Skip to main content

Olfactory reference syndrome: a systematic review of the world literature

  • M. Begum (a1) and P. J. McKenna (a2)

The nosological status of olfactory reference syndrome (ORS) is a matter of debate and there is uncertainty as to what treatments are effective.


The world literature was searched for reports of cases of ORS. Clinical, nosological and therapeutic information from cases meeting proposed diagnostic criteria for the disorder was summarized and tabulated.


A total of 84 case reports (52 male/32 female) were found. Age of onset was <20 years in almost 60% of cases. Smell-related precipitating events were recorded in 42%. Most patients could not smell the smell or only did so intermittently. Authors of the reports expressed reservations about the delusional nature of the belief in slightly under half of the cases. Over two-thirds were improved or recovered at follow-up, with the disorder responding to antidepressants and psychotherapy more frequently than to neuroleptics.


ORS is a primary psychiatric syndrome that does not fit well into its current classification as a subtype of delusional disorder, both in terms of its nosology and its response to treatment.

Corresponding author
*Address for correspondence: Dr M. Begum, NHS Forth Valley, Behavioural Psychotherapy Service, 2 the Bungalows, Stirling Rd, Larbert FK5 4SD, Scotland. (Email:
Hide All
*Beary MD, Cobb JP (1981). Solitary psychosis – three cases of monosymptomatic delusion of alimentary stench treated with behavioural psychotherapy. British Journal of Psychiatry 138, 6466.
*Bishop ER Jr. (1980). An olfactory reference syndrome – monosymptomatic hypochondriasis. Journal of Clinical Psychiatry 41, 5759.
*Bizamcer AN, Dubin WR, Hayburn B (2008). Olfactory reference syndrome. Psychosomatics 49, 7781.
*Bourgeois M (1973). L'autodysosmophobie et le syndrome ou delire olfactif de relation (a propos de 7 observations). Annales Médico-psychologiques 2, 353376.
*Brosig B, Kupfer J, Niemeyer V, Milch W, Gieler U (2001). Delusional bromidosis in psychotherapy – a case study. Dermatology and Psychosomatics 2, 8285.
*Brotman AW, Jenike MA (1984). Monosymptomatic hypochondriasis treated with tricyclic antidepressants. American Journal of Psychiatry 141, 16081609.
Castle DJ, Rossell S, Kyrios M (2006). Body dysmorphic disorder. Psychiatric Clinics of North America 29, 521538.
*Clarvit SR, Schneier FR, Liebowitz MR (1996). The offensive subtype of Taijin-kyofu-sho in New York City: the phenomenology and treatment of a social anxiety disorder. Jouirnal of Clinical Psychiatry 57, 523527.
*Dominguez RA, Puig A (1997). Olfactory reference syndrome responds to clomipramine but not fluoxetine: a case report. Jounral of Clinical Psychiatry 58, 497498.
*Fazal MA, Shah AM (1985). Monosymptomatic delusions of smell: are these new symptoms in East Africa? Nordic Journal of Psychiatry 39, 389393.
*Fishbain DA, Goldberg M (1991). Fluoxetine for obsessive fear of loss of control of malodorous flatulence. Psychosomatics 32, 105107.
Freeman D, Garety PA, Bebbington PE, Smith B, Rollinson R, Fowler D, Kuipers E, Ray K, Dunn G (2005). Psychological investigation of the structure of paranoia in a non-clinical population. British Journal of Psychiatry 186, 427435.
Green CE, Freeman D, Kuipers E, Bebbington P, Fowler D, Dunn G, Garety PA (2008). Measuring ideas of persecution and social reference: the Green et al. Paranoid Thought Scales (GPTS). Psychologcal Medicine 38, 101111.
*Habeck D (1965). Contribution to smell hallucinosis with delusion of reference. Archiv fur Psychiatrie und Nervenkrankheiten 207, 196205.
Jaspers K (1959). General Psychopathology (trans. J. Hoenig & M. W. Hamilton, 1963). Manchester University Press: Manchester.
*Johanson E (1964). Mild paranoia. Acta Psychiatrica Scandinavica, Supplement 177, 1100.
*Johnson BE (1996). The olfactory reference syndrome and halitosis. In Bad Breath. A Mulitidisciplinary Approach (ed. Van Steenberghe D. and Rosenberg M.), pp. 231240. Leuven University Press: Leuven.
*Kizu A, Miyagishi T (1993). Behaviour therapy for two cases complaining of emitting body odour. Japanese Journal of Behaviour Therapy 19, 3845.
*Kobayashi N, Kurauchi S, Sawamura T, Shigemura J, Sano SY, Nomura S (2003). The effect of paroxetine on Taijinkyofusho: a report of three cases. Psychiatry 66, 262267.
*Kopecek M, Horacek J, Motlova L, Preiss M, Belohlavek O (2004). The 18FDG PET imaging of an olfactory paranoid syndrome (case report). Psychiatrie (Praha) 7, 214217.
*Lochner C, Stein DJ (2003). Olfactory reference syndrome: diagnostic criteria and differential diagnosis. Journal of Postgraduate Medicine 49, 328331.
*McArdle M (1974). Treatment of a phobia. Nursing Times 70, 637639.
*McGoldrick T, Begum M, Brown KW (2008). EMDR and olfactory reference syndrome. Journal of EMDR Practice and Research 2, 6368.
McKenna PJ (1984). Disorders with overvalued ideas. British Journal of Psychiatry 145, 579585.
*Malasi TH, el-Hilu SM, Mirza IA, el-Islam MF (1990). Olfactory delusional syndrome with various aetiologies. British Journal of Psychiatry 156, 256260.
*Masuda Y, Takemura T, Shimizu T, Hishikawa Y (1998). A case with smell-egorrhea symptom improved by administration of risperidone. Japanese Journal of Psychosomatic Medicine 38, 267271.
*Milan MA, Kolko DJ (1982). Paradoxical intention in the treatment of obsessional flatulence ruminations. Journal of Behavior Therapy and Experimental Psychiatry 13, 167172.
*Miyamoto T (1965). Psychiatric problems in patients with self-odors. Dental Outlook (Japan) 25, 461471.
*Monti M, Sambvani N, Sacrini F (1998). Obsessive-compulsive disorders in dermatology. Journal of the European Academy of Dermatology and Venereology 11, 103108.
Munro A (1980 a). Monosymptomatic hypochondriacal psychosis. British Journal of Hospital Medicine 24, 34, 3638.
*Munro A (1980 b). Monosymptomatic hypochondriacal psychosis (MHP): new aspects of an old syndrome. Journal of Psychiatric Treatment and Evaluation 2, 7986.
*Munro A (1981). Delusional hypochondriasis: a description of monosymptomatic hypochondriacal psychosis (MHD). University of Liverpool: Liverpool.
Munro A (1988). Monosymptomatic hypochondriacal psychosis. British Journal of Psychiatry (Suppl.), 3740.
Munro A (1999). Delusional Disorder: Paranoia and Related Illnesses. Cambridge University Press: Cambridge.
*Nakazawa A (1962). Of the illness mentality of people who complain of body smells: a consideration from the anthropological point of view. Psychiatrica et Neurologica Japonica 65, 451469.
*Nelki J (1988). Making sense of a delusion of smell: a psychotherapeutic approach. British Journal of Medical Psychology 61, 267275.
*Oxtoby A, Field EA (1994). Delusional symptoms in dental patients: a report of four cases. British Dental Journal 176, 140143.
Phillips K, Gunderson C, Gruber U, Castle D (2006). Delusions of body malodour: the olfactory reference syndrome. In Olfaction and the Brain (ed. Brewer W., Castle D. and Pantelis C.),pp. 334–353. Cambridge University Press: Cambridge.
Phillips KA (2004). Psychosis in body dysmorphic disorder. Journal of Psychiatric Research 38, 6372.
Phillips KA, Castle DJ (2007). Recognizing and treating olfactory reference syndrome. Current Psychiatry 6, 4965.
*Popella E, Greger J (1965). Smell delusions and smell hallucinations. a clinical contribution to the psychopathology of the sense of smell. Psychiatria et Neurologia (Basel) 149, 171181.
Potts CS (1891). Two cases of hallucination of smell. University of Pennsylvania Medical Magazine, 226.
*Pryse-Phillips W (1968). Olfactory Hallucinations: A Clinical Study. University of London: London.
Pryse-Phillips W (1971). An olfactory reference syndrome. Acta Psychiatrica Scandinavica 47, 484509.
*Sano A, Kakimoto Y (1990). A case in which clomipramine proved effective in relieving body odor phobia and obsessive compulsive symptoms. Seishinigaku (Clinical Psychiatry) 32, 10111012.
Séglas MJ (1892). De l'obsession hallucinatoire et de l'hallucination obsédante. Annales Médico-psychologiques 50, 119130.
*Singh GP (2006). Is olfactory reference syndrome an OCD. Indian Journal of Psychiatry 48, 201202.
*Stein DJ, Le Roux L, Bouwer C, Van Heerden B (1998). Is olfactory reference syndrome an obsessive-compulsive spectrum disorder?: two cases and a discussion. Journal of Neuropsychiatry and Clinical Neurosciences 10, 9699.
*Strnad M, Widdernannová L (1965). Contribution to the psychiatric problem of the pathological conviction about the incontinence of intestinal gases. Psychiatrie (Praha) 61, 113118.
Sutton RL (1919). Bromidrosiphobia. Journal of the American Medical Association 72, 12671268.
*Suwaki H (1971). Sexual problem and guiltfeeling of olfactory paranoid patient. Japanese Journal of Clinical Psychiatry 13, 879883.
*Suzuki K, Takei N, Iwata Y, Sekine Y, Toyoda T, Nakamura K, Minabe Y, Kawai M, Iyo M, Mori N (2004). Do olfactory reference syndrome and jiko-shu-kyofu (a subtype of taijin-kyofu) share a common entity? Acta Psychiatrica Scandinavica 109, 150155.
*Toyofuku A, Umemoto G, Naitou Y, Kikuta T, Miyako H (2000). A case of a halitosis patient who needed behaviour restriction therapy. Japanese Journal of Psychosomatic Dentistry 15, 197202.
*Tsunoda H, Miyaoka H, Takagi K, Tsunoda K, Takamori K, Nagai T, Nakagawa T, Fujino M, Katayama Y (2003). ‘Adolescent paranoia’ complaining of emitting foul breath: report of a case. Japanese Journal of Psychosomatic Dentistry 18, 8588.
Veale D (2002). Over-valued ideas: a conceptual analysis. Behaviour Research and Therapy 40, 383400.
*Videbech T (1966). Chronic olfactory paranoid syndromes. A contribution to the psychopathology of the sense of smell. Acta Psychiatrica Scandinavica 42, 183213.
Walter K (1965). Über das ‘phobische beziehungssyndrom’. Nervenarzt 36, 711.
Wing JK, Cooper JE, Sartorius N (1974). The Measurement and Classification of Psychiatric Symptoms. Cambridge University Press: Cambridge.
*Yamada M, Kashiwamura K, Nakamura Y, Ota T (1977). Fear of emitting bad odours. Bulletin of the Yagamuchi Medical School 24, 141161.
*Yamashita I (1993). Taijin-kyofu or Delusional Social Phobia. Hokkaido University Press: Sapporo.
*Yamazaki T, Morita S, Ogiuchi H (2005). A case of halitophobia with two planned attempts at suicide. Japanese Journal of Psychosomatic Dentistry 20, 1719.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 13
Total number of PDF views: 68 *
Loading metrics...

Abstract views

Total abstract views: 497 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 21st November 2017. This data will be updated every 24 hours.