- Email: [email protected]
A Psychiatric Appraisal of “Glossodynia”
A Psychiatrie Appraisal of "Glossodynia" HITOSHI MIYAOKA, M.D., KUN/TOSHI KAMIJIMA, M.D. YOSHIRO KATAYAMA, M.D., TSUTOMU EBIHARA, D.D.S. TETSUO NAGAI, D.D.S.
"Glossodynia" is a diagnostie rubrie that includes patients enduring pain or a buming sensation in the tongue without any oral pathology or systemie disease. Psychiatrie prafiles oj 50 women patients with "glossodynia" were eompared with those oj contral subjeets. The patients scored signifieantly lower on the Extraversion Scale oj the Eysenek Personality Questionnaire and higher on the Toronto Alexithymia Scale than the contral subjeets. whereas there was no signifieant differenee in the mean General Health Questionnaire seore. The psyehopathology oj "glossodynia" may be more markedly assoeiated with personality trait eharaeteristies than with neuratie or depressive symptoms. (Psychosomatics 1996; 37:346-348)
I
n dental practice. patients with pain or a buming sensation on the surface of the tongue are frequently encountered, although they have neither observable oral pathology nor systemic disease. This syndrorne is known as "glossodynia" or "idiopathic tongue pain syndrorne." Among 4, 149 outpatients who attended the Department of Dentistry and Oral Surgery. Keio University Hospital, Tokyo, for the first time in 1988, 86 (2. 1%) (16 males and 70 females) were diagnosed as having "glossodynia." In 1989 and 1990. 1190f4,415(2.7%)(M:Fratio= 11:108) and 179 of 4,320 (4.1%) (M:F ratio = 20:159) outpatients with this condition were diagnosed. Received November II. 1994; accepted January 5. 1995. From the Depanment of Psychiatry. Showa University School of Medicine; Inokashira Hospital; and the Depanment of Dentistry and Oral Surgery. Keio University School of Medicine. Tokyo. Japan. Address reprint requests to Dr. Miyaoka. Depanment of Psychiatry. Showa University School of Medicine. 1-5-8 Hatanodai. Shinagawa-ku. Tokyo 142. Japan. Copyright © 1996 The Academy of Psychosomatic Medicine.
346
respectively. These data indicate that "glossodynia" is a common disorder and that women are affected far more frequently than men. Some reports have described this syndrome as being psychogenie and an expression of psychiatric disturbance;-4 although little research has been done by psychiatrists. The purpose of this study is to obtain a psychiatrie profile of female patients with "glossodynia." SUBJECTS AND METHODS The subjects were 55 outpatients (50 females, 5 males) anending the Department of Dentistry and Oral Surgery. Keio University Hospital. Tokyo, for the first time in 1989, who met the following criteria: I) presence of pain or a buming sensation on the surface of the tongue; 2) absence of local or systemic diseases (xerostornia. candidiasis. anemia, diabetes, referred pain from dentalgia, etc.); and 3) no administration of any drugs for more than 4 weeks before the first attendance. The psychiatric profiles of PSYCHOSOMATICS
Miyaoka et al.
the 50 female patients, with a mean age of 55.8 (SD = 8.7) (range: 37-73 years) were compared with those of control subjects. The healthy control group comprised 24 volunteer women with a mean age of 53.2 (SD =8.4) (range: 36-70 years), who were employees of a single company, and their family members. They were interviewed using the Schedule of Affective Oisorders and Schizophrenia 5 and were found to have no psychiatric morbidity. There was no significant difference in mean age between the female patients and the control subjects (t-test). Ali subjects completed the Eysenck Personality Questionnaire (EPQ)6 to assess personality traits, the 30-item version of the General Health Questionnaire (GHQ)7 to assess the severity of neurotic symptoms and to screen mental disorders, and the Toronto Alexithymia Scale (TAS)8 to assess alexithymic personality. In responding to the EPQ, the subjects were required to answer questions about their personalities before the pain or buming sensations had occurred. The Mann-Whitney U-test was used to test differences in the scores between the glossodynia patients and the control subjects. RESULTS Table I compares the mean EPQ, GHQ, and TAS scores of the patients and the healthy controI subjects. The patients with glossodynia scored significantly lower on the extraversion TARLE I.
DISCUSSION Patients enduring pain or a buming sensation in the tongue with no oral pathology or systemic disease are often referred to as having glossodynia or idiopathic tongue pain syndrome. Though psychological factors have been considered important etiologically, there have been few investigations of this syndrome in the psychiatric field. Typical patients are women over 40 years old who have a dread of tongue cancer and experience decreased pain while eating. Typical patients have often had dental treatment or have leamed of someone's death from cancer just before the appearance ofthe tongue sensations. 9 According to the OSM-II1-R, the patients are diagnosed as having hypochondriasis or an undifferentiated somatoform disorder. The results of this study showed that the mean EPQ neuroticism score of the patients tended to be higher and that their extraversion score was lower than those of the control subjects. According to the EPQ, neuroticism measures trait anxiety, lability, and dysphoria, and extraversion measures sociability and impul-
EPQ, TAS, and GUQ scores or glossodynia patients and Glossodynia Patients
Scale EPQ:
scale of the EPQ and higher on the TAS than the healthy control subjects. The mean neuroticism score of the EPQ and the mean GHQ score among the glossodynia patients were higher than those of the control subjects, but the differences were not statistically significant.
Neuroticism Extraversion Psychoticism
GHQ (30·ilem) TAS No/e: EPQ =Eysenck Questionnaire.
Personałity
Uealłhy
healłhy controi
subjects
Control Subjects
(N = 50)
(N=24)
Mean±SD
Mean ±SD
Mann-Whitney U-Test p
11.0 ± 4.6
8.6± 5.4
0.08
8.6±5.1
\3.2 ±4.2
<0.01 0.06
5.0 ± 1.8
6.6± 27
6.5 ±6.2
4.2± 3.5
0.22
75.7 ± 7.2
70.2± 8.0
< 0.01
Questionnaire; TAS =Toronto Alexithymia Scale; GHQ =Generał Health
VOLUME 37 • NUMBER 4. JULY - AUGUST 1996
347
Psychiatrie Appraisal of Glossodynia
slvlty. The subjeets were required to answer questions about their personalities before the symptoms oeeurred. This additional eomment ean help to cłarify the premorbid personality.1O The patients' labile and anxious premorbid personality may be a predisposing faetor to the syndrorne. When patients had had their teeth treated or had heard of someone having eaneer, they paid much more attention to their bodily sensations than before, whieh resulted in abnormaI sensations of the tongue. The psyehopathology of glossodynia is similar to that of hypoehondriasis. There was no signifieant differenee in the mean GHQ seore between the patients and the eontroi subjeets. van der Ploeg 2 and Ott and Ott 4 pointed out that the seores of the self-rating anxiety and depression seales among the patients with this syndrorne were higher than in healthy subjeets. These eontlieting results may be attributable to the faet that the present study used eontroI subjeets matehed for gender and age. Women may have more neurotie symptoms during the menopausal and presenile periods. It ean be said that glossodynia syndrorne is more markedly associated with personality trait eharaeteris-
tics than with neurotie or depressive symptoms. The patients were found to be more alexithymic than the eontroI subjeets. Alexithymia is eharaeterized by relative eonstrietion in emotional funetioning and inability to find appropriate words for deseribing one's emotions. 1I Patients with somatization disorder are more alexithymie than healthy eontroI subjeets. 12 As alexithymic patients are not good eandidates for dynamie psyehotherapy, JJ psyehiatrists must deteet the presenee of alexithymia at an early stage of treatment for glossodynia. Tentative diagnostie eriteria for glossodynia have been developed, and the effieaey of this diagnostie rubrie is now being validated. The eriteria are as follows: l) pain or a buming sensation on the surfaee of the tongue; 2) no foeal or systemie disorders revealed by appropriate physical evaluation; 3) a deerease or disappearanee of the pain or buming sensation while eating; 4) presenee of at least one of the following symptoms: 4a) dread of tongue eancer, and 4b) patient's misinterpretation of their lingual organization (e.g., lingual papillae) as abnorrnal.
References I. Haneke E: Psychische aspekle der glossodynie. Dlsch Med Wochenshr 1978; 103: 1302-1305 2. van der Ploeg HM. van der Wal N. Eijkman MAJ. et al: Psychological aspecls of palienls wilh buming mouth syndrorne. Oral Surgery 1987; 63:664--668 3. Sullivan PD: The diagnosis and lrealment of psychogenic glossodynia. Ear Nose Throal J 1989; 68:795-798 4. Olt G. Olt C: Glossodynia-Psychodynamic basis and results of psychopalhometric investigalions. J Psychosom Res 1992; 36:677-686 5. Spilzer RL. Endicolt J: Schedule for AffeClive Disorders and Schizophrenia. New York. Biomelrics Research. New York Slale Psychialric InsIilule. 1977 6. Eysenck HJ: Manual of Eysenck Personalily Queslionnaire (junior and Adull). London. England. Hodder and Sloughlon.1975
348
7. Goldberg DP: The detection of psychiatric illness by Questionnaire. Maudley Monograph No. 21. London. England. Ollford University Press. 1972 8. Taylor GT: Toward the development of a new self-repon a1ellithymia scale. Psychother Psychosom 1985; 44; 19 t-199 9. Nagai T. Ebihara T. Sintani H. et al: Diagnosis and lreatment of glossodynia. Joumal of Japanese Stomatological Society 1987; 36:596-601 10. Kendell RE. DiScipio: Eysenck personality inventory scores of patients with depressive illnesses. Br J Psychiatry 1968; t 14:767-770 1I. Sifneos PE: The prevalence of "alexithymic" characleristics in psychosomatic patients. Psycholher Psychosom 1973; 22:255-262 12. Shipko S: Alellithymia and somatization. Psychother Psychosom 1982; 37: 193-201
PSYCHOSOMATICS
"Glossodynia" is a diagnostie rubrie that includes patients enduring pain or a buming sensation in the tongue without any oral pathology or systemie disease. Psychiatrie prafiles oj 50 women patients with "glossodynia" were eompared with those oj contral subjeets. The patients scored signifieantly lower on the Extraversion Scale oj the Eysenek Personality Questionnaire and higher on the Toronto Alexithymia Scale than the contral subjeets. whereas there was no signifieant differenee in the mean General Health Questionnaire seore. The psyehopathology oj "glossodynia" may be more markedly assoeiated with personality trait eharaeteristies than with neuratie or depressive symptoms. (Psychosomatics 1996; 37:346-348)
I
n dental practice. patients with pain or a buming sensation on the surface of the tongue are frequently encountered, although they have neither observable oral pathology nor systemic disease. This syndrorne is known as "glossodynia" or "idiopathic tongue pain syndrorne." Among 4, 149 outpatients who attended the Department of Dentistry and Oral Surgery. Keio University Hospital, Tokyo, for the first time in 1988, 86 (2. 1%) (16 males and 70 females) were diagnosed as having "glossodynia." In 1989 and 1990. 1190f4,415(2.7%)(M:Fratio= 11:108) and 179 of 4,320 (4.1%) (M:F ratio = 20:159) outpatients with this condition were diagnosed. Received November II. 1994; accepted January 5. 1995. From the Depanment of Psychiatry. Showa University School of Medicine; Inokashira Hospital; and the Depanment of Dentistry and Oral Surgery. Keio University School of Medicine. Tokyo. Japan. Address reprint requests to Dr. Miyaoka. Depanment of Psychiatry. Showa University School of Medicine. 1-5-8 Hatanodai. Shinagawa-ku. Tokyo 142. Japan. Copyright © 1996 The Academy of Psychosomatic Medicine.
346
respectively. These data indicate that "glossodynia" is a common disorder and that women are affected far more frequently than men. Some reports have described this syndrome as being psychogenie and an expression of psychiatric disturbance;-4 although little research has been done by psychiatrists. The purpose of this study is to obtain a psychiatrie profile of female patients with "glossodynia." SUBJECTS AND METHODS The subjects were 55 outpatients (50 females, 5 males) anending the Department of Dentistry and Oral Surgery. Keio University Hospital. Tokyo, for the first time in 1989, who met the following criteria: I) presence of pain or a buming sensation on the surface of the tongue; 2) absence of local or systemic diseases (xerostornia. candidiasis. anemia, diabetes, referred pain from dentalgia, etc.); and 3) no administration of any drugs for more than 4 weeks before the first attendance. The psychiatric profiles of PSYCHOSOMATICS
Miyaoka et al.
the 50 female patients, with a mean age of 55.8 (SD = 8.7) (range: 37-73 years) were compared with those of control subjects. The healthy control group comprised 24 volunteer women with a mean age of 53.2 (SD =8.4) (range: 36-70 years), who were employees of a single company, and their family members. They were interviewed using the Schedule of Affective Oisorders and Schizophrenia 5 and were found to have no psychiatric morbidity. There was no significant difference in mean age between the female patients and the control subjects (t-test). Ali subjects completed the Eysenck Personality Questionnaire (EPQ)6 to assess personality traits, the 30-item version of the General Health Questionnaire (GHQ)7 to assess the severity of neurotic symptoms and to screen mental disorders, and the Toronto Alexithymia Scale (TAS)8 to assess alexithymic personality. In responding to the EPQ, the subjects were required to answer questions about their personalities before the pain or buming sensations had occurred. The Mann-Whitney U-test was used to test differences in the scores between the glossodynia patients and the control subjects. RESULTS Table I compares the mean EPQ, GHQ, and TAS scores of the patients and the healthy controI subjects. The patients with glossodynia scored significantly lower on the extraversion TARLE I.
DISCUSSION Patients enduring pain or a buming sensation in the tongue with no oral pathology or systemic disease are often referred to as having glossodynia or idiopathic tongue pain syndrome. Though psychological factors have been considered important etiologically, there have been few investigations of this syndrome in the psychiatric field. Typical patients are women over 40 years old who have a dread of tongue cancer and experience decreased pain while eating. Typical patients have often had dental treatment or have leamed of someone's death from cancer just before the appearance ofthe tongue sensations. 9 According to the OSM-II1-R, the patients are diagnosed as having hypochondriasis or an undifferentiated somatoform disorder. The results of this study showed that the mean EPQ neuroticism score of the patients tended to be higher and that their extraversion score was lower than those of the control subjects. According to the EPQ, neuroticism measures trait anxiety, lability, and dysphoria, and extraversion measures sociability and impul-
EPQ, TAS, and GUQ scores or glossodynia patients and Glossodynia Patients
Scale EPQ:
scale of the EPQ and higher on the TAS than the healthy control subjects. The mean neuroticism score of the EPQ and the mean GHQ score among the glossodynia patients were higher than those of the control subjects, but the differences were not statistically significant.
Neuroticism Extraversion Psychoticism
GHQ (30·ilem) TAS No/e: EPQ =Eysenck Questionnaire.
Personałity
Uealłhy
healłhy controi
subjects
Control Subjects
(N = 50)
(N=24)
Mean±SD
Mean ±SD
Mann-Whitney U-Test p
11.0 ± 4.6
8.6± 5.4
0.08
8.6±5.1
\3.2 ±4.2
<0.01 0.06
5.0 ± 1.8
6.6± 27
6.5 ±6.2
4.2± 3.5
0.22
75.7 ± 7.2
70.2± 8.0
< 0.01
Questionnaire; TAS =Toronto Alexithymia Scale; GHQ =Generał Health
VOLUME 37 • NUMBER 4. JULY - AUGUST 1996
347
Psychiatrie Appraisal of Glossodynia
slvlty. The subjeets were required to answer questions about their personalities before the symptoms oeeurred. This additional eomment ean help to cłarify the premorbid personality.1O The patients' labile and anxious premorbid personality may be a predisposing faetor to the syndrorne. When patients had had their teeth treated or had heard of someone having eaneer, they paid much more attention to their bodily sensations than before, whieh resulted in abnormaI sensations of the tongue. The psyehopathology of glossodynia is similar to that of hypoehondriasis. There was no signifieant differenee in the mean GHQ seore between the patients and the eontroi subjeets. van der Ploeg 2 and Ott and Ott 4 pointed out that the seores of the self-rating anxiety and depression seales among the patients with this syndrorne were higher than in healthy subjeets. These eontlieting results may be attributable to the faet that the present study used eontroI subjeets matehed for gender and age. Women may have more neurotie symptoms during the menopausal and presenile periods. It ean be said that glossodynia syndrorne is more markedly associated with personality trait eharaeteris-
tics than with neurotie or depressive symptoms. The patients were found to be more alexithymic than the eontroI subjeets. Alexithymia is eharaeterized by relative eonstrietion in emotional funetioning and inability to find appropriate words for deseribing one's emotions. 1I Patients with somatization disorder are more alexithymie than healthy eontroI subjeets. 12 As alexithymic patients are not good eandidates for dynamie psyehotherapy, JJ psyehiatrists must deteet the presenee of alexithymia at an early stage of treatment for glossodynia. Tentative diagnostie eriteria for glossodynia have been developed, and the effieaey of this diagnostie rubrie is now being validated. The eriteria are as follows: l) pain or a buming sensation on the surfaee of the tongue; 2) no foeal or systemie disorders revealed by appropriate physical evaluation; 3) a deerease or disappearanee of the pain or buming sensation while eating; 4) presenee of at least one of the following symptoms: 4a) dread of tongue eancer, and 4b) patient's misinterpretation of their lingual organization (e.g., lingual papillae) as abnorrnal.
References I. Haneke E: Psychische aspekle der glossodynie. Dlsch Med Wochenshr 1978; 103: 1302-1305 2. van der Ploeg HM. van der Wal N. Eijkman MAJ. et al: Psychological aspecls of palienls wilh buming mouth syndrorne. Oral Surgery 1987; 63:664--668 3. Sullivan PD: The diagnosis and lrealment of psychogenic glossodynia. Ear Nose Throal J 1989; 68:795-798 4. Olt G. Olt C: Glossodynia-Psychodynamic basis and results of psychopalhometric investigalions. J Psychosom Res 1992; 36:677-686 5. Spilzer RL. Endicolt J: Schedule for AffeClive Disorders and Schizophrenia. New York. Biomelrics Research. New York Slale Psychialric InsIilule. 1977 6. Eysenck HJ: Manual of Eysenck Personalily Queslionnaire (junior and Adull). London. England. Hodder and Sloughlon.1975
348
7. Goldberg DP: The detection of psychiatric illness by Questionnaire. Maudley Monograph No. 21. London. England. Ollford University Press. 1972 8. Taylor GT: Toward the development of a new self-repon a1ellithymia scale. Psychother Psychosom 1985; 44; 19 t-199 9. Nagai T. Ebihara T. Sintani H. et al: Diagnosis and lreatment of glossodynia. Joumal of Japanese Stomatological Society 1987; 36:596-601 10. Kendell RE. DiScipio: Eysenck personality inventory scores of patients with depressive illnesses. Br J Psychiatry 1968; t 14:767-770 1I. Sifneos PE: The prevalence of "alexithymic" characleristics in psychosomatic patients. Psycholher Psychosom 1973; 22:255-262 12. Shipko S: Alellithymia and somatization. Psychother Psychosom 1982; 37: 193-201
PSYCHOSOMATICS