Olfactory Reference Syndrome
Olfactory reference syndrome (ORS) is a psychiatric disorder. The term was first created in 1971 by neurologist William Pryse-Phillips. There have been many reported cases of ORS around the world, and several cases were reported in the literature between 1891 and 1966. People who have this disorder have an irrational and extreme fear, believing that they are producing a foul, unpleasant, and offensive odor. People with ORS believe that others around them can smell the odor and sometimes they may think that they themselves can smell the odor too. They may believe that they smell natural body smells, such as anal, vaginal, or overall body odor or a nonbody odor, such as a chemical odor. Patients feel ashamed and embarrassed, which can cause a great amount of distress and behavioral change. ORS can significantly impair a person’s life. Many times people affected with ORS will stop working and will not be involved in social situations, because they wish to avoid the embarrassment they think they will experience. ORS can also have an effect on a person’s academic life and relationships. A recent study showed that of patients with ORS who experienced symptoms, 74 percent avoided social circumstances and 47 percent avoided job-related, academic, or other significant activities (Feusner et al., 2010). People with ORS may also become depressed and may have suicidal feelings and/or actions. Furthermore, a study by Pryse-Phillips that included 26 patients reported that 43 percent experienced suicidal thoughts or actions. During their follow-up period, which is believed to have been approximately one to two years, 5.6 percent of the patients committed suicide (Feusner et al., 2010). People with ORS many times will construe others’ actions as a reaction to their alleged body odor. Actions such as scratching the face, sneezing, turning away, or making comments can be misunderstood. Patients with ORS will usually perform certain characteristic repetitive behaviors. These include smelling/checking themselves; taking many unneeded showers; attempting to disguise the smell; changing their clothes often; using an excessive amount of deodorant, cologne, or perfumes; asking others around them for reassurance that they do not smell; avoiding public locations; and going to the doctor multiple times about their odor.
Classification and Diagnosis
ORS has not been defined as its own category in the Diagnostic and Statistical Manual of Mental Disorders (DSM). There are several different psychological disorders that ORS can resemble. These psychological disorders include social anxiety disorder (SAD), avoidant personality disorder (APD), Taijin Kyofusho (TKS), body dysmorphic disorder (BDD), hypochondriasis, obsessive compulsive disorder (OCD), major depression and social withdrawal, and psychotic disorders such as schizophrenia or delusional disorder. There are also general medical conditions such as skin conditions and infections that could be causing the odor. These medical conditions must be ruled out before making an ORS diagnosis. It is believed that ORS and BDD are closely related and that BDD would probably come closest to an ORS diagnosis. BDD is the condition of imagining one’s body is somehow deformed in appearance. However, there are data demonstrating that individuals with BDD also have obsessions regarding odor. The diagnosis of ORS can be difficult. This is mostly because ORS does not have its own classification, and there are no specific diagnostic criteria. Many people with ORS are never properly diagnosed. Often, they will receive no diagnosis or will receive an incorrect diagnosis.
The treatment for ORS uses many of the same techniques and treatments that are used to treat other related disorders such as OCD. Most treatments focus on cognitive behavioral intervention, using cognitive behavioral therapy (CBT) methods. Types of CBT methods include exposure and response prevention (ERP), imaginal exposure, cognitive restructuring, and mindfulness-based cognitive behavioral therapy. Cognitive restructuring can lessen the frequency and extent of the obsession. In exposure and response prevention, patients are exposed to situations they would normally avoid, while not being allowed to use their normal behaviors related to their perceived odor such as checking the odor or trying to get rid of it. In imaginal exposure, prerecorded videos are used to allow the patients to be exposed to experiences and situations that they are fearful of and imagine. In mindfulness-based CBT, the aim is to get the patient to be more willing to experience the fears, feelings, and urges without using any obsessive repetitive behaviors such as asking for reassurance. Some medications can also be used to treat ORS. These include antidepressants, specifically a type known as selective serotonin reuptake inhibitors (SSRIs), and antipsychotic drugs.
There are limited data and research regarding ORS, thus further research is warranted. Research should focus on developing specific diagnostic criteria and also deciding if ORS should have its own classification or if it should be classified under another disorder.
See also: Dysosmia; Odor Intensity Scale; Odor Threshold; Olfactory System
Feusner, Jamie D., Katharine A. Phillips, & Dan J. Stein. (2010). Olfactory reference syndrome: Issues for DSM-V. Depression and Anxiety, 27(6), 592—599. Retrieved from http://www.dsm5.org/Research/Documents/Feusner_ORS.pdf
Houston OCD Program. (2016). Olfactory reference syndrome. Retrieved from http://houstonocdprogram.org/olfactory-reference-syndrome/
Lochner, Christine, & Dan J. Stein. (2003). Olfactory reference syndrome: Diagnostic criteria and differential diagnosis. Journal of Post-Graduate Medicine, 49(4), 328—331.