Psychiatric disorders associated with atypical facial pain

Case report: Treatment of persistent atypical odontalgia with attention deficit hyperactivity disorder and autism spectrum disorder with risperidone and atomoxetine

Chronic pain has recently been associated with developmental disorders [autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD)]. Regarding chronic pain in adulthood, fibromyalgia, migraine, and chronic low back pain have been associated with ADHD. The ICD-11 disease classification categorizes these pain diseases as chronic primary pain, suggesting high comorbidity with developmental disorders in chronic primary pain. Atypical odontalgia (AO) is a persistent tooth pain that occurs in the absence of any of the usual dental causes, most of which are triggered by dental treatment. Conditions characterized by tooth pain with no apparent cause are also classified as chronic primary pain. Approximately half the patients with AO are diagnosed with psychiatric disorders; the most common are depression (15.4%) and anxiety disorders (10.1%). However, there are no reports on neurodevelopmental disorders comorbid with AO. In the present study, we report a case of a 46-year-old man with numerous complaints (e.g., occlusal instability, difficulty eating, difficulty speaking), who took work leave due to worsening of his symptoms after periodontal scaling (“gingival recession” and “aggressive periodontal treatment”) and frequently expressed dissatisfaction and anger at the hospital, making the dental treatment difficult. After a referral to a psychiatrist specializing in chronic pain, AO and previously undiagnosed comorbidity of ASD and ADHD were confirmed. Atypical antipsychotic risperidone for ASD irritability and an ADHD medication, atomoxetine dramatically reduced anger, pain, anxiety, depression, and pain catastrophizing thoughts, leading to reduced obsession with his symptoms and less frequent complaints. After risperidone (1 mg/day) + atomoxetine (120 mg/day) were ultimately prescribed after adjustment, he was able to return to work 226 days after initiation of psychiatric treatment. Recent studies show that comorbidity of developmental disorders in patients with chronic pain is likely to be undetected. Clinicians should include screening for ASD and ADHD not only in cases of fibromyalgia, migraine, and chronic low back pain, but also in orofacial pain such as AO and other treatments for chronic primary pain. For patients diagnosed with ASD or ADHD, an effective drug therapy for ASD and ADHD should be considered.

[Studies on the psychodynamics of Chronic Orofacial Pain Disorder]

Studies on the psychodynamics of Chronic Orofacial Pain Disorder Objectives: Psychodynamic factors play an important role in its emergence and development of Chronic Orofacial Pain Disorder (COP), which is also known as Chronic Primary Orofacial Pain. This factors form the basis for differentiated psychotherapy. Methods: Seven female and two male patients with COP who had visited the Dental School, University Hospital, Ludwig Maximilian University of Munich, and the dental surgery of a practising dentist over the year were included in the study. Following a detailed dental examination, a psychodynamic interview was videotaped, reconstructing the connections between the life history and the development of the illness. Psychosomatic data were assessed by 3 psychotherapists based on a consensus model with regard to symptom trigger mechanisms such as conflicts and pressure, the development of symptoms, and the personality structure. Pathogenetically, we differentiated among conversion, somatization and projection. Results: The patients had a mean age of 57 years (range: 44-67) and an average illness duration of three (1-5) years. The average age where the illness had manifested was 54 (43-64). All patients showed clear psychodynamic factors in the development and course of the illness. The symptoms developed mainly during transitional situations during the life history, predominately in midlife. During this phase, dental treatment undertaken for whatever reason could trigger the chronic symptoms, which could then be further exacerbated by further dental interventions. The mode of symptom development by equal number of patients related to a somatoform disorder, such as a somatization of affect, a conversion with conflict symbolism and a projective-hypochondriac disorder. In the remaining patients, COP was an accompanying symptom of depressive disorder or the consequence of a posttraumatic stress disorder with self-mutilating tendencies. Conclusion: The consideration of psychosomatic connections and pathogenetic differentiation is helpful for the understanding and management of COP. This diagnostic differentiation could serve as a basis for prognosis and for specific therapeutic indications. Despite numerous general researches about chronic pain syndromes, there is a lack of intervention studies which take into account the specific conditions of COP on a larger sample.

Neuropathic orofacial pain: Characterization of different patient groups using the ICOP first edition, in a tertiary level Orofacial Pain Clinic

OBJECTIVE

To characterize patients with chronic neuropathic orofacial pain in accordance with the International Classification of Orofacial Pain (ICOP first edition) criteria.

STUDY DESIGN

A retrospective chart review of 108 patients was conducted. The most common categories observed were trigeminal neuralgia (TN) (25.9%), burning mouth syndrome (BMS) (11.1%), persistent idiopathic facial pain (PIFP) (26.9%), and posttraumatic trigeminal neuropathic pain (PTTNP) (26.9%); 9.3% of patients could not be categorized.

RESULTS

TN and BMS was more prevalent in the sixth decade, and PIFP and PTTN were more prevalent in the fifth decade. All categories showed female predilection. The pain in TN was predominantly episodic, described as "sharp shooting" and like an "electric shock," unilateral and affecting the V2 division, and with trigger zones in 50% of patients. Pain in BMS was predominantly constant and described as "burning," with the tongue being the most common site. Pain in PIFP and PTTNP was as follows: varied from constant to episodic; described as "burning," "sharp shooting," "throbbing," or "dull aching"; intraoral or extraoral; and mostly involving the V2 or V3 division.

CONCLUSION

This study is the first to characterize patients with neuropathic orofacial pain using the new ICOP criteria. PIFP and PTTNP were most commonly misdiagnosed categories. Using diagnostic criteria will increase the understanding of this patient group.

Patients with Psychiatric Disorders: What the General Dental Practitioner Needs to Know

Psychiatric illness is extremely common and the general dental practitioner (GDP) will inevitably encounter patients with such an illness. This article outlines common psychiatric conditions that the GDP should be familiar with alongside its impact on oral health. It also gives a systematic approach to dealing with a patient who presents to practice with an undiagnosed psychiatric illness, whereby the illness interferes with delivery of suitable dental care.

Psychiatric (axis I) and personality (axis II) disorders in patients with burning mouth syndrome or atypical facial pain

Background and aims

Burning mouth syndrome (BMS) and atypical facial pain (AFP) are often persistent idiopathic pain conditions that mainly affect middle-aged and elderly women. They have both been associated with various psychiatric disorders. This study examined current and lifetime prevalence of psychiatric axis I (symptom-based) and II (personality) disorders in patients with chronic idiopathic orofacial pain, and investigated the temporal relationship of psychiatric disorders and the onset of orofacial pain.

Method

Forty patients with BMS and 23 patients with AFP were recruited from Turku university hospital clinics. Mean age of the patients was 62.3 years (range 35–84) and 90% were female. BMS and AFP diagnoses were based on thorough clinical evaluation, and all patients had undergone clinical neurophysiological investigations including blink reflex and thermal quantitative tests. Current and lifetime DSM-IV diagnoses of axis I and II disorders were made on clinical basis with the aid of SCID-I and II-interviews. The detected prevalence rates and their 95% confidence intervals based on binomial distribution were compared to three previous large population-based studies.

Results

Of the 63 patients, 26 (41.3%) had had an axis I disorder that preceded the onset of orofacial pain, and 33 (52.4%) had had a lifetime axis I disorder. Rate of current axis I disorders was 36.5%, indicating that only about 16% of lifetime disorders had remitted, and they tended to run chronic course. The most common lifetime axis I disorders were major depression (30.2%), social phobia (15.9%), specific phobia (11.1%), and panic disorder (7.9%). Twelve patients (19.0%) had at least one cluster C personality disorder already before the emergence of orofacial pain. Patients with cluster C personality disorders are characterized as fearful and neurotic. None of the patients had cluster A (characterized as odd and eccentric) or B (characterized as dramatic, emotional or erratic) personality disorders. The most common personality disorders were obsessive–compulsive personality (14.3%), dependent personality (4.8%), and avoidant personality (3.2%). The majority of the patients (54%) had also one or more chronic pain conditions other than orofacial pain. In almost all patients (94%) they were already present at the onset of orofacial pain.

Conclusions

Our results suggest that major depression, persistent social phobia, and neurotic, fearful, and obsessive–compulsive personality characteristics are common in patients with chronic idiopathic orofacial pain. Most psychiatric disorders precede the onset of orofacial pain and they tend to run a chronic course.

Implications

We propose that the high psychiatric morbidity, and comorbidity to other chronic pain conditions, in chronic idiopathic orofacial pain can be best understood in terms of shared vulnerability to both chronic pain and specific psychiatric disorders, most likely mediated by dysfunctional brain dopamine activity.

Medically unexplained symptoms and somatoform disorders: diagnostic challenges to psychiatrists

BACKGROUND

Clinical limitations of the criteria of somatoform disorders (SDs) have been criticized. However, little objective evidence supports this notion. We aimed to examine the prevalence of SDs in a population with medically unexplained symptoms (MUS), which was expected to have higher probabilities meriting such diagnoses, and to evaluate factors that may influence the clinical judgment of psychiatrists.

METHODS

Data of subjects with MUS (n = 101, 9.5%) as their chief consulting problems, of 1,068 consecutive ethnic Chinese adult medical inpatients referred for consultation-liaison psychiatry services, were reviewed. Psychiatric diagnoses including SDs and clinical variables were collected. Those with SDs were followed-up 1 year later, and structured interviews were applied.

RESULTS

Patients with MUS had a high level of psychiatric comorbidity, especially depression (35.6%) and anxiety disorder (29.7%), rather than SDs (9.9%). Most diagnosed with SDs suffered from persistent MUS at the 1-year follow-up. Pain was the most common presentation of MUS. Most of the subjects diagnosed with SDs were female and younger, with multiple painful sites at presentation, no past psychiatric diagnosis and no comorbid organic diagnoses. The diagnosis of SDs was seldom given in those with simultaneous MUS and mood symptoms.

CONCLUSION

A significant proportion (9.5%) of patients in psychiatric consultation suffered from MUS, and most were comorbid with depression and anxiety. The identification of SDs was made in only 9.9%. Because MUS are associated with a high rate of mental comorbidities, psychiatric consultations while facing such clinical conditions are encouraged.

[Schizophrenia and pain reactivity]

INTRODUCTION

Medical practitioners do not for a long time pay enough attention to patient's pain. This approach is in the line of society feelings. Pain was long consider to be a contingency to withstand as showed in Christian's bible or Stoicism's principle. Changes in mentality appear in present times. It Seems obvious that for sociological and scientific reasons pain's care in medical and psychiatric disorders is now an important subject. Recent research in autistic disorders suggest that insensitivity observed in autism is not and analgesic phenomenon but a different behavioural reactivity to pain. Prevalence of schizophrenic disorder is from 0.5 to 1%. It is also a complex disorder that has defied decades of concerted efforts to uncover its origins and attenuate its symptoms. The most promising hypotheses suggest that neurodevelopmental impairment increases the risk of later schizophrenia. Most of recent researches in this topic did focus to trait or state markers. According to the vulnerability models of schizophrenia, trait marker are clinical, psychological, physiological, anatomical or cognitive impairments found in patients with schizophrenia during all the course of the illness and even before the onset. Several lines of evidence (case report, epidemiological studies, experimental studies) suggest that patients with schizophrenia shows a relative insensitivity to physical pain. We will review and critic the scientific literature in this specific topic. We will see if datas are relevant with the neurodevelopmental hypothesis and vulnerability models.

METHODS

An OLDMEDLINE/MEDLINE query was performed to identify 50 articles relevant to our subject. 9 were case report or case series, 21 were clinical or epidemiological studies, 15 were experimental studies and we also found 5 previous review.

RESULTS

Clinical and experimental data strongly suggest a decrease of Behavioural Reactivity to Pain (BRP) but there is a lack of argument to prove a real analgesia. Because schizophrenia is a severe disease with impairment in communication and social skills it may be very difficult to affirm that the insensitivity to pain does really exist for patients. It seems inappropriate at this point to speak about insensitivity or analgesia. We could hypothesis that the decrease of BRP is less a consequence of analgesia than a different way to express emotion in general and pain in particular. It is well known that patients with schizophrenia show communication and thinking impairment, not adapted social skills and also a lack of body representation. However, this decrease of behavioural response seems to be frequent and may be explore by objective research protocol to understand if patients don't feel pain or probably don't express pain by adapted social skills. Furthermore, decrease of BRP may take place in a comprehensive theory of schizophrenia. in the line of stress-vulnerability model. Impairment or lack of behavioural pain reactivity could induce an increasing anxiety level for patient with vulnerability to schizophrenia and a higher risk of onset of the pathology. We may argue that pain stimuli would conduct to a nociceptive stress witch couldn't discharge by usual ways of regulation and behavioural expression of pain. Exploration and interview about pain reactivity in vulnerable to schizophrenia subjects could be interesting to increase a the amount of information in a vulnerability check-up. Further studies in this axis may be useful to test this hypothesis.

[Differential and common characteristics of patients with atypical facial pain and craniomandibular dysfunction]

BACKGROUND

Craniomandibular disorders (CMD) and atypical facial pain (AFP) represent a clinical challenge. Whereas CMD patients respond to somatic approaches, somatization should be strictly avoided in AFP. The aim of this study was to establish prognostic criteria to identify an aggravated risk of a chronic course in CMD and AFP.

METHOD

A total of 124 consecutive patients with CMD ( n=108) or AFP ( n=16) were examined by two interdisciplinary academic pain centers. Psychometric evaluation was conducted with standardized questionnaires (SCL-90R, STAXI, modified SBAS-IV). All patients were clinically assessed by a maxillofacial surgeon or specialized dentist.

RESULTS

The following variables proved to be significant: age (risk for AFP vs CMD increased by 6% p.a.), decreased dysfunction index (13% higher risk for AFP vs CMD), and low scores concerning outwardly directed anger (12% higher risk for AFP vs CMD). There was no correlation between initial pain intensity and somatic parameters of disease as assessed by the standardized clinical examination. Low educational status proved to be the best predictor ( p<0.001) for patients presenting high initial pain with a marked discrepancy between somatic findings and subjective status.

CONCLUSIONS

CMD patients differ from AFP patients regarding age, psychosocial isolation, outwardly directed anger, and a decreased dysfunction index. Additionally, initial pain intensity in patients presenting indistinct CMD/AFP can be considered as a valid predictor for a chronic course in pain.

Sensory and affective components of orofacial pain: is it all in your brain?

In this paper, we shall review several chronic orofacial pain conditions with emphasis on those that are essentially refractory to treatment. We shall present a review of current and past literature that describes the various pain phenomena as well as their underlying central mechanisms. New data concerning refractory pain will be used to underscore the importance of central processing of pain, with particular emphasis on neuropsychological and cognitive function and capacity that may play important roles in pain processing and maintenance of the pain state. Further, neurophysiological data showing that the anterior cingulate cortex (ACC) and other structures in the brain may play key roles in modulation of chronic pain will also be discussed. Although peripheral triggering events surely play an important role in initiating pain, the development of chronic and, in particular, refractory pain may depend on changes or malfunctions in the central nervous system. These changes may be quite subtle and require sophisticated approaches, such as functional MRI, to study them, as is now being done. New findings obtained therefore may lead to more rational and reliable treatment for orofacial pain.

Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient

A number of different types of comorbidities have been described within psychiatric patients. These comorbidity types are reviewed and their application to the chronic pain population is discussed. These various types of comorbidities are then utilized to generate an approach for treatment decisions in the management of the chronic pain patient.

Stress, depression and left-sided psychogenic chest pain

Ninety men between the ages of 20 to 65 were studied to investigate the relationships between stress, depression and psychogenic pain. Three groups (the coronary heart disease (CHD) group; the left-sided psychogenic chest pain (LPCP) group; and the control group) comprising 30 patients per group, each completed the Social Readjustment Rating Scale (SRRS), as a measure of stress; the Schedule of Recent Experience, to document the recency of actual life events experienced as listed in the SRRS; and the Beck Depression Inventory, as a measure of the severity of depression. Separate analyses of the variables stress and depression failed to yield significant stress differences in the 3 groups, but the LPCP group was significantly more depressed than the CHD and control groups. Factor analysis, however, indicated that the stress profiles were significantly different in each of the 3 groups. This study indicates that the condition of LPCP shares a similar depressive profile to other psychogenic pain conditions and further lends support to the hypothesis linking psychogenic pain to depressive disorders.

Is atypical odontalgia a psychological problem?

Several authors have asserted that psychological factors are the underlying cause of atypical odontalgia. However, objective evidence is lacking to support this claim. In this study, the Minnesota Multiphasic Personality Inventory was used to assess psychological functioning of an atypical odontalgia population. Means of the standard scores for each Minnesota Multiphasic Personality Inventory scale were within normal ranges. Standard scores for atypical odontalgia profiles compared with standard scores for a chronic headache group (matched for age, sex, and chronicity) were similar and scales for both groups were within normal ranges. These findings fail to support psychological dysfunction as a primary condition associated with patients suffering from atypical odontalgia.

Characteristics of patients with chronic idiopathic orofacial pain. A retrospective study

Chronic orofacial pain without obvious pathologic findings is not uncommon and is a diagnostic problem. It is uncertain whether this type of pain is different from other chronic idiopathic pain conditions. Fifty-five patients referred to the Facial Pain Diagnostic Group at The Karolinska Institute, School of Dentistry at Huddinge University Hospital, Stockholm, were investigated retrospectively. There were 49 women and 6 men, ranging in age from 30 to 81 years, all with orofacial pain of more than 6 months' duration, which the patients considered to be of dental or paradental origin. Despite dental treatment aimed to relieve the pain, no permanent relief was observed. The results suggest that chronic idiopathic orofacial pain resembles other chronic idiopathic pain, and adequate diagnosis and treatment require not only dental but also medical competence.

Major psychological disorders in chronic TMD patients: implications for successful management

The authors assessed psychological disorders in 50 chronic TMD patients. These disorders appear to be a major concomitant factor in chronic TMD, and may need to be treated for successful outcomes.

Facial pain, distress, and immune function

Chronic facial pain syndromes are associated with high levels of distress and depression. Immune system measures were investigated in otherwise healthy patients suffering from chronic temporomandibular pain and dysfunction syndrome (TMPDS) and in matched controls. No mean differences were found between TMPDS patients and the controls on any of the immune measures; however, both ConA and PWM responses in TMPDS patients were decreased in relation to the level of demoralization (P less than 0.05). Cognitive symptoms such as low self-esteem and perceptions of helplessness/hopelessness were implicated in these effects. In addition, among patients pain severity was independently associated with decreased ConA response (P less than 0.05). The data suggest possible correlates of stress-induced changes in the immune system.

Screening for psychiatric illness in patients with oral dysesthesia by means of the General Health Questionnaire--twenty-eight item version (GHQ-28) and the Irritability, Depression and Anxiety Scale (IDA)

Thirty-one consecutive subjects suffering from oral dysesthesia and without detectable organic disease were seen in a university outpatient dental clinic. They were assessed with a screening test for psychiatric illness, the General Health Questionnaire, 28-item version (GHQ-28). Twelve subjects also completed the Irritability, Depression and Anxiety Scale (IDA). At the 4/5 cutoff on the GHQ, 51.9% of the patients showed evidence of psychiatric illness. The IDA appeared to be more sensitive than the GHQ-28 in terms of detecting psychiatric illness, especially depression, and 75% of the 12 subjects who completed both scales were found to be depressed on the IDA. These results were compared to results obtained by another cross-sectional study of different types of pain clinics in which the same scales were used to screen for psychiatric illness. The subjects with oral dysesthesia as measured by the IDA appeared to have psychiatric illness more often than the other subjects with chronic pain, except those attending a psychiatric clinic. The GHQ-28 results on the other hand showed less psychiatric illness in the latter group. Our findings indicate that psychiatric illness, especially depression, may play an important role in this disorder and that the IDA may be more sensitive than the GHQ for detecting depression.

The lateralization of atypical facial pain

Various theories have been proposed to explain the reported predominance of left-sided symptoms in patients with conversion disorders, psychogenic symptoms, and chronic pain. In a population of 110 patients with atypical facial pain (AFP), there were no significant differences in the side of pain or lateralization of pain between psychiatric and non-psychiatric patients. A non-significant trend to left-sided pain in psychiatric patients was found if only those patients with lateralized pain were examined. The significance of these results to etiological theories of chronic pain lateralization is discussed.

Orofacial pain of psychogenic origin: current concepts and classification

A description and attempt to classify the newly revised DSM-III and IASP classification schemes and those persistent orofacial pain syndromes that are commonly considered to be significantly associated with psychological or psychosocial factors, either as primary causes or as factors contributing to the maintenance of the chronic pain state are presented. The classification schemes include the DSM-III-R of the American Psychiatric Association and the new IASP taxonomy system, are the two systems currently available for classifying chronic orofacial pain states that are often considered to represent psychogenic pain conditions.

On the relationship between chronic pain and depression when there is no organic lesion

Patients suffering from pain without evidence of either depression or organic lesions, or of any pathophysiological process to which the pain might be attributed, may be diagnosed as suffering from 'indeterminate pain.' The evidence in the literature which suggests that some of these cases might be due to a 'depressive equivalent' is examined. It is suggested that it is difficult, if not impossible, to formulate a diagnosis of depressive illness in patients who do not have clear symptoms of depression. However, there is evidence in the literature that a relatively high percentage of patients with chronic indeterminate pain appear to have a family history of depression and depressive spectrum disorders. Biological markers of depression also give some indication that certain of these patients may have a link with depressive illness as well as with pain. It is suggested that there is a need to explore the existence of a sub-group of patients with indeterminate pain in whom the mechanism of the pain may be related to the mechanism of depressive illness even though formal depressive symptoms are not found.

Dilemma in treatment of patients suffering from orofacial dysaesthesia

A retrospective study of 64 patients with orofacial dysaesthesia is presented. Special emphasis is placed on the patients' symptoms and on the manipulative treatments they received before they were referred for psychiatric consultation. The patients had suffered from chronic orofacial pain or feelings of discomfort for periods ranging from 6 months up to 25 years. The patients had visited several specialists and had received numerous manipulative or medical treatments, the most common of which were repeated medication (drug treatment), TMJ dysfunction treatment, endodontic or exodontic treatment, and surgical explorations. However, the success of all these clinical efforts was very limited because of the apparent psychosomatic origin of the complaints. This study clearly shows that psychiatric consultations are still too seldom made in patients with chronic orofacial dysaesthesia, that many patients have a mental disorder, and that most chronic psychosomatic pain disorders are treated as acute specific pain.

Psychiatric disorders in orofacial dysaesthesia

70 patients with orofacial dysaesthesia were clinically examined at the Department of Oral and Maxillofacial Surgery of the University of Helsinki. All the patients were referred for a psychiatric consultation. Later 16 refused to attend. 12 of the 54 patients (22.2%) who took part in the psychiatric interview were psychotic, 27 patients (50.0%) had a moderate mental disorder and 11 patients (20.4%) a mild psychiatric disorder. 4 of the patients had no psychic diagnosis (psychically healthy). The control group, which comprised 44 patients referred to the Department for surgical extraction of an impacted tooth, filled in the Cornell Medical Index questionnaire. 3 of the controls (6.8%) had a severe mental disturbance, 5 (11.4%) a moderate psychic disorder and 4 (9.1%) a mild psychiatric disorder, whereas 32 patients (72.7%) were mentally healthy. The results show that there is a psychic background in most patients with chronic orofacial pain who have no clinical findings corresponding to the sensation of somatic pain.

A simple examination of the relationships between pain, organic lesions and psychiatric illness

It is often assumed that pain can be caused by psychological illness and also that severely painful organic lesions may cause emotional change. If these assumptions are correct, pain in the absence of lesions should be associated with a very high rate of psychiatric diagnosis; pain with lesions should occur with psychological illness more often than by chance but less often than in the group without lesions. To test these hypotheses two groups have been compared, one with pain and no evidence of organic lesions, the other with pain proportionate to organic lesions. Ninety-seven per cent of the first group and 39% of the second group were found to have psychiatric conditions (P less than 0.001).

Long-term results of sphenopalatine ganglioneurectomy for facial pain

Hemifacial pain associated with increased ipsilateral autonomic discharge can be both a diagnostic and therapeutic dilemma. Although frequently treatable with medication, some patients require surgical therapy in the form of sphenopalatine ganglion neurectomy. We report our experience with this procedure in 12 patients with long-term follow-up. Although there is a high incidence of pain recurrence, the pain is usually less severe and can be managed with medications.

Psychogenic/idiopathic pain syndromes

The concept of psychogenic pain is discussed and reviewed from multiple theoretical perspectives. The validity of psychogenic pain disorder as a clinical diagnosis is also examined, as are regional pain syndromes such as psychogenic abdominal, facial, pelvic, chest, and headache pain. The term "psychogenic pain" is considered to have limited clinical or diagnostic usefulness and the preferred term "idiopathic pain syndrome" used in DSM-III-R is advocated.

Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria

Two hundred and eighty-three chronic pain patients, consecutive admissions to the Comprehensive Pain Center of the University of Miami School of Medicine, received an extensive psychiatric evaluation based upon the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria and flowsheets. All patients received the following type of diagnoses: DSM-III axis I; DSM-III axis II, and personality type. The distribution of assigned diagnoses for the entire patient sample was reviewed and a statistical comparison between male and female patients was performed with regards to the prevalence of each diagnosis. Anxiety syndromes and depression of various diagnostic types were the most frequently assigned axis I diagnoses with over half the patient sample receiving each of these diagnoses. Males were significantly overrepresented in the axis I diagnoses of intermittent explosive disorders, adjustment disorders with work inhibitions, and alcohol abuse and other drug dependence, while females were significantly overrepresented in disorders of current depression of various diagnostic types and somatization disorders. 58.4% of the patients fulfilled criteria for axis II personality disorder diagnoses. The most frequently personality disorders found in the patient group were dependent (17.4%), passive aggressive (14.9%), and histrionic (11.7%). Males were significantly overrepresented in paranoid and narcissistic disorders while females were overrepresented in histrionic disorder. The most frequent personality types found in the patient group were compulsive (24.5%) and dependent (10.6%). All personality types were similarly distributed between the sexes. The results of the present study were compared to a previous study of DSM-III diagnoses in chronic pain patients and are discussed in terms of the prevalence of DSM-III diagnoses in the general population. Questions are raised as to the applicability of certain DSM-III diagnoses in the chronic pain population.

Tardive dyskinesia: an unrecognized cause of orofacial pain

Tardive dyskinesia has not previously been discussed in the dental literature. It is a drug-induced movement disorder commonly involving the perioral and masticatory muscles. It can sometimes be a cause of orofacial pain. Two brief cases reports are provided as examples. Clinical features of tardive dyskinesia are presented to assist the dental practitioner in recognizing the syndrome. Suggestions for management are included.

Atypical facial pain: a retrospective study

Among the most challenging patients seen for evaluation by a health care practitioner are those suffering from the atypical facial pain syndrome. They have almost inevitably been subjected to extensive treatment which either has had no effect on the symptoms or has aggravated them. This article reports a retrospective study of thirty-four randomly selected cases of atypical facial pain that have been seen by a multidisciplinary pain group.

The psychiatric referral in dentistry: indications and mechanics

Psychiatric consultation is sometimes a part of the diagnostic evaluation of facial pain. The indications for referral arise out of the history. Several brief questions may indicate whether or not a psychiatric illness is present. Patients may hold beliefs or attitudes about their illness or about psychiatric treatment that make referral difficult. Successful referral depends on the relationship that the dentist establishes with the patient. Recommendations to facilitate the referral are presented.