Psychiatric morbidity in burning mouth syndrome Psychiatric interview versus depression and anxiety scales

Seventy-four patients with burning mouth syndrome underwent a psychiatric Interview; Hamllton s Depression and Anxiety Scales were applied independently. A psychiatric diagnosis was established in 38 cases (51.35%). Depression was the predominant disorder. The evaluation scales showed that when present. anxiety greatly influences the psychiatric condition of these patients. The differences in the results obtained with the two methods are discussed. (OH\1 SI Kc; OH\I l/lur, OH'\1 P\-rtwr 1993:75:308-11 I

B * urning mouth syndrome (BMS) is characterized bq an intraoral burning sensation that particularlq affects the tongue but may also involve other areas of the oral mucosa.’ No intraoral lesions are apparent. however, and the cause of the condition remains open to controversy.’ Nevertheless, BMS has been funda- mentally related to menopause?.’ and to psychologi- cal and psychopathologic factors.‘. I1 The supposed implication of psychological factors in BMS is not new. Ziskin and Moulton’ considered BMS to involve ;I strong emotional component. and attributed its cause to psychogenic factors. Psychological causes arc frequent]) postulated when no physical cause is apparent’: however. a number of authors claim that such a diagnosis requires positive confirmation of some underlying psychological or psychiatric condi- tion in these patients.*

The possibility of a nonorganic cause in BMS is the subject of the present study, and it is in line with the model proposed by Blummer and Heilbronn” for be- nign chronic pain as the manifestation of an emotional

~‘Profecsor. Department of Psychiatr). IJnivers~t) of V:~lencw

“Rrsociate Professor, Department of Oral Mediane. Univeraitj ol

Valencia.

‘Profeswr and Chairman, Department ol Oral Medicine, Univcr-

5ity of Vnlen&.

“Clinical /\csistant. Department of Pqxhiatq. Ilniversit) (11

Valcncia.

Copyright 1993 by Mosby-Year Book. Inc.

0030.4220!93/$1.00 + .I0 7/13/40654

308

disorder. Thus BMS could be associated with psychi- atric conditions or may even constitute an expression of some underlying mental disorder. Two method- ologic approaches may be adopted to evaluate this possibility. clinical interviewing of patients with BMS’, 10. /i and the use of general psychiatric mor- bidity” or specific psychiatric sytnptom evaluation scales.’ i

Many authors have considered latent LL~ well :LS clinically manifest depression to be an important fac- tor in BMS.“-” However. the reported proportion 01‘ patients with depression varies considerably.‘. ‘(‘, !’ These discrepancies may be attributed in part to the application of different diagnostic criteria or to the use of different operator training protocols. A numbcj of standard diagnostic criteria of great sensitivity and apccificity have been developed to counter interviewer subjectivity :Ind to secure reproducible results. Se\- cral authors.’ ” applying psychopathologic evalua- tion scales. consider depression to be the most con- mon emotional disorder in patients with BMS. aI-. though anxiety 31~0 appears to play an important role, On the contrary. other authorsI applying the Hospi- tal Anxiety and Depression Scale to patients with BMS claim anxiety to be more relevant than depres- sion. As these scales are reliable in the clinical detec- tion of anxiety and depression, we decided to combine them with a psychiatric interview of patients with BMS. with the use of operative criteria administered by trained personnel. The aim of the present study was

ORAI. SURGERY OR \L MEDICINE ORAL PATHOLOGY Volume 79, Number 3

Kojo et al. 309

Table I. Mean scores corresponding to the two Hamilton scales for patients with BMS

~ BMS- Depression BMS-Anxiet) BMS- Mixed BMS-No psychiatric disorder

Hamilton depresion 16 k 3.91 10.75 f 4.43* 15.33 i- I.96 X.26 :t 3.29+

Hamilton anxiety 22.71 + 5.88 2 I .40 ? 8.47 17.60 k 12.34 12.59 -r 7.63

*Significant ditTerences (p c 0.05) with BMS-anxiety and BMS without psychiatric symptoms ‘6ignilicant diffwmx (p 5 0.05) with BMS without psychiatrvz disorders.

to reproduce the results reported by others and to de- termine whether a good correlation exists between the results obtained by applying both methodologic ap- proaches. We consider this to be the best approach to reach conclusions regarding the most common psy- chiatric disorders in BMS.

MATERIAL AND METHODS

A total of I IO patients (92 women and 18 men, mean age 6 1.9 years) with BMS were seen in the Oral Medicine Unit of the Valencia University Dental School. The diagnosis of BMS was based on estab- lished criteria.‘. ‘* The absence of visible oral lesions was verified in all cases. After oral explorations, the patients were evaluated with the use of Hamilton’s Autoapplied Anxiety Scale”. 2o and Hamilton’s De- pression Scale 2’; the latter in its heteroapplied form was administered by one of us who was specifically trained (F.J.S.). The patients were then referred to the Department of Psychiatry of the Valencia Uni- versity Clinic Hospital where they were interviewed by one of two psychiatrists. The interviewers were unaware of the evaluation scale outcomes. In the event of psychiatric disorders being detected, the pa- tients were diagnosed according to criteria of the Di- agnostic and Statistical Manual of Mental Disorders. Seventy-four patients (67.3%) accepted this inter- view.

RESULTS Psychiatric evaluation of patients with BMS

The psychiatric interviews showed that 38 of the 14 patients (5 1.35%) suffered psychiatric disorders. Di- agnoses according to criteria of the Diagnostic and Statistical Manual of Mental Disorders revealed 13 adaptive disorders: 4 cases with a predominant anx- iety component, 3 cases of depression, and 6 cases with mixed presentations. Also found were I2 cases of dysthymic disorders, 8 cases with major or nonspecific depression disorders, 4 cases of general anxiety, and I case of senile dementia. Only three patients (one with a predominantly depressive adaptive disorder and two with dysthymic disorders) associated these alterations with their oral pathology. The oral condi- tion was not identified as the psychosocial stress un- derlying the psychiatric pathology in any of the

remaining adaptive disorders. The two interviewing psychiatrists were aware of the oral symptoms of these patients, but not of the results of the psycho- pathologic questionnaires. For our purposes, the psy- chiatric cases were classified into groups: pure de- pression, pure anxiety, and mixed anxiety-depression. The patient with senile dementia was excluded from further evaluations.

Analysis of psychiatric symptoms in patients with BMS

Depression was the prevalent psychiatric diagnosis among patients with BMS (31%, 23 of 73); anxiety was much less common and affected only eight patients (10.8%). Mixed pathologic conditions were diagnosed in six cases (8.1%). The Hamilton Scales scorings are shown in Table I for each of the clinical subgroups studied, The psychiatric diagnoses are seen to correlate well with these scorings. Patients with pure depression and patients with mixed depression and anxiety showed mean scores above the cutoff point on the Hamilton Depression Scale. These mean scores were significantly higher (p < 0.05) than those obtained from patients with BMS without psychiat- ric disorders. Patients with depression were also sig- nificantly different from patients with anxiety in this measure.

In the case of the Hamilton Anxiety Scale, patients with BMS and pure depression again surprisingly showed the highest mean score, followed by patients with pure anxiety and patients with mixed anxiety- depression. Although all three groups yielded scores above the critical threshold of 15 points, significant differences were observed only between the first two groups and patients with BMS who are free of psychiatric conditions. In view of the results obtained, anxiety symptoms appear to offer the highest capac- ity to discriminate between patients with BMS who have psychiatric disorders and those who do not. In a further analysis of the three clinical subgroups, we found that 15 of 23 depressed patients (65%‘) showed Hamilton Depression scores greater than the critical threshold of 15 points; this occurred in only two of the eight anxiety cases (25%). In the mixed symptoms group, 50% of the patients scored above I5 points. It should be pointed out that only one of the 36 patients

310 Rqjo et al

with BMSwithout psychiatricdisorders (2.8%) scored above the critical threshold of 15 points on this scale.

The Hamilton Anxiety Scale was therefore found to be sensitive in detecting anxiety symptoms; thus all patients with a diagnosed pure anxiety disorder. rn which anxiety symptoms were always present and predominated the clinical picture. scored above the cut-oil‘ point.

However, this test was not specitic for diagnostic purposes since 75% of depressed patients, and 6O’;/r 01‘ those without psychiatric disorders also obtained ;I score above the cut-off point in this scale.

DISCUSSION

The results of the present study agree with those reported elsewhere. Thus depression was found to be the most common psychiatric disorder in patients with BMS. A number of clinical studies obtained results partially similar to our own. Browning ct aI.’ carried out interviews with 25 patients with BMS; depression was diagnosed in 36% of the cases (major and minor depression. according to research diagnostic criteria). This was essentially similar to the 3 15~~ observed in our study. On the other hand, our 10.8% of patients with anxiety disorders was slightly greater than the 8”s re- ported by Browning et al.5 In any case, these tigures differ greatly from the 8 IF of patients with depres- sion reported by Schoenberg et al.“’ who, unlike the other authors. did not use operative diagnostic critc- ria in their psychiatric evaluations.

Varying results are reported from applying the de- pression or anxiety scales. Zilli et al.” reported depression in 75% of cases and anxiety in 41’:; of cases. This contrasts with 396 of patients with clin- ically significant anxiety and 24”; of casts with depression and mixed symptoms reported by Lame! and Lamb.‘” In our study, almost 405 of patients were beyond the threshold score on the Hamilton Anxiety Scale. whercas only 29g; exceeded I5 points on the Hamilton Depression Scale. The three studies yielded very similar proportions of patients with anr- icty, and all were \vell above the 8? to 10% incidence observed in the clinical interviews. The din‘erenccs between the depression results reported by Zilli CI al.” and those of the present study may be attributed to the direrent evaluation scales used.

In vieu of the discordant results obtained with rc- spect to clinical interview, these evaluation sculex must be applied \rith caution and should not aim to establish clinical diagnoses: rather. they should be used to determine the severit) of symptoms. This ih well demonstrated by the 26.5% of patients with BMS

who revealed no psychiatric disorders In the clinlcal interview hut who nevertheless scored ahovc the 1 lamilton Anxiety Scale threshold. In agrcelnent with other rcccnt studies. “. ’ ’ we observed ;I high incidence of anxiet> \!.mptoms In these patients. ;\lthough dc- pression was found to predominate. anxict) was still an important presence: 75 % of the patients uith BMS and clinical depre\aion 4cored high on the Ilamiltori Anxiety Scale. that is. depression \vith thlx oral COP dition invol\ja :in importanl anxiety component. Age cannot he discarded as ;I factor influencing this aspat in depressed patients. Thus Brown et aI ” and Des- 5onville cl al. ” clainl that depression iti the eldcri! in\,ol\re< ,I grcatcr an\icty component than similar conditions in \‘ounger patients. Howcvcr. \\c do nt)t hclievc age to hc ;i decisive factor in this WYX. for not only was the “,tnxict! state” considered above cutoil‘ point but also the “trait anxict),” ib grcatcr among these person< than in the hcalthl, population ” We :IX of the opinion that the predominant a)‘mptoms in p:~- tients with BMS ma!’ he related to life rxpericnccs associated I\ ith the disorder that emerge :IS importani source> of\trchh It i4 csithin this context ijf\tress and it\ repercussions on the adaptive capacit! of the per. son that the ;I h~~vc phenomena may bc ;tccounted fo-. II should bc rcmembcrcd that BMS C;I~WS ;I great deal d \ufTcring 44 ith dire conseyuence5 for the patient’\ persrnal relationships and qualit> of lilt. I’crceived 10~5 01 health is great in Ihc~ person\. Consideration ,hould also he given to olher circum- xtancc\ that contribute to the de\elopmcnt ,tl‘the \b II- drome. such ;I\ the many aaociated metf1~11 consul- tntions. ;t\vareness 01’ the underlying GIUW. ci;olut~t)n of the discomfort. and the scarce and siomctimcs WI!- tradictor) int~~rmation received, These ahpec:s C;IW.Y uricertainl\ :inli Icad 10 fear (IICT the futur’c. Patient, ~4 ith BMS :i/‘!cn \\orr\ ah(,ut pcr\Lln:t! hc;~lth. .:\ demonxtratccf h! Browning ct 31.‘ in addition. ,L fig- ure as high ;I\ iiX”c ol’the patients studied h\ Van der I’loeg ct ill ” 14 Ished to receive iiiorc infctrmation i~tl 1 heir illma. ;~rid 50 i specilically ioniplained that the) received loo little information from their ph!,ar- clans or dcntibts Ilndouhtedlv these \ltllations ;iru related to the psychiatric disorders invuh cd. Chronic health difticulties” and saere ph~sicai health lo\\ cvcnts ha\u hccn rclatcd to the I)~x\ ~11’ depra- sion.“.” On the other hand. cvcnts that sIgnif dan- gcr h;ivc been ;15sociated with anxiet! :I. .\4 pointed out carllcr. !III\ i.- :I vcr> important ,~spect 111 BMS: indeed. those patients with BMS who c\pre<scd the greatest need Ior information were :ilso the grates1 consumers 01‘ h\ pnotic drugs and ccd;rt i\ e:2.”

OKZI SI KGI I<)’ OI<,\I MI I)I(.IUE OK.\I P!\-r~~oi o(i\ Volume 75. Number 3

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