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] The character of the odor may be reported as similar to bodily substances, e.g. feces, flatus, urine, sweat, vomitus, semen, vaginal secretions; or alternatively it may be an unnatural, non-human or chemical odor, e.g. ammonia,[5] detergent,[5] rotten onions,[5] burnt rags,[1] candles,[1] garbage,[2] burning fish,[2] medicines,[2] old cheese.
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. anosmia) exists.
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.
[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] Usually, these involve misinterpretations of comments, gestures and actions of other people such that it is believed that an offensive smell from the individual is being referred to.
[2] These thoughts of reference are more pronounced in social situations which the individual with ORS may find stressful, such as public transport, crowded lift, workplace, classroom, etc.
[1] Example ORS behaviors include: repetitive showering and other grooming behaviors,[9] excessive tooth brushing,[9] or tongue scraping (a treatment for halitosis), repeated smelling of oneself to check for any odor,[5] over-frequent bathroom use,[1] attempts to mask the odor,[5] with excessive use of deodorants, perfumes, mouthwash, mint, chewing gum, scented candles, and soap;[1] changing clothes (e.g. underwear),[10] multiple times per day,[2] frequent washing of clothes, wearing several layers of clothing, wrapping feet in plastic,[1] wearing garments marketed as odor-reducing,[1] eating special diets, dietary supplements (e.g. intended to reduce flatulence odor),[1][10] repeatedly seeking reassurance from others that there is no odor, although the negative response is usually interpreted instead as politeness rather than truth,[1] and avoidance behaviors such as habitually sitting at a distance from others, minimizing movement in an attempt "not to spread the odor", keeping the mouth closed and avoiding talking or talking with a hand in front of the mouth.
[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.
[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.
Hexamethylpropyleneamine oxime single-photon emission computed tomography (HMPAO SPECT) demonstrated hypoperfusion of the frontotemporal lobe in one case.
Compared to an age and sex matched healthy control subject under the same conditions, the individual with ORS showed more activation areas in the brain when listening to emotionally loaded words.
However, in the "persistent delusional disorders" section, ICD-10 states that affected individuals can "express a conviction that others think that they smell.
"[5] ORS has also never been allocated a dedicated entry in any edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.
"[5] In the fifth edition (DSM-5), ORS again does not appear as a distinct diagnosis, but it is mentioned in relation to taijin kyōfushō (対人恐怖症, "disorder of fear of personal interaction").
The typical history of ORS involves a long delay while the person continues to believe there is a genuine odor.
[10] Repeated consultation with multiple different non-psychiatric medical specialists ("doctor shopping") in an attempt to have their non-existent body odor treated is frequently reported.
Despite the absence of any clinically detectable odor, physicians and surgeons may embark on unnecessary investigations (e.g. gastroscopy),[11] and treatments, including surgical procedures such as thoracic sympathectomy, tonsillectomy, or others.
For example, one otolaryngologist researcher noted "behavioral problems such as continuous occupation with oral hygiene issues, obsessive use of cosmetic breath freshening products such as mouthwashes, candies, chewing gums, and sprays, avoiding close contact with other people, and turning the head away during conversation" as part of what was termed "skunk syndrome" in patients with genuine halitosis secondary to chronic tonsillitis.
[6] Genuine halitosis has been described as a social barrier between the individual and friends, relatives, partners and colleagues, and may negatively alter self-esteem and quality of life.
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] Body dismorphic disorder (BDD) has been described as the closest diagnosis in DSM-IV to ORS as both primarily focus on bodily symptoms.
[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.
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] Dunne (2015) reported a Case Study treatment of ORS using EMDR which was successful using a trauma model formulation rather than an OCD approach.
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.
[5] 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.