Original articleSicca symptoms are associated with similar fatigue, anxiety, depression, and quality-of-life impairments in patients with and without primary Sjögren's syndrome
Introduction
Primary Sjögren's syndrome (pSS) is a chronic autoimmune disorder that decreases the water content of salivary and lacrimal gland secretions, thereby inducing dryness of the mouth (xerostomia) and eyes (keratoconjunctivitis sicca). Chronic lymphocytic infiltration of the affected glands is the histological hallmark of pSS. A wide variety of clinical manifestations, including neurological disorders [1], may develop, and autoantibodies may be produced. The prevalence of pSS is debated in the literature [2] and a recent meta-analysis reported a global worldwide prevalence of 0.06% [3] and 0.04% when taking into account only population-based studies performed in Europe [4]. Adult women are predominantly affected. In addition to disabling symptoms related to the oral and ocular dryness, pSS causes fatigue [5], [6], which severely impairs quality of life (QoL) [7], [8]. Diffuse pain and fibromyalgia are present in pSS patients [9], with a frequency similar to that seen in systemic lupus erythematosus (SLE) [6]. None of these symptoms are specific of pSS and the prevalence of dry eye and/or dry mouth symptoms varies from 5% to more than 30% depending on the population studied [10]. They are particularly common in elderly individuals, with a prevalence of dry eye or dry mouth of up to 27% after 65 years [11], [12]. Thus, pSS accounts for only a small part of the patients complaining from oral or ocular dryness. Objective oral and ocular dryness without pSS is known as Dry Eyes and Mouth Syndrome (DEMS) or Sicca, Asthenia, and Polyalgia Syndrome (SAPS) [13], [14].
Most patients with pSS report dryness-related discomfort and severe fatigue responsible for QoL impairments, depression, and anxiety. Abnormalities in several QoL indexes have been reported in patients with pSS [15], [16], [17]. The 36-item Short Form Health Survey (SF-36) is widely used to assess QoL in patients with pSS. The fatigue frequently reported by the patients and used as an inclusion criteria for therapeutic trials of rituximab [18], [19] can be easily self-evaluated using a visual analog scale (VAS). However, specific tools have been validated, such as the Multidimensional Fatigue Inventory (MFI). In patients with pSS, studies have shown fatigue on all MFI dimensions [5], [20]. Depression and anxiety can also be assessed using the validated Hospital Anxiety and Depression Scale (HADS). Two studies indicated that depression and anxiety were more common in patients with pSS than in healthy controls or patients with rheumatoid arthritis [17], [21].
Sicca syndrome without pSS can induce psychological disturbances consisting chiefly in anxiety and depression, which in turn adversely affect QoL [22]. Very few studies have compared QoL, fatigue, anxiety, and depression in patients with pSS and in patients with sicca syndrome but no pSS [7], [23], [24], [25].
Here, our objective was to compare QoL, fatigue, anxiety, and depression in patients with sicca syndrome with or without pSS. To this end, we used validated tools to assess patients with suspected pSS included in the Brittany cohort.
Section snippets
Study population
Between November 2006 and December 2013, 241 patients with suspected pSS were included prospectively in the single-center Brittany cohort. The same standardized investigations were performed in all patients. Inclusion criteria were subjective oral and/or ocular dryness, recurrent or bilateral parotid gland swelling, and/or extraglandular symptoms or laboratory abnormalities suggesting pSS.
Written informed consent was obtained from all participants before inclusion. The study was conducted in
Patient characteristics (Table 1)
Of the 241 patients, 95 (39.4%) completed the questionnaires, including 55 (57.9%) with pSS and 40 (42.1%) without pSS. Among the 55 patients with pSS according to the physician, 48 (87%) fulfilled AECG criteria, compared to none of the patients without pSS. Concordance between AECG criteria and the physician diagnosis was good (kappa coefficient = 0.85). Diagnoses in the group without pSS were idiopathic sicca syndrome (n = 26), connective tissue diseases (n = 8; SLE, n = 3; rheumatoid arthritis, n = 2;
Discussion
Oral and ocular dryness is associated with QoL impairments in both patients with autoimmune disorders and those with idiopathic sicca [7], [25]. We compared QoL, fatigue, depression, and anxiety in patients referred to a specialized center for suspected pSS. The patients completed three validated questionnaires. Alterations in the results of all three questionnaires were found in the groups with and without a diagnosis of pSS.
The study participation rate of only 39.4% may be related to several
Disclosure of interest
The authors declare that they have no competing interest.
References (38)
- et al.
Is there specific neurological disorders of primary Sjögren's syndrome?
Joint Bone Spine Rev Rhum
(2015) - et al.
Ultrasound assessment of the entheses in primary Sjögren syndrome
Ultrasound Med Biol
(2013) - et al.
The French SF-36 health survey: translation, cultural adaptation and preliminary psychometric evaluation
J Clin Epidemiol
(1998) - et al.
Three-dimensional structure of the Hospital Anxiety and Depression Scale in a large French primary care population suffering from major depression
Psychiatry Res
(2001) - et al.
Epidemiology of Sjögren's syndrome: where are we now?
Clin Exp Rheumatol
(2007) - et al.
Epidemiology of primary Sjögren's syndrome: a systematic review and meta-analysis
Ann Rheum Dis
(2014) - et al.
Is primary Sjögren's syndrome an orphan disease? A critical appraisal of prevalence studies in Europe
Ann Rheum Dis
(2015) - et al.
Fatigue in primary Sjögren's syndrome
Ann Rheum Dis
(1998) - et al.
Measurement of fatigue and discomfort in primary Sjogren's syndrome using a new questionnaire tool
Rheumatol Oxf Engl
(2004) - et al.
Quality of life and psychological status in patients with primary Sjögren's syndrome and sicca symptoms without autoimmune features
Arthritis Rheum
(2006)
Effects of rituximab therapy on quality of life in patients with primary Sjögren's syndrome
Clin Exp Rheumatol
The differential diagnosis of dry eyes, dry mouth, and parotidomegaly: a comprehensive review
Clin Rev Allergy Immunol
Prevalence of symptoms of dry mouth and their relationship to saliva production in community dwelling elderly: the SEE project. Salisbury Eye Evaluation
J Rheumatol
Dry eye and dry mouth in the elderly: a population-based assessment
Arch Intern Med
Dry eyes and mouth syndrome – a subgroup of patients presenting with sicca symptoms
Rheumatol Oxf Engl
Dry eyes and mouth syndrome or sicca, asthenia and polyalgia syndrome?
Rheumatol Oxf Engl
Health-related quality of life, employment and disability in patients with Sjogren's syndrome
Rheumatology
Health-related quality of life in primary Sjögren's syndrome, rheumatoid arthritis and fibromyalgia compared to normal population data using SF-36
Scand J Rheumatol
Evaluation of quality of life in relation to anxiety and depression in primary Sjögren's syndrome
Mod Rheumatol
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