Many Delusional About Smelling Bad

Researchers Say Olfactory Reference Syndrome Is Vastly Under-Recognized

By Charlene Laino
WebMD Health News

Reviewed By Laura J. Martin, MD

May 25, 2010 (New Orleans) -- Researchers say a psychiatric condition characterized by a person's mistaken belief that he or she smells bad is vastly under-recognized.

Called olfactory reference syndrome, the condition is "probably very common," says Katharine Phillips, MD, of Rhode Island Hospital in Providence.

"These patients suffer tremendously," she tells WebMD. "They are preoccupied with the belief that they are emitting a foul or offensive body odor, which is not perceived by others."

"They're impaired in terms of functioning and they have high rates of suicidality," Phillips says.

At a news briefing at the American Psychiatric Association meeting, Phillips said the condition has been described around the world for more than a century but has only been minimally studied.

So she and colleagues examined the features of olfactory reference syndrome in 20 patients seen at a Providence, R.I. hospital.

Their average age was 33, and 60% were female. Their symptoms started between ages 15 and 16, on average.

Many Hours Spent Preoccupied With Smelling Bad

Overall, patients spent three to eight hours a day preoccupied with their concerns that they smelled bad.

"They had thoughts such as "I smell horrid' or "People are moving because I stink,'" Phillips says.

A total of 85% were completely convinced that that they emitted a foul odor, even though they didn't.

About three-fourths thought others took special notice of them, misinterpreting benign acts like scratching their nose or wanting to open a window because a room is stuffy, she says.

Also, 44% sought non-psychiatric treatment for their perceived body odor, including visits to gastroenterologists, dentists, and dermatologists.

"Usually, those treatments didn't diminish their worry about body odor," Phillips says.

Bad Breath No. 1 Complaint

The majority (75%) thought they had bad breath, and 65% believed their sweat smelled bad. About 30% blamed flatulence or feces for their foul smell, and 20% blamed their urine.

"Most were preoccupied with three different smells on average," Phillips says.

To mask their perceived odors, 90% turned to perfume or powders. "One person even swallowed perfume to improve her breath," Phillips says.

About 70% resorted to frequent showers, 60% constantly chewed gum, and 50% sucked on mints. About a quarter changed their clothes several times a day to get rid of the imaginary stench.

"Some of these patients would use an entire bar of soap in one shower," she says.

Two-Thirds Think About Suicide

The condition affected their entire life, she says. A total of 74% said they avoided social situations, and 40% stayed in for at least a week because they were so embarrassed by their problem.

More problematic, Phillips says, is that 68% had suicidal thoughts and 32% actually attempted killing themselves. About half had been hospitalized for a psychiatric problem.

If someone thinks they suffer from the condition, they should seek psychiatric help, she says.

"We're not clear what treatment is best, but selective serotonin reuptake inhibitors (SSRIs) may be helpful," she says.

SSRIs work by blocking a receptor in the brain that absorbs a chemical called serotonin that is known to influence mood. They're commonly used to treat depression and other mood disorders.

Phillips says olfactory refractory syndrome is not an actual diagnosis in the current version of DSM-IV, the bible of psychiatry, although it is mentioned under the heading of psychoses.

For the new version of DSM-V, which is expected by 2013, doctors want to add an appendix of disorders for which further research is needed, so "we can have an agreed-upon definition," Phillips says.

There are no good figures on how common the condition is, but one Japanese study showed that more than 2% of college students were concerned about having strange body odors.

"But we can't assume that translates to olfactory reference syndrome," she says.

Jeffrey Borenstein, MD, chairman of the APA's communication council and medical director of Holliswood Hospital in Queens, N.Y., tells WebMD he never heard of the condition until Phillips presented her research.

"It sounds very debilitating; we need a lot more research," says Borenstein, who moderated the news briefing.

This study was presented at a medical conference. The findings should be considered preliminary as they have not yet undergone the "peer review" process, in which outside experts scrutinize the data prior to publication in a medical journal.

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SOURCES: 163rd Annual Meeting of the American Psychiatric Association, New Orleans, May 22-26, 2010.

Katharine Phillips, MD, Rhode Island Hospital, Providence.

Jeffrey Borenstein, MD, chair, communication council, American Psychiatric Association; medical director, Holliswood Hospital, Queens, N.Y.

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