INTRODUCTION
Bromhidrosis or osmidrosis is a problem that leads many patients to seek
specialized medical treatment. Removing sweat glands from the axillary region
through excision and complementary liposuction is a small procedure that is
technically simple and with few complications1.
Axillary osmidrosis is caused by excessive apocrine secretion, which causes an
arid odor and extreme social embarrassment2.
The disease is also related to the patient’s emotions, leading to psychic
changes that interfere in these people’s lives.
Bromhidrosis and its interference with self-esteem
According to Oliveira (2019)3, self-esteem is one of the elements that guide human
behavior, enabling healthy and functional intra- and interpersonal
relationships.
Individual who suffers from bromhidrosis disease has a great negative impact
on their self-esteem. Many out of shame, fear, especially insecurity, move
away from family and friends, leave their jobs, and socially isolate
themselves.
They end up living only in their world. They become insecure due to
people’s opinions, which hurt them many times with words, debauchery
and jokes, making their self-esteem more and more destroyed. Low self-esteem
can develop several psychological disorders.
Bromhidrosis and its relationship to depression
Depression is classified as a mood disorder; it comes to govern the
subjects’ attitudes, modify their perception, and start to see their
problems as major catastrophes4.
In the diagnostic and statistical manual of mental disorders (DSM-5),
depressive disorders are the presence of sad, empty or irritable mood,
accompanied by somatic and cognitive changes that significantly affect the
individual’s ability to function. What differs between them are
aspects of duration, timing or presumed etiology5.
Lack of self-esteem can lead to depression; bromhidrosis causes great
psychological distress in people who have this disease.
They question all the time if they are being punished or if they did
something wrong in life to deserve it. They feel anguished, bitter; many
want to die to end this suffering, triggering depression for not knowing how
to deal with this situation.
OBJECTIVE
The main objective of this work is to evaluate how bromhidrosis emotionally
affects patients who have this diagnosis and what are the psychological
disorders presented in them.
METHODS
The study consisted of 34 patients diagnosed with bromhidrosis, of which 27 were
women (aged 22 to 42 years old), and 7 were men (aged 21 to 32 years old).
All patients received an application/response sheet from the Beck Depression
Inventory (BDI-II) by e-mail. After being answered and resent, an analysis of
the inventory responses was made. Patients who presented the level of severe
symptoms are in psychological follow-up.
The following procedures were used to assess the severity of depression in
patients.
The Beck Depression Inventory (BDI-II) is used worldwide to detect depressive
symptoms. It is an instrument that aims to measure the intensity of symptoms of
depression, has achieved a prominent role in the clinical and research
environment for being able to assess subjective feelings and self-perception,
important aspects of assisting in the formal diagnosis of depression and which
are more difficult to be observed only by clinical evaluation, facilitating the
referral of cases of depression for appropriate treatment6.
The Beck-II Depression Inventory (BDI-II) consists of 21 groups of statements
about depressive symptoms that could have occurred in the past 15 days. The
groups are sadness, pessimism, past failure, loss of pleasure, guilt, feeling of
punishment, self-esteem, self-criticism, suicidal thoughts or desires, crying,
agitation, loss of interest, indecision, devaluation, lack of energy, changes in
sleep pattern, irritability, changes in appetite, difficulty concentrating,
tiredness or fatigue and loss of interest in sex.
Each question in the inventory has increasing scores arranged on a Likert-type
scale, from 0 to 3, allowing the sum of scores in the range between 0 and 63. In
general, the application takes around 10 to 15 minutes and is well accepted by
the respondents7.
Special attention should be paid to correctly score sleep pattern changes (item
16) and appetite changes (item 18). Each item contains seven options with values
ordered as 0, 1a, 1b, 2a, 2b, 3a and 3b to differentiate the increase and
decrease in behavior or motivation. If the respondent selects an alternative
with a higher score, both the increase and decrease in any of these symptoms
should be considered clinically for diagnostic purposes.
The instruments applied in their order were an informed consent form and the Beck
Depression Inventory (BDI-II).
The patients were classified into four groups (mildly depressed, moderately
depressed, severely depressed and without depression), following the criteria
defined by the diagnostic and statistical manual of mental disorders. In the
Beck Depression Inventory (BDI-II), the more intense the symptoms, the more
severe or severe the manifestation of depression.
According to the diagnostic and statistical manual of mental disorders8, the level of mild intensity
corresponds to the individual with few or no symptoms. They cause suffering but
are manageable, and the symptoms result in little impairment of social or
professional functioning.
At the moderate level, symptoms are already more present; their intensity or
functional impairment are between those specified for “mild” and
“severe.”
In severe intensity, the number of symptoms is substantially beyond what is
required to diagnose; their intensity causes severe suffering. It is not
manageable, and the symptoms strongly interfere with social and professional
functioning.
RESULTS
Of the 34 patients evaluated who had a diagnosis of bromhidrosis, 23 were
diagnosed with severe depression, eight moderately depressed, two mildly
depressed and one without depression (Figure 1).
Figure 1 - Depression symptoms in the evaluated patients.
Figure 1 - Depression symptoms in the evaluated patients.
As shown in Figure 1, of the 34 evaluated
patients diagnosed with bromhidrosis, 23 had symptoms of severe depression.
Chart 1 shows the responses of the 34
patients related to the 21 groups of symptoms in Beck’s inventory; the
larger the scale that the numbers (2 and 3) are, the greater the symptom of
depression.
In the manual from the Beck-II inventory, there is an alert suggesting observing
in particular the items that assess pessimism and suicidal ideation that are
part of the diagnosis of depression and maybe predictive of a potential for
suicide.
In the 21 groups of symptoms presented in the Beck Depression Inventory (BDI-II),
the most prevalent statements about depressive symptoms were: Chart 2.
Most of the patients in the pessimism item answered that they have no hope
related to the future, with a tendency to worsen. In the item of suicidal
thoughts or desires, most have thoughts of killing themselves, but they
wouldn’t take it further. Patients are socially isolated due to
bromhidrosis; out of fear, they cannot find a solution to the problem, they have
tried everything, such as medication, dermo-cosmetics, and others. Due to this
pessimism, most begin to have suicidal thoughts to get rid of this anguish.
They feel like failures and punished, losing the pleasure of living. They care
about the opinions of people, friends, family and co-workers. They end up
criticizing themselves, becoming fragile, anxious, insecure, with their
self-esteem destroyed and vulnerable.
The diagnostic hypotheses of patients with bromhidrosis disease, based on the
results of the BDI-II depression inventory answered, and the psychological
follow-up with them are:
• Major depressive disorder
Diagnostic criteria:
Five(or more) of the following symptoms were present in the same two-week
period and represented a change from previous functioning; at least one
of the symptoms (1) depressed mood or (2) loss of interest or pleasure.
Symptoms of criteria for major depressive disorder must be present
almost every day to be considered current, except for weight change and
suicidal ideation. The depressed mood should be present most of the day,
in addition to being present almost every day [...].
Humor depressed most of the day, most days;
A marked decrease in interest or pleasure in all or almost
all activities for most of the day, practically every
day;
Significant weight loss or weight gain without dieting;
Insomnia or hypersomnia almost every day;
Agitation or psychomotor retardation almost every day;
Fatigue or loss of energy almost every day;
Feelings of excessive or inappropriate worthlessness or
guilt;
Decreased ability to think or concentrate, or indecision
almost every day;
Recurring thoughts of death.
• Persistent depressive disorder (dysthymia)
The essential feature of persistent depressive disorder (dysthymia) is a
depressive mood that occurs most of the day, most days, for at least two
years.
“I have difficulty accepting this disease; it messes with my mind a
lot.” (MS, 32 years old).
Presence, while depressed, of two (or more) of the following characteristics:
Decreased appetite or overeating;
Insomnia or hypersomnia;
Low energy or fatigue;
Low self-esteem;
Poor concentration or difficulty making decisions;
Feelings of hopelessness.
Symptoms cause clinically significant suffering or impairment in social,
professional or other important areas of life.
Chart 1 - It can be seen in the set of patients’ responses that
scales 2 and 3 were the most marked. The larger the scale, the
greater the symptom of depression.
| SYMPTOMS |
Affirmations
about depressive symptoms
|
| 1-Sadness |
0 I
don’t feel sad. (3 patients) 1 I feel sad a lot
of the time. (27 patients) 2 I am sad all the
time. (2 patients) 3 I am so sad or so unhappy that I cannot
bear it. (2 patients)
|
| 2- Pessimism |
0 I am not discouraged about my future. (10
patients) 1 I feel more discouraged about my future than
usual. (8 patients). 2 I don’t expect things to work
out for me. (5 patients) 3 I feel there is no hope for
my future. I think it will only get worse. (11
patients) |
| 3- Past
failure
|
0 I
don’t feel like a failure. (6 patients) 1 I have
failed more than I should. (7 patients) 2 When I think
about the past, I see many failures. (15
patients) 3 I feel that as a person, I am a total
failure. (6 patients)
|
| 4-Loss of Pleasure |
0 I continue to feel the same pleasure I used
to get from the things I like. (5 patients) 1 I
don’t get as much pleasure from things as I used
to. (16 patients) 2 I take very little pleasure
in the things I used to enjoy. (10 patients) 3 I no longer
enjoy the things I used to like. (3 patients)
|
| 5-Feeling of
guilt
|
0 I
don’t feel particularly guilty. (7 patients) 1
I feel guilty about many things I have done and/or
should have done. (12 patients) 2 I feel guilty
most of the time. (11 patients) 3 I feel guilty all the
time. (4 patients)
|
| 6-Feeling of punishment |
0 I don’t feel like I’m being
punished. (7 patients) 1 I feel I can be punished. (8
patients) 2 I think I will be punished. (4 patients) 3
I feel like I’m being punished. (15
patients) |
| 7-Self-esteem |
0 I feel the
way I always felt about myself. (6 patients) 1 I lost
confidence in myself. (11 patients) 2 I’m
disappointed in myself. (9 patients) 3 I don’t like
me. (8 patients)
|
| 8-Self-criticism |
0 I don’t criticize or blame myself more
than usual. (7 patients) 1 I’m being more critical of
myself than I used to be. (5 patients) 2 I criticize
myself for all my mistakes. (13 patients) 3 I
blame myself for everything bad that happens. (9
patients)
|
| 9-Suicidal
thoughts or desires
|
0 I have no
thoughts of killing myself. (14 patients) 1 I have
ideas of killing myself, but I wouldn’t go
through with it. (17 patients) 2 I would like to
kill myself. (1 patient) 3 I would kill myself if given a
chance. (5 patients)
|
| 10-Cry |
0 I don’t cry any more than I used to
cry. (5 patients) 1 I cry more now than I used to. (4
patients) 2 cries for anything. (15 patients) 3
I feel like crying, but I can’t. (10 patients)
|
| 11-Agitation |
0 I
don’t feel any more restless or agitated than I used
to feel. (5 patients) 1 I feel more restless or agitated
than I felt before. (10 patients) 2 I feel so restless
or agitated that it’s hard to sit still. (11
patients) 3 I’m so restless or agitated
that I always have to be moving or doing something. (6
patients)
|
| 12-Loss of interest |
0 I haven’t lost interest in other
people or my activities. (3 patients) 1 I am less interested
in other people or things than I used to be. (7 patients)
2 I have lost almost all interest in other people
or things. (18 patients) 3 It’s hard to
get interested in anything. (6 patients)
|
| 13-Indecision |
0 I make my
decisions as well as before. (4 patients) 1 I find it harder
to make decisions now than before. (4 patients) 2 I have a
lot more difficulty making decisions now than I did before.
(3 patients) 3 I have difficulty making any decision.
(23 patients) |
| 14- Devaluation |
0 I don’t feel worthless. (7 patients) 1
I don’t consider myself as useful today or value
myself as I used to. (4 patients) 2 I feel less
valuable when I compare myself to other people. (15
patients) 3 I feel completely worthless. (8
patients)
|
| 15-Energy |
0 I have as
much energy today as I ever had. (4 patients) 1 I have less
energy than I used to have. (10 patients) 2 I
don’t have enough energy to do much. (17
patients) 3 I don’t have enough energy for
anything. (3 patients)
|
| 16-Change in sleep pattern |
0 I didn’t notice any change in my
sleep. (5 patients) 1a I sleep a little longer than
usual. (9 patients) 1b I sleep a little less than
usual. (2 patients) 2a I sleep a lot more than usual. (5
patients) 2b I sleep much less than usual. (9
patients) 3a I sleep most of the day. (3
patients) 3b I wake up 1 or 2 hours early and can’t
go back to sleep. (1 patient)
|
| 17-Irritability |
0 I’m
not angrier than usual. (5 patients) 1 I am angrier than
usual. (3 patients) 2 I am much angrier than usual.
(14 patients) 3 I get irritated all the time. (12
patients)
|
| 18-Appetite changes |
0 I didn’t notice any change in my
appetite. (3 patients) 1a My appetite is a little less than
usual. (8 patients) 1b My appetite is a little bigger than
usual. (5 patients) 2nd My appetite is much smaller than
before. (1 patient) 2b My appetite is much bigger than
before. (7 patients) 3rd I have no appetite. (9
patients) 3b I want to eat all the time. (1
patient)
|
| 19-Difficulty
concentrating
|
0 I can
concentrate as well as before. (4 patients) 1 I can’t
concentrate as well as usual. (2 patients) 2 It is
very difficult to stay focused on something for a long
time. (27 patients) 3 I don’t think I can
concentrate on anything. (1 patient)
|
| 20- Tiredness or fatigue |
0 I am no more tired or fatigued than usual. (2
patients) 1 I get tired or fatigued more easily than usual.
(11 patients) 2 I feel too tired or fatigued to do many of
the things I used to do. (7 patients) 3 I feel too
tired or fatigued to do most of the things I used to do.
(14 patients) |
| 21-Loss of
interest in sex
|
0 I
haven’t noticed any recent changes in my interest in
sex. (6 patients) 1 I’m less interested in sex than I
used to be. (11 patients) 2 I’m much less
interested in sex now. (17 patients) 3 I
completely lost interest in sex.
|
Chart 1 - It can be seen in the set of patients’ responses that
scales 2 and 3 were the most marked. The larger the scale, the
greater the symptom of depression.
Chart 2 - Answers that most prevailed in the BDI-II depression
inventory.
|
BDI-II
DEPRESSION INVENTORY
|
| SYMPTOMS |
ANSWERS RELATED TO THE SYMPTOMS THAT MOST PREVAILED |
| Sadness |
I
feel sad a lot of the time.
|
| Difficulty in Concentration |
It's very difficult to stay
focused on something for a long time.
|
| Indecision |
I
have difficulty making any decision.
|
| Loss of interest |
I almost lost interest in other
people or things.
|
| Suicidal thoughts or wishes |
I
have thoughts of killing myself, but I wouldn't go through
with it.
|
| Lack of energy |
I don't have enough energy to do
much.
|
| Loss of interest in sex |
I'm much less interested in sex now. |
| Loss of pleasure |
I don't get as much pleasure from
things as I used to.
|
| Past failure |
When I think about the past, I see many failures. |
| Cry |
I cry for anything. |
| Devaluation |
I
feel less valuable when I compare myself to other
people.
|
| Feelings of punishment |
I feel like I'm being
punished.
|
| Irritability |
I'm much angrier than usual. |
| Tiredness or fatigue |
I feel too tired or fatigued to do
most of the things I used to do.
|
| Self-criticism |
I
criticize myself for all my mistakes.
|
| Guilt |
I feel guilty about a lot of
things I've done and/or should have done.
|
| Pessimism |
I
feel there is no hope for my future. I think it will only
get worse.
|
| Self-esteem |
I lost confidence in myself. |
| agitation |
I
feel so restless or agitated that it's hard to sit
still.
|
| Change in sleep pattern |
-I sleep a little longer than usual. -I sleep
less than usual.
|
| Appetite change |
I
have no appetite.
|
Chart 2 - Answers that most prevailed in the BDI-II depression
inventory.
• Anxiety Disorders
Anxiety disorders include disorders that share characteristics of excessive
fear and anxiety and related behavioral disturbances. Fear and emotional
response, and real or perceived imminent threat, while anxiety is the
anticipation of future threat9.
“I get very anxious because of bromhidrosis, sometimes I have thoughts
of cutting my wrist. I want to cry, but I can’t.” (RS, 25
years old).
“Since the first year of college, my classmates made fun of me. The
more nervous I was, the greater the smell.” (AG, 22 years old).
“Anxiety is like a portal for bromhidrosis to attack.” (AL, 30
years old).
“When I start studying, I get very nervous, the smell increases, but
when I’m taking a walk, or playing video games, the smell
disappears.” (FA, 31 years old).
• Generalized Anxiety Disorder
Second Zuardi (2017)10,
persistent and excessive worry is the main feature of a generalized anxiety
disorder (GAD), but these worries are accompanied by physical symptoms
related to autonomic hyperactivity and muscle tension. Among these symptoms,
tachycardia, sweating, insomnia, fatigue, difficulty in relaxing and muscle
pain are common, which can cause suffering and damage to the
individual’s performance.
• Somatic Symptoms Disorder
Arenales et al. (2014)11
cite in the article the illness of suffering from illness, which the DSM-5
manual (diagnostic and statistical manual of mental disorders) uses as its
diagnostic core the somatic complaints associated with suffering and
disturbance in the patient’s daily life. These complaints can be
specific like pain, or not as specific as fatigue. The diagnosis is made
when we observe excessive thoughts, feelings or behavior related to somatic
symptoms or associated with health concerns.
Diagnostic criteria
A. One or more somatic symptoms that cause distress or result in
significant disruption of daily life.
B. Excessive thoughts, feelings or behavior related to somatic symptoms
or associated with health concerns expressed by at least one of the
following:
Thoughts disproportionate and persistent about the severity
of the symptoms themselves.
Level of persistently high anxiety about health and
symptoms.
Time and excessive energy devoted to these symptoms or health
concerns.
“I was sitting talking to my friend, who knows about bromhidrosis,
everything was calm.... an acquaintance of hers arrived, I started to
feel tense, I felt a heat as if my blood pressure was rising and the
odor started to increase too much, it ended up with me.” (AL, 30
years old).
• Social Anxiety Disorder (Social Phobia)
Individuals with social anxiety disorder (SAD) manifest an excessive and
persistent fear of one or more social or performance situations. They fear
being seen to behave in a humiliating or embarrassing way, and a consequent
disapproval or rejection by others. It is observed in these patients a fear
of negative evaluation by people, generating feelings of embarrassment,
humiliation and shame. They are also characterized by being extremely
inhibited and self-critical in social situations that generate anxiety,
behaving in a tense and rigid manner, with difficulties in verbally
articulating, causing damage to the social performance.12
“I suffered bullying from teachers, they said I was stinking. Laugh at
me. I ended up deciding to leave the college.” (AG, 22 years
old).
“I was always isolated from my group of friends or distanced myself in
conversations for fear of people smelling it.” (RS, 33 years
old).
• Obsessive-compulsive disorder
Obsessive-compulsive disorder is characterized by obsessive ideas and/or
recurrent compulsive behaviors and has been recognized for its chronic and
disabling course. Such ideas and behaviors are very disturbing and consume
time in the subject’s life, interfering occupationally and
socially13.
“I take a shower several times a day; I even take five showers a day.
And I feel the odor doesn’t come out. The more nervous I get, the
more the smell increases, I get very distressed, I get out of
control.” (GJ, 30 years old).
“I lost count of how many deodorant packages I have at home. I
practically work to buy products to get rid of this horrible smell.”
(ME, 38 years old).
“Sometimes I think I’m getting paranoid, I start to notice the
people around me, and I feel like they’re looking at me, scratching
their nose and making a bad face.” (AL, 30 years old).
“In the classroom, I go out almost all the time to go to the bathroom
to wash under my arms. It makes me upset people are looking at me all the
time.” (GJ, 30 years old).
DISCUSSION
The results show that patients diagnosed with bromhidrosis present psychological
distress, which manifests itself through sadness, existential emptiness, causing
anxiety, mood swings and social isolation, leading the individual to have
depression and other psychological disorders.
Bromhidrosis is a disease that, in addition to treatment, dermatological and
surgical, requires specific monitoring of these patients. Psychological support
is necessary, considering that people diagnosed with the disease feel
psychologically fragile.
This monitoring aims to work on all their emotional and behavioral issues, aiming
to minimize the causes that cause the emergence of the odor of bromhidrosis.
CONCLUSION
Through this work, we conclude that patients diagnosed with bromhidrosis are
emotionally vulnerable, depressed, impulsive, and have low self-esteem, which
causes them to suffer great psychological distress.
Psychological support throughout the surgical process will help the patient with
bromhidrosis to feel better, guiding them to seek alternatives to alleviate the
feeling of sadness, pessimism and discouragement, and especially, to avoid a
future obsession on the part of the patient after the surgery of
bromhidrosis.
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1. Hospital Ruben Berta, São Paulo, SP,
Brazil.
Corresponding author: Alexandre
Kataoka, Rua Av. Paulista, nº 2494 cj 14, São Paulo,
SP, Brasil, Zip Code 01310-300, E-mail:
drkataoka@hotmail.com
Article received: January 28, 2021.
Article accepted: July 14, 2021.
Conflicts of interest: none.
Institution: Hospital Ruben Berta, São Paulo, SP, Brasil.
