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Year : 2017  |  Volume : 1  |  Issue : 2  |  Page : 129-131

Olfactory reference syndrome treated with electroconvulsive therapy

Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Date of Web Publication8-Dec-2017

Correspondence Address:
Avinash De Sousa
De Sousa, Carmel, 18, Street Francis Road, Off S. V. Road, Santacruz West, Mumbai - 400 054, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_28_17

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Olfactory reference syndrome(ORS) is a distressing clinical condition characterized by the belief that one's body emits a foul odor which disturbs others though others are unable to perceive the same. The disorder is characterized also by delusions of reference and olfactory hallucinations which may be present. The disorder usually shows a multifaceted picture and may mimic depression, somatoform disorders, obsessive–compulsive disorder, hypochondriasis and at times delusional disorder or schizophrenia. We present here a case of ORS that presented with delusions and suicidal ideation and responded well to a course of electroconvulsive therapy.

Keywords: Olfactory reference syndrome, electroconvulsive therapy, foul odor, schizophrenia

How to cite this article:
Bhagat H, Bendre A, Dikshit R, De Sousa A, Shah N, Karia S. Olfactory reference syndrome treated with electroconvulsive therapy. Ann Indian Psychiatry 2017;1:129-31

How to cite this URL:
Bhagat H, Bendre A, Dikshit R, De Sousa A, Shah N, Karia S. Olfactory reference syndrome treated with electroconvulsive therapy. Ann Indian Psychiatry [serial online] 2017 [cited 2023 Mar 27];1:129-31. Available from: https://www.anip.co.in/text.asp?2017/1/2/129/220249

  Introduction Top

The published literature on olfactory reference syndrome(ORS) spans more than a century and provides consistent descriptions of its clinical features.[1] The core symptom is the preoccupation with the belief that one emits a foul or offensive body odor and olfactory hallucination about the same, which is not perceived by others.[2] This syndrome is associated with substantial distress and disability to the patient who may become suicidal and aggressive in relation to his symptoms.[3] It is interesting to note that ORS may not always be delusional in nature and may be seen in the context of major depression and somatoform disorders as well.[4] The diagnostic dilemma lies in whether it would be a psychotic or a neurotic disorder.[5] Common specific concerns include halitosis, genital odor, flatulence or anal odor, or sweat that may be reported.[6] This is often accompanied by ideas or delusions of reference, i.e., the belief that other people take special notice of the odor in a negative way.[7] In addition, many patients perform repetitive behaviors, such as smelling themselves, showering excessively, and attempting to mask the odor sometimes bordering onto an obsessive–compulsive disorder like picture.[8] We present herewith a case of ORS that presented with hallucinations and suicidal ideations leading to a suicide attempt and ultimately responded to a course of electroconvulsive therapy(ECT).

  Case Report Top

A 32-year-old unmarried Marathi-speaking Hindu male educated up to the 8thstandard and rickshaw driver by occupation, residing at Kurla, Mumbai, was brought by his brother and sister in emergency department with chief complaints of self-inflicted cut injuries over neck and wrist, sadness of mood, smelling foul odors of his own body not smelled by others, hearing of voices inaudible to others, and suspiciousness that people talk ill about him. The total duration of the illness was 3years and it followed a continuous course since onset. The patient was apparently alright 3years back, when he started experiencing the smell of foul odors from his own body. It was sudden in onset and the patient could smell feces and sewage, which would initially come from genital area and later from the whole body. He would smell it once or twice a day which later increased to most of the day and a belief that others were also smelling the odor and were disturbed by the same. In order to get rid of the odor he bathed 2-3 times a day and repeatedly asked his family members for assurance about the odor.

Gradually the patient felt that people spoke ill about him because of the foul odor from his body and also complained of auditory hallucinations where 3–4 unknown male and female voices would abuse and pass derogatory comments on his body odor and use abusive language toward him. The patient stopped working, going out with friends which he used to like earlier and his interaction with family members and friends decreased. He would not sleep properly and his appetite was reduced. The family members took the patient to multiple faith healers but perceived no improvement. The patient started experiencing sadness of mood, felt he would never improve and had suicidal ideations. The patient was taken to a private psychiatrist and started on medications but perceived minimal improvement. One day, when the patient was alone at home, he cut his left wrist on flexor aspect and anterior side of neck with razor, which was noticed by his neighbor. He was brought to the emergency department, his wounds were sutured and the patient was admitted in psychiatry ward. The patient had no history suggestive of any substance use, significant head injury, or seizure disorder, He had no major medical or surgical illness in the past and no history of psychiatric illness in the family members was elicited.

Birth and developmental history details were unavailable and the patient had finished schooling till the 8thstandard which he then left due to financial reasons. He was a rickshaw driver by occupation but was not working since 8months. He had good family support from his brother and sister. His premorbid personality was reported to be extrovert, calm, responsible, religious, and socially well adjusted.

On mental status examination, he was conscious, cooperative, and communicative. The patient was dressed appropriately, kempt, and had a wound dressing over neck and wrist. The patient showed normal psychomotor activity and was oriented to time, place, and person. Eye-to-eye contact was initiated and maintained. Rapport was established and attention was aroused and sustained. Passive attention was normal and mood conveyed was sad. The affect was congruent to the mood, constricted in range, and appropriate to surroundings. His speech was continuous, coherent, and relevant. He demonstrated delusions of reference, ideas of helplessness, hopelessness, and worthlessness. He had suicidal ideations due to the foul odor. He had 2ndperson auditory hallucinations in the form of 3–4 unknown male and female voices in both ears blaming the patient for foul smell and this was distressing for the patient. Olfactory hallucinations in the form of foul smell were present. His concepts were intact and memory was normal. Intelligence was average while judgment was intact. Insight reported was Grade3 out of 6. The clinical impression was ORS in the patient with schizophrenia having depressive features currently.

The patient was admitted in view of suicidal ideations. He was started on oral olanzapine(10 mg/day), mirtazapine 15mg at night, and lorazepam 2mg at night. The patient was considered for ECT as his symptoms showed just 30% improvement even after 3weeks of medication. The patient received a course of bitemporal brief pulse ECT on alternate days and a total of 10 ECTs were administered. The patient showed 90% improvement and is currently symptom free and maintained on the same medication. He is following up regularly in the outpatient department at our hospital.

  Discussion Top

Our case of ORS had features suggestive of both depression and schizophrenia. Such mixed clinical picture along with compulsive behaviors such as bathing 2–3times a day is common in patients with ORS. Considering ORS as a type of delusional disorder is wrong from a clinical standpoint. ORS might have variable presentations of several different disorders, such as BDD, social phobia, or others, rather than being a distinct syndrome.[9] The treatment of ORS may thus involve polypharmacy including antipsychotic and antidepressant medications as in our case.[10] ECT has been used successfully in the management of ORS in the past and has usually been reserved for cases that do not respond to medical treatments or where suicidal behavior is present with delusions.[11] There is limited but emerging literature on its treatment, which appears to differ in some ways from that of delusional disorders.[12] It is important that clinicians remain vigilant that disorders such as ORS may have multifaceted presentations and thus may be misdiagnosed and treated as some other disorder where the desired treatment response may not be achieved.

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Conflicts of interest

There are no conflicts of interest.

  References Top

BegumM, McKennaPJ. Olfactory reference syndrome: Asystematic review of the world literature. Psychol Med 2011;41:453-61.  Back to cited text no. 1
PhillipsKA, MenardW. Olfactory reference syndrome: Demographic and clinical features of imagined body odor. Gen Hosp Psychiatry 2011;33:398-406.  Back to cited text no. 2
PhillipsKA, CastleDJ. How to help patients with olfactory reference syndrome: Delusion of body odor causes shame, social isolation. Curr Psychiatry 2007;6:49-56.  Back to cited text no. 3
FeusnerJD, PhillipsKA, SteinDJ. Olfactory reference syndrome: Issues for DSM-V. Depress Anxiety 2010;27:592-9.  Back to cited text no. 4
StraussGP, AllenDN, RossSA, DukeLA, SchwartzJ. Olfactory hedonic judgment in patients with deficit syndrome schizophrenia. Schizophr Bull 2010;36:860-8.  Back to cited text no. 5
Van AmeringenM, PattersonB, SimpsonW. DSM-5 obsessive-compulsive and related disorders: Clinical implications of new criteria. Depress Anxiety 2014;31:487-93.  Back to cited text no. 6
CroyI, NordinS, HummelT. Olfactory disorders and quality of life–An updated review. Chem Senses 2014;39:185-94.  Back to cited text no. 7
UguruC, UmeanukaO, UguruNP, AdigunO, EdafioghorO. The delusion of halitosis: Experience at an Eastern Nigerian tertiary hospital. Niger J Med 2011;20:236-40.  Back to cited text no. 8
LochnerC, SteinDJ. Olfactory reference syndrome: Diagnostic criteria and differential diagnosis. JPostgrad Med 2003;49:328-31.  Back to cited text no. 9
[PUBMED]  [Full text]  
EliI, BahtR, KoriatH, RosenbergM. Self-perception of breath odor. JAm Dent Assoc 2001;132:621-6.  Back to cited text no. 10
BizamcerAN, DubinWR, HayburnB. Olfactory reference syndrome. Psychosomatics 2008;49:77-81.  Back to cited text no. 11
PhillipsKA, WilhelmS, KoranLM, DidieER, FallonBA, FeusnerJ, etal. Body dysmorphic disorder: Some key issues for DSM-V. Depress Anxiety 2010;27:573-91.  Back to cited text no. 12


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