A Rose By Any Other Name
by Steven J Phillipson, Ph.D.
Clinical Director, Center for Cognitive-Behavioral Psychotherapy
& Robert K. Stewart, MA
Long Island University, Brooklyn, NY
While driving home, recently, I was listening to one of those popular radio call-in shows hosted by a licensed clinical psychologist, popular author, and certified sex therapist. At this particular moment, a young caller named Julie was presenting a unique dilemma: Julie was concerned that her vagina emitted a strange, unpleasant odor that could be detected by those around her. Despite reassurance from her boyfriend, numerous gynecologists, and comprehensive medical testing that ruled out any abnormalities, such as unusual bacteria levels, Julie could not be dissuaded; she was absolutely convinced of her offensive smell, spending hours and hours anxiously preoccupied with the thought of being found out. Intrigued by Julie's problem, I anxiously awaited the therapist's response:
"Julie, you have some sort of nutritional imbalance, and you would benefit from a change in your diet. Go see a nutritionist, and in the meantime, perhaps you should look into using a douche as part of your hygienic routine."
Hmmm. Despite the therapist's keen diagnostic skills, I must differ with the radio therapist's diagnosis in this case; I suspect that Julie's conflict has an entirely different cause. The ineffectiveness of disconfirming evidence, the excessive rumination, the high level of anxiety: experience tells me that these symptoms are all hallmarks of a psychological problem -- not a physical malady -- clearly rooted in Obsessive-Compulsive Disorder (OCD). This article will discuss this proposed form of OCD and how it relates to those preoccupied with olfactory obsessions. Although I have not come across any specific mention of this condition in the literature, I have found from my clinical work that a significant fraction of OCD sufferers are convinced of the possibility that some part of their body is producing an unpleasant odor. The great majority of persons suffering from this condition are completely unaware that they may have OCD since these concerns are so far removed from such well known symptoms as hand washing and stove checking. For this select group, the most frequently reported areas of concern involve underarms, breath, genital regions, feet, and hair. Like Julie, persons with this type of olfactory obsession are convinced that their noxious odor has a great likelihood of offending either a significant other or the population at large.
I liken this condition to another more clinically recognizable OCD phenomenon known as Body Dysmorphic Disorder (BDD is a condition in which persons obsess that some part of the body is misshapen or deformed). In a recent article on BDD (Rosen, 1995), the author described the most pronounced cognitive and affective features of the disorder. The similarities clearly suggest that BDD and the olfactory obsession operate within the same clinical spectrum of symptoms. The most striking correspondences include the intensification of anxiety during periods of social contact, as well as tremendous concern related to what others will negatively conclude about the person when the imperfection is discovered.
The intensity of concern about the odor approximates that of a delusional belief and/or hallucinatory experience. However, if psychotic processes really were the issue, the sufferers would merely persist in their conviction without experiencing anxiety; in cases such as Julie's, anxiety is painfully present, and leads to the characteristic OCD attempt to reduce the anxiety by desperately trying to verify the existence of the odor. The same holds true for BDD: "BDD patients recognize obsessions and admit that their preoccupation is excessive, even if they are entirely convinced their appearance is abnormal" (Rosen, 1995). Since many clinicians are not sensitive to this underlying anxiety as a differential marker between psychosis and obsessive-compulsive phenomenon, misdiagnosis is a frequent occurrence.
To help illustrate how entrenched an olfactory belief can be, let me present a case from early in my career. Laura was a client who was sure she had bad breath, and her intense anxiety and preoccupation was sabotaging her work performance and interpersonal relationships. At the time, I worked out of a shoebox office whose size dictated that I sit in close proximity to all of my clients, and after four consecutive sessions of my "experiencing" Laura's breath face-to-face, I was convinced that her breath was normal. In my naiveté, I felt I needed to disconfirm her hyperconscientious belief, and sure enough, I met impenetrable resistance. I found myself haplessly attempting to reassure Laura that she did not have bad breath, which only seemed to amplify her insecurity. Nor was she satisfied with the solace offered by her dentist or other naive physicians. In fact, Laura's obsessions made it impossible for me to ventilate my shoebox in the middle of July because she would interpret the fan as a blatant action on my part to diffuse her odor.
As my experience grew with OCD, I came to realize that persons afflicted with this olfactory obsession had certain characteristics in common with other OCD sufferers. While it seems a close cousin of BDD, the olfactory problem shows classic hallmarks of all OCD disorders. The similarities include the following:
- Intense Anxiety: Specifically, extreme discomfort and an overly suspicious awareness that other people are taking some subtle actions to avoid, escape, or diffuse the odor (e.g. opening windows, offering chewing gum, turning on fans, etc.).
- Hypervigilance to Subtle Environmental Cues: The resulting sensitivity and scrutiny of others' behaviors increases the likelihood that the OCD sufferer will find confirmation for their obsessive concerns.
- Shame: Intense sense of shame which typically far exceeds that experienced by the general OCD sufferer.
- Need for Reassurance: Increasingly, as the disorder becomes more pervasive, persons intimately connected to the sufferer are sought after to provide reassurance; however, like in Laura's case, rather than reduce the anxiety, this constant reassurance further increases the ambiguity. The condition worsens, and any social and intimate relationships are strained as the checking behavior slowly alienates all close, personal contacts.
Many sufferers attempt to avoid being detected either by avoiding close contact with others (e.g. crowded elevators, public transportation, etc.) or through spending an excessive amount of time washing the particular area of concern. There is typically an abundant use of perfume or cologne in a fruitless attempt to mask the odor. Take, for example, a comment made by another olfactory client: "If I smell someone else's perfume, then I must assume that no one notices mine . . . therefore, without my perfume to mask it, my offensive scent will be noticed." Immediately, one recognizes the distorted logic of this statement: most people would agree that if "no one notices my perfume because theirs is too strong, then how could they possibly pick up my odor?" However, this example illustrates just how powerful and influential the disorder can be. Despite how irrational the belief system may appear to observers, for the individual with OCD there is no greater or more immediate reality than the perceived smell, and no more powerful a motivation than disguising it.
Similarly, persons frequently check themselves in an effort to obtain confirming evidence from their body. Realistically, thanks to Mother Nature, all humans periodically produce noticeable odors which are not always pleasant. Tragically, because these individuals are so hypersensitive and attuned to even the most subtle changes in their bodies, they use this sporadic evidence to validate the legitimacy of their OCD belief system.
As is the case with any psychological condition amenable to behavioral interventions, a proper diagnosis is essential in formulating an effective course of action. Unfortunately, this peculiar OCD manifestation has frequently eluded detection by both patient and therapist: For example, persons who seek treatment for hand washing rituals may wait indefinitely before ever mentioning any olfactory component, often times never realizing that the obsession is also a product of OCD. Similarly, although a number of my colleagues have mentioned having contact with clients who have reported these unusual olfactory concerns, they were typically unaware that OCD was the underlying culprit, frequently misdiagnosing the condition and the prescribed therapeutic interventions.
Recognizing the problem, however, is only half the battle. Once again, employing appropriate treatment is essential to addressing the problem. I have found that effective treatment strategies do not differ radically from those already established for persons suffering from BDD. This typically involves having the client become increasingly tolerant of the possible existence of the disorder (e.g. not giving in to the compelling desire to ruminate about the automatic thoughts or resisting attempts to solve the problem). Ultimately, managing the menacing thoughts effectively, even in the face of overwhelming anxiety, is the primary goal of this olfactory OCD, as it is with any anxiety disorder.
Typical homework assignments for this disorder might include having a client who bathes 5 times per day, gradually increase his delay between showers. One of the tricky parts of treatment, however, is making these exposure exercises really sink in, and often times treatment calls for "bending the rod back over to the other extreme in order to make it stand straight again." In other words, while one shower per day may seem "normal" for most people, treatment for stubborn olfactory OCD may require longer periods without washing; it is not unimaginable that an advanced homework assignment would ask the client to tolerate only one shower per week.
At intermediate stages of treatment, one would ask the client to raise the stakes in their response prevention exercises by intentionally contaminating themselves. The goal we set for one client was for her to eat garlic bread early in the morning, and then go to work, with specific instructions not to brush her teeth until she returned home at the end of the day. Although she reported that the first hour of the exercise was very distressing, by the mid-afternoon she had completely forgotten about her potentially offensive breath.
Once having reached this level of tolerance, now would be an excellent time for this client to implement in vivo exercises; specifically, while on the way to work in a cramped subway car, her task would be to intentionally take the risk of having her garlic breath be noticed by those around her, fully aware and prepared that many will find her breath offensive and probably complain. In this instance, the client engages in the most potent form of cognitive-behavioral therapy, surviving the shame and anxiety which they have controlled and actively created for themselves.
Regardless of the specific treatment, however, the ultimate goal is for the olfactory OCD client to gradually learn to tolerate greater levels of risk associated with their offensive smell. For persons suffering from an olfactory obsession (and for all forms of OCD), the experience of their concern's legitimacy often seems overwhelming. A chronic error is for the client to monitor the intensity of this experience as a measure of progress. Instead, the preferred measure of progress is the client's willingness for the feared issue to be possibly "true." Behavioral exercises are designed to gradually expose persons to the ambiguity of their fear, not to have them ultimately realize that it was never valid in the first place. These individuals must embrace the ambiguity of whether they may indeed be emitting noxious odors, and accept their capacity to survive detection, even at the risk of offending other people. In a society so preoccupied with "not letting them see you sweat," this is a monumental task.
Originally printed in the Obsessive-Compulsive Newsletter, June, 1996, pages 2-3, published by the OCF