Health-Related Anxiety in the Management of Oral Soreness in an HIVSeropositive Patient

The number of people living with HIV (PLHIV) has been increasing since the first known case in the early 1980s. However, PLHIV can also experience comorbidities, such as health anxiety. In the oral cavity, anxiety is often associated with the etiology of parafunctional habits. Anxiety can be measured using self-administered instruments, such as the Hospital Anxiety and Depression Scale (HADS) and Short-Health Anxiety Inventory (SHAI), which is specifically used in the medical setting. Objectives: We are describing a case of HIV positive patient with health anxiety who presented to the oral medicine clinic in our hospital with a complaint of discomfort on his lateral sides of the tongue. Case Report: A 35-year-old male patient came to the oral medicine clinic complaining of discomfort on his tongue, which presented for one week. The patient was alarmed by two bumps seen on the right lateral side of his tongue and soreness on the left lateral side. Nystatin oral suspension was prescribed by a medical doctor but discontinued by the patient. The patient was positive for HIV and took ART routinely. Extraoral and intraoral examinations showed unremarkable findings except slightly enlarged and erythematous foliate papillae on the left lateral side of the tongue. The patient was prescribed an antiseptic mouth rinse. After several days, his symptoms had dissipated. Since the patient reported anxiety regarding his health and HIV status, we asked the patient to complete the HADS and SHAI self-assessment tools to measure his level of anxiety. The patient was shown to have anxiety using the SHAI (total score = 21). Conclusion: Health anxiety is a condition that an individual misinterprets as a benign bodily sensation. The management of this type of patient involves addressing the local predisposing factor of the oral complaint and maintaining oral hygiene, followed by an evaluation of health anxiety for the basis of referral to a psychological expert.


INTRODUCTION
Since the early 1980s, when HIV was first discovered, the number of people infected with HIV worldwide has been increasing. 1,2 The WHO reported that by the end of 2017, 36.9 million people were living with HIV (PLHIV). 2 The number of PLHIV in Indonesia has also been increasing. The Ministry of Health of Indonesia reported 628,492 cases of HIV nationwide, with 46,300 new cases in 2017.
With the transition of HIV/AIDS from being a terminal to a chronic illness in both the developed and developing countries, studies have shown comorbidities among PLHIV. One of them is anxiety disorder. 3,4 Anxiety is not directly linked with HIV progression, but it is significantly related to somatic symptoms; thus, it can decrease the quality of life of PLHIV. 3 Moreover, individuals with anxiety may also experience health anxiety, a term which explains the tendency to misinterpret bodily variations and ambiguous health-related information. 5 In the oral cavity, a psychological factor such as anxiety is often associated with the etiology of parafunctional habits that can cause temporomandibular disorder, myofascial pain, bruxism, chronic oral mucosal biting/chewing, and scalloped/crenated tongue. [6][7][8] There are various instruments to measure anxiety in medical settings. In this case report, we used the Short Health Anxiety Inventory (SHAI) and Hospital Anxiety and Depression Scale (HADS). The SHAI is used specifically for measuring patient's health anxiety. 9 The questionnaire consists of 18 items with a maximum total score of 54; it can be used on both healthy and physically ill individuals. On the other hand, the HADS is commonly used to measure the psychological distress of anxiety and depression in patients with a physical health problem. There are 14 items in the HADS, which are divided evenly between the anxiety and depression subscales, yielding a maximum possible score of 21 for each scale. 10

OBJECTIVE
This case report highlights the case of health anxiety in an HIV positive patient. The patient reported to our dental hospital with an oral complaint of discomfort on the lateral side of his tongue. After his examination, the patient's complaint turned out to be a benign condition, and the patient showed health-related anxiety.

CASE REPORT
An HIV-positive, 35-year-old male patient reported to the Oral Medicine Clinic in our dental hospital with the chief complaint of tongue discomfort for one week. He denied any modifi cation in diet before the event of tongue discomfort. Initially, the patient realized that there were two bumps on the right lateral side of his tongue and felt soreness on the left side of the lateral tongue. The patient said that the intensity of the discomfort was mild. He quickly visited a general practitioner medical doctor in another hospital and was prescribed nystatin oral suspension and given instructions to apply the topical nystatin on the tongue and swish for 30 seconds, four times a day. He followed the instruction for fi ve days; however, the patient felt that the topical nystatin caused soreness, so he stopped using the nystatin solution and fi nally came to our hospital.
The patient adhered to daily ART, and his most current viral load was undetected with a normal CD4+ cell count (792 cells/µL). His other blood indices were within normal ranges. The patient confessed that being HIV-positive has made him anxious regarding his health, which prompted him to seek medical consultation.
The patient's extraoral f indings were normal. Examination of the patient's intraoral, including the oropharynx, showed moderate oral hygiene with the presence of dental calculus and no unusual fi ndings other than a slight enlargement and redness of the papilla on the left lateral side of his tongue ( Figure  1) and scalloped tongue. We made the fi nal diagnosis for the patient as gingivitis and transient lingual papillitis. We referred the patient to the periodontal clinic for calculus removal and prescribed the patient chlorhexidine gluconate 0.2% oral rinse solution, used twice a day. Several days later, through text communication, the patient said that he has been feeling better.
Following up on the patient's confession of having anxiety regarding his health, we asked him to complete two self-assessment tools, the SHAI and the HADS. For the SHAI, our patient's total score was 21, which put him slightly above anxiety sufferers' mean score of 18.5 (SD ±7.3). This result, however, was under the mean total score of 37.9 (SD ±6.8) in respondents with health anxiety. The patient scored a total of 7 in both anxiety and depression items, which put him within the normal range, but at borderline to mild anxiety and depression. We relayed these results to our patient and asked him to consult with a psychiatric professional. However, the patient refused psychological consultation at this moment.

DISCUSSION
Patients with HIV can present with oral manifestations associated with HIV. Dental health professionals must be familiar with these oral lesions since they can provide diagnostic and prognostic information. 11 Our patient complained of soreness and bumps on the lateral sides of his tongue. After intraoral examination, we concluded that he had transient lingual papillitis, which was most likely caused by local irritation of the dental calculus. This fi nding was not correlated with the patient's HIV status. We managed the patient by informing him of the fi nding and improved his oral hygiene by calculus removal and prescription of chlorhexidine oral rinse, which resolved his complaint. However, another aspect of the patient's wellbeing must be considered, which is his mental health.
It has been reported that there is a strong correlation between mental health and physical health. Disturbances in mental and physical health can affect an individual's capability to work and earn an income, thus, limiting his/her access to healthcare and proper nutrition. Moreover, poor mental health can also impair judgment in making health-related decisions, including lifestyle choices, impacting one's physical health. Finally, limitation in social interaction can be resulted from poor mental and physical health, causing loneliness and isolation which further increased mortality risk. 12 While ART has managed the physical wellbeing of PLHIV, the psychological wellbeing has been neglected in this population. Lowther et al. reported in their review article that PLHIV under treatment may experience psychological distress such as anxiety and depression, 34%-42% and 21%-40%, respectively. These numbers were higher than in other patients with chronic disease. 13 Stigma and psychological distress, such as anxiety and depression, can also create dire consequences since they can affect PLHIV adherence to ART, which determines the success of HIV therapy and prevents infectious transmission. 13,14 Nonetheless, anxiety, and to some extent, health anxiety, can also serve as a positive inf luence, specifically, to PLHIV. The heightened body vigilance motivates PLHIV to seek timely health consultation and treatment, comply with treatment regimens, and cease unhealthy habits and lifestyles. 3 This notion was reflected in our patient. He adhered to his daily ART, which contributed to his physical wellbeing, inferred from his undetected viral load, normal CD4+ cell count, and the absence of HIV-associated oral lesions. However, patients with health anxiety may develop intense anxiety by misinterpreting a benign bodily sensation. It may become a preoccupation and an irresistible urge to seek medical advice and reassurance to the extent of disrupting patients' daily lives. Health anxiety can also be precipitated by misinterpretation of vague health information, including those provided by medical professionals, medical test results, and the media. 5 Care should be taken so that patients do not feel more anxious.
Anxiety and depression in patients are commonly measured with the HADS in a medical setting. This self-assessment was developed in 1983 by Zigmond and Snaith to detect depression and anxiety in patients with physical health problems. 10 The patient in this case report reported having a normal score of 7 for both anxiety and depression, albeit both were borderline. The SHAI is a self-assessment tool for specifically measuring patient's health-related anxiety and has been considered to be reliable and consistent in various samples. 9 The scale can measure both anxiety and health anxiety but was not found to be elevated in patients with physical illness. Thus, it has good sensitivity and specificity. 5,15 Our patient's total score for the SHAI was 21.
According to the developers of SHAI, Salkovskis et al., the mean total score of respondents with anxiety was 18.5 (±7.3), and respondents with hypochondriasis were 37.9 (±6.8). 5 Abramowitz et al. have demonstrated that a cutoff point of 45 using SHAI gave the best sensitivity and specificity to classify patients with hypochondriasis and other anxiety disorders correctly. Patients above the cutoff points were considered to have hypochondriasis. 15 Therefore, it can be suggested that although our patient was not considered to be a hypochondriac, he exhibited anxiety, which could contribute to his complaint of oral discomfort despite the benign and mild change found in his oral cavity.
Last, patients with anxiety or health anxiety would benefit from the prompt referral to a psychologist or psychiatrist since mental health is not the main competency of dentists. A meta-analysis published in 2017 by Cooper et al. reported that among types of treatment, cognitive behavioral therapy was the most effective treatment for health anxiety compared with a treatment-as-usual, waiting list, medication, or other psychological therapies. 16

CONCLUSION
Health anxiety is a condition in which an individual misinterprets a benign bodily sensation. In this case report, we presented a patient who was HIV positive and felt anxious regarding the mild lesion in his oral cavity. Patient management involved addressing the local predisposing factor for the oral complaint and maintenance of oral hygiene, followed by an evaluation of health anxiety for the basis of referral to a psychology practitioner.

PATIENT CONSENT
The patient gave his consent regarding the publication of this case report.

ACKNOWLEDGMENT
Authors thanked Dr. Jiemi Ardian for discussion regarding anxiety and Prof. Paul Salkovskis for advising and permitting the use of SHAI in this case report.