Olfactory Reference Disorder

Patients with olfactory reference disorder are preoccupied, usually for many hours a day, with the distressing or impairing belief that they emit 1 or more foul or offensive body odors, which are not perceived by others or are actually only slight (1, 2). They may believe, for example, that they have very bad breath or emit foul-smelling sweat from their armpits or other areas of their skin. Other worries include emitting a smell of urine, flatulence, or unpleasant odors from the genital area. Occasional patients believe that they emit foul odors like garbage or rotten food (usually in addition to perceptions of typical body odor).

The preoccupation with body odor is usually accompanied by repetitive behaviors (eg, smelling themselves, excessive showering, changing clothes, reassurance seeking); these behaviors attempt to alleviate the substantial distress caused by the preoccupation with body odor (1). Most people with olfactory reference disorder also make efforts to camouflage the perceived odor (eg, with perfume, deodorant, mouthwash, gum).

Insight is usually poor or absent (ie, most people think that they probably or definitely emit a foul body odor when this is actually not the case [1, 3]). Very few recognize that their belief about the body odor is inaccurate, probably because most people with olfactory reference disorder report that they actually smell the odor themselves. A seizure disorder such as temporal lobe epilepsy, or migraine headache aura, should be considered and excluded if presenting symptoms suggest that one of these disorders may be present.

Referential thinking is common; for example, patients may inaccurately believe that their body odor is the reason people are sitting far away from them, opening a window, or touching their nose (1).

Olfactory reference disorder usually substantially impairs functioning, and patients typically avoid social situations, often because they feel so embarrassed and ashamed about smelling bad. Many also avoid work or other important life activities. Some patients are completely housebound because they feel too distressed, self-conscious, and embarrassed about the perceived odor to be around other people, or because they fear that their body odor will be offensive to others. In very severe cases, olfactory reference disorder is incapacitating.

Athough data are limited, rates of suicidality appear high (1).

Because insight is usually poor or absent, many patients seek general medical, surgical, or dental treatment rather than psychiatric treatment (eg, tonsillectomy for perceived halitosis, proctectomy [anus removal] for perceived anal/flatulence odor), which does not appear to be helpful.

• Psychiatric assessment

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) describes olfactory reference disorder as follows (1):

• Patient's preoccupation with emitting foul, unpleasant, or offensive body odor(s) that is not actually perceived by others or is considered only slight

• Performance of repetitive behaviors (eg, smelling oneself to check for body odor, excessive showering or clothes changing) in response to the odor concerns and/or attempts to camouflage the perceived odor

• The preoccupation causes significant distress or significant impairment in social, occupational, or other areas of functioning

• Selective serotonin reuptake inhibitors (SSRIs) or clomipramineSelective serotonin reuptake inhibitors (SSRIs) or clomipramine

• Sometimes an antipsychotic agent (usually atypical) (in addition to an SSRI or clomipramine)Sometimes an antipsychotic agent (usually atypical) (in addition to an SSRI or clomipramine)

• Cognitive-behavioral therapy

Treatment studies of olfactory reference disorder are limited. However, clinical experience and available evidence suggest that SSRIs or clomipramine (a tricyclic antidepressant with potent serotonergic effects), often at high doses, can be helpful (Treatment studies of olfactory reference disorder are limited. However, clinical experience and available evidence suggest that SSRIs or clomipramine (a tricyclic antidepressant with potent serotonergic effects), often at high doses, can be helpful (1–3). They can be used alone or with a neuroleptic (an atypical is preferred) if needed. Cognitive-behavioral therapy that includes cognitive therapy (eg, cognitive restructuring) and exposure and ritual prevention (similar to therapy for body dysmorphic disorder) may be helpful. Pharmacotherapy plus cognitive-behavioral therapy may be used, especially for severe cases.