Sleep Breath
DOI 10.1007/s11325-013-0928-y
ORIGINAL ARTICLE
Psychiatric disorders and symptoms in children
and adolescents with sleep bruxism
Serhat Türkoğlu & Ömer Faruk Akça & Gözde Türkoğlu &
Müzeyyen Akça
Received: 1 June 2013 / Revised: 29 September 2013 / Accepted: 9 December 2013
# Springer-Verlag Berlin Heidelberg 2013
Abstract
Objective This study examines state-trait anxiety, anxiety sen-
sitivity (AS), depressive symptom levels, and psychiatric dis-
orders in children and adolescents with sleep bruxism (SB).
Subjects and method Thirty-five patients (aged 8–17 years)
with a diagnosis of SB and 35 healthy controls were included
in the study. All participants were evaluated for psychiatric
disorders using a structured clinical interview and completed
self-report questionnaires.
Results At least one psychiatric disorder was present in
42.9 % of the patient group and 17.1 % of the control group
(p<0.05). Trait and state anxiety, anxiety sensitivity, and the
severity of depression symptoms were also higher in the SB
group (p<0.05). After the multivariate analysis, the associa-
tions between state and trait anxiety, depression, and SB
became statistically insignificant, while the association with
anxiety sensitivity persisted.
Conclusion This study suggests that SB is related to AS,
regardless of the severity of anxiety or depressive symptoms.
This study was accepted for poster presentation in 15th International
Congress of ESCAP (European Society for Child and Adolescent
Psychiatry), Dublin, 2013.
S. Türkoğlu (*)
Department of Child and Adolescent Psychiatry, Ordu Government
Hospital, 52200 Ordu, Turkey
e-mail: drserhat@gmail.com
Ö. F. Akça
Department of Child and Adolescent Psychiatry, Meram School of
Medicine, Necmettin Erbakan University, Konya, Turkey
G. Türkoğlu
Ordu Government Hospital, The Clinics of Physical Medicine and
Rehabilitation, Ordu, Turkey
M. Akça
Samsun, Turkey
Keywords Sleep bruxism . Child and adolescent .
Psychopathology . Anxiety sensitivity . Depression . Anxiety
Introduction
Sleep bruxism (SB) is characterized as joint movements, such
as gritting, clenching, and grinding of teeth as a result of
prolonged and involuntary contractions and hyperactivity of
the temporomandibular joint muscles during sleep [1]. SB is
categorized under the heading of “parasomnias not defined
otherwise” in the DSM-IV and was reported as being the third
leading parasomnia by the American Psychiatric Association
in 1994 [2]. Despite being categorized as a parasomnia, it is
usually not accompanied by a sleep disorder and is frequently
seen in the second phase of sleep [3, 4]. The reported preva-
lence of SB among children ranges from 15 to 49 % in
different investigations [5–8]. Studies on gender distribution
of SB have shown inconsistent findings. While some studies
report that the incidence of SB is greater among females than
males, there are other studies reporting that the incidence of
SB is equal in both genders [5, 8, 9].
SB is known to be a long-lasting disease. In a 20-year
observational survey, SB that was evident in childhood was
reported to continue for many years in numerous cases [10].
Long-lasting SB may have negative effects on the temporo-
mandibular joint and can result in hypertrophy, particularly of
the chewing muscles. Furthermore, symptoms such as
myofacial pain syndrome, tension-type headaches, drooling
during sleep, thumb sucking, lip sucking, sucking a pacifier,
and temporomandibular pain upon awakening in the morning
are frequently associated with SB [3, 11]. In one study, head-
ache was reported to accompany SB in 73 % of the cases [11].
The most commonly reported psychiatric conditions ob-
served in conjunction with SB are anxiety accompanied by mild
depression, atypical depression, somatoform disorder, and

hypochondriasis [12]. Different etiological factors have been
investigated, but presently, the etiology of SB is not well defined.
Factors affecting the development of the disorder have been
classified as systemic, psychological, or structural [13]. The
etiological factor that is most strongly associated with SB may
be emotional stress [5, 14]. Stress and anxiety increase tooth
grinding and associated phenomena by increasing muscle ten-
sion, and this can result in SB [15]. Additionally, it has been
reported that under experimental conditions the electrical activity
in the chewing muscles increases when psychological stress is
increased and the incidence of symptoms associated with SB is
positively associated with “stressful and exhausting days” [9].
While various forms of emotional input may trigger SB by
affecting neural sleep–wakefulness mechanisms, it has been
suggested that the central (cerebral cortex) and/or the autonomic
(cardiac) nervous systems are often involved in the development
of SB [16]. Considered together, these data suggest that certain
psychiatric disorders and the symptoms commonly associated
with them are frequently observed in conjunction with SB and
that these symptoms may play an important role in determining
causation. Accordingly, psychiatric evaluation of SB patients has
been suggested in the context of treatment for this disease [8].
Anxiety sensitivity (AS) is an anxiety-related construct that
is defined as a tendency to fear anxiety symptoms, including
somatic sensations, and to interpret them as signals of
impending social, psychological, or physical catastrophe [17].
It has been suggested that AS is a relatively stable dispositional
variable, distinguishable from anticipatory anxiety and trait
anxiety [18]. Indeed, psychometric, clinical, and genetic studies
provide converging evidence that AS is a distinct entity that has
a strong hereditary component [19]. The results from one twin
study indicated that 45 % of the observed variance in AS scores
was associated with genetic variance between the subjects [19].
These findings suggest that AS is a specific vulnerability factor
for the development of anxiety disorders throughout life and
that it is dissimilar from trait anxiety [20]. Therefore, because
AS is a relatively stable dispositional variable, investigating the
relationship between SB and AS may enhance our understand-
ing about etiology of SB.
The aim of this study was to determine the levels of anxiety
and depression, psychiatric diagnoses, and levels of anxiety
sensitivity in children and adolescents diagnosed with SB and
to compare these levels with those of an otherwise comparable
non-SB control group.
Methods
Subjects
The study sample consisted of 35 children with SB who were
consecutively referred to four clinics of two different hospitals
in Turkey: (1) the Child and Adolescent Psychiatry Unit of the
Sleep Breath
Samsun Psychiatry Hospital and (2) the Child and Adolescent
Psychiatry Unit, Physical Medicine and Rehabilitation Unit, and
Dentistry Unit of Ordu State Hospital. The control group com-
prised children and adolescents who were seen in an outpatient
dental clinic for a routine oral inspection, not on the basis of any
specific dental complaint. The SB and control groups were
matched in terms of age and gender. The inclusion criteria were
as follows: children from 8 to 17 years of age, had a diagnosis of
SB according to International Classification of Sleep Disorders
in 2005 [21], and had enough social and mental functionality to
complete the self-report questionnaires. The exclusion criteria
included the following: the presence of a major physical or
neurological illness (e.g., cardiac problems or epilepsy) and
major psychiatric disorders, such as pervasive developmental
disorders, mental retardation, psychotic disorders, or a history of
psychiatric treatment. The same inclusion–exclusion criteria
(except a SB diagnosis) applied to the controls.
Study tools
Childhood Anxiety Sensitivity Index (CASI)
The Childhood Anxiety Sensitivity Index (CASI) was devel-
oped by Silverman in 1991 for school children aged 6 to
17 years. The index includes 18 items and is based on the
levels at which children are scared of physical sensations, as
evidenced by anxiety. Each item is scored as none (1), a little
(2), or very much (3); thus, total CASI scores range from 18 to
54. In a validity and reliability study of the scale, the
Cronbach-alpha internal consistency coefficient was reported
as 0.87 and the two-week test-retest reliability was 0.76 [22].
State-Trait Anxiety Inventory for Children (STAI-C)
This inventory, developed by Spielberger in 1976 [23] has two
subscales, each composed of 20 multiple choice questions for
state-trait anxiety. Each item is scored as 0,1, or 2 according to
the severity of the symptom. State anxiety is defined as the
anxiety experienced under certain conditions and at a certain
time and changes according to external factors. On the other
hand, trait anxiety defines the feelings of the individual in
general and reflects the individual's general predisposition to
anxiety. The reliability and validity study of the scale for the
Turkish population was conducted by Özusta in 1993 [24].
Children's Depression Inventory (CDI)
The Children's Depression Inventory (CDI) was developed by
Kovacs (1981) and is used to assess depression levels in
children. It is a self-assessment scale that comprised 27 items
and is designed to be administered to children and adolescents
aged between 6 and 17 years. Each item includes three state-
ments (response options) that the child chooses from
Sleep Breath

according to their experiences during the previous 2 weeks. regression analysis was also conducted. A p value of <0.05
Each statement set includes statements relating to symptoms (two-tailed) was used to indicate statistical significance in all
of depression. The scale may be filled out by the child or statistical tests.
administered to the child verbally. Answers are scored be-
tween 0 and 2, and the depression score is obtained by adding
these scores together. The maximum score that may be ob- Results
tained from the scale is 54, and high scores indicate a severe
depression level. CDI raw scores of 19 and standard t-scores The SB group and the control group both comprised 17 girls
of 65 or above identify potentially clinically depressed indi- and 18 boys. The mean ages of the SB and control groups
viduals [25]. The scale was adapted for use in Turkey by Oy in were 11.5±3.1 and 12.1±3.3 years, respectively. No signifi-
1991 [26]. cant differences were found between the patient and control
groups in terms of age, gender, educational level, parental age
Schedule for affective disorders and schizophrenia and educational status, mean family income, or family struc-
for school-aged children-Present and Lifetime Version ture (nuclear family vs. extended family) (p>0.05).
(K-SADS-PL) The proportion of the presence of at least one psychiatric
disorder was significantly higher (15 cases, 42.9 %) for SB
The Kiddie-Sads-Present and Lifetime Version (K-SADS-PL) patients than for controls (six cases, 17.1 %) (p< 0.05,
is a semi-structured diagnostic interview that was developed to χ2 5.51). While psychiatric disorders were evaluated separate-
detect present and former psychopathologies of children and ly, there were no statistically significant differences evident
adolescents according to the DSM-III and DSM-IV diagnostic between the two groups for any specific psychiatric diagnosis.
criteria (American Psychiatric Association in 1994). It was However, when all anxiety disorders (generalized anxiety
developed by Kaufman et al. in 1997 and translated into disorder, obsessive-compulsive disorder, separation anxiety,
Turkish. A validity and reliability study of the schedule for specific phobia, panic disorder, posttraumatic stress disorder,
Turkish children was conducted by Gökler in 2004 [27]. It is and social phobia) were considered together, a significant
administered via an interview with the child and the child's difference in frequency was evident between the groups
parents, and an assessment is made using all of the data (p<0.05 χ2 4.15). The psychiatric diagnoses of the SB group
obtained. When there is inconsistency between the data obtain- and the control group are presented in Table 1.
ed from the different resources, the clinician relies on his/her
clinical judgment. Present and previous diagnoses are deter- Table 1 Psychiatric diagnoses of the SB group and the control group
mined via assessment of present and past items. The K-SADS-
PL was administered to participants in the current study by Clinical diagnosis SB Control Total p valueb
n (%) n (%) n (%)
child psychiatrists (ST and ÖFA), and current psychiatric diag-
noses were determined according to the DSM-IV diagnostic Attention deficit 3 (8.6 %) 1 (2.9 %) 4 (5.7 %) 0.614
criteria (American Psychiatric Association in 1994). hyperactivity disorder
Enuresis 1 (2.9 %) 0 (0.0 %) 1 (1.4 %) 1
Procedures Major depression 6 (17.1 %) 1 (2.9 %) 7 (10.0 %) 0.106
Obsessive- 2 (5.7 %) 0 (0.0 %) 2 (2.8 %) 0.493
compulsive disorder
The study protocol was reviewed and approved by the institu- Generalized anxiety 4 (11.4 %) 1 (2.9 %) 5 (7.1 %) 0.356
tional ethical committee. The patients, control subjects, and their disorder
parents were given a patient information sheet and granted Panic disorder 2 (5.7 %) 0 (0.0 %) 2 (2.8 %) 0.493
written informed consent. A SB diagnosis was made using the Tic disorders 1 (2.9 %) 0 (0.0 %) 1 (1.4 %) 1
SB criteria described by the American Academy of Sleep Med- Post-traumatic 1 (2.9 %) 0 (0.0 %) 1 (1.4 %) 1
icine in 2005 of the International Classification of Sleep Disor- stress disorder
Encopresis 2 (5.7 %) 0 (0.0 %) 2 (2.8 %) 0.493
ders [21]. Initially, all children were interviewed by an experi-
Specific phobia 1 (2.9 %) 1 (2.9 %) 2 (1.4 %) 1
enced child-and-adolescent psychiatrist using the K-SADS-PL.
Next, children were administered with all the questionnaires. Social phobia 4 (11.4 %) 1 (2.9 %) 5 (7.1 %) 0.356
Separation anxiety 1 (2.9 %) 1 (2.9 %) 2 (2.8 %) 1
Statistical assessment Total numbera 28 6 34

Statistical analyses were conducted using SPSS version 17 for
Windows. The Mann–Whitney U test was used for compari-
son of constant variables, Fisher's analysis was used for com-
parison of categorical variables, and multivariate logistic
SB sleep bruxism
a
A patient can receive psychiatric diagnosis more than one (one comor-
bidity was detected in 5 cases, two comorbidities were found in 7 cases,
and three comorbidities were detected in 3 cases)
b
Analyses were conducted using the Fisher's exact test
 Sleep Breath

The questionnaire scores (CASI, SAI, TAI, and CDI) were Table 3 Logistic regression analysis of the SB versus control groups
significantly higher for SB patients than for controls. Both raw β SE df p Exp. (B)
scores and standard t-scores of the scales were given in Table 2.
However, after adjusting for multiple confounders, the asso- CASI 0.159 0.696 1 0.005 1.970
ciations between state and trait anxiety, depression and SB CDI 0.120 0.072 1 0.098 1.127
became statistically insignificant, while the association with SAI 0.027 0.045 1 0.540 1.028
AS persisted (Table 3). TAI 0.014 0.052 1 0.792 −2.690
PD 0.678 0.696 1 0.330 1.970
Constant −7.366 2.263 1 0.001 0.001
Discussion
SE standard error, df degrees of freedom, SB sleep bruxism, CASI Child-
hood Anxiety Sensitivity Index, CDI Children's Depression Inventory,
There is very limited data available regarding the relationship SAI State Anxiety Inventory, TAI Trait Anxiety Inventory, Exp. (B)
between SB and psychiatric symptoms in children and ado- Exponentiated logistic coefficients
lescents. The present study provides preliminary evidence
concerning SB related to the presence of psychiatric disorders difference was found with regard to any specific psychiatric
and higher anxiety and depression symptoms in children and disorder. This may be related to the study's small sample size.
adolescents. The study also produced data indicating that SB According to the results of our study, the severity of depres-
is related to higher AS levels in this age group, regardless of sion symptoms and state-trait anxiety levels in children with SB
the severity of anxiety or depressive symptoms. were found to be higher than those in the non-SB control group.
In previous studies, it has been reported that psychiatric Similar results have been reported in adults; Somtürk et al. [29]
disorders frequently accompanied SB; in a large study includ- reported that state-trait anxiety levels were higher in adults with
ing adults, anxiety disorder, adjustment disorder, bipolar disor- SB than in controls. In another study, the severity of anxiety and
der, and depression were more frequent in subjects with SB depression symptoms was reported to be significantly higher in
compared to subjects without SB [28]. Similar results were individuals with SB compared to those without SB [30]. Further,
obtained in studies in children. In a study including 854 chil- anxiety-related disorders including agoraphobia, claustrophobia,
dren and adolescents, SB was reported to be 3.6 times more social phobia, and alcohol misuse have also been reported in high
prevalent in individuals with psychiatric disorders [6]. In our rates in patients with SB [31]. However, studies investigating the
study, a higher number of psychiatric disorders were detected in relationship between SB and psychiatric symptom severity in
the SB group than in the control group. Additionally, anxiety children are limited. In a study, SB was shown to be positively
disorders were more common in SB subjects compared to associated with anxiety [32]. While high anxiety scores were
controls. This finding is consistent with previous studies and observed in 72 % of children with SB, the corresponding rate in
suggests that SB may accompany various psychiatric disorders. children without SB was 12 %, which indicates a statistically
Thus, psychiatric evaluation and intervention may help to im- significant difference [32]. Another recent study reported that SB
prove the mental health of SB patients. However, when we is associated with increased internalizing behaviors [8].
evaluated psychiatric disorders separately, no significant However, in the logistic regression analysis performed in
the current study, only the AS levels of the SB group were
found to be significantly higher than those of the control
Table 2 Raw and the standard scores of CASI, CDI, SAI, and TAI group. This finding suggests that rather than anxiety or de-
SB Control p z pressive symptoms, AS may be a factor in emerging SB.
Min–max/ Min−max/ Because AS is defined as a tendency factor in various psychi-
median raw scores median raw scores atric disorders [33–36], individuals with high AS may dem-
(min–max/median (min − max/median onstrate both SB and particular psychiatric symptoms or dis-
standard t-scores) standard t-scores)
orders. The knowledge that AS is associated with autonomic
CASI 23–58/39 20–41/30 <0.001 −4.3 nervous system hyperactivity [37, 38] supports the hypothesis
(37.0–80, 6/56.9) (33.2–59.4/45.7) that AS is a structural, long-term variable rather than a state-
CDI 9–32/14 4–27/10 0.001 −3.4 dependent psychological factor. Thus, we may suggest that
(42.3–87, 6/52.1) (32.4–77.8/44.2)
SAI 22–50/34 20–62/31 0.010 −2.5
individuals with high AS are structurally more vulnerable to
(34.5–72.5/50.8) (31.8–88.8/46.7) develop SB. Some investigations have reported findings that
TAI 23–54/41 20–48/37 0.014 −2.4 support this assumption. For example, Serra-Negra et al. [39]
(31.7–71.6/54.9) (27.9–63.9/49.7) stated that SB is related to personality characteristics but is not
SB sleep bruxism, CASI Childhood Anxiety Sensitivity Index, CDI Chil-
related to anxiety. In another study investigating stress hor-
dren's Depression Inventory, SAI State Anxiety Inventory, TAI Trait mone levels in individuals with SB, urinary catecholamine
Anxiety Inventory metabolites were investigated, and higher levels of adrenaline,
Sleep Breath
noradrenaline, and dopamine were detected in the urine of
individuals with SB [40]. Moreover, another study indicated
that adrenaline and noradrenaline increase rhythmic mandib-
ular movements [41]. Additionally, some authors stated that
SB is related to the autonomic nervous system [16]. These
studies support our findings if they are interpreted in the light
of the recent literature indicating that AS is related to auto-
nomic nervous system hyperactivity [37, 38]. A limited num-
ber of studies investigating the relationship between SB and
AS in adults have been reported; however, to our knowledge
there are currently no reported studies available that have
included children. However, it has been reported that AS is
positively associated with SB in adults [42].
Some limitations should be considered when
interpreting the results of the current study. All patients
in the experimental group were seeking treatment, and
some individuals seeking treatment tend to over-report
psychopathology in general. Other limitations are the small
sample size, the fact that it was a questionnaire-based study,
and the absence of sleep recordings.
In conclusion, psychiatric symptoms, particularly depres-
sion and anxiety, are frequently seen in conjunction with SB.
Coexistence of SB with depression and anxiety has been
found in previous studies in children and adults and is further
suggested by the results of this study. Moreover, SB was
found to be predicted by AS levels, regardless of anxiety or
depressive symptom severity in children. These findings sug-
gest that AS may play an important role in emerging or
ongoing SB because of structurally high sensitivity to anxiety
or stress. These trait tendencies also indicate that these chil-
dren may be more vulnerable to developing psychiatric symp-
toms or disorders. Thus, these children should be followed by
psychiatrists along with dentists and physiotherapists and
appropriate interventions should be made.
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