Anxiety, depression, and pain in burning mouth syndrome: first chicken or egg?

BACKGROUND: Burning mouth syndrome (BMS) is an idiopathic and chronic pain condition for which patients may experience high levels of pain, anxiety, and depression. So far, it has not yet been well investigated whether specific psychiatric features (anxious traits, personality disorder, or somatization) may play a role in the BMS pathogenesis or whether some BMS symptoms, or BMS itself, may cause secondary psychiatric symptoms. OBJECTIVE: The aim of this study was to evaluate the relationship between pain, depression, and anxiety in BMS and healthy patients in order to hypothesize a possible underlying pathogenetic model. METHODS: Fifty-three patients with BMS and 51 healthy volunteers matched for sex and age were enrolled. All patients underwent a physical examination, laboratory screening tests, and psychiatric assessment with the following instruments: Visual Analog Scale, the Hamilton Rating Scale for Depression, the State-Trait Anxiety Inventory Form Y 1-2 (STAI Y1-Y2), and the Symptom Checklist-90-Revised (SCL-90-R). RESULTS: BMS patients and healthy volunteers showed a statistically significant difference in psychiatric features: Regression analysis showed that pain is affected by depression (R = 0.373; R(2) corrected = 0.123; F = 8.563; P < .005), and depression is affected by anxiety (R = 0.512; R(2) corrected = 0.248; F = 18.519; P < .001). BMS patients have statistically significant higher scores of anxiety (STAI Y1, P = .026 and STAI Y2, P = .046) and depression (P < .001), and higher SCL-90-R scores on somatization (P = .036) and hostility dimensions (P = .028) than the control group. CONCLUSIONS: We may hypothesize that anxiety could determine a secondary demoralization in BMS patients (depression) and depressive symptoms could contribute to pain, accordingly. Therefore, pain could be a somatic feature of depression. Our findings provide an example of a possible pathogenetic model for BMS.

Burning mouth syndrome responsive to duloxetine: a case report.

INTRODUCTION: Burning mouth syndrome (BMS) is a chronic, idiopathic, intraoral mucosal pain condition in the absence of specific oral lesions and systemic disease. Among evidence-based pharmacological treatments for this disorder, topical and systemic clonazepam, levosulpiride, selective serotonin reuptake inhibitors have been used with partial results. CASE: We report a case of a 65-year-old otherwise healthy woman with a 3-year history of oral burning. Clinical and laboratory evaluations allowed us to make a diagnosis of burning mouth syndrome. She was treated with duloxetine (60 mg p.o. qd), a selective serotonin, and norepinephrine reuptake inhibitor, obtaining a complete remission of symptoms, evaluated via standardized clinical rating scales, and an improvement of her quality of life and level of functioning. DISCUSSION: The pathogenesis of BMS still remains unclear. Recently, it has been suggested an underlying neuropathic mechanism, demonstrating a dysfunction in the trigeminal nociceptive pathways at peripheral and/or central nervous system level. The rationale behind the administration of duloxetine resides in its central mechanism of action, and analgesic effects previously demonstrated in diabetic peripheral neuropathy, and fibromyalgia. Also, it has been shown to reduce painful physical symptoms associated with depression. CONCLUSION: We hypothesize that duloxetine might represent a useful, effective, and additional therapeutic option in the treatment of BMS.

First contact with psychiatric services: who leaves and who remains.

OBJECTIVE: The objective of this study was to obtain information on patients in their first contact with community mental health departments in the south of Italy, particularly on dropout patients leaving care without a previous agreement. METHOD: A 3-month cohort of 265 "first-contact" psychiatric patients assisted at four different community mental health centers (CMHCs) was examined and followed up at 6 months. RESULTS: The overall dropout rate after 6 months was 38.7%; it was higher for patients receiving pharmacological therapy alone and for patients seeking help on their own initiative, whereas physician-referred patients showed a lower dropout rate. More severely ill patients, as evaluated by physicians, showed dropout rates lower than those of patients "rating" themselves as severely ill. CONCLUSIONS: To lower dropout rates in CMHC settings, physicians should be provided with more concrete support in the patient selection and referral process. Greater focus should be placed on patients' motivational aspects and on their perceptions of their own symptom severity, as well as on the risks of dispensing "easy" solutions such as pharmacological therapy alone.