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Halitophobia, also known as Delusional Halitosis or as a manifestation of Olfactory Reference Syndrome (ORS), is an abiding fear of having bad breath, whether a valid concern or not. In some cases it may be symptomatic of mental illness or delusion. Halitophobia is a delusional disorder that stems from halitosis. Halitosis is a term used to describe noticeably unpleasant odors exhaled in breathing. Bad breath can be caused by a number of problems. Bad breath can be caused by a number of problems.

There are many factors that can contribute halitosis, these things include: Oral diseases, fermentation of food particles in the mouth, sinus infections, and unclean dentures can all contribute to mouth odor. However, some one quarter of the patients seeking professional advice on bad breath suffer from a highly exaggerated concern of having bad breath, which is ‘’halitophobia’’.

Delusional Disorder
Halitophobia is a type of Delusional Disorder. A Delusional disorder is an illness characterized by the presence of non-bizarre delusions in the absence of other mood or psychotic symptoms, according to the ‘’Diagnostic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)’’. . Non-bizarre refers to the fact that this type of delusion is about situations that could occur in real life, such as being followed, being loved, having an infection, etc.

The ‘’Diagnostic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)’’. defines delusions as false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary and these beliefs are not ordinarily accepted by other members of the person's culture or subculture.

This term has been used to describe an illness with persistent delusions and stable course, separate though from delusions that occur in other medical and psychiatric conditions. However, the concept of paranoia has been used for centuries. Originally, the word paranoia comes from Greek para, meaning along side, and noos or nous, meaning mind, intelligence. The Greeks used this term to describe any mental abnormalities similar to how we use the word insanity.

The ‘’DSM-IV-TR’’ defines delusional disorder with the following criteria:

A: Non-bizarre delusions (ie, involving situations that occur in real life, such as being followed, poisoned, infected, loved at distance, deceived by spouse or lover, or having a disease) occurring for at least 1 month's duration.

B: Criterion A for schizophrenia has never been met (ie, patients do not have simultaneous hallucinations, disorganized speech, negative symptoms such as affective flattening, or grossly disorganized behavior). Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme.

C: Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.

D: If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.

E: The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition. .

Halitosis
The term halitosis dates from the 1870s, combining the Latin ‘’halitus’’, meaning 'breath', with the Greek suffix ‘’osis’’ often used to describe a medical condition. Bad breath is not, however, a modern affliction. Records mentioning bad breath have been discovered dating to 1550 B.C. Bad breath, halitosis, is an unpleasant problem most people try to avoid. Physicians seem particularly adept at avoiding halitosis by referring patients with this problem to a dentist. Bad breath is caused by mixture of the breath with malodorous compounds emanating from different areas of the respiratory and upper digestive tracts. Halitosis originating in the oral cavity is most frequently associated with poor oral hygiene, dental plaque, dental caries, gingivitis, stomatitis, periodontitis, hairy tongue and oral carcinoma. Halitophobia is a delusional form of Halitosis. Delusional in this sense means something that is only in the mind, and halitosis referring bad breath. Although the absence of bad breath may be evident, the individual believes they still have bad breath.

Olfactory Reference Syndrome (ORS)
Lochner and Stein (2003) defined Olfactory reference syndrome (ORS) as a psychiatric condition characterized by persistent preoccupation about body odor accompanied by shame, embarrassment, significant distress, avoidance behavior and social isolation. In examination of ‘’Halitophobia (delusional halitosis)’’, a conclusion can be found that it is an offshoot or manifestation of olfactory reference syndrome, and the two can be treated as the same. Olfactory Reference Syndrome is an overly excessive concern for one's body odors, and delusional halitosis may fall under this category. People with ORS believe that they have a foul or excessive body odor, despite any evidence or reassurance to the contrary. They too can have shame, embarrassment, social avoidance disorders, distress, depression and the like. ORS and Halitophobia are sometimes also thought to be manifestations of body dysmorphic disorder, or being obsessed with the thought that there is something wrong with one's body when there really isn't.

Diagnosis
A research done by Seemann et al. (2006) at the Charité-University Medical School of Berlin, Germany, describes the data collected from a multidisciplinary breath consultation in Germany. According to this research, 28% of the patients complaining on bad breath did not show detectable signs of bad breath – meaning that their concern of halitosis was exaggerated. Within this group, 76% received prior treatments for bad breath, 36% received gastroscopies and 14% underwent an ENT operation – all that without having any detectable signs of bad breath. Only 9% of those patients went through an actual organoleptic evaluation of their breath before they underwent these medical procedures.

When delusional halitosis becomes evident, one can assume halitophobia is present in the individual. Many researchers are still examining this Delusional Disorder to find the exact root. As classified according to ‘’the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)’’, a diagnoses is based on the primary diagnoses of a Social Phobia, which is the fears involving other people or social situations such as performance anxiety or fears of embarrassment by scrutiny of others.

Social Aspect
‘’Halitophobia’’ may being to have a social impact on those that have this delusional disorder. Halitophobia can begin to interfere with one's job or life in general. Some who have this phobia avoid work and any other social situation in general. They may lose their job and have difficulties with intimate physical relationships. They avoid any social situation that brings them into close contact with others. People diagnosed with Halitophobia (Delusional halitosis) have been known to give up their careers because they can no longer face the embarrassment of their imaginary bad breath. Some choose to not travel outside their homes, a comfortable sanctuary where they do not need to worry about their malodor breath. Some other reactions to their phobia include people attempting physical harm upon themselves, abuse oral hygiene products, and social isolation.

In the event the phobia cannot be avoided entirely, the sufferer will endure the situation or object with marked distress and significant interference in social or occupational activities. The terms ‘’distress’’ and ‘’impairment’’ as defined by the ‘’DSM-IV-TR’’ should also take into account the context of the sufferer's environment if attempting a diagnosis.

Controversies
The question revolving around halitophobia is, is halitophobia a true problem among the general population? Halitophobia is a concern that may severely affect the lives of some 0.5-1.0% of the adult population. One thing among many individuals mind, especially those that suffer with this phobia is, can this be phobia be overcome? The answer that many have found is, yes, but through common psychological procedures.

Cognitive behavioral treatments
Most bad breath can be treated successfully with good oral hygiene and/or medical care. Occasionally, for patients who feel that these therapies are unsuccessful, some delusional or obsessive behavior pattern might pertain, and mental health counseling may be appropriate. Cognitive behavior therapy, or training oneself to think and feel differently, can also be successful when considering what some delusional halitosis treatments are options without medication. Patients are taught to think differently about the situation or circumstance that gives them fear, and learn to talk themselves either cope with their phobias or overcome them. Delusional Halitosis can best be treated with a doctor or therapist.

Psycho pharmaceutical treatments
Many people with phobias are treated with anti-anxiety medications or antidepressants. Prozac and Xanax are two popular prescriptions for those with depression or anxiety, and both seem to work well for most patients. Doctors need to be consulted before a patient with Halitophobia begins taking medication to treat their disorder.

Alternative treatments
In discussion of cognitive behavioral therapy treatments, improving oral hygiene can help to overcome a phobia. Poor oral hygiene can be improved by regular brushing and flossing, as well as regular dental checkups. Gentle brushing of the tongue should be part of daily oral hygiene. In addition to good oral hygiene, the judicious use of mouthwashes is helpful. Mouth dryness, experienced at night or during fasting, or due to certain medications and medical conditions, can contribute to bad breath. As well, such things like chewing gum may be used as a comfort to mask bad breath, whether present or not.