Successful Treatment of Olfactory Reference Syndrome With Paroxetine

To the Editor: Olfactory reference syndrome (ORS) is characterized by the erroneous belief that one emits an offensive body odor (which is not perceived by others) and that the odor displeases others.¹ ORS is classified as a delusional disorder, somatoform disorder, obsessive-compulsive spectrum disorder, or social anxiety disorder in DSM-IV.^2,3 ORS also appears to share symptomatological similarities with jiko-shu-kyofu, which is a severe subtype of taijin kyofusho, described in DSM-IV as a culture-bound syndrome.⁴ There is no consensus on diagnostic classification of ORS in the current diagnostic systems. Description of ORS cases can contribute to modifying its nosological status and promoting its recognition by physicians. Herein, we report a case of an ORS patient who had undergone polysurgery and showed good response to paroxetine monotherapy.

Case Report

The case was of a married 51-year-old woman with no family history of psychiatric disease. In her teens, she was temporarily distressed by osmidrosis, for which she had used an over-the-counter drug. After her menopause, she started believing that her body odor, mainly from the armpit, was causing distress to others, especially her colleagues at her part-time job. Noticing people around her touching their nose or frowning confirmed her belief that they were displeased by her odor. She used many supplementary drugs and bathed frequently to get rid of the odor; however, she failed to eliminate it. She became socially withdrawn, although she continued working. She was bothered by her odor even when she was alone in her house, on holidays, or after work. She decided to undergo plastic surgery for her suspicious osmidrosis. After failed attempts at several surgeries and laser treatment for relieving osmidrosis, she was introduced to psychiatry. She was convinced of her odor and showed lack of insight. She had no obsessions or compulsions that did not directly relate to her odor. She had no history of substance abuse, delusions other than her personal odor, hallucinations, or other physical medical disorder. Neurological examination showed no abnormality. Her EEG and brain CT were within normal limits. Paroxetine treatment was initiated because she showed a few symptoms of depression. She responded to a dose of 30 mg and had full remission in 1 month. She has remained symptom-free with the same dose of paroxetine for over 2 years.

Discussion

ORS onset might occur between adolescence and the 20s, and the patients visit a mean of 4.5 different nonpsychiatric doctors.^2,4 In this case, ORS was manifested after menopause as a precipitating event, and the patient underwent polysurgery. Elderly patients might opt for unnecessary treatments because they are economically independent and have to make their own decisions. To avoid delay in treatment, public awareness of ORS and its early diagnosis by nonpsychiatric and psychiatric physicians is necessary. We were able to achieve complete remission of the patient's delusional belief about her odor by paroxetine monotherapy. Neuroleptics and antidepressants, as well as psychotherapy, are also effective for ORS, although research on their use is still sparse.⁵ Case descriptions of phenomenology and neurobiology of ORS might help in proper categorization of, and promote further research on, ORS.