|Year : 2022 | Volume
| Issue : 2 | Page : 198-202
A comparative study on the evaluation of stress in patients with lichen planus and normal healthy individuals using hospital anxiety and depression questionnaire, depression anxiety stress scale 21, and state-trait anxiety inventory
Abhik Sikdar, S Bhuvaneshwari, NC Sangamesh, Silpiranjan Mishra, Atul Anand Bajoria, Snehjyoti Jha
Department of Oral Medicine and Radiology, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha, India
|Date of Submission||07-Oct-2021|
|Date of Decision||14-May-2022|
|Date of Acceptance||20-May-2022|
|Date of Web Publication||22-Jun-2022|
Kalinga Institute of Dental Sciences KIIT is Deemed to be University, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Lichen planus is an idiopathic chronic inflammatory mucocutaneous disease that frequently involves the oral mucosa and skin. It has been proposed that psychological factors like high stress and anxiety levels have a strong association with lichen planus. Estimation of the stress level in patients with oral lichen planus. Aims: To estimate the stress in patients with Oral Lichen Planus by Hospital Anxiety and Depression Questionnaire, Depression Anxiety Stress Scale 21, and State-trait anxiety inventory and compare these with normal healthy individuals. Methods and Material: Twenty oral lichen planus patients and twenty normal subjects were included in the study. Every individual gave the hospital Anxiety and Depression Questionnaire, Depression Anxiety Stress Scale 21, and State-trait anxiety inventory. Statistical Analysis Used: Data obtained were analyzed with SPSS software 26. The findings of various parameters were evaluated and analyzed statistically using Mann Whitney U test. Results: Hospital Anxiety and Depression Questionnaire, State-trait anxiety inventory, Depression Anxiety Stress Scale 21 scores were significantly higher in the oral lichen planus group than in normal individuals. Conclusions: Psychological factors like anxiety and depression play a major role in the pathogenesis of OLP, and non-invasive procedures like the Hospital Anxiety, and Depression Questionnaire, Depression Anxiety Stress Scale 21, and State-trait anxiety inventory scores can be used as a useful indicator to estimate stress levels in OLP patients.
Keywords: Depression anxiety stress scale 21 and state-trait anxiety inventory, hospital anxiety and depression, lichen planus, stress
|How to cite this article:|
Sikdar A, Bhuvaneshwari S, Sangamesh N C, Mishra S, Bajoria AA, Jha S. A comparative study on the evaluation of stress in patients with lichen planus and normal healthy individuals using hospital anxiety and depression questionnaire, depression anxiety stress scale 21, and state-trait anxiety inventory. J Indian Acad Oral Med Radiol 2022;34:198-202
|How to cite this URL:|
Sikdar A, Bhuvaneshwari S, Sangamesh N C, Mishra S, Bajoria AA, Jha S. A comparative study on the evaluation of stress in patients with lichen planus and normal healthy individuals using hospital anxiety and depression questionnaire, depression anxiety stress scale 21, and state-trait anxiety inventory. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Jul 1];34:198-202. Available from: https://www.jiaomr.in/text.asp?2022/34/2/198/347925
| Introduction|| |
Lichen planus is an inflammatory disease that affects the oral mucosa and skin. It has a prevalence rate of 0.5-2.2% and occurs more commonly in women than men, with a mean age of 55 years. It is considered a potentially malignant condition with a malignant transformation rate of 0.4-5.6%. In recent years, it is seen that the immune system has a role in the development of the disease. Several investigators proposed that psychological factors like high stress and anxiety are strongly associated with lichen planus.,,,,
Oral lesions, based on the extent of subepithelial inflammation, six types of clinical manifestations are evident, - reticular, papular, plaque-like, bullous, erythematous, and ulcerative.
The present study proved the relationship between stress in patients suffering from lichen planus by non-invasive methods since many patients hesitate to undergo invasive procedures. This study was intended to determine that the stress level in lichen planus patients is higher than in healthy individuals.
| Aim of the Study|| |
To estimate the stress levels in patients with OLP by Hospital Anxiety and Depression (HAD) Questionnaire, Depression Anxiety Stress Scale (DASS), and State-Trait Anxiety Inventory (STAI) and compare these with normal healthy individuals. This study assessed and demonstrated the correlation between the different parameters inducing stress levels in patients suffering from oral lichen planus. The questionnaire mentioned above has been previously used in separate studies—however, the present study aimed at establishing a co-relation among them.
| Subjects and Methods|| |
A case-control study involving 40 patients was carried out in the Oral Medicine and Radiology department. Routine patients visiting the outpatient department were incorporated into the study. Written informed consent was taken from each individual, and they were included with voluntary participation.
The principles of the Helsinki Declaration were followed. The Institutional Ethics Committee approved the study (Letter no. KIIT/KIMS/IEC/171/2019 dated 08.11.2019).
Method of Collection of Data (Including sampling Procedure, if any):
Sample Size Determination:
Type: Empirical Data Used.
Comparisons of the MEAN DIFFERENCE between the different groups were taken into consideration.
Level of significance = 5%, Power = 80%, Type of test = two-sided
Formula of calculating sample size is
n = sample size required in each group,
r = Correlation coefficient between the groups = 0.3604 (data from previous studies)
d = Expected mean difference between the groups = 7.3 (data from previous studies)
SD = Standard deviation
Zα/2: This depends on the level of significance; for 5%, this is 1.96
Zβ: This depends on power; for 80%, this is 0.84
Based on the above formula, the sample size required per group is 20.
Hence, the total sample size required was 40.
- Patients diagnosed with oral lichen planus
- Lichen Planus patients with or without skin involvement.
- Patients with no other tobacco-associated lesions.
- Reticular, Plaque like Papular, Bullous, Erythematous, Ulcerative clinical subtypes of Oral lichen Planus
- Patients taking medications for systemic diseases such as cardiovascular disease, renal dysfunctions
- Quid-induced lichenoid reactions were excluded from the study
- Tobacco chewing habit
- Pregnant and lactating women
- Other systemic illness.
Method of Collection of Data:
Patients were divided into two groups:
Group A – 20 patients diagnosed with Oral Lichen Planus.
Group B – 20 individuals with no oral lesions
The procedure involved, including Materials/Armamentarium, used:
Recording of the detailed case history of the patient and oral examination using diagnostic instruments (mouth mirror and probe, in [Figure 1]) were done.
Clinical diagnosis of Oral Lichen Planus was followed by an incisional biopsy (armamentarium used in [Figure 1]) under local anesthesia [Figure 2] to confirm it histopathologically.
|Figure 2: Graphical representation of gender distribution of the population|
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Each of the patients was asked to fill up a Questionnaire. The questions were translated into regional language for patients who could not read English. Scoring was done separately for anxiety and depression, and they were assigned as normal (0-7), borderline abnormal (8-10), and abnormal (11-21).
DASS 21 questionnaire has three subscales that measure depression, anxiety, and stress.
STAI is a scale that measures trait anxiety (general personality) and state anxiety (response to a particular situation. It is scored on a four-point scale in which the response criteria vary according to the type of question.
Data obtained were analyzed with SPSS software 26. The findings of various parameters were evaluated and analyzed statistically using Mann–Whitney U test.
| Results|| |
- Demographic Characteristics
The mean age of the Case Group was 44.60 ± 2.06, and that of the Control Group was 44.35 ± 1.48. No significant difference was noted in age between the case and control group. There were 40% male population and 60% female in the case group, whereas 35% male population and 65% female in the control group. The demographic characteristic of the study population has been given in [Table 1]. The graphical representation of the demographic characteristics has been presented in [Figure 1] and [Figure 2].
- Hospital Anxiety and Depression (HAD)
HAD scores for the Case and Control groups have been given in [Table 2]. The mean score of the HAD levels in the case group was 7.60 ± 1.60, and that of the control group was 4.90 ± 1.16. The difference between mean scores is statistically significant (p < 0.0001). The same has been graphically represented in [Figure 3].
- Depression Anxiety Stress Scale (DASS)
|Figure 3: Graphical representation of Hospital Anxiety and Depression (HAD) scores for Case and Control group|
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|Table 2: Hospital Anxiety and Depression scores for Case and Control group|
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DASS scores for the Case and Control groups have been given in [Table 3]. The mean scores of the Depression, Anxiety, and Stress levels in the case group were 12.54, 11.15, and 8.69, respectively. The mean scores of the Depression, Anxiety, and Stress levels in the control group were 7.69, 6.62, and 3.85, respectively. Significantly higher Depression, Anxiety, and Stress scores were noted in the lichen planus group than in the control group. The same has been graphically represented in [Figure 4].
- State-Trait Anxiety Inventory (STAI)
|Figure 4: Graphical representation of Depression Anxiety Stress Scale (DASS) scores for Case and Control group|
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STAI scores for the Case and Control groups have been given in [Table 4]. The case group's State Anxiety and Trait Anxiety mean scores were 48.85 and 49.77, respectively. The mean scores of the control group's State Anxiety and Trait Anxiety were 39.45 and 38.51, respectively. The same has been graphically represented in [Figure 5].
|Figure 5: Graphical representation of State-Trait Anxiety Inventory (STAI) scores for Case and Control group|
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|Table 4: State-Trait Anxiety Inventory scores for Case and Control group|
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| Discussion|| |
Lichen planus is a mucocutaneous disease that involves the oral mucosa and skin. It has a prevalence rate of 0.5-2.2%. It occurs more commonly in females than males, with a mean age of 55 years. Lesions often occur bilaterally and appear as a mixture of subtypes. In recent years, studies have shown that stress and anxiety are among the etiologic factors of lichen planus.,,
In the present study, estimation of anxiety and depression was done using the hospital anxiety depression scale, which was compared between two groups comprising lichen planus patients and normal healthy individuals. The mean hospital anxiety & depression scores were markedly higher in lichen planus patients.
In our study, the age range of OLP patients was 31-59 years, with a mean age of 44.6 ± 2.06 years, which was in close accordance with a study done by Chaitanya et al., Subash et al., Jose et al. The mean age was higher in studies conducted by Kalkur et al. (50.6 years), and Sandhu et al. (56.2 years). In contrast, the mean age was lower in a study done by Shah et al. (40.1 years).
Out of 20 OLP patients in our study, 60% were females compared to 40% males, similar to studies conducted by Krasowska et al. Manolache et al. (76% females), Shah et al. (56.7% females), Sandhu et al. (53.6% females), Jose et al. (66.6% females). On the contrary, in studies conducted by Shetty et al. (73.6% males), and Munde et al. (male to female ratio 1.61:1) males outnumbered females.
In the present study, the HAD Scale developed by Zigmond and Snaith was used to assess the psychological profile of OLP patients. This screening tool comprised a quick, simple questionnaire consisting of 14 questions, out of which 7 reflected anxiety and 7 depression.
In the present study, statistical analysis of HAD scores showed a notable variation between the study and control group. The HAD scale was also used by S Chaudhary et al., Shetty et al. & Sandhu et al. to evaluate stress levels in the study and control group. Mean anxiety, depression; stress levels were higher in the case group than in the control, the same relation as the current study.
McCartan et al. investigated anxiety and depression in 50 OLP patients using the Cattell 16 PF Questionnaire and HAD scale. There was no statistically significant association between OLP patients and anxiety or depression. The results of this study were inconsistent with the current study.
Shah et al. used the Depression Anxiety and Stress Scale (DASS) to assess the personality profile of OLP patients; they concluded that stress contributed to the pathogenesis of OLP, which was similar to the results of our study.
Kalkur et al. conducted a psychometric evaluation using the Depression Anxiety and Stress Scale (DASS)-42 questionnaire. They observed that the lichen planus group demonstrated a higher level of Depression, Anxiety, and Stress levels when compared to the control group. This was by the present study.
Valter et al. conducted a comparative evaluation between symptomatic and asymptomatic OLP patients with the control group using the STAI and observed no differences in the level of anxiety, depression, and stress between the two stages of OLP disease. Still, both groups had significantly higher values when compared to the healthy controls, which were in the present study.
Alves et al. conducted a study for the emotional assessment of patients with oral lichen planus using the STAI and observed that the mean scores for the lichen planus patients were significantly higher than the control group, which was by the present study.
Although the results of the present study were by most of the available literature, few studies showed a difference in results which may be due to the difference in the study population, the ethnic diversity of the study groups, geographic distribution, genetic predisposition of the participants, and sample size of the study population.
Limitations and future scope of the study
The present study has been conducted to estimate the stress levels in lichen planus patients compared to healthy individuals. The major limitation of the study was the inadequate sample size. Future studies can be conducted with a larger sample size for a better conclusive result. A more extensive and subjective evaluation of the various parameters such as anxiety and stress can be done using other more elaborate questionnaires and scales to better assess the correlation between the said parameters in further studies.
| Conclusion|| |
After a careful evaluation and relative comparison with other studies, it was observed that oral lichen planus occurs in the age group of 31-60 years. Hospital anxiety-depression scores in oral lichen planus patients were significantly higher than in the control group. Thus, we can conclude that psychological factors like anxiety and depression play a major role in the pathogenesis of OLP. Results of the present study suggest that stress has a positive correlation with oral lichen planus. Hence, stress management and patient counseling should be included in the treatment protocol for oral lichen planus patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Estimation of stress levels in lichen patients was done to assess the etiology of lichen planus. Results show that stress has a role in the pathogenesis of lichen planus.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Michael Glick. S. Burket's Oral Medicine. 12th
ed. USA: People's Medical Publishing House. 2015. p. 104-110.
Van Dis ML, Parks ET. Prevalence of oral lichen planus in Brazilian patients with cutaneous lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol 1995;79:696–700.
Meij EH van der. A review of the recent literature regarding the malignant transformation of oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:311–6.
Ivanovski K, Nakova M, Warburton G, Pesevska S, Filipovska A, Nares S, et al
. Psychological profile in oral lichen planus. J Clin Periodontol 2005;32:1034–40.
Chaudhary S. Psychosocial stressors in oral lichen planus. Aust Dent J 2004;49:192–5.
Hampf BG, Malmström MJ, Aalberg VA, Hannula JA, Vikkula J. Psychiatric disturbance in patients with oral lichen planus. Oral Surg Oral Med Oral Pathol 1987;63:429–32.
McCartan. Psychological factors associated with oral lichen pianus. J Oral Pathol Med 1995;24:273–5.
Rojo-Moreno JL, Bagán JV, Rojo-Moreno J, Donat JS, Milián MA, Jiménez Y. Psychologic factors and oral lichen planus. A psychometric evaluation of 100 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:687–91.
Chaitanya C, Reshmapriyanka, Pallav K. Serological and psychological assessment of patients with oral lichen planus using serum cortisol levels and has questionnaire—A case-control study. J Popul Ther Clin Pharmacol 2020;27:19–27.
Subhash S, Bindu RS, Nair PS, George AE. A study of serum cortisol levels in patients with lichen planus. J Skin Sex Transm Dis 2022;4:57–62.
Jose S, Mukundan JV, Johny J, Tom A, Mohan SP, Sreenivasan A. Estimation of serum cortisol levels in oral lichen planus patients with electrochemiluminescence. J Pharm Bioallied Sci 2019;11:S265–8.
Kalkur C, Sattur AP, Guttal KS. Role of depression, anxiety and stress in patients with oral lichen planus: A pilot study. Indian J Dermatol 2015;60:445–9.
] [Full text]
Sandhu S V, Sandhu JS, Bansal H, Dua V. Oral lichen planus and stress: An appraisal. Contemp Clin Dent 2014;5:352–6.
] [Full text]
Shah B, Ashok L, Gp S. Evaluation of salivary cortisol and psychological factors in patients with oral lichen planus. Indian J Dent Res 2009;20:288–92.
] [Full text]
Krasowska D, Pietrzak A, Surdacka A. Psychological stress, endocrine and immune response in patients with lichen planus. Int J Dermatol 2008;21:457–87.
Manolache L, Benea V. Lichen planus patients, and stressful events. J Eur Acad Dermatol Venereol 2008;22:437–41.
Shetty S, Thomas P, Chatra L, Shenai P, Rao P. An association between serum cortisol levels in erosive and non-erosive oral lichen planus patients. Web Med Cent Dent 2010;1:280–6.
Munde AD, Karle RR, Wankhede PK, Shaikh SS, Kulkarni M. Demographic and clinical profile of oral lichen planus : A retrospective study. Contemp Clin Dent 2013;4:181–5.
] [Full text]
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–70.
Valter K, Boras VV, Buljan D, Juras DV, Susic M, Panduric DG, et al
. The influence of psychological state on oral lichen planus patients. Acta Clin Croat 2013;52:145-9.
Alves MGO, Carvalho BFC, Balducci I, Cabral LAG, Nicodemo D, Almeida JD. Emotional assessment of patients with oral lichen planus. Int J Dermatol 2015;54:29-32.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]