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INTRODUCTION: Recent epidemiological and longitudinal studies indicate that attachment relationships may be a significant predictor of physical health in adulthood1 . Empirical studies have found that insecure attachment orientations are associated with higher physical and psychological symptom reporting both in non-clinical and clinical samples2 . Recurrent aphthous stomatitis (RAS) is one of the most common oral mucosal diseases. It is diagnosed clinically with painful, recurrent, yellowish white or grey, single or multiple, round or oval ulcers with erythematous margins, mainly confined to non–keratinized oral mucosa. Despite its worldwide occurrence and the extensive amount of research that has been devoted to the subject, the etiology of the disease is not well understood. Psychological-emotional factors are considered as one of the major predisposing factors. We hypothesized that RAS patients’ physical status would be negatively associated with scores on adult attachment. As far as we know, this is the first study to compare the parental bonding of the RAS patients with healthy controls, also taking into consideration their state of anxiety and depression.
METHODS: The study subjects were recruited from the Ear, Nose and Throat (ENT) Department of Kahramanmaraş City State Hospital. All of the study subjects signed an informed consent form according to the Helsinki II Declaration, obtained from the Ethical Committee of the University of Kahramanmaraş, Turkey, prior to the launch of the study. All the patients and the individuals of the control group were aged 18 or above, ensuring that they could understand and score the questionnaires correctly. Included in this study were 34 patients with RAS who were not undergoing any psychiatric and medical treatment, as well as 34 age- and gender-matched healthy individuals as the control group. Both the experimental and the control groups were resident in the same geographic area and had the same socioeconomic status. Patients were evaluated with sociodemographic form, Beck Depression Inventory, State-Trait Anxiety InventoryState form (STAI-S), State-Trait Anxiety Inventory-Trait form (STAI-T), Short Form of Inventory of Parent and Peer Attachment (IPPA-Armsden ve Greenberg 1987) which was developed by Raja, McGee & Stanton (1992). The IPPA short form is composed of “trust”, “communication” and “alienation” factors, and each one of them contain 4 sub-items which were completed for mother and father separately. Anxiety levels were measured using Spielberger’s STAI (1983), which evaluates both trait anxiety as a general aspect of personality (STAI-T) and state anxiety as a response to a specific situation (STAI-S). The sensitivity of the STAI-S and STAI-T scale to general stress has been shown consistently in research of emotional reactions. STAI is unique in its measurement of anxiety independently of depression and includes 40 questions for the assessment of both trait anxiety (20 questions) and state anxiety (20 questions). Each item is scored on a four-point scale, with response categories varying according to the nature of the question. For both levels, the range of values falls between 20 and 80, with a high score indicating a higher level of anxiety. Beck Depression Inventory is in common use as a self-report scale to assess the severity of depression. The BDI was developed to determine the type and the degree of depression based on symptoms and takes the form of a questionnaire containing 21 items rating emotional, cognitive, motivational and physiological symptoms, among others. The data were analyzed using SPSS version 20.0. All data were first analyzed for normality of distribution using the Kolmogorov–Smirnov test of normality. When comparing differences between groups, unpaired t test was used for normally distributed variables. Correlation analysis was performed by Pearson or Spearman correlation test. Results were considered statistically significant at p<0.05.
RESULTS: The mean age of the patient group was 35.68±13.5. 53% (n=18) were women, 47% (n=16) were men. STAI-S scores were significantly higher in the RAS patients when compared to the healthy controls (p=0.023). In contrast, the scores of STAI-T of the patients did not significantly differ from the control group. Patients with a Beck-D score of higher than 16 were regarded as depressive. Accordingly, 35.2% (n=12) of the patient group were depressive and 64.7% (n=22) were not. There was no significant difference between the patients and the control groups according to depressive state. On the other hand, depressive patients had significantly higher scores in STAI-S (p=0.046) and lower scores in the factors of alienation from father (p=0.011) and trust in father (p=0.002) in IPPA when compared to the non-depressive patients with RAS. There was no relationship between the sub-items and total scores of IPPA and STAI-S or STAI-T scores.
DISCUSSION: The definitive etiology and pathogenesis of RAU is still unclear, although several factors are generally considered as essential in the development of RAU, such as nutrition, drugs, food hypersensitivity, hormones, infections, trauma, tobacco, and psychological stress3 . A correlation between psychological status and RAU has commonly been reported. For instance, Albanidou-Farmaki et al. came up with findings similar to our research, claiming that anxiety as both a trait and state could play a role in patients with RAU, reporting significant differences between patients with RAU and controls. Soto-Araya et al. reported that anxiety and stress were significantly connected with RAU, unlike depression. Cohen also found a high incidence of RAU in patients under stressful situations. According to our study, STAI-S scores were significantly higher in the RAS patients when compared to the healthy controls, similar to the mentioned literature. But there was no significant difference between the patients and the control groups according to the depressive state. In this study, we could not find any difference between the patients and the control group according to their parental bonding. Our findings reveal that the patients with RAS showed higher levels of state anxiety than the healthy controls, confirming the findings of the previous studies4,5. State anxiety, alienation from father and trust in father sub-items were significantly worse in RAS patients with comorbid depression than the patients without depression. Future research is needed to clarify whether depression comorbidity is the result or cause of these factors.