Psychiatric symptoms of bed breath

A study, published in the last 2010 issue of Psychotherapy and Psychosomatics by a group of researchers of the University of Torino (Italy), has explored the personality correlates and psychiatric symptoms of bed breath. 

If the complaint of a halitosis that does not exist is improved by counselling and simple oral hygiene measures, this condition has been defined as pseudo-halitosis; if the complaint persists, halitosis has been defined as halitophobia. Pryse-Phillips introduced the term 'olfactory reference syndrome' (ORS) to describe a syndrome in which patients claim to actually perceive a malodour that others cannot detect. ORS has not been included in the DSM-IV as a separate category, but several anxiety or somatic disorders, i.e. obsessive-compulsive disorder and body dysmorphic disorder (BDD), have sufficient overlap with the symptomatology of ORS. In the present study, a group of Italian researchers investigated the relationship between the degree of malodour, both objective and subjective, and the psychopathological and personality profile of patients who had been examined at the Division of Periodontology at the Dental School of the University of Turin between February and December 2004. The study population included 66 consecutive subjects (33 women and 33 men) with a complaint of oral malodour. The subject's oral malodour was evaluated by the measurement of volatile sulphur compound levels inside the mouth using a portable gas chromatograph (Oral Chroma). Subjects were requested to score their self-perception of oral malodour using a 10-cm visual analogue scale (VAS). The Revised Symptom Checklist 90 (SCL-90-R) was given to assess psychopathology. The presence of a psychiatric disorder was investigated using the Structured Clinical Interview for DSM-IV. In order to evaluate a subject's personality profile, the Minnesota Multiphasic Personality Inventory (MMPI-2) was used. The overall sample was divided into 3 groups. The first group (8 women and 7 men) included patients with a complaint of halitosis but no appreciable or slight oral malodour (subjective halitosis). The second one (19 women and 23 men) included subjects with a complaint of halitosis and clearly noticeable or strong oral malodour (objective halitosis). From those groups, subjects who fulfilled DSM-IV criteria for a psychiatric disorder were excluded and subsequently included in a third group (psychiatric patients, all showing clearly noticeable or strong oral malodour; 6 women and 3 men; 3 adjustment disorders, 3 mood disorders, 2 anxiety disorders and 1 sexual disorder). To compare these 3 groups, a one-way analysis of variance was used. Univariate linear regressions and a subsequent multiple stepwise regression were used to determine predictors of self-perception of malodour. The 3 groups had similar self-perceptions of oral malodour (VAS scores) and demographic profiles (age and education) but showed differences in psychopathological and personality profiles. The regression models selected by the stepwise method showed that: (a) psychoticism subscales (SCL-90-R score), psychopathic deviation and masculine/feminine scales (MMPI-2 scores) were selected as significant predictors of VAS scores>0.046) for subjective halitosis subjects and (b) only the positive symptom distress index (PSDI; SCL-90-R score) scale (p = 0.016) was selected for objective halitosis subjects.

The results highlight that subjective halitosis patients showed high levels of psychopathological indices, similarly to psychiatric patients. In the group of objective halitosis patients, the PSDI, a scale that can provide useful information on respondent distress style, predicted self-perception of oral malodour. Thus, with basically the same level of halitosis, a subject who scored higher on the PSDI subscale could adapt poorly to the stress caused by the presence of halitosis and perceive a higher subjective level of halitosis. Taken together, these findings highlighted that, even though the first group of patients did not fulfil criteria for any DSM-IV disorder, the psychopathology of subjective halitosis patients seems to be particularly reminiscent of that of individuals with BDD. Further studies, maybe longitudinal ones, will provide more accurate data regarding treatment options for these subjects.