(SGB) characterized by numerous belches/min. In SGB, air is either sucked or pushed into the upper esophagus by decreased intrathoracic pressure or contraction of pharyngeal muscles during closure of the glottis. The subsequent air expulsion results in a burping sound. 1 Important differential diagnoses are persistent hiccups (singultus), aerophagia, dyskinesia as well as tics. We report the case of a 55-year-old man who presented with a 2-year history of therapy-refractory SGB with up to 25 belches/ min. He denied premonitory sensations and was unable to voluntarily suppress belching. Numerous medications, includ- ing gabapentin 2400 mg/day, tetrabenazine 150 mg/day, trihexyphenidyl hydrochloride 15 mg/day, tiapride hydrochlo- ride 600 mg/day, valproate 1800 mg/day, carbamazepine 1200 mg/day and baclofen 30 mg/day, had not resulted in meaningful improvement. He had been on 40 mg pantoprazole for reflux esophagitis and recurrent gastric ulcers for at least 10 years without a marked effect on his belching. Esophageal impedance manometry demonstrated excessive SGB, but yielded no evidence for hiccups or respiratory dyskinesia. Cranial magnetic resonance imaging and thoracoabdominal computed tomography were without note. Gastroscopy demonstrated moderate erosive esophagitis. There is little evidence to guide the management of SGB. Biofeedback and behavioral therapy may be beneficial. However, these procedures are complex and few therapists have experience in this specific area. 2 Here, combined treat- ment of 10 mg baclofen t.i.d. and 100 mg pregabalin t.i.d. resulted in sustained reduction of the rate of belching to less than 10% of the pretreatment value. The patient reported initial mild sedation, which resolved during the second week of treatment. We speculate that the combination of baclofen and pregabalin exerts synergistic effects by reducing both increased mechanosensitivity and chemosensitivity of the esophagogastric junction associated with SGB. Blondeau and co-workers showed a correlation between increased lower esophageal sphincter pressure under baclofen therapy and a reduction in belching events. 2 Experimentally, baclofen inhibits mechanosensitivity of vagal afferents periph- erally. However, baclofen does not affect chemosensitivity. 3 Recently, a small placebo-controlled study showed that pregabalin attenuates the development of hypersensitivity in the proximal esophagus after distal esophageal acidification. 4 In conclusion, clinicians should be aware of the disease entity of SGB. Further studies will have to establish an evidence-based approach to the management of these patients. REFERENCES 1. Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Psychologi- cal factors affect the frequency of belching in patients with aerophagia. Am. J. Gastroenterol. 2006; 101: 2777–2781. 2. Blondeau K, Boecxstaens V, Rommel N et al. Baclofen improves symptoms and reduces postprandial flow events in patients with rumination and supragastric belching. Clin. Gastroenterol. Hepatol. 2012; 10: 379–384. 3. Partosoedarso ER, Young RL, Blackshaw LA. GABA(B) receptors on vagal afferent pathways: Peripheral and central inhibition. Am. J. Physiol. Gastrointest. Liver Physiol. 2001; 280: G658–G668. 4. Chua YC, Ng KS, Sharma A et al. Randomised clinical trial: Pregabalin attenuates the development of acid-induced oesophageal hypersensitivity in healthy volunteers – a placebo- controlled study. Aliment Pharmacol. Ther. 2012; 35: 319–326. Hagen Kunte, MD, 1 Golo Kronenberg, MD, 1 Katharina Fink, MD, 3 Lutz Harms, MD 2 and Rainer Hellweg, MD 1 Departments of 1 Psychiatry and Psychotherapy and 2 Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany, and 3 Department of Neurology, Karolinska University Hospital, Stockholm, Sweden Email: hagen.kunte@charite.de Received 14 March 2014; revised 13 June 2014; accepted 14 July 2014. Psychosomatic consideration to the burning mouth syndrome doi:10.1111/pcn.12229 B URNING MOUTH SYNDROME (BMS) represents a clinical condition of burning pain over the tongue and/or lips without abnormalities in the oral cavity examination. BMS can involve the whole oral cavity with the distress being described as ‘discomfort’, ‘tender’, ‘annoying’ or ‘burning pain’ accompanied with dryness, oral paresthesia and altered taste. Variety in the affected region and sensation make the terms diverse in the published work, including: glossodynia, glossopyrosis, and oral dysesthesia. 1 Here, we report one case to highlight clinical wisdom. A 62-year-old woman visited the psychiatric clinic for insomnia. She was robust until 6 months ago, when she suf- fered from burning mouth pain. She had visited different pro- fessionals, including the dentist, the neurologist, the oral pathologist, and the ear–nose–throat doctors. All the exami- nations, including oral pathology, were normal but the pain persisted. She was then recommended to visit a psychiatrist. In the mental status examination, dysthymic mood, decreased interest and poor appetite were noted. Further interview pre- sented her severe anxiety about salivary gland tumor – a hypo- chondriacal idea. Considering the symptoms, low-dose antipsychotics (quetiapine 12.5 mg/day) and antidepressants (duloxetine 30 mg/day) were prescribed. Three months later, her depression and sleep improved. Also, the hypochondriacal ideation and the anxiety were relieved partially. Although the burning mouth sensation did not disappear, her quality of life enhanced remarkably. With no conclusively identified cause, BMS predominantly affects women with increasing prevalence with age and follow- ing menopause. 2 Besides the oral discomfort, psychiatric comorbidity is another focus worth noticing. Studies had reported BMS to have anxiety, depression and increased ten- dency for somatization as well as several other psychiatric features when measured by the Symptom Checklist-90 ques- tionnaire. 3 Evidence suggested that BMS is often chronic, with only 50% of patients spontaneously remitting within 6–7 years. 4 Thus, BMS may exacerbate one’s long-term quality of life, making the treatment important. A recent Cochrane review had categorized the management into six types: antidepressants, cognitive behavioral therapy, Psychiatry and Clinical Neurosciences 2015; 69: 122–127 Letters to the Editor 125 © 2014 The Authors Psychiatry and Clinical Neurosciences © 2014 Japanese Society of Psychiatry and Neurology