What is Olfactory Reference Disorder?
Olfactory reference disorder (ORD) is a brain-related condition in which a person believes they persistently emit some kind of foul order when, in reality, there is no odor present. As a result, a person with ORD often engages in repetitive behaviors such as smelling themselves, showering, or changing clothes to try to rid themselves of the odor. The disorder may also be called olfactory reference syndrome.
The symptoms of ORD cause significant distress or impair the person’s ability to function socially.
Symptoms of ORD
Symptoms of ORD can include:
- The inaccurate perception that the person is emitting an unpleasant odor, such as bad breath, armpit sweat, flatulence, urine, genital odor, or odors resembling rotten food
- Engaging in repetitive behaviors such as showering, changing or washing clothes, smelling themselves, or seeking reassurance from others about the smell
- Using methods such as deodorant, mouthwash, or chewing gum to try to mask the odors
- Believing that other people are avoiding them because of odors
- Avoiding social situations because of shame
ORD and Insight
In many disorders where people engage in repetitive behaviors, they may understand that their perceptions are not real and their behaviors are unusual. People with ORD are less likely to understand the odors they perceive don’t exist, a condition that doctors call a lack of insight. People with ORD tend to strongly believe the odors are real and may seek unnecessary medical treatment to make them stop.
What Causes Olfactory Reference Disorder?
Doctors and researchers have not yet determined the exact causes of ORD, but some risk factors may increase an individual’s likelihood of developing the disorder. In particular, in the past, many people with ORD have experienced trauma associated with odor, such as being bullied or called out for having an unpleasant odor. Some scientists believe the misperceptions of ORD are a reaction to these situations. In addition, other types of trauma, including abuse, violence, or loss of a loved one, may play a role in some cases.
Is Olfactory Reference Disorder Hereditary?
Research into the genetic basis of ORD is incomplete, and there is little evidence so far to suggest that the disorder runs in families. However, some research has suggested the disorder may be more common in people with a family history of certain mental health-related issues, such as schizophrenia, obsessive-compulsive disorder (OCD), or anxiety.
How Is Olfactory Reference Disorder Detected?
Because the onset of BFRB disorder often occurs in childhood or adolescence, detecting the early signs of the disorder often falls on parents. In most cases, BFRBs are not serious enough to cause significant problems. The behaviors will become so severe in some cases that they interfere with a child’s functioning. However, the symptoms may be subtle at first.
Potential warning signs of ORD include:
- Avoidance of social situations
- Excessive showering or changing clothes
- Excessive use of deodorant or mouthwash
- Avoidance of close relationships
- Poor performance at school
- Use of alcohol or drugs
How Is Olfactory Reference Disorder Diagnosed?
To diagnose ORD, a doctor will first rule out other potential medical causes of the symptoms. If the symptoms seem to meet the diagnostic criteria for the disorder, the patient will likely be referred to a mental health professional for further assessment.
Diagnostic steps may include:
- A physical exam. This exam aims to rule out physical conditions that could be causing the symptoms.
- Blood tests. These tests will look at the patient’s blood chemistry for issues such as thyroid function. Screenings for drugs and alcohol may also be conducted to rule out symptoms that may be caused by substance abuse.
- Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.
The results of the psychological assessments will be compared to the diagnostic criteria for ORD in the Diagnostic and Statistical Manual of Mental Disorders. Comparing these criteria will help a mental health professional decide whether the symptoms indicate ORD or another psychiatric problem (such as obsessive-compulsive disorder, anxiety disorders, or depression).
The diagnostic criteria for ORD disorder include:
- Persistent perception of an unpleasant body odor that is unnoticeable or insignificant to other people
- Repetitive behaviors associated with the perception of odor
- Poor insight into the reality of the odor’s non-existence
How Is Olfactory Reference Disorder Treated?
The most common treatment course for ORD involves psychotherapy combined with medications to treat some of the disorder’s symptoms or co-existing conditions.
Commonly used therapeutic approaches for the treatment of ORD include:
- Cognitive behavioral therapy (CBT). This type of treatment focuses on teaching the patient to recognize inaccurate perceptions about themselves and others and develop strategies for dealing with these misperceptions when they occur.
- Family therapy
No medications have been approved by the FDA specifically to treat ORD. However, medicines may be used to treat symptoms such as depression or anxiety, which often co-exist with BDD. The drugs used to treat these symptoms include selective serotonin reuptake inhibitors (SSRIs), which help to increase levels of a naturally occurring biochemical called serotonin. Low serotonin levels can cause symptoms of depression, and they may be a factor in ORD itself, so treatment with SSRIs may improve ORD symptoms in some cases.
The antidepressant clomipramine or antipsychotic medications may be used in some cases.
How Does Olfactory Reference Disorder Progress?
People with ORD typically feel shame and embarrassment due to their compulsions, and their self-esteem generally suffers. Attempts to avoid embarrassing or humiliating situations can lead to social isolation, which may feed feelings of depression or anxiety.
Left untreated, ORD may eventually lead to long-term mental and physical complications, including:
- Lack of close relationships
- Emotional distress
- School or work problems
- Severe social isolation
How Is Olfactory Reference Disorder Prevented?
ORD cannot be prevented, but early diagnosis and a consistent treatment plan can help manage symptoms and prevent them from becoming as disruptive as they would be if they were left untreated. Unfortunately, because of their typical lack of insight into their condition, people with ORD are unlikely to seek treatment on their own and may have trouble following through on a treatment plan. Therefore, it’s essential for those diagnosed with ORD to seek regular evaluation from their mental health providers and stick to any prescribed medication plan.
Olfactory Reference Disorder Caregiver Tips
Many people with ORD also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with ORD:
Olfactory Reference Disorder Brain Science
Some scientists believe that ORD is closely related to body dysmorphic disorder (BDD) and may be a type of BDD. In an attempt to understand how differences in brain activity may explain the symptoms of BDD, researchers have conducted studies that compare neurocognitive function in people with the disorder to that of healthy participants. The findings of these studies may prove useful in understanding ORD as well.
- One study showed people with BDD images of their own faces and used functional magnetic resonance imaging (fMRI) to measure brain activity in response to the pictures. The study found unusual brain activity when the participants viewed their own faces, especially when the images were altered to show a low level of detail. The results suggest that people with BDD may be relatively unable to perceive their own faces as a whole and instead become preoccupied with details of their appearance.
- Other studies have shown people with BDD to have problems accurately identifying emotional expressions when they’re shown images of faces. The participants were more likely to interpret neutral expressions as showing anger or contempt.
Olfactory Reference Disorder Research
Title: Safety and Efficacy of Psilocybin for Body Dysmorphic Disorder
Principal investigator: Franklin Schneier, MD
New York State Psychiatric Institute
New York, NY
In this pilot study, up to 12 adult outpatients with body dysmorphic disorder that has not responded to at least one adequate trial of a serotonin reuptake inhibitor will be treated openly with a single oral dose of psilocybin. Procedures will follow those previously established in depression studies of psilocybin. Patients will receive intensive preparation and support from two therapists, including 8-9 hours accompanying the patient on the day of medication administration in the Biological Studies Unit of New York State Psychiatric Institute. Follow-up visits to monitor safety and clinical outcome will be conducted on day 1, week 1, and months 1, 2, and 3 post-administration. Resting-state functional magnetic resonance imaging will be performed before and one day after psilocybin administration to assess the effect of medication on brain circuits.
Title: Milk Thistle in Body Dysmorphic Disorder
Principal investigator: Jon E. Grant, JD, MD, MPH
University of Chicago
The proposed study aims to evaluate the efficacy and safety of silymarin (milk thistle) in adults with body dysmorphic disorder. The hypothesis to be tested is that silymarin will be more effective and well-tolerated in adults with body dysmorphic disorder compared to placebo. The proposed study will provide needed data on treating a disabling disorder that currently lacks a clearly effective treatment.
The primary aim of this application is to conduct a randomized placebo-controlled pharmacotherapy trial using silymarin (milk thistle) in 15 participants with body dysmorphic disorder. The study will consist of three phases: a four-week active treatment phase with milk thistle, a four-week placebo phase, and a one-week wash-out phase between the active and placebo phases. The subjects will be randomized to either receive active or placebo treatment in the first four weeks and the other during the remaining four-week phase.
This will be one of the few studies assessing the use of pharmacotherapy to treat body dysmorphic disorder in adults. Assessing the efficacy and safety of silymarin (milk thistle) will help inform clinicians about additional treatment options for adults suffering from this disorder.
Title: Understanding Daily Changes in BDD Risk Using Smartphones
Principal investigator: Hilary Weingarden, PhD
Massachusetts General Hospital
Body dysmorphic disorder (BDD) is associated with a high risk for suicide attempts (22-28%) and substance use disorders (49%), underscoring the importance of accurate, real-time risk detection in BDD. This study aims to use smartphone-based digital phenotyping to develop and validate unobtrusive, time-sensitive, and ecologically valid measures of key risk factors for suicide and substance misuse in BDD: negative affect states. As next steps, this research can be extended to detect risk transdiagnostically, with the goal of enabling just-in-time interventions to target suicide and substance misuse across psychiatric illnesses.