Are You Afraid of Bad Breath?

Halitophobia, or fear of bad breath, is a widespread but poorly understood condition. The diagnosis rests on the disconnection between the person's sense of foul mouth odor and the perceived experience by others that there is no unusual odor. Most treatment protocols advance one of two distinct approaches:

1. Behavioral modification or cognitive behavioral therapy(CBT). Each encourages thought changes to encounter the unreality of the symptom. Frequently combined with a non-therapist partner who reassuringly responds to exhaled breath by commenting on the odor.

2. Psychoanalytically oriented psychotherapy connects the current experience ( enhanced belief in the person's bad smell) with fears of rejection from the past. Through an emotionally corrective experience with the therapist, patients gain confidence that their anxiety about smelling bad can be reduced to a treatable symptom rather than a global anxiety.

While both therapies offer important relief ( along with anti-anxiety or anti-depression meds to reduce symptom pressure) neither is sufficient to control the phobic elements of the disorder which include:

--Hyper-vigilance to others' reaction 

--Signs of reference, i.e that people are turning away from them because of repulsion at their mouth odor which can create self-fulfilling reactions 

--Panic responses including shallow breathing, sweating, faintness, etc

The challenge for successful psychotherapy of these individuals remains the persistence of the delusional elements of the phobia. Even if today they don't smell bad how can they trust that tomorrow their mouth odor won't recur?

For example, a patient referred by his dentist complained of social isolation based on his perception of his breath odor. After taking an extensive history, the patient acknowledged that he had no real information regarding his actual mouth odor but deduced from peoples' reactions that he was disgusting to them. His deductions referenced people on the subway turning away from him or covering their mouths or noses in his presence. He acknowledged the possibility that he might be creating self-consciousness in others but felt helpless to prove or disprove his theory. As we developed more rapport he agreed to allow me to smell his mouth odor by exhaling into my face.

He was stunned when I did not turn away in disgust, but found a completely neutral mouth odor. He agreed to recruit a partner-- either a family member or friend-- to respond to his anxiety about his mouth However, he found the "recruiting" process overwhelming and so maintained his individual connection with me as his therapeutic ally. Although we partially contained his anxiety, the case highlights some of the challenges of treatment:

Challenges to successful treatment:

1. Referrals, usually by dentists, are difficult. Halitophobes should not be directly confronted about the unreality of their symptom. Usually some milder form of "exploring" "the issue is more successful, a skill many traditional dentists may lack.

2. Treatment requires a committed patient. The therapies recommended above both require time, effort and training.

3. The process of de-stimulation is long-- potentially life-long-- with peaks and valleys of disturbance

4. The resistance to the change of belief in the reality of their breath odor may be accompanied by increased anxiety in other functions of daily life. This should be understood and prepared for in advance of halitophobic treatment.

Treatment Recommendations;

There has been no literature on the use of group psychotherapy for the treatment of bad breath  I imagine that the principles of AA ( shared belief in the lack of control over the symptom) sponsorship by and of other group members, and on-call availability during crisis periods may be important underpinnings for successful resolution of bad breath.

However, I do not believe that in and of itself the model is sufficient. AA is dedicated to substance use and exhibits a "black and white" test which halitophobia lacks. The anxiety of a halitophobe, when untreated, is global, based on self referred tests of the environment.

A group experience would optimally benefit from traditional group psychotherapy methods which focus on how our current life reenacts -- frequently unconsciously-- experiences from our earlier life experiences. Without the depth of understanding which group members can provide, the AA model can alleviate the symptom without uniquely understanding the meaning of the symptom in that person's life. By doing so, the halitophobe can lack the emotional maturity to fully engage the connection between his current symptom and other life events. A mature therapy group actually mirrors the reenactment experience during the group. Emotionally educated and resilient groups can feed back to its participants the impact of their behavior and language and emotions. And potentially other group members represent a grounding for their anxiety.

The casualty issues for bad breath are indeed high. Frequently there is panic about entering social relations for fear of rejection. The AA model is a starting point for confronting symptom control. However, a course of individual treatment addressing both the etiology of the symptom as well as behavioral modification would be helpful. Optimal would be a continuing psychotherapy group dedicated to bad breath but also to life adjustment issues after a lifetime of delusional isolation and fear.

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