Chem. Senses 24: 705-712,
1999
© Oxford University Press 1999
Assessing the Impact of Anosmia: Review of a Questionnaire's Findings
Warwick Olfaction Research Group, Department of Psychology, University of Warwick, Coventry CV4 7AL, UK
Steve Van Toller, Warwick Olfaction Research Group, Department of Psychology, University of Warwick, Coventry CV4 7AL, UK e-mail:psraw{at}csv.warwick.ac.uk
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Abstract |
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The inability to detect odours, anosmia, can cause profound psychological effects resulting in feelings of physical and social vulnerability and victimization. In addition, there may be unhappiness related to the loss of the ability to detect pleasurable food smells and, as a consequence, anosmics may develop problems relating to eating. These profound effects arise from a condition which can have a rapid onset and a very poor prognosis for recovery, and are largely treated with a lack of sympathy and indifference by people with normal olfactory ability. In an attempt to educate, inform and help sufferers, a questionnaire was developed in the early 1980s and sent to those who contacted the Warwick Olfaction Research Group. The responses from this questionnaire form the basis of this review. Feelings of personal isolation, lack of interest in eating and emotional blunting were common responses from these sufferers and it seems that we still have some way to go before an adequate recognition of problems associated with anosmia is gained by the general population and, more importantly, within the medical profession.
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Introduction |
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TopAbstractIntroductionAnosmiaGenetic factorsEating behaviourThe trigeminal sense and...ConclusionsReferences |
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The first recorded scientific observations of anosmia were made by Hughling Jackson (Jackson, 1864
), who wrote, ‘In 1837 a gentleman of Sheepwash in
Devon was
struck from his horse. All the worst effects of concussion resulted—his sense of smell was
lost
forever’. Since this early paper there have been periodic accounts concerning the
condition.
Ogle (Ogle, 1870) discussed nine cases and reported variability in the
ability in
his anosmic patients to sense odours. Leigh (Leigh, 1943) analysed 1000
patients, reporting that 8.3% showed some recovery. Sumner (Sumner, 1964)
reported a survey of 1200 patients, stating that in 12.3% of the patients, anosmia followed frontal
blows to the head and in 2.08% it followed occipital blows.
As the earlier work suggested, it is important to remember that the condition of anosmia
represents
a continuum of impairment. It can arise from a nasal obstruction or neurological damage to
primary
olfactory processing up to the level of the olfactory bulb and tract. Furthermore, impairment of
the
sense of smell can be caused by a large number of diseases and there are several recent reviews
related
to the condition (Hendriks, 1988; Finelli and Mair, 1990; Doty, 1995; Sullivan et al.,
1995). In addition, clinical accounts have also been presented (Krmpotic-Nemanic, 1969; Hill and Jafek, 1989; Eloit and Trotier,
1994). It is the intention of this review to report and comment upon
what anosmics say about
their condition and to suggest ways in which they may be psychologically helped. Sumner (Sumner, 1964) reported that recovery from anosmia involved some
relearning about the
perception of odours. Mair et al. (Mair et al., 1995)
point
out that by comparison with what is known neurologically about the visual sense, with its
welldefined
disorders such as achromatopsia, prosopagnosia and aperceptive agnosia, we are far from having
an
equivalent understanding of the olfactory sense.
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Anosmia |
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TopAbstractIntroductionAnosmiaGenetic factorsEating behaviourThe trigeminal sense and...ConclusionsReferences |
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Smell is a sense whose value seems to be only really appreciated after it is lost. Forty-nine students were asked which of their five senses they would choose to lose if they were forced to make a choice. Seventy-eight per cent of them chose their sense of smell, yet few could explain what such a loss would entail and none pointed out the obvious potential aesthetic impairment to the lives of sufferers. In this they were reflecting the general state of ignorance about the sense of smell. In the early 1980s the Warwick Olfaction Research Group (WORG) began to receive requests from people claiming to be unable to detect smells. A desire to help and inform these sufferers led to the production of a questionnaire which was sent to all who contacted us. It was recognized from the start that the most important function of the questionnaire was to provide knowledge and support for sufferers. A recurrent theme in the letters we received from anosmics was the expressed feeling that each was the only person in the world to be affected by the condition. This appears to be a direct reflection of the lack of sympathy that anosmics encounter concerning their condition. Although the responses reported in this paper are largely concerned with answers to the questionnaire, whenever possible we test subjects in our laboratory. The individually tested anosmics represent small numbers but they do allow for interesting comparisons to be made. Often the laboratory tests are made in connection with industrial and insurance claims.
Unlike the Connecticut Chemosensory Clinical Research Center (CCCRC) questionnaire
reported by Gent et al. (Gent et al., 1986), the WORG
questionnaire
was not given as part of a standard, controlled clinical interview situation. The majority of the
267
replies were obtained by sending out the questionnaire in the post and the findings on which this
review
is based represents phenomenological accounts of the condition by anosmic sufferers. An
overwhelming
number of the statements received from anosmics relate to the indifference they felt they had
received
from the medical profession in response to requests for advice and help. An extreme example of
this is
found in an ENT medical report received in 1996 containing the statement, ‘the patient
was able
to detect odours because they were able to detect ammonia’. This quote suggests a total
lack of
awareness by an ENT specialist concerning the function of the fifth cranial trigeminal nerve
(touch) as
opposed to the first cranial nerve (olfactory). Anosmics stated that they had often been brusquely
informed by doctors that there was nothing that could be done for them and they would just have
to get
on with their lives as best they could. This attitude of indifference demonstrates a lack of
sensitivity and
a poor understanding of possible psychological problems that could arise from loss of the ability
to
detect smells. This statement is supported by Mattes (Mattes, 1993), who,
in a
review of medical knowledge concerning smell and taste disorders, reports a lack of
understanding by
the medical profession. Also, Smith and Seiden (Smith and Seiden, 1991)
report a lack of sympathy by the medical profession towards patients with smell and taste
disorders. It
is not known exactly how many sufferers there are, but Smith and Seiden (Smith and
Seiden, 1991) and Smith and Duncan (Smith and Duncan, 1992)
suggest that at least two million Americans suffer from disorders relating to taste or smell and we
can
suppose that this US estimate reflects the incidence pro rata in other countries.
The attitude displayed by the medical profession is important because it will certainly
influence how
anosmics respond when asked about their condition. An example from another area of medicine
serves
to demonstrate this point. It concerns the levels of emotion said to be experienced by paraplegics.
Hohmann (Hohmann, 1966) reported that paraplegics described loss of
emotional feelings following accidents which resulted in the transection of their spinal cords.
However,
McKilligott (McKilligott, 1959) in an earlier study of this same group of
paraplegics claimed that they did not suffer from loss of emotional feelings following their
accidents. The
solution to these contradictory results appears to lie in the fact that McKilligott was an
ambulatory
person to whom the paraplegics were attempting to present a picture of essential normality
whereas
with Hohman, who himself was a paraplegic, they presented a truer picture of their condition and
admitted to difficulties. Of course the answer to such a question is complicated because if a
period of
time has elapsed since the accident, a ‘yes’ answer may merely be reflecting a
diminution
of feelings over time. This appears to be the case with the anosmics in that those with the greatest
intervening time since their loss tended to report fewer problems.
One reason for this lack of empathy and sympathy related to loss of the sens of smell, as Mair
et al. (Mair et al., 1995) have pointed out, may be that
flavour,
incorrectly, is primarily associated with the sense of taste rather than that of smell. The
assumption,
presumably, is that because anosmics still have a sense of taste, their food flavour appreciation is
not
impaired. Flavour is a complex interaction of smell, taste, pH, temperature, food texture and
mouth-feel, but it is to a very large degree dependent upon odour, and the statement ‘it
tastes
good’ really means ‘it smells good’. This universal smell/taste confusion is
paradoxical. For example, people entering a restaurant and savouring the cooking smells coming
from
the kitchen will usually correctly involve the sense of smell and say ‘the food or the
cooking
smells good’. However, once the food arrives at their table they revert to saying ‘it
tastes
good’. Anosmic people forced to rely solely upon their sense of taste, which involves
sweet,
salty, bitter and sour, are truly in a position to appreciate the actual value of the sense of smell in
the
eating process. Interestingly, the smell/taste confusion is also often found in anosmics. When
they come
to the laboratory for testing, they often claim to have lost their sense of taste as well as their sense
of
smell. A demonstration that they still retain their taste sense is often felt by them to be little short
of
magical. When testing taste levels in the laboratory, we use the concentrations and step sizes
reported
by Cooper et al. (Cooper et al., 1959). Tests for
anosmia in
the WORG laboratory also contain checks for malingering as prescribed by Von Feldman (Von Feldman, 1976). These involve using odours mixed with trigeminal
substances, and
flavours such as coconut which have a sour or bitter taste added to them. The major problem
when
testing anosmics is that there is rarely information available concerning their former sensitivity
and level
of olfactory interest prior to the loss. When testing in the laboratory we attempt to estimate the
former olfactory ability and interest.
Sixty-seven per cent of the replies came from females and 33% came from males. However,
the average age of both groups was very similar. For females the average age was 57 years, with
the
median age being 60 years. For males the average age was 56 years, with the median age being
59.5
years. The youngest person sending in a completed questionnaire was 18 whilst the oldest was 87
years
of age. Van Toller et al. (Van Toller et al., 1985)
investigated loss of olfactory ability due to ageing and found that between the ages of 20 and 80
years
there was an average 20% loss in sensitivity to the odours tested. The study used nine common
odours
and one trigeminal compound. Unlike ageing losses in the visual and auditory senses, little or no
compensations are made for olfactory losses in the elderly and olfactory deterioration often goes
undetected. One reason is that ageing losses are often slow and insidious, and loss of the ability
to
detect odours is not intrusive on other family members. Causes of ageing losses are complex but
may
relate to cribriform plate thickening or increased degradation of olfactory receptors due to slower
turnover of the olfactory receptors. It has been suggested that the loss of olfactory sensitivity
through
ageing should be referred to as presbyosmia (Van Toller and Dodd, 1987). It
is argued that use of such a term would enable the condition of olfactory loss in the elderly to be
clearly
identified and sought.
One of the questions on the questionnaire related to the effects of anosmia on general mood states. The answers from the questionnaires were in sharp contradiction to anosmics interviewed in the laboratory who claimed generalized depression arising from their condition. However, as mentioned above, anosmics being personally tested were usually making industrial or insurance claims and as a consequence might have had a negative bias in terms of their responses. Also, in terms of time they were closer to the onset of the condition and more likely to be in a grieving mode and still coming to terms with their sensory loss. In other areas relating to insurance claims there is a recognized condition called ‘compensation’ neurosis where a marked improvement can take place after compensation has been paid.
As expected, questions related to cause of anosmia produced most problems. Some replies were definite while others were probably incorrect guesses. A number of respondents suggested multiple causations for their condition and many of the elderly respondents had probably lost their ability to detect smells as a result of a slow ageing deterioration. However, overall the replies agree with previously published accounts in that the most common causes were stated as a ‘blow to the head’ or ‘viral infection’. It can reasonably be speculated that many of the replies in the large ‘unknown’ category would probably fall into one or other of these two groups. We were unable to measure directly, nor could we estimate the number of anosmics whose losses were due to age. As indicated previously, loss of the sense of smell can be particularly insidious and escape detection because, unlike vision and hearing, loss of olfactory sensitivity does not clearly manifest itself to relatives and friends. It is worth noting that insidious loss of hearing and vision can often escape notice by patients themselves. For example, peripheral visual field effects are often not detected, and marked unilateral hearing defects can be unnoticed by a patient. Under the medical/surgery heading the cause of the anosmia was often stated to be ‘due to surgery for removal of nasal polyps’.
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Genetic factors |
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The group claiming ‘no sense of smell from birth’ is difficult to evaluate because the loss could have occurred from a fall or a blow to the head at a very young age. The respondents were asked to indicate if any other family members were known to have suffered from anosmia. Overall, 49% of the returned questionnaires had something written in this particular box. Many of the statements related to coincidences and some were clearly not genetic in origin; some replies indicated ‘son in law’ or ‘husband’. However, there were some replies that suggested a family link. For example: ‘maternal cousins’ (four replies were in this category), ‘paternal grandfather’, ‘mother and son’, ‘sister and daughter’ and ‘siblings’ (overall, six sisters and two brothers; also, three sons and two daughters were reported as being anosmic). Patterson and Lauder (Patterson and Lauder, 1948
) in their discussion of ‘smell blindness’ included
accounts of
families who were unable to detect smells. Singh et al. (Singh et al.,
1970) reported a family with anosmia extending over three generations. Their report
consisted
of a grandfather, father and three sons, all claiming an inability to detect smells as far back as
they could
recall. In addition, one sister was said to be unable to detect odours. Lygonis (Lygonis,
1969) reported anosmia in a Faroe Isle family extending over four generations. The
condition included both male and female members, and Lygonis reported that the anosmia caused
distress for the females but not for the males. He described using water and ammonia as control
substances but failed to comment on the family members' ability to detect the trigeminal
stimulating ammonia. Sparkes et al. (Sparkes et al., 1968)
considered familial hypogonadotropic hypogonadism which was linked with anosmia. More
recently,
Leopold et al. (Leopold et al., 1992) have discussed
problems related to congenital inability to detect smells. When confronted with a claim of
anosmia from
birth it is necessary to try to establish if the person could have sustained an injury as a baby or a
young
child.
Sixty-three per cent of our respondents indicated that the onset of their anosmia was sudden
and
37% that the onset was slow. Sumner (Sumner, 1964) reported the
remarkable case of a chef who, whilst carrying a tray of chickens along a passageway, struck his
head.
By the time (said to be 30 s) he reached the end of the passageway he realized that he was unable
to
detect the smell of the chickens. Sumner reported that 2 years later the chef was still anosmic.
From our
laboratory testing of anosmics we have found that realization about loss of the sense of smell can
be
very slow, particularly if the loss is connected to a traumatic accident requiring hospitalization.
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Eating behaviour |
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TopAbstractIntroductionAnosmiaGenetic factorsEating behaviourThe trigeminal sense and...ConclusionsReferences |
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One question asked respondents to state their current food preferences relative to their former likes. Replies to this second food preference question were: ‘same’, 24%; ‘different’, 46%. Nutrition and food preferences is one of the most important and controversial questions concerning anosmia. A recent review of clinical physiology of taste and smell can be found in Schiffman and Gatlin (Schiffman and Gatlin, 1993
).
Gilland
(Gilland, 1921) tested an anosmic in an attempt to show increased
sensitivity in
her taste sense. He reported that he was not able to demonstrate any such compensatory changes
due
to loss of the sense of smell. Crosland et al. (Crosland et al., 1926), using themselves as controls, tested a single anosmic person's ability to taste
food.
They stated that under blindfold conditions the anosmic person's ability to detect food
placed
into his mouth did not differ from, or may even have been superior to, that of a person with a
sense of
smell in the normal range. Clark and Dodge (Clark and Dodge, 1955)
tested a
44-year-old single female anosmic using various flavours. They pointed out that the
psychological state
of the person was an important factor in eating. They found that the woman they used was able to
detect many of the foods they placed in her mouth, but not all the foods were correctly named.
They
required the woman to close her eyes when they presented the food, but like Crosland and his
colleagues, made no attempts to disguise the textures of the foods. Clark and Dodge pointed out
that
the woman they tested might have been exceptional. An alternative explanation was that she was
a
partial anosmic. Doty (Doty, 1977) examined the food preference ratings
of
15 anosmics and 15 controls. He concluded from his survey of a 94-food-item checklist that for
some
of his listed foods his controls gave statistically significant larger preference ratings. However,
this was
not the case for most of the items on the food checklist. Doty stated ‘overall, these data
indicate
that congenital absence of olfaction does not result in markedly aberrant food preferences in
human
beings’. Ferris et al. (Ferris et al., 1985) stated
categorically that anosmics did not have nutritional problems.
However, some reports (Mattes et al., 1990; Mattes,
1993, 1995) are contrary to the earlier suggestions that
anosmics
do not experience problems related to their food intake. These authors report that ~14% of
anosmic
patients experienced a body weight gain exceeding 10% while ~6.5% experienced a loss of at
least that
amount. The authors point out that weight changes of this magnitude would not be expected in
healthy,
non-dieting individuals. The effect of the sense of smell on food intake is also indirectly reported
by
Griep et al. (Griep et al., 1996). These authors
examined the
variation in nutrient intake with dental status, age and odour perception in the elderly. They
found that
eating was correlated with olfactory ability and elderly people with a poor sense of smell tended
to eat
less. Similarly, Devore (Devore, 1992) discussed olfactory defects in 50
elderly people living in the community. He found that olfactory dysfunction was present in 39%
of his sample, with 18% unable to
detect smoke. Importantly, Devore stated that he found no correlation between olfactory and
cognitive
dysfunction.
In contrast to the above findings, many of the anosmics personally interviewed expressed concerns about eating. They would mention noticing that their hands were shaking and realize that it was many hours, in some cases a day or more, since they had last eaten. It seems that in a normal situation ansomics eat regularly because they are subjected to food pacing; colleagues, friends or the family eat and they join them. However, left on their own they may forget about the need to eat. Thus, for some anosmics eating seems to have become a refuelling exercise which they may easily overlook. It is important to note that when asked about their eating habits anosmics are often concerned to present a picture of normality and probing may be needed to discover lapses. It is not unusual for an anosmic to recall former pleasures of dining out and then go on to state that eating out is a recreational activity in which they no longer engage. Complete anosmics cannot experience the normal pleasurable pre-eating smells of food cooking.
One question was used to draw attention to the fact that foods have different textures and mouth-feel qualities, and that these can be used by anosmics to provide some limited variety when eating. An example would be the use of curries for chemical hotness and other foods for coldness. When asked if they were using more sugar since the onset of their anosmia, 70% said ‘No’ and 30% said ‘Yes’.
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The trigeminal sense and sensory interaction |
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TopAbstractIntroductionAnosmiaGenetic factorsEating behaviourThe trigeminal sense and...ConclusionsReferences |
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A set of questions was included to find out how well respondents detected trigeminal stimulations. As with other questions, this one was also used to help increase awareness and to draw attention to the important touch sense which should remain relatively unimpaired in ansomics. The trigeminal nerve (the fifth cranial nerve) innervates the nasal passageways and is also found mixed in with the olfactory receptors. It has extensive innervations throughout the mouth, nose and facial areas. Often confused with the sense of smell, the trigeminal nerve is separate from the olfactory nerve. For example, trigeminal innervation on the cornea of the eye is responsible for tearing when volatile lacrimator chemicals are released when peeling an onion. Odours are sometimes mixed with trigeminal compounds, e.g. smelling salts contain eucalyptus oil. From our experience of testing anosmics in the laboratory, we find that they have increased thresholds to trigeminal substances. The reason for this trigeminal/sensory interaction loss is not known, but other investigators have similarly reported decreased trigeminal sensitivity in anosmics (Hummel et al., 1996
).
Doty et al. (Doty et al., 1978) tested normals and
anosmics with 47 compounds and asked the subjects to rate the odours by using psychometric
scales.
The control subjects from both categories used in the study were instructed to concentrate on
trigeminal
sensations which were carefully explained to them. The authors stated that 45 of the compounds
were
detected by at least some of the anosmics. Unfortunately the authors did not use the trigeminal
stimulant
CO2, which has the advantage that it is odourless and can be administered in
controlled and
measured doses. The concentrations of the compounds used by Doty et al. are not clear
from
the report but they were obviously at suprathreshold levels. Hummel et al. (Hummel et al., 1996) tested normal controls against patients with reduced
olfactory sensitivity and reported decreased chemosensory event-related potentials in their
patients to
CO2.
These finding point to sensory interaction being an important area of research that still awaits
scientific exploration. A recent paper by Laska et al. (Laska et al.,
1997) reported testing 20 congenitally anosmic subjects and 50 normal controls
using six
odorants believed to have strong trigeminal components—menthol, 1,8-cineole, acetic
acid,
acetone, ethanol and n-propanol. The authors hoped to determine whether or not it was
possible for anosmics to use trigeminal components to judge aspects of odour quality. As pointed
out
by von Skramlik (von Skramlik, 1926), trigeminal components can be
classified as ‘cooling/fresh’, ‘warming/burning’ or
‘pungent/painful’. In the Laska et al. study, control and anosmic subjects
were
asked to assign verbal adjectives, selected from a list, to the odours, and were also tested for their
ability to discriminate between intensity-matched pairs of the six odorants. The authors found
that the
normal subjects judged menthol and cineole as cool and fresh, acetic acid as pungent and sour,
and
acetone as pungent. They gave no clear descriptive profiles for either ethanol or propanol. The
descriptive profiles given by the anosmics correlated significantly with those given by controls
for
menthol, cineole and ethanol. In an ‘oddball’ discrimination task control subjects
correctly identified eight out of the nine items presented, with most mistakes occurring when
they were
presented with pairs of odours having similar trigeminal profiles. The anosmic subjects, with an
average
of 7.2 of the nine items correctly judged, were not significantly different from the control
subjects. The
anosmic patients used by Laska et al. were suffering from Kallmann's syndrome
and,
although control subjects were stated to be matched for age, it was not reported if they were
matched
for IQ. The authors concluded that the trigeminal components of odours could contribute
significantly to
odour quality for anosmics.
An important fact for anosmics is that any increased threshold in their trigeminal sense would result in less sensitivity to trigeminal stimulants such as combustion odours found in smoke. Many of our respondents reported fear of not being able to detect burning and/or escaping gas. Trigeminal levels within combustion smoke might need to be well above normal threshold levels for detection by the majority of anosmics.
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Conclusions |
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TopAbstractIntroductionAnosmiaGenetic factorsEating behaviourThe trigeminal sense and...ConclusionsReferences |
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Anosmia is a continuum, with sufferers showing degrees of olfactory disability ranging from a blunting of the sense to total loss of olfactory ability. At the present time we lack suitable labels to describe and characterize the anosmic continuum. Douek (Douek, 1974
)
suggested the word panosmia to describe total anosmia, and the word hyposmia to describe
partial
anosmia. However, at this time even this crude twofold distinction is not made. The term
presbyosmia
has been proposed to describe olfactory sensory loss arising from ageing processes (Van
Toller and Dodd, 1987). From various individual tests carried out in our laboratories
there
is little doubt that loss of the sense of smell can radically and adversely affect the quality of life
and in
some cases can lead to severe depression.
Mair et al. (Mair et al., 1995), in a chapter dealing
with
the neuropsychology of odour memory, make a number of important points relating to anosmia.
The
authors distinguish between reception and perception of odours. Using computed tomagraphy
scans of
354 patients suffering from hyposmia and/or hypogeusia, they draw attention to the fact that
anosmia
arises from lesions of the olfactory nerve, bulb or tract, i.e. lesions or compressions in the
primary
olfactory processing areas. The effect of these primary olfactory lesions is to reduce the ability to
detect
odours. The authors argue that lesions affecting the more central olfactory pathways of the brain
alter
olfactory perceptions such as discrimination, recognition and identification but leave the ability
to detect
weak odours intact. The fruitful suggestions put forward by these authors require future
investigation.
Despite the fact that most anosmics need advice and help, it is rare to find an anosmic who
has
received counselling about his or her condition. Varney (Varney, 1988)
has
written: ‘Among 40 patients who developed total anosmia as a result of closed-head
injury,
virtually all had major vocational problems during the two or more years after being medically
cleared
to return to work’. None of the cases Varney reported had major motor or sensory deficits
and,
importantly, the majority were above average in terms of cognitive abilities. An anosmic tested in
the
laboratory at WORG said that since his anosmia he thought that he had become maladroit as a
teacher.
Initially this statement was puzzling because he was perceived as a sensitive person. However, on
reflection it seems that he was indicating that, because they were no longer appropriate to him, he
had
stopped using common olfactory similes and metaphors in his teaching and had intuitively come
to
recognize his diminished communication skills.
Tennen et al. (Tennen et al., 1991) have discussed
the
important psychological and social consequences that may arise from the condition of anosmia.
The
authors state that a feeling of vulnerability is the single most stressful aspect of living with a
smell and
taste disorder. They report that 28% of anosmics answering the CCCRC questionnaire quoted
vulnerability as their major problem. Problems like ‘Is this food OK to eat?’ and
‘Is there a gas leak?’ leave anosmics feeling vulnerable. Twenty-six per cent of the
CCCRC respondents in the above study mentioned some disruption of their marital, sexual and
social
relationships. Although the problems quoted above may not be solely related to the anosmia, the
WORG studies have also identified these types of problems. Anosmics often state that their
interest in
sex has dwindled and, as we have already pointed out, many report that they no longer dine out.
It is
also common to find anosmics obsessed with bodily hygiene.
Tennen et al. asked anosmics to complete the Beck Depression Inventory (BDI) (Beck et al., 1961) and the revised symptom checklist 90
(SCL-90R)
(Deragatis, 1987). They reported that 17% were moderately depressed,
scoring significantly higher on the SCL-90R than the normal sample used in the construction of
the
scale. Higher scores were recorded in patients with the most recent onset of anosmia. A
significant
correlation was found between the SCL-90R index of global distress and the degree of olfactory
functioning index. However, it is important to point out that the correlation obtained accounted
for only
5% of the shared variance. Tennen and his colleagues argue that a person's psychological
well-being is to a large degree determined by his or her ability to cope with a loss. Accordingly, a
large
part of their chapter is concerned with coping and appraisal mechanisms. Clearly individuals vary
in the
way they are affected by anosmia, and our findings indicate that males are more likely to deny
that loss
of their olfactory ability is a problem. Often there is a suspicion that a stereotypical male
machismo
response is being made. However, some anosmics cope reasonably well. One was proud of the
fact
that neighbours called him in whenever they had a problem with their drains. Peatfield et al.
(1981) stated that of 16 cigarette smokers, both male and female, who
developed what they called
complete anosmia, eight were unchanged in their smoking habit, four had increased their
cigarette
consumption and four had decreased. Tennen et al. are to be congratulated on their
pioneering
study, and for drawing attention to the very real and often overlooked disadvantages that can be
experienced by people suffering from olfactory complaints.
A valuable heuristic approach when advising anosmics has been found to be Maslow's
(Maslow, 1954) hierarchical system of human needs, shown in Figure 1.
Maslow placed physiological needs, which include food and drink, at his most fundamental level.
As
indicated from the findings quoted in this review, both of these basic needs can be adversely
affected by
anosmia. Normal salivary and pancreatic/gastric anticipatory secretion increases in response to
food
smells are presumably absent or severely attenuated in the panosmic. The unpalatability of food
when it
arrives serves further to decrease food enjoyment. The condition of ansomia is relevant to
Maslow's second level, which is related to ‘safety’ in that the ability to
detect
warning odours is diminished and many anosmics show great concern about safety. The third and
fourth
levels of Maslow's hierarchy, which relate to ‘belonging’ and
‘esteem’, are applicable to anosmics in relation to their fear of unpleasant levels of
personal body odour. Wariness and a feeling of social vulnerability seem to be characteristics of
many
anosmics. The highest levels of Maslow's pyramid, relating to ‘cognitive’
and
‘aesthetic’ needs, can clearly be adversely affected by anosmia, and the dramatic
and
pleasurable olfactory stimulations are denied to anosmics. When testing an anosmic it is
important to
attempt to gain an estimate of the role of the sense of smell prior to the loss. For comparison
purposes,
attempts should be made to estimate the importance of the visual and auditory senses. An
aesthetic
analogy with monochromatic vision, with its loss of hues and textures, can be used to highlight
and
illustrate anosmia. Anosmia is often likened to colour blindness.
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It is frequently stated that anosmics do not suffer from problems related to eating. However, it is suggested that ‘meal pacing’ or ‘food pacing’ may mask real problems for these sufferers. Eating has ceased to be the pleasurable experience it is for people with a normal sense of smell, and when deprived of ‘food pacing’ an anosmic may overlook the need to eat. When alone, anosmics may go for long periods without feeling the need to eat. In support of this view, one anosmic claimed that as a result of his condition he had become ‘greedy’, stating ‘eating had become a mere refuelling exercise to be got over as quickly as possible’.
There is clearly a large variation in the way that individuals react to loss of the ability to detect odours. Some anosmics realize the nature of their loss and have discovered that they still have their taste sense, but surprisingly many are not aware of the taste/smell distinction and come for testing stating that they do not have a sense of taste. For many the demonstration that they can still taste is often a revelation. When counselling anosmics there is a need to draw attention to this by emphasizing the basic taste senses and pointing out that textures, mouth-feel and temperature (both chemical and thermal, hot and cold) can be used to make eating more attractive.
Using a cognitive/emotional hierarchical distinction, Schiffman has written,
‘Olfaction
disorders are not taken seriously because they are viewed as affecting the "lower"
senses—those involved with the sensual and emotional life—instead of the
"higher" senses that serve the intellect’ (Schiffman, 1983). Similarly, in a postscript to an account of an enhanced olfactory episode induced
by drug use in a
medical student, Sacks (Sacks, 1985), in what he calls an
‘osmalgia’ account, quotes a gifted man who had lost his sense of smell following
a head
injury, saying, ‘Sense of smell? . . . I never gave it a thought. You don't normally
give it a
thought. But when I lost it—it was like being struck blind. Life lost a lot of its
savour—one
doesn't realise how much "savour" is smell. You smell people, you smell
books,
you smell the city, you smell the spring—maybe not consciously, but as a rich unconscious
background to everything else. My whole world was suddenly radically poorer . . .’
Anosmia
may not be the catastrophe in humans that it would be for the majority of the animal kingdom,
but we
must begin to gain a wider recognition that it can be a very traumatic condition and that anosmics
may
be seriously affected at many psychological levels by their sensory loss. Odours are semiotic
messages
(Van Toller and Kendal-Reed, 1995) and deprivation of them can affect
us in subtle ways that we are only now slowly coming to comprehend.
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Acknowledgments |
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Thanks are due to the many anosmics who answered the WORG anosmia questionnaire; to Lionel King who first fired my interest in this tragic sensory loss and who formed the UK Anosmic/ Aguesic self-help association; to my technician David Sleight, who transcribed the answers in the questionnaires; and to Shellie Cross, a former student, who pointed out the value of using Maslow’s model to help our understanding of the plight of anosmics. Thanks are also due to Chris Hawkes, John King, Bill Cain, Susan Schiffman, Sam Van Toller, Martin Kendal-Reed and Theresa White, who read and made valuable comments on an earlier draft of this manuscript. In some European countries the condition of anosmia is recognized as a disability, and a proportion of the total disability pension is paid to sufferers. At the moment this is not the case in the UK. The UK anosmic self-help group is the Aguesic and Anosmic (AA) Association. The present organizer is: Dr J. Beazley Richards, 2, Quarry View, Whitehill Road, Crowborough, East Sussex TN6 1JT, UK. The method of collection and lack of validation of the WORG questionnaire precludes a detailed presentation of the findings in this review but the author will send detailed copies to interested people.
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Accepted July 7, 1999
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