Living with an imagined odor: first case report of olfactory reference syndrome in East Africa treated using a multimodal approach

BACKGROUND: Olfactory reference syndrome is a psychiatric disorder characterized by a persistent and distressing preoccupation with emitting a foul body odor despite the absence of objective evidence. It is classified under "other specified obsessive-compulsive and related disorders" in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Although olfactory reference syndrome has been described in several regions globally, there are no published case reports from East Africa. CASE PRESENTATION: A 50-year-old Ethiopian man was referred from the otorhinolaryngology department to psychiatry with 3 years history of preoccupation that his nose emits a foul odor, described as "like a dead mouse." Despite repeated reassurance and medical evaluations, he remained convinced of the odor, engaging in excessive nasal cleansing and social avoidance. His symptoms led to marked functional impairment, marital separation, and social withdrawal. MANAGEMENT AND OUTCOME: Treatment included fluoxetine titrated to 60 mg/day, risperidone 2 mg nightly, and supportive psychotherapy incorporating cognitive-behavioral techniques. Over the course of 1 year, the patient showed marked improvement in odor-related preoccupation, depressive symptoms, and social engagement, with no significant side effects reported. DISCUSSION: This case highlights the debilitating impact of olfactory reference syndrome and the diagnostic challenges it poses, particularly in differentiating from delusional disorder, primary psychotic disorders, and mood disorders with psychotic features. CONCLUSION: Olfactory reference syndrome is an underrecognized condition with significant psychosocial consequences. Reporting this case from Ethiopia aims to raise awareness among clinicians in low-resource settings, encourage timely diagnosis, and promote multidisciplinary management.