Katharine A. Phillips, MD

Ms. A, a 21-year-old teacher, recalled always having been “sensitive,” but when she started her first job at age 19 she began to believe that she emitted an offensive odor. She experienced thoughts that she passed offensive flatus, her breath had a fecal odor, and people noticed and were offended.

Gradually Ms. A became more convinced of these distressing beliefs and began to think that she permeated fecal odor through her skin. She also became sure that colleagues were talking about her and that they complained about her “disgusting” smell.

Patients with olfactory reference syndrome (ORS) falsely believe they emit an offensive body odor. Prominent referential thinking—believing that other people perceive the odor—also is common. To introduce you to ORS, we discuss its clinical diagnosis and treatment based on our review of several hundred cases, including the largest reported series of patients with ORS.^1-4

Box 1

Clinical features of ors

Ms. A quit her job and felt confident enough to work again only when she performed a 2-hour daily cleansing routine, doused herself in per-fume, and placed an incontinence pad in her underwear. Despite these precautions, she still thought her colleagues avoided her.

She always averted her mouth when speaking, held her hand in front of her mouth, and sat far from others and close to the door in meetings. She tried to keep meeting room doors open and believed that colleagues held their hands to their noses to “protect” themselves from her odor.

ORS symptoms are most often reported as beginning when patients are in their mid 20s, although some reports suggest onset during puberty or adolescence.⁴ In clinical series, the ratio of men to women is approximately 2:1.

Preoccupation. Individuals with ORS are preoccupied with the belief that they emit an unpleasant or offensive body odor (Box 1),^1,2,5-9 most commonly:

• flatulence, fecal, or anal odors
  
• general body odor
  
• halitosis
  
• genital odors.^1-3
  

Although most reports suggest that patients focus on one odor, some describe being concerned about several smells simultaneously or different odors over time.^10,11

Referential thinking. As the syndrome’s name implies, many ORS patients have delusions of reference, falsely believing that other people perceive the odor.³ They misinterpret the behavior of others, assuming it is a reaction to how the patient smells (Box 2).^2,3

They may misperceive comments (such as, “It’s stuffy in here”), receiving perfume or soap as a gift, or behaviors such as people sniffing, touching or rubbing their nose, clearing their throat, opening a window to get fresh air, putting a newspaper in front of their face, or looking or moving toward or away from the patient.^1,3,5,7

Because they are ashamed, embarrassed, and concerned about offending others with their odor,¹³ many patients engage in repetitive and “safety” behaviors intended to check, eliminate, or camouflage the supposed odor (Box 3).^1,3,7,12,14

Box 2

• avoid activities such as dating
  
• break off engagements
  
• refuse to travel
  
• move to another town
  
• become housebound.^3,7,10,12
  

The distress and impaired functioning may lead to psychiatric hospitalization, depression, suicidal ideation, suicide attempts, and completed suicide.^7,10,12,15 Pryse-Phillips studied 36 patients with ORS and reported:

• nearly one-half (43%) experienced “suicidal ideas or action”
  
• 2 (5.6%) committed suicide.³
  

Some authors have questioned whether ORS can transform into schizophrenia, but others have found little evidence for this.^3,6

Psychiatric comorbidity. Depression is mentioned most often in the literature.^12,13 In Pryse-Phillips’ 36 ORS patients (who did not have a “primary” depressive disorder), depression symptoms tended to be severe.³ The depression generally is considered secondary to ORS, although Pryse-Phillips evaluated 50 additional patients with ORS symptoms whom she considered to have a “primary” depressive disorder.³ Other psychiatric comorbidities include bipolar disorder, personality disorder, schizophrenia, hypochondriasis, alcohol and/or drug abuse, obsessive-compulsive disorder (OCD), and body dysmorphic disorder.^3,7,15 In a study of 200 individuals with body dysmorphic disorder, 8 had comorbid ORS.¹⁶

Diagnosing ORS

Clinical clues to ORS (Table 1) probably are not present in all patients and some are not specific to ORS. They appear to be common features of the illness, however, and may alert you to its presence. Our clinical impression is that many patients with ORS are secretive about their symptoms because they are ashamed of them. Thus, you need to be alert to clues and specifically inquire about ORS symptoms to detect its presence.

Criteria. DSM-IV-TR and ICD-10 lack specific diagnostic criteria for ORS, instead applying criteria for delusional disorder. One problem with this approach is that delusional disorder criteria specify that any co-occurring mood symptoms must be brief relative to the duration of the delusional periods. This requirement may not be valid when applied to ORS.

In our experience, some patients have protracted depressive symptoms that appear secondary to “primary” ORS symptoms, and another diagnosis—such as psychotic depression—does not appear to account for their symptoms.

We propose working diagnostic criteria for ORS (Table 2), which are similar to those proposed by Lochner and Stein¹⁷ and require empiric validation. Suggested questions for the patient interview (Table 3) can help you identify and diagnose ORS.

Differential diagnosis. Keep in mind that a false belief that one emits a bad smell may be a symptom of schizophrenia, and this would trump an ORS diagnosis if other schizophrenia symptoms are present. Some patients with severe depression may believe they smell bad as part of a nihilistic delusional belief system (such as in Cotard’s syndrome—nihilistic delusions in severe depression).

Whether to conceptualize a false belief about body odor as a symptom of depression or as ORS with comorbid or secondary depression may be unclear from case to case.

Table 1

Clinical clues to the presence of olfactory reference syndrome

Working diagnostic criteria for olfactory reference syndrome

Diagnosing ORS: Suggested questions for patient interview

Treatment-seeking behavior

Ms. A consulted several proctologists and a dentist but was not convinced by their reassurance and continued to believe she “stank.” Her relationship with her boyfriend suffered because she continually asked for reassurance about how she smelled and avoided sexual intercourse because of her odor concerns.

Eventually she confronted her boss about her belief that her coworkers were complaining about her smell. Despite reassurance that she didn’t smell bad, she left her job.

Box 3

Convincing patients such as Ms. A of the falsity of their beliefs can be difficult,¹ and some succeed in having medical procedures or surgery, such as excision of tonsils or axillary glands.^3,7,12 To our knowledge, controlled prospective studies of nonpsychiatric treatments have not been done, but it appears that such treatments usually are ineffective.^1,3,6,9

Psychiatric interventions. Convincing patients with ORS to obtain mental health treatment can be difficult.^2,6 Patients with delusional halitosis “would rather go in search of a ‘better dentist’ than go to a psychiatrist.”¹

To get patients to accept psychiatric treatment, we suggest an approach similar to that recommended for body dysmorphic disorder. It may be helpful, for example, to focus on the distress and disability caused by the odor preoccupation, rather than on whether the patient actually smells bad.

Medication and psychotherapy

Limited evidence. The ORS treatment literature is very limited, consisting largely of case reports and small case series. To our knowledge, no controlled treatment trials have been done, no treatments have been compared head to head, and most studies did not use standardized measurements of psychopathology.

Published data therefore must be interpreted cautiously. Some medication reports used relatively low doses and short treatment durations (although what constitutes an adequate therapeutic trial for ORS is not known). Psychotherapy reports often did not specify details of the intervention or the number and duration of sessions. It is not known whether adding a cognitive component to behavioral therapy enhances efficacy, and the combination of psychotherapy and medication has not been studied systematically. More methodologically rigorous treatment studies are needed.

Because of space limitations, we cite representative case reports in the following section of this treatment review, rather than all of the cases found in our literature search.

Antidepressants. Although most ORS patients are delusional, serotonin reuptake inhibitor (SRI) monotherapy has been reported to be efficacious in 10 of 15 cases (67%). Most of these patients received clomipramine.¹⁸ In reports of non-SRI antidepressants, 6 of 15 cases (43%) responded. Some patients’ symptoms responded to an antidepressant after failing to respond to antipsychotic treatment.¹⁹

Antipsychotics. Pimozide is the most studied medication for ORS, with 15 of 31 cases (48%) responding.^2,20 In a series of 12 patients, pimozide responders received 2 to 4 mg/d, except for one patient who needed 6 mg/d.²¹ Patients usually responded within 1 to 4 weeks (an average time to response was not reported). In 2 of these cases, ORS symptoms recurred after pimozide was discontinued and then remitted again after it was restarted.²¹ In another report,² 7 of 14 patients (50%) responded to pimozide.

Clinicians using other first-generation antipsychotics (trifluoperazine, thioridazine, and chlorpromazine) reported a positive response in only 2 of 19 cases (11%).^12,22

Combination therapy. Ten of 17 cases (59%) of ORS responded to combined treatment with an antidepressant and an antipsychotic.^2,12

Other somatic treatments. Several reports found benzodiazepine monotherapy lacked efficacy, as was the case for electroconvulsive therapy.^12,15 One report noted an unsuccessful outcome with leucotomy and a partial response with bilateral partial division of the thalamo-frontal tract.¹⁵

Psychosocial treatment. All reports of psychosocial therapies are single cases or small series, and none used a control intervention.^2,7,14

Behavioral treatment has been efficacious, although patients require months to years to habituate. Several reports totalling 14 patients describe behavioral treatment over weeks to months.^7,23 These treatments involved exposure to avoided social situations and response prevention, which consisted of refraining from repetitive or camouflaging behaviors such as showering, visits to the toilet, or deodorant use. Gomez-Perez and colleagues²³ noted that exposure therapy was less effective for ORS than for social phobia or OCD.

One report described a patient with flatulence concerns who responded to a paradoxical intention consisting of instructions to emit gas as soon as it was experienced; at 1-year follow-up, her symptoms had not recurred.²⁴

Psychodynamic interventions show no benefit for ORS symptoms.

Treatment summary

Ms. A became increasingly despondent and depressed. She eventually sought the help of her family doctor, who referred her to a psychiatrist. With a combination of a serotonergic antidepressant (escitalopram, 40 mg/d), a low-dose atypical antipsychotic (quetiapine, 50 mg at night), and cognitive-behavioral therapy, she started to re-engage in daily activities. During 6 months of treatment, the intensity of her belief about having body odor abated.

Limited data support the use of SRI monotherapy or an SRI plus an antipsychotic. Using SRI monotherapy for delusional patients may sound counterintuitive, but this approach appears efficacious for patients with delusional body dysmorphic disorder, which has similarities to ORS.^17,25,26

Clinically, we have found the use of atypical antipsychotics as an adjunct to SRIs to be helpful, although this strategy has not been subjected to clinical trials. Pimozide alone or in combination with an antidepressant also appears promising, as does exposure and response prevention. Do not combine pimozide with clomipramine because of the risk of cardiac toxicity.

Related resources

• Phillips KA, Gunderson C, Gruber U, Castle DJ. Delusions of body malodour: the olfactory reference syndrome. In: Brewer W, Castle D, Pantelis C. Olfaction and the brain. Cambridge, UK: Cambridge University Press; 2006:334-53.
  
• Pryse-Phillips W. An olfactory reference syndrome. Acta Psychiatr Scand 1971;47:484-509.
  

• Chlorpromazine • Thorazine
  
• Clomipramine • Anafranil
  
• Escitalopram • Lexapro
  
• Pimozide • Orap
  
• Quetiapine • Seroquel
  
• Thioridazine • Mellaril
  
• Trifluoperazine • Stelazine
  

Dr. Phillips receives research support from the National Institute of Mental Health, the Food and Drug Administration, UCB Pharma, and Forest Pharmaceuticals.

Dr. Castle receives research support from Janssen-Cilag; is a consultant to Eli Lilly and Company., Bristol-Myers Squibb, and Lundbeck; and is a speaker for Eli Lilly and Co., sanofi-aventis, Bristol-Myers Squibb, Janssen-Cilag, Lundbeck, and Organon.

Acknowledgment

The authors would like to thank Craig Gunderson, MD, and Uschi Gruber, MB, for their assistance with a literature search on olfactory reference syndrome.

Ms. A, a 21-year-old teacher, recalled always having been “sensitive,” but when she started her first job at age 19 she began to believe that she emitted an offensive odor. She experienced thoughts that she passed offensive flatus, her breath had a fecal odor, and people noticed and were offended.

Gradually Ms. A became more convinced of these distressing beliefs and began to think that she permeated fecal odor through her skin. She also became sure that colleagues were talking about her and that they complained about her “disgusting” smell.

Patients with olfactory reference syndrome (ORS) falsely believe they emit an offensive body odor. Prominent referential thinking—believing that other people perceive the odor—also is common. To introduce you to ORS, we discuss its clinical diagnosis and treatment based on our review of several hundred cases, including the largest reported series of patients with ORS.^1-4

Box 1

Clinical features of ors

Ms. A quit her job and felt confident enough to work again only when she performed a 2-hour daily cleansing routine, doused herself in per-fume, and placed an incontinence pad in her underwear. Despite these precautions, she still thought her colleagues avoided her.

She always averted her mouth when speaking, held her hand in front of her mouth, and sat far from others and close to the door in meetings. She tried to keep meeting room doors open and believed that colleagues held their hands to their noses to “protect” themselves from her odor.

ORS symptoms are most often reported as beginning when patients are in their mid 20s, although some reports suggest onset during puberty or adolescence.⁴ In clinical series, the ratio of men to women is approximately 2:1.

Preoccupation. Individuals with ORS are preoccupied with the belief that they emit an unpleasant or offensive body odor (Box 1),^1,2,5-9 most commonly:

• flatulence, fecal, or anal odors
  
• general body odor
  
• halitosis
  
• genital odors.^1-3
  

Although most reports suggest that patients focus on one odor, some describe being concerned about several smells simultaneously or different odors over time.^10,11

Referential thinking. As the syndrome’s name implies, many ORS patients have delusions of reference, falsely believing that other people perceive the odor.³ They misinterpret the behavior of others, assuming it is a reaction to how the patient smells (Box 2).^2,3

They may misperceive comments (such as, “It’s stuffy in here”), receiving perfume or soap as a gift, or behaviors such as people sniffing, touching or rubbing their nose, clearing their throat, opening a window to get fresh air, putting a newspaper in front of their face, or looking or moving toward or away from the patient.^1,3,5,7

Because they are ashamed, embarrassed, and concerned about offending others with their odor,¹³ many patients engage in repetitive and “safety” behaviors intended to check, eliminate, or camouflage the supposed odor (Box 3).^1,3,7,12,14

Box 2

• avoid activities such as dating
  
• break off engagements
  
• refuse to travel
  
• move to another town
  
• become housebound.^3,7,10,12
  

The distress and impaired functioning may lead to psychiatric hospitalization, depression, suicidal ideation, suicide attempts, and completed suicide.^7,10,12,15 Pryse-Phillips studied 36 patients with ORS and reported:

• nearly one-half (43%) experienced “suicidal ideas or action”
  
• 2 (5.6%) committed suicide.³
  

Some authors have questioned whether ORS can transform into schizophrenia, but others have found little evidence for this.^3,6

Psychiatric comorbidity. Depression is mentioned most often in the literature.^12,13 In Pryse-Phillips’ 36 ORS patients (who did not have a “primary” depressive disorder), depression symptoms tended to be severe.³ The depression generally is considered secondary to ORS, although Pryse-Phillips evaluated 50 additional patients with ORS symptoms whom she considered to have a “primary” depressive disorder.³ Other psychiatric comorbidities include bipolar disorder, personality disorder, schizophrenia, hypochondriasis, alcohol and/or drug abuse, obsessive-compulsive disorder (OCD), and body dysmorphic disorder.^3,7,15 In a study of 200 individuals with body dysmorphic disorder, 8 had comorbid ORS.¹⁶

Diagnosing ORS

Clinical clues to ORS (Table 1) probably are not present in all patients and some are not specific to ORS. They appear to be common features of the illness, however, and may alert you to its presence. Our clinical impression is that many patients with ORS are secretive about their symptoms because they are ashamed of them. Thus, you need to be alert to clues and specifically inquire about ORS symptoms to detect its presence.

Criteria. DSM-IV-TR and ICD-10 lack specific diagnostic criteria for ORS, instead applying criteria for delusional disorder. One problem with this approach is that delusional disorder criteria specify that any co-occurring mood symptoms must be brief relative to the duration of the delusional periods. This requirement may not be valid when applied to ORS.

In our experience, some patients have protracted depressive symptoms that appear secondary to “primary” ORS symptoms, and another diagnosis—such as psychotic depression—does not appear to account for their symptoms.

We propose working diagnostic criteria for ORS (Table 2), which are similar to those proposed by Lochner and Stein¹⁷ and require empiric validation. Suggested questions for the patient interview (Table 3) can help you identify and diagnose ORS.

Differential diagnosis. Keep in mind that a false belief that one emits a bad smell may be a symptom of schizophrenia, and this would trump an ORS diagnosis if other schizophrenia symptoms are present. Some patients with severe depression may believe they smell bad as part of a nihilistic delusional belief system (such as in Cotard’s syndrome—nihilistic delusions in severe depression).

Whether to conceptualize a false belief about body odor as a symptom of depression or as ORS with comorbid or secondary depression may be unclear from case to case.

Table 1

Clinical clues to the presence of olfactory reference syndrome

Working diagnostic criteria for olfactory reference syndrome

Diagnosing ORS: Suggested questions for patient interview

Treatment-seeking behavior

Ms. A consulted several proctologists and a dentist but was not convinced by their reassurance and continued to believe she “stank.” Her relationship with her boyfriend suffered because she continually asked for reassurance about how she smelled and avoided sexual intercourse because of her odor concerns.

Eventually she confronted her boss about her belief that her coworkers were complaining about her smell. Despite reassurance that she didn’t smell bad, she left her job.

Box 3

Convincing patients such as Ms. A of the falsity of their beliefs can be difficult,¹ and some succeed in having medical procedures or surgery, such as excision of tonsils or axillary glands.^3,7,12 To our knowledge, controlled prospective studies of nonpsychiatric treatments have not been done, but it appears that such treatments usually are ineffective.^1,3,6,9

Psychiatric interventions. Convincing patients with ORS to obtain mental health treatment can be difficult.^2,6 Patients with delusional halitosis “would rather go in search of a ‘better dentist’ than go to a psychiatrist.”¹

To get patients to accept psychiatric treatment, we suggest an approach similar to that recommended for body dysmorphic disorder. It may be helpful, for example, to focus on the distress and disability caused by the odor preoccupation, rather than on whether the patient actually smells bad.

Medication and psychotherapy

Limited evidence. The ORS treatment literature is very limited, consisting largely of case reports and small case series. To our knowledge, no controlled treatment trials have been done, no treatments have been compared head to head, and most studies did not use standardized measurements of psychopathology.

Published data therefore must be interpreted cautiously. Some medication reports used relatively low doses and short treatment durations (although what constitutes an adequate therapeutic trial for ORS is not known). Psychotherapy reports often did not specify details of the intervention or the number and duration of sessions. It is not known whether adding a cognitive component to behavioral therapy enhances efficacy, and the combination of psychotherapy and medication has not been studied systematically. More methodologically rigorous treatment studies are needed.

Because of space limitations, we cite representative case reports in the following section of this treatment review, rather than all of the cases found in our literature search.

Antidepressants. Although most ORS patients are delusional, serotonin reuptake inhibitor (SRI) monotherapy has been reported to be efficacious in 10 of 15 cases (67%). Most of these patients received clomipramine.¹⁸ In reports of non-SRI antidepressants, 6 of 15 cases (43%) responded. Some patients’ symptoms responded to an antidepressant after failing to respond to antipsychotic treatment.¹⁹

Antipsychotics. Pimozide is the most studied medication for ORS, with 15 of 31 cases (48%) responding.^2,20 In a series of 12 patients, pimozide responders received 2 to 4 mg/d, except for one patient who needed 6 mg/d.²¹ Patients usually responded within 1 to 4 weeks (an average time to response was not reported). In 2 of these cases, ORS symptoms recurred after pimozide was discontinued and then remitted again after it was restarted.²¹ In another report,² 7 of 14 patients (50%) responded to pimozide.

Clinicians using other first-generation antipsychotics (trifluoperazine, thioridazine, and chlorpromazine) reported a positive response in only 2 of 19 cases (11%).^12,22

Combination therapy. Ten of 17 cases (59%) of ORS responded to combined treatment with an antidepressant and an antipsychotic.^2,12

Other somatic treatments. Several reports found benzodiazepine monotherapy lacked efficacy, as was the case for electroconvulsive therapy.^12,15 One report noted an unsuccessful outcome with leucotomy and a partial response with bilateral partial division of the thalamo-frontal tract.¹⁵

Psychosocial treatment. All reports of psychosocial therapies are single cases or small series, and none used a control intervention.^2,7,14

Behavioral treatment has been efficacious, although patients require months to years to habituate. Several reports totalling 14 patients describe behavioral treatment over weeks to months.^7,23 These treatments involved exposure to avoided social situations and response prevention, which consisted of refraining from repetitive or camouflaging behaviors such as showering, visits to the toilet, or deodorant use. Gomez-Perez and colleagues²³ noted that exposure therapy was less effective for ORS than for social phobia or OCD.

One report described a patient with flatulence concerns who responded to a paradoxical intention consisting of instructions to emit gas as soon as it was experienced; at 1-year follow-up, her symptoms had not recurred.²⁴

Psychodynamic interventions show no benefit for ORS symptoms.

Treatment summary

Ms. A became increasingly despondent and depressed. She eventually sought the help of her family doctor, who referred her to a psychiatrist. With a combination of a serotonergic antidepressant (escitalopram, 40 mg/d), a low-dose atypical antipsychotic (quetiapine, 50 mg at night), and cognitive-behavioral therapy, she started to re-engage in daily activities. During 6 months of treatment, the intensity of her belief about having body odor abated.

Limited data support the use of SRI monotherapy or an SRI plus an antipsychotic. Using SRI monotherapy for delusional patients may sound counterintuitive, but this approach appears efficacious for patients with delusional body dysmorphic disorder, which has similarities to ORS.^17,25,26

Clinically, we have found the use of atypical antipsychotics as an adjunct to SRIs to be helpful, although this strategy has not been subjected to clinical trials. Pimozide alone or in combination with an antidepressant also appears promising, as does exposure and response prevention. Do not combine pimozide with clomipramine because of the risk of cardiac toxicity.

Related resources

• Phillips KA, Gunderson C, Gruber U, Castle DJ. Delusions of body malodour: the olfactory reference syndrome. In: Brewer W, Castle D, Pantelis C. Olfaction and the brain. Cambridge, UK: Cambridge University Press; 2006:334-53.
  
• Pryse-Phillips W. An olfactory reference syndrome. Acta Psychiatr Scand 1971;47:484-509.
  

• Chlorpromazine • Thorazine
  
• Clomipramine • Anafranil
  
• Escitalopram • Lexapro
  
• Pimozide • Orap
  
• Quetiapine • Seroquel
  
• Thioridazine • Mellaril
  
• Trifluoperazine • Stelazine
  

Dr. Phillips receives research support from the National Institute of Mental Health, the Food and Drug Administration, UCB Pharma, and Forest Pharmaceuticals.

Dr. Castle receives research support from Janssen-Cilag; is a consultant to Eli Lilly and Company., Bristol-Myers Squibb, and Lundbeck; and is a speaker for Eli Lilly and Co., sanofi-aventis, Bristol-Myers Squibb, Janssen-Cilag, Lundbeck, and Organon.

Acknowledgment

The authors would like to thank Craig Gunderson, MD, and Uschi Gruber, MB, for their assistance with a literature search on olfactory reference syndrome.

Ms. A, a 21-year-old teacher, recalled always having been “sensitive,” but when she started her first job at age 19 she began to believe that she emitted an offensive odor. She experienced thoughts that she passed offensive flatus, her breath had a fecal odor, and people noticed and were offended.

Gradually Ms. A became more convinced of these distressing beliefs and began to think that she permeated fecal odor through her skin. She also became sure that colleagues were talking about her and that they complained about her “disgusting” smell.

Patients with olfactory reference syndrome (ORS) falsely believe they emit an offensive body odor. Prominent referential thinking—believing that other people perceive the odor—also is common. To introduce you to ORS, we discuss its clinical diagnosis and treatment based on our review of several hundred cases, including the largest reported series of patients with ORS.^1-4

Box 1

Clinical features of ors

Ms. A quit her job and felt confident enough to work again only when she performed a 2-hour daily cleansing routine, doused herself in per-fume, and placed an incontinence pad in her underwear. Despite these precautions, she still thought her colleagues avoided her.

She always averted her mouth when speaking, held her hand in front of her mouth, and sat far from others and close to the door in meetings. She tried to keep meeting room doors open and believed that colleagues held their hands to their noses to “protect” themselves from her odor.

ORS symptoms are most often reported as beginning when patients are in their mid 20s, although some reports suggest onset during puberty or adolescence.⁴ In clinical series, the ratio of men to women is approximately 2:1.

Preoccupation. Individuals with ORS are preoccupied with the belief that they emit an unpleasant or offensive body odor (Box 1),^1,2,5-9 most commonly:

• flatulence, fecal, or anal odors
  
• general body odor
  
• halitosis
  
• genital odors.^1-3
  

Although most reports suggest that patients focus on one odor, some describe being concerned about several smells simultaneously or different odors over time.^10,11

Referential thinking. As the syndrome’s name implies, many ORS patients have delusions of reference, falsely believing that other people perceive the odor.³ They misinterpret the behavior of others, assuming it is a reaction to how the patient smells (Box 2).^2,3

They may misperceive comments (such as, “It’s stuffy in here”), receiving perfume or soap as a gift, or behaviors such as people sniffing, touching or rubbing their nose, clearing their throat, opening a window to get fresh air, putting a newspaper in front of their face, or looking or moving toward or away from the patient.^1,3,5,7

Because they are ashamed, embarrassed, and concerned about offending others with their odor,¹³ many patients engage in repetitive and “safety” behaviors intended to check, eliminate, or camouflage the supposed odor (Box 3).^1,3,7,12,14

Box 2

• avoid activities such as dating
  
• break off engagements
  
• refuse to travel
  
• move to another town
  
• become housebound.^3,7,10,12
  

The distress and impaired functioning may lead to psychiatric hospitalization, depression, suicidal ideation, suicide attempts, and completed suicide.^7,10,12,15 Pryse-Phillips studied 36 patients with ORS and reported:

• nearly one-half (43%) experienced “suicidal ideas or action”
  
• 2 (5.6%) committed suicide.³
  

Some authors have questioned whether ORS can transform into schizophrenia, but others have found little evidence for this.^3,6

Psychiatric comorbidity. Depression is mentioned most often in the literature.^12,13 In Pryse-Phillips’ 36 ORS patients (who did not have a “primary” depressive disorder), depression symptoms tended to be severe.³ The depression generally is considered secondary to ORS, although Pryse-Phillips evaluated 50 additional patients with ORS symptoms whom she considered to have a “primary” depressive disorder.³ Other psychiatric comorbidities include bipolar disorder, personality disorder, schizophrenia, hypochondriasis, alcohol and/or drug abuse, obsessive-compulsive disorder (OCD), and body dysmorphic disorder.^3,7,15 In a study of 200 individuals with body dysmorphic disorder, 8 had comorbid ORS.¹⁶

Diagnosing ORS

Clinical clues to ORS (Table 1) probably are not present in all patients and some are not specific to ORS. They appear to be common features of the illness, however, and may alert you to its presence. Our clinical impression is that many patients with ORS are secretive about their symptoms because they are ashamed of them. Thus, you need to be alert to clues and specifically inquire about ORS symptoms to detect its presence.

Criteria. DSM-IV-TR and ICD-10 lack specific diagnostic criteria for ORS, instead applying criteria for delusional disorder. One problem with this approach is that delusional disorder criteria specify that any co-occurring mood symptoms must be brief relative to the duration of the delusional periods. This requirement may not be valid when applied to ORS.

In our experience, some patients have protracted depressive symptoms that appear secondary to “primary” ORS symptoms, and another diagnosis—such as psychotic depression—does not appear to account for their symptoms.

We propose working diagnostic criteria for ORS (Table 2), which are similar to those proposed by Lochner and Stein¹⁷ and require empiric validation. Suggested questions for the patient interview (Table 3) can help you identify and diagnose ORS.

Differential diagnosis. Keep in mind that a false belief that one emits a bad smell may be a symptom of schizophrenia, and this would trump an ORS diagnosis if other schizophrenia symptoms are present. Some patients with severe depression may believe they smell bad as part of a nihilistic delusional belief system (such as in Cotard’s syndrome—nihilistic delusions in severe depression).

Whether to conceptualize a false belief about body odor as a symptom of depression or as ORS with comorbid or secondary depression may be unclear from case to case.

Table 1

Clinical clues to the presence of olfactory reference syndrome

Working diagnostic criteria for olfactory reference syndrome

Diagnosing ORS: Suggested questions for patient interview

Treatment-seeking behavior

Ms. A consulted several proctologists and a dentist but was not convinced by their reassurance and continued to believe she “stank.” Her relationship with her boyfriend suffered because she continually asked for reassurance about how she smelled and avoided sexual intercourse because of her odor concerns.

Eventually she confronted her boss about her belief that her coworkers were complaining about her smell. Despite reassurance that she didn’t smell bad, she left her job.

Box 3

Convincing patients such as Ms. A of the falsity of their beliefs can be difficult,¹ and some succeed in having medical procedures or surgery, such as excision of tonsils or axillary glands.^3,7,12 To our knowledge, controlled prospective studies of nonpsychiatric treatments have not been done, but it appears that such treatments usually are ineffective.^1,3,6,9

Psychiatric interventions. Convincing patients with ORS to obtain mental health treatment can be difficult.^2,6 Patients with delusional halitosis “would rather go in search of a ‘better dentist’ than go to a psychiatrist.”¹

To get patients to accept psychiatric treatment, we suggest an approach similar to that recommended for body dysmorphic disorder. It may be helpful, for example, to focus on the distress and disability caused by the odor preoccupation, rather than on whether the patient actually smells bad.

Medication and psychotherapy

Limited evidence. The ORS treatment literature is very limited, consisting largely of case reports and small case series. To our knowledge, no controlled treatment trials have been done, no treatments have been compared head to head, and most studies did not use standardized measurements of psychopathology.

Published data therefore must be interpreted cautiously. Some medication reports used relatively low doses and short treatment durations (although what constitutes an adequate therapeutic trial for ORS is not known). Psychotherapy reports often did not specify details of the intervention or the number and duration of sessions. It is not known whether adding a cognitive component to behavioral therapy enhances efficacy, and the combination of psychotherapy and medication has not been studied systematically. More methodologically rigorous treatment studies are needed.

Because of space limitations, we cite representative case reports in the following section of this treatment review, rather than all of the cases found in our literature search.

Antidepressants. Although most ORS patients are delusional, serotonin reuptake inhibitor (SRI) monotherapy has been reported to be efficacious in 10 of 15 cases (67%). Most of these patients received clomipramine.¹⁸ In reports of non-SRI antidepressants, 6 of 15 cases (43%) responded. Some patients’ symptoms responded to an antidepressant after failing to respond to antipsychotic treatment.¹⁹

Antipsychotics. Pimozide is the most studied medication for ORS, with 15 of 31 cases (48%) responding.^2,20 In a series of 12 patients, pimozide responders received 2 to 4 mg/d, except for one patient who needed 6 mg/d.²¹ Patients usually responded within 1 to 4 weeks (an average time to response was not reported). In 2 of these cases, ORS symptoms recurred after pimozide was discontinued and then remitted again after it was restarted.²¹ In another report,² 7 of 14 patients (50%) responded to pimozide.

Clinicians using other first-generation antipsychotics (trifluoperazine, thioridazine, and chlorpromazine) reported a positive response in only 2 of 19 cases (11%).^12,22

Combination therapy. Ten of 17 cases (59%) of ORS responded to combined treatment with an antidepressant and an antipsychotic.^2,12

Other somatic treatments. Several reports found benzodiazepine monotherapy lacked efficacy, as was the case for electroconvulsive therapy.^12,15 One report noted an unsuccessful outcome with leucotomy and a partial response with bilateral partial division of the thalamo-frontal tract.¹⁵

Psychosocial treatment. All reports of psychosocial therapies are single cases or small series, and none used a control intervention.^2,7,14

Behavioral treatment has been efficacious, although patients require months to years to habituate. Several reports totalling 14 patients describe behavioral treatment over weeks to months.^7,23 These treatments involved exposure to avoided social situations and response prevention, which consisted of refraining from repetitive or camouflaging behaviors such as showering, visits to the toilet, or deodorant use. Gomez-Perez and colleagues²³ noted that exposure therapy was less effective for ORS than for social phobia or OCD.

One report described a patient with flatulence concerns who responded to a paradoxical intention consisting of instructions to emit gas as soon as it was experienced; at 1-year follow-up, her symptoms had not recurred.²⁴

Psychodynamic interventions show no benefit for ORS symptoms.

Treatment summary

Ms. A became increasingly despondent and depressed. She eventually sought the help of her family doctor, who referred her to a psychiatrist. With a combination of a serotonergic antidepressant (escitalopram, 40 mg/d), a low-dose atypical antipsychotic (quetiapine, 50 mg at night), and cognitive-behavioral therapy, she started to re-engage in daily activities. During 6 months of treatment, the intensity of her belief about having body odor abated.

Limited data support the use of SRI monotherapy or an SRI plus an antipsychotic. Using SRI monotherapy for delusional patients may sound counterintuitive, but this approach appears efficacious for patients with delusional body dysmorphic disorder, which has similarities to ORS.^17,25,26

Clinically, we have found the use of atypical antipsychotics as an adjunct to SRIs to be helpful, although this strategy has not been subjected to clinical trials. Pimozide alone or in combination with an antidepressant also appears promising, as does exposure and response prevention. Do not combine pimozide with clomipramine because of the risk of cardiac toxicity.

Related resources

• Phillips KA, Gunderson C, Gruber U, Castle DJ. Delusions of body malodour: the olfactory reference syndrome. In: Brewer W, Castle D, Pantelis C. Olfaction and the brain. Cambridge, UK: Cambridge University Press; 2006:334-53.
  
• Pryse-Phillips W. An olfactory reference syndrome. Acta Psychiatr Scand 1971;47:484-509.
  

• Chlorpromazine • Thorazine
  
• Clomipramine • Anafranil
  
• Escitalopram • Lexapro
  
• Pimozide • Orap
  
• Quetiapine • Seroquel
  
• Thioridazine • Mellaril
  
• Trifluoperazine • Stelazine
  

Dr. Phillips receives research support from the National Institute of Mental Health, the Food and Drug Administration, UCB Pharma, and Forest Pharmaceuticals.

Dr. Castle receives research support from Janssen-Cilag; is a consultant to Eli Lilly and Company., Bristol-Myers Squibb, and Lundbeck; and is a speaker for Eli Lilly and Co., sanofi-aventis, Bristol-Myers Squibb, Janssen-Cilag, Lundbeck, and Organon.

Acknowledgment

The authors would like to thank Craig Gunderson, MD, and Uschi Gruber, MB, for their assistance with a literature search on olfactory reference syndrome.

A 52-year-old man becomes intoxicated with alcohol so he can lie in his backyard and get a tan. Convinced that his skin is too pale and that he looks “like a ghost,” he is so self-conscious about how he looks that he can’t go outside without drinking excessively.

An attractive 23-year-old woman dropped out of the 10th grade because of her “hideous” appearance and has hidden in her bedroom in her parents’ house ever since. She leaves her room no more than once a month, only after covering her face with a veil, not letting even her family see her face.

A middle-aged man cuts his nose open with a razor blade, trying to remove his nasal cartilage and replace it with chicken cartilage, in the desired shape.

These patients have body dysmorphic disorder (BDD), a somatoform disorder that the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) defines as a preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning that are not attributed to another mental disorder.

Most of us are dissatisfied with some aspect of how we look. In fact, more than half of all women and nearly half of all men in the United States are dissatisfied with their overall appearance.¹ As the preceding cases illustrate, however, BDD does not consist simply of normal appearance concerns.

BDD is a relatively common disorder² (Box 1) that occurs in children as well as adults. It usually begins during the early teenage years.² BDD has been described around the world for more than a century.³ It causes notable distress and impaired functioning, and can lead to suicide.⁴ This disorder typically goes undiagnosed in clinical settings, however, in part because many patients are too embarrassed and ashamed to discuss their symptoms with their physicians unless specifically asked.^2,5 BDD often masquerades as other psychiatric disorders, and misdiagnosis appears common⁶ (Table 1). Diagnosing BDD is usually straightforward, however, and can be achieved using the questions in Box 2.⁴ Clues to the presence of BDD are presented in Box 3; patients who present with any of them should be carefully evaluated for BDD.

Box 1

Perceptions of patients with BDD

Individuals with BDD obsess that there is something wrong with their appearance when in fact they look fine; the perceived flaw is actually minimal or nonexistent.⁷ Prior to treatment, insight is usually poor or absent, however, so that most patients are convinced or fairly certain that they look abnormal.^2,8 They may describe the perceived flaw as unattractive or deformed, or they may even say that they look like a freak, a monster, or the “elephant man” (Box 4). Individuals with this disorder think about the perceived appearance flaws, on average, for 3 to 8 hours a day, and they usually find the thoughts difficult to resist or control.⁹ Diagnostic errors that cause BDD to be missed

Table 1

Diagnostic errors that cause BDD to be missed

Although repetitive behaviors are not part of BDD’s diagnostic criteria, virtually all patients perform such behaviors, usually in an attempt to improve, hide, examine, or be reassured about the perceived flaw.^7,9 (See Box 3 for a partial listing.) These behaviors are usually time-consuming, occurring for many hours a day, and, like the preoccupations, are typically difficult to resist or control. With the exception of camouflaging, however, they often do not diminish appearance concerns. In fact, some of them (e.g., mirror checking) may actually increase anxiety about the perceived flaw.

Comorbidity is common in patients seen in clinical settings.^2,8 Major depression is the most frequent comorbid disorder, which often appears secondary to BDD.¹⁰ Other common comorbidities include substance-use disorders, obsessive-compulsive disorder (OCD), social phobia, and personality disorders (most often, avoidant personality disorder).

Individuals with BDD are distressed over their appearance, many to the point of contemplating, attempting, or completing suicide.^4,5 Nearly one quarter of patients seen in a clinical setting have attempted suicide.⁹ Although some patients appear to function reasonably well, they usually function below their capacity—for example, by avoiding social situations or meetings at work where others will see them. Others are completely incapacitated by their BDD symptoms, unable to work or socialize, and may be housebound for years.^2,8,9 In a study that used the SF-36 to measure health-related quality of life, outpatients with BDD scored notably worse in all mental health domains than did the general U.S. population and patients with depression, type II diabetes, or a recent myocardial infarction.²

Box 2

Box 3

BDD CLUES

 

• Mirror checking or avoidance, or checking other reflective surfaces, such as windows, car bumpers, or the backs of spoons
• Reassurance seeking, that is, asking other people how they look or insisting that they look bad
• Skin picking, which may be manifested by skin lesions or scarring
• Excessive grooming, for example hair styling, applying makeup, shaving, tweezing hair, or cutting hair or wigs
• Camouflaging with a hat, toupee, makeup, sunglasses, clothes, or body position
• Excessive tanning, to darken “pale” skin
• Ideas or delusions of reference, thinking others take special notice of the “flaw” in a negative way (e.g., mock it or stare at it)
• Treatment-resistant anxiety, especially social anxiety, or depression
• Social avoidance or being housebound
• Unnecessary surgery, dermatologic treatment, or other nonpsychiatric treatment (e.g., electrolysis)

Guidelines for treating BDD

• Establish trust. It is important to convey that you take the patient’s appearance concerns seriously. Many patients with BDD fear being considered silly or vain and do not divulge their symptoms. It is usually best to avoid reassuring patients that they look fine, since they usually do not believe the reassurance and can interpret it as trivializing their concerns.
• Provide psychoeducation. Explain to patients that they have a relatively common and treatable body image disorder. To decrease the patient’s reluctance to accept the diagnosis and treatment, it can be helpful to emphasize the excessive preoccupation, distress, and other problems their symptoms are causing. Discussions about whether the defect is “real” are usually fruitless, unless the patient already has good insight, which is rare. Several educational books and Web sites for patients are available. See Related Resources.
• Target BDD symptoms in treatment. Ignoring BDD symptoms and focusing treatment on other symptoms only may be unsuccessful because effective treatment for BDD differs in some important ways from that of most other psychiatric disorders, such as depression.¹⁰ It appears, for example, that non-selective serotonin reuptake inhibitor (SSRI) antidepressants are generally ineffective for BDD, unless used at higher SSRI doses than are often needed for depression. BDD symptoms also do not necessarily improve in concert with symptoms of other disorders, such as depression or OCD.¹⁰
• Avoid nonpsychiatric medical treatment. Although no one can predict how an individual patient will respond to nonpsychiatric treatment, (e.g., surgery or dermatologic treatment), explain that as best we know, such treatment usually appears to be ineffective for BDD and even can make the symptoms worse.¹¹

Which psychopharmaceuticals should you consider?

Although BDD’s response to pharmacotherapy has received far less investigation than that of many other psychiatric disorders, research on this treatment approach has dramatically increased in recent years. The following strategies are suggested on the basis of evidence from controlled studies, open-label trials, and the author’s clinical experience (Figure 1):^2,6,8,12-17

Box 4

CASE REPORT

‘I’m as ugly as the elephant man’

Chris is a shy, anxious-appearing, 31-year-old man who was hospitalized after attempting suicide. He wears a baseball cap pulled down over his forehead and partially covering his eyes. It is difficult for him to reveal the reason for his suicide attempt: “It’s really hard to talk about this. I don’t know if I can. It’s too embarrassing.” Then he adds, “Well I guess I should tell you—after all, I’m in the hospital because of it. It’s my nose—these huge pock marks on my nose. They’re grotesque! I look like a monster. I’m as ugly as the elephant man!

“These marks on my nose are all I can think about. I’ve thought about them for hours a day every day for the past 15 years. I even have nightmares about them. And I think that everyone can see them and that they laugh at me because of them. That’s why I wear this hat all the time. And that’s why I couldn’t talk to you in a bright room. You’d notice the marks and see how ugly I am.” Chris actually appeared entirely normal, but no one could convince him of this.

“This has affected me in a lot of ways,” Chris adds. “This may be hard for you to believe, but this problem has ruined my life. All I can think about is my face, and I spend hours a day looking at the marks in the mirror. I just can’t resist. I thought I looked so ugly that I started missing more and more work, and I stopped going out with my friends and my girlfriend. I got so anxious when people looked at me that I started staying in the house most of the time. Sometimes when I did go out, I went through red lights so I wouldn’t have to sit at the light, where people might be staring at me. The hat helped a little, but it didn’t cover all the marks. I tried covering them with makeup for a while, but I thought people could see the makeup so that didn’t really help. The only time I really felt comfortable is when I wore my nephew’s Batman mask on Halloween—then no one could see the marks.

I finally missed so much work that I was fired. My girlfriend stuck it out with me for a long time, but finally she couldn’t take it any more. One thing that was really hard for her was that I started asking her about 50 times a day whether I looked OK and whether she could see the marks—I think that was the final straw. If I had a choice, I’d rather have cancer. It must be less painful. This is like an arrow through my heart.”

Chris had a notable, although only partial, response to fluoxetine 100 mg/d and buspirone 60 mg/d (higher doses of fluoxetine and buspirone were tried but were not more effective). Adding clonazepam was helpful for severe anxiety. Clomipramine, venlafaxine, lithium, mirtazapine, and various antipsychotics were sequentially added to this regimen, with minimal success, although a second trial of olanzapine, at a higher dose (15 mg/d) than he had been willing to try previously, further decreased Chris’ BDD and depressive symptoms. The addition of bupropion was somewhat helpful for depression but not for BDD.

Figure 1 Proposed pharmacotherapy for treating BDD

• Use an SSRI as a first-line approach. Other medications, including other antidepressants, appear less effective than SSRIs or clomipramine.^2,8,9,13,15 An SSRI or clomipramine is also recommended for patients with delusional BDD (those who are completely convinced that they look abnormal and cannot be convinced otherwise), as Proposed pharmacotherapy for treating BDD these patients appear to respond to SSRIs as well as nondelusional patients do.^12-17
• Use the maximum recommended or tolerated SSRI dose if lower doses are ineffective. Although no studies have compared different SSRI dosages, BDD appears to often require higher doses than those that are typically used for depression.

In a chart-review study of 90 patients with BDD treated in the author’s clinical practice, the mean SSRI doses used were fluoxetine 66.7 ±23.5 mg/d, fluvoxamine 308.3 ±49.2 mg/d, paroxetine 55.0 ± 12.9 mg/d, sertraline 202.1 ± 45.8 mg/d, and clomipramine 203.3 ±52.5 mg/d.¹⁷ Some patients respond only to doses higher than the maximum recommended dose (for example, 80-100 mg/d of citalopram or paroxetine).

• Treat for 12 to 16 weeks with an SSRI before concluding that the medication is ineffective. The average time to response is between 6 to 9 weeks.^12,14,16 Clinical experience suggests that with continued treatment, relapse is rare and many patients further improve.
• Try sequential SSRIs if the first or second one does not work. A substantial percentage of patients who fail an initial SSRI trial will respond to a subsequent SSRI.¹⁷
• Continue an effective SSRI for at least 1 year before discontinuing it, as relapse appears likely with discontinuation.¹⁷ Severely ill patients may require treatment for life.
• Several SSRI augmentation and combination strategies might be helpful (Figure 1).^16,17 If clomipramine is used in combination with an SSRI, the clomipramine level should be monitored.

What is the role of psychotherapy?

Although research on psychotherapy for BDD is limited, findings from clinical series and studies using waiting-list controls indicate that cognitive-behavioral therapy (CBT) is often effective.^18-20 In contrast, supportive psychotherapy and insight-oriented and psychodynamic psychotherapy alone appear to be ineffective.⁹ CBT usually consists of a cognitive element (e.g., changing distorted views of the appearance “flaw”), exposure to feared and avoided situations (often social), and response prevention, avoiding repetitive behaviors such as excessive grooming.

• Consider using CBT as a first-line approach for milder BDD without significant comorbidity requiring pharmacotherapy.
• Use more intensive CBT treatment including frequent sessions and use of homework rather than less intensive treatment, although the optimal number and frequency of sessions is unknown.
• Consider maintenance and booster sessions for patients with more severe BDD following treatment to prevent relapse.
• Consider combining CBT and an SSRI. Although it is not known whether a combination of these treatments is more effective than either one alone, they are compatible and their combination may benefit certain patients. For patients with severe BDD, especially very depressed or suicidal patients, it is probably best to use CBT in combination with medication only, as sicker patients may not be able to tolerate or participate in CBT without first experiencing some improvement with medication.

Related Resources

• Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press, 1996.
• Pope HG, Phillips KA, Olivardia R. The Adonis Complex: The Secret Crisis of Male Body Obsession. New York, NY: The Free Press, 2000.
• Phillips KA, Van Noppen B, Shapiro L. Learning to Live with Body Dysmorphic Disorder. Milford, Conn: Obsessive-Compulsive Foundation, 1997.
• Body Dysmorphic Disorder (BDD)and Body Image Program Homepage at Butler Hospital (Providence, RI). http://www.bodyimageprogram.com

Drug brand names

• Bupropion • Wellbutrin, Zyban
• Buspirone • Buspar
• Citalopram • Celexa
• Clomipramine • Anafranil
• Clonazepam • Ativan, Diastat, Halcion
• Fluoxetine • Prozac, Sarafem
• Fluvoxamine • Luvox
• Mirtazapine • Remeron, Remeron Solitab
• Olanzapine • Zyprexa
• Paroxetine • Paxil
• Sertraline • Zoloft
• Venlafaxine • Effexor

Disclosure

The author reports that she receives grant support and occasional speaking honoraria from Eli Lilly and Co.; receives grant support from Forest Pharmaceuticals and Gate Pharmaceuticals; is on the speakers' bureau of Solvay Pharmaceuticals; and serves as a consultant for Wyeth-Ayerst Pharmaceuticals.

A 52-year-old man becomes intoxicated with alcohol so he can lie in his backyard and get a tan. Convinced that his skin is too pale and that he looks “like a ghost,” he is so self-conscious about how he looks that he can’t go outside without drinking excessively.

An attractive 23-year-old woman dropped out of the 10th grade because of her “hideous” appearance and has hidden in her bedroom in her parents’ house ever since. She leaves her room no more than once a month, only after covering her face with a veil, not letting even her family see her face.

A middle-aged man cuts his nose open with a razor blade, trying to remove his nasal cartilage and replace it with chicken cartilage, in the desired shape.

These patients have body dysmorphic disorder (BDD), a somatoform disorder that the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) defines as a preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning that are not attributed to another mental disorder.

Most of us are dissatisfied with some aspect of how we look. In fact, more than half of all women and nearly half of all men in the United States are dissatisfied with their overall appearance.¹ As the preceding cases illustrate, however, BDD does not consist simply of normal appearance concerns.

BDD is a relatively common disorder² (Box 1) that occurs in children as well as adults. It usually begins during the early teenage years.² BDD has been described around the world for more than a century.³ It causes notable distress and impaired functioning, and can lead to suicide.⁴ This disorder typically goes undiagnosed in clinical settings, however, in part because many patients are too embarrassed and ashamed to discuss their symptoms with their physicians unless specifically asked.^2,5 BDD often masquerades as other psychiatric disorders, and misdiagnosis appears common⁶ (Table 1). Diagnosing BDD is usually straightforward, however, and can be achieved using the questions in Box 2.⁴ Clues to the presence of BDD are presented in Box 3; patients who present with any of them should be carefully evaluated for BDD.

Box 1

Perceptions of patients with BDD

Individuals with BDD obsess that there is something wrong with their appearance when in fact they look fine; the perceived flaw is actually minimal or nonexistent.⁷ Prior to treatment, insight is usually poor or absent, however, so that most patients are convinced or fairly certain that they look abnormal.^2,8 They may describe the perceived flaw as unattractive or deformed, or they may even say that they look like a freak, a monster, or the “elephant man” (Box 4). Individuals with this disorder think about the perceived appearance flaws, on average, for 3 to 8 hours a day, and they usually find the thoughts difficult to resist or control.⁹ Diagnostic errors that cause BDD to be missed

Table 1

Diagnostic errors that cause BDD to be missed

Although repetitive behaviors are not part of BDD’s diagnostic criteria, virtually all patients perform such behaviors, usually in an attempt to improve, hide, examine, or be reassured about the perceived flaw.^7,9 (See Box 3 for a partial listing.) These behaviors are usually time-consuming, occurring for many hours a day, and, like the preoccupations, are typically difficult to resist or control. With the exception of camouflaging, however, they often do not diminish appearance concerns. In fact, some of them (e.g., mirror checking) may actually increase anxiety about the perceived flaw.

Comorbidity is common in patients seen in clinical settings.^2,8 Major depression is the most frequent comorbid disorder, which often appears secondary to BDD.¹⁰ Other common comorbidities include substance-use disorders, obsessive-compulsive disorder (OCD), social phobia, and personality disorders (most often, avoidant personality disorder).

Individuals with BDD are distressed over their appearance, many to the point of contemplating, attempting, or completing suicide.^4,5 Nearly one quarter of patients seen in a clinical setting have attempted suicide.⁹ Although some patients appear to function reasonably well, they usually function below their capacity—for example, by avoiding social situations or meetings at work where others will see them. Others are completely incapacitated by their BDD symptoms, unable to work or socialize, and may be housebound for years.^2,8,9 In a study that used the SF-36 to measure health-related quality of life, outpatients with BDD scored notably worse in all mental health domains than did the general U.S. population and patients with depression, type II diabetes, or a recent myocardial infarction.²

Box 2

Box 3

BDD CLUES

 

• Mirror checking or avoidance, or checking other reflective surfaces, such as windows, car bumpers, or the backs of spoons
• Reassurance seeking, that is, asking other people how they look or insisting that they look bad
• Skin picking, which may be manifested by skin lesions or scarring
• Excessive grooming, for example hair styling, applying makeup, shaving, tweezing hair, or cutting hair or wigs
• Camouflaging with a hat, toupee, makeup, sunglasses, clothes, or body position
• Excessive tanning, to darken “pale” skin
• Ideas or delusions of reference, thinking others take special notice of the “flaw” in a negative way (e.g., mock it or stare at it)
• Treatment-resistant anxiety, especially social anxiety, or depression
• Social avoidance or being housebound
• Unnecessary surgery, dermatologic treatment, or other nonpsychiatric treatment (e.g., electrolysis)

Guidelines for treating BDD

• Establish trust. It is important to convey that you take the patient’s appearance concerns seriously. Many patients with BDD fear being considered silly or vain and do not divulge their symptoms. It is usually best to avoid reassuring patients that they look fine, since they usually do not believe the reassurance and can interpret it as trivializing their concerns.
• Provide psychoeducation. Explain to patients that they have a relatively common and treatable body image disorder. To decrease the patient’s reluctance to accept the diagnosis and treatment, it can be helpful to emphasize the excessive preoccupation, distress, and other problems their symptoms are causing. Discussions about whether the defect is “real” are usually fruitless, unless the patient already has good insight, which is rare. Several educational books and Web sites for patients are available. See Related Resources.
• Target BDD symptoms in treatment. Ignoring BDD symptoms and focusing treatment on other symptoms only may be unsuccessful because effective treatment for BDD differs in some important ways from that of most other psychiatric disorders, such as depression.¹⁰ It appears, for example, that non-selective serotonin reuptake inhibitor (SSRI) antidepressants are generally ineffective for BDD, unless used at higher SSRI doses than are often needed for depression. BDD symptoms also do not necessarily improve in concert with symptoms of other disorders, such as depression or OCD.¹⁰
• Avoid nonpsychiatric medical treatment. Although no one can predict how an individual patient will respond to nonpsychiatric treatment, (e.g., surgery or dermatologic treatment), explain that as best we know, such treatment usually appears to be ineffective for BDD and even can make the symptoms worse.¹¹

Which psychopharmaceuticals should you consider?

Although BDD’s response to pharmacotherapy has received far less investigation than that of many other psychiatric disorders, research on this treatment approach has dramatically increased in recent years. The following strategies are suggested on the basis of evidence from controlled studies, open-label trials, and the author’s clinical experience (Figure 1):^2,6,8,12-17

Box 4

CASE REPORT

‘I’m as ugly as the elephant man’

Chris is a shy, anxious-appearing, 31-year-old man who was hospitalized after attempting suicide. He wears a baseball cap pulled down over his forehead and partially covering his eyes. It is difficult for him to reveal the reason for his suicide attempt: “It’s really hard to talk about this. I don’t know if I can. It’s too embarrassing.” Then he adds, “Well I guess I should tell you—after all, I’m in the hospital because of it. It’s my nose—these huge pock marks on my nose. They’re grotesque! I look like a monster. I’m as ugly as the elephant man!

“These marks on my nose are all I can think about. I’ve thought about them for hours a day every day for the past 15 years. I even have nightmares about them. And I think that everyone can see them and that they laugh at me because of them. That’s why I wear this hat all the time. And that’s why I couldn’t talk to you in a bright room. You’d notice the marks and see how ugly I am.” Chris actually appeared entirely normal, but no one could convince him of this.

“This has affected me in a lot of ways,” Chris adds. “This may be hard for you to believe, but this problem has ruined my life. All I can think about is my face, and I spend hours a day looking at the marks in the mirror. I just can’t resist. I thought I looked so ugly that I started missing more and more work, and I stopped going out with my friends and my girlfriend. I got so anxious when people looked at me that I started staying in the house most of the time. Sometimes when I did go out, I went through red lights so I wouldn’t have to sit at the light, where people might be staring at me. The hat helped a little, but it didn’t cover all the marks. I tried covering them with makeup for a while, but I thought people could see the makeup so that didn’t really help. The only time I really felt comfortable is when I wore my nephew’s Batman mask on Halloween—then no one could see the marks.

I finally missed so much work that I was fired. My girlfriend stuck it out with me for a long time, but finally she couldn’t take it any more. One thing that was really hard for her was that I started asking her about 50 times a day whether I looked OK and whether she could see the marks—I think that was the final straw. If I had a choice, I’d rather have cancer. It must be less painful. This is like an arrow through my heart.”

Chris had a notable, although only partial, response to fluoxetine 100 mg/d and buspirone 60 mg/d (higher doses of fluoxetine and buspirone were tried but were not more effective). Adding clonazepam was helpful for severe anxiety. Clomipramine, venlafaxine, lithium, mirtazapine, and various antipsychotics were sequentially added to this regimen, with minimal success, although a second trial of olanzapine, at a higher dose (15 mg/d) than he had been willing to try previously, further decreased Chris’ BDD and depressive symptoms. The addition of bupropion was somewhat helpful for depression but not for BDD.

Figure 1 Proposed pharmacotherapy for treating BDD

• Use an SSRI as a first-line approach. Other medications, including other antidepressants, appear less effective than SSRIs or clomipramine.^2,8,9,13,15 An SSRI or clomipramine is also recommended for patients with delusional BDD (those who are completely convinced that they look abnormal and cannot be convinced otherwise), as Proposed pharmacotherapy for treating BDD these patients appear to respond to SSRIs as well as nondelusional patients do.^12-17
• Use the maximum recommended or tolerated SSRI dose if lower doses are ineffective. Although no studies have compared different SSRI dosages, BDD appears to often require higher doses than those that are typically used for depression.

In a chart-review study of 90 patients with BDD treated in the author’s clinical practice, the mean SSRI doses used were fluoxetine 66.7 ±23.5 mg/d, fluvoxamine 308.3 ±49.2 mg/d, paroxetine 55.0 ± 12.9 mg/d, sertraline 202.1 ± 45.8 mg/d, and clomipramine 203.3 ±52.5 mg/d.¹⁷ Some patients respond only to doses higher than the maximum recommended dose (for example, 80-100 mg/d of citalopram or paroxetine).

• Treat for 12 to 16 weeks with an SSRI before concluding that the medication is ineffective. The average time to response is between 6 to 9 weeks.^12,14,16 Clinical experience suggests that with continued treatment, relapse is rare and many patients further improve.
• Try sequential SSRIs if the first or second one does not work. A substantial percentage of patients who fail an initial SSRI trial will respond to a subsequent SSRI.¹⁷
• Continue an effective SSRI for at least 1 year before discontinuing it, as relapse appears likely with discontinuation.¹⁷ Severely ill patients may require treatment for life.
• Several SSRI augmentation and combination strategies might be helpful (Figure 1).^16,17 If clomipramine is used in combination with an SSRI, the clomipramine level should be monitored.

What is the role of psychotherapy?

Although research on psychotherapy for BDD is limited, findings from clinical series and studies using waiting-list controls indicate that cognitive-behavioral therapy (CBT) is often effective.^18-20 In contrast, supportive psychotherapy and insight-oriented and psychodynamic psychotherapy alone appear to be ineffective.⁹ CBT usually consists of a cognitive element (e.g., changing distorted views of the appearance “flaw”), exposure to feared and avoided situations (often social), and response prevention, avoiding repetitive behaviors such as excessive grooming.

• Consider using CBT as a first-line approach for milder BDD without significant comorbidity requiring pharmacotherapy.
• Use more intensive CBT treatment including frequent sessions and use of homework rather than less intensive treatment, although the optimal number and frequency of sessions is unknown.
• Consider maintenance and booster sessions for patients with more severe BDD following treatment to prevent relapse.
• Consider combining CBT and an SSRI. Although it is not known whether a combination of these treatments is more effective than either one alone, they are compatible and their combination may benefit certain patients. For patients with severe BDD, especially very depressed or suicidal patients, it is probably best to use CBT in combination with medication only, as sicker patients may not be able to tolerate or participate in CBT without first experiencing some improvement with medication.

Related Resources

• Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press, 1996.
• Pope HG, Phillips KA, Olivardia R. The Adonis Complex: The Secret Crisis of Male Body Obsession. New York, NY: The Free Press, 2000.
• Phillips KA, Van Noppen B, Shapiro L. Learning to Live with Body Dysmorphic Disorder. Milford, Conn: Obsessive-Compulsive Foundation, 1997.
• Body Dysmorphic Disorder (BDD)and Body Image Program Homepage at Butler Hospital (Providence, RI). http://www.bodyimageprogram.com

Drug brand names

• Bupropion • Wellbutrin, Zyban
• Buspirone • Buspar
• Citalopram • Celexa
• Clomipramine • Anafranil
• Clonazepam • Ativan, Diastat, Halcion
• Fluoxetine • Prozac, Sarafem
• Fluvoxamine • Luvox
• Mirtazapine • Remeron, Remeron Solitab
• Olanzapine • Zyprexa
• Paroxetine • Paxil
• Sertraline • Zoloft
• Venlafaxine • Effexor

Disclosure

The author reports that she receives grant support and occasional speaking honoraria from Eli Lilly and Co.; receives grant support from Forest Pharmaceuticals and Gate Pharmaceuticals; is on the speakers' bureau of Solvay Pharmaceuticals; and serves as a consultant for Wyeth-Ayerst Pharmaceuticals.

A 52-year-old man becomes intoxicated with alcohol so he can lie in his backyard and get a tan. Convinced that his skin is too pale and that he looks “like a ghost,” he is so self-conscious about how he looks that he can’t go outside without drinking excessively.

An attractive 23-year-old woman dropped out of the 10th grade because of her “hideous” appearance and has hidden in her bedroom in her parents’ house ever since. She leaves her room no more than once a month, only after covering her face with a veil, not letting even her family see her face.

A middle-aged man cuts his nose open with a razor blade, trying to remove his nasal cartilage and replace it with chicken cartilage, in the desired shape.

These patients have body dysmorphic disorder (BDD), a somatoform disorder that the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) defines as a preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning that are not attributed to another mental disorder.

Most of us are dissatisfied with some aspect of how we look. In fact, more than half of all women and nearly half of all men in the United States are dissatisfied with their overall appearance.¹ As the preceding cases illustrate, however, BDD does not consist simply of normal appearance concerns.

BDD is a relatively common disorder² (Box 1) that occurs in children as well as adults. It usually begins during the early teenage years.² BDD has been described around the world for more than a century.³ It causes notable distress and impaired functioning, and can lead to suicide.⁴ This disorder typically goes undiagnosed in clinical settings, however, in part because many patients are too embarrassed and ashamed to discuss their symptoms with their physicians unless specifically asked.^2,5 BDD often masquerades as other psychiatric disorders, and misdiagnosis appears common⁶ (Table 1). Diagnosing BDD is usually straightforward, however, and can be achieved using the questions in Box 2.⁴ Clues to the presence of BDD are presented in Box 3; patients who present with any of them should be carefully evaluated for BDD.

Box 1

Perceptions of patients with BDD

Individuals with BDD obsess that there is something wrong with their appearance when in fact they look fine; the perceived flaw is actually minimal or nonexistent.⁷ Prior to treatment, insight is usually poor or absent, however, so that most patients are convinced or fairly certain that they look abnormal.^2,8 They may describe the perceived flaw as unattractive or deformed, or they may even say that they look like a freak, a monster, or the “elephant man” (Box 4). Individuals with this disorder think about the perceived appearance flaws, on average, for 3 to 8 hours a day, and they usually find the thoughts difficult to resist or control.⁹ Diagnostic errors that cause BDD to be missed

Table 1

Diagnostic errors that cause BDD to be missed

Although repetitive behaviors are not part of BDD’s diagnostic criteria, virtually all patients perform such behaviors, usually in an attempt to improve, hide, examine, or be reassured about the perceived flaw.^7,9 (See Box 3 for a partial listing.) These behaviors are usually time-consuming, occurring for many hours a day, and, like the preoccupations, are typically difficult to resist or control. With the exception of camouflaging, however, they often do not diminish appearance concerns. In fact, some of them (e.g., mirror checking) may actually increase anxiety about the perceived flaw.

Comorbidity is common in patients seen in clinical settings.^2,8 Major depression is the most frequent comorbid disorder, which often appears secondary to BDD.¹⁰ Other common comorbidities include substance-use disorders, obsessive-compulsive disorder (OCD), social phobia, and personality disorders (most often, avoidant personality disorder).

Individuals with BDD are distressed over their appearance, many to the point of contemplating, attempting, or completing suicide.^4,5 Nearly one quarter of patients seen in a clinical setting have attempted suicide.⁹ Although some patients appear to function reasonably well, they usually function below their capacity—for example, by avoiding social situations or meetings at work where others will see them. Others are completely incapacitated by their BDD symptoms, unable to work or socialize, and may be housebound for years.^2,8,9 In a study that used the SF-36 to measure health-related quality of life, outpatients with BDD scored notably worse in all mental health domains than did the general U.S. population and patients with depression, type II diabetes, or a recent myocardial infarction.²

Box 2

Box 3

BDD CLUES

 

• Mirror checking or avoidance, or checking other reflective surfaces, such as windows, car bumpers, or the backs of spoons
• Reassurance seeking, that is, asking other people how they look or insisting that they look bad
• Skin picking, which may be manifested by skin lesions or scarring
• Excessive grooming, for example hair styling, applying makeup, shaving, tweezing hair, or cutting hair or wigs
• Camouflaging with a hat, toupee, makeup, sunglasses, clothes, or body position
• Excessive tanning, to darken “pale” skin
• Ideas or delusions of reference, thinking others take special notice of the “flaw” in a negative way (e.g., mock it or stare at it)
• Treatment-resistant anxiety, especially social anxiety, or depression
• Social avoidance or being housebound
• Unnecessary surgery, dermatologic treatment, or other nonpsychiatric treatment (e.g., electrolysis)

Guidelines for treating BDD

• Establish trust. It is important to convey that you take the patient’s appearance concerns seriously. Many patients with BDD fear being considered silly or vain and do not divulge their symptoms. It is usually best to avoid reassuring patients that they look fine, since they usually do not believe the reassurance and can interpret it as trivializing their concerns.
• Provide psychoeducation. Explain to patients that they have a relatively common and treatable body image disorder. To decrease the patient’s reluctance to accept the diagnosis and treatment, it can be helpful to emphasize the excessive preoccupation, distress, and other problems their symptoms are causing. Discussions about whether the defect is “real” are usually fruitless, unless the patient already has good insight, which is rare. Several educational books and Web sites for patients are available. See Related Resources.
• Target BDD symptoms in treatment. Ignoring BDD symptoms and focusing treatment on other symptoms only may be unsuccessful because effective treatment for BDD differs in some important ways from that of most other psychiatric disorders, such as depression.¹⁰ It appears, for example, that non-selective serotonin reuptake inhibitor (SSRI) antidepressants are generally ineffective for BDD, unless used at higher SSRI doses than are often needed for depression. BDD symptoms also do not necessarily improve in concert with symptoms of other disorders, such as depression or OCD.¹⁰
• Avoid nonpsychiatric medical treatment. Although no one can predict how an individual patient will respond to nonpsychiatric treatment, (e.g., surgery or dermatologic treatment), explain that as best we know, such treatment usually appears to be ineffective for BDD and even can make the symptoms worse.¹¹

Which psychopharmaceuticals should you consider?

Although BDD’s response to pharmacotherapy has received far less investigation than that of many other psychiatric disorders, research on this treatment approach has dramatically increased in recent years. The following strategies are suggested on the basis of evidence from controlled studies, open-label trials, and the author’s clinical experience (Figure 1):^2,6,8,12-17

Box 4

CASE REPORT

‘I’m as ugly as the elephant man’

Chris is a shy, anxious-appearing, 31-year-old man who was hospitalized after attempting suicide. He wears a baseball cap pulled down over his forehead and partially covering his eyes. It is difficult for him to reveal the reason for his suicide attempt: “It’s really hard to talk about this. I don’t know if I can. It’s too embarrassing.” Then he adds, “Well I guess I should tell you—after all, I’m in the hospital because of it. It’s my nose—these huge pock marks on my nose. They’re grotesque! I look like a monster. I’m as ugly as the elephant man!

“These marks on my nose are all I can think about. I’ve thought about them for hours a day every day for the past 15 years. I even have nightmares about them. And I think that everyone can see them and that they laugh at me because of them. That’s why I wear this hat all the time. And that’s why I couldn’t talk to you in a bright room. You’d notice the marks and see how ugly I am.” Chris actually appeared entirely normal, but no one could convince him of this.

“This has affected me in a lot of ways,” Chris adds. “This may be hard for you to believe, but this problem has ruined my life. All I can think about is my face, and I spend hours a day looking at the marks in the mirror. I just can’t resist. I thought I looked so ugly that I started missing more and more work, and I stopped going out with my friends and my girlfriend. I got so anxious when people looked at me that I started staying in the house most of the time. Sometimes when I did go out, I went through red lights so I wouldn’t have to sit at the light, where people might be staring at me. The hat helped a little, but it didn’t cover all the marks. I tried covering them with makeup for a while, but I thought people could see the makeup so that didn’t really help. The only time I really felt comfortable is when I wore my nephew’s Batman mask on Halloween—then no one could see the marks.

I finally missed so much work that I was fired. My girlfriend stuck it out with me for a long time, but finally she couldn’t take it any more. One thing that was really hard for her was that I started asking her about 50 times a day whether I looked OK and whether she could see the marks—I think that was the final straw. If I had a choice, I’d rather have cancer. It must be less painful. This is like an arrow through my heart.”

Chris had a notable, although only partial, response to fluoxetine 100 mg/d and buspirone 60 mg/d (higher doses of fluoxetine and buspirone were tried but were not more effective). Adding clonazepam was helpful for severe anxiety. Clomipramine, venlafaxine, lithium, mirtazapine, and various antipsychotics were sequentially added to this regimen, with minimal success, although a second trial of olanzapine, at a higher dose (15 mg/d) than he had been willing to try previously, further decreased Chris’ BDD and depressive symptoms. The addition of bupropion was somewhat helpful for depression but not for BDD.

Figure 1 Proposed pharmacotherapy for treating BDD

• Use an SSRI as a first-line approach. Other medications, including other antidepressants, appear less effective than SSRIs or clomipramine.^2,8,9,13,15 An SSRI or clomipramine is also recommended for patients with delusional BDD (those who are completely convinced that they look abnormal and cannot be convinced otherwise), as Proposed pharmacotherapy for treating BDD these patients appear to respond to SSRIs as well as nondelusional patients do.^12-17
• Use the maximum recommended or tolerated SSRI dose if lower doses are ineffective. Although no studies have compared different SSRI dosages, BDD appears to often require higher doses than those that are typically used for depression.

In a chart-review study of 90 patients with BDD treated in the author’s clinical practice, the mean SSRI doses used were fluoxetine 66.7 ±23.5 mg/d, fluvoxamine 308.3 ±49.2 mg/d, paroxetine 55.0 ± 12.9 mg/d, sertraline 202.1 ± 45.8 mg/d, and clomipramine 203.3 ±52.5 mg/d.¹⁷ Some patients respond only to doses higher than the maximum recommended dose (for example, 80-100 mg/d of citalopram or paroxetine).

• Treat for 12 to 16 weeks with an SSRI before concluding that the medication is ineffective. The average time to response is between 6 to 9 weeks.^12,14,16 Clinical experience suggests that with continued treatment, relapse is rare and many patients further improve.
• Try sequential SSRIs if the first or second one does not work. A substantial percentage of patients who fail an initial SSRI trial will respond to a subsequent SSRI.¹⁷
• Continue an effective SSRI for at least 1 year before discontinuing it, as relapse appears likely with discontinuation.¹⁷ Severely ill patients may require treatment for life.
• Several SSRI augmentation and combination strategies might be helpful (Figure 1).^16,17 If clomipramine is used in combination with an SSRI, the clomipramine level should be monitored.

What is the role of psychotherapy?

Although research on psychotherapy for BDD is limited, findings from clinical series and studies using waiting-list controls indicate that cognitive-behavioral therapy (CBT) is often effective.^18-20 In contrast, supportive psychotherapy and insight-oriented and psychodynamic psychotherapy alone appear to be ineffective.⁹ CBT usually consists of a cognitive element (e.g., changing distorted views of the appearance “flaw”), exposure to feared and avoided situations (often social), and response prevention, avoiding repetitive behaviors such as excessive grooming.

• Consider using CBT as a first-line approach for milder BDD without significant comorbidity requiring pharmacotherapy.
• Use more intensive CBT treatment including frequent sessions and use of homework rather than less intensive treatment, although the optimal number and frequency of sessions is unknown.
• Consider maintenance and booster sessions for patients with more severe BDD following treatment to prevent relapse.
• Consider combining CBT and an SSRI. Although it is not known whether a combination of these treatments is more effective than either one alone, they are compatible and their combination may benefit certain patients. For patients with severe BDD, especially very depressed or suicidal patients, it is probably best to use CBT in combination with medication only, as sicker patients may not be able to tolerate or participate in CBT without first experiencing some improvement with medication.

Related Resources

• Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press, 1996.
• Pope HG, Phillips KA, Olivardia R. The Adonis Complex: The Secret Crisis of Male Body Obsession. New York, NY: The Free Press, 2000.
• Phillips KA, Van Noppen B, Shapiro L. Learning to Live with Body Dysmorphic Disorder. Milford, Conn: Obsessive-Compulsive Foundation, 1997.
• Body Dysmorphic Disorder (BDD)and Body Image Program Homepage at Butler Hospital (Providence, RI). http://www.bodyimageprogram.com

Drug brand names

• Bupropion • Wellbutrin, Zyban
• Buspirone • Buspar
• Citalopram • Celexa
• Clomipramine • Anafranil
• Clonazepam • Ativan, Diastat, Halcion
• Fluoxetine • Prozac, Sarafem
• Fluvoxamine • Luvox
• Mirtazapine • Remeron, Remeron Solitab
• Olanzapine • Zyprexa
• Paroxetine • Paxil
• Sertraline • Zoloft
• Venlafaxine • Effexor

Disclosure

The author reports that she receives grant support and occasional speaking honoraria from Eli Lilly and Co.; receives grant support from Forest Pharmaceuticals and Gate Pharmaceuticals; is on the speakers' bureau of Solvay Pharmaceuticals; and serves as a consultant for Wyeth-Ayerst Pharmaceuticals.