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Patients with olfactory reference disorder are preoccupied, usually for many hours a day, with a distressing or impairing belief that they emit one or more foul or offensive body odors, which are not perceived by others or are actually only slight. They may believe, for example, that they have very bad breath or emit foul-smelling sweat from their armpits or other areas of their skin. Other worries include emitting a smell of urine, flatulence, or unpleasant odors from the genital area. Occasional patients believe that they emit foul odors like garbage or rotten food.

The preoccupation with body odor is usually accompanied by repetitive behaviors (eg, smelling themselves, excessive showering, changing clothes, reassurance seeking); these behaviors attempt to alleviate the substantial distress caused by the preoccupation with body odor. Most people with olfactory reference disorder also make efforts to camouflage the perceived odor (eg, with perfume, deodorant, mouthwash, gum).

Insight is usually poor or absent (ie, most people think that they probably or definitely emit a foul body odor when this is actually not the case). Very few recognize that their belief about the body odor is inaccurate, possibly because many people with olfactory reference disorder report that they actually smell the odor themselves. A seizure disorder such as temporal lobe epilepsy should be considered and ruled out if presenting symptoms suggest that this disorder may be present.

Referential thinking is common; for example, patients may inaccurately believe that their body odor is the reason people are sitting far away from them, opening a window, or touching their nose.

Olfactory reference disorder usually substantially impairs functioning, and patients typically avoid social situations, often because they feel so embarrassed and ashamed about smelling bad. Many also avoid work or other important life activities. Some patients are completely housebound because they feel too distressed, self-conscious, and embarrassed about the perceived odor to be around other people, or because they fear that their body odor will be offensive to others. In very severe cases, olfactory reference disorder is incapacitating.

Athough data are limited, rates of suicidality appear high (1).

Because insight is usually poor or absent, many patients seek treatment (eg, tonsillectomy for perceived halitosis, proctectomy [anus removal] for perceived anal/flatulence odor) from clinicians other than psychiatrists, which does not appear to be helpful.

• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria

Core symptoms for olfactory reference disorder typically include the following:

• Patient's preoccupation with emitting foul or unpleasant body odor(s) that is not perceived by others or is considered only slight

• The preoccupation causes significant distress or impairment in social, occupational, or other areas of functioning

• Performance of repetitive behaviors (eg, smelling oneself to check for body odor, excessive showering or clothes changing) in response to the odor concerns and/or attempts to camouflage the perceived odor

• Selective serotonin reuptake inhibitors (SSRIs) or clomipramine

• Antipsychotic agent (usually atypical)

• Cognitive-behavioral therapy

Treatment studies of olfactory reference syndrome are limited mostly to case reports and small case series. However, clinical experience and available evidence suggest that SSRIs or clomipramine, alone or used with an antipsychotic (an atypical is preferred) if needed, and cognitive-behavioral therapy similar to therapy for body dysmorphic disorder may be helpful (1–3).