No abstract

Overlap between unexplained clinical conditions is substantial. Most studies are limited by methodologic problems, such as case definition and the selection and recruitment of case-patients and controls.

We evaluated the short- and long-term efficacy of a brief cognitive-behavioral therapy (CBT) for chronic temporomandibular disorder (TMD) pain in a randomized controlled trial. TMD clinic patients were assigned randomly to four sessions of either CBT (n=79) or an education/attention control condition (n=79). Participants completed outcome (pain, activity interference, jaw function, and depression) and process (pain beliefs, catastrophizing, and coping) measures before randomization, and 3 (post-treatment), 6, and 12 months later. As compared with the control group, the CBT group showed significantly greater improvement across the follow-ups on each outcome, belief, and catastrophizing measure (intent-to-treat analyses). The CBT group also showed a greater increase in use of relaxation techniques to cope with pain, but not in use of other coping strategies assessed. On the primary outcome measure, activity interference, the proportion of patients who reported no interference at 12 months was nearly three times higher in the CBT group (35%) than in the control group (13%) (P=0.004). In addition, more CBT than control group patients had clinically meaningful improvement in pain intensity (50% versus 29% showed > or =50% decrease, P=0.01), masticatory jaw function (P<0.001), and depression (P=0.016) at 12 months (intent-to-treat analyses). The two groups improved equivalently on a measure of TMD knowledge. A brief CBT intervention improves one-year clinical outcomes of TMD clinic patients and these effects appear to result from specific ingredients of the CBT.

Objective. To compare the frequency of lifetime psychiatric disorders among 3 groups of subjects: patients with fibromyalgia syndrome (FMS) from a tertiary care setting, community residents with FMS who had not sought medical care for their FMS symptoms (' 'FMS nonpatients' '), and healthy controls. Fibromyalgia syndrome (FMS) is a relatively common, chronic musculoskeletal pain disorder of unknown cause that affects -15% of rheumatology clinic patients (1). The etiopathogenesis of FMS is not understood, but peripheral factors (e.g., muscle tissue abnormalities) and central factors (e.g., ,neurohormonal changes, abnormal regional cerebral blood flow) have been associated with symptom onset ( 2 4 ) .Psychiatric disorders and psychological distress represent one set of central factors that may influence the behavior of patients with FMS. Some investigators have suggested that psychiatric illness also may play a role in the development of FMS. For example, Hudson and colleagues recently utilized a structured interview, the Diagnostic Interview Schedule, to assess lifetime rates of psychiatric diagnoses in patients with FMS or rheumatoid arthritis (RA) in a tertiary care rheumatology clinic. Higher rates both of major mood disorders (64% versus 22%) and of panic disorder or agoraphobia (33% versus 11%) were found in FMS versus RA patients. Moreover, for the majority of diagnoses, initial symptoms predated the onset of pain among the FMS patients (5,6). Although these observations were based on the interview responses of patients who may not have been representative of community residents with FMS, it was concluded that FMS may share a common pathophysiology with depressive and anxiety disorders.Wolfe and colleagues recently examined psychological distress in FMS clinic patients and community residents with FMS (7). They found high levels of psychological distress in both groups and therefore suggested that psychological distress is intrinsically related to the FMS syndrome. However, the cornmu-

Progress in advancing understanding of the role of "catastrophizing" in pain and associated physical and psychosocial disability may be furthered by (1) consideration of the construct of catastrophizing, (2) evaluation of the extent to which currently available measures of pain catastrophizing tap into that construct, (3) investigation of the relation of catastrophizing to personal trait variables (e.g., neuroticism and worry), and (4) identification of the conditions (or states) under which catastrophizing is most likely to occur. In this article, the authors discuss these issues and suggest directions for future research.