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A Pilot study
Journal of Psychosomatic Research 49 (2000) 1 ± 2
Short report
A Pilot study Stability of psychiatric diagnoses over 6 months in burning mouth syndrome M. Nicholsona,*, G. Wilkinsonb, E. Fieldb, L. Longmanb, B. Fitzgeraldb a
University Department of Psychiatry, Royal Liverpool University Hospital, Liverpool, UK b Liverpool University Dental Hospital, Liverpool, UK Received 12 March 1998; accepted 1 June 1999
Abstract Ten people with burning mouth syndrome (BMS) were interviewed by a psychiatrist using the Schedules of Clinical Assessment in Neuropsychiatry (SCAN) at initial presentation and at 6-month follow-up. A range of psychiatric disorders from the neurotic spectrum was identified using the International Classification of Diseases (ICD-10) criteria, but the diagnoses
were unstable. Six of the ten individuals received a psychiatric diagnosis, suggesting that the prevalence of psychiatric morbidity is high in this common dental syndrome. Psychiatric aspects of BMS require further investigation. D 2000 Elsevier Science Inc. All rights reserved.
Keywords: Burning mouth syndrome; Psychiatric diagnoses
Introduction
Method
The burning mouth syndrome (BMS) is a chronic orofacial pain disorder that has been estimated to be prevalent in 3% of the general population [1]. It is characterized by a painful burning sensation in the oral mucosa with no visual muscosal abnormality on examination. Although screening tests may, in some cases, identify a physical cause, such as oral candidiasis, most cases of BMS appear to be idiopathic. Psychological factors are, however, frequently associated with BMS. Previous studies have shown diagnoses such as depression, generalized anxiety, hypochondriasis, and cancer phobia are often represented in patients with BMS [2]. However, these studies have not demonstrated the stability of these diagnoses over time. This pilot study examined the stability of psychiatric diagnoses over 6 months in BMS patients.
Clinic
* Corresponding author. Arundle House Community Mental Health Resource Centre, Sefton General Site, Smithdown Road, Liverpool L9 7JP, UK. Tel: 0151-330-8028; fax: 0151-280-0929.
Fourteen patients with persistent symptoms of BMS were identified at the Psychiatric Liaison Clinic in the Oral Medicine Unit at the Liverpool University Dental Hospital. The clinic was established in 1992 and also has referral links to a clinical psychologist. Patients are referred from a variety of sources and are mostly referrals from dental surgeons. At initial assessment, patients are seen jointly by a consultant in oral medicine and restorative dentistry and a psychiatrist. They are screened at interview for psychiatric disorders and psychogenic factors such as stressful life events. They also undergo an orodental examination and a full organic work-up, including pain assessment, blood tests, urinalysis, and microbiological sampling. They are then screened for psychiatric disorder by the attending psychiatrist. Following assessment, a care plan is constructed that may include a treatment range of local pharmacotherapy; for example,
0022-3999/00/$ ± see front matter D 2000 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 9 9 ) 0 0 0 5 6 - 2
2
M. Nicholson et al. / Journal of Psychosomatic Research 49 (2000) 1±2
from analgesic sprays to psychopharmacology. Some patients are referred to the affiliated clinical psychologist for cognitive-behavioral therapy. Initial assessment The 14 patients identified were invited to complete the Hospital Anxiety and Depression (HAD) scale [3] and, within 2 weeks, at the same campus, attended the University Department of Psychiatry for the Schedules of Clinical Assessment in Neuopsychiatry (SCAN) interview [4]. All patients completing the initial SCAN interview were then invited for follow-up at 6 months for repeat HAD and SCAN interviews. Those who did not complete the initial SCAN interview were invited to complete a follow-up HAD questionnaire by post. Results Of the 14 patients who agreed to be included in this study, 13 were women and 1 was a man. Five were single, six were married, and three were widowed. On average, those studied had been complaining of burning mouth with oral dysesthesia for 2 years at the time of presentation. At baseline assessment, four patients were already taking psychotropic medication: one carbamazepine, two benzodiazepines, and one a tricyclic antidepressant. At baseline physical examination, the oral mucosa appeared to be normal in all patients. Hematology, biochemistry, and microbiology were normal for all patients except for one with microcytic hypochromic anemia. The 14 cases of BMS identified all completed HAD scales. Ten attended for initial SCAN interview, and six of these attended for 6-month follow-up SCAN and completed follow-up HAD questionnaires. None of the patients sent postal HAD questionnaires returned them. Therefore, 6 follow-up HAD scales were collected out of 14 cases. Two patients had definite HAD-scale caseness for anxiety at baseline. One patient had definite HAD caseness for anxiety at follow-up. Two patients had definite caseness for depression at baseline, and one patient definite HAD caseness for depression at follow-up. At initial assessment, seven cases of BMS had no International Classification of Diseases (ICD-10) psychiatric diagnosis. The others had ICD-10 diagnoses of specific isolated phobia, general anxiety disorder, and recurrent depressive disorder. At 6-month follow-up four of ten patients did not attend. Of the remaining six, two patients had no psychiatric diagnosis. The patient at initial assessment with specific isolated phobia had the same diagnosis at 6-month follow-up. The
other patients had follow-up at diagnoses of somataform autonomic dysfunction (cardiovascular and gastrointestinal), dementia of Alzheimer's disease with late onset, and depressive episode of mild severity without somatic symptoms.
Discussion The absence of causative organic factors is consistent with assumptions that, in most cases, BMS is a functional disorder, encompassing psychological, emotional, and neurological dysfunction [5]. This has been the experience in our BMS clinic where we have found that most patients suffering from this syndrome have psychological and emotional difficulties. Our investigation is consistent with studies in which the majority of patients with BMS were postmenopausal women and psychogenesis was considered to be an important etiological factor [6]. This pilot study has presented methodological issues that a substantial study of this syndrome would need to address. Further research will need to address why a considerable percentage of this population would not take part, with a high attrition rate. One solution for addressing this is to visit patients at home for initial and follow-up SCAN interviews and questionnaires. The number of patients recruited for the study is not sufficiently large to comment in detail on the psychiatric disorders present. Our general experience, partly borne out by this study, is of a high prevalence of neuroses in these patients, particularly the somatization disorders and anxiety/depressive disorders with somatizationÐhence our referrals for cognitive therapy to attempt to reattribute somatic symptoms to psychosocial stresses. Further research of this syndrome in a larger cohort would establish which mental disorders have high prevalence and would likely confirm the need for cognitive-behavioral therapy. References [1] Mott AE, Grushka M, Seesle BJ. Diagnosis and management of taste disorders and burning mouth syndrome. Dent Clin N Am 1993;37:33 ± 71. [2] Grushka M, Seesle BJ, Miller R. Pain and personality profiles in burning mouth syndrome. Pain 1987;28:155 ± 67. [3] Zigmond AS, Snaith RP. The Hospital Anxiety and Depression scale. Acta Psychiatrica Scand 1983;67:361 ± 70. [4] Schedules of Clinical Assessment in Neuropsychiatry, version 2.1. Geneva: WHO Division of Mental Health, 1995. [5] Gorsky M, Silverman S, Chinn H, Fan Francisco C. Clinical characteristics and management outcome in the burning mouth syndrome. Oral Surg Oral Med Oral Pathol 1991;72:192 ± 5. [6] Eli J, Klleinhauz M, Baht R, Littner M. Antecedents of burning mouth syndrome (Glossodynia) Ð recent life events vs psychopathological aspects. J Dent Res 1984;73:567 ± 72.
Short report
A Pilot study Stability of psychiatric diagnoses over 6 months in burning mouth syndrome M. Nicholsona,*, G. Wilkinsonb, E. Fieldb, L. Longmanb, B. Fitzgeraldb a
University Department of Psychiatry, Royal Liverpool University Hospital, Liverpool, UK b Liverpool University Dental Hospital, Liverpool, UK Received 12 March 1998; accepted 1 June 1999
Abstract Ten people with burning mouth syndrome (BMS) were interviewed by a psychiatrist using the Schedules of Clinical Assessment in Neuropsychiatry (SCAN) at initial presentation and at 6-month follow-up. A range of psychiatric disorders from the neurotic spectrum was identified using the International Classification of Diseases (ICD-10) criteria, but the diagnoses
were unstable. Six of the ten individuals received a psychiatric diagnosis, suggesting that the prevalence of psychiatric morbidity is high in this common dental syndrome. Psychiatric aspects of BMS require further investigation. D 2000 Elsevier Science Inc. All rights reserved.
Keywords: Burning mouth syndrome; Psychiatric diagnoses
Introduction
Method
The burning mouth syndrome (BMS) is a chronic orofacial pain disorder that has been estimated to be prevalent in 3% of the general population [1]. It is characterized by a painful burning sensation in the oral mucosa with no visual muscosal abnormality on examination. Although screening tests may, in some cases, identify a physical cause, such as oral candidiasis, most cases of BMS appear to be idiopathic. Psychological factors are, however, frequently associated with BMS. Previous studies have shown diagnoses such as depression, generalized anxiety, hypochondriasis, and cancer phobia are often represented in patients with BMS [2]. However, these studies have not demonstrated the stability of these diagnoses over time. This pilot study examined the stability of psychiatric diagnoses over 6 months in BMS patients.
Clinic
* Corresponding author. Arundle House Community Mental Health Resource Centre, Sefton General Site, Smithdown Road, Liverpool L9 7JP, UK. Tel: 0151-330-8028; fax: 0151-280-0929.
Fourteen patients with persistent symptoms of BMS were identified at the Psychiatric Liaison Clinic in the Oral Medicine Unit at the Liverpool University Dental Hospital. The clinic was established in 1992 and also has referral links to a clinical psychologist. Patients are referred from a variety of sources and are mostly referrals from dental surgeons. At initial assessment, patients are seen jointly by a consultant in oral medicine and restorative dentistry and a psychiatrist. They are screened at interview for psychiatric disorders and psychogenic factors such as stressful life events. They also undergo an orodental examination and a full organic work-up, including pain assessment, blood tests, urinalysis, and microbiological sampling. They are then screened for psychiatric disorder by the attending psychiatrist. Following assessment, a care plan is constructed that may include a treatment range of local pharmacotherapy; for example,
0022-3999/00/$ ± see front matter D 2000 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 9 9 ) 0 0 0 5 6 - 2
2
M. Nicholson et al. / Journal of Psychosomatic Research 49 (2000) 1±2
from analgesic sprays to psychopharmacology. Some patients are referred to the affiliated clinical psychologist for cognitive-behavioral therapy. Initial assessment The 14 patients identified were invited to complete the Hospital Anxiety and Depression (HAD) scale [3] and, within 2 weeks, at the same campus, attended the University Department of Psychiatry for the Schedules of Clinical Assessment in Neuopsychiatry (SCAN) interview [4]. All patients completing the initial SCAN interview were then invited for follow-up at 6 months for repeat HAD and SCAN interviews. Those who did not complete the initial SCAN interview were invited to complete a follow-up HAD questionnaire by post. Results Of the 14 patients who agreed to be included in this study, 13 were women and 1 was a man. Five were single, six were married, and three were widowed. On average, those studied had been complaining of burning mouth with oral dysesthesia for 2 years at the time of presentation. At baseline assessment, four patients were already taking psychotropic medication: one carbamazepine, two benzodiazepines, and one a tricyclic antidepressant. At baseline physical examination, the oral mucosa appeared to be normal in all patients. Hematology, biochemistry, and microbiology were normal for all patients except for one with microcytic hypochromic anemia. The 14 cases of BMS identified all completed HAD scales. Ten attended for initial SCAN interview, and six of these attended for 6-month follow-up SCAN and completed follow-up HAD questionnaires. None of the patients sent postal HAD questionnaires returned them. Therefore, 6 follow-up HAD scales were collected out of 14 cases. Two patients had definite HAD-scale caseness for anxiety at baseline. One patient had definite HAD caseness for anxiety at follow-up. Two patients had definite caseness for depression at baseline, and one patient definite HAD caseness for depression at follow-up. At initial assessment, seven cases of BMS had no International Classification of Diseases (ICD-10) psychiatric diagnosis. The others had ICD-10 diagnoses of specific isolated phobia, general anxiety disorder, and recurrent depressive disorder. At 6-month follow-up four of ten patients did not attend. Of the remaining six, two patients had no psychiatric diagnosis. The patient at initial assessment with specific isolated phobia had the same diagnosis at 6-month follow-up. The
other patients had follow-up at diagnoses of somataform autonomic dysfunction (cardiovascular and gastrointestinal), dementia of Alzheimer's disease with late onset, and depressive episode of mild severity without somatic symptoms.
Discussion The absence of causative organic factors is consistent with assumptions that, in most cases, BMS is a functional disorder, encompassing psychological, emotional, and neurological dysfunction [5]. This has been the experience in our BMS clinic where we have found that most patients suffering from this syndrome have psychological and emotional difficulties. Our investigation is consistent with studies in which the majority of patients with BMS were postmenopausal women and psychogenesis was considered to be an important etiological factor [6]. This pilot study has presented methodological issues that a substantial study of this syndrome would need to address. Further research will need to address why a considerable percentage of this population would not take part, with a high attrition rate. One solution for addressing this is to visit patients at home for initial and follow-up SCAN interviews and questionnaires. The number of patients recruited for the study is not sufficiently large to comment in detail on the psychiatric disorders present. Our general experience, partly borne out by this study, is of a high prevalence of neuroses in these patients, particularly the somatization disorders and anxiety/depressive disorders with somatizationÐhence our referrals for cognitive therapy to attempt to reattribute somatic symptoms to psychosocial stresses. Further research of this syndrome in a larger cohort would establish which mental disorders have high prevalence and would likely confirm the need for cognitive-behavioral therapy. References [1] Mott AE, Grushka M, Seesle BJ. Diagnosis and management of taste disorders and burning mouth syndrome. Dent Clin N Am 1993;37:33 ± 71. [2] Grushka M, Seesle BJ, Miller R. Pain and personality profiles in burning mouth syndrome. Pain 1987;28:155 ± 67. [3] Zigmond AS, Snaith RP. The Hospital Anxiety and Depression scale. Acta Psychiatrica Scand 1983;67:361 ± 70. [4] Schedules of Clinical Assessment in Neuropsychiatry, version 2.1. Geneva: WHO Division of Mental Health, 1995. [5] Gorsky M, Silverman S, Chinn H, Fan Francisco C. Clinical characteristics and management outcome in the burning mouth syndrome. Oral Surg Oral Med Oral Pathol 1991;72:192 ± 5. [6] Eli J, Klleinhauz M, Baht R, Littner M. Antecedents of burning mouth syndrome (Glossodynia) Ð recent life events vs psychopathological aspects. J Dent Res 1984;73:567 ± 72.