Management of olfactory reference disorder^*¶

BDD: body dysmorphic disorder; CBT: cognitive-behavioral therapy; CGI-S: Clinical Global Impressions-Severity; OCD: obsessive-compulsive disorder; ORD: olfactory reference disorder; SGA: second-generation antipsychotic; SSRI: selective serotonin reuptake inhibitor; TCA: tricyclic antidepressant; Y-BOCS: Yale-Brown Obsessive Compulsive Scale.

* For all individuals with diagnosis of ORD, our initial intervention is brief psychoeducation stressing the rationale for treatment including potential benefits of treatment.

¶ Our management decisions are guided by level of severity of symptoms. However, patient preference is considered in all treatment decisions. Our preference for initial management is with either medication, CBT tailored to ORD, or a combination of them. For severe ORD, a combination of medication and CBT is recommended.

Δ We consider individuals with an ORD Y-BOCS score >30 or a CGI-S score ≥5, to have severe ORD. Furthermore, we consider individuals with active suicidal ideation, prominent passive suicidal ideation, or suicidal behavior to have severe ORD. Refer to UpToDate content for discussion of assessment and management of individuals with suicidal ideation.

◊ Refer to UpToDate content for factors used in deciding choice of SSRI including adverse effects and drug interactions.

§ We consider a therapeutic trial of SSRI to be 12 to 16 weeks with at least 4 weeks at the target dose, if needed. Refer to UpToDate content and table for discussion of initiation and titration of SSRI in the treatment of ORD.

¥ We prefer CBT targeted towards ORD as initial psychotherapeutic management of ORD. CBT for ORD is based on CBT tailored to BDD or OCD. Refer to UpToDate content for discussion of CBT for related disorders (eg, OCD and BDD).

‡ We treat for at least 4 to 6 weeks at the maximum SGA dose attained prior to assessing response. Our preference among SGAs is aripiprazole. However, other factors are considered in choosing SGA. Refer to UpToDate content for choice of SGA.

† In individuals with co-occurring disorders that may be responsive to SSRI treatment, we often prefer treatment with an SSRI. Refer to UpToDate content for use of SSRIs in the treatment of ORD and other disorders.

** For individuals who respond adequately to treatment, we continue SSRI medication for several years or indefinitely (eg, if multiple relapses). We consider trying to taper off of antipsychotics after 1 to 2 years. For those who improve with CBT, we offer booster sessions.

¶¶ We are cautious in using supratherapeutic doses of medications. We treat with supratherapeutic dose of medication (the highest dose attained) for at least 4 to 6 weeks (if needed) prior to assessing efficacy. We do not use supratherapeutic doses in youth (eg, age <14). We use caution in adults age >65. Refer to UpToDate topic for treatment and monitoring with supratherapeutic doses of SSRI.

ΔΔ When switching between SSRI medications, our preference is to cross-titrate from the initial SSRI to the new medication. Refer to UpToDate content for discussion of switching between SSRI medications.