Academic journal article South African Journal of Psychiatry

Sniffing out Olfactory Reference Syndrome

Academic journal article South African Journal of Psychiatry

Sniffing out Olfactory Reference Syndrome

Article excerpt


Olfactory reference syndrome (ORS) is characterised by the erroneous belief that one emits a foul or unpleasant body odour. (1) This condition is characterised by the belief that others take special notice of the unpleasant odour, prompting repetitive behaviour such as frequent showering or excessive deodorant use to camouflage the perceived odour. As individuals with ORS believe they are the cause of social offence, interpersonal interactions are avoided or else endured with significant distress with the accompaniment of shame and embarrassment. (2) The body odour concerns may have a delusional quality, that is, they may be fixed and unwavering and the person cannot be dissuaded despite evidence to the contrary or reassurance to the contrary.

The first published descriptions date back to the late 1800s. (3) Several other case reports and small case-series have since then been published from around the world. (4,5) Notably, the term ORS was first used in 1971 to describe the consistent phenomenology noted in a large patient case-series. (2) Here, Pryse-Phillips and his colleagues identified 100 cases of patients who experienced olfactory hallucinations of unpleasant body odour and the concomitant belief of patients that people were reacting negatively towards them because of it.

Despite increasing recognition of the olfactory reference symptomatology, the nosological status of ORS remains unclear. In both the DSM-IV-TR as well as the International Classification of Diseases 10 (ICD), ORS patients with no insight may meet the criteria for a delusional disorder (somatic type). Although ORS was proposed for inclusion in DSM-5 as an independent disorder, (6) this classification system only mentions ORS in the section on 'other specified obsessive-compulsive and related disorders'. Specifically, the DSM-5 chapter of Obsessive Compulsive and Related Disorders (OCRD) includes an 'insight specifier'. The level of insight into the excessiveness or irrationality that individuals with OCD have into their symptoms varies widely, and the intention with the inclusion of this specifier is to improve differential diagnoses by highlighting that an individual who presents with delusional beliefs may warrant a diagnosis of the relevant OCRD, rather than schizophrenia or another psychotic disorder. ORS is currently being considered for inclusion in the upcoming ICD-11. (7)

When patients present with ORS symptoms, a range of differential diagnoses should be considered. (4) Indeed, this condition can present a diagnostic dilemma in clinical practice. Descriptions of ORS cases may foster further research and promote its recognition by clinicians. In the following report, we describe an interesting ORS case with comorbid depressive symptomatology. This patient was thought worthy of presentation for a number of reasons such as his atypical older age of onset of ORS, and his interesting treatment history which included numerous visits to clinicians from different disciplines and polysurgery. Furthermore, a multimodal approach employing a combination of judicious medication use, combined with cognitive behavioural therapy (CBT), in context of a therapeutic alliance resulted in treatment success.

Case introduction

A 46-year-old single male was referred for assessment to Consultation Liaison Psychiatry services at a tertiary academic hospital in Cape Town, with a complaint of a bad odour that had been emanating from his body for the past 8 years. No distinct antecedent events were reported prior to the onset of an increasing awareness that people were sniffing and coughing around him. Over the next few months, he came to believe that an unpleasant smell, described as 'rotting', was emitting from multiple sites of his body: his nose, throat, axillae, feet and anal area. He noticed his colleagues rubbed their noses when he passed by, purposefully opened windows or turned away in disgust when he was in their presence. …

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