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The temporomandibular disorders (TMDs) are a heterogeneous group of painful musculoskeletal conditions that include masticatory muscle pain. TMD is a common condition but its etiology is, as yet, poorly understood. Although TMD can be quite disabling, most patients presenting with symptoms improve regardless of treatment type. This article focuses on nonpharmacologic treatments for TMD; recent articles on etiology, assessment, and treatment for this muscle pain condition are reviewed. Psychological approaches include biofeedback, minimal therapist contact interventions, relaxation, and cognitive-behavioral therapy. We suggest that treatments based on the biopsychosocial model of illness should be used concurrently with treatments focusing only on the biomedical aspects of TMD. Psychological treatments need not be viewed as a treatment of last resort, but rather should be delivered concurrent with biomedical treatments. We present data from recent clinical trials showing that treatment-matching approaches tailoring psychological and educational treatments to psychosocial profiles, delivered concurrent with usual dental care, results in greater and more sustained improvement than usual dental care alone. As such, treatment for TMD should be viewed in much the same way as treatment for most other chronic pain conditions, that is, from a multidisciplinary perspective.

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To compare phosphorus intake and renal phosphorus regulation between thermally injured patients and multiple trauma patients, 40 consecutive critically ill patients, 20 with thermal injury and 20 with multiple trauma, who required enteral tube feeding were evaluated. Phosphorus intakes were recorded for 14 days from the initiation of tube feeding which was started 1 to 3 days postinjury. Serum for determination of phosphorus concentrations was collected at days 1, 3, 7, and 14 of the study period. A 24-hour urine collection was obtained during the first and second weeks of nutrition support for urinary phosphorus excretion, fractional excretion of phosphorus, renal threshold phosphate concentration, and phosphorus clearance. Average total daily phosphorus intake during the 14-day study for thermally injured patients and multiple trauma patients was 0.99+/-0.26 mmol/kg/d vs 0.58+/-0.21 mmol/kg/d, respectively, p < .001. Serum phosphorus concentration on the third day of observation was significantly lower in the thermally injured group than those with multiple trauma (1.9+/-0.8 mg/dL vs 3.0+/-0.8 mg/dL, p < or = .01). A trend toward hypophosphatemia in the thermally injured group persisted by the seventh day of feeding (2.7+/-1.2 mg/dL vs 3.3+/-0.6 mg/dL, p < or = .04). Differences in urinary phosphorus excretion was not statistically significant between the thermally injured and multiple trauma groups (271+/-213 mg/d vs 171+/-181 mg/d for week 1, and 320+/-289 mg/d vs 258+/-184 mg/d for week 2, respectively). Urinary phosphorus clearance, fractional excretion of phosphorus, or renal threshold phosphate concentrations were also not significantly different between thermally injured and multiple trauma patients. During nutrition support, serum phosphorus concentrations are lower in thermally injured patients compared with multiple trauma patients despite receiving a significantly greater intake of phosphorus. Renal phosphorus regulation does not significantly contribute to the profound hypophosphatemia observed in thermally injured patients when compared with multiple trauma patients during nutrition support.

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OBJECTIVE: Traumatic events can result in a set of symptoms including nightmares, recurrent and intrusive recollections, avoidance of thoughts or activities associated with the traumatic event, and symptoms of increased arousal such as insomnia and hypervigilance. These posttraumatic stress disorder (PTSD)-like symptoms are frequently observed in persons with chronic pain syndromes. Little is known about how these two phenomena interact with one another. The present study evaluated PTSD-like symptoms in patients with fibromyalgia syndrome (FMS) and examined the relation between PTSD-like symptoms and problems associated with FMS. DESIGN: Ninety-three consecutive patients underwent a comprehensive FMS evaluation and completed self-report questionnaires measuring PTSD-like symptoms, disability, and psychosocial responses to their pain condition. Subjects were divided in two groups based on level of self-reported PTSD-like symptoms. RESULTS: Approximately 56% of the sample reported clinically significant levels of PTSD-like symptoms (PTSD+). The PTSD+ patients reported significantly greater levels of pain (p < 0.01), emotional distress (p < 0.01), life interference (p < 0.01), and disability (p < 0.01) than did the patients without clinically significant levels of PTSD-like symptoms (PTSD-). Over 85% of the PTSD+ patients compared with 50% of the PTSD- patients demonstrated significant disability. Based on response to the Multidimensional Pain Inventory, a significantly smaller percentage of PTSD+ patients were classified as adaptive copers (15%) compared with the PTSD- group (48.2%). CONCLUSIONS: Results suggest that PTSD-like symptoms are prevalent in FMS patients and may influence adaptation to this chronic illness. Clinicians should assess the presence of these symptoms, as the failure to attend to them in treatment may impede successful outcomes.

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OBJECTIVE: To examine the relationship between fibromyalgia syndrome (FM) and depression by determining the set of factors that differentiate FM patients with and without depressive disorders. METHODS: A sample of 69 patients with FM underwent a standardized tender point examination and a semistructured psychological interview and completed a set of self-report inventories. RESULTS: Of the sample, 39 met criteria for depressive disorder and 30 did not. Depressed patients with FM were significantly more likely to live alone, report elevated functional limitations, and display maladaptive thoughts than nondepressed patients. Nondepressed patients were significantly more likely to have received prior physical therapy than depressed patients. Pain severity, numbers of positive tender points, and pain intensity of tender points and control points did not differentiate the depressed and nondepressed patients. Discriminant analysis revealed that living status, the perception of functional limitations, maladaptive thoughts, and physical therapy treatment together identified diagnoses of depressive disorders for 78% of the patients. CONCLUSION: Concurrent depressive disorders are prevalent in FM and may be independent of the cardinal features of FM, namely, pain severity and hypersensitivity to pressure pain, but are related to the cognitive appraisals of the effects of symptoms on daily life and functional activities.

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This meta-analysis synthesized the results from controlled, clinical trials of psychotherapeutic treatments for posttraumatic stress disorder (PTSD). Psychotherapeutic modalities included behavioral, cognitive, and psychodynamic treatments, in group and individual settings. Participants in the studies included combat veterans from the Vietnam and Lebanon Wars, crime-related victims, and severe bereavement sufferers. The impact of psychotherapy on PTSD and psychiatric symptomatology was significant, d = .52, r = .25, when measured immediately after treatments were administered. Similarly, there was no decay in the effect of treatment at follow-up, d = .64, r = .31. Moreover, for target symptomes of PTSD and general psychological symptomes (intrusion, avoidance, hyperarousal, anxiety, and depression), effect sizes were significant, ranging from r's of .2-.49. Results suggest substantial promise for improving psychological health and decreasing related symptoms for those suffering from PTSD.

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OBJECTIVE: Laboratory experiments suggest that endogenous opioids inhibit blood pressure responses during psychological stress. Moreover, there seem to be considerable individual differences in the efficacy of opioid blood pressure inhibition, and these differences may be involved in the expression of risk for cardiovascular disease. To further evaluate the possible role of opioid mechanisms in cardiovascular control, the present study sought to document the effects of the long-lasting oral opioid antagonist naltrexone (ReVia, DuPont, Wilmington, DE) on ambulatory blood pressure responses during naturally occurring stress. METHOD: Thirty male volunteers participated in a laboratory stress study using naltrexone followed by ambulatory blood pressure under placebo and during the subsequent 24-hour period. Within-subject analyses were performed on ambulatory blood pressures under placebo and naltrexone conditions. RESULTS: Laboratory results indicate no significant group effects of naltrexone on blood pressure levels or reactivity. Ambulatory results indicate that during periods of low self-reported stress, no effect of opioid blockade was apparent. In contrast, during periods of high stress, opioid blockade increased ambulatory blood pressure. CONCLUSIONS: These findings suggest that naltrexone-sensitive opioid mechanisms inhibit ambulatory blood pressure responses during naturally occurring stress.

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The increasing prevalence of essential hypertension is a growing public health concern for Zimbabwe and other African countries. Two important risk factors for hypertension are urbanization and parental history of hypertension. The relations among parental history of hypertension, urbanization, and blood pressures (BPs) are poorly understood. The objective of this study is to clarify these relations in a population of urbanized, African, young adults. The relation between parental history of hypertension and urbanization on resting BP's and Bp responses to a mental arithmetic stressor was examined in a group of normotensive, Black medical students with (n = 36) and without (n = 34) a parental history of high BP, and with (n = 49) and without (n = 19) a parental history of urbanization. Results indicate that those with a positive parental history counterparts. Further, those with parents residing in urban areas had higher resting SBPs than those with parents residing in rural areas. However, no reactivity differences were apparent between the urban and rural parent groups. These data suggest that although parental history for hypertension influences both resting and reactivity BP's parental history of urbanization may influence only resting BP.

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There is a growing body of evidence that psychologic stressors can affect physical health and proneness to disease through depletion of the body's immune system. Relatively little research, however, has investigated the potential immunoenhancing effect of stress-relieving strategies such as progressive muscle relaxation. This study explored the relationship between immune functioning and relaxation training with persons experiencing persistent facial pain. In a single experimental session, 21 subjects either received relaxation training or rested for an equivalent time period. Salivary immunoglobulin A, mood, pain, and tension levels were measured before and after relaxation and rest periods. Results indicated that a greater proportion of those receiving relaxation training had increases in secretion of salivary immunoglobulin A. These findings suggest that immunoenhancement may be another potential benefit of progressive relaxation training for persons with chronic pain conditions.

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The purpose of this study was to determine the relationship between tongue position and mandibular muscle activity. Thirty-three subjects (28 women) between the ages of 18 and 34 years (mean = 22.1 years) with no prior injury to or pain in the jaw, mouth, or tongue participated in the study. Subjects were asked to rest quietly while baseline electromyographic recordings were made from the temporalis, masseter, and suprahyoid muscle regions. Afterwards, subjects were randomly assigned to conditions requiring them to position the tongue either "against the anterior palate" or "on the floor of the mouth, making sure the tip does not press against any part of the mouth." The results indicated that right temporalis activity was higher when the tongue was positioned against the roof of the mouth than when it was either at baseline or resting on the floor of the mouth (P < .03). A similar pattern of results was observed for the suprahyoid muscle group (P < .01). There were no significant differences in masseter muscle activity as a function of tongue position (Ps > .20). These findings suggest caution in labeling the "rest" position of the tongue and indicate that further study of the relationship between tongue position and orofacial pains in needed.

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Offspring with a parental history of hypertension are, by some estimates, four times more likely to develop the disease (Corvol et al., 1992). While some studies suggest that an increased risk is observable in eight year old children, others suggest that the increased risk does not become apparent until age 20. This study examined this discrepancy by screening resting blood pressures from 403 young adults. After adjusting for body mass, a significant family history x age x gender interaction (p < .01) suggests that the effect of family history on systolic blood pressure varies by age and gender. The influence of positive family history becomes apparent in males by age 20 and in females by age 22. This relationship may help provide a rationale for interpretation and reconciliation of disparate results in the literature, and clarify our understanding of the etiologic mechanisms responsible for development of essential hypertension.

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OBJECTIVES: This study examined the influence of terbutaline, a beta-adrenergic sympathomimetic amine on pain/pressure thresholds in the index fingers and masseter and trapezius muscles and electromyographic activity in trapezii. STUDY DESIGN: In a randomized and double-blind controlled trial, 20 asymptomatic female subjects were assigned to receive either an injection of terbutaline or sterile water before collection of pain/pressure thresholds and electromyographic levels. Repeated analysis of variance and paired t tests were calculated to test for baseline and postinjection differences between groups. RESULTS: No significant baseline or postinjection group differences in pain/pressure thresholds or electromyographic were detected. CONCLUSIONS: beta-adrenergic sympathomimetic stimulation does not influence pain/pressure thresholds or electromyographic activity in the masselet and trapezius muscles or pain/pressure thresholds in the index fingers. These results suggest that development of painful muscle conditions is not caused by elevations of sympathetic activity.

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OBJECTIVE: The objective was to test the prospective association between prenatal maternal circulatory responses to a standardized psychologic challenge and birth outcome. STUDY DESIGN: We examined the relationship between blood pressure responses to a cognitive arithmetic stressor and birth outcome in 40 healthy primigravid women. Pregnant women between 18 and 37 years old were recruited from the University of Kentucky Prenatal Service Clinic for participation. All women performed an interactive arithmetic task while maternal heart rate and blood pressures were determined. Subsequent birth outcome parameters of birth weight and gestational age were obtained for prospective analyses. RESULTS: Results indicated that maternal systolic and diastolic blood pressures and heart rates were significantly increased during the arithmetic task (p < or = 0.01). Regression analyses suggested that women with larger diastolic blood pressure responses during stress had infants with lower birth weights (p < 0.01) and decreased gestational age (p < 0.05). CONCLUSIONS: This effect was specific to psychologic stress reactivity and was not related to maternal age, maternal race, baseline blood pressures, the trimester of stress testing, nor expired carbon monoxide. The relationship between maternal blood pressure response and birth outcome may reflect the transplacental impact of individual differences in systemic stress responsivity.

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This study examined the relationship among endogenous opioids, Monitoring and Blunting coping styles, and acute pain responses. Fifty-eight male subjects underwent a 1-min pressure pain stimulus during two laboratory sessions. Subjects experienced this pain stimulus once under endogenous opioid blockade with naltrexone and once in a placebo condition. Blunting was found to be negatively correlated with pain ratings, but this relationship was significantly more prominent under opioid blockade. Results for coping behaviors subjects used to manage the experimental pain were generally consistent with the Blunting results, indicating that cognitive coping was related more strongly to decreased pain ratings and cardiovascular stress responsiveness under opioid blockade. Overall, the beneficial effects of Blunting and cognitive coping on pain responses did not depend upon endogenous opioids and, in fact, became stronger when opioid receptors were blocked. The relationship between endogenous opioids and coping appears to be dependent upon situational and stimulus characteristics.

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Estimates of the proportion of persons aged 65 and older with diagnosable mental disorders, residing both in the community and in institutions, range from 13.5% to 22%. Mental health services, both inpatient and outpatient, short and long term, are necessary for the well-being of these older Americans. Mental health benefits are covered under Medicare. However, less than 3% of the $90.5 billion Medicare budget in 1988 was spent on mental health services. Of that 3%, $2.2 billion was used for Part A (hospital insurance) and $300 million for Part B (medical insurance). In contrast, in the same year, payments for mental health services represented 20% to 30% of total health expenditures made by private insurers. Differences in payments abound when comparing freestanding psychiatric facilities with both exempt and nonexempt psychiatric units in general hospitals. This article describes these differences and how they influence the use of mental health services by Medicare beneficiaries.

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This study examined the role of endogenous opioids in the relation between hostility and cardiovascular stress responsiveness. Forty-six men completed the Cook-Medley Hostility Scale and experienced a laboratory pain stressor once under opioid blockade and once under placebo. Hostility scores were significantly related to the magnitude of change in cardiovascular reactivity/recovery resulting from opioid blockade. Low scorers on the Cynicism subscale displayed increases in heart rate (HR) reactivity under blockade relative to placebo, with reactivity decreases noted in high scorers. Low Hostile Affect scores were similarly associated with impaired diastolic blood pressure recovery under opioid blockade. HR recovery results were somewhat different, with high scorers on Aggressive Responding and the total Cook-Medley displaying improved HR recovery under opioid blockade, with no change noted in low scorers. These data provide preliminary support for the hypothesis that low hostile individuals rely on endogenous opioids for buffering cardiovascular stress responsiveness, but high hostiles do not.

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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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