Olfactory reference syndrome: what is it and what are its symptoms?

The olfactory reference syndrome is a psychiatric disorder, characterized mainly because the person suffering from it is vehemently convinced that it emits a bad body odor. But are there hallucinations in such a disorder? And delusions?

Throughout this article we will try to answer these questions. In addition, based on different studies, we will explain in detail what this disorder consists of, what are some of the etiological hypotheses raised, its symptoms and, finally, the treatments used to combat it.

  • Recommended article: “Delusions: what they are, types and differences with hallucinations”

Olfactory reference syndrome

Olfactory Reference Syndrome (ORS) consists of an hallucinatory psychiatric disorder . It is mainly characterized by a persistent worry about the smell, along with other symptoms such as shame and anguish. On a social level, it is accompanied by avoidance and social isolation behaviors.

This syndrome is a variety of delusional disorder , somatic type. The individual with Olfactory Reference Syndrome strongly believes that it emits a foul odor, and that others may notice that smell.

At the clinical level, it is therefore a delusion added to a hallucination (although there is controversy in the existence of these symptoms, as we will see later). In the DSM-5 (Diagnostic Manual of Mental Disorders) it is proposed to catalog the ORS as an independent disorder.

Due to the characteristics of the syndrome, the majority of patients with olfactory reference syndrome do not consult psychiatrists or psychologists, but other professionals, such as: dermatologists, dentists, dermatologists or even surgeons, due to their “obsession” with evil body odor they give off.


The prognosis of the olfactory reference syndrome had always been considered unfavorable; However, a review of the year 2012, prepared by the authors Begum and McKenna, showed that two thirds of the patients (from a sample of 84) partially improved or recovered completely.

Demographic data

The prevalence of ORS is higher among men than among women. Specifically, single men predominate. As for the age of onset, this oscillates between the end of adolescence and the beginning of adulthood.


As for the origin of the olfactory or olfactory reference syndrome, it was Pryse-Phillips who, in 1971, published a long list of cases. Philips separated the cases of ORS from cases with similar symptoms, belonging to schizophrenic, affective or organic psychosis.


As for the cause of the olfactory reference syndrome, it is actually unknown, as in many other psychiatric disorders. However, there are some etiological hypotheses, which refer to certain serotonergic and dopaminergic dysfunctions in the brains of people with ORS .

These dysfunctions are related to the repetitive cleaning and check-up behaviors that these patients show, similar to those shown by people with an Obsessive Compulsive Disorder (OCD).

Other causal hypotheses are in line with certain mismatches in some regulatory genes, such as Hoxb8 and SAPAP3 (related to the limbic lobe and basal ganglia).

On the other hand, there are also cases of people with olfactory reference syndrome who have suffered some type of brain injury, as well as temporal lobe epilepsy. However, all these are hypotheses of neurobiological bases, and there is none that has been proven as 100% causative of ORS.

Social and psychological factors

As for the most psychological and social causes, in the case of ORS there is a precipitating event just before the onset of the symptoms of the disorder. These events usually involve some type of denigrative reprimand by others.

Stress can also be at the base of this disorder, as well as an obsessive, distrustful and paranoid personality (and in extreme cases, an obsessive personality disorder or a paranoid personality disorder).


What symptoms accompany the olfactory reference syndrome? Let’s see the 4 main symptoms, in addition to the suffering inherent in the disorder .

1. Concern about body odor

The main symptom of the olfactory reference syndrome is a significant concern regarding body odor; that is, the person believes vehemently that it gives off a bad smell.

However, there is controversy as to whether this concern is delusional in all cases of the Syndrome or not. It is also not clear if there is always a hallucination associated with this concern, or not.

Hallucination and / or delirium?

Regarding these controversies about the presence or not of delirium and hallucination, a recent review (2012) by the authors Begum and McKenna, found that 22% of patients with olfactory reference syndrome manifested an hallucination of olfactory type associated with Concern about the bad smell (vs. 75% of the original Pryse-Phillips list, which presented such hallucination).

Regarding the presence or not of delirium, this review reflects how 52% of the patients had it; In the rest of the patients, however, the concern was based on an idea that oscillated between the overrated idea and the obsessive idea.

2. Feeling of shame

Another symptom of the ORS is an intense feeling of shame about others; Thus, the person suffers because he is convinced that it smells bad, and that in addition, others notice it. That is why she feels deeply ashamed, and has a hard time.

On the other hand, according to studies, more than 75% of patients with olfactory reference syndrome interpret the gestures and words of others in relation to oneself. That is, patients believe they speak ill of them and criticize them.

3. Constant check

People with ORS spend a lot of their time checking their body odor, since they are “obsessed” with smelling more. They also manifest other compulsive behaviors in order to disguise that they are in one place, or to disguise their own smell.

4. Social isolation

The above symptoms end up causing the person to isolate himself socially, which also translates into a social and work disability, and in great difficulties to carry out a “normal” life.

In fact, of the original list of cases prepared by Pryse-Phillips, only 3% of those affected by the olfactory reference syndrome led an active social life.


Regarding the treatment of the olfactory reference syndrome, we find, in broad strokes, two types of treatment: psychological and pharmacological.

On a psychological level, psychotherapy is used . Although it is possible to work from different orientations, cognitive behavioral therapy is recommended, in order to eliminate cognitive distortions associated with body odor, as well as check and check behaviors.

EMDR therapy (Desensitization and Reprocessing of Eye Movements) has also been used . Specifically, a 2008 study, prepared by McGoldrick, Begum and Brown, reveals the success of 5 patients through this therapy, a therapy that, however, is not useful in other psychotic conditions.

At the pharmacological level, antipsychotics and antidepressants are used . On the other hand, a study reveals that 33% of patients with olfactory reference syndrome treated with antipsychotics had obtained very positive results; The same happened with 55% of patients treated with antidepressants.

Bibliographic references:

  • Begum, M. and McKenna, PJ (2011). Olfactory reference syndrome: a systematic review of the world literature. Psychol Med, 41: 453-61.
  • Bizamcer AN, Dubin WR, Hayburn B. (2008). Olfactory reference syndrome. Psychosomatics, 49: 77-81.
  • Cruzado, L., Cáceres-Taco, E. and Calizaya, JR (2012). About a case of olfactory reference syndrome. Clinical case. Actas Esp Psiquiatr, 40 (4): 234-8.
  • McGoldrick T, Begum M, Brown KW. (2008). EMDR and Olfactory Reference Syndrome. A case series. Journal of EMDR, 2: 63-8.
  • Phillips KA, Gunderson C, Gruber U, Castle D. (2006). Delusions of body malodour; the olfactory reference syndrome. In: Brewer W, Castle D, Pantelis C, eds. Olfaction and the Brain. New York: Cambridge University Press, 334-53.
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