Olfactory reference syndrome: demographic and clinical features of imagined body odor

The challenge of diagnosing cultural syndromes: A narrative review

BACKGROUND

In 2022 the total world migrant population was 281 million (an increase of approximately 62% compared to year 2000), of whom 169 million were migrant workers. The number of refugees, asylum seekers and others in need of international protection increased by 22% compared to 2021. Research has shown that the forcibly displaced have high rates of mental disorders (including depression, post-traumatic stress disorder (PTSD) and anxiety), with an estimated prevalence almost 6 to 7 times higher than the general population. Given the increase of the overall migration phenomenon and the challenge raised by the cultural features concerning mental health, we consider that this is an area that requires close attention to ensure that culturally sensitive health services be available to the migrant and displaced population.

AIMS

The aim of this narrative review is to provide a background to the issue and take stock of what is currently available in the literature regarding culture-bound illnesses and the relevant diagnostic tools.

METHODS

A comprehensive search was performed in PubMed, Psychinfo, Embase, Google Scholar, organized in stages to assure inclusion of all the relevant studies. Of the 703 papers initially identified, only 30 papers finally satisfied the inclusion criteria.

RESULTS

Eleven diagnostic scales were found, only two of which are being used for displaced people.

CONCLUSIONS

Further work is required in this field, including a debate as to whether scales are indeed an appropriate tool for use with this population.

Associations between olfactory reference disorder and social phobia - results of an internet-based study

Despite the similar clinical features of Olfactory Reference Disorder (ORD) and Social Phobia (SP), or studies showing elevated comorbidity of the two disorders, and the conceptualization of ORD as a form of SP in the East Asian culture, to our knowledge, the relationship between ORD and SP has not been investigated. This study examined the association of ORD according to the 11th revision of the International Classification of Diseases (ICD-11) and SP in 225 German university / college students who completed self-ratings with regard to socio-demographic data and symptoms of SP and ORD within an anonymous internet-based survey. Symptoms of SP were assessed with the Social Phobia Inventory (SPIN). Symptoms of ORD according to the ICD-11 were assessed with the Olfactory Reference Disorder Questionnaire (ORDQ), developed for this study. In our sample, 86.6% of the participants who met the self-rated features for ORD also met the self-rated criteria for current SP. ORD severity scores were significantly related to SP. Participants with and without self-reported ORD differed significantly in their SP total scores. SP severity was also significantly correlated with poorer insight of ORD-related beliefs, greater ORD-related avoidance of intimate relationships and higher levels of shame and fear of rejection due to body odor. These preliminary findings indicate that ORD could be closely related to SP and highlight the need for future research on the relationship of ORD and SP in order to gain a better understanding of the development, maintenance, treatment and classification of ORD.

Olfactory Reference Syndrome: Its Relationship to Comorbidity of Social Anxiety Disorder and Obsessive-Compulsive Disorder

ABSTRACT

Olfactory reference syndrome (ORS) is known to have the clinical features of both obsessive-compulsive disorder (OCD) and social anxiety disorder (SAD). However, there has been no clear explanation as to why ORS has the characteristics of two different disorders. In the present study, the comorbidity rates of ORS in patients with SAD (without OCD, n = 83), ORS in patients with OCD (without SAD, n = 42), and patients with SAD and OCD comorbidity (n = 17) were compared. Of all 142 patients studied, 11 were diagnosed with ORS. The comorbidity rate of ORS in comorbid SAD/OCD group was significantly higher than those in both SAD and OCD groups. Logistic regression analysis of 100 cases of SAD and selected 69 cases of generalized SAD showed that the risk of ORS was significantly higher in patients with OCD and bulimia nervosa. Of 59 cases with OCD, the risk of ORS was significantly higher in patients with SAD. The results of the present study suggest that the comorbidity of SAD and OCD most likely explains the development of ORS.

Human skin gas profile of individuals with the people allergic to me phenomenon

Recent studies have shown that some people claim that their skin gases provoke allergy-like reactions in people in their near vicinity. Such a phenomenon or symptom is called 'people allergic to me (PATM)'. Although numerous people suffer from PATM, the actual conditions are unknown. The aim of this study was to investigate the characteristics of human skin profiles in patients with PATM by measuring the dermal emission fluxes of 75 skin gases using passive flux sampler and gas chromatography/mass spectrometry. We found common features in the human skin gas profiles of 20 subjects with PATM, with a significant difference from those of 24 non-PATM subjects: greater emissions of petrochemicals, organosulfur compounds, and some aldehydes and lower emissions of aroma compounds and others. The ratio of toluene to benzaldehyde is considered a vital sign that suggests the fundamental of PATM. These findings indicate that PATM is a medically unexplained phenomenon or symptom worthy of further research, which requires an interdisciplinary approach.

Olfactory Obsessions: A Study of Prevalence and Phenomenology in the Course of Obsessive-Compulsive Disorder

Olfactory obsessions (OOs) are rarely described in the medical literature. The features of OOs appear consistent with characteristics of a typical obsession, but since they do not involve the realm of thought, it is questionable to term them obsessions per se. Olfactory Reference Syndrome (ORS) presents OOs inconsistently and is a distinctive diagnostic category related to OCD. Therefore, the primary objectives of our study were not only to assess the prevalence of OOs in OCD patients, but also to demonstrate their phenomenological consistency with other OCD symptoms. The study group consisted of 75 patients already diagnosed and treated for OCD. Hence, a comparison was made between OCD patients with and without OOs in terms of: symptom severity, level of insight and comorbidities. Olfactory obsessions (OOs) were found in 21.33% (n = 16). OOs induced compulsive behavior in more than 93% of subjects. The presence of OOs did not significantly differentiate the studied groups in terms of OCD severity (p = 0.876), level of insight (p = 0.680), depression (p = 0.746), mania (p = 0.525) and OCDP traits (p = 0.624). However, a comparison of the two groups showed that OOs patients presented higher levels of hostility (p = 0.036), cognitive impulsivity (p = 0.039), magic-type obsession (75% vs. 35.59%), and contamination obsession (87.50% vs. 67.80%). Conclusions: OOs frequently occur in the course of OCD, and their phenomenology is typical of this disorder. OOs are not a symptom of thought content disorders and are sensory in nature, which is not included in the definition of obsession. The presence of OOs in OCD provokes hostility and cognitive impulsivity. It can be assumed that the Olfactory Obsessions Questionnaire accurately identifies olfactory obsessions.

Verhaltensanalysen und objektive Merkmalsbeurteilungen bei Personen mit olfaktorischer Referenzstörung

Zusammenfassung. Hintergrund: Personen mit olfaktorischer Referenzstörung (ORS) befürchten einen unangenehmen Körpergeruch zu verbreiten. Für andere ist dieser Geruch jedoch nicht objektivierbar. Fragestellung: Studienziele waren, zu eruieren, welche Situationen bei Betroffenen spezifische Verhaltens- und Denkmuster auslösen, welche Emotionen, Kognitionen, Körperempfindungen und Verhaltensweisen beschrieben werden, und wie diese Personen auf Andere bezüglich Aussehen, Habitus und Körpergeruch wirken. Methode: 38 ORS-Betroffene und 38 gematchte Kontrollpersonen durchliefen qualitative Interviews, es wurden Videoaufnahmen (Habitus), Fotos (Aussehen) und Schweißproben (Körpergeruch) durch unabhängige, verblindete Personen beurteilt. Ergebnisse: Als auslösende Situationen werden überwiegend soziale Situationen beschrieben. Als Reaktionen werden Sicherheitsverhalten (motorisch), Scham (affektiv), Selbstabwertungen (kognitiv) und Schwitzen (vegetativ) am häufigsten genannt. Die objektiven Beurteilungen unterschieden sich nicht signifikant zwischen den Gruppen. Diskussion: Es sind vorwiegend soziale Situationen, die ORS-spezifische Symptome auslösen. Dabei lassen sich die befürchteten Symptome (insbesondere der unangenehme Geruch oder die negative soziale Bewertung) durch unabhängige Beurteilende nicht objektivieren, was den sozialen Aspekt der Befürchtungen verdeutlichen könnte.

Olfactory Reference Syndrome (Halitophobia) With Oral Cenesthopathy Treated With Low-Dose Aripiprazole: A Case Report

Introduction

Olfactory reference syndrome (ORS) (halitophobia) is the excessive fear of having bad breath without clinical findings supporting the patient's complaints. In this case report, a low dose of aripiprazole (ARP) successfully improved oral cenesthopathy and then improved ORS.

Case Presentation

A 44-year-old female patient complained of a sensation of astringent film sticking on her tongue. She was also very anxious about her bad breath at work.

We prescribed 0.5 mg of ARP for her symptoms because she worried about potential drowsiness. One week later, the patient reported that the oral sensation had resolved 2 to 3 days after the mediation was administered. No obvious adverse effects were observed except temporary arousal during sleep. Three months after the initial visit, her symptoms worsened, partly because of her job change, so we increased the dose of ARP from 0.5 mg to 1 mg. Later, the patient reported that she was better able to manage the anxiety about her breath. At the 2-year follow-up, her symptoms have continued to improve without medication.

Conclusions

Although the most effective approach to ORS is not established, the current study indicates that a low dose of ARP to treat oral cenesthopathy might improve ORS.

The use of 33 MHz ultra-high-frequency ultrasonography for the evaluation of sweat glands in the axilla with osmidrosis

Background

This study aimed to assess the use of 33 MHz ultra-high-frequency ultrasonography (33MHz-UHFUS) for evaluating axillary sweat glands with osmidrosis in comparison with histological techniques. Axillary osmidrosis is a common problem in Asian societies, and the number and size of apocrine sweat glands have a strong relationship with osmidrosis severity. Currently, there are no methods to evaluate sweat gland distribution non-invasively.

Methods

In this study, 35 skin specimens from 10 fresh human cadavers without osmidrosis and retrospective ultrasonographic images from 20 patients with osmidrosis were used. Skin specimens were embedded in paraffin, thinly sliced, and finally stained with hematoxylin and eosin. Histologically, the apocrine and eccrine glands were evaluated, and the top and bottom depths of follicles were measured from the skin surface. In 33 MHz ultrasonography images, the depths of sweat glands were measured, and the mean grey value was calculated using Image J.

Results

Compared to histological data, 33MHz-UHFUS could be used to identify sweat glands as a hyperechoic structure between the dermis and fat layer. Furthermore, it could evaluate sweat gland distribution but could not distinguish between types of sweat glands.

Conclusions

The distribution of sweat glands in the axilla can be non-invasively evaluated via 33MHz-UHFUS.

The latent structure of olfactory reference disorder symptoms: A taxometric analysis

Olfactory reference disorder (ORD), a newly included disorder in the ICD-11, is characterized by 'pathological' concerns about emitting body odor. While research is emerging on the construct, no study has directly examined the boundary between ORD and normal body odor concerns. That is, should ORD be considered as categorical in nature versus a more dimensional construct? As such, the current study explored the extent to which ORD symptoms correspond to a distinct category or dimension in a mixed university student and community sample (n = 757). Three indicators, derived from the Yale-Brown Obsessive Compulsive Scale Modified for Olfactory Reference Syndrome, were submitted to three independent taxometric procedures: MAMBAC, MAXEIG, and L-Mode. Two of three procedures showed that the latent structure of ORD is dimensional rather than categorical. The comparison curve fit index profile method yielded dimensional structure. Results suggested that researchers and clinical practitioners would be well-advised to conceptualize, assess, and treat ORD symptoms in a dimensional way.

Accuracy of diagnostic judgments using ICD-11 vs. ICD-10 diagnostic guidelines for obsessive-compulsive and related disorders

BACKGROUND

We report results of an internet-based field study evaluating the diagnostic guidelines for the newly introduced ICD-11 grouping of obsessive-compulsive and related disorders (OCRD). We examined accuracy of clinicians' diagnostic judgments applying draft ICD-11 as compared to the ICD-10 diagnostic guidelines to standardized case vignettes.

METHODS

1,717 mental health professionals who are members of the World Health Organization's Global Clinical Practice Network completed the study in Chinese, English, French, Japanese, Russian or Spanish. Participants were randomly assigned to apply ICD-11 or ICD-10 guidelines to one of nine pairs of case vignettes.

RESULTS

Participants using ICD-11 outperformed those using ICD-10 in correctly identifying newly introduced OCRD, although results were mixed for differentiating OCRD from disorders in other groupings largely due to clinicians having difficulty differentiating challenging presentations of OCD. Clinicians had difficulty applying a three-level insight qualifier, although the 'poor to absent' level assisted with differentiating OCRD from psychotic disorders. Brief training on the rationale for an OCRD grouping did not improve diagnostic accuracy suggesting sufficient detail of the proposed guidelines.

LIMITATIONS

Standardized case vignettes were manipulated to include specific characteristics; the degree of accuracy of clinicians' diagnostic judgments about these vignettes may not generalize to application in routine clinical practice.

CONCLUSIONS

Overall, use of the ICD-11 guidelines resulted in more accurate diagnosis of case vignettes compared to the ICD-10 guidelines, particularly in differentiating OCRD presentations from one another. Specific areas in which the ICD-11 guidelines did not perform as intended provided the basis for further revisions to the guidelines.

On Psychosomatic Problems in Dentistry

In their daily practice dentists frequently have patients showing signs of stress-related oral manifestations in different forms. Stress-related aetiology of oral changes are still not investigated enough, and present a subgroup of psychosomatic diseases which had been recognized in medicine a long time ago. Recognition of such psychological or emotional disturbance needs deep evaluation "per exclusionem", and is beneficial for both the patient and clinician. Psychological management should be taken into consideration when treating patients with these psychosomatic disorders. Therapeutic approach comprises different forms of psychotherapy and medication as well.

Transdiagnostic Approach to Olfactory Reference Syndrome: Neurobiological Considerations

Olfactory reference syndrome (ORS) describes a constellation of emotional and behavioral symptoms that cause clinically significant distress or impairment arising from the false belief that one is emitting an offensive odor. Despite cases of ORS reported throughout the world over the last century, our knowledge and understanding of ORS remain relatively poor because of the limited literature-mostly case studies and series, but no clinical trials. ORS continues to pose significant diagnostic challenges within our current frameworks of categorizing mental disorders, including the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases. We review the ORS literature and discuss diagnostic parallels and challenges of placing ORS within specific categories. We also review the current research on the neurocircuitry of olfaction and of disorders with potential clinical relevance to patients presenting with ORS. While no primary neuroscientific research has specifically investigated ORS, an overlapping circuitry has been implicated in the neurobiology of obsessive-compulsive, trauma and stressor, and psychotic spectrum disorders, suggesting that the phenomenology of ORS can best be understood through a dimensional, rather than categorical, approach.

Olfactory and Neuropsychological Functioning in Olfactory Reference Syndrome

BACKGROUND

Olfactory reference syndrome (ORS) is an underrecognized, understudied, and often severe psychiatric disorder characterized by a prominent and distressing or impairing preoccupation with a false belief of emitting an offensive body odor. As this condition has only recently been recognized in the International Classification of Diseases (the 11th Edition), no empirical evidence exists about the underlying features and etiology of the disorder.

OBJECTIVE

To examine the neuropsychological and olfactory functioning of individuals with ORS and address whether there is central nervous system or sensory dysfunction associated with the condition.

METHODS

In this preliminary investigation, 9 consecutive participants with ORS completed a structured clinical interview and neuropsychological and olfaction evaluations.

RESULTS

A proportion of individuals with ORS displayed deficits in aspects of cognitive functioning (i.e., processing speed, executive functioning, recognition memory bias for ORS-related words), olfaction functioning (i.e., odor detection and discrimination), and emotional processing.

CONCLUSIONS

Based on these preliminary findings of cognitive, olfaction, and emotional processing deficits in individuals with ORS, further neuropsychological and olfaction studies are needed that better characterize this understudied patient group and address this study's limitations.

Olfactory Reference Syndrome: A Case Report and Screening Tool

Olfactory reference syndrome (ORS) is a lesser known disorder that is related to obsessive-compulsive disorder. ORS is the obsessional and inaccurate belief that one is emitting a foul odor leading to embarrassment or concern about offending others, excessive hygiene behaviors, and social avoidance that significantly interferes with daily functioning. Although ORS is rare, it is challenging to diagnose. ORS-sufferers first seek treatment from non-psychiatric providers (e.g., dermatologists, dentists.) to alleviate the perceived odor, which frequently leads to misdiagnosis and unnecessary treatments. Additionally, because ORS-sufferers can have limited insight and ideas of reference, they can be misdiagnosed as having a psychotic or delusional disorder. We present a case report of a 42-year-old woman with ORS, and how the correct diagnosis of ORS provided with psychiatric treatment led to significant improvement in her daily functioning. We provide a literature review on the disorder as well as a short screener to assess ORS.

"Would you tell me If i smelled bad?," 14-year-old Dylan diagnosed with olfactory reference syndrome: A case report

TOPIC

Olfactory reference syndrome (ORS) is a psychiatric condition that is not known to many psychiatric providers and yet it is thought to be far more common than generally recognized. Symptoms of ORS are disruptive, debilitating, and can severely impair the daily functioning of patients dealing with it.

PURPOSE

This article provides an overview of ORS and explores how it can be mistaken for other diagnostic constellations. A case report that details the treatment of a 14-year-old male illustrates how a clinician employs a multimodal approach to address symptoms that overlap with other diagnoses to successfully treat a patient with ORS.

SOURCES

Existing literature on the treatment of ORS and obsessive-compulsive disorder in adults, adolescents, and children and the clinical experience of providing care to a 14-year-old patient in an outpatient setting.

CONCLUSIONS

Nurses and other healthcare providers should be made more aware of the symptoms, criteria, and diagnosis of ORS. Research needs to be increased to solidify ORS as a formal diagnosis and treatment recommendations are required to better treat this underserved population.

Diagnosis and phenotypic assessment of trimethylaminuria, and its treatment with riboflavin: 1H NMR spectroscopy and genetic testing

Background

Trimethylaminuria (TMAU) is a metabolic disorder characterized by the excessive excretion of the malodorous compound trimethylamine (TMA). The diagnosis of TMAU is challenging because this disorder is situated at the boundary between biochemistry and psychiatry. Here, we used nuclear magnetic resonance spectroscopy to assess TMAU in 13 patients. We also sequenced the FMO3 gene in 11 of these patients. Treatment with vitamin B2 was prescribed.

Results

Two patients (aged 3 and 9 years at the initial consultation) had a particularly unpleasant body odor, as assessed by their parents and the attending physicians. The presence of high urine TMA levels confirmed the presence of a metabolic disorder. The two (unrelated) children carried compound heterozygous variants in the FMO3 gene. In both cases, vitamin B2 administration decreased TMA excretion and reduced body odor. The 11 adults complained of an unpleasant body odor, but the physicians did not confirm this. In all adult patients, the urine TMA level was within the normal range reported for control (non-affected) subjects, although two of the patients displayed an abnormally high proportion of oxidized TMA. Seven of the 9 tested adult patients had a hypomorphic variant of the FMO3 gene; the variant was found in the homozygous state, in the heterozygous state or combined with another hypomorphic variant. All 11 adults presented a particular psychological or psychiatric phenotype, with a subjective perception of unpleasant odor.

Conclusions

The results present the clinical and biochemical data of patients complaining of unpleasant body odor. Contrary to adult patients, the two children exhibited all criteria of recessively inherited trimethylaminuria, suspected by parents in infancy. B2 vitamin treatment dramatically improved the unpleasant body odor and the ratio of TMA/Cr vs TMAO/Cr in the urine in the children. Other patients presented a particular psychological or psychiatric phenotype.

The Nose Knows… or Does it? Olfactory Reference Syndrome in Patients Presenting for Assessment of Unusual Body Odor

Olfactory reference syndrome (ORS) is a rarely diagnosed psychiatric disorder in which individuals falsely believe that they emit an offensive body odor. This retrospective cohort study characterizes the clinical and demographic features of 54 individuals who presented to a Canadian genetics clinic for query trimethylaminuria (TMAU), an inherited disorder in which a pungent fishy odor is produced. The majority (83%) were found to have a likely diagnosis of ORS and a high rate (73.3%) of concomitant psychiatric disorders; only two patients were diagnosed with TMAU. This study highlights the genetics clinic as an unexpected and major ascertainment point for ORS, and shows that ORS can be differentiated from TMAU by age of onset (~28 years), odor characterization (refuse-related), and the presence of associated comorbid psychiatric diagnoses. There is a low diagnostic rate of ORS, attesting to the need for improved education and awareness.

Treatments for smell and taste disorders: A critical review

A key concern of both the patient and physician is whether treatment is available that will eliminate or quell a given chemosensory disturbance. In cases where obvious oral, nasal, or intracranial pathology is involved, rational straightforward approaches to treatment are often available. In cases where damage to the sensory pathways is secondary to chronic inflammatory disease, trauma, viral invasion, toxic exposure, or unknown causes, the direction for therapy is more challenging. Indeed, many chemosensory disorders, if present for any period of time, cannot be reversed, while others spontaneously remit without any therapeutic intervention. This review assesses the strengths and weaknesses of more than two dozen approaches to treatment that have been suggested for a wide range of taste and smell disorders.

Olfactory reference syndrome symptoms in Chinese university students: Phenomenology, associated impairment, and clinical correlates

BACKGROUND

The present study aimed to explore the phenomenology, associated impairment, and clinical correlates of olfactory reference syndrome (ORS) symptoms in a Chinese university student sample, and establish estimated ORS prevalence.

METHODS

A total of 421 undergraduate students completed self-report measures assessing symptoms of ORS, obsessive-compulsive disorder, depression, anxiety, stress, taijin kyofushu, fear of negative evaluation, and ORS-related functional impairment.

RESULTS

Higher ORS symptom severity was moderately associated with poorer insight, greater avoidance, and higher ORS-related functional impairment. ORS severity was weakly associated with increased comorbid disorder symptoms, and was not associated with gender. Clinically significant ORS symptoms were present in 2.4% of the sample.

DISCUSSION

Collectively, these findings suggest that ORS symptoms are relatively distinct from other disorders in a non-clinical sample. Future studies are encouraged to further explore the phenomenology, etiology, neurobiology, and treatment of ORS in order to inform diagnosis and nosology.

Unterschiede und Gemeinsamkeiten zwischen Körperdysmorpher Störung und Olfaktorischer Referenzstörung

Zusammenfassung. Theorie: Die Körperdysmorphe Störung (KDS) und die Olfaktorische Referenzstörung (ORS) überschneiden sich nach klinischen Beobachtungen in verschiedenen Bereichen, ohne dass es bisher Untersuchungen hierzu gibt. Fragestellung: Unterscheiden sich Personen mit KDS oder ORS und eine psychisch gesunde Vergleichsgruppe in Hinblick auf soziale Ängste, wahnhafte Symptome, körperbezogene Emotionen und interpersonelle Probleme? Methode: Wir führten Interview- und Fragebogenerhebungen an n = 21 ORS-Betroffenen, n = 21 KDS-Betroffen und n = 21 gesunden Vergleichspersonen durch. Ergebnisse: Es existieren Gruppenunterschiede hinsichtlich sozialphobischer und wahnhafter Symptome, körperbezogener Emotionen und interpersoneller Probleme, wobei die KDS-Gruppe die höchsten Skalenmittelwerte erzielte. ORS-Betroffene berichteten häufiger von positiven körperbezogenen Emotionen als KDS-Betroffene. Schlussfolgerungen: Soziale Interaktionsangst und ein selbstunsicheres / unterwürfiges Interaktionsverhalten könnten für eine gemeinsame Grundlage beider Störungen sprechen. Die Unterschiede körperbezogener Emotionen könnten ein Unterscheidungsmerkmal sein.

Treatment utilization and barriers to treatment among individuals with olfactory reference syndrome (ORS)

OBJECTIVE

Olfactory reference syndrome (ORS) is characterized by a preoccupation that one is emitting a foul or offensive odor. Despite the profound psychosocial impact of ORS, many patients do not receive appropriate treatment, and there is no empirical research on treatment-seeking behavior in ORS. This study investigated treatment utilization patterns and barriers to treatment in individuals with ORS.

METHOD

253 subjects completed an online survey between January-March 2010. Data were obtained from the Yale-Brown Obsessive Compulsive Scale Modified for ORS (ORS-YBOCS), Depression Anxiety Stress Scales (DASS), Work and Social Adjustment Scale (WSAS), and questionnaires specific to treatment utilization and barriers.

RESULTS

The sample was ethnically diverse, predominately male (67%), with an average age of 33.7years, and moderately severe ORS symptoms. Most participants first sought care from a medical specialist (44%), and mental health services were underutilized (14%). Higher functional impairment was significantly correlated with seeking care from a mental health provider, compared to a medical specialist. Nearly all participants endorsed multiple barriers to treatment, including (a) logistical/financial, (b) stigma/discrimination, and (c) treatment perception barriers. ORS symptom severity was significantly, positively correlated with number of logistical/financial and stigma/discrimination barriers. Treatment barriers were significantly influenced by ethnic group, ORS symptom severity, and source of odor.

CONCLUSION

Results highlight the importance of increasing awareness and enhancing access to care for individuals with ORS.

Psychocutaneous disease: Clinical perspectives

Psychocutaneous disease, defined in this review as primary psychiatric disease with skin manifestations, is commonly encountered in dermatology. Dermatologists can play an important role in the management of psychocutaneous disease because patients visit dermatology for treatment of their skin problems but often refuse psychiatric intervention. This review describes common psychocutaneous syndromes, including delusional, factitious, obsessive-compulsive and related, and eating disorders, as well as psychogenic pruritus, cutaneous sensory (pain) syndromes, posttraumatic stress disorder, and sleep-wake disorders. The updated classification of these disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition is included. Strategies for management are reviewed.

Relationships between pathologic subjective halitosis, olfactory reference syndrome, and social anxiety in young Japanese women

BACKGROUND

Pathologic subjective halitosis is known as a halitosis complaint without objective confirmation of halitosis by others or by halitometer measurements; it has been reported to be associated with social anxiety disorder. Olfactory reference syndrome is a preoccupation with the false belief that one emits a foul and offensive body odor. Generally, patients with olfactory reference syndrome are concerned with multiple body parts. However, the mouth is known to be the most common source of body odor for those with olfactory reference syndrome, which could imply that the two conditions share similar features. Therefore, we investigated potential causal relationships among pathologic subjective halitosis, olfactory reference syndrome, social anxiety, and preoccupations with body part odors.

METHODS

A total of 1360 female students (mean age 19.6 ± 1.1 years) answered a self-administered questionnaire regarding pathologic subjective halitosis, olfactory reference syndrome, social anxiety, and preoccupation with odors of body parts such as mouth, body, armpits, and feet. The scale for pathologic subjective halitosis followed that developed by Tsunoda et al.; participants were divided into three groups based on their scores (i.e., levels of pathologic subjective halitosis). A Bayesian network was used to analyze causal relationships between pathologic subjective halitosis, olfactory reference syndrome, social anxiety, and preoccupations with body part odors.

RESULTS

We found statistically significant differences in the results for olfactory reference syndrome and social anxiety among the various levels of pathologic subjective halitosis (P < 0.001). Residual analyses indicated that students with severe levels of pathologic subjective halitosis showed greater preoccupations with mouth and body odors (P < 0.05). Bayesian network analysis showed that social anxiety directly influenced pathologic subjective halitosis and olfactory reference syndrome. Preoccupations with mouth and body odors also influenced pathologic subjective halitosis.

CONCLUSIONS

Social anxiety may be a causal factor of pathologic subjective halitosis and olfactory reference syndrome.

Sniffing out olfactory reference syndrome

Olfactory reference syndrome is characterised by the erroneous belief that one emits an unpleasant body odour. This results in significant distress and is often accompanied by repetitive behaviour such as frequent showering in an attempt to camouflage the perceived odour. The body odour concerns may have a delusional quality and do not respond to simple reassurance or counterexample. Herein, we report the case of an olfactory reference disorder (ORD) patient who had received multiple medical interventions and undergone polysurgery prior to an accurate diagnosis being established. ORD may lead to significant disability, yet often goes unrecognised for many years. For many patients, poor insight will contribute to their reluctance to consider psychiatric treatment. This case demonstrated that a multimodal treatment approach comprising judicious medication use, combined with cognitive behavioural therapy, in the context of a therapeutic alliance yielded therapeutic success.

Obsessive compulsive and related disorders: comparing DSM-5 and ICD-11

Obsessive-compulsive disorder (OCD) has been recognized as mainly characterized by compulsivity rather than anxiety and, therefore, was removed from the anxiety disorders chapter and given its own in both the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the Beta Draft Version of the 11th revision of the World Health Organization (WHO) International Classification of Diseases (ICD-11). This revised clustering is based on increasing evidence of common affected neurocircuits between disorders, differently from previous classification systems based on interrater agreement. In this article, we focus on the classification of obsessive-compulsive and related disorders (OCRDs), examining the differences in approach adopted by these 2 nosological systems, with particular attention to the proposed changes in the forthcoming ICD-11. At this stage, notable differences in the ICD classification are emerging from the previous revision, apparently converging toward a reformulation of OCRDs that is closer to the DSM-5.

Psychosomatic problems in dentistry

Many dental patients complain of oral symptoms after dental treatment, such as chronic pain or occlusal discomfort, for which the cause remains undetermined. These symptoms are often thought to be mental or emotional in origin, and patients are considered to have an "oral psychosomatic disorder". Representative medically unexplained oral symptoms/syndromes (MUOS) include burning mouth syndrome, atypical odontalgia, phantom bite syndrome, oral cenesthopathy, or halitophobia. With an increasing prevalence of these MUOS, dentists are being asked to develop new approaches to dental treatment, which include taking care of not only the patient's teeth but also the patient's suffering. Progress in the understanding of mind-body interactions will lead to investigations on the pathophysiology of MUOS and the development of new therapeutic approaches.

Diagnosis of Human Axillary Osmidrosis by Genotyping of the Human ABCC11 Gene: Clinical Practice and Basic Scientific Evidence

The importance of personalized medicine and healthcare is becoming increasingly recognized. Genetic polymorphisms associated with potential risks of various human genetic diseases as well as drug-induced adverse reactions have recently been well studied, and their underlying molecular mechanisms are being uncovered by functional genomics as well as genome-wide association studies. Knowledge of certain genetic polymorphisms is clinically important for our understanding of interindividual differences in drug response and/or disease risk. As such evidence accumulates, new clinical applications and practices are needed. In this context, the development of new technologies for simple, fast, accurate, and cost-effective genotyping is imperative. Here, we describe a simple isothermal genotyping method capable of detecting single nucleotide polymorphisms (SNPs) in the human ATP-binding cassette (ABC) transporter ABCC11 gene and its application to the clinical diagnosis of axillary osmidrosis. We have recently reported that axillary osmidrosis is linked with one SNP 538G>A in the ABCC11 gene. Our molecular biological and biochemical studies have revealed that this SNP greatly affects the protein expression level and the function of ABCC11. In this review, we highlight the clinical relevance and importance of this diagnostic strategy in axillary osmidrosis therapy.

The classification of Obsessive-Compulsive and Related Disorders in the ICD-11

BACKGROUND

To present the rationale for the new Obsessive-Compulsive and Related Disorders (OCRD) grouping in the Mental and Behavioural Disorders chapter of the Eleventh Revision of the World Health Organization's International Classification of Diseases and Related Health Problems (ICD-11), including the conceptualization and essential features of disorders in this grouping.

METHODS

Review of the recommendations of the ICD-11 Working Group on the Classification for OCRD. These sought to maximize clinical utility, global applicability, and scientific validity.

RESULTS

The rationale for the grouping is based on common clinical features of included disorders including repetitive unwanted thoughts and associated behaviours, and is supported by emerging evidence from imaging, neurochemical, and genetic studies. The proposed grouping includes obsessive-compulsive disorder, body dysmorphic disorder, hypochondriasis, olfactory reference disorder, and hoarding disorder. Body-focused repetitive behaviour disorders, including trichotillomania and excoriation disorder are also included. Tourette disorder, a neurological disorder in ICD-11, and personality disorder with anankastic features, a personality disorder in ICD-11, are recommended for cross-referencing.

LIMITATIONS

Alternative nosological conceptualizations have been described in the literature and have some merit and empirical basis. Further work is needed to determine whether the proposed ICD-11 OCRD grouping and diagnostic guidelines are mostly likely to achieve the goals of maximizing clinical utility and global applicability.

CONCLUSION

It is anticipated that creation of an OCRD grouping will contribute to accurate identification and appropriate treatment of affected patients as well as research efforts aimed at improving our understanding of the prevalence, assessment, and management of its constituent disorders.

Clinical features of olfactory reference syndrome: An internet-based study

OBJECTIVE

Preoccupation with perceived bodily odor has been described in neuropsychiatric disorders for more than a century; however, empirical research on olfactory reference syndrome (ORS) is scarce. This study investigated the phenomenology of ORS in a broadly ascertained, diverse sample.

METHOD

Data were obtained from 253 subjects in an internet-based survey that operated from January - March 2010. Measures included the Yale-Brown Obsessive Compulsive Scale Modified for ORS (ORS-YBOCS), Work and Social Adjustment Scale (WSAS), Depression Anxiety Stress Scales (DASS), and symptom specific questionnaires developed for this study.

RESULTS

Individuals reported, on average, moderately severe ORS symptoms. The average age of onset of ORS symptoms was 21.1 years, with 54% reporting a chronic, unremitting course. Individuals endorsed a lifetime average of two malodorous preoccupations, most commonly stool, garbage, and ammonia. Odors were most often reported to emanate from the armpits, feet, and breasts. Nearly all participants engaged in time-consuming rituals to try to hide or fix their perceived malodor (e.g., checking and camouflaging). Eighteen percent reported poor or delusional insight and 64.0% reported ideas or delusions of reference. More severe ORS symptoms were moderately associated with female gender, poorer insight, and higher levels of impairment (in work, social leisure, ability to maintain close relationships, and consecutive days housebound).

CONCLUSION

This is the largest study on ORS to date. Results underscore the clinical significance and psychosocial impact of this understudied disorder, and highlight the need for subsequent research to examine clinical features and inform treatment.

Olfactory Reference Disorder: Diagnosis, Epidemiology and Management

Although not included as a disorder in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), olfactory reference disorder (ORD) is being considered for inclusion as a discrete disorder in the ICD-11 (International Classification of Diseases, 11th edition). ORD is likely underdiagnosed and undertreated. The purpose of this paper is to provide information to clinicians and researchers on the epidemiology, clinical presentation and treatment options for this condition. A narrative overview of the literature as retrieved from a computerized database search is provided. ORD is a condition that is characterized by the erroneous belief that one emits a foul or unpleasant body odour, resulting in significant distress and impairment. It is often accompanied by referential thinking and repetitive behaviours aimed at camouflaging the perceived odour. Level of insight varies, with some patients having concerns that are delusional. Patients usually do not spontaneously report their symptoms and so screening in suspected cases is crucial. The literature regarding ORD treatment remains limited.

Jikoshu-kyofu in Singapore

OBJECTIVE

Jikoshu-kyofu (JKF), a condition characterised by a fear of offending others through emitting foul body odour, was first described in Japan in the 1960s. Although initially thought to be a culture-bound syndrome, it has been described in other countries. It is well established that there are two variants, a non- delusional and a delusional variant.

METHOD

We describe two cases of JKF who sought treatment from a hospital in Singapore, compare and contrast their characteristics, and in view of overlaps with other conditions, discuss differential diagnoses.

RESULTS

Both cases involved women with fairly similar symptomatology except that the first case was younger, had overvalued ideas (but not delusions), an earlier age of onset and good treatment response, while the other had delusions, late age of onset, became too distressed to continue working and was initially resistant to treatment.

CONCLUSION

It appears that the delusional variant may have a longer symptomatic duration before presentation, poorer insight, more resistance to treatment and multiple physician consultations, as well as greater impairment of socio-occupational functioning in contrast to the non-delusional variant.

Olfactory reference syndrome: a still open nosological and treatment debate

OBJECTIVE

The objective was to report a case of olfactory reference syndrome (ORS) with several co-occurring disorders and to discuss ORS differential diagnoses, diagnostic criteria and classification.

METHOD

Case report.

RESULTS

A 37-year-old married woman presented overvalued ideas of having bad breath since adolescence. She met current diagnostic criteria for social anxiety disorder, specific phobia, obsessive-compulsive disorder, generalized anxiety disorder, body dysmorphic disorder and major depressive disorder. ORS similarities and differences with some related disorders are discussed.

CONCLUSION

Further studies regarding symptoms, biomarkers and outcomes are needed to fully disentangle ORS from existing depressive, anxiety and obsessive-compulsive spectrum disorders.

Halitosis management by the general dental practitioner--results of an international consensus workshop

Clinical investigations on patients suffering from halitosis clearly reveal that in the vast majority of cases the source for an offensive breath odor can be found within the oral cavity (90%). Based on these studies, the main sources for intra-oral halitosis where tongue coating, gingivitis/periodontitis or a combination of the two. Thus, it is perfectly logical that general dental practitioners (GDPs) should be able to manage intra-oral halitosis under the conditions found in a normal dental practice. However, GDPs who are interested in diagnosing and treating halitosis are challenged to incorporate scientifically based strategies for use in their clinics. Therefore, the present paper summarizes the results of a consensus workshop of international authorities held with the aim to reach a consensus on general guidelines on how to assess and diagnose patients' breath odor concerns and general guidelines on regimens for the treatment of halitosis.

Unnecessary surgical treatment in a case of olfactory reference syndrome

We present a case of olfactory reference syndrome (ORS) with complaints of bromhidrosis. This patient underwent a lumbar sympathectomy to correct the imagined body odor problem. The patient reported experiencing an improvement after surgery, but later, the olfactory symptoms returned. The main objective with ORS patients should be to begin psychiatric treatment early. Other treatments usually appear to be ineffective and cause great dissatisfaction.

Delusional disorder, somatic type: olfactory reference syndrome in a patient with delusional trimethylaminuria

Delusions of foul body odors (often referred to as olfactory reference syndrome [ORS]) currently fall under the category of delusional disorder, somatic type (DDST), in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). We present the case of a 51-year-old man with no previous psychiatric history who presented with perceived foul odors that he delusionally attributed to trimethylaminuria (TMAU). TMAU is a rare metabolic disorder associated with foul body odors. The patient also experienced severe concurrent mood symptoms because of social isolation resulting from his delusion about his body odors. After considerable discussion of differential diagnoses, a diagnosis of DDST was ultimately made, given the patient's unrelenting nonbizarre delusions and lack of insight pertaining to his body odors. However, this case proved to be very useful in exploring the diagnostic challenges in this type of disorder and recent discussions of ORS and its proposed inclusion in the DSM-5.

Considerações sobre a clínica e o tratamento de uma manifestação incomum do transtorno dismórfico corporal: a síndrome de referência olfatória

Neste relato, descreve-se o caso de um rapaz de 23 anos que apresentava a crença de exalar um odor desagradável proveniente da transpiração e acreditava que incomodava as outras pessoas. O paciente foi medicado com amissulprida associada a técnicas de terapia cognitivo-comportamental (TCC), tendo havido acentuada melhora do quadro clínico. Foram abordados aspectos relativos à nosologia e às manifestações clínicas da síndrome de referência olfatória (SRO), e o seu tratamento foi discutido. Observou-se que experimentos comportamentais envolvendo exposição com desafio às crenças delirantes podem ser úteis no tratamento desse transtorno e que os antipsicóticos, particularmente a amissulprida, podem ser uma boa alternativa aos inibidores de recaptação da serotonina (IRSs) no tratamento da SRO.