Olfactory reference syndrome: when you're obsessed with your BO

In 5 seconds Exploring a condition in which people falsely believe they emit bad body odour, Ph.D. student Morganne Masse highlights the significance of smell in psychiatry.

In psychiatry, sensory perception is considered critically important. Yet despite its vital role in social and emotional functioning, when it comes to assessing a patient, how well the person exercises their sense of smell is frequently overlooked.

To probe deeper, Université de Montréal Ph.D. candidate Morganne Masse decided to research a little-known syndrome related to the perception of smell, called olfactory reference syndrome (ORS).

An article she co-authored on the topic with her research supervisor Emmanuel Stip, a professor emeritus in UdeM’s Department of Psychiatry and Addiction, was published last October in Santé mentale au Québec. 

A little-known condition

Morganne Masse

ORS is a misperception that leads people to believe they are emitting a foul odour. This understudied syndrome was first described in 1891 by C.S. Potts. It is also known by other names, such as autodysomophobia and olfactory phobic syndrome.

ORS is characterized by stubborn belief and significant distress that can interfere with daily functioning. Patients may experience significant impairment in their social and professional lives because of their constant preoccupation with body odour.

Symptoms typically appear in a person’s 20s. They may be triggered by external stress or a specific olfactory experience.

ORS has a dramatic effect on social relationships. Patients misinterpret innocent gestures by people around them (such as touching their nose or clearing their throat) as reactions to their offensive body odour and often develop avoidant behaviours.

Two case studies

Emmanuel Stip

During her psychiatric internship at the l'Institut universitaire en santé mentale de Montréal, Masse assessed two men with ORS. There were interesting similarities and differences between the two cases. While one patient was able to maintain a social and professional life despite his challenges, the other became increasingly isolated, avoiding public places and falling into prolonged unemployment.

The first patient, a 63-year-old man, had struggled with body odour misperception since the age of 20. He described a nauseating odour emanating from his body, accompanied by an unpleasant sensation in his mouth. He had an active social life, including friendships and a romantic relationship, but avoided public transit and social events out of fear of bothering others.

The second patient, a 53-year-old man, presented with similar symptoms, but with greater intensity. He perceived an odour of excrement emanating from his mouth and rectum, leading him to avoid all social contact and live as a recluse. He also experienced auditory hallucinations and suicidal ideation.

Therapeutic strategies

Masse also reviewed 53 scientific publications on ORS to identify the challenges associated with managing the syndrome and possible treatments.

“People with ORS have often gone from doctor to doctor before being referred to psychiatry,” said Masse. “They will consult numerous specialists—dentists, dermatologists—to try to eliminate the odours they believe they emit. The two patients in our study spent years seeing various doctors and trying drug therapies before receiving an accurate diagnosis.”

According to the literature, despite the complexity of the disorder, the prognosis is favourable in around two-thirds of cases. Treatment typically involves a combination of cognitive behavioural therapy (CBT) and medication, usually antidepressants and anxiolytics. New therapeutic approaches, such as repetitive transcranial magnetic stimulation, also show promise.

“CBT has been shown to reduce dysfunctional thoughts and anxiety, while antidepressants are also recommended, often in combination with CBT,” said Masse. “Another approach is to address the delusional component of ORS similarly to the way we treat the positive symptoms of psychosis. Isolated case studies suggest the efficacy of combining antidepressants and antipsychotics, although the latter are generally less effective.”

Research directions

Masse and Stip’s study underscores the need for systematic assessment of smell-related symptoms in psychiatry and for further research into ORS. They hope to present their findings at the June meeting of the Association des médecins psychiatres du Québec, accompanied by a peer helper who can share their lived experience.

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