Occup Med.

1994; 44: 107-108

A case of phobic anxiety

related to the inability to smell
cyanide
P. J. Nicholson* and G. E. P. Vincentif
*ICI Chemicals & Polymers Ltd, Billingham, Cleveland and
^Department of Mental Health, Friar age Hospital, Northallerton,
North Yorkshire, UK

BACKGROUND
Cyanide is well known for its properties as one of the
most rapidly acting lethal poisons - inhalation of high
cyanide gas concentrations produces symptoms within
seconds. Hydrolysis of cyanide salts by atmospheric
water vapour causes the slow release of hydrogen
cyanide, the odour of which is described as bitter
almonds by those who can smell it. Some individuals
can only detect hydrogen cyanide either as an unpleasant
metallic taste or as a vague sensation in the mouth or
nasal passages; while other individuals are unable to
detect hydrogen cyanide by odour.
Laboratory studies have demonstrated a sex difference
in the ability to smell hydrogen cyanide when subjects
are presented with a solution of 20 per cent potassium
cyanide (Table / ) . It has been suggested that the ability
to smell cyanide is a sex-linked recessive phenomenon1
with multiple allelism or genetic modifiers2*3. Sayek3
and Brown and Robinette4 have also demonstrated three
groups of 'smellers', ie good smellers, weak smellers
and non-smellers. However, in the latter study, no
consistent or significant sex difference was observed.
Studies on the ability to smell hydrogen cyanide are
based on different methodologies, which makes exact
comparison between studies difficult; however, a sex
difference appears to be more demonstrable in adults
than in children.
A report of an acute exposure incident at an industrial
plant lends support to laboratory studies which show
that some individuals cannot detect the odour of
hydrogen cyanide. Peden et al? described nine men
who developed symptoms as a result of absorption of
appreciable amounts of hydrogen cyanide, as shown by
blood analysis, when none of the men had definitely
identified hydrogen cyanide by smell.

Personal alarm monitors are available to detect

cyanide; however, the ability to smell hydrogen cyanide
at low concentrations remains an important method of
detecting low-grade accidental releases. The odour
threshold for hydrogen cyanide is between 0.2 and 5.0
parts per million6, below the occupational exposure
limit or threshold limit value of 10 parts per million, and
well below concentrations that would produce acute
symptoms. A 'sniff test' is available for recognition
training, and it is possible to train some individuals to
smell cyanide by allowing them to sniff from a test bottle
containing potassium cyanide solution every day for
several days.
CASE REPORT
Mr X was a 29-year-old process operator who had
worked for 18 months in the cyanide production area
of a large chemical plant. His manager suspected that
he was developing a phobia in relation to cyanide,
because it was known that Mr X could not smell cyanide
despite attempts at training and because he had
generated three false 'HCN alarms'. He was referred
to the occupational health department, and it was noted
from his health records that he had attended the
department four months earlier as a case of suspected

Table 1. Incidence of inability to smell a 20 per cent solution of

potassium cyanide
Incidence of
inability
Population
White Australians
Japanese

Correspondence and reprint requests to: P. J. Nicholson, Procter &

Gamble Ltd, PO Box 1EE, Qosfortti, Newcastle upon Tyne NE99 1EE,
UK.
1994 Butterworth-Helnemann for SOM
0962-7480/94/020107-02

Turks

Sex

Reference

M
F
M
F
M
F

24/132
5/112
39/214
12/219
9/68
2/98

18.2
4.5
18.2
5.5
13.2
2.0

1
2
3

Downloaded from http://occmed.oxfordjournals.org/ at Harvard University on April 15, 2015

This report describes a case of phobic anxiety relating to cyanide in a process

operator who is unable to smell hydrogen cyanide. This case demonstrates that
hazardous substances in the workplace can provoke this mental disorder in
individuals who are unable to detect by special senses whether or not a specific
hazard is present. The clinical management of such individuals is complicated since
they must be able to perceive the feared object or substance in order to overcome
their anxiety.

108

Occup. Med. 1994, Vol 44, No 2

DISCUSSION
The clinical diagnosis was phobic anxiety (ICD9 code
300.2) focused on the cyanide facility at Mr X's place
of work. There was no evidence of depression or
free-floating anxiety. The death of Mr X's friend
impressed on him a sense of personal vulnerability, and
the unfortunate death of his brother-in-law came in the
midst of an anniversary reaction at a time when Mr X
was trying to adjust to the new challenge of the hydrogen
cyanide plant.
Mr X is unable to smell cyanide, and only felt safe
in the plant if accompanied by a colleague. Mr X is not
generally an anxious individual, and his pre-morbid
personality would seem to have been stable.
Phobic disorders have an overall prevalence of 6 per
cent, with agoraphobia and social phobia being the most

common7. Simple or specific phobias can occur in

response to single traumatic events, or they can arise
at a time of background stress and concern8, as perhaps
happened in this case. Once established, phobias tend
to persist, as predicted from learning theory.
There are two ways in which an individual can deal
with phobic anxiety. One is to avoid the fear-provoking
situation altogether. Alternatively, desensitization through
gradually increasing exposure to the feared stimulus is
employed, and forms the cornerstone of treatment9.
Additionally, anxiety management and cognitive therapy
can enhance treatment efficacy10. Drug treatment has
its advocates11>12, but it is generally agreed that exposure
treatment forms the basis for a successful outcome13.
In Mr X's case, it seemed unlikely that desensitization
would be successful. Increasing his exposure at the plant
to solid and liquid forms of cyanide (which he could
perceive visually) would be unlikely to resolve his
problem because his phobic anxiety was specifically to
hydrogen cyanide gas and his inability to perceive its
presence by virtue of its odour. An individual must be
able, to perceive the specific feared object or substance
if he is to be able to accommodate it through exposure.
Therefore, it was recommended that Mr X be moved
to a different job within the plant.
REFERENCES
1. Kirk RL, Stenhouse NS. Ability to smell solutions of
potassium cyanide. Nature 1953; 171: 698-9.
2. Fukomoto Y, Nakajima H, Uetake M, Matsuyama A,
Yashida T. Smell ability to solutions of potassium cyanide
and its inheritance. Jpn J Hum Genet 1957; 2: 7-16.
3. Sayek I. The incidence of the inability to smell solutions
of potassium cyanide in the rural health centre of
Ortabcreket. Turk J Pediatr 1970; 12: 72-5.
4. Brown KS, Robinette RR. No simple pattern of
inheritance in ability to smell solutions of cyanide. Nature
1967; 215: 406-8.
5. Peden NR, Taha A, McForley E, Bryden GT, Murdoch
IB, Anderson JM. Industrial exposure to hydrogen cyanide:
implications for treatment. Br Med J 1986; 293: 538.
6. Ellenhorn MJ, Barceloux DG. Medical Toxicology.
Diagnosis and Treatment of Human Poisoning. New York:

Elsevier, 1988.
7. Swinson RP. Phobic disorders. Curr Opin Psychiatry
1992; 5: 238-^4.
8. Hawton K, Salkovskis P, Kirk J, Clark D (eds). Cognitive
behaviour therapy for psychiatric

problems.

Oxford:

Oxford University Press, 1989.

9. Marks IM. Fears, phobias and rituals. Oxford: Oxford
University Press, 1987.
10. Michelson L, Ascher M (eds). Anxiety and stress
disorders: cognitive-behavioural assessment and treatment.

New York: Guildford Press, 1986.

11. Munjack DJ, Bruns J, Baltazar PL et al. A pilot study of
buspirone in the treatment of social phobia. J Anxiety
Disord 1991; 5: 87-98.
12. Reiter SR, Pollack MH, Rosenbaum JF, Cohen LS
Clonazepam for the treatment of social phobia. J Clin
Psychiatry 1990; 51: 470-2.
13. Gelder M, Gath D, Mayou R. Oxford Textbook of
Psychiatry (2nd edn). Oxford: Oxford Medical Publications,
1989.

Downloaded from http://occmed.oxfordjournals.org/ at Harvard University on April 15, 2015

cyanide poisoning. On this occasion, Mr X had been

drawing samples from an effluent tank for laboratory
analysis. He felt dizzy on return to his place of work,
and he assumed that he had been exposed to hydrogen
cyanide gas. Qualitative analysis of a venous blood
sample was negative for cyanide and he returned to
work.
At interview in the occupational health department,
Mr X reported feeling anxious and aroused whenever
he was in the vicinity of hydrogen cyanide at work. He
described a feeling of panic that would last between 10
and 90 minutes, during which he felt dizzy and weak.
He also reported muscle tension, occipital headache,
blurred vision, shortness of breath and marked sweating.
These attacks only ever started at work, and their
frequency and intensity had increased over a period of
four to six months, so that even attending safety lectures
on cyanide made him uncomfortably agitated. It was
decided to refer Mr X for psychiatric opinion.
There was no family history of mental disorder, and
no formal history of previous psychiatric contact.
Mr X reported that his marriage was stable and he had
no pressing psychosocial concerns. However, two years
earlier, while on holiday, he learnt that a close friend
had been killed in an accident at the plant and the news
upset him greatly. A year later to the day, his
brother-in-law died unexpectedly from a myocardial
infarction, and at the same time Mr X was transferred
to the hydrogen cyanide plant.
Mr X presented as a fit-looking young man. His mood
was stable and calm at interview. There were no
psychotic phenomena and he denied any biological
symptoms of depression. He seemed to be of average
intelligence. He maintained that he could not smell
cyanide. He had experienced no problems either in
training or working with liquid cyanide, but he admitted
that his inability to smell cyanide worried him greatly.
In his previous jobs, he had become used to working
with more obviously pungent chemicals such as urea
and chlorine, and so had felt no sense of personal danger.