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Olfactory reference syndrome: issues for dsmvReviewOLFACTORY REFERENCE SYNDROME: ISSUES FOR DSM-V Jamie D. Feusner, M.D.,1Ã Katharine A. Phillips, M.D.,2 and Dan J. Stein, M.D. Ph.D.3 The published literature on olfactory reference syndrome (ORS) spans morethan a century and provides consistent descriptions of its clinical features. Thecore symptom is preoccupation with the belief that one emits a foul or offensivebody odor, which is not perceived by others. This syndrome is associated withsubstantial distress and disability. DSM-IV and ICD-10 do not explicitlymention ORS, but note convictions about emitting a foul body odor in theirdescription of delusional disorder, somatic type. However, the fact that suchsymptoms can be nondelusional poses a diagnostic conundrum. Indeed, DSM-IValso mentions fears about the offensiveness of one’s body odor in the social phobiatext (as a symptom of taijin kyofusho). There also seems to be phenomenologicaloverlap with body dysmorphic disorder, obsessive–compulsive disorder, andhypochondriasis. This article provides a focused review of the literature toaddress issues for DSM-V, including whether ORS should continue to bementioned as an example of another disorder or should be included as a separatediagnosis. We present a number of options and preliminary recommendationsfor consideration for DSM-V. Because research is still very limited, it is unclearhow ORS should best be classified. Nonetheless, classifying ORS as a type ofdelusional disorder seems problematic. Given this syndrome’s consistent clinicaldescription across cultures for more than a century, substantial morbidity and asmall but growing research literature, we make the preliminary recommenda-tion that ORS be included in DSM-Vs Appendix of Criteria Sets Provided forFurther Study, and we suggest diagnostic criteria. Depression and Anxiety0:1–8, 2010.
Key words: odor; smell; delusional disorder; hallucinations; olfactory; DSM-V 1Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los his article focuses on some key issues pertaining to 2Butler Hospital and the Department of Psychiatry and Human the classification of olfactory reference syndrome Behavior, Alpert Medical School of Brown University, Provi- (ORS), a condition in which individuals erroneously believe that they emit an unpleasant, foul, or offensive 3Department of Psychiatry, University of Cape Town, Cape body odor. Odors include almost anything foul smelling and are often believed to originate from the ÃCorrespondence to: Jamie D. Feusner, 300 UCLA Medical mouth, genitals, rectum, or skin. Common specific Plaza, Suite 2345, Los Angeles, CA 90095.
concerns include halitosis, genital odor, flatulence or anal odor, or sweat. Occasional patients reportemitting non-bodily odors, such as ammonia, deter- The authors report they have no financial relationships within the gent, or rotten onions. This belief is often accompanied by ideas or delusions of reference; i.e., Received for publication 6 November 2009; Revised 15 February the belief that other people take special notice of the odor in a negative way (for example, rub their nose in reference to the odor or turn away in disgust). In Published online in Wiley InterScience (www.interscience.wiley.
addition, many patients perform repetitive behaviors, such as smelling themselves, showering excessively, and and gender features.’ Here the text states: ‘‘In certain cultures (e.g., Japan and Korea), individuals with Social In this article, we first summarize the history of Phobia may develop persistent and excessive fears of ORSs classification to provide a context for the issues giving offense to others in social situationsy. These discussed. We then address several key issues that are fears may take the form of extreme anxiety that specifically relevant to DSM-V. This article was blushing, eye-to-eye contact, or one’s body odor will commissioned by the DSM-V Anxiety, Obsessive– be offensive to others (taijin kyofusho in Japan).’’ Compulsive Spectrum, Posttraumatic, and Dissociative Similarly, the DSM-IV section on culture-bound Disorders Work Group. It represents the work of the syndromes implicitly refers to ORS, again under the authors for consideration by the work group. Recom- rubric of taijin kyofusho, which is included in the official mendations provided in this article should be considered Japanese diagnostic system for mental disorders. preliminary at this time; they do not necessarily reflect thefinal recommendations or decisions that will be made for DSM-V, as the DSM-V development process is still ongoing.
It is possible that this article’s recommendations will berevised as additional data and input from experts andthe fields are obtained.
1. Should ORS continue to be mentioned as an example of another disorder, such as delusionaldisorder or social phobia, or another disorder? Or should it instead be included as a separate diagnosisin DSM-V? 2. If ORS is included as a separate disorder, what Published descriptions of ORS date back to the late should its diagnostic criteria consist of? 1800s.[2,3,7–11] Several hundred cases from around theworld have been reported, including Europe, the United States, Asia, the Middle East, and Africa. Between 1891and 1966, multiple cases consistent with this syndrome ORS has been described as a discrete syndrome appeared in the literature.[3,7,10–14] Many of these across many cultures for more than a century. How- were described as schizophrenia, although the clinical ever, its clinical features are confusingly mentioned in descriptions did not contain signs and symptoms three different sections of DSM-IV, and they are not sufficient to meet criteria. In 1971, Pryse-Phillips noticed adequately described. Furthermore, the term ORS this, and after characterizing a large case series and (currently the most widely used term for this syn- carefully considering the differential diagnosis, coined drome) is not explicitly mentioned. Given the suffering the term ORS for a separate group with consistent and impairment associated with ORS, it is important to phenomenology. Other terms that have appeared in examine its classification in DSM-V.
the literature include delusions of bromosis, hallucina-tions of smell, chronic olfactory paranoid syndrome, and olfactory delusional syndrome, among others. It hasalso been referred to as a type of monosymptomatic To identify published articles on ORS, we used hypochondriacal psychosis based on the observation that PubMed, WebofScience, and PsychInfo databases with it involves a single delusional belief.[15–19] the keywords ‘‘olfactory reference syndrome,’’ ‘‘olfac- ORS has never been classified as a separate disorder tory paranoid syndrome,’’ ‘‘monosymptomatic hypo- in DSM or the International Classification of Disease chondriasis’’ and ‘ olfactory,’’ ‘‘taijin kyofu’’ and (ICD). DSM-III-R mentioned ORS in the text, stating ‘‘olfactory,’’ ‘‘taijin kyofusho’’ and ‘‘olfactory,’’ ‘‘jiko- that ‘‘convictions that the person emits a foul odoryare shu-kyofu,’’ ‘‘delusional halitosis,’’ ‘‘psychosomatic one of the most common types of delusional disorder, halitosis,’’ ‘‘olfactory hallucination,’’ ‘‘hallucinations of somatic type.’’ Similarly, DSM-IV considers ORS a smell,’’ ‘‘olfactory delusional syndrome,’’ ‘‘olfactory type of delusional disorder, somatic type, although the delusional disorder,’’ ‘‘olfactory paranoia,’’ ‘‘olfactory term ‘‘olfactory reference syndrome’’ is not mentioned.
hypochondriasis,’’ ‘‘monosymptomatic hypochondria- The DSM-IV text states: ‘‘Somatic delusions can occur cal psychosis’’ and ‘‘olfactory,’’ ‘‘delusion’’ and ‘‘smell,’’ in several forms. Most common are the person’s ‘‘delusions of bromosis,’’ and ‘‘bromidrosiphobia.’’ conviction that he or she emits a foul odor from the Additional relevant articles identified from reference skin, mouth, rectum, or vaginay.’’ Similarly, in its lists were also included.[2–4,7,11–13,17,19,22–28] Only peer- section on persistent delusional disorders, ICD-10 does reviewed manuscripts published in the English lan- not use the term ‘‘olfactory reference syndrome,’’ but guage were included. Articles that appeared in these the text notes that delusions may ‘‘express a conviction searches but did not provide any data or clinical thatyothers think that he or she smellsy.’’ description of ORS were excluded (n 5 7). Two DSM-IV also implicitly refers to ORS in the text for recently published reviews on ORS, one from a book social phobia, in the section on ‘‘specific culture, age, and one from a professional journal, were also included. The DSM-IV Sourcebook and DSM-IV and 15.4% had nondelusional ORS beliefs (good to poor insight) [Phillips, unpublished data]. Thus, ORS Sixty journal articles[2–8,11–16,19–69] and four book beliefs may not always be delusional and in such cases chapters[2,12,25,26] fit the inclusion criteria. Fifty-nine would not meet criteria for delusional disorder.
journal articles were case reports or case series, some in An additional consideration is that the DSM-IV combination with reviews of the literature, and one definition of delusional disorder requires the total was a literature review without a case report. The duration of any concurrent mood episodes to be brief four largest published reports contain systematically relative to the duration of the delusional periods. described patients from Japan (N 5 38), Canada Depression is the most commonly reported comorbid disorder or symptom [Phillips, unpublished data], often (N 5 15).[6,18,28,30] Recently analyzed data from a series considered secondary to ORS.[6,32] Data are lacking on of 20 cases of ORS (primarily outpatients) in the the duration of delusional ORS symptoms versus United States are also included [Phillips KA, unpub- duration of concurrent mood episodes. However, lished data], because cases were systematically assessed clinical experience suggests that patients with ORS with the Structured Clinical Interview for DSM and often have prolonged depressive episodes. In the certain other standard measures that were not used in majority of cases, these episodes appear after the development of odor concerns [Phillips, unpublisheddata] and may be secondary to the distress and suffering that ORS causes. Thus, this delusional disordercriterion may not be suitable for ORS.
Although controlled studies are lacking, patterns of response to pharmacotherapy reported in the literature also suggest that ORS is probably not simply a type of delusional disorder. Several case reports and series describe response to antipsychotic monotherapy, particu-larly pimozide,[18,34] but multiple case reports and series describe improvement with serotonin reuptake inhibitor (SRI) monotherapy.[35–38] Some individuals did not To examine whether or not a syndrome is distinct respond to an antipsychotic but did respond to an from other disorders, the DSM-V process has focused SRI. Other reports describe response to non-SRI on validators such as symptom profile; familial antidepressants, such as tricyclic antidepressants.[39,40] aggregation; environmental risk factors; cognitive, And, yet others describe improvement with a combination emotional, temperament, and personality correlates; of an antipsychotic and antidepressant medication.[18,32,41] biological markers; patterns of comorbidity; course of Might ORS be a form of a disorder other than illness; and response to treatment. Unfortunately for delusional disorder? Available data on this issue are also ORS, there is a lack of empirical data for most of these very limited. Some published reports included indivi- validators. However, there are some early data to duals with comorbid Axis I conditions, with the authors suggest that ORS does seem to differ in important ways providing evidence as to how the ORS symptoms were from other disorders in terms of its symptom profile, phenomenologically and/or temporally distinct from comorbidity, and response to treatment.
We will first consider whether ORS should ORS seems to have some features in common with be classified as a type of delusional disorder, as in social phobia, and is considered a form of taijin DSM-IV. This requires consideration of whether ORS kyofusho in Japan and Korea. Taijin kyofusho is beliefs are delusional in nature. Data on this issue are considered a culturally bound syndrome in which limited. Most published case reports include patients individuals fear that their body or bodily functions with delusional beliefs (i.e., complete conviction of may displease, embarrass, or be offensive to others in emitting a foul or offensive body odor). However, the terms of appearance, odor, facial expressions, or literature contains reports of patients whose beliefs movements. An estimated 17% of individuals with were not delusional; that is, the person recognized that taijin kyofusho have fears of emitting body odor, he/she might not actually be emitting a noticeable although this is one of only several fears in this odor. Osman noted that overvalued ideation may syndrome (see also the review for DSM-V of culture occur rather than delusions, and Suzuki et al. reported and anxiety disorders, [Lewis-Ferna´ndez et al., under that three of seven patients in their series had good review]). The literature suggests that most individuals insight. Other authors have also commented on the with ORS are concerned about the social implications existence of nondelusional forms of ORS.[16,18,32] In a of emitting a foul odor, with patients commonly recently analyzed data set, which used the reliable and experiencing shame, embarrassment, and anxiety in valid Brown Assessment of Beliefs Scale to assess social situations, as well as avoidance of social delusionality/insight of ORS beliefs, 84.6% patients situations. Some fear offending others with their with current ORS currently had delusional ORS beliefs odor. One small study that directly compared individuals with ORS symptoms to those with social in ORS [85%] and appearance in BDD [36–60%]), phobia found similarities in demographics, comorbid- current ideas or delusions of reference (77% in ORS ity with depression, and symptom scores on social versus 38% in BDD), and more frequent lifetime phobia ratings scales (although the study was under- comorbidity with DSM-IV social phobia (65% in ORS powered to detect differences between groups). How- versus 37–39% in BDD)[56–58] [Phillips KA, unpub- ever, the key characteristic of social phobia is the fear that one will act in a way that will be embarrassing or Finally, there are apparent similarities with other humiliating; thus, patients are typically primarily somatoform disorders, primarily hypochondriasis.
concerned about how they speak (or eat, write, etc.) Both disorders involve preoccupation with the body, rather than how they smell. Another apparent differ- are often marked by obsessional thinking, and include ence between ORS and social phobia is the often repetitive behaviors, such as checking and seeking delusional nature of the core belief in ORS. In medical diagnoses and treatments. However, unlike addition, it seems that most individuals with ORS ORS, in hypochondriasis the core fear is about having a perform excessive, repetitive behaviors that are com- serious disease. Moreover, unlike hypochondriasis, pulsive in nature. The intent of these behaviors is ORS is typically characterized by prominent ideas/ usually to check or eliminate the perceived odor, obtain delusions of reference and social avoidance.
reassurance about it, or prevent others from smelling it.
We will now address issue ]1 from a different Examples include checking their body for odor, perspective, which is whether ORS should be included excessive showering or other washing, or repetitive as a diagnosis in DSM-V, separate from delusional use of deodorant, mouthwash, or perfume.[6,16,32,48] In disorder or another mental disorder. First, we draw in the sample noted above, 95% of subjects performed at part on recent considerations for what constitutes a least one such behavior [Phillips, unpublished data].
mental disorder while also considering ongoing dis- These behaviors raise the question of whether ORS cussion in the literature on this topic [e.g.,[59,60]. We may be related to OCD. Another similarity with OCD then address several additional considerations for is that individuals with ORS usually report troubling, adding a disorder to the nomenclature. repetitive, and intrusive thoughts about their ‘‘odor,’’ The condition is a behavioral or psychological syndrome or which some describe as obsessive.[12,18,49] Indeed, pattern that occurs in an individual: As detailed above, sufferers may spend many hours per day preoccupied ORS has long been recognized in the psychiatric with these thoughts [Phillips, unpublished data].
literature as a syndrome that occurs in individuals, and These symptoms, in addition to case reports of ORS it has been described in multiple regions of the world.
symptoms responding to SRIs,[35,38,50] has led some to The consequences of which are clinically significant distress posit a relationship between ORS and OCD. or disability: The literature consistently indicates that However, ORS seems to differ from OCD in that ORS causes clinically significant limitations in func- OCD beliefs are delusional in fewer than 5% of cases, tioning or distress. A number of authors have noted and ideas/delusions of reference seem less common in significant social disability associated with ORS. In OCD than in ORS.[51–53] In addition, available data, Pryse-Phillips’ case series, only 3% of patients were although very preliminary, suggest that comorbidity ‘‘socially active.’’ Prominent social avoidance and patterns may differ, with comorbid major depressive isolation seems common, which is usually attributed to disorder and social phobia more common in ORS shame, embarrassment, and/or concern about offend- ing others with the odor.[6,16,32,42] Impairment of work More than 20 years ago, Isaac Marks noted that or school functioning is also common.[6,16,32,42] This, ORSs clinical features have many similarities to body too, is often noted to be owing to avoidance of other dysmorphic disorder (BDD); the primary symptoms of people because of shame, embarrassment, or concern both disorders involve a belief of a bodily defect which about offending others with the perceived odor, or it leads to anxious avoidance of relevant (often social) may result from time spent preoccupied with thoughts situations. Other similarities include preoccupation about the odor and engaging in behaviors to check or and repetitive behaviors to check or remediate the minimize it. In a small recently analyzed data set, perceived problem.[2,15,16,40,42,48,55] In addition, both ORS symptoms had caused 74% of subjects to avoid disorders are characterized by frequent seeking of social situations and 47% to avoid occupational, nonmental health medical treatment in an attempt to academic, or other important role activities [Phillips, alleviate the symptoms. Examples include surgery and unpublished data]. Forty percent reported that they dermatologic treatment in BDD, and treatment from had been completely housebound for at least 1 week dentists and gastroenterologists in ORS.[16,18,30,32,42] because of ORS symptoms. The mean score on the However, BDD and ORS have some apparent differ- Global Assessment of Functioning Scale among those ences. The content of the core beliefs, many of the with current ORS was 47.5 (SD 5 13.2). A majority repetitive behaviors, and treatment response may all of subjects (52.6%) reported a history of psychiatric differ. In addition, available preliminary data hospitalization, with 31.6% of the sample reporting (although very limited) suggest that ORS is more often characterized by current delusional beliefs (about odor primarily because of ORS symptoms. Furthermore, 68% of subjects had a history of suicidal ideation, 47% The syndrome has clinical utility: In our clinical reported lifetime suicidal ideation that they attributed experience, many patients with ORS receive no primarily to the distress caused by ORS symptoms, diagnosis or an inaccurate diagnosis, such as schizo- 32% had attempted suicide, and 16% had made at phrenia, OCD, or major depressive disorder. This, in least one suicide attempt that they attributed primarily turn, may lead to treatment for another disorder. Such to ORS [Phillips, unpublished data]. Of Pryse-Phillips’ misidentification may occur because DSM-IV only very 36 subjects, 43% experienced ‘‘suicidal ideas or briefly mentions ORS symptoms in the text, does not action’’ and 5.6% committed suicide over the follow- include the specific term ‘ olfactory reference syn- up period (the duration of the follow-up period drome,’ and lacks diagnostic criteria. Alternatively, is unclear but seems to have been 1–2 years), with patients present to nonmental health professionals, the author implying that the suicides were attributable such as dentists, gastroenterologists, dermatologists, and gynecologists, who may not be aware that ORS is a The proposed syndrome is not merely an expectable known form of mental illness. Many patients do not response to common stressors or losses or a culturally seek treatment at all, which may in part be owing to sanctioned response to a particular event: The literature lack of public awareness that the symptoms represent a provides no evidence or suggestion that ORS is merely an expectable response to common stressors or losses, Taken together, then, the potential benefits of or a culturally sanctioned response to a particular creating a new diagnosis (e.g., identifying individuals who require appropriate clinical attention) seem to The proposed syndrome reflects an underlying psychobio- outweigh any potential harm. However, research data logical dysfunction: To our knowledge, disturbances in on this syndrome are still limited. Therefore, we biological and psychological processes in ORS have not propose that ORS be included in an Appendix of been studied, although preliminary (uncontrolled) Criteria Sets Provided for Further Study rather than in reports of improvement in ORS with pharmacotherapy the main part of the manual. The following are or psychosocial treatment (behavioral therapy,[15,48] additional considerations that may arise when propos- ing a new disorder for the nomenclature (including intention) indirectly support the presence of such underlying mechanisms. In addition, excessive groom- Is there a need for the category; for example, is the ing behaviors in animals offer a possible ethological syndrome sufficiently common in clinical or population model for human ORS. One purpose of grooming samples that it merits an independent category as opposed across species is to clean in order to maintain health; to being one example in an NOS category? Prevalence for example, by improving predation or avoiding studies using the proposed diagnostic criteria below predators via removal of odors. Although the have not been done. However, in a tertiary referral unit relationship between evolutionary function/dysfunc- for the behavioral treatment of psychiatric disorders tion and disorders remains controversial,[66,67] con- (the Psychological Treatment Unit at the Maudsley ceivably such processes can go awry and result in Hospital in London), 9 of 2,000 patients (0.5%) spontaneously reported ORS symptoms. This figure The syndrome is not primarily a result of social deviance or is likely an underestimate, given the shame and secrecy conflicts with society: There is no evidence or suggestion that often characterizes ORS. A self-report survey of in the literature that ORS is solely a result of social 2,481 university students in Japan found that 2.1% deviance, other conflicts with society, or ‘‘eccentricity.’’ had been concerned with emitting a strange bodily ORS has many features of an ‘‘internalizing’’ disorder odor during the previous year. Although this rather than reflecting social deviance or conflict.
symptom is not necessarily equivalent to a clinical Responsiveness (in many cases) to psychotropic agents diagnosis of ORS, the authors nonetheless imply or behavioral therapy (as noted above) is consistent that ORS is relatively common in Japan and conclude that in Japan ‘‘fears of bodily odor are.encountered The syndrome has diagnostic validity on the basis of almost every day.’ Several authors have suggested that various diagnostic validators: For ORS, there is a lack of ORS is more common than usually recognized. Iwu empirical data for most of these validators (mentioned noted that delusional halitosis (one form of ORS) ‘‘may above) and only minimal data for others. As noted be frequently encountered by the dental surgeon.’’ above, however, ORS does seem to differ in important Osman concluded that the monosymptomatic hypo- ways from other disorders in terms of its symptom chondriacal psychoses are likely to be underreported profile and possibly comorbidity. Furthermore, it and ‘‘form an important and not uncommon cause of seems to differ from delusional disorder on the basis psychiatric morbidity in [developing countries].’’ of preliminary observations that some patients seem to What is the relationship of the proposed disorder with respond to antidepressant monotherapy.[6,18,32,34–40] other DSM-IV diagnoses; for example, is the diagnosis However, the fact that some patients seem to respond sufficiently distinct from other diagnoses? As noted, ORS to antipsychotics alone[6,32,43] suggests that ORS also seems to differ from diagnostic near neighbors in differs from social phobia, BDD, and OCD. several ways, although further research is needed.
Are there proposed diagnostic criteria with clinical face criteria. Furthermore, impairment in functioning validity, reliability, and adequate sensitivity and specificity should cover clinically significant avoidance. The for the proposed construct? As discussed below, available diagnostic hierarchy criterion (criterion C) specifically criteria exist. Nevertheless, further work is needed to emphasizes psychotic disorders. We considered includ- ing social phobia in the exclusion criterion, given the Can the criteria be easily implemented in a typical clinical relationship between taijin kyofusho and concerns interview and reliably operationalized/assessed for research about body odor, but concluded that insufficient data purposes? Suggested criteria are provided below, but are available to support this. We suggest a dimensional have not yet been rigorously studied.
approach to insight, consistent with the emphasis inDSM-V on dimensional constructs, and given that there seems to be a range of insight in ORS. We considered whether these criteria are appropriate for both genders, for patients throughout the course of development, andfor all cultures, and are not aware of a compelling Two different sets of criteria have been proposed for reason for modifying the proposed criteria for any of ORS.[8,36] The research diagnostic criteria proposed below reflect features of each criteria set, with furtherminor modifications; in addition, we propose theaddition of insight specifiers: (A) Preoccupation with the belief that one emits a foul or offensive body odor, which is not perceived by Considering ORS a type of delusional disorder poses a number of diagnostic problems, as discussed above.
(B) The preoccupation causes clinically significant In addition, available data suggest that ORS differs distress (for example, depressed mood, anxiety, from other ‘‘near neighbor’’ disorders. One possibility shame) or impairment in social, occupational, or is that ORS might represent variable presentations of other important areas of functioning.
several different disorders, such as BDD, social phobia, (C) The symptoms are not a symptom of schizophre- or others, rather than being a distinct syndrome.
nia or another psychotic disorder, and are not Although this possibility requires investigation, studies owing to the direct physiological effects of a and case descriptions of ORS over the past century substance (e.g., a drug of abuse or medication) or a provide a consistent description of its clinical features, suggesting that ORS is likely a distinct entity, althoughone that shares some features with other disorders. In Specify whether ORS beliefs are currently character- addition, ORS seems to meet many of the above considerations for what constitutes a mental disorder 1. Good or fair insight: Recognizes that ORS beliefs and for adding a disorder to the nomenclature. In are definitely or probably not true, or that they may particular, ORS seems to characterize a distinct and suffering group of people who need clinical attention; 2. Poor insight: Thinks ORS beliefs are probably true.
in our experience, its near absence in DSM has led to 3. Delusional beliefs about body odor: Completely underdiagnosis and undertreatment of a severe mental illness. Also of clinical importance is that there islimited but emerging literature on its treatment, which We suggest the phrase ‘‘which is not perceived by seems to differ in some ways from that of other others’ in criterion A rather than a phrase, such disorders[2,8]—in particular, delusional disorder, under as ‘‘false belief,’’ because it may be more patient friendly and thus perhaps less likely to deter patients Nevertheless, data on ORS are still limited, and with ORS, whose insight is usually absent or poor, research on the above criteria is needed. For example, from seeking treatment. Criterion B is based on the reliability data are not available on the proposed DSM-IV clinical significance criterion and will ulti- diagnostic criteria, many of the above-noted validators have not been examined, and ORSs prevalence and the used throughout DSM-V. We considered adding a nature of its relationship to other disorders have been phrase about ‘‘associated avoidance’’ to this criterion; only minimally examined. Thus, it is probably pre- although possibly open to somewhat different inter- mature to include ORS in the main body of DSM as a pretations by clinicians, it seems clear that avoidance contributes to the clinical distress and impairment Taken together, we recommend including a criteria associated with ORS. However, in the absence of set for ORS in an Appendix of Criteria Sets Provided adequate data on the prevalence of avoidant behavior in for Further Study. ORS has been clinically ob- ORS, and whether it is characteristic of all patients with served and reported for more than a century ORS, avoidance may be better in the text than in the around the world, with the literature consistently underscoring the suffering of these individuals. ORSs 21. World Health Organization. The ICD-10 classification of current classification is problematic, causing it to be mental and behavioural disorders. Geneva, 1992.
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