Cognitions, chronicity, distress and disability in temporomandibular disorder (idiopathic orofacial pain)

This thesis attempts to bring the understanding of orofacial pam, and temporomandibular disorder (TMD) in particular, into line with that of other chronic pain conditions, in order that the principles of psychological pain control through education and self-management, apparently effective in other conditions, may be specifically adapted to facial pain. Reviews of the literature on coping, beliefs, depression, and anxiety, establish the current status of theoretically derived measurement instruments, their use in chronic pain patient groups, and the findings there from. Further reviews of psychological aspects of dental pain and primary headache present these as acute and chronic pain conditions for comparison. The first study, assessing disability by means of the Oral Health Impact Profile (OHIP), found no significant relationships between OHIP factors and clinical signs. However, all OHIP factors, except for the functional and physical subscales, correlated significantly with pain intensity, suggesting that psychosocial rather than physical aspects of disability relate to pain report. Anxiety, measured by the Hospital Anxiety and Depression scale (HAD), was associated with pain intensity (McGill Pain Questionnaire, MPQ), catastrophising (Coping Strategies Questionnaire, CSQ), and with 'psychological' pain beliefs (pain Beliefs Questionnaire, PBQ). In addition, anxiety appeared to be related to perceived problems with speech (GHIP). Depressive symptoms (HAD) were associated with 'passive' coping strategies, notably catastrophising, and with emphasis on the impact on tasting and digesting food (OHIP). The second study sought to evaluate how pain symptoms of different character and intensity (MPQ) might influence cognitions relating to cause, time1ine, consequence, and controI/cure (Illness Perceptions Questionnaire, IPQ). Greater intensity of 'constant' pain contributed to greater advocation of physiological cause, and greater perceived consequence of pain on psychosocial functioning, whilst a longer period in full-time education appeared to increase endorsement of psychological causes, and to beneficially influence judgments of time1ine and consequence. Facial pain, though reportedly less painful of lesser consequence, and more controllable than headache, was also found to be less responsive to treatment, as demonstrated over six months following hospital specialist consultation. The contribution of perceived permanence and consequence (lPQ), and of catastrophising (CSQ), to continuing pain, disability, and distress indicates that these factors were suitable targets for a psycho-educational approach aimed specifically at ameliorating pain beliefs and coping strategies. In the final study, a self-management programme for TMD was developed from the findings of the earlier studies, and successfully piloted in a small sample of patients, demonstrating the acceptability of the programme, indicating a need for a full-scale trial