Olfactory reference syndrome: what is it and what are its symptoms?

We explain the causes and effects of this psychiatric disorder.

The Olfactory reference syndrome is a psychiatric disorder, characterized mainly because the person suffering from it is vehemently convinced that he/she gives off a bad body odor. But are there hallucinations in such a disorder, and delusions?

Throughout this article we will try to answer these questions. In addition, based on different studies, we will explain in detail what this disorder consists of, what are some of the etiological hypotheses put forward, its symptoms and, finally, the treatments used to combat it.

• Recommended article: "Delusions: what they are, types and differences with hallucinations".

Olfactory reference syndrome

The olfactory reference syndrome (ORS) consists of a hallucinatory psychiatric disorder. It is characterized mainly by a persistent preoccupation with odor, together with other symptoms such as embarrassment and distress. At the social level, it is accompanied by avoidance behaviors and social isolation.

This syndrome is a variety of delusional disorder, of somatic type. The individual with olfactory reference syndrome vehemently believes that he/she gives off a foul odor, and that others can notice this odor.

At the clinical level, it is therefore a delirium coupled with a hallucination (although there is controversy about the existence of these symptoms, as we will see below). The DSM-5 (Diagnostic Manual of Mental Disorders) proposes to classify ORS as an independent disorder.

Due to the characteristics of the syndrome, most patients with olfactory reference syndrome do not consult psychiatrists or psychologists, but other professionals, such as dermatologists, dentists, dermatologists or even surgeons, because of their "obsession" with bad body odor.

Prognosis

The prognosis of olfactory referral syndrome had always been considered unfavorable; however, a 2012 review by authors Begum and McKenna showed that two-thirds of patients (out of a sample of 84) partially improved or recovered completely.

Demographics.

The prevalence of ORS is higher among men than among women. Specifically, single men predominate. As for the age of onset, it ranges from late adolescence to early adulthood.

Origin

As for the origin of olfactory reference syndrome or olfactory reference syndrome, it was Pryse-Phillips who, in 1971, published a long list of cases. Philips separated cases of ORS from cases with similar symptoms, belonging to schizophrenic, affective or organic psychoses.

Causes

As for the cause of olfactory reference syndrome, it is actually unknown, as in many other psychiatric disorders. However, there are some etiological hypotheses, there are some etiological hypotheses, which refer to certain serotonergic and dopaminergic dysfunctions in the brain of people with ORS..

These dysfunctions are related to the repetitive cleaning and checking behaviors shown by these patients, similar to those shown by people with Obsessive Compulsive Disorder (OCD).

Other causal hypotheses go along the lines of certain mismatches in some regulatory genes, such as Hoxb8 and SAPAP3 (related to the limbic lobe and basal ganglia).

On the other hand, there are also cases of people with olfactory reference syndrome who have suffered some kind of brain injury, as well as temporal lobe epilepsy. However, these are all neurobiologically based hypotheses, and none has been proven to be 100% causative of ORS.

Social and psychological factors

As for the more psychological and social causes, in half of the cases of ORS there is a precipitating event just prior to the onset of symptoms of the disorder. Such events usually involve some kind of denigrating admonishment from others.

Stress may also underlie this disorder, as well as an obsessive, suspicious, and paranoid personality (and in extreme cases, an obsessive personality disorder or paranoid personality disorder).

Symptoms

What symptoms accompany olfactory reference syndrome? Let's look at the 4 main symptoms, in addition to the suffering inherent to the disorder.

1. Preoccupation with body odor

The main symptom of olfactory reference syndrome is a significant preoccupation with body odor; that is, the person vehemently believes that he or she gives off a bad odor.

However, there is controversy as to whether such a preoccupation is delusional in all cases of the syndrome or not. It is also unclear whether or not there is always a hallucination associated with such a preoccupation.

Hallucination and/or delirium?

In relation to these controversies about the presence or not of delirium and hallucination, a recent review (2012) by authors Begum and McKenna, found that 22% of patients with olfactory reference syndrome manifested an olfactory hallucination associated with concern about bad odor (vs. 75% of the original Pryse-Phillips list, who presented such hallucination).

As for the presence or not of delirium, this review shows that 52% of the patients had it; in the rest of the patients, however, the concern was based on an idea that oscillated between the overvalued idea and the obsessive idea.

2. Sense of shame

Another symptom typical of ORS is an intense feeling of shame in relation to others; thus, the person suffers because he/she is convinced that he/she smells bad and that others notice it. This is why he/she feels deeply ashamed, and has a hard time.

On the other hand, according to studies, more than 75% of patients with olfactory reference syndrome interpret the gestures and words of others in relation to oneself. In other words, patients believe that they are being spoken ill of and criticized.

3. Constant checking

People suffering from ORS spend a great deal of their time checking their body odor, as they are "obsessed" with the fact that they smell more. They also manifest other compulsive behaviors in order to disguise that they are in a place, or to disguise their own odor.

4. Social isolation

The above symptoms eventually cause the person to become socially isolated, which also results in social and occupational disability, and great difficulty in leading a "normal" life.

In fact, of the original list of cases drawn up by Pryse-Phillips, only 3% of those affected by olfactory reference syndrome had an active social life.

Treatment

Regarding the treatment of olfactory reference syndrome, we find, broadly speaking, two types of treatment: psychological and pharmacological.

At the psychological level, psychotherapy is used. Although it can be worked from different orientations, cognitive behavioral therapy is recommended, in order to eliminate cognitive distortions associated with body odor, as well as checking and checking behaviors.

EMDR (Eye Movement Desensitization and Reprocessing) therapy has also been used. Specifically, a 2008 study by McGoldrick, Begum and Brown reveals the success of 5 patients through this therapy, a therapy that, however, is not useful in other psychotic conditions.

At the pharmacological level, antipsychotics and antidepressants are used.s. On the other hand, a study reveals that 33% of patients with olfactory reference syndrome treated with antipsychotics had obtained very positive results; the same was true for 55% of patients treated with antidepressants.

Bibliographical references:

• Begum, M. and McKenna, P.J. (2011). Olfactory reference syndrome: a systematic review of the world literature. Psychol Med, 41:453-61.

• Bizamcer AN, Dubin WR, Hayburn B. (2008). Olfactory reference syndrome. Psychosomatics, 49:77-81.

• Cruzado, L., Cáceres-Taco, E. and Calizaya, J.R. (2012). About a case of olfactory referential syndrome. Clinical case. Actas Esp Psiquiatr, 40(4):234-8.

• McGoldrick T, Begum M, Brown KW. (2008). EMDR and Olfactory Reference Syndrome. A case series. Journal of EMDR, 2:63-8.

• Phillips KA, Gunderson C, Gruber U, Castle D. (2006). Delusions of body malodour; the olfactory reference syndrome. In: Brewer W, Castle D, Pantelis C, eds. Olfaction and the Brain. New York: Cambridge University Press, 334-53.