A simplified psychologic questionnaire as a treatment planning aid for patients with temporomandibular joint disorders

E. N. Gale, Ph.D.,* and D. C. Dixon** State University of New York at Buffalo, School of Dental Medicine, Buffalo, N.Y.

Psychologic factors are often believed to have a significant role in the etiology and

maintenance of temporomandibular joint disorders. Anxiety and depression have

received the greatest focus. Approximately 132 patients with temporomandibular joint disorders completed seven self-administered depression questionnaires and

four anxiety questionnaires. Correlation among all 11 questionnaires was signifi- cant. Factor analysis was interpreted as indicating the 11 questionnaires were measuring a single factor. For preliminary screening diagnosis, two questions were

were suggested to be a good approximation of the total battery of questionnaires. (J PROSTHET DENT 1989;61:235-8.)

A lthough moat investigators believe that psychologic factors play a significant role in the etiology or maintenance of temporomandibular joint disorders (TMJD), their impact on individual cases is often difficult to determine. Among many psychologic factors contributing to TMJD, depression and anxiety have been the primary focus of attention. Sol- berg et al.,l in a study of symptomatic and control subjects, observed that half of the symptom group showed clinical signs of anxiety. He pointed out that although the symptoms of this subgroup may be due, in part, to anxiety, it is an er- ror to consider all TMJD patients as homogeneous in psychological makeup. Psychologic factors may be impli- cated to a greater extent in patients unresponsive to con- ventional therapy. Schwartz et al.’ found elevations on sev- eral scales of the Minnesota Multiphasic Personality Inven- tory (MMPI)3 in a group of patients unresponsive to conventional treatment. The greatest elevations were in de- pression, agitation, and anger. Gesse14 treated eight TMJD patients unresponsive to biofeedback relaxation therapy with cyclic antidepressants. Four of these patients, all judged to have significantly elevated clinical depression, responded to the medications. The remaining four nonresponding pa- tients were judged to have serious depression accompanied with disability to the extent that they had abandoned pro- ductive pursuits. Attempts have been made to predict response to treatment by using the MMPI.‘, 5 Individual outcome could not be predicted although, as a group, non- responders were found to be less emotionally healthy.

Many investigators have stressed the need to consider anxiety and depression in treatment planning. Molin et al6

Presented before the International Association for Dental Research, Chicago, Ill.

Supported in part by NIDR grants DE 04358 and DE 07089. *Professor, Department of Behavioral Sciences. **Lieutenant, United States Air Force, Lackland Air Force Base,

San Antonio, Tex.

THE JOURNAL OF PROSTHETIC DENTISTRY

concluded that anxiety and muscle tension played a signif- icant role in TMJD and that muscle- and joint-associated pain further accentuated the anxiety. He also urged clini- cians to consider psychologic factors in formulating treat- ment plans. Gross and Vacchiano7 compared personality characteristics of controls and TMJD patients, finding, among other factors, anxiety and depression in the symp- tomatic group. He asserted that dentists must recognize the emotional component of this disorder and refer or treat ac- cordingly. Fines suggested that psychologic evaluations may be appropriate for patients with nonorganic TMJD.

In contrast to the above findings, Malow et al.’ could find no difference between TMJD patients and normals with two self-administered psychologic tests. Turner and Romanol’ recommended restraint in basing treatment solely on cutoff scores from self-administered psychologic tests because of the possibility of false positives and false negatives. Galell contended that the anxiety and hostility found in TMJD patients may be of minor etiologic significance and it is just as likely that the TMJD causes the anxiety as vice versa. Olsen” cited a lack of evidence verifying the validity of self- rating psychologic tests and does not recommend them for use as diagnostic or treatment selection guide.

Underlying these widely varying opinions is the multifac- eted etiology of TMJDs. However, there is a subgroup of TMJD patients in whom anxiety and depression may con- tribute to the development and maintenance of muscle hy- peractivity, parafunctional habits, and altered pain percep- tion and tolerance.13 Although anxiety and depression may not be of etiologic significance, their interface with treatment may affect outcome. In view of this, an indication of the pa- tient’s emotional status is an important part of the diagnos- tic picture and may affect the clinician’s approach in coun- seling the patient regarding the course of the disorder.

The purpose of this study was to examine interrelation- ships of several psychologic questionnaires that may give an indication of patient emotional status and to determine how

235

Table I. Depression scales correlations Table II. Anxiety scales correlations

GALE AND DIXON

SQDA DQfGD DQfDD ADSIGD POMSID ATQ SQAA ADS/AN POMSIT

DQ/GD 0.52

DQiDD 0.37 0.59

ADWGD 0.56 0.71 0.53

POMS/D 0.60 0.69 0.43 0.77

A’JJQ 0.50 0.75 0.46 0.83 0.81

CES-D 0.56 0.67 0.48 0.84 0.79 0.82

Correlation significance of p < ,001. Key to questionnaires: SQDA, Single Question Depression Assessment; D&l CD, Depression Questionnaire/General Depression; DQiDD, Depression Questionnaire/Depth of Depression; ADWGD, Anxiety Depression Scale/ Global Depression; POMWD, Profile of Mood States/Depression-Dejection; ATQ, Automatic Thoughts Questionnaire; CES-D, Center for Epidemiologic Studies Depression Scale.

well a simple, time-efficient questionnaire correlates with more complex and lengthy standardized psychological ques- tionnaires.

METHODS Subjects

The subjects in this study were 19 men and 113 women patients who were evaluated at the School of Dental Medi- cine, State University of New York at Buffalo. The age range of the patients was 19 to 75 years with a mean age of 40.4 years. Of the patients, 108 were considered to have chronic conditions because their pain was of 2 years duration or greater and previous treatment had been unsuccessful. The remaining 24 patients had symptoms of acute TMJD of less than 6 months’ duration. All patients gave informed consent before participation.

Measures

Seven self-administered questionnaires measuring de- pression and four measuring anxiety were given to each pa- tient during the initial diagnostic session. The following is a brief description of each questionnare.

The Taylor Manifest Anxiety Scale (TMAS) is a true/false 51-item questionnaire extracted from items dealing with anxiety in the MMPI.3 It has high score reproducibility over a period of time.14

The Profile of Mood States, Tension-Anxiety (POMS/T) is a nine-item anxiety subscale of the Profile of Mood States (POMS) instrument. The POMS is a 65-item scale in which subjects rate how various mood adjectives apply to self-feel- ings on a scale of (0) “not at all” to (4) “extremely.” It has been correlated to symptom improvement in psychotherapy and drug treatment trials. The Profile of Mood States/De- pression-Dejection (POMWD) is a 15-item depression sub- scale of the 65-item POMS.i5

The Anxiety and Depression Scale (ADS) is a 68-item yes/no response questionnaire including anxiety and depres- sion subscales. Scores have been correlated to clinical diag- noses. One study suggests that the scale is sufficiently sen-

ADS/AN 0.55

POMSIT 0.56 0.66

TMAS 0.61 0.68 0.69

Correlation significance of p < ,001. Key to questionnaires: POMWT, Profile of Mood Stat&Tension-Anxiety; TMAS, Taylor Manifest Anxiety Scale; ADS/AN, Anxiety and Depression Scale/Anxiety; SQAA, Single Question Anxiety Assessment.

sitive to separate depression from anxiety and to determine depth of depression.“j

The Depression Questionnaire (DQ) is a 57-item yes/no response inventory that gauges depth of depression and dis- tinguishes depressed from nondepressed subjects.i7 The in- strument correlates well with clinical diagnoses and im- provement of symptoms during psychotherapy. The two subscales of this questionnaire used in the study were: gen- eral depression (DQ/GD), and depth of depression (DQ/ DD).

The Automatic Thoughts Questionnaire (ATQ-30) de- vised by Hollon and Kendall’* contains 30 items dealing with depression. Subjects indicate the extent to which they iden- tified with each statement during the preceding week on a scale from (1) “not at all” to (5) “all the time.” The scale correlated highly with the Beck Depression Inventory” and MMPL3

The Center for Epidemiologic Studies Depression Scale (CES-D) is a 20-statement inventory dealing with depres- sion. Subjects indicate the extent to which they identified with the statements during the previous week on a contin- uum from (0) “rarely or none of the time” to (3) “most or all of the time.” Scores correlate well with other depression scales and the instrument has adequate test and retest consistency.”

On the Single Question Depression Assessment (SQDA), the first half of the two-item simplified assessment, the pa- tient responds to the question: How depressed are you? by rating himself on a continuum from (0) “never” to (4) “often.” Similarly on the single-question anxiety assessment (SQAA), the other half of the two-item simplified assess- ment, the patient rates himself on the question: Do you con- sider yourself more tense than calm or more calm than tense? on a continuum from (0) “calm” to (4) “tense.”

RESULTS

Matrices of correlation coefficients for the depression scales and anxiety scales are shown in Tables I and II.

All correlations were positive and statistically significant at the p < .OOl level. The range of correlations was from 0.37 to 0.83 for depression scales and from 0.51 to 0.69 for anx- iety scales. Average corrdations were calculated by convert- ing r coefficients to z scores, finding the mean of the z scores, and then reconverting the z means to mean r coefficients.

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SIMPLIFIED PSYCHOLOGIC QUESTIONNAIRE

The mean correlation for all depression tests was 0.66 and for

all anxiety tests was 0.63.

The mean correlation of the SQDA to other depression questionnaires was 0.52 with r values ranging from 0.37 to 0.60. The low r = .37 for the SQDA correlation to the DQ/DD follows the pattern of low correlations of the DQ/DD to the other depression scales (Table I). A t-test comparing the mean r value of all depression questionnaires to the mean r value of the SQDA correlated to the longer questionnaires showed no significant difference at the p > .05 level (Table III).

The mean r value of the SQAA correlated to the other anxiety tests was 0.57 and the range was 0.55 to 0.61 (Table

III). A t-test comparing the mean r value of all the anxiety questionnaires to the mean r value of the SQAA correlated to the longer anxiety questionnaires also showed no signif- icant difference at the p < .05 level (Table III).

Although correlations of the single question assessments to the longer instruments were somewhat lower than the av- erage of all correlations combined, the single question corre- lations were still very strong and significant at the p < .OOl level for both anxiety and depression (Table III).

Principal component factor analysis of the anxiety and depression scores revealed one factor common to both types of tests. The factor loadings ranged from 0.60 to 0.91.

DISCUSSION

The present data indicate that the potential of the two-question simplified assessment for detecting tendencies toward anxiety and depression compares favorably with the more complex psychological questionnaires. The signifi- cance of these results will be discussed in relation to other depression/anxiety studies and to the evaluation of these characteristics in TMJD patients.

Several studies of depression and anxiety and other emo-

tional disorders by, among others, Mendles et a1.,21 Dobson,22 and Gotlieb and Robinson23 have found that de- pression and anxiety scores among the currently available

self-administered psychologic questionnaires were highly correlated. These investigators have concluded that ques- tionnaires do not clearly differentiate between depression

and anxiety. Factor analysis applied to the tests results re- veals one common factor that Gotlieb and Robinson23 labeled “psychological distress.” Applying factor analysis to the data in the present study corroborated this common fac- tor finding. The “distress” factor, which appears to be the core characteristic detected by these tests, may currently be the most measurable psychologic factor applicable to TMJD patients. We contend that since the single-question assess- ments are highly correlated with the more complex tests, they are nearly as effective in detecting this factor.

Because there is some question regarding the interplay of psychologic factors with temporomandibular disorders and the ability of questionnaires to assess and differentiate accurately between anxiety and depression, great caution

Table III. Mean correlations among all depression questionnaires, all anxiety questionnaires, and among depression and anxiety questionnaires and single-question scale

Average correlation forall scales

(X r value)

Average correlation of single question scale

to o_ther scales (X r value)

Depression .66 NS* .52

Anxiety .63 NS .57

*NS indicates no significant difference between mean r values.

must be exercised in the clinical use of information elicited

from these tests. However, the assessments may provide valuable insight into emotional status that might otherwise

be undetected. One cannot argue that the treatment ap- proach to patients experiencing emotional or psychologic distress should be the same as patients without such com- plications. This becomes even more germane in patients who do not respond to conventional therapy in a reasonable amount of time. We are, therefore, suggesting that the inclusion of a simplified questionnaire in the health history or standard questionnaire that most TMJD patients com- plete before treatment may give valuable information in a

concise and time-efficient manner. This information could be used as a screening aid in a multiple-approach treatment philosophy or as an alternative approach in cases that do not respond to conventional therapy. A positive response on the questionnaire could be used as a departure point for further questioning or investigation into the possibility that emo- tional factors may be contributing to the etiology or inter- fering with treatment. Treatment alternatives for cases in which emotional involvement is suspected include referral

for psychologic evaluation or antidepressive medications, stress reduction, relaxation therapy, or biofeedback.

The diagnosis and treatment of the emotional component of TMJDs is on an uncertain foundation. Most agree, how-

ever, that emotional factors have a significant effect on the course of many TMJD cases. Yet, there is little consensus on how the clinician should approach this dilemma. The alter- natives presented here represent a conservative application of the presently available evidence relative to self-adminis- tered psychologic questionnaires. The awareness by the cli- nician of potential interference with conventional treatment strategies caused by emotional distress could be of aid in planning and completing treatment.

SUMMARY

Seven depression and four anxiety self-administered ques- tionnaires were given to 126 temporomandibular joint dis- order patients. All depression questionnaires correlated sig- nificantly, p < .OOl, as did the anxiety questionnaires where p was also less than 0.001. The single-question depression and anxiety subscales that compose the two-item simplified

THE JOURNAL OF PROSTHETIC DENTISTRY 237

GALE AND DIXON

assessment correlated well with the corresponding long-form depression and anxiety scales. The favorable correlation of the short assessment to the longer assessments indicates that the shorter assessment may be nearly as effective in provid- ing evidence regarding the emotional status of TMJD patients.

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Reprint requests to: DR. ELLWIT N. GALE STATE UNIVERSITY OF NEW YORK AT BUFFALO SCHOOL OF DENTAL MEDICINE BUFFALO, NY 14214

238 FEBRUARY 1999 VOLUME 61 NUMBER 2