less than complete conviction, and was able to varying degrees to consider the possibility that the odor was not existent.[2]
Other symptoms may be reported and are claimed to be related to the cause of the odor, such as malfunction of the anal sphincter, a skin disease, "diseased womb", stomach problems or other unknown
Referential ideas
People with ORS misinterpret the behavior of others to be related to the imagined odor (
Repetitive behavior
95% of persons with ORS engage in at least one excessive hygiene, grooming or other related repetitive practice in an attempt to alleviate, mask and monitor the perceived odor.
Functional impairment
Persons with ORS tend to develop a behavior pattern of avoidance of social activities and progressive social withdrawal. They often avoid travel, dating, relationships, break off engagements and avoid family activities.[8] Due to shame and embarrassment, they may avoid school or work, or repeatedly change jobs and move to another town.[8] Significant developments may occur such as loss of employment,[10] divorce, becoming housebound, psychiatric hospitalization, and suicide attempts.[8] According to some reports, 74% of persons with ORS avoid social situations,[5] 47% avoid work, academic or other important activities,[5] 40% had been housebound for at least one week because of ORS,[5] and 31.6% had experienced psychiatric hospitalization.[5] With regards to suicide, reports range from 43 to 68% with suicidal ideation, and 32% with a history of at least one suicide attempt. 5.6% died by suicide.[5][8]
Psychiatric co-morbidity
Psychiatric
Causes
The causes of ORS are unknown.[10] It is thought that significant negative experiences may trigger the development of ORS. These have been considered as two types: key traumatic experiences related to smell, and life stressors present when the condition developed but which were unrelated to smell.[2] In one review, 85% of reported cases had traumatic, smell-related experiences, and 17% of cases had stress factors unrelated to smell.[2] Reported smell-related experiences usually revolve around family members, friends, co-workers, peers or other people making comments about an odor from the person, which causes embarrassment and shame.[2] Examples include accusation of flatulence during a religious ceremony,[10] or being bullied for flatulence such at school,[2] accidental urination in class,[10] announcements about a passenger needing to use deodorant over speaker by a driver on public transport,[10] sinusitis which caused a bad taste in the mouth,[2] mockery about a fish odor from a finger which had been inserted into the person's vagina in the context of a sexual assault,[10] and revulsion about menarche and brother's sexual intimacy.[2] It has been suggested that a proportion of such reported experiences may not have been real, but rather early symptom of ORS (i.e. referential thoughts).[11] Examples of non smell-related stressful periods include guilt due to a romantic affair,[2] being left by a partner,[2] violence in school,[2] family illness when growing up (e.g. cancer),[2] and bullying.[2]
The importance of a
Diagnosis
Classification
Although the existence of ORS is generally accepted,[2][10] there is some controversy as to whether it is a distinct condition or merely a part or manifestation of other psychiatric conditions, mainly due to the overlapping similarities.[4] Similarly, there is controversy with regards how the disorder should be classified.[2][5] As ORS has obsessive and compulsive features, some consider it as a type of obsessive–compulsive spectrum disorder, while others consider it an anxiety disorder due to the strong anxiety component. It is also suggested to be a type of body dysmorphic disorder or, as it involves a single delusional belief, some suggest that ORS is a monosymptomatic hypochondriacal psychosis (hypochondriacal type of delusional disorder, see monothematic delusion).[2][5]
The
ORS has also never been allocated a dedicated entry in any edition of the
Synonyms for ORS, many historical, include bromidrosiphobia,[2] olfactory phobic syndrome,[2] chronic olfactory paranoid syndrome,[2] autodysomophobia,[2] delusions of bromosis,[5] hallucinations of smell[5] and olfactory delusional syndrome.[citation needed] By definition, the many terms which have been suggested in the dental literature to refer to subjective halitosis complaints (i.e. when a person complains of halitosis yet no odor is detectable clinically) can also be considered under the umbrella of ORS. Examples include halitophobia,[11] non-genuine halitosis, delusional halitosis,[11] pseudo-halitosis, imaginary halitosis,[8] psychosomatic halitosis, and self halitosis.[citation needed]
Diagnostic criteria
- Persistent (more than six months), false belief that one emits an offensive odor, which is not perceived by others. There may be degrees of insight (i.e. the belief may or may not be of delusional intensity).
- This pre-occupation causes clinically significant distress (depression, anxiety, shame), social and occupational disability, or may be time-consuming (i.e. preoccupies the individual at least one hour per day).
- The belief is not a symptom of schizophrenia or other psychotic disorder, and not due to the effects of medication or recreational drug abuse, or any other general medical condition.
Differential diagnosis
The
The typical history of ORS involves a long delay while the person continues to believe there is a genuine odor. On average, a patient with ORS goes undiagnosed for about eight years.
Conversely, some have suggested that medical conditions which cause genuine odor may sometimes be misdiagnosed as ORS.
Various organic diseases may cause parosmias (distortion of the sense of smell). Also, since smell and taste are intimately linked senses, disorders of gustation (e.g. dysgeusia—taste dysfunction) can present as a complaint related to smell, and vice versa. These conditions, collectively termed chemosensory dysfunctions, are many and varied, and they may trigger a person to complain of an odor than is not present;[29] however, the diagnostic criteria for ORS require the exclusion of any such causes.[4] They include pathology of the right hemisphere of the brain,[4] substance abuse,[10] arteriovenous malformations in the brain,[10] and temporal lobe epilepsy.[10]
Social anxiety disorder (SAD) and ORS have some demographic and clinical similarities.[10] Where the social anxiety and avoidance behavior is primarily focussed on concern about body odors, ORS is a more appropriate diagnosis than avoidant personality disorder or SAD.[4] Body dismorphic disorder (BDD) has been described as the closest diagnosis in DSM-IV to ORS as both primarily focus on bodily symptoms.[4] The defining difference between the two is that in BDD the preoccupation is with physical appearance, not body odors.[4] Similarly, where obsessive behaviors are directly and consistently related to body odors rather than anything else, ORS is a more appropriate diagnosis than obsessive–compulsive disorder, in which obsessions are different and multiple over time.[4]
ORS may be misdiagnosed as schizophrenia.[2][5] About 13% of people with schizophrenia have olfactory hallucinations.[10] Generally, schizophrenic hallucinations are perceived as having an imposed, external origin, while in ORS they are recognized as originating from the individual.[10] The suggested diagnostic criteria mean that the possibility of ORS is negated by a diagnosis of schizophrenia in which persistent delusions of an offensive body odor and olfactory hallucinations are contributing features for criterion A.[7] However, some reported ORS cases were presented as co-morbid.[1] Indeed, some have suggested that ORS may in time transform into schizophrenia, but others state there is little evidence for this.[1] Persons with ORS have none of the other criteria to qualify for a diagnosis of schizophrenia.[4]
It has been suggested that various special investigations may be indicated to help rule out some of the above conditions. Depending upon the case, this might include neuroimaging, thyroid and adrenal hormone tests, and analysis of body fluids (e.g. blood) with gas chromatography.[4]
Treatment
There is no agreed treatment protocol.[10] In most reported cases of ORS the attempted treatment was antidepressants, followed by antipsychotics and various psychotherapies.[10] Little data are available regarding the efficacy of these treatments in ORS, but some suggest that psychotherapy yields the highest rate of response to treatment, and that antidepressants are more efficacious than antipsychotics (response rates 78%, 55% and 33% respectively).[1] According to one review, 43% of cases which showed overall improvement required more than one treatment approach, and in only 31% did the first administered treatment lead to some improvement.[10]
Pharmacotherapies that have been used for ORS include antidepressants,[10] (e.g. selective serotonin reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors), antipsychotics, (e.g. blonanserin,[10] lithium,[10] chlorpromazine),[6] and benzodiazepines.[10] The most common treatment used for ORS is SSRIs. Specific antidepressants that have been used include clomipramine.[4]
Psychotherapies that have been used for ORS include cognitive behavioral therapy, eye movement desensitization and reprocessing.[4] Dunne (2015) reported a Case Study treatment of ORS using EMDR which was successful using a trauma model formulation rather than an OCD approach.
Prognosis
When untreated, the prognosis for ORS is generally poor. It is chronic, lasting many years or even decades with worsening of symptoms rather than spontaneous remission.[1] Transformation to another psychiatric condition is unlikely, although very rarely what appears to be ORS may later manifest into schizophrenia,[1] psychosis,[2] mania,[2] or major depressive disorder.[2] The most significant risk is suicide.
When treated, the prognosis is better. In one review, the proportion of treated ORS cases which reported various outcomes were assessed. On average, the patients were followed for 21 months (range: two weeks to ten years). With treatment, 30% recovered (i.e. no longer experienced ORS odor beliefs and thoughts of reference), 37% improved and in 33% there was a deterioration in the condition (including suicide) or no change from the pre-treatment status.[2]
Epidemiology
Cases have been reported from many different countries around the world. It is difficult to estimate the prevalence of ORS in the general population because data are limited and unreliable,[10] and due to the delusional nature of the condition and the characteristic secrecy and shame.[1]
For unknown reasons, males appear to be affected twice as commonly as females.[1] High proportions of ORS patients are unemployed, single,[1] and not socially active.[11] The average age reported is around 20–21 years,[2][8] with almost 60% of cases occurring in subjects under 20 in one report,[2] although another review reported an older average age for both males (29) and females (40).[10]
History
The term olfactory reference syndrome was first proposed in 1971 by William Pryse-Phillips.[30] Prior to this, published descriptions of what is now thought to be ORS appear from the late 1800s,[5] with the first being Potts 1891.[2] Often the condition was incorrectly described as other conditions, e.g. schizophrenia.[5]
Society
In modern times, commercial advertising pressures have altered the public's attitude towards problems such as halitosis,[6] which have taken on greater negative psychosocial sequelae as a result. For example, in the United States, a poll reported that 55–75 million citizens consider bad breath a "principal concern" during social encounters.[6]
Etymology
The term olfactory reference syndrome comes from:
- Olfactory, pertaining to the sense of smell.
- Reference, because of the belief that the behavior of others is referential to a supposed odor.
- Syndrome, because it is a recognizable set of features that occur together.
See also
References
- ^ ISBN 978-0-521-84922-7. Archived from the original(PDF) on 2014-01-08.
- ^ S2CID 34660521.
- PMID 20533369.
- ^ PMID 14699232.
- ^ PMID 20533369.
- ^ PMID 9051972.
- ^ PMID 21762838.
- ^ a b c d e f g h i Phillips KA, Castle DJ (2007). "How to help patients with olfactory reference syndrome" (PDF). Current Psychiatry. 6 (3). Archived from the original (PDF) on 2015-05-11.
- ^ PMID 19890232.
- ^ PMID 23307351.
- ^ ISBN 978-3-642-19312-5.
- ^ ISBN 978-0-89042-554-1.
- ^ ISBN 978-1-4419-5659-0.
- PMID 18713583.
- ^ ISBN 978-1-4377-0416-7.
- PMID 21851918.
- ISBN 978-1-60547-159-4.
- PMID 21771869.
- PMID 7661625.
- PMID 11255985.
- PMID 11143967.
- S2CID 207027103.
- S2CID 21530432.
- PMID 12090450.
- S2CID 25036981.
- PMID 17117270.
- S2CID 35200507.
- PMID 19893792.
- S2CID 814114.
- ISBN 978-1-139-42732-6.
- Dunne, T.P. (2015). "EMDR: An Effective and Less Stigmatising Treatment for Olfactory Reference Syndrome", EMDR Now, Vol. 7, No.1, Jan, pp 6–7.