Background: Olfactory reference syndrome (ORS) is a psychiatric condition characterized by the belief that one is emitting a foul body odor. The earliest cases of this disorder were often labeled as variants of schizophrenia. There remains significant controversy over whether this condition represents a manifestation of other psychiatric conditions or if it is a unique disorder in its own right. Through various revisions of the DSM, the disorder has been categorized at times as an atypical somatoform disorder (DSM-III), a delusional disorder (DSM-IV-TR), and an Other Specified Obsessive-Compulsive Disorder (DSM-5).

We present the case of a 51 year old African American female who initially presented to an emergency room with chief complaint of vaginal odor. She stated that if the odor was not treated, she would commit suicide. Medical workup in the emergency room was unremarkable and no odor was detected. The patient was placed on a psychiatric hold and transferred to the Psychiatric Emergency Room. In the PES, the patient reported that she was afraid of eviction from her apartment due to the “horrible” smell that she was emitting. The patient had presented to multiple emergency departments over the preceding year complaining of vaginal odor. The patient persisted in her belief about this smell despite multiple medical providers informing her that they could detect no abnormal smell. Unconvinced, the patient went to great lengths to treat this odor. When normal showering did not cause the odor to cease, the patient began manually inserting pieces of deodorant into her vaginal canal. This was extracted at an outside hospital after the patient presented for treatment after developing an infection. After discharge, the patient began mixing a household cleaning product containing benzalkonium chloride with bleach and used this mixture for vaginal douching. When even this did not eliminate the perceived odor, she presented to our emergency room stating that if the odor was not treated, she would attempt suicide.

Although ORS has been described since the 1800’s, the first systematic description in the literature was a case series in 1971 by Pryse-Phillips. While ORS has been increasingly reported in the scientific literature, the DSM-5 does not consider it to be a unique clinical entity.

This case highlights the importance of clinicians being aware of clinical entities which exist outside the DSM-5. As shown in this case, ORS may lead to severe impairment and even suicidal ideation Despite this, there is a scarcity of literature on evidence based treatments for ORS. It has typically been treated with either a moderate dose SSRI or a low dose antipsychotic, with or without CBT. Given the high level of distress and disability caused by the condition, greater awareness of its existence and greater research on its treatment is certainly warranted.