ReviewOLFACTORY REFERENCE SYNDROME: ISSUES FOR DSM-V
Jamie D. Feusner, M.D.,1Ã Katharine A. Phillips, M.D.,2 and Dan J. Stein, M.D. Ph.D.3
The published literature on olfactory reference syndrome (ORS) spans morethan a century and provides consistent descriptions of its clinical features. Thecore symptom is preoccupation with the belief that one emits a foul or offensivebody odor, which is not perceived by others. This syndrome is associated withsubstantial distress and disability. DSM-IV and ICD-10 do not explicitlymention ORS, but note convictions about emitting a foul body odor in theirdescription of delusional disorder, somatic type. However, the fact that suchsymptoms can be nondelusional poses a diagnostic conundrum. Indeed, DSM-IValso mentions fears about the offensiveness of one’s body odor in the social phobiatext (as a symptom of taijin kyofusho). There also seems to be phenomenologicaloverlap with body dysmorphic disorder, obsessive–compulsive disorder, andhypochondriasis. This article provides a focused review of the literature toaddress issues for DSM-V, including whether ORS should continue to bementioned as an example of another disorder or should be included as a separatediagnosis. We present a number of options and preliminary recommendationsfor consideration for DSM-V. Because research is still very limited, it is unclearhow ORS should best be classified. Nonetheless, classifying ORS as a type ofdelusional disorder seems problematic. Given this syndrome’s consistent clinicaldescription across cultures for more than a century, substantial morbidity and asmall but growing research literature, we make the preliminary recommenda-tion that ORS be included in DSM-Vs Appendix of Criteria Sets Provided forFurther Study, and we suggest diagnostic criteria. Depression and Anxiety0:1–8, 2010.
Key words: odor; smell; delusional disorder; hallucinations; olfactory; DSM-V
1Department of Psychiatry and Biobehavioral Sciences, David
Geffen School of Medicine at University of California, Los
his article focuses on some key issues pertaining to
2Butler Hospital and the Department of Psychiatry and Human
the classification of olfactory reference syndrome
Behavior, Alpert Medical School of Brown University, Provi-
(ORS), a condition in which individuals erroneously
believe that they emit an unpleasant, foul, or offensive
3Department of Psychiatry, University of Cape Town, Cape
body odor. Odors include almost anything foul
smelling and are often believed to originate from the
ÃCorrespondence to: Jamie D. Feusner, 300 UCLA Medical
mouth, genitals, rectum, or skin.[1] Common specific
Plaza, Suite 2345, Los Angeles, CA 90095.
concerns include halitosis, genital odor, flatulence or
anal odor, or sweat.[2] Occasional patients reportemitting non-bodily odors, such as ammonia,[3] deter-
The authors report they have no financial relationships within the
gent,[4] or rotten onions.[5] This belief is often
accompanied by ideas or delusions of reference; i.e.,
Received for publication 6 November 2009; Revised 15 February
the belief that other people take special notice of the
odor in a negative way (for example, rub their nose in
reference to the odor or turn away in disgust). In
Published online in Wiley InterScience (www.interscience.wiley.
addition, many patients perform repetitive behaviors,
such as smelling themselves, showering excessively, and
and gender features.’ Here the text states: ‘‘In certain
cultures (e.g., Japan and Korea), individuals with Social
In this article, we first summarize the history of
Phobia may develop persistent and excessive fears of
ORSs classification to provide a context for the issues
giving offense to others in social situationsy. These
discussed. We then address several key issues that are
fears may take the form of extreme anxiety that
specifically relevant to DSM-V. This article was
blushing, eye-to-eye contact, or one’s body odor will
commissioned by the DSM-V Anxiety, Obsessive–
be offensive to others (taijin kyofusho in Japan).’’
Compulsive Spectrum, Posttraumatic, and Dissociative
Similarly, the DSM-IV section on culture-bound
Disorders Work Group. It represents the work of the
syndromes implicitly refers to ORS, again under the
authors for consideration by the work group. Recom-
rubric of taijin kyofusho, which is included in the official
mendations provided in this article should be considered
Japanese diagnostic system for mental disorders.[1]
preliminary at this time; they do not necessarily reflect thefinal recommendations or decisions that will be made for
DSM-V, as the DSM-V development process is still ongoing. It is possible that this article’s recommendations will berevised as additional data and input from experts andthe fields are obtained.
1. Should ORS continue to be mentioned as an
example of another disorder, such as delusionaldisorder or social phobia, or another disorder? Or
should it instead be included as a separate diagnosisin DSM-V?
2. If ORS is included as a separate disorder, what
Published descriptions of ORS date back to the late
should its diagnostic criteria consist of?
1800s.[2,3,7–11] Several hundred cases from around theworld have been reported, including Europe, the United
States, Asia, the Middle East, and Africa. Between 1891and 1966, multiple cases consistent with this syndrome
ORS has been described as a discrete syndrome
appeared in the literature.[3,7,10–14] Many of these
across many cultures for more than a century. How-
were described as schizophrenia, although the clinical
ever, its clinical features are confusingly mentioned in
descriptions did not contain signs and symptoms
three different sections of DSM-IV, and they are not
sufficient to meet criteria. In 1971, Pryse-Phillips noticed
adequately described. Furthermore, the term ORS
this, and after characterizing a large case series and
(currently the most widely used term for this syn-
carefully considering the differential diagnosis, coined
drome) is not explicitly mentioned. Given the suffering
the term ORS for a separate group with consistent
and impairment associated with ORS, it is important to
phenomenology.[6] Other terms that have appeared in
examine its classification in DSM-V.
the literature include delusions of bromosis, hallucina-tions of smell, chronic olfactory paranoid syndrome, and
olfactory delusional syndrome, among others.[2] It hasalso been referred to as a type of monosymptomatic
To identify published articles on ORS, we used
hypochondriacal psychosis based on the observation that
PubMed, WebofScience, and PsychInfo databases with
it involves a single delusional belief.[15–19]
the keywords ‘‘olfactory reference syndrome,’’ ‘‘olfac-
ORS has never been classified as a separate disorder
tory paranoid syndrome,’’ ‘‘monosymptomatic hypo-
in DSM or the International Classification of Disease
chondriasis’’ and ‘ olfactory,’’ ‘‘taijin kyofu’’ and
(ICD). DSM-III-R mentioned ORS in the text, stating
‘‘olfactory,’’ ‘‘taijin kyofusho’’ and ‘‘olfactory,’’ ‘‘jiko-
that ‘‘convictions that the person emits a foul odoryare
shu-kyofu,’’ ‘‘delusional halitosis,’’ ‘‘psychosomatic
one of the most common types of delusional disorder,
halitosis,’’ ‘‘olfactory hallucination,’’ ‘‘hallucinations of
somatic type.’’[20] Similarly, DSM-IV considers ORS a
smell,’’ ‘‘olfactory delusional syndrome,’’ ‘‘olfactory
type of delusional disorder, somatic type, although the
delusional disorder,’’ ‘‘olfactory paranoia,’’ ‘‘olfactory
term ‘‘olfactory reference syndrome’’ is not mentioned.
hypochondriasis,’’ ‘‘monosymptomatic hypochondria-
The DSM-IV text states: ‘‘Somatic delusions can occur
cal psychosis’’ and ‘‘olfactory,’’ ‘‘delusion’’ and ‘‘smell,’’
in several forms. Most common are the person’s
‘‘delusions of bromosis,’’ and ‘‘bromidrosiphobia.’’
conviction that he or she emits a foul odor from the
Additional relevant articles identified from reference
skin, mouth, rectum, or vaginay.’’[1] Similarly, in its
lists were also included.[2–4,7,11–13,17,19,22–28] Only peer-
section on persistent delusional disorders, ICD-10 does
reviewed manuscripts published in the English lan-
not use the term ‘‘olfactory reference syndrome,’’ but
guage were included. Articles that appeared in these
the text notes that delusions may ‘‘express a conviction
searches but did not provide any data or clinical
thatyothers think that he or she smellsy.’’[21]
description of ORS were excluded (n 5 7). Two
DSM-IV also implicitly refers to ORS in the text for
recently published reviews on ORS, one from a book[2]
social phobia, in the section on ‘‘specific culture, age,
and one from a professional journal,[8] were also
included. The DSM-IV Sourcebook and DSM-IV
and 15.4% had nondelusional ORS beliefs (good to
poor insight) [Phillips, unpublished data]. Thus, ORS
Sixty journal articles[2–8,11–16,19–69] and four book
beliefs may not always be delusional and in such cases
chapters[2,12,25,26] fit the inclusion criteria. Fifty-nine
would not meet criteria for delusional disorder.
journal articles were case reports or case series, some in
An additional consideration is that the DSM-IV
combination with reviews of the literature, and one
definition of delusional disorder requires the total
was a literature review without a case report.[29] The
duration of any concurrent mood episodes to be brief
four largest published reports contain systematically
relative to the duration of the delusional periods.[2]
described patients from Japan (N 5 38), Canada
Depression is the most commonly reported comorbid
disorder or symptom [Phillips, unpublished data], often
(N 5 15).[6,18,28,30] Recently analyzed data from a series
considered secondary to ORS.[6,32] Data are lacking on
of 20 cases of ORS (primarily outpatients) in the
the duration of delusional ORS symptoms versus
United States are also included [Phillips KA, unpub-
duration of concurrent mood episodes. However,
lished data], because cases were systematically assessed
clinical experience suggests that patients with ORS
with the Structured Clinical Interview for DSM and
often have prolonged depressive episodes. In the
certain other standard measures that were not used in
majority of cases, these episodes appear after the
development of odor concerns[6] [Phillips, unpublisheddata] and may be secondary to the distress and suffering
that ORS causes. Thus, this delusional disordercriterion may not be suitable for ORS.
Although controlled studies are lacking, patterns of
response to pharmacotherapy reported in the literature
also suggest that ORS is probably not simply a type of
delusional disorder. Several case reports and series
describe response to antipsychotic monotherapy, particu-larly pimozide,[18,34] but multiple case reports and series
describe improvement with serotonin reuptake inhibitor
(SRI) monotherapy.[35–38] Some individuals did not
To examine whether or not a syndrome is distinct
respond to an antipsychotic but did respond to an
from other disorders, the DSM-V process has focused
SRI.[35] Other reports describe response to non-SRI
on validators such as symptom profile; familial
antidepressants, such as tricyclic antidepressants.[39,40]
aggregation; environmental risk factors; cognitive,
And, yet others describe improvement with a combination
emotional, temperament, and personality correlates;
of an antipsychotic and antidepressant medication.[18,32,41]
biological markers; patterns of comorbidity; course of
Might ORS be a form of a disorder other than
illness; and response to treatment. Unfortunately for
delusional disorder? Available data on this issue are also
ORS, there is a lack of empirical data for most of these
very limited. Some published reports included indivi-
validators. However, there are some early data to
duals with comorbid Axis I conditions, with the authors
suggest that ORS does seem to differ in important ways
providing evidence as to how the ORS symptoms were
from other disorders in terms of its symptom profile,
phenomenologically and/or temporally distinct from
comorbidity, and response to treatment.
We will first consider whether ORS should
ORS seems to have some features in common with
be classified as a type of delusional disorder, as in
social phobia, and is considered a form of taijin
DSM-IV. This requires consideration of whether ORS
kyofusho in Japan and Korea. Taijin kyofusho is
beliefs are delusional in nature. Data on this issue are
considered a culturally bound syndrome in which
limited. Most published case reports include patients
individuals fear that their body or bodily functions
with delusional beliefs (i.e., complete conviction of
may displease, embarrass, or be offensive to others in
emitting a foul or offensive body odor). However, the
terms of appearance, odor, facial expressions, or
literature contains reports of patients whose beliefs
movements.[1] An estimated 17% of individuals with
were not delusional; that is, the person recognized that
taijin kyofusho have fears of emitting body odor,[46]
he/she might not actually be emitting a noticeable
although this is one of only several fears in this
odor. Osman[18] noted that overvalued ideation may
syndrome (see also the review for DSM-V of culture
occur rather than delusions, and Suzuki et al. reported
and anxiety disorders, [Lewis-Ferna´ndez et al., under
that three of seven patients in their series had good
review]). The literature suggests that most individuals
insight.[31] Other authors have also commented on the
with ORS are concerned about the social implications
existence of nondelusional forms of ORS.[16,18,32] In a
of emitting a foul odor, with patients commonly
recently analyzed data set, which used the reliable and
experiencing shame, embarrassment, and anxiety in
valid Brown Assessment of Beliefs Scale[33] to assess
social situations, as well as avoidance of social
delusionality/insight of ORS beliefs, 84.6% patients
situations.[36] Some fear offending others with their
with current ORS currently had delusional ORS beliefs
odor.[47] One small study that directly compared
individuals with ORS symptoms to those with social
in ORS [85%] and appearance in BDD [36–60%]),
phobia found similarities in demographics, comorbid-
current ideas or delusions of reference (77% in ORS
ity with depression, and symptom scores on social
versus 38% in BDD), and more frequent lifetime
phobia ratings scales (although the study was under-
comorbidity with DSM-IV social phobia (65% in ORS
powered to detect differences between groups). How-
versus 37–39% in BDD)[56–58] [Phillips KA, unpub-
ever, the key characteristic of social phobia is the fear
that one will act in a way that will be embarrassing or
Finally, there are apparent similarities with other
humiliating; thus, patients are typically primarily
somatoform disorders, primarily hypochondriasis.
concerned about how they speak (or eat, write, etc.)
Both disorders involve preoccupation with the body,
rather than how they smell. Another apparent differ-
are often marked by obsessional thinking, and include
ence between ORS and social phobia is the often
repetitive behaviors, such as checking and seeking
delusional nature of the core belief in ORS. In
medical diagnoses and treatments.[1] However, unlike
addition, it seems that most individuals with ORS
ORS, in hypochondriasis the core fear is about having a
perform excessive, repetitive behaviors that are com-
serious disease. Moreover, unlike hypochondriasis,
pulsive in nature. The intent of these behaviors is
ORS is typically characterized by prominent ideas/
usually to check or eliminate the perceived odor, obtain
delusions of reference and social avoidance.
reassurance about it, or prevent others from smelling it.
We will now address issue ]1 from a different
Examples include checking their body for odor,
perspective, which is whether ORS should be included
excessive showering or other washing, or repetitive
as a diagnosis in DSM-V, separate from delusional
use of deodorant, mouthwash, or perfume.[6,16,32,48] In
disorder or another mental disorder. First, we draw in
the sample noted above, 95% of subjects performed at
part on recent considerations for what constitutes a
least one such behavior [Phillips, unpublished data].
mental disorder while also considering ongoing dis-
These behaviors raise the question of whether ORS
cussion in the literature on this topic [e.g.,[59,60]. We
may be related to OCD. Another similarity with OCD
then address several additional considerations for
is that individuals with ORS usually report troubling,
adding a disorder to the nomenclature.[61]
repetitive, and intrusive thoughts about their ‘‘odor,’’
The condition is a behavioral or psychological syndrome or
which some describe as obsessive.[12,18,49] Indeed,
pattern that occurs in an individual: As detailed above,
sufferers may spend many hours per day preoccupied
ORS has long been recognized in the psychiatric
with these thoughts[49] [Phillips, unpublished data].
literature as a syndrome that occurs in individuals, and
These symptoms, in addition to case reports of ORS
it has been described in multiple regions of the world.
symptoms responding to SRIs,[35,38,50] has led some to
The consequences of which are clinically significant distress
posit a relationship between ORS and OCD.[2]
or disability: The literature consistently indicates that
However, ORS seems to differ from OCD in that
ORS causes clinically significant limitations in func-
OCD beliefs are delusional in fewer than 5% of cases,
tioning or distress. A number of authors have noted
and ideas/delusions of reference seem less common in
significant social disability associated with ORS. In
OCD than in ORS.[51–53] In addition, available data,
Pryse-Phillips’ case series, only 3% of patients were
although very preliminary, suggest that comorbidity
‘‘socially active.’’[6] Prominent social avoidance and
patterns may differ, with comorbid major depressive
isolation seems common, which is usually attributed to
disorder and social phobia more common in ORS
shame, embarrassment, and/or concern about offend-
ing others with the odor.[6,16,32,42] Impairment of work
More than 20 years ago, Isaac Marks noted that
or school functioning is also common.[6,16,32,42] This,
ORSs clinical features have many similarities to body
too, is often noted to be owing to avoidance of other
dysmorphic disorder (BDD); the primary symptoms of
people because of shame, embarrassment, or concern
both disorders involve a belief of a bodily defect which
about offending others with the perceived odor, or it
leads to anxious avoidance of relevant (often social)
may result from time spent preoccupied with thoughts
situations.[36] Other similarities include preoccupation
about the odor and engaging in behaviors to check or
and repetitive behaviors to check or remediate the
minimize it.[2] In a small recently analyzed data set,
perceived problem.[2,15,16,40,42,48,55] In addition, both
ORS symptoms had caused 74% of subjects to avoid
disorders are characterized by frequent seeking of
social situations and 47% to avoid occupational,
nonmental health medical treatment in an attempt to
academic, or other important role activities [Phillips,
alleviate the symptoms. Examples include surgery and
unpublished data]. Forty percent reported that they
dermatologic treatment in BDD, and treatment from
had been completely housebound for at least 1 week
dentists and gastroenterologists in ORS.[16,18,30,32,42]
because of ORS symptoms. The mean score on the
However, BDD and ORS have some apparent differ-
Global Assessment of Functioning Scale among those
ences. The content of the core beliefs, many of the
with current ORS was 47.5 (SD 5 13.2). A majority
repetitive behaviors, and treatment response may all
of subjects (52.6%) reported a history of psychiatric
differ.[2] In addition, available preliminary data
hospitalization, with 31.6% of the sample reporting
(although very limited) suggest that ORS is more often
characterized by current delusional beliefs (about odor
primarily because of ORS symptoms. Furthermore,
68% of subjects had a history of suicidal ideation, 47%
The syndrome has clinical utility: In our clinical
reported lifetime suicidal ideation that they attributed
experience, many patients with ORS receive no
primarily to the distress caused by ORS symptoms,
diagnosis or an inaccurate diagnosis, such as schizo-
32% had attempted suicide, and 16% had made at
phrenia, OCD, or major depressive disorder. This, in
least one suicide attempt that they attributed primarily
turn, may lead to treatment for another disorder. Such
to ORS [Phillips, unpublished data]. Of Pryse-Phillips’
misidentification may occur because DSM-IV only very
36 subjects, 43% experienced ‘‘suicidal ideas or
briefly mentions ORS symptoms in the text, does not
action’’ and 5.6% committed suicide over the follow-
include the specific term ‘ olfactory reference syn-
up period (the duration of the follow-up period
drome,’ and lacks diagnostic criteria. Alternatively,
is unclear but seems to have been 1–2 years), with
patients present to nonmental health professionals,
the author implying that the suicides were attributable
such as dentists, gastroenterologists, dermatologists,
and gynecologists, who may not be aware that ORS is a
The proposed syndrome is not merely an expectable
known form of mental illness. Many patients do not
response to common stressors or losses or a culturally
seek treatment at all, which may in part be owing to
sanctioned response to a particular event: The literature
lack of public awareness that the symptoms represent a
provides no evidence or suggestion that ORS is merely
an expectable response to common stressors or losses,
Taken together, then, the potential benefits of
or a culturally sanctioned response to a particular
creating a new diagnosis (e.g., identifying individuals
who require appropriate clinical attention) seem to
The proposed syndrome reflects an underlying psychobio-
outweigh any potential harm. However, research data
logical dysfunction: To our knowledge, disturbances in
on this syndrome are still limited. Therefore, we
biological and psychological processes in ORS have not
propose that ORS be included in an Appendix of
been studied, although preliminary (uncontrolled)
Criteria Sets Provided for Further Study rather than in
reports of improvement in ORS with pharmacotherapy
the main part of the manual. The following are
or psychosocial treatment (behavioral therapy,[15,48]
additional considerations that may arise when propos-
ing a new disorder for the nomenclature (including
intention[63]) indirectly support the presence of such
underlying mechanisms. In addition, excessive groom-
Is there a need for the category; for example, is the
ing behaviors in animals offer a possible ethological
syndrome sufficiently common in clinical or population
model for human ORS.[64] One purpose of grooming
samples that it merits an independent category as opposed
across species is to clean in order to maintain health;
to being one example in an NOS category? Prevalence
for example, by improving predation or avoiding
studies using the proposed diagnostic criteria below
predators via removal of odors.[65] Although the
have not been done. However, in a tertiary referral unit
relationship between evolutionary function/dysfunc-
for the behavioral treatment of psychiatric disorders
tion and disorders remains controversial,[66,67] con-
(the Psychological Treatment Unit at the Maudsley
ceivably such processes can go awry and result in
Hospital in London), 9 of 2,000 patients (0.5%)
spontaneously reported ORS symptoms.[48] This figure
The syndrome is not primarily a result of social deviance or
is likely an underestimate, given the shame and secrecy
conflicts with society: There is no evidence or suggestion
that often characterizes ORS. A self-report survey of
in the literature that ORS is solely a result of social
2,481 university students in Japan found that 2.1%
deviance, other conflicts with society, or ‘‘eccentricity.’’
had been concerned with emitting a strange bodily
ORS has many features of an ‘‘internalizing’’ disorder
odor during the previous year.[70] Although this
rather than reflecting social deviance or conflict.
symptom is not necessarily equivalent to a clinical
Responsiveness (in many cases) to psychotropic agents
diagnosis of ORS, the authors nonetheless imply
or behavioral therapy (as noted above) is consistent
that ORS is relatively common in Japan and conclude
that in Japan ‘‘fears of bodily odor are.encountered
The syndrome has diagnostic validity on the basis of
almost every day.’ Several authors have suggested that
various diagnostic validators: For ORS, there is a lack of
ORS is more common than usually recognized.[13] Iwu
empirical data for most of these validators (mentioned
noted that delusional halitosis (one form of ORS) ‘‘may
above) and only minimal data for others. As noted
be frequently encountered by the dental surgeon.’’[30]
above, however, ORS does seem to differ in important
Osman concluded that the monosymptomatic hypo-
ways from other disorders in terms of its symptom
chondriacal psychoses are likely to be underreported
profile and possibly comorbidity. Furthermore, it
and ‘‘form an important and not uncommon cause of
seems to differ from delusional disorder on the basis
psychiatric morbidity in [developing countries].’’[18]
of preliminary observations that some patients seem to
What is the relationship of the proposed disorder with
respond to antidepressant monotherapy.[6,18,32,34–40]
other DSM-IV diagnoses; for example, is the diagnosis
However, the fact that some patients seem to respond
sufficiently distinct from other diagnoses? As noted, ORS
to antipsychotics alone[6,32,43] suggests that ORS also
seems to differ from diagnostic near neighbors in
differs from social phobia, BDD,[68] and OCD.[69]
several ways, although further research is needed.
Are there proposed diagnostic criteria with clinical face
criteria. Furthermore, impairment in functioning
validity, reliability, and adequate sensitivity and specificity
should cover clinically significant avoidance. The
for the proposed construct? As discussed below, available
diagnostic hierarchy criterion (criterion C) specifically
criteria exist. Nevertheless, further work is needed to
emphasizes psychotic disorders. We considered includ-
ing social phobia in the exclusion criterion, given the
Can the criteria be easily implemented in a typical clinical
relationship between taijin kyofusho and concerns
interview and reliably operationalized/assessed for research
about body odor, but concluded that insufficient data
purposes? Suggested criteria are provided below, but
are available to support this. We suggest a dimensional
have not yet been rigorously studied.
approach to insight, consistent with the emphasis inDSM-V on dimensional constructs, and given that there
seems to be a range of insight in ORS. We considered
whether these criteria are appropriate for both genders,
for patients throughout the course of development, andfor all cultures, and are not aware of a compelling
Two different sets of criteria have been proposed for
reason for modifying the proposed criteria for any of
ORS.[8,36] The research diagnostic criteria proposed
below reflect features of each criteria set, with furtherminor modifications; in addition, we propose theaddition of insight specifiers:
(A) Preoccupation with the belief that one emits a foul
or offensive body odor, which is not perceived by
Considering ORS a type of delusional disorder poses
a number of diagnostic problems, as discussed above.
(B) The preoccupation causes clinically significant
In addition, available data suggest that ORS differs
distress (for example, depressed mood, anxiety,
from other ‘‘near neighbor’’ disorders. One possibility
shame) or impairment in social, occupational, or
is that ORS might represent variable presentations of
other important areas of functioning.
several different disorders, such as BDD, social phobia,
(C) The symptoms are not a symptom of schizophre-
or others, rather than being a distinct syndrome.
nia or another psychotic disorder, and are not
Although this possibility requires investigation, studies
owing to the direct physiological effects of a
and case descriptions of ORS over the past century
substance (e.g., a drug of abuse or medication) or a
provide a consistent description of its clinical features,
suggesting that ORS is likely a distinct entity, althoughone that shares some features with other disorders. In
Specify whether ORS beliefs are currently character-
addition, ORS seems to meet many of the above
considerations for what constitutes a mental disorder
1. Good or fair insight: Recognizes that ORS beliefs
and for adding a disorder to the nomenclature. In
are definitely or probably not true, or that they may
particular, ORS seems to characterize a distinct and
suffering group of people who need clinical attention;
2. Poor insight: Thinks ORS beliefs are probably true.
in our experience, its near absence in DSM has led to
3. Delusional beliefs about body odor: Completely
underdiagnosis and undertreatment of a severe mental
illness. Also of clinical importance is that there islimited but emerging literature on its treatment, which
We suggest the phrase ‘‘which is not perceived by
seems to differ in some ways from that of other
others’ in criterion A rather than a phrase, such
disorders[2,8]—in particular, delusional disorder, under
as ‘‘false belief,’’ because it may be more patient
friendly and thus perhaps less likely to deter patients
Nevertheless, data on ORS are still limited, and
with ORS, whose insight is usually absent or poor,
research on the above criteria is needed. For example,
from seeking treatment. Criterion B is based on the
reliability data are not available on the proposed
DSM-IV clinical significance criterion and will ulti-
diagnostic criteria, many of the above-noted validators
have not been examined, and ORSs prevalence and the
used throughout DSM-V. We considered adding a
nature of its relationship to other disorders have been
phrase about ‘‘associated avoidance’’ to this criterion;
only minimally examined. Thus, it is probably pre-
although possibly open to somewhat different inter-
mature to include ORS in the main body of DSM as a
pretations by clinicians, it seems clear that avoidance
contributes to the clinical distress and impairment
Taken together, we recommend including a criteria
associated with ORS. However, in the absence of
set for ORS in an Appendix of Criteria Sets Provided
adequate data on the prevalence of avoidant behavior in
for Further Study. ORS has been clinically ob-
ORS, and whether it is characteristic of all patients with
served and reported for more than a century
ORS, avoidance may be better in the text than in the
around the world, with the literature consistently
underscoring the suffering of these individuals. ORSs
21. World Health Organization. The ICD-10 classification of
current classification is problematic, causing it to be
mental and behavioural disorders. Geneva, 1992.
confused with other disorders, missed in clinical
22. Johanson E. Mild paranoia. Acta Psychiatr Scand 1964;40:
settings, or unsuccessfully treated. Including ORS in
an Appendix would also have the advantage of
23. Kizu A, Miyoshi N, Yoshida Y, et al. A case with fear of emitting
stimulating further systematic research on ORS, using
body odour resulted in successful treatment with clomipramine.
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Matsunaga, Harrison Pope, and Susan Bogels for their
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27. Yamada M, Kobashi K, Shigemoto T, et al. On dysmorphopho-
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