Olfactory Reference Syndrome: Characteristics, Causes, & Treatment

What Is Olfactory Reference Syndrome?

Olfactory reference syndrome (ORS) is when someone has a preoccupation, sometimes to the point of obsession, about being worried about omitting an unpleasant smell such as bad breath or underarm odor that are undetected by others.¹ While some people have obsessive thoughts about more than one potential source of body odor, most people with ORS tend to have one or two main obsessions, such as worrying about bad breath.

ORS is often thought of as a type of obsessive compulsive disorder (OCD)² due to the obsessive thoughts and the behaviors that come with ORS. Many people engage in repeated compulsions such as frequent showering or bathing in an attempt to limit any perceived body odor.³ However, it is also linked closely with body dysmorphic disorder as well as anxiety or specific phobias.

Symptoms of Olfactory Reference Syndrome

Along with obsessive thoughts, many people have referential thinking, which is when they interpret random behaviors, such as observing someone turn their head, or someone sitting across the room instead of in the chair next to them, as evidence of their body odor.⁴ However, it is important to note that insight is usually limited in these cases, as people assume that others can smell things that they usually can’t.⁵

Common obsessions in olfactory reference syndrome include:

• I have such bad breath, and every time I talk to someone, they notice and are repulsed
• My underarms have a bad smell so people don’t want to sit next to me
• I have smelly feet that are noticeable to others
• My genitals are omitting a bad smell
• My hair is oily and smelly, so I have to shampoo it twice daily
• I have a bad smell coming from my skin
• I have a strong flatulence smell that bothers others

 Common compulsions in olfactory reference syndrome OCD include:

• Repeatedly showering
• Repeatedly applying perfume or deodorant
• Using hand sanitizer or lotion to mask any perceived smells
• Asking for reassurance
• Frequently changing clothes
• Not sitting close to others
• Using gum to mask bad breath
• Frequent teeth brushing

What Triggers A Fear of Smelling Bad?

Certain circumstances and situations may trigger a fear of smelling bad, often due to the person’s already present concerns, coupled with referential thinking. Being around a stressor, such as others who are reporting that they are sweating during a hot and muggy day, can intensify obsessions or compulsions due to concerns of one’s body odor.

Common triggers for olfactory reference syndrome include:

• Overhearing someone talk about their own coffee breath
• Someone sniffing audibly as if they smell an odor
• Someone looking around them as if searching for the source of an odor
• Listening to someone else talk about being sweaty
• Someone rubbing or covering their nose
• Exercising and being sweaty
• Having to skip a shower due to being late

Possible Causes of Olfactory Reference Syndrome

There are a few different factors that might cause ORS, from having a family history of OCD or other mental health conditions, to physical factors such as a traumatic head injury.

Possible causes of olfactory reference syndrome include:

• Family history: Having a family history of OCD or other mental health conditions can influence the onset.
• Trauma history: A history of being bullied or shamed can leave survivors with an overwhelming feeling that something is defective or wrong, such as having a bad odor.
• Having a head trauma or cognitive decline: A traumatic brain injury, or other factors that influence the person cognitively can sometimes be a precursor to ORS.⁶
• Aging and cognitive decline: Smell and taste disorders are more common as we age, and can sometimes be a sign of dementia or another cognitive disorder.⁶
• Schizophrenia: As olfactory hallucinations are one of the signs of schizophrenia, a differential diagnosis must be considered if other symptoms of schizophrenia are present.⁷

Impacts of the Fear of Smelling Bad

Not surprisingly, there are many impacts of living with a fear of smelling bad. Many people who struggle with OFS isolate themselves from others due to their fears, which reduces social connection and support. This can lead to feelings of depression and/or social anxiety, or even suicidal thoughts.⁵

How Is Olfactory Reference Syndrome Diagnosed?

Like all mental health or clinical disorders, ORS is diagnosed by a licensed mental health professional such as a licensed therapist or a psychiatrist. The Diagnostic and Statistical Manual for Mental Disorders (DSM V) does not identify Olfactory Reference Syndrome specifically.⁷ However, it lists olfactory concerns under different areas such as delusional disorders.⁷

Questions to ask your doctor about olfactory reference syndrome include:

• I have some concerns about my body odor that I would like to discuss with you
• Where can I find specialized olfactory reference syndrome treatment?
• What are the recommendations you have to help me with these concerns?
• What does a typical treatment plan look like?

Treatment for Olfactory Reference Syndrome

The treatment process for ORS is similar to OCD treatment, in that a combination of medication management and behavioral or therapeutic practices have been found to be helpful. However, since most people with ORS have been found to be delusional,⁸ medication is often recommended by physicians.

Treatment options for OCD include:

• Exposure response therapy (ERP): Exposure therapy for OCD is a process where people are exposed to triggers gradually in order to help desensitize them and hopefully decrease compulsive behaviors.
• Medications: Depending on the reason behind the symptoms of ORS, such as whether they are due to self esteem issues or a delusional disorder, medications have been found to be helpful. If the ORS is due to symptoms of depression or anxiety, medication such as SSRIs, or Selective Serotonin Reuptake Inhibitors, have been found to be helpful.⁸ For patients whose ORS is due to a delusional disorder, an antipsychotic is sometimes recommended, or even a combination therapy where a combination of antidepressant and antipsychotic.⁸
• Cognitive Behavioral Therapy: CBT for OCD and olfactory reference syndrome is a technique that helps people learn how their thoughts affect their behaviors, and for learning ways to reduce or stop these negative thoughts.
• Dialectical Behavioral Therapy: Dialectical behavior therapy (DBT) focuses on helping people decrease the intensity and severity of emotional reactions to stressful situations, and can be a tool for those who suffer from ORS who have capacity for insight.
• Therapy for body dysmorphia: Researchers who study ORS recommend treatment that is along the lines of treatment used for body dysmorphia. “It may be helpful, for example, to focus on the distress and disability caused by the odor preoccupation, rather than on whether the patient actually smells bad.”⁷
• Group therapy: Because many with ORS tend to isolate due to their symptoms, group therapy can be a great tool both due to the social element as well as the therapeutic aspect. Look for an online group if there are none in your area.

8 Tips for Coping With the Fear of Smelling Bad

There are a few different ways that a person can cope with the effects of the fear of smelling bad. Along with developing increased insight into how this condition manifests, maintaining healthy coping mechanisms is essential.

Here are 8 tips for coping with olfactory reference syndrome:

• Check the facts: This is a common dialectical behavior therapy (DBT) skill used to help people decrease the anxious thoughts that can spiral out of control. It can help someone with ORS by prompting them to consider the facts. For example, if you are worried that your underarms smell, but you know you just applied deodorant, it can be useful to consider this fact and the logic behind it to conclude that you do not smell.
• Increase coping skills: As with any mental health condition, increasing self care and coping skills can help decrease symptoms of depression and anxiety. Make sure to take time to do activities you enjoy, such as taking solo hikes or getting a pedicure, or simply reading a book that you enjoy.
• Improve self awareness: Many people benefit from improving self awareness, such as recognizing that you tend to assume you smell when you actually do not, which causes obsessive thoughts.
• Increase education about ORS: By learning more about this condition, you can help empower yourself to understand what is going on. This may help you decrease some of the resulting symptoms.
• Normalize body odor: None of us smell perfectly all the time! By normalizing the fact that our bodies sometimes have unpleasant smells, it can help you increase comfort and decrease anxiety. For example, one study examined a patient who was instructed to pass gas as soon as their body recognized the sensation, which helped them to decrease the obsession that they constantly smelled like flatulence.⁸
• Seek ORS knowledgeable therapists: It is important to find a treatment provider who understands ORS, who can help you determine the cause of your condition. A therapist who has experience with ORS will understand your symptoms rather than pathologizing or judging.
• Inform friends and family: By informing others in your social circle of your condition of living with ORS, you can give them insight into why you may behave in certain ways.
• Remain medication compliant: If you were prescribed medications by your doctor such as antidepressants or antipsychotics, make sure to take them as prescribed. Skipping doses or stopping altogether can make your symptoms return or increase.

When to Seek Professional Support

Symptoms of olfactory reference syndrome can be troubling, but there are many online OCD resources that can help, including therapy, apps, and support groups. If you are looking for support for obsessive thoughts about your body or body odor, consider finding a therapist to help. An online therapist directory can be a helpful resource for finding therapists who are licensed in your area who specialize in OCD, or you can use  the NOCD online therapy platform which specializes in OCD treatment. If needed, online psychiatrist options are a good choice for finding OCD medication management.