LAUSR

Olfactory reference syndrome (ORS) is one of several primary psychiatric disorders with which dermatologists can be faced. ORS has been described as a condition in various neuropsychiatric and psychological disorders since 1891, and is characterized by the patient having a preoccupation that they are exuding an offensive body odour that is undetectable to others. Those with ORS often misinterpret others’ behaviour, such as opening a window, as being a reaction to the perceived body odour, whereas in reality an odour is undetectable. This disorder is often accompanied by the patient’s feeling of shame or embarrassment, and by avoidance behaviour, social phobia and social isolation. The exact cause of ORS remains unknown, and diagnosis is often challenging to healthcare professionals, as although some diagnostic criteria exist, a persistent preoccupation with body odours can be witnessed in other psychiatric illnesses or organic diseases. Therefore, an assessment of potential differential diagnoses is essential. A 28-year-old Anglo-Indian man presented to our psychodermatology clinic with concerns about his body odour, which he reported had commenced approximately 5 years previously. He described the odour as ‘foul’, and said it emanated from different parts of his body, particularly around his nose. Although the patient could smell the ‘foul’ odour, nobody else could detect it. The patient also misinterpreted other people’s behaviour (e.g. rubbing their nose) as a reaction to his odour. He had previously sought a dental opinion, but no intraoral disease had been found and his ‘odour’ persisted. He had no other relevant medical or psychiatric history. He was not using prescribed medication, and denied any recreational drug use. Physical examination was normal and no odour could be detected. In our service, patients are seen concurrently by a consultant dermatologist and a consultant liaison psychiatrist. Our psychiatrist carried out a full psychiatric assessment, and based on that, diagnosed the patient as having anxiety and depression. We also diagnosed the ORS (a monosymptomatic delusional hypochondriasis) according to published criteria. The patient’s scores on the Generalised Anxiety Disorder-7 and Patient Health Questionnaire-9 were 5 and 10, respectively. Our patient’s quality of life was severely affected, with a Dermatology Life Quality Index of 26. He refused any alternative explanation for his ‘odour’, believing that there was an underlying, undiagnosed medical pathology. Nevertheless, he confessed that at times, he thought his preoccupation was excessive. Finally, the patient fulfilled the criteria for social anxiety provided by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Tests for liver function, urea, creatinine, electrolytes, and antinuclear antibodies, as well as syphilis and human immunodeficiency virus serology, were all normal or negative. In order to exclude trimethylaminuria (fish odour syndrome) and dymethylglycinuria, a urine test for trimethylamine (TMA), TMA-n-oxide and TMA/TMA-n-oxide ratio was performed, which was also negative/normal. Brain magnetic resonance imaging (MRI) scan was negative for tumours, and temporal lobe epilepsy was excluded clinically. Neurological examination, electroencephalography (EEG) and videoEEG were unremarkable. ’Our patient was commenced on citalopram 20 mg daily for all his conditions. He refused any Correspondence: Dr Maria-Angeliki Gkini, Department of Dermatology, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, E1 1BZ, UK E-mails: [email protected]