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Letters to the Editor

Prevalence of Olfactory Reference Syndrome in Obsessive-Compulsive Disorder and Social Anxiety Disorder

Prevalence of Olfactory Reference Syndrome in Obsessive-Compulsive Disorder and Social Anxiety Disorder

To the Editor: Olfactory reference syndrome (ORS) is a condition characterized by concerns about perceived body odor, which may lead to repetitive behaviors to diminish the odor, as well as to avoidance of social interactions.1,2 A range of other terms describing olfactory reference symptomatology has appeared in the literature; for example, based on the observation that it involves a single belief that is often delusional in intensity, ORS has been referred to as a type of monosymptomatic hypochondriacal psychosis (eg, see references 3-5). ORS is now referred to in DSM-5 as a type of "other specified obsessive-compulsive and related disorder." In this section, DSM-5 lists the Japanese construct of jikoshu-kyofu, which appears similar to ORS. It notes that jikoshu-kyofu is considered a variant of taijin kyofusho,6 a diagnosis that has features in common with social anxiety disorder (SAD). Although it has been argued that ORS is sufficiently prevalent to include in DSM-5,7 there is a relative lack of prevalence studies that employ structured diagnostic interviews. Suggested prevalence rates range from 0.5% to 2.1% (eg, see references 8 and 9). Given the increased prevalence of some obsessive-compulsive-related disorders in obsessive-compulsive disorder (OCD), it might be expected that ORS is also seen in OCD patients. Given that ORS may have features, such as heightened social concerns, in common with SAD, it might also be hypothesized that ORS is comorbid with SAD. To our knowledge, this is the first study to examine the prevalence of ORS in OCD and SAD.

Method. We performed a cross-sectional assessment of 106 OCD patients (47 male, 59 female; mean age = 31.8 [SD = 11.2] years) and 65 SAD patients (32 male, 33 female; mean age = 31.2 [SD = 10.9] years), seen consecutively, to assess the prevalence of comorbid ORS in patients with primary DSM-IV OCD or SAD. We incorporated a module focused on proposed diagnostic criteria for ORS7 into our Structured Clinical Interview for Obsessive-Compulsive Spectrum Disorders10 and assessed all participants with this structured diagnostic interview.

Results. In the OCD sample, 1 female was diagnosed with comorbid ORS (current and lifetime). In the SAD sample, 2 female patients had comorbid ORS (current and lifetime). The patient with OCD indicated that fluoxetine 60 mg and risperidone (dose unknown) had helped reduce the severity of her OCD symptoms, but that her ORS symptoms remained distressing and impairing. One of the patients with SAD indicated that sertraline 50 mg and methylphenidate (dose unknown) had improved her SAD symptomatology but had no effect on ORS.

Our data indicate that ORS may present in patients with OCD and SAD. However, patients may be embarrassed about these symptoms and often have limited insight, and may therefore not specifically inform clinicians regarding their persistent concerns about perceived body odor unless relevant screening questions are employed. Although our sample is small, it is notable that ORS was more prevalent in SAD than in OCD patients. Further work using the proposed diagnostic criteria for ORS is needed to establish its prevalence in various psychiatric populations and in the community.

References

1. Lochner C, Stein DJ. Olfactory reference syndrome: diagnostic criteria and differential diagnosis. J Postgrad Med. 2003;49(4):328-331. PubMed

2. Pryse-Phillips W. An olfactory reference syndrome. Acta Psychiatr Scand. 1971;47(4):484-509. PubMed doi:10.1111/j.1600-0447.1971.tb03705.x

3. Bishop ER Jr. An olfactory reference syndrome—monosymptomatic hypochondriasis. J Clin Psychiatry. 1980;41(2):57-59. PubMed

4. Munro A. Monosymptomatic hypochondriacal psychosis. Br J Psychiatry Suppl. 1988;153(2):37-40. PubMed

5. Osman AA. Monosymptomatic hypochondriacal psychosis in developing countries. Br J Psychiatry. 1991;159(3):428-431. PubMed doi:10.1192/bjp.159.3.428

6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing; 2013.

7. Feusner JD, Phillips KA, Stein DJ. Olfactory reference syndrome: issues for DSM-V. Depress Anxiety. 2010;27(6):592-599. PubMed doi:10.1002/da.20688

8. Kasahara T, Kenji S. Ereuthophobia and allied conditions: a contribution toward the psychopathological and crosscultural study of a borderline state. The World Biennial of Psychiatry in Psychotherapy. New York, NY: Basic Books; 1971.

9. Marks I, Mishan J. Dysmorphophobic avoidance with disturbed bodily perception: a pilot study of exposure therapy. Br J Psychiatry. 1988;152(5):674-678. PubMed doi:10.1192/bjp.152.5.674

10. du Toit PL, van Kradenburg J, Niehaus D, et al. Comparison of obsessive-compulsive disorder patients with and without comorbid putative obsessive-compulsive spectrum disorders using a structured clinical interview. Compr Psychiatry. 2001;42(4):291-300. PubMed doi:10.1053/comp.2001.24586

Christine Lochner, PhD

cl2@sun.ac.za

Dan J. Stein, PhD

Author affiliations: MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Stellenbosch (Drs Lochner and Stein), Stellenbosch; and Department of Psychiatry and Mental Health, University of Cape Town (Dr Stein), Cape Town, South Africa.

Potential conflicts of interest: Dr Stein has received research grants and/or consultancy honoraria from Abbott, AstraZeneca, Eli Lilly, GlaxoSmithKline, Jazz Pharmaceuticals, Johnson & Johnson, Lundbeck, Orion, Pfizer, Pharmacia, Roche, Servier, Solvay, Sumitomo, Takeda, Tikvah, and Wyeth. Dr Lochner has no conflicts to report.

Funding/support: Drs Lochner and Stein’s work on OCD and related disorders is supported by the Medical Research Council of South Africa.

Role of the sponsor: The funding organizations are public institutions and had no role in the design and conduct of the study; collection, management, and analysis of the data; or preparation, review, and approval of the manuscript.

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