Facial pain, distress, and immune function

Demoralization: a systematic review on its clinical characterization

BACKGROUND

Demoralization has been described as a psychological state characterized by helplessness, hopelessness, a sense of failure and the inability to cope.

METHODS

We conducted a systematic review with qualitative data analysis following PRISMA criteria with the following aims: to review validated assessment instruments of the demoralization syndrome, report main findings regarding demoralization as measured by validated instruments that emerge in the literature, compare and report evidence for the clinical utility of the identified instruments. Utilizing the key word 'demoralization' in PubMed and PsycINFO databases, an electronic search was performed, supplemented by Web of Science and manual searches. Study selection criteria included the assessment of medical patients and use of instruments validated to assess demoralization. Seventy-four studies were selected.

RESULTS

Four instruments emerged in the literature. Main findings concern prevalence rates of demoralization, evidence of discriminant validity from major depression, factors associated with demoralization and evidence of clinical utility. The instruments vary in their definition, the populations they aim to assess, prevalence rates they estimate and their ability to discriminate between different conditions. Nonetheless, demoralization appears to be a distinctive psychological state characterized by helplessness, hopelessness, giving up and subjective incompetence. It is not limited to life-threatening diseases such as cancer, but may occur in any type of clinical situation. It is associated with stress and adverse health outcomes.

CONCLUSIONS

Studies addressing the incremental value of demoralization in psychiatry and psychology are needed. However, demoralization appears to entail specific clinical features and may be a distinct condition from major depression.

Review of aetiological concepts of temporomandibular pain disorders: towards a biopsychosocial model for integration of physical disorder factors with psychological and psychosocial illness impact factors

Several studies have reported that musculoskeletal disorders of the stomatognathic system, commonly known as temporomandibular disorders (TMD) resemble musculoskeletal disorders and chronic pain disorders in general. There is also general consensus that combined biomedical and biopsychosocial methods best support the assessment and management of the cardinal features of TMD, i.e., pain and dysfunction or physical (peripheral) and psychosocial (central) factors. This overview of the aetiology of TMD will outline conceptualizations of past models and present the current view that patients with TMD should be assessed according to both the physical disorder and the psychosocial illness impact factors. The conceptual theories outlined in this review include biomedical models related to temporomandibular joints, muscles of mastication and occlusal factors, psychological models and the biopsychosocial models. An integrated and multidimensional approach concerning physical and psychosocial factors in temporomandibular pain and dysfunction is presented as an example of how the biopsychosocial model and information processing theory may apply in the conceptualization and management of TMD for various health care professionals.

How may stressful experiences contribute to the development of temporomandibular disorders?

Temporomandibular disorders (TMD) comprise the most common cause of chronic facial pain conditions, and they are often associated with somatic and psychological complaints including fatigue, sleep disturbances, anxiety, and depression. For many health professionals, the subjectivity of pain experience is frequently neglected even when the clinic does not find any plausible biologic explanation for the pain. This strictly biomedical vision of pain cannot be justified scientifically. The purpose of this study is to demonstrate, by original articles from the literature and recent studies conducted in our own laboratory, the biological processes by which psychological stress can be translated into the sensation of pain and contribute to the development of TMD. The role of the hypothalamic-pituitary-adrenal axis, the serotoninergic and opioid systems in the pathogenesis of facial pain is exposed, including possible future therapeutic approaches. It is hoped that knowledge from apparently disparate fields of dentistry, integrated into a multidisciplinary clinical approach to TMD, will improve diagnosis and treatment for this condition through a clinical practice supported by scientific knowledge.

Prevalence of post-traumatic stress disorder symptoms in orofacial pain patients

OBJECTIVE

There is a high comorbidity between symptoms of post-traumatic stress disorder (PTSD) and chronic pain incidence. The objective of this investigation was to determine the prevalence of PTSD symptoms in chronic orofacial pain patients.

STUDY DESIGN

The study included 1478 adult patients (mean age 36.4 +/- 12.7 years) with primary diagnoses of masticatory/cervical muscle pain or temporomandibular joint pain. Patients completed a battery of psychometric questionnaires including a screening for PTSD symptoms. The sample was divided into a PTSD-positive group (n=218, 15%) a PTSD-negative group (n=551, 37%), and a no-stressor group (n=709, 48%) according to stressor incidence and symptom severity.

RESULTS

The current prevalence of PTSD symptomatology was considerably higher than that reported in surveys from the general population. Patients in the PTSD-positive symptom group reported significantly higher psychological distress, sleep dysfunction, and pain severity compared to patients in the other groups. Psychological distress as measured by the SCL-90-R reached clinically significant levels only in those patients with PTSD symptomatology.

CONCLUSIONS

The results of this study performed at a tertiary care center suggest that TMD patients without PTSD symptomatology show low levels of psychological distress, if any. Clinically significant levels of psychological distress are likely indicators for PTSD. PTSD screening should be included as part of a routine psychometric test battery in TMD patients.

Differences in functional immune responses of high vs. low hardy healthy individuals

An association between the personality trait of hardiness and immune responses was explored. Blood samples were collected from 21 healthy individuals under nonstressful conditions, who had either high or low levels of hardiness. Functional immune assays tested for natural killer (NK) cell activity and proliferation responses to Candida albicans (Candida), purified protein derivative from Mycobacterium tuberculosis (PPD), lipopolysaccharide (LPS), concanavalin A (Con A), and Staphylococcus enterotoxin A (Staph A). Differences between high and low hardy groups on these immune responses were examined using Bonferroni adjusted independent t-tests. Results revealed significant differences between the groups for Candida, PPD, Con A, and Staph A. In all instances, the high hardy group had larger mean proliferative responses than the low hardy group. Implications of the study as well as avenues for future research are discussed.

Depression, pain, exposure to stressful life events, and long-term outcomes in temporomandibular disorder patients

PURPOSE

This study investigated the role of psychological factors in temporomandibular disorders (TMD). Orofacial pain patients' pretreatment levels of depression, disability caused by pain, and exposure to stressful life events were measured, and differences on these variables between temporomandibular joint (TMJ) disease patients and patients whose pain was of muscular origin (MPD) were evaluated. The use of these variables and patient diagnostic status in predicting response to treatment in a subsample of these patients was also evaluated.

PATIENTS AND METHODS

Before undergoing treatment, 258 patients were administered the Beck Depression Inventory (BDI), the Pain Disability Index (PDI), and the Social Readjustment Rating Scale (SRRS). Follow-up data on pain disability, current level of pain, depression, and satisfaction with treatment were obtained on 48 of these patients who were contacted at varying intervals after completing treatment.

RESULTS

BDI scores obtained at the outset of treatment were significantly elevated and were positively correlated with SRRS and PDI scores. MPD patients had higher SRRS, BDI depression, and PDI pain disability scores than TMJ patients, and differences between the 2 groups in pain disability were greatest in areas that are often sources of interpersonal stress. Among follow-up patients, PDI scores declined after treatment, with MPD patients showing greater decreases than TMJ patients. Independent of patients' diagnostic status, their pretreatment PDI scores were predictive of their pain level at follow-up and were inversely related to their degree of satisfaction with treatment at follow-up; their pretreatment BDI scores were predictive of their depression level at follow-up.

CONCLUSIONS

The findings are consistent with previous research indicating a link between emotional dysfunction and TMD and are largely supportive of the conclusion that psychological factors play a more pronounced role when pain is of muscular origin. Promising behavioral interventions are available for TMD patients in whom psychological factors appear to be playing a significant role.

The effects of epidural block on the distribution of lymphocyte subsets and natural-killer cell activity in patients with and without pain

Although epidural anesthesia prevents immune suppression during surgery, no reports have elucidated how epidural block affects immune response in nonsurgical patients. We examined changes in proportion of lymphocyte subsets and in natural-killer (NK) cell activity in patients with and without pain. Fifteen patients with pain (Pain group) and 15 preoperative patients without pain (Preoperative group) received three different treatments in random order: epidural block with 7 mL 1% lidocaine, epidural injection of an identical volume of normal saline, and IV injection of 1 mg/kg lidocaine. Blood samples were drawn before and after 30, 60, and 120 min of treatment. During epidural block at 30 and 60 min, both groups showed significantly decreased epinephrine, norepinephrine, and cortisol levels, and the proportion of NK cells decreased, whereas the CD4+/CD8+ ratio increased significantly. NK cell activity in both groups decreased significantly at 30 and 60 min. At 120 min, the variables had all returned to preblock values. During treatments with saline and IV lidocaine, neither group showed significant changes in any of the above variables. We conclude that epidural block causes a transient and significant alteration of lymphocyte subsets and NK cell activity regardless of pain status.

Self-reported systemic, immune-mediated disorders in patients with and without proplast-teflon implants of the temporomandibular joint

PURPOSE

This study investigates the self-reported immune-related health status of patients exposed to Proplast-Teflon (P/T) temporomandibular joint (TMJ) implants, comparing their health status with a group of patients who were not exposed to any alloplastic TMJ implants. It also compares those whose implants were removed with those in whom they were retained.

PATIENTS AND METHODS

Patients seen in a single oral and maxillofacial surgical practice completed a detailed self-report questionnaire about physical symptoms and disorders. Sixty-four had received P/T implants, and 22 were unexposed to any TMJ alloplastic implant. Of the P/T-exposed group, 44 had removed and 20 had retained implants.

RESULTS

In general, P/T-exposed patients did not differ from unexposed patients in rates of reported immune-mediated and somatization-related conditions, allergies, or symptoms of environmental sensitivity. However, patients with removed P/T implants reported significantly more problems in all categories of conditions than those with retained P/T implants. This difference was no longer statistically significant after controlling for pain severity and sex.

CONCLUSIONS

Although P/T-exposed patients do not report more systemic health conditions than similar patients who were unexposed to alloplastic jaw implants, those with removed implants report more conditions and are more likely to be seen in clinical practice. This may lead to a bias in the general perception regarding the systemic health status of P/T-exposed patients. In addition, effects may be secondary to high levels of pain and dysfunction among patients with removed implants, rather than implant exposure itself. Future prospective research is needed to identify factors associated with implant failure.

Searching for the biological pathways between stress and health

Population-based, person-specific health surveys, with concomitant biological measures, should provide important information about the processes by which socioeconomic and psychosocial factors embed themselves in human health. Questionnaire responses allow for assessment of the perceived psychosocial environment, but biological measurements will measure the status of the psychoneuroimmunology/ psychoneuroendocrinology (PNI/PNE) pathways and may allow us to identify people who have "adapted" to their stress because of experience, expectations, stoicism, etc. This review sets criteria to evaluate potential physiological markers of chronic stress. Because population health surveys involve a massive number of samples, special consideration must be given to the laboratory analysis method and transportation time of the markers chosen. We reviewed five areas: glycosylated proteins, the immune system, hemostasis peripheral benzodiazepine receptors, and the waist-hip ratio.

Pain severity, negative affect, and microstressers as predictors of life interference in TMD patients

The purpose of this study was to examine the relationships among negative affect (depression, anxiety, and anger), microstressors (hassles), temporomandibular disorder (TMD) pain severity, and life interference, using structural equations modeling. One hundred four subjects were recruited from the Parker Mahan Facial Pain Clinic at the University of Florida. Significant positive direct effects were found for paths between pain severity and life interference; pain severity and negative affect; and negative affect and life interference. These results are consistent with a learning or behavioral model of suffering and suggest that negative affect is an important mediating variable in the relationship between pain and life interference. Microstressors were not a significant predictor and may not be a relevant issue in the TMD population. The results suggest that the impact of chronic pain conditions is influenced by both pain and negative affect, and assessment and treatment of chronic TMD disorders may better benefit from a multidisciplinary approach.

Gender differences in pain

Apparent gender differences have been identified in epidemiologic surveys of patients with pain and in clinical studies of responses to pain. Women are reported to have lower pain thresholds and lower pain tolerance than men have. Whether women are more willing to report pain than men are or experience pain differently than men do is unclear. However, beliefs about gender differences and pain affect nurses' decisions made regarding the treatment of pain. This article reviews the literature addressing pain in women and suggests how clinical practice is affected. Literature from Medline (1966 to 1994), CINAHL (1983 to 1994), and Psych-Lit (1967 to 1994) data bases was searched using the key words pain, gender, and sex. Comments in the manuscript reflect only those studies addressing epidemiology, experimentally-induced pain, or pain in the clinical setting. Studies describing gender differences in an animal model were not included. Limitations of space required that representative examples of studies in the major areas be included; others describing similar design and outcome were not included.

Systemic interleukin-1 alpha and interleukin-2 secretion in response to acute stress and to corticotropin-releasing hormone in humans

Acute stress results in activation of the hypothalamic-pituitary-adrenal (HPA) axis. ACTH and cortisol secretion is stimulated by corticotropin-releasing hormone (CRH). It has also been shown that activation of the HPA axis during stress is accompanied by changes in the immune response. However, little is known about the influence of acute stress on the release of cytokines such as interleukin-1 (IL-1) or interleukin-2 (IL-2). In this study, we determined serum IL-1 alpha and IL-2 levels in 19 patients undergoing the acute stress of angioplasty for coronary artery disease. A second protocol was devised to determine serum IL-1 alpha and IL-2 concentrations as well as lymphocyte subpopulations in 10 normal volunteers receiving 1 microgram kg-1 human CRH intravenously. Finally, IL-1 alpha concentrations were measured in CRH-incubated mononuclear cell (MNC) and monocyte cultures. In response to the stress of angioplasty, ACTH and cortisol as well as IL-1 alpha and IL-2 concentrations were clearly above baseline levels (IL-1 alpha, mean +/- SEM, baseline: 1.39 +/- 0.34 ng ml-1, after angioplasty: 2.64 +/- 0.73 ng ml-1, P < 0.05; IL-2, baseline: 1.2 +/- 0.13 ng ml-1, after angioplasty: 2.8 +/- 1.14 ng ml, P < 0.05). A similar pattern was obtained in normal subjects in response to CRH (Il-1 alpha, baseline: 0.8 +/- 0.2 ng ml-1, after angioplasty: 3.7 +/- 1.4 ng ml-1, P < 0.05; IL-2, baseline: 1.9 +/- 0.4 ng ml-1, after angioplasty: 5.4 +/- 2.2 ng ml-1, P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Return to work following an aquafitness and muscle strengthening program for the low back injured

Our purpose, in this prospective clinical study, was to identify the best predictors of 2-month return to work or retraining for a group of low back injured subjects (n = 40) who completed at least 8 weeks of a community-based rehabilitation program that combined aerobic and flexibility exercise conducted in the water (aquafitness) with muscle strength and endurance training. Baseline demographic characteristics and changes in physical fitness, pain, disability, and psychological well-being during the course of program participation were compared between two groups of low back injured subjects: those who returned to work (RTW) [n = 24], and those who did not (N-RTW) [n = 16]. Subjects in both groups showed comparable improvement in measures of physical fitness at 8 weeks. However, multivariate analyses showed significant between-group differences in self-report measures. The RTW group showed significant improvement in measures of pain, disability, anxiety, and vigor while self-esteem and affect remained stable. The N-RTW group displayed no change in pain and disability variables and had significant deterioration in mean overall psychological well-being over time. The best predictors of return to work using logistic regression analyses were a first injury rather than a repeat injury to the lower back, and stability in self-esteem. Suggestions are offered for further research to examine the benefits of aquafit exercise for the low back injured, for additional interventions for those with a reinjury, and for maintaining or enhancing self-esteem as a treatment goal.

The 'temporomandibular pain dysfunction syndrome' personality: fact or fiction?

It is widely accepted that abnormal personality traits are important factors in the aetiology and maintenance of the temporomandibular pain and dysfunction syndrome (TMPDS). However, the foundation upon which this paradigm rests is largely based on clinical lore rather than evidence. The continued belief in the stress theory has onerous implications. First of all, clinicians could be lulled into a false sense of security about the efficacy of traditionally sanctioned treatments. Second, and potentially more important is the chilling effect on research that results from the premature and unsupported conclusions voiced by many, that certain issues regarding the diagnosis and treatment of TMPDS are solved. Such conclusions will lead not only to problems of patient care but may forge an unstable foundation for future research. Three theories are examined for convergent evidence in support of the putative relationship between personality and TMPDS. They are the 1) psychosomatic 2) coping and 3) psychophysiological theories. Currently evidence lacks for all three theories although there is partial support for the latter. It has not been demonstrated that TMPDS cases are characterized by a specific premorbid personality.

Immunity, major depression, and panic disorder comorbidity

Because recent research reports indicated clinical and biological differences in major depression with and without comorbid Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) panic disorder, and as altered immune measures were reported in selected subgroups of depressive patients, we investigated 51 pairs of major depressive episode (MDE) subjects, and gender- and age-matched healthy controls in order to determine if T lymphocytes number and function abnormalities were associated with Panic Disorder comorbidty. We found that those MDE subjects with DSM-III-R panic disorder (PD) had greater numbers of T cells (p less than 0.05) and PHA mitogen (p less than 0.05) responses than depressive patients without PD, as well as increased phytohemagglutinin (PHA) (p less than 0.05) concanavalin A (ConA) (p less than 0.02) mitogen responses compared to their controls. These data suggest that panic disorder comorbidity significantly contributes to the variance of immunologic parameters in major depression and has to be carefully assessed within psychoimmunological studies of psychiatric patients with affective disorders.

Losing face: sources of stigma as perceived by chronic facial pain patients

The purpose of this paper is to identify potential sources of estrangement and feeling psychologically flawed as perceived by temporomandibular pain and dysfunction syndrome (TMPDS) patients. It is our hypothesis that a primary source of patients' perceived stigma results from pejorative labeling by clinicians. The data come from a study of 151 women TMPDS patients. The results show that the lack of a known etiology or pathogenesis for the condition allows the possibility of pejorative labeling by influential others such as physicians and dentists that in turn causes TMPDS sufferers to feel stigmatized. Stigmatization is not the result of clinical factors per se or personality problems. Perceived stigma associated with TMPDS leads to the same sorts of strained interactions and feeling estranged that have been shown to be typical of people with other stigmatized conditions. These strains and feelings in turn may contribute to ill health.