Journal of Orofacial Sciences

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 12  |  Issue : 2  |  Page : 84--90

Evaluation of Stressful Life Events and Psychiatric Disorders in Patients Presenting with Psychogenic or Organic Origin Complaints Referred to Mashhad Faculty of Dentistry


Zahra Delavarian1, Abbas Javadzadeh Bolouri1, Ala Ghazi1, Zohreh Dalirsani1, Peyman Hashemian2, Tahereh Nosratzehi3,  
1 Oral and Maxillofacial Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
2 Psychiatry and Behavioral Sciences Research Center, Ibn-e-Sina Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
3 Dental Research Center and Department of Oral Medicine, School of Dentistry, Zahedan University of Medical Sciences, Zahedan, Iran

Correspondence Address:
Zohreh Dalirsani
Department of Oral Medicine, School of Dentistry, Mashhad University of Medical Sciences, Vakilabad Blv, Mashhad
Iran

Abstract

Introduction: Diagnosis of stressful life events and psychiatric disorders plays an important role in the management of patients having somatic complaints of psychogenic origin. The aim of this study is to compare stressful events among patients presenting with complaints of psychogenic or organic origin referred to the Oral and Maxillofacial Pain Clinic of Mashhad Faculty of Dentistry. Materials and Methods: 132 patients with complaints of psychogenic or organic origin were enrolled in our study. Both control and case groups completed the Scl-90 questionnaire, and the case-group patients were further evaluated by interview with a psychiatrist using DSM-IV-TR criteria. Results: In the case group, changes in work responsibilities and in family member’s health were the most common events in females and males, respectively. In the control group, the most common event among females was change in financial status, while for males this was change in work responsibilities. The mean severity of stressful events in the case group was significantly higher than that in the control group. According to the Scl-90 questionnaire, most of the control group patients (69.9%) were lacking any psychiatric disorders while most of the case patients (53.8%) were classified as having a tendency towards psychogenic disorders. Conclusion: Dentists come across Patients with psychogenic origin disorders on a daily basis. Thus, diagnosis and efficient management of such disorders becomes critical in populations of both modern and developing countries having persistent worries and stressful lifestyles.



How to cite this article:
Delavarian Z, Bolouri AJ, Ghazi A, Dalirsani Z, Hashemian P, Nosratzehi T. Evaluation of Stressful Life Events and Psychiatric Disorders in Patients Presenting with Psychogenic or Organic Origin Complaints Referred to Mashhad Faculty of Dentistry.J Orofac Sci 2020;12:84-90


How to cite this URL:
Delavarian Z, Bolouri AJ, Ghazi A, Dalirsani Z, Hashemian P, Nosratzehi T. Evaluation of Stressful Life Events and Psychiatric Disorders in Patients Presenting with Psychogenic or Organic Origin Complaints Referred to Mashhad Faculty of Dentistry. J Orofac Sci [serial online] 2020 [cited 2021 Mar 8 ];12:84-90
Available from: https://www.jofs.in/text.asp?2020/12/2/84/309580


Full Text



 Introduction



The diagnosis and treatment of patients who complain from symptoms without any sign to indicate the exact cause of the complaint is a challenge for different medical specialists. Physicians are sometimes unable to find any particular physical origin for the symptoms. Many of these diseases have physical symptoms that are rooted in mental or emotional factors. The most common of these factors are stress, anxiety and depression, and the most typical problems of these patients include persistent idiopathic facial pain/atypical facial pain (AFP), burning mouth syndrome (BMS), and other atypical sensory disorders (atypical odontalgia (AO), subjective xerostomia (SX).[1],[2],[3]

The International Association for the Study of Pain describes BMS (stomatodynia, oral dysesthesia, glossodynia, glossopyrosis, and stomatopyrosis) as “any form of burning or stinging sensation in the mouth in association with a normal mucosa in the absence of local or systemic disease”.[4],[5] BMS is a complicated condition due to the interaction of biological and psychological factors.[6] Persistent idiopathic facial pain or atypical facial pain is a chronic persistent pain in the oral cavity, jaw, face, and/or teeth without any organic causes; it does not begin suddenly and is not limited to special anatomic region. Touching of trigger zone or daily activity does not exacerbate this pain.[7]

Since in most of such cases there is not any organic origin, these atypical sensory disorders are considered as psychogenic conditions. Evaluation of these patients show that some complaints developed after psychiatric pressure.

As a result of wrong diagnosis, patients may have to undergo unnecessary laboratory tests and consequently improper treatments such as root canal therapy, surgery and medicinal treatments that may exacerbate of their psychiatric disorders. Although these patients do not have any pathological conditions, they need to be treated properly.

The prevalence of psychiatric disorders and stressful life events is different in various countries and patients tend to respond to stressful life events differently depending on their cultural and socio-economic status. Therefore, the detection of psychiatric disorders and stressful life events in different geographic areas can be helpful in the management of patients.

Cultural and socio-economic status may affect the type and severity of stressful events and no study has investigated this issue in our particular geographic area. Therefore, this study focuses on stressful events in the lives of patients with psychogenic origin complaints. These patients had referred to the Oral and Maxillofacial Pain Clinic of Mashhad Faculty of Dentistry due to the inexistence of any physical explanation for their complaint.

 Materials and Methods



An analytical cross-sectional study was performed at the Oral and Maxillofacial Pain Clinic of Mashhad Faculty of Dentistry from February 2016 to February 2017.

Ethical approval for this study (Ethical Committee N° IR.MUMS.DENTISTRY.REC.1387.87337) was provided by the Ethical Committee of Mashhad University of Medical Sciences, Mashhad, on 31 December 2014. 132 patients complaining of oral and maxillofacial pain, burning, paresthesia, xerostomia, etc., without any organic cause volunteered for this study as a case group. Their diagnosis consisted of persistent idiopathic facial pain/AFP, BMS, and other Atypical Sensory Disorders. These disorders were confirmed by an oral medicine specialist. Inclusion criteria for the case group included patients with chronic complaint without any evidence for organic origin including any neurological, physical or radiological explanation. Their sensory disorders were confirmed by an oral medicine specialist. The patients were required to have sufficient cooperation for completing the Scl-90 questionnaire. Exclusion criteria for case group included any local or systemic causes for symptoms. For the control group, 132 patients were selected.

For diagnosis of persistent idiopathic facial pain, the patients were examined carefully and physical factors that can lead to pain in head and neck were ruled out. Obtaining exact history revealed that most of these patients suffered from the chronic pain that continues throughout the day. It does not follow a nervous pathway and has involved the patients for several months or years. Their complaints were exacerbated by stress and emotional pressures. Diagnosis of BMS was confirmed by ruling out all systemic and local factors that cause oral burning sensation. Other complaints such as anesthesia and other complaints without any organic cause classified as “Other Atypical Sensory Disorders”.

The type and duration of stressful life events that occurred in the last month of the patients’ lives were evaluated by the Holmes-Rahe Stress Test. The duration of these stressful events prior to referring to the clinic was classified as being: less than 6 months, between 6 months and 2 years, between 2 and 5 years, more than 5 years.

The Scl-90 questionnaire was used to determine the type of psychiatric disorder. After the assessment of each patient’s score, the researchers categorized the patients according to the mean score. The categories are as follows: 1) without psychiatric disorders (mean score < 2), 2) trending to psychiatric disorders (2≤ mean score < 3) 3) with psychiatric disorders (mean score ≥3 patients).

If any psychiatric disorder was identified in control group patients, according to the Scl-90 questionnaire, they were referred to a psychiatrist.

After that, for case patients, the type of psychiatric disorder was defined by an interview with a psychiatrist using the DSM-IV-TR criteria (Diagnostic and statistical manual of mental disorder IV-text Revision). Patients who gave their consent underwent psychiatric treatment. The relationship between stressful events and the type of sensory and psychiatric disorders was investigated. ANOVA, t-test, Chi-square and Pearson tests were used for comparative analysis. Statistical analysis was performed using SPSS 13.5 (SPSS Inc, Chicago, IL, USA). A P-value of <0.5 was considered to indicate statistical significance.

 Results



The case and control groups were matched according to sex, age, and level of education.

The mean age of control and case groups was 31±10.06 and 43±14.75, respectively. The patients in case group were between 12 and 80 and in control group were between 13 and 70 years old. Among the control group, 53.1% were female and in the case group 64.4% were female.

Only 25.4% of the control group subjects and 25% of the case group patients had bachelor degree or higher level of education. Regarding to marital status, 59.2% of the control group and 68.9% of the case group were single and the rest were married. The percentage of unemployment subjects between the two groups was different: although 39.4% of the case group patients were unemployed, just 15.4% were unemployed in the control group. In the control and case groups 44.6% and 20.5% were students, respectively.

[Table 1] illustrates the frequency of sensory disorders in the case group. The most common sensory disorder in females were persistent idiopathic facial pain (60.86%), other atypical sensory disorders (34.78%) and in the males were atypical facial pain (36.5%) and burning mouth syndrome (22.22%). All types of these disorders with mental-based were observed in female patients more than males.{Table 1}

Pearson analysis did not show any significant relationship between type of mental based disorders and patients’ sex (P = 0.8). The correlation between type of these disorders and patients’ age was not significant, too (P = 0.15).

Change in living conditions was the most common stressful event. The rate for this condition in the control and case groups was 10.8% and 20%, respectively. In the case group, the most common event among females was change in work responsibilities, while for males this was a change in a family member’s health. However, the events in the control group were different. The males in the control group reported a change in work responsibilities being stressful events while females mentioned a change in financial status as the most common stressful event in their lives [Table 2] and [Table 3]. The mean severity of stressful events in the case group was 43.26±19.07 that was significantly more than the control group (22.4±11.7) (P = 0.001(. Duration of exposure to stressful events is demonstrated in [Table 4].{Table 2}{Table 3}{Table 4}

In this study, the most common sensory disorder was atypical facial pain and the least common disorder was subjective xerostomia. The type of psychiatric disorders was determined by a psychiatrist via Scl-90. In the present study, most of the control group patients (69.9%) were lacking any psychiatric disorders while most of the case patients (53.8%) were classified as having a tendency towards psychogenic disorders.

Although according to the Scl-90 questionnaire, 15.1% of case group patients were without psychiatric disorders, interviews with a psychiatrist showed that 100 % of cases have a type of psychiatric disorder according to the DSM-IV-TR criteria. Furthermore, an evaluation of the type of psychiatric disorder by DSM-IV-TR according to an interview with a psychiatrist showed that the most prevalent psychiatric disorders were anxiety disorders (40.2% of case patients) depression disorders (36.8%), and somatoform disorder, respectively [Table 5]. In addition, 8.3% of case patients had concurrent disorders (i.e., five patients with concurrent major depression disorder and generalized anxiety disorder, three patients with concurrent major depression disorder and obsessive-compulsive disorder, two patients with concurrent major depression disorder and obsessive-compulsive disorder and generalized anxiety disorder and one patient with concurrent generalized anxiety disorder and dysthymia). Concurrent psychiatric disorders may increase susceptibility to mental-based disorders. There was no significant relationship between the duration of stressful events and psychiatric disorders (P = 0.15).{Table 5}

Most of the females had anxiety disorder (42.4%) whereas most of males suffered from depressive disorder (40.4%). Most of the patients afflicted by anxiety disorder were between 40 and 49 years of age while most of the patients with anxiety and somatoform disorders were younger than 30 years and between 30 and 39 years old, respectively. Also, there was no significant relationship between patients’ sex and age and type of psychiatric disorder as shown by the Scl-90 questionnaire (P = 0.12, P = 0.84, respectively). [Table 6] shows prevalence of sensory disorders of oral and maxillofacial region according to psychiatric disorders in the case group.{Table 6}

 Discussion



In the present study, the prevalence of stressful events was evaluated according to the Holmes-Rahe Stress Test and it was observed that changes in living conditions, changes in family member’s health and changes in work responsibilities were the most common life events in the patients suffering from psychogenic origin disorders. The mean severity of stressful events in the case group was significantly higher than the control group. Although in the present study, the mean severity of stressful events was higher in the case group, it should be considered that the severity of stressful events could be affected by cultural and social status in different societies.

Most of these patients encountered stressful event more than 5 years which indicates that long durations of stress could increase the possibility of sensory disorders. However, there was no significant relationship between the duration of stressful events and psychiatric disorders. Most of our patients in the case group reported some stressful events and some encountered multiple stressful problems. The type of stressful events in life was different between patients with and without sensory disorders and also between males and females. In addition to gender, age was an effective factor in the type of stressful problems and some events were more frequent in younger people. Furthermore, a higher percentage of case group patients were single and unemployed compared to those in the control group. The marital- and job status of patients could be effective in the type of stressful events in patients’ lives. Adamo et al.[8] confirmed that BMS is more prevalent in unemployed or low educated patients and job status has a significant relationship with the Visual Analogue Scale (VAS). Cultural and socio-economic status affect the number and type of stressful events which may engender emotional and psychiatric problems and lead to atypical pain and sensory disorders. In Smith’s study, the majority of the patients were from poor families and low social conditions in the time of evaluation.[9]

By now, some controlled studies on stressful events in patients with sensory disorders have been conducted. The first one revealed that some patients described the occurrence of "significant" physical or psychosocial trauma immediately before the initiation of the pain, including divorce, hysterectomy, miscarriage, death of a mother, work overload, caring for a sick mother, birth of a first grandchild, and dental extraction[9] According to another study, patients suffering from chronic diseases such as oro-facial pain reported high levels of anxiety and recent unpleasant life events.[10] Another study revealed that about

50% of patients mentioned stressful life events as being more effective than dental treatments in triggering their pain.[11] One study revealed that the higher levels of pain severity in idiopathic continuous oro-facial neuropathic pain (ICONP) patients than masticatory muscle pain (MMP) patients could be related to their higher levels of reported life intervention.[12] Furthermore, one particular study reported that psychological factors are strong predictors in the initiation and perpetuation of several types of oral mucosal and orofacial pain conditions.[13] Some researchers reported that BMS patients might have faced more stressful life events in life than controls.[14],[15],[16] Moreover, accumulated research results indicate that psychological problems play an important role in symptom development and aggravation of BMS..[17],[18] In contrast, in some cases, the occurrence of depression or anxiety shortly after the beginning of BMS suggests that BMS could be a precipitating factor in the onset of these disorders.[19]

Our study evaluated psychiatric disorders by a Scl-90 questionnaire and a psychiatric interview and determined all types of these disorders. Another study demonstrated that most patients with oral disorders had low oral health-related quality of life scores and suffered from “psychological discomfort” or “psychological disability”.[20] Some epidemiological studies and psychiatric assessments have pointed out that psychological factors may possibly play a role in atypical facial pain condition and that many patients of this kind are likely to experience other chronic pain in other parts of their bodies.[21],[22],[23] One study showed that in some instances psychogenic factors are closely linked to the neuropathic pain of BMS.[24] In some studies, the prevalence of psychiatric disorders is reported to be less than our study. Takenoshita’s study showed that 50.8% of BMS patients and 33.3% of AO patients had no specific psychiatric diagnoses.[11] Difference in the prevalence of psychiatric disorders in various societies, different diagnostic tests for psychiatric disorders, various sample tests and different cultural, socio-economic statuses may affect the prevalence of psychiatric disorders in various studies. In the present study, most female patients had anxiety disorders similar to another study that showed that in 13–65% of AFP cases, anxiety is an initiating factor.[25] Also, a recent systematic review of psychiatric aspects of BMS showed the high prevalence of anxiety and depression in BMS patients.[26]Briefly, proper diagnosis of the sensory disorders and identifying and reducing stressful conditions could be useful for controlling psychiatric problems. Physicians and dentists should avoid multiple unnecessary treatments and refer the patient for psychiatric consultation, if necessary.

 Conclusion



Patients with psychogenic origin disorders refer to dental clinics on a daily basis. Hence, the recognition and efficient management of such disorders has become a necessity in the modern and developing world. This issue draws our attention to the link between dentistry and psychiatry. Hence, most dental colleges and hospitals should establish a liaison between the Dentistry and Psychiatry fields for early referral and better treatment of such psychologically compromised patients.

Acknowledgement

The authors would like to extend their appreciation to the vice chancellor for research, Mashhad University of Medical Sciences for the financial support. The results described in this paper were part of a post-graduated student’s thesis proposal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Dhimole A, Bhasin N, Pandya D, Dwivedi N, Nagarajappa AK. Psychosomatic disorders affecting the mouth: a critical review. BJMMR 2016;14:1-9.
2Ghurye S, McMillan R. Orofacial pain − an update on diagnosis and management. Br Dent J 2017;223:639-47.
3Joanna M. Zakrzewska. Multi-dimensionality of chronic pain of the oral cavity and face. J Headache Pain 2013;14:37.
4Merskey H, Bogduk N. Classification of Chronic Pain. 2nd ed. Seattle, WA: International Association for the Study of Pain; 2004.
5Galeotti F, Truini A, Cruccu G. Neurophysiological assessment of craniofacial pain. J Headache Pain 2006;7:61-9. Epub 2006 Apr 26.
6Yamaguchi K. Traditional Japanese herbal medicines for treatment of odontopathy. Frontiers in Pharmacology 2015;6:176. PubMed PMID: 26379550. Pubmed Central PMCID: PMC4551818. Epub 2015/09/18. Eng.
7Melis M, Secci S. Diagnosis and treatment of atypical odontalgia: a review of the literature and two case reports. J Contemp Dent Pract 2007;8:81-9.
8Adamo D, Celentano A, Ruoppo E, Cucciniello C, Pecoraro G, Aria M et al. The relationship between sociodemographic characteristics and clinical features in burning mouth syndrome. Pain Medicine (Malden, Mass) 2015;16:2171-9.
9Smith DP, Pilling LF, Pearson JS, Rushton JG, Goldstein NP, Gibilisco JA. A psychiatric study of atypical facial pain. Can Med Assoc J 1969;100:286-91.
10Aggarwal VR, McBeth J, Zakrzewska JM, Lunt M, Macfarlane GJ. The epidemiology of chronic syndromes that are frequently unexplained: do they have common associated factors? Int J Epidemiol 2006;35:468-76.
11Takenoshita M, Sato T, Kato Y, Katagiri A, Yoshikawa T, Sato Y et al. Psychiatric diagnoses in patients with burning mouth syndrome and atypical odontalgia referred from psychiatric to dental facilities. Neuropsychiatr Dis Treat 2010;6:699-705.
12Porto F, de Leeuw R, Evans DR, Carlson CR, Yepes JF, Branscum A et al. Differences in psychosocial functioning and sleep quality between idiopathic continuous orofacial neuropathic pain patients and chronic masticatory muscle pain patients. J Orofac Pain 2011;25:117-24.
13Alrashdan MS, Alkhader M. Psychological factors in oral mucosal and orofacial pain conditions. Eur J Dent 2017;11:548-52.
14Lamey PJ, Freeman R, Eddie SA, Pankhurst C, Rees T. Vulnerability and presenting symptoms in burning mouth syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:48-54.
15Hakeberg M1, Hallberg LR, Berggren U. Burning mouth syndrome: experiences from the perspective of female patients. Eur J Oral Sci 2003;111:305-11.
16Gao J, Chen L, Zhou J, Peng J. A case-control study on etiological factors involved in patients with burning mouth syndrome. J Oral Pathol Med 2009;38:24-28
17Kim MJ, Kho HS. Understanding of burning mouth syndrome based on psychological aspects. Chin J Dent Res 2018;21:9-19.
18Kim MJ, Kim J, Kho HS. Comparison between burning mouth syndrome patients with and without psychological problems. Int J Oral Maxillofac Surg 2018;47:879-87.
19Bogetto F, Maina G, Ferro G, Carbone M, Gandolfo S. Psychiatric comorbidity in patients with burning mouth syndrome. Psychosom Med 1998;60:378-85.
20Llewellyn C, Warnakulasuriya S. The impact of stomatological disease on oral health-related quality of life. Eur J Oral Sci 2003;111:297-304.
21Taiminen T, Kuusalo L, Lehtinen L, Forssell H, Hagelberg N, Tenovuo O, Luutonen S, Pertovaara A, Jaaskelainen S. Psychiatric (axis 1) and personality (axis11) disorders in patients with burning mouth syndrome or atypical facial pain. Scandinavian J Pain 2011;14:155–60.
22Aggarwal VR, Macfarlane GJ, Farragher TM, McBeth J. Risk factors for onset of chronic oro-facial pain − results of the North Cheshire oro-facial pain prospective population study. Pain 2010;14:354-59.
23Sardella A, Demarosi F, Barbieri C, Lodi G. An up-to-date view on persistent idiopathic facial pain. Minerva Stomatol. 2009;58:289-99.
24Feller L, Fourie J, Bouckaert M, Khammissa RAG, Ballyram R, Lemmer J. Burning mouth syndrome: aetiopathogenesis and principles of management. Pain Res Manag 2017;2017:1926269.
25Melis M, Secci S. Diagnosis and treatment of atypical odontalgia: a review of the literature and two case reports. J Contemp Dent Pract 2007;8:81-9.
26Galli F, Lodi G, Sardella A, Vegni E. Role of psychological factors in burning mouth syndrome: a systematic review and meta-analysis. Cephalalgia 2017;37:265-77.