For three years, a 50-year-old man in Addis Ababa was convinced his nose gave off the smell of a dead mouse. He washed it with water, then salt water, then nasal drops. He wore a mask and said the smell escaped it anyway. He stopped going to funerals, weddings and church. Eventually he separated from his wife and children and moved out alone.
Every physical examination came back clean. He had been through multiple hospitals without an answer before an ear, nose and throat department referred him to psychiatry. The diagnosis, described in a case report published in January in the Journal of Medical Case Reports, was olfactory reference syndrome. The author, a psychiatrist at Addis Ababa University, reports that a structured search of regional literature turned up no previously published case from East Africa.
Three Years, Multiple Hospitals and No Physical Source
The belief started ordinarily enough. His wife and children commented on a bad odor in the house. No source was ever found, but over time he became convinced it came from him, and specifically from his nose. He had undergone surgery for nasal polyps in Cape Town 17 years earlier and decided the old condition had returned.
He began collecting evidence. When people on public transportation covered their noses or mouths, he read it as confirmation. This is a hallmark of the condition, known clinically as ideas of reference: neutral behavior by strangers gets absorbed into the belief as proof.
Two years in, depression arrived on top of it. The report describes hopelessness, emptiness, low self-worth, poor sleep, and passive thoughts about death, though he denied active suicidal plans or past attempts. He had no prior psychiatric history and no family history of mental illness. Before the illness, he described himself as sociable.
Anyone experiencing persistent hopelessness or thoughts about death should contact a clinician or a crisis line. Help is available, and these symptoms are treatable.
The Odor Is Not Imaginary to the Person Smelling It
The word imaginary does a lot of unhelpful work here. On examination, this patient was recorded as having an olfactory hallucination. He was smelling something. His insight was rated as partial, and the diagnosis was made with poor insight noted, meaning he could not accept that others did not smell it too.
He is not unusual in that. Among 20 patients assessed with structured measures for a study in General Hospital Psychiatry, 85 percent reported actually smelling the odor themselves, and the same proportion held convictions at delusional intensity. The preoccupation focused most often on the mouth, armpits, and genitals, with bad breath and sweat the most commonly described smells, and 95 percent performed at least one repetitive behavior. This patient's fixation on his nose, and on a dead mouse, is unusual in both location and specificity.
That combination is what makes olfactory reference syndrome so hard to treat with reassurance. Repeated negative examinations do not resolve it, and each can be reinterpreted as a missed diagnosis. Compulsive behaviors follow: washing, spraying, mask wearing, mouthwash, constant checking. Those rituals bring brief relief and then feed the cycle. The condition was first described in a series of 137 patients in 1971, and has been recognized far longer than it has been reliably diagnosed.
A Diagnosis That Sits in an Awkward Corner of the Manual
Olfactory reference syndrome does not have its own entry in the Diagnostic and Statistical Manual of Mental Disorders. In the fifth edition, text revision, it appears as an example under other specified obsessive-compulsive and related disorders. The World Health Organization's ICD-11 gives it a cleaner home as olfactory reference disorder.
That ambiguity has consequences. The report lists the differentials the team had to exclude: delusional disorder of the somatic type, obsessive-compulsive disorder, social anxiety disorder, mood disorder with psychotic features, temporal lobe epilepsy, and migraine. Neurology evaluation found no seizure activity or other neurological contributor, and the final diagnosis included a comorbid persistent depressive disorder. The Merck Manual professional edition puts the likely prevalence at roughly 2 percent with a slight female predominance, which would make it far more common than its visibility in clinical training suggests.
The pattern of this case is the pattern of the condition. Merck notes that because insight is usually poor or absent, patients tend to seek general medical, surgical or dental treatment rather than psychiatric care, which does not appear to help. Dermatologists, dentists and ENT surgeons often come first, a delay The International OCD Foundation also flags. Every one of those visits is a chance for the belief to harden.
One Year of Treatment and What a Single Case Cannot Prove
Treatment followed the outline a review of diagnosis and management in CNS Drugs sets out, pairing a high-dose serotonin reuptake inhibitor with antipsychotic augmentation and structured therapy. Fluoxetine was started at 20 milligrams daily, raised to 40 after two weeks and to 60 by week four. Risperidone was added at week four at 1 milligram nightly and raised to 2 milligrams after three weeks, chosen for the delusional intensity and poor insight. Twelve weekly sessions of supportive psychotherapy added cognitive behavioral techniques: psychoeducation, cognitive restructuring, graded exposure, and response prevention aimed at the nasal cleaning and mask reliance.
Over a year, the report describes marked improvement in odor preoccupation, depressive symptoms, and social engagement. He resumed family contact and returned to church. No significant side effects were recorded.
The author is candid about the limits. No standardized instrument such as the Yale-Brown Obsessive Compulsive Scale was used, so severity and response were judged on clinical impression rather than measurement. And it is one patient. A single case cannot establish that this combination works for others, or separate the treatment effect from the natural course of the illness.
What it does illustrate is a diagnostic delay measured in years, in a condition where the distress is real, the compulsions are real, the smell is real to them, and the source is not.
Key Questions Answered
What is olfactory reference syndrome? A psychiatric condition in which a person is persistently preoccupied with the belief that they emit a foul body odor that others cannot detect or barely notice.
Is the patient actually smelling something? Often yes. This patient was recorded as having an olfactory hallucination, and in one clinical series, 85 percent of patients reported smelling the odor themselves.
How common is it? Merck's professional reference puts the likely prevalence at roughly 2 percent, with a slight female predominance, though underdiagnosis makes estimates uncertain.
Why did it take three years to diagnose? Patients typically consult non-psychiatric specialists first, including ENT, dental, and dermatology clinics. This man went to multiple hospitals before an ENT department referred him to psychiatry.
How is it treated? Usually a high-dose selective serotonin reuptake inhibitor, sometimes with a low-dose antipsychotic when insight is poor, plus cognitive behavioral therapy. This patient received fluoxetine, risperidone, and 12 psychotherapy sessions.
What should someone worried about their own body odor do? See a clinician. Real medical causes of body odor exist and should be checked. If examinations repeatedly find nothing and the worry is dominating daily life, a mental health assessment is appropriate.
