Psychiatrists meeting this week in New Orleans at their annual confab got a first look at a largely unresearched patient population beset with a deeply distressing delusion: that they smell bad -- really bad.
Patients with the proposed diagnosis of "olfactory reference disorder" (sometimes referred to as a "syndrome") are certain beyond doubt that they stink, when in fact they smell no worse than is average for a 21st century American. According to Dr. Katharine Phillips, director of Rhode Island Hospital's Body Image Program, four in 10 people who likely have the disorder have sought out medical treatments for what they believe to be bad breath, foul body odor, stinky feet or residual fecal or urine smell. Their worry preoccupies them for between three and eight hours a day, on average, and impels patients to shower for hours, consume bars of soap or gallons of mouthwash in a single day -- even to drink perfume in an effort to eradicate the imagined smell.
A slight majority -- 60% -- of sufferers appear to be women, Phillips told her colleagues, and most began to suspect that they emitted foul odors at around 15 to 16 years of age.
For people afflicted with this delusion, social situations can be a gantlet of shame and self-consciousness, said Phillips: When people with whom they come into contact innocently scratch their noses or a stray allergen causes someone to sniff, people with this unique bodily delusion report they feel certain it is in response to their own foul body odor. Another person's move to open a window or door in a stuffy room will fill such a patient with fear that he or she has stunk up the place. When they confide their fears to others and are assured they smell perfectly fine, these patients do not believe it: They suspect a friend is just being nice or has a poor sense of smell, Phillips said.
Not surprisingly, 40% report they have remained housebound for at least a week out of fear of offending others. Two-thirds have contemplated suicide, and a third have attempted it, Phillips reported. The vast majority suffer from depression or some other mental disorder, and substance abuse -- possibly an effort to "self-medicate," according to Phillips -- is common.
"I'm just so struck by the incredible distress they're feeling, the incredible sense of social ostracism," Phillips said.
Is it real -- not the body odor, but the psychiatric disorder? That is something psychiatrists will likely begin to explore over the next decade: The American Psychiatric Assn. has proposed adding "olfactory reference disorder" to the appendix of the Diagnostic and Statistic Manual (DSM) V as an entity worthy of further research and consideration. Among the many questions that must be explored before the nation's psychiatrists would consider conferring on "olfactory reference disorder" the full status of a diagnosable disease: How widespread are these symptoms in the general population? How impairing is it? How does it start and manifest itself over a patient's life? Are these symptoms more closely related to compulsive behavior, depression, body dysmorphia? And what therapies does it respond to?
On this last point, Phillips said there is early evidence that cognitive behavioral therapy -- a form of "talk therapy" that is narrowly focused on problematic behavior and the thought processes that contribute to it -- can be helpful to some sufferers. She said antidepressants that are in wide use -- known as SSRIs -- may help some as well.
An article in the Journal of Family Pracitice is a good overview of the condition. If you think you may suffer from this, you could take this test. For a Los Angeles-based treatment program, see here.
-- Melissa Healy
[Updated at 12:15 p.m.: An earlier version of this post incorrectly stated the number of people who have sought out medical treatments for "olfactory reference disorder."]