Olfactory reference disorder

Essential (Required) Features:

• Persistent preoccupation about emitting a foul or offensive body odour or breath (i.e., halitosis) that is either unnoticeable or slightly noticeable to others such that the individual’s concerns are markedly disproportionate to the smell, if any is perceptible.
• Excessive self-consciousness about the perceived odour, often including ideas of self-reference (i.e., the conviction that people are taking notice, judging, or talking about the odour).
• The preoccupation or self-consciousness is accompanied by any of the following:
• Repetitive and excessive behaviours, such as repeatedly checking for body odour or checking the perceived source of the smell (e.g., clothing), or repeatedly seeking reassurance;
• Excessive attempts to camouflage, alter, or prevent the perceived odour (e.g., using perfume or deodorant, repetitive bathing, brushing teeth, or changing clothing, avoidance of certain foods);
• Marked avoidance of social or other situations or stimuli that increase distress about the perceived foul or offensive odour (e.g., public transportation or other situations of close proximity to other people).
• The symptoms are not a manifestation of another medical condition and are not due to the effects of a substance or medication on the central nervous system, including withdrawal effects.
• The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Insight specifiers:

Individuals with Olfactory Reference Disorder vary in the degree of insight they have about the accuracy of the beliefs that underlie their symptoms. Although many can acknowledge that their thoughts or behaviours are untrue or excessive, some cannot, and the beliefs of some individuals with Olfactory Reference Disorder may at times appear to be delusional in the degree of conviction or fixity with which these beliefs are held (e.g., an individual is convinced that she is emitting a foul odour). Insight may vary substantially even over short periods of time, for example depending on the level of current anxiety or distress, and should be assessed with respect to a time period that is sufficient to allow for such fluctuation (e.g., a few days or a week). The degree of insight that an individual exhibits in the context of Olfactory Reference Disorder can be specified as follows:

6B22.0 Olfactory Reference Disorder with fair to good insight

• Much of the time, the individual is able to entertain the possibility that their disorder-specific beliefs may not be true and they are willing to accept an alternative explanation for their experience. This specifier level may still be applied if, at circumscribed times (e.g., when highly anxious), the individual demonstrates no insight.

6B22.1 Olfactory Reference Disorder with poor to absent insight

• Most or all of the time, the individual is convinced that the disorder-specific beliefs are true and they cannot accept an alternative explanation for their experience. The lack of insight exhibited by the individual does not vary markedly as a function of anxiety level.

6B22.Z Olfactory Reference Disorder, unspecified

Additional Clinical Features:

• The diagnosis of Olfactory Reference Disorder partly depends on determining whether there is evidence of the odour reported by the individual. A variety of other medical and dental conditions can be associated with unpleasant odours (e.g., periodontal disease, trimethylaminuria), and these underlying causes should be ruled out, particularly if the odour is detectable even if slight. However, the perceived odour may vary in intensity or the individual may be unable or unwilling to remove camouflaging odours (e.g., perfume), which may make it difficult to judge how noticeable the odour is. In such cases corroborative evidence may be required from a knowledgeable informant or physician who has conducted a physical examination of the individual.

Boundary with Normality (Threshold):

• Fear of emitting offensive odours is, to some extent, common in many cultures. However Olfactory Reference Disorder can be differentiated from normal concerns by the degree of preoccupation, frequency of related recurrent behaviours performed, as well as the degree of distress or interference the individual experiences as a consequence of these symptoms.

Course Features:

• Onset of Olfactory Reference Disorder is most often reported as occurring during the mid-twenties; however, onset during puberty or adolescence is also common.
• Olfactory Reference Disorder is generally considered a chronic and persistent disorder with a potential worsening over time.
• Embarrassment and shame, in conjunction with limited insight and false beliefs that may be delusional in intensity, may lead to underreporting of concerns related to perceived body odour in clinical settings.
• Individuals with Olfactory Reference Disorders often consult non-mental health services on multiple occasions (i.e., medical, surgical, dental specialists) about their perceived odour prior to receiving a diagnosis.

Developmental Presentations:

• Developmentally distinct presentations of Olfactory Reference Disorder for children, adolescents, or older adults have not been reported.

Culture-Related Features:

• Within more collectivistic cultures, or cultures that emphasize shame, the nature of the concern about bodily odour may be focused around fears of causing offense to others.
• Cultural concepts related to Olfactory Reference Disorder include taijin kyofusho in Japan and related conditions in Korea and other societies. They are characterized by intense fear of offending, embarrassing or hurting others through improper or awkward social behaviour, movements, or appearance. If the concerns focus specifically on body odour, Olfactory Reference Disorder is the appropriate ICD-11 diagnosis. In these cases, insight is typically poor to absent.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Obsessive-Compulsive Disorder: Recurrent thoughts and repetitive behaviours occur in Obsessive-Compulsive Disorder. However, in Olfactory Reference Disorder, the intrusive thoughts and repetitive behaviours are limited to concerns about body or breath odour. If obsessive thoughts and compulsive behaviours are not restricted to concerns about emitting a smell, both disorders can be diagnosed.
• Boundary with Delusional Disorder and other Primary Psychotic Disorders: Many individuals with Olfactory Reference Disorder lack insight about the irrationality of their thoughts and behaviours to such an extent that convictions that they are emitting a foul odour may at times appear to be delusional in the degree of conviction or fixity with which these beliefs are held (see Insight specifiers, page __). If these beliefs are restricted to the fear or conviction of emitting a foul odour in an individual without a history of other delusions, that is, these beliefs occur entirely in the context of symptomatic episodes of Olfactory Reference Disorder and are fully consistent with the other clinical features or the disorder, Olfactory Reference Disorder should be diagnosed instead of Delusional Disorder. Individuals with Olfactory Reference Disorder do not exhibit other features of psychosis (e.g., hallucinations or formal thought disorder).
• Boundary with Mood Disorders: In Depressive Disorders with psychotic symptoms, somatic delusions related to a perceived odour can occur (e.g., that their flesh is rotting and smells fetid), but typically are an integral part of a range of preoccupations or delusions (e.g., related to guilt, nihilism, poverty, etc.) and occur alongside other depressive symptoms (e.g., loss of interest in pleasurable activities, suicidality, sleep disturbances, weight loss or gain, etc.). However, both disorders may co-occur and both diagnoses may be assigned if warranted.
• Boundary with Social Anxiety Disorder: Individuals with Olfactory Reference Disorder may avoid social situations specifically because they believe they are emitting a foul odour. In contrast, in Social Anxiety Disorder, social situations are avoided because the individual is concerned that he or she will act in a way, or show anxiety symptoms, that will be negatively evaluated by others (i.e., be humiliating, embarrassing, lead to rejection, or be offensive).