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The purpose of this presentation is to review the elements that comprise the concept of illness behavior including elaboration of a more formal theoretical and operational model for illness behavior and then discuss the application of the illness behavior model to chronic pain, especially chronic orofacial pain. The model of illness behavior presented emphasizes four critical areas of conceptual interest, namely, (1) monitoring of somatic signals; (2) cognitive processes whereby bodily symptoms are interpreted; (3) attaching meaning to symptoms in the context of emotional state and concurrent environmental events; and (4) the ethnocultural influences that pervade meaning and shape coping responses. Our model of illness behavior was generalized from a closely related model developed to guide research when the specific illness behavior of interest was dysfunctional chronic pain behavior. We also include a time dimension in our chronic pain model. Dysfunctional chronic pain is understood to be the most important undesirable consequence associated with suffering a persistent pain condition. Dysfunctional chronic pain is a subset of illness behaviors inconsistent with medically documented findings, while the complaints of pain are prominent. Changes occur in emotional status, most typically reported as mood and behavioral changes associated with depression, such as demoralization, helplessness, and social isolation. Excesses in medical care, hospitalizations for surgery, and abuse of medications are further characteristics of dysfunctional chronic pain.
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PMID:Illness behavior and dysfunction: review of concepts and application to chronic pain. 186 18

Orofacial pain is usually evaluated and treated from a biomedical perspective. There is no question that the large majority of individuals having acute orofacial pain benefit from timely and appropriate medical intervention. When orofacial pain persists, however, the likelihood that this pain can influence and be influenced by behavioral factors increases. While some individuals are able to adapt and cope with chronic orofacial pain, others develop significant behavioral problems. These problems may include an overly sedentary lifestyle, dependence on habit-forming narcotic medications, or severe depression or anxiety. The hallmark of the behavioral perspective on chronic pain is the insistence that a careful assessment and treatment of such behavioral problems is just as important as appropriate biomedical intervention.(1)
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PMID:Behavioral assessment of chronic orofacial pain. 208 2

The mouth is frequently affected by psychosomatic manifestations and communicative intimacy. Together with the age-related changes to central nervous system and organic changes in the chewing mechanism and oropharynx, these changes represent a failure of psychodynamic coping. With advanced age a "tempora minoris resistentiae" associates with a "locus minoris resistentiae". This etiopathogenetic constellation triggers psychosomatic conversion phenomena and "circumscribed" hypochondrias, as well as dysmorphobobic delusional developments, and hypochondric cyclothymic depressions. When there is an organic, nerval accentuation of these changes the symptoms often became chronic. It must be pointed out that a mimic disease often resembles a monosymptomatic masked depression, frequently resulting in false diagnosis. Contextual to anthropologic-psychologic dimensions of pain sensation, this work finally deals with the psychophysiologic complementary model of orofacial pain-dysfunction syndrome.
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PMID:[Psychosomatic and psychopathological aspects in dental-orofacial medicine with special reference to old age]. 229 Dec 98

This study was carried out to explore the value of the tyramine conjugation test, an established trait marker for 'endogenous unipolar depression', in patients with chronic idiopathic temporomandibular joint and orofacial pain. Our results show that the pain patients excrete significantly lower amounts of tyramine sulphate than controls (P < 0.0004). Psychiatric assessment by the structured clinical interview for the diagnosis of mental disorders according to DSM-III-R revealed that 48% of the patients had a history of depression and 10% were currently depressed. However, the never-depressed group of patients had the lowest tyramine sulphate excretion values. These findings suggest that a common biological abnormality underlies the pathogenesis of both chronic idiopathic facial pain and depression.
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PMID:Tyramine conjugation deficit in patients with chronic idiopathic temporomandibular joint and orofacial pain. 823 29

This study examines the incidence of and the potential correlates of sexual and physical abuse among facial pain patients. An anonymous survey composed of standardized self-report measures of abuse, pain, and psychologic status was distributed to 120 adult facial pain patients following their initial evaluations. Forty-five questionnaires were returned by mail. In addition, 206 charts were randomly selected from a population of 520 new patients seen at the Orofacial Pain Center during the same time period that data from the anonymous survey were collected. Results of the anonymous survey indicated that 68.9% of the patients reported a history of abuse. Conversely, a chart review revealed that only 8.5% of the patients indicated a history of abuse on the clinic questionnaire. History of abuse was significantly related to greater pain severity, depression, psychologic distress, and various personality characteristics. Overall, this study indicates that the assessment of the history of abuse may be an important factor in the evaluation and treatment of facial pain.
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PMID:Physical and sexual abuse among orofacial pain patients: linkages with pain and psychologic distress. 899 5

Tricyclic antidepressants, or "tricyclics" as they are commonly called, are effective in reducing pain in chronic neurological and musculoskeletal disorders. Tricyclics appear to be effective in the control of chronic orofacial pain of non-inflammatory origin, and include amitriptyline, doxepin, nortriptyline and desipramine. Daily doses of the medications are smaller for the management of pain than doses typically used in the treatment of depression. Certain medical conditions may contraindicate tricyclic trials, while others may warrant starting at a lower dose with more conservative dose adjustments. Common side effects include dry mouth, sedation, constipation and orthostasis. Tricyclics are just one therapeutic modality which can be considered in the management and treatment of chronic refractory orofacial pain that is suspected to arise from neurogenic or myofascial etiologies.
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PMID:The use of tricyclic antidepressants for the control of chronic orofacial pain. 958 88

It is generally recognized that psychological factors play an important role in chronic orofacial pain patients. This study analysed psychological profiles of chronic pain patients affected with temporomandibular disorders (TMD), by means of the Minnesota Multiphasic Personality Inventory (MMPI) test. Fifty consecutive TMD patients were examined and were then divided into two subgroups: 1. myofascial pain and 2. temporomandibular joint articular disorders. Sixty-two percent of the whole sample presented pathological MMPI scores. Both subgroups presented similar profiles with alteration of the neurotic triad (hypochondriasis, depression, hysteria), and pathological values of hypochondriasis and hysteria ("V" configuration). Since the personality profile did not differ between the two subgroups investigated, it was not dependent on the dysfunctional origin of the pathology (myalgia or primary TMJ pathology). Chronic TMD patients presented personality characteristics similar to those of other chronic pain patients according to the MMPI.
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PMID:Personality characteristics of temporomandibular disorder patients using M.M.P.I. 970 66

The temporomandibular disorders (TMDs) comprise a constellation of symptoms affecting the joints and muscles involved in jaw movement. Patients complain of orofacial pain, limited jaw opening, and clicking or popping sounds. Although pain is generally the defining characteristic of TMD, patients often report marked degrees of stress and interference in daily life. This article reviews recent studies on epidemiology, sex differences, pediatric TMD, classification systems, comparisons to other chronic pain disorders of uncertain etiology, psychological assessment, depression, central modulation and hypervigilance, sleep disturbances, stress, and the management of TMD by conservative physical interventions and cognitive behavioral therapy. Both the assessment and the management of TMD requires a multidisciplinary perspective with strong emphasis on psychosocial variables.
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PMID:The role of psychosocial factors in temporomandibular disorders. 1099 18

Neuropathic orofacial pain can be difficult to diagnose because of the lack of clinical and radiographic abnormalities. Further difficulties arise if the patient exhibits significant distress and is a poor historian regarding previous diagnostic tests and treatments, such as somatosensory local anaesthetic blockade. Valuable information can be obtained by utilising the McGill Pain Questionnaire that allows the patient to choose words that describe the qualities of his/her pain in a number of important dimensions (sensory and effective). Basal pain intensity should be measured with the visual analogue scale, a simple instrument that can evaluate the efficacy of subsequent treatments. The dentist or endodontist can employ sequential analgesic blockade with topical anaesthetics and perineural administration of plain local anaesthetic to ascertain sites of neuropathology in the PNS. These can be performed in the dental chair and in a patient blinded manner. Other, more specific, tests necessitate referral to a specialist anaesthetist at a multidisciplinary pain clinic. These tests include placebo controlled lignocaine infusions for assessing neuropathic pain, and placebo controlled phentolamine infusions for sympathetically maintained pain. The treatment/management of neuropathic pain is multidisciplinary. Medication rationalisation utilises first-line antineuropathic drugs including tricyclic antidepressants such as amitriptyline and nortriptyline, and possibly an anticonvulsant such as carbamazepine, sodium valproate, or gabapentin if there are sharp, shooting qualities to the pain. Mexiletine, an antiarrhythmic agent and lignocaine analogue, may be considered following a positive patient response to a lignocaine infusion. All drugs need to be titrated to achieve maximum therapeutic effect and minimum side effects. Topical applications of capsaicin to the gingivae and oral mucosa are a simple and effective treatment in two out of three patients suffering from neuropathic orofacial pain. Temporomandibular disorder is present in two thirds of patients and should be assessed and treated with physiotherapy and where appropriate, occlusal splint therapy. Attention to the patient's psychological status is crucial and requires the skill of a clinical psychologist and/or psychiatrist with pain clinic experience. Psychological variables include distress, depression, expectations of treatment, motivation to improve, and background environmental factors. Unnecessary dental treatment to "remove the pain" with dental extractions is contraindicated and aggravates neuropathic orofacial pain.
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PMID:Neuropathic orofacial pain. Part 2-Diagnostic procedures, treatment guidelines and case reports. 1135 83

Associations between pain, depression, and sleep disturbance have been documented in several chronic pain patient samples. The current study assessed the prevalence and magnitude of sleep disturbance in a sample of 128 orofacial pain patients referred for clinical evaluation and tested linkages between sleep, depression, anxiety, and pain using cross-sectional and longitudinal data. Seventy-seven percent of the patients reported reduced sleep quantity since pain onset. In cross-sectional analyses, reduced sleep quantity was associated with depression and pain. Reduced sleep quality was associated with negative affect. Longitudinally, initial depression and pain predicted sleep at time two and initial pain predicted negative affect. Sleep did not predict pain. Results support the hypothesis that pain, rather than sleep disturbance, increases negative affect across time, whereas negative affect is more a cause of concurrent reduced sleep quality than is pain. The results highlight the importance of assessing for sleep disturbance in orofacial pain patients.
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PMID:Sleep disturbance in orofacial pain patients: pain-related or emotional distress? 1184 61


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