Olfactory Reference Syndrome (ORS)

What Is Olfactory Reference Syndrome (ORS)?

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Olfactory reference syndrome (ORS) is an underrecognized condition that has similarities to obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). People with ORS think they smell bad, but in reality they don't. There's a profound mismatch between their own perception and the perception of other people.

People with ORS may worry, for example, that they have bad breath or bad-smelling armpits, or that they emit a foul odor from their genitals, anus (often flatulence), feet, skin, or other body area. People with ORS may worry about emitting a bad body odor from any part of their body; the types of odors and body areas listed here are just some examples. The odor concerns cause significant emotional distress or interfere with the person's day-to-day functioning.

What Are Some Other Symptoms of ORS?

People with ORS perform repetitive behaviors (also called "rituals" or "compulsions") in response to the distress that their body odor preoccupations cause. Common excessive behaviors (and lifetime rates) include:

  • Smelling one's self: 80%
  • Showering (to get rid of perceived odor): 68%
  • Changing clothes (so the perceived body odor doesn't make clothes smell bad): 50%
  • Seeking reassurance about body odor (for example, "Do I have bad breath?"): 45%
  • Dieting/unusual food intake (for example, to decrease perceived flatulence): 45%
  • Brushing teeth (to minimize perceived bad breath): 40%
  • Laundering clothes (to get rid of perceived odor): 30%
  • Comparing one's body odor to that of other people: 30%

Other common symptoms of ORS include:

  • Camouflaging the perceived odor - for example, by using lots of perfume or fragrance, gum, deodorant, mints, mouthwash, or toothpaste
  • Embarrassment and shame
  • A belief that other people take special notice of the person in a negative way because of how they smell (for example, talk about them or move away from them)
  • Social anxiety and social avoidance
  • Anxiety and depressed mood
  • Use of alcohol or street drugs to try to cope with ORS symptoms
  • Suicidal thinking and behavior

How Is ORS Different from More Typical Body Odor Concerns That People May Have?

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Here are some of the key differences:

  • Preoccupation: People with ORS are preoccupied with body odor; they obsess about it. Typically, they think about their perceived body odor for hours a day.
  • Emotional Distress and/or Interference in Functioning: The preoccupation with perceived body odor causes significant emotional distress, such as depressed mood, anxiety, or even thoughts of suicide. Or, the odor concerns interfere with the person's day-to-day functioning -- for example, they may make it hard to be around other people and participate in social activities, go to school or work, or do other activities. Some people with ORS think they smell so bad that they won't leave their house because they don't want other people to smell the odor they believe they emit.

How Common Is ORS?

Good prevalence studies haven't been done. It's likely, however, that ORS is more common than generally believed. But ORS often goes unrecognized and undiagnosed.

Who Gets ORS?

Anyone can get ORS. This condition occurs around the world. It affects people of all ages, genders, races, and ethnicities. ORS usually starts during adolescence.

How Serious Is ORS?

ORS is a serious psychiatric disorder. It's associated with high rates of psychiatric hospitalization, suicidal thinking, and suicidal behavior.

What If I Think I Might Have ORS Except I Believe I Really Do Smell Bad?

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This is a common situation: a person obsesses about perceived body odor, which causes them emotional distress or interferes with daily functioning. Yet, the person thinks they don't have ORS because they think they really do smell bad (even though they really don't). These individuals actually do have ORS.

By definition, people with ORS have a distorted perception of how they smell. ORS isn't a problem with how the person actually smells; it's a problem with how they perceive themselves. Most people with ORS think that their view of how they smell is definitely or probably accurate. But in reality, it's inaccurate.

If you think you smell bad but other people don't, I encourage you to be open-minded and find out if you have ORS. There's no downside to doing this. If you actually smell a bad odor, depending on the type of odor and your other symptoms it may be wise to be sure that you don't have a seizure disorder or another medical condition that might explain your symptoms. If you're diagnosed with ORS, I encourage you to try treatment for ORS (see below).

What Treatments Work for ORS?

Treatments for ORS haven't been well studied. However, clinical experience and published case reports and case series suggest that treatments similar to those used for body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD) may be helpful:

  • Medications called serotonin reuptake inhibitors (also known as SRIs, or SSRIs): These are medications that help stop obsessive thoughts and compulsive behaviors; they also often alleviate depression, anxiety, and other symptoms. They are usually well tolerated and are not habit forming.
  • It's possible that medications called neuroleptics may be helpful when added to an SRI.
  • Cognitive-behavioral therapy (CBT): This "here-and- now" practical treatment helps change problematic ORS thoughts and behaviors. A published evidence-based treatment manual isn’t available for therapists to use. However, CBT for ORS is probably most similar to CBT for BDD; thus, therapists can consider using the following treatment manual, while adapting it to ORS symptoms: Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual, by Sabine Wilhelm, Ph.D., Katharine A. Phillips, M.D., and Gail Steketee, Ph.D. (published by Guilford Press, New York, NY, 2013).

In my experience, these treatments often improve ORS preoccupations and compulsive behaviors such as checking one's body for odor. These treatments also usually help people feel more comfortable in social situations and less depressed and anxious. Some people improve when treated with medication alone or with CBT alone, whereas others benefit from receiving both treatments at the same time.

Some people with ORS seek treatment of their odor concerns from non-mental health clinicians, such as ENT (ear, nose, and throat) doctors, dentists, dermatologist, surgeons, gastroenterologists, and gynecologists. Although very little scientific research has been done on the effectiveness of these treatments, they do not appear to be helpful. Thus, non-mental health treatments are not recommended for ORS.

What Causes ORS?

The cause of ORS isn't known. However, it's likely that -- like other psychiatric conditions -- ORS results from a complex combination of genetic predisposition/neurobiologic factors as well as life experiences and cultural factors.

Hope for People With ORS

ORS can be severely distressing and impairing, to the point where some people consider suicide. But there is hope for people with ORS! If you're diagnosed with ORS, I encourage you to try medication and/or therapy. These treatments can help free you of odor preoccupations and rituals, depression, anxiety, and other symptoms.

For More Information About ORS

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3139109/

Contact Me

I've spent the past 25 years evaluating and treating people with ORS. If you'd like to see me for a one-time evaluation so I can give you treatment recommendations, or if you live in the New York City area and would like to see me for ongoing treatment, please contact us.

Photo credit: Sander van der Wel. Foter. CC BY-SA (young man)