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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 28  |  Issue : 1  |  Page : 24-29

Psychosomatic disorders: An overview for oral physician


1 Department of Oral Medicine and Radiology, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Oral Medicine and Radiology, College of Dental Sciences, Davangere, Karnataka, India

Date of Web Publication8-Sep-2016

Correspondence Address:
Nerella Narendra Kumar
Department of Oral Medicine and Radiology, Narayana Dental College and Hospital, Nellore, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.189979

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   Abstract 

A psychosomatic disorder involves both the body and mind. These diseases have physical symptoms originating from mental or emotional causes. Most common causes are stress, anxiety, and depression. When these psychological entities are not perceived properly, it may result in somatic disease due to conversion hysteria. Even the oral and paraoral structures show manifestations of these psychosomatic disorders. The present review has been done from text books and articles relevant to psychosomatic disorders. Relevant articles have been selected and filtered from databases using MeSH terms psychosomatic diseases, oral mucosal diseases, stress, etc., with boolean operators from 1990 till date. This review highlights the important aspects of the psychosomatic diseases affecting oral cavity.

Keywords: Conversion hysteria, oromucosal diseases, psyche, soma, stress


How to cite this article:
Kumar NN, Panchaksharappa MG, Annigeri RG. Psychosomatic disorders: An overview for oral physician. J Indian Acad Oral Med Radiol 2016;28:24-9

How to cite this URL:
Kumar NN, Panchaksharappa MG, Annigeri RG. Psychosomatic disorders: An overview for oral physician. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2019 Mar 26];28:24-9. Available from: http://www.jiaomr.in/text.asp?2016/28/1/24/189979


   Introduction Top


Health is a state of complete physical, mental, and social well-being and not merely the absence of a disease or infirmity.[1] Mental illness affects people of all nations and at all economic levels. One of the primary targets regarding the health of a nation should be to improve the health and social functioning of mentally ill people. Psychiatric disorders affect the behaviour and level of function of an individual.[2]The term psychosomatic is derived from the Greek words psyche and soma. “Psyche” in earlier times meant “soul or mind” which now also implies “behaviour.” “Soma” refers to “physical organism of the body.” It has been known for centuries that psychological/emotional factors are related to many physical illnesses. Traditionally, we regard mind (psyche) and body (soma) to be separate, but where and how do they interact? As an answer, the basic concept in psychosomatic medicine was described clearly by Sigmond Freud, who used the term “conversion hysteria,” which is nothing but change in expressive behavior, i.e. from an unresolved emotion to somatic symptom.[3]

Body and mind influence each other and work as a unit. Most of the diseases are psychosomatic, which involve both the mind and body. Every physical disease has some aspect of mental component, and how an individual reacts and copes with it varies significantly.[3],[4],[5] The mouth represents an organ of the expression of certain 'instinctional' cravings and is charged with a high psychologic potential. Certain diseases which affect the oral mucosa may be the direct or indirect expression of emotions or conflicts. Oral diseases with psychosomatic etiology have long been known in medicine, and mental or emotional factors may act as risk factor that could influence the initiation and progression of oromucosal diseases.[6],[7],[8]


   Relationship between “psyche” and “soma” Top


The relationship between the psyche and soma was explained by two hypotheses: Specific hypothesis suggests that expression of a predetermined disease or illness occurs due to a specific stimulus or conflicts or stressors. This is due to the heightened response of the body, which persists even after the cessation of stimulus which evoked the change and eventually resulting in a disease. Nonspecific hypothesis states that generalized stress create preconditions for a number of not necessarily predetermined diseases. According to this hypothesis, four varieties of reactions occur due to stress viz., healthy normal, neurotic, psychotic, and psychosomatic.[7]


   Stress and Body's Response to Stress Top


Life exists by maintaining homeostasis that is constantly confronted by intrinsic and extrinsic forces such as stressors. Favorable conditions enhance the growth, development, and survival of the species. In contrast, activation of the stress response during threatening situations, which are beyond the normal control of an individual, may result in dysphoria and eventually emotional orsomatic disease.[9],[10],[11] Stress response activates autonomic nervous system, mainly sympathetic, via hypothalamic–pituitary–adrenal (HPA) axis, which secretes corticotropin-releasing factor (CRF) and arginine–vasopressin (AVP), leading to release of adrenocorticotrophic hormone (ACTH), enkephalins, and endorphins. Thus, the stress-response function acts by a positive, bidirectional feedback loop.[12]

Under nonstressful situations, both CRH and AVP are secreted in a circadian, pulsatile manner with approximately 2–3 secretory episodes per hour. In resting conditions, these levels peak in the early morning and gradually decrease as the day progresses. Under stressful situations, these diurnal variations are disrupted. During acute stress, the pulsations of CRH and AVP are enhanced resulting in increased ACTH and cortisol. Various other factors are also released in response to stress, such as angiotensin II, various cytokines, and lipid mediators of inflammation, which act on various components of HPA axis potentiating its activity.[13]


   Classification of Psychosomatic Disorders Top


According to international classification of diseases (ICD-10; WHO-1993):[7]

Psychosomatic disorders are broadly classified depending on whether or not there is tissue damage.

  • “Psychological malfunction arising from mental factors:” It describes a variety of physical symptoms or types of psychological malfunctioning of mental origin, not involving tissue damage, and usually mediated through the autonomic nervous system (ANS). For example, respiratory disturbances, such as hyperventilation and psychogenic cough; cardiovascular disturbances, such as cardiac neurosis; and skin disorders such as pruritis.
  • Mental disturbances or psychic factors of any type that might have played a major part in the etiology of certain physical conditions usually involving tissue damage. For example, psychogenic conditions, such as asthma, dermatitis, eczema, gastric ulcer, mucouscolitis, ulcerative colitis, and urticaria.


According to Zegarelli et al. (1978)[3]

  • Psychoneurotic disorders
  • Psychophysiologic disorders
  • Personality disorder
  • Psychotic disorder.



   Classification of Psychosomatic Disorders Pertaining to Oral Cavity Top


According to McCarthy and Shklar (l980) [14]

  • Oral psychosomatic disease




    1. Lichen planus
    2. Apthous stomatitis
    3. Glossitis and stomatitis areatamigrans


  • Oral diseases in which psychologic factors may play some etiologic role




    1. Erythema multiforme
    2. Mucous membrane pemphigoid
    3. Chronic periodontal diseases




  • Oral infections in which emotional stress serves as a predisposing factor




    1. Recurrent herpes labialis
    2. Necrotizing gingivitis




  • Oral diseases induced by neurotic habits




    1. xLeukoplakia
    2. Biting of oral mucosa (self mutilation)
    3. Physical/mechanical irritation
    4. Dental/periodontal disease produced by bruxism




  • Neurotic oral symptoms




    1. Glossodynia (glossopyrosis)
    2. Dysgeusia
    3. Mucosal pain.






According to Bailoor and Nagesh (2001)[15]

  1. Pain-related disorders





    1. Myofacial pain dysfunction syndrome
    2. Atypical facial pain




  2. Disorders related to altered oral sensation





    1. Burning mouth syndrome
    2. Idiopathic xerostomia
    3. Idiopathic dysguesia




  3. Miscellaneous





    1. Oral lichen planus
    2. Recurrent apthous ulcers
    3. Psoriasis
    4. Erythema multiforme
    5. Cancerophobia
    6. Acute necrotizing ulcerative gingivitis
    7. Anorexia nervosa
    8. Bruxism.




Revised simple working type classification proposed for psychosomatic disorders pertaining to dental practice by Shamim (2014)[16]

  1. Pain related disorders:





    1. Myofascial pain dysfunction syndrome (MPDS)
    2. Atypical facial pain
    3. Atypical odontogenic pain
    4. Phantom pain




  2. Disorders related to altered oral sensation:





    1. Burning mouth syndrome
    2. Idiopathic xerostomia
    3. Idiopathic dysgeusia
    4. Glossodynia
    5. Glossopyrosis




  3. Disorders induced by neurotic habits:





    1. Dental and periodontal diseases caused by bruxism
    2. Biting of oral mucosa (self mutilation)




  4. Autoimmune disorders:





    1. Oral lichen planus
    2. Recurrent aphthous stomatitis
    3. Psoriasis
    4. Mucous membrane pemphigoid
    5. Erythema multiforme




  5. Disorder caused by altered perception of dentofacial form and function:





    1. Body dysmorphic disorder




  6. Miscellaneous disorders:





    1. Recurrent herpes labialis
    2. Necrotising ulcerative gingivostomatitis
    3. Chronic periodontal diseases
    4. Cancerophobia
    5. Delusional Halitosis.





   Common Oral Diseases in Which Psychological Factors Play a Role in Pathogenesis Top


Myofascial Pain Dysfunction Syndrome

Myofascial pain dysfunction syndrome (MPDS) is a muscle-contraction headache-like pain of the face. Patients with MPDS report psychological symptoms such as frustration, anxiety, depression, hypochondriasis, and anger. Maladaptive behaviours such as pain verbalization, poor sleep, dietary habits, lack of exercise, clenching, and bruxism can be seen when pain becomes prolonged.[17] Various studies have been conducted for these factors which found that depression and anxiety play an important role in the perpetuation of symptoms of MPDS.[18],[19]

Atypical Facial Pain

Atypical facial pain is the pain in a limited area of the face which is poorly localized, which does not show any abnormality on investigations. The etiology of atypical facial pain is not known, however, the role of psychological factors are evident.[20] Bailoor and Nagesh conducted a study on 21 female and 7 male cases and a strong relationship was noted between the atypical facial pain and depression and life stressors. The females invariably showed higher intensities of the varied symptomatology. Most responded to antidepressants and multiple counselling sessions.[16]

Atypical Odontalgia

Atypical odontogenic (AO) pain implies toothache of unknown origin. Exact etiology of this condition is unknown. It is considered to be deafferentation neuralgia (causalgia) arising when a dental extraction or pulp extirpation produces either an amputation neuroma or a central degenerative change in the trigeminal nucleus. Some consider AO as vascular/neurovascular in origin. Recently, psychogenic etiology was considered. In a study, 42% of AO patients experienced depression and were confused regarding “did the depression cause the pain or did the pain lead to depression.” Another study supported the concept that at least some of the patients in this category had strong psychogenic component to their symptoms and that depressive, somatization, and conversion disorders have been described as major factors in some patients.[16],[21]

Burning Mouth Syndrome

The term “burning mouth syndrome” (BMS) refers to a chronic oral burning pain diagnosed in the absence of any visible mucosal abnormality or other organic disease. It is considered a multifactorial disease in which neurogenic, local, systemic, and psychogenic factors play a role. The various psychogenic factors implicated in the etiology of BMS are anxiety, depression, compulsive disorders, psychosocial stress, and cancerophobia.[22] The psychological aspects of BMS can be categorized into chronic somatoform dysfunction, chronic vegetative disorders, and chronic pain phenomenon.[23]

Idiopathic xerostomia

Xerostomia is defined as the subjective feeling of oral dryness and it is the result of salivary gland hypofunction. Xerostomia is a common and significant side effect of many commonly prescribed medications. Psychotropic medications are the most common ones. Antidepressants, anticonvulsants, antipsychotics, anticholinergics, and alpha-agonists also cause xerostomia.[24] This can be caused by various systemic diseases such as Sjogren's syndrome, psychological conditions, and physiological changes. Depressive symptoms are often seen in persons experiencing the idiopathic xerostomia.[25]

Idiopathic dysgeusia

Dysgeusia refers to persistent abnormal taste. It can also occur as a result of dry mouth, because adequate saliva is necessary for the function of taste, or it can be secondary to BMS in psychiatric patients. Individuals undergoing cancer therapy (radiotherapy, chemotherapy) usually experience alteration in taste which has a negative impact on the quality of life. In a majority of cases, the exact etiology of dysgeusia cannot be ruled out, and hence, they are considered as idiopathic dysgeusia cases.[26]

Dental and periodontal diseases caused by bruxism

Bruxism is the excessive grinding of the teeth which is a parafunctional activity. This results in many untoward dental problems such as abfractions, hypersensitivity, periodontal destruction, and temporomandibular dysfunction. Exact pathophysiology of bruxism is unknown, however, stress and anxiety are considered to be one of the risk factors. Behavioral problems and potential emotional problems have been found to be potential risk factors for bruxism in children.[3],[16],[27]

Biting of oral mucosa (self-mutilation)

Biting of oral mucosa or tongue can induce severe trauma. Self-mutilation due to biting of the oral mucosa originates as a result of chronic cheek, lip, or tongue biting. Neurotic patients may also traumatize their mouth with foreign objects such as sharp pencils, toothpicks, or fingernails. Greater difficulty may be experienced in recognizing the discrete lesion where local abrasion with a finger nail or sharp instrument may produce a linear palatal or faucial ulcer or several gingival ulcers. Rubbing the alveolar mucosa with a finger leaves an elongated erythematous patch. All of these will be seen to be on the accessible areas of the oral mucosa.[4]

Factitious ulceration or stomatitis artefacta: The appearance of the lesions may vary according to the manner in which they are created. The most common and least troublesome lesion is caused by cheek chewing. Here, usually a young, anxious, neurotic individual continually chews the buccal mucosa producing wide areas of peeling, macerated, hyperkeratinized epidermis. Similarly, lip biting may produce fissures, white areas of hyperkeratosis, or a mucous extravasation cyst which presents as a round, bluish, fluctuant swelling on the lower labial vermilion border which may vary in size from time to time. In old anxious or agitated patients, lip chewing produces varicosities such that the vermilion border becomes curiously cyanotic in appearance.[3]

Classification of self-inflicted injuries:[3]

  1. According to Stewart and KernmohanType A: Injuries superimposed upon pre-existing lesion

    Type B: Injuries secondary to another established habit

    Type C: Injuries of unknown and/or complex etiology

  2. Sneddon (1977) classification:





    1. True malingerers: Injury is consciously aggravated for momentary gain or avoidance of responsibility
    2. Munchausen's syndrome: Psychiatric factitious disorder, illness, or psychological trauma to draw attention, sympathy, or reassurance to themselves
    3. Part of emotional instability, such as a personality disorder where the underlying problem is a disturbance in personal relationships.




Oral lichen planus

Wilson first described lichen planus as a chronic disease affecting the skin, scalp, nails, and mucosa with possible malignant degeneration. It affects 0.9–2.2% of the population. Among all forms, the erosive form is commonly associated with psychic factors. Etiology of the lichen planus is not clear, and various psychic factors contributing to the pathogenesis of lichen planus are stress, anxiety, depression, and increased cortisol levels.[28],[29]

Recurrent aphthous stomatitis

Oral disorders have a considerable impact on the quality of life because they affect the speech, nutrition, physical appearance, self-esteem, and social interaction. Recurrent aphthous stomatitis (RAS) has a negative impact on the quality of life because individuals experience multiple recurrent bouts of burning sensation. Psychological stress may play a role in the manifestation of RAS, and it may serve as a trigger or a modifying factor rather than being a cause of the disease.[30] Previous studies demonstrated the role of stress, anxiety, and depression in the occurrence and intensity of symptoms in RAS. Psychological stress induces immunoregulatory activity by increasing the number of leukocytes at the sites of inflammation, this is a characteristic often observed during the pathogenesis of RAS. It is hypothesized that anxiety could lead to parafunctional oral habits such as lip and cheek biting, which may result in physical trauma that predisposes an individual to RAS.[31],[32]

Pemphigus

Psyche, immunity, and skin are mutually connected such that a pathogenic link between an intensive emotional stress and an autoimmune skin disorder can often be envisaged. Cases of pemphigus triggered by emotional stress are not exceedingly rare. It is very likely that the role of the psychological stress in triggering pemphigus is still underestimated.[33]

Recurrent herpes labialis

Recurrent herpes labialis infections are characterized by multiple outbreaks of herpetic lesions and are estimated to occur in 20–40% of the population. Various factors leading to herpes simplex virus (HSV) recurrences have been described including physical trauma, menstruation, nutritional factors, fever or ultraviolet light. Clinical observations further suggest that psychological factors such as stress or negative affective states may be related to HSV lesions. A positive relationship exists between stressful life events and number of HSV-2 or HSV-1 recurrences. Previous studies have shown that negative moods or emotional discomfort such as unhappiness, anxiety, or depression precede HSV recurrences.[3],[34] Schmidt et al. showed duration of the illness and herpes specific social support were found to be significant moderators between stress and the number of HSV episodes.[35]

Periodontal diseases

The etiology of inflammatory periodontal disease is complex. The etiological significance of biological and behavioral risk factors, including systemic conditions, smoking, oral hygiene, and age has been demonstrated. However, a significant proportion of the variation in disease severity cannot be explained by taking only these factors into consideration. A psychosomatic disorder affects periodontium by two ways:



  1. Self-inflicted injuries seen in these patients
  2. Via disturbance in autonomic nervous system altering tissue response.[36]


Necrotizing ulcerative gingivitis

Necrotizing ulcerative gingivitis (NUG) is a fusospirochetal infection caused by local and systemic predisposing factors. Among these, emotional stress appears to be the most common, although debilitating diseases, nutritional deficiencies, and neurologic diseases also play important roles.[3] Emotional stress may lead to NUG indirectly by an expression of cortisol and catecholamine levels.[37]

Dysmorphophobia

Dysmorphophobia is the belief in a cosmetic defect in a person of normal appearance. The complaint may range from mild unattractiveness to ugliness, and frequently the patient seeks treatment to correct the supposed deformity. Not surprisingly, the face and its components (the teeth, nose, mouth, ears, eyes, and chin) make up a large percentage of structures for which patients seek and undergo cosmetic surgery. These patients often have bizarre complaints regarding their profile or their smile. The disorder is in fact not a phobia at all but an obsession, or a delusion, and hence the more appropriate term of morphodysphoria. Primary dysmorphophobia is a neurotic or psychotic characteristic diagnosed in the absence of any other psychiatric illness. Secondary dysmorphophobia arises secondary to depression, schizophrenia, or anxiety.[4],[38]


   Management of Psychosomatic Disorders Top
[39]

Various treatment modalities tried out are:

  1. Psychotherapy or the remedial influence of mind:



    1. Cognitive–behavioral therapy
    2. Self-observation
    3. Relaxation training
    4. Hypnotherapy
    5. Biofeedback


  2. Pharmacotherapy



    1. Antidepressants
    2. Antianxiety drugs
    3. Antipsychotic drugs.





   Conclusion Top


To conclude, we can say that many diseases manifesting in the oral cavity have a psychological component in their etiology or have some effect of psychologic factors. Further, many psychiatric disorders have an influence upon health of oral tissue. Because stress is increasing in everyday life due to cut-throat competition in every field, there are more chances of dental practitioners encountering patients with such disorders. Hence, one should be familiar with such manifestations, and if accounted, should try to manage them with psychiatrists, whenever needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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