1. health and fitness
2. disease
3. chronic pain

The Effects of a Cognitive-Behavioral Treatment
Program on Temporo-Mandibular Pain and
Dysfunction Syndrome
HENDERIKUS J. STAM, PHD, PATRICIA A. MCGRATH, PHD,
AND RALPH I. BROOKE, BCHD, FDSRCS, FRCD, MRCS
Sixty-one patients clearly diagnosed as suffering from Temporo-Mandibular Pain and Dysfunction Syndrome (TMPDS) were randomly assigned to one of three groups, 1) hypnosis and
cognitive coping skills, 2) relaxation and cognitive coping skills, or 3) a no-treatment control
group. All patients were evaluated with a standard hypnotic susceptibility scale before treatment. The two treatment groups received four weekly sessions of their respective treatments.
Patients in the hypnosis and relaxation groups reported equivalent decrements in pain, abnormal
sounds in the temporomandibular joint, and limitations of jaw mobility. Hypnotic susceptibility
was significantly correlated with reductions in reported pain for the treatment groups. Patients
age and the duration of pain before treatment were not related to treatment outcome. Patients
who dropped out of treatment had fewer limitations in jaw movement but did not differ in any
other variable from patients who remained in treatment. These findings are discussed in relation
to the hypothesis that Temporo-Mandibular Pain and Dysfunction Syndrome is stress-related
muscular pain and dysfunction.
Temporo-Mandibular Pain and Dysfunction Syndrome1 (TMPDS) is usually
differentiated from other facial pains by
the absence of clinical or radiographic evidence of organic changes in the tempo-
'TMPDS is the name proposed for this syndrome
by the subcommittee on taxonomy of the International Association for the Study of Pain. It is frequently referred to as myofascial pain dysfunction
syndrome in the dental literature to eliminate diagnoses involving known pathology in the temporomandibular joint (1-3). The term myofascial pain
dysfunction syndrome, however, does not convey the
fact that the syndrome is limited to the area of the
temporomandibular joint.
From the Department of Oral Medicine, University
of Western Ontario, London, Ontario. Canada.
Address requests for reprints to: Henderikus J. Stam,
PhD, Department of Psychology, University of Calgary, Calgary, Alberta, Canada T2N 1N4.
Received for publication July 6, 1983; revision received December 2, 1983.
534
romandibular joint and lack of tenderness
in the condyles (2, 3). It is typically associated with three symptoms, namely pain
and tenderness of the muscles of mastication and the temporomandibular joint,
sounds during condylar movements (i.e.,
popping, clicking, or crepitus in the temporomandibular joint), and limitations of
mandibular movements (4). TMPDS has
been attributed to spasm in the muscles of
mastication that may be mediated by physical or psychologic stress (3-8). Support
for this hypothesis has come from several
areas of research. First, pain that is similar
in intensity and quality to TMPDS pain
can be induced in healthy volunteers by
vigorously thrusting the mandibles so that
the lateral pterygoid muscles are hyperactivated (9). Second, TMPDS patients exhibit hyperactivity of the mandibular musculature (6, 8, 10, 11). Such hyperactivity
Psychosomatic Medicine Vol. 46, No. 6 (Nov./Dec. 1984)
Copyright © 1984 by the American Psychosomatic Society, Inc
Published by Elsevier Science Publishing Co . Inc.
52 Vanderbilt Ave , New York. NY 10017
0033-3174/84/53.00
COGNITIVE-BEHAVIOR TREATMENT
in these patients can be induced by stress
(3,6,8, 10, 11, 12).
Evidence that the muscle hyperactivity
in TMPDS is related to psychologic stress
comes from studies that have examined or
induced stress in these patients (6, 8). These
studies have found both elevated stress and
psychophysiologic disorders in TMPDS
patients. Although several methodologic
problems may make these results equivocal, the hypothesis that stress-related
muscular hyperactivity is responsible for
TMPDS pain has led to the development
of relaxation-based psychologic treatment
programs. Both electromyographic (EMGj
biofeedback and progressive muscular relaxation training have successfully led to
decrements in pain and dysfunction (6, 8,
13-15).
For example, Brooke and Stenn (15)
compared 190 patients in four treatment
groups: ultrasound, use of occlusal splint,
relaxation training with biofeedback, and
relaxation training without biofeedback.
These authors concluded that relaxation
training was as effective as other conservative methods of treatment and also produced the most rapid beneficial effect.
Furthermore, at six months after treatment
there were no significant differences in the
percentage of successfully treated patients
when relaxation training patients were
compared with those who had received
more than one treatment modality because
of the failure of the first method.
The exact mechanisms by which relaxation therapies come to reduce TMPDS
symptoms are not known. It may be, however, that they aid in accentuating the relationship between muscle hyperactivity
and stressful situations, thus leading to a
more attentive monitoring of sensations and
activity from the region of the temporomandibular joint. Consequently, the ha-
bitual manner of coping with variables that
precipitate and maintain the symptoms is
altered. In this manner the effects of relaxation therapies may be cognitively mediated. Because cognitive-behavioral therapies have not been explicitly evaluated
in the treatment of TMPDS, one purpose
of the present study was to compare the
effectiveness of cognitive pain control
techniques in a no-treatment control procedure. Furthermore, the inclusion of a notreatment control procedure was also
deemed important because there are reports in the literature that symptoms occasionally abate in the absence of treatment (6). However, no-treatment control
groups are rarely used in TMPDS research.
Hypnosis is often used as an adjuvant
to relaxation-based therapies (16-19). In
fact, the cognitive behavior therapies and
the hypnotic situation have several variables in common (20). The most important
of these is what is often referred to as "involved imagining" or the ability to become
involved in and absorbed in one's imaginings (20-23). Most investigators of hypnosis agree that involvement in suggestion-related imaginings is closely related
to responsiveness to suggestions or hypnotic susceptibility (20, 24). Furthermore,
numerous clinical and laboratory studies
of hypnotic and suggested analgesia have
found a direct relationship between pain
reductions and hypnotic susceptibility
(25-28). Thus another purpose of the present study was to examine the predictiveness of hypnotic susceptibility for treatment outcomes in hypnotic and
nonhypnotic treatment groups for chronic
oral facial pain.
Hypnotically suggested analgesia and
suggestions for analgesia given in the absence of an hypnotic induction procedure
typically result in equivalent reductions
Psychosomatic Medicine Vol. 46, No. 6 (Nov./Dec. 1984)
535
H. J. STAM et al.
in reported pain or equivalent increments
METHODS
in pain tolerance in between-subjects designs (25, 29, 30). When hypnotic analSubjects
gesia is found to be superior to suggestions
Sixty-one patients who had been referred to the
alone as an analgesic, it is typically in expain clinic in the Department of Oral Medperiments using within-subjects designs oral-facial
icine at the University of Western Ontario agreed to
in which subjects are aware of the order take part in this study. They were diagnosed as sufof treatment (28). Stam and Spanos (31) fering from TMPDS on the basis of 1) lack of changes
showed that the superiority of hypnotic or organic disease of either temporomandibular joint
analgesia in such experiments was due to as determined by radiographs, 2) lack of tenderness
the condyles on physical examination, and 3) the
the carry-over effects of within-subjects of
presence of at least one of the following symptoms:
designs. Hypnotic analgesia was found to pain and tenderness of the muscles of mastication;
be more effective, less effective, or equally sounds during condylar movements, mainly clickeffective as suggestions for analgesia alone, ing; and limitations of mandibular movements. Padepending upon the expectations induced tients ranged in age from 15 to 41 (M = 25.7 years,
SD = 7), and 51 (84%) were women. The mean duby varying treatment order (31).
ration of pain before treatment was 23 months
Although these issues have been eval- (SD = 26); the median duration was 12 months. Fortyuated in the laboratory, few clinical stud- one patients completed the entire assessment, treaties have been conducted to evaluate the ment and follow-up sequence. The remaining 20 were
classified As dropouts.
efficacy of an hypnotic induction procedure in augmenting pain reductions beyond suggestions for analgesia alone. TypProcedure
ically, investigators present hypnosis and
A research assistant interviewed all patients in a
suggestions and compare these to no treat- pretest session.1 Patients completed a multidimenment at all. For example, Reeves et al. (27) sional oral-facial pain questionnaire and were then
studied two groups of cancer patients about tested on the Carleton University Responsiveness to
to undergo painful hyperthermia treat- Suggestion Scale (CURSS) (32). The CURSS is a stanments with either hypnosis plus sugges- dardized, reliable, and valid scale of hypnotic susceptibility that yields three suggestibility scores for
tions or no treatment. Although the highly each
subject; 1) an objective score reflecting overt
susceptible patients receiving hypnosis re- response to suggestion (CURSS : O), 2) a subjective
ported less pain, it is not clear what as- score reflecting experiential response to suggestion
pects of the treatment were responsible for (CURSS : S), and 3) an objective involuntariness score
this reduction. A further purpose of the that reflects the extent to which objectively passed
were experienced as occurring involunpresent experiment, then, was to compare responses
tarily (CURSS : O-I).
a group of patients who received hypnosis
Each patient was tested individually. The assistant
plus suggested cognitive strategies with a presented an hypnotic induction procedure orally,
group that received relaxation training plus followed by the seven CURSS test suggestions and
suggested cognitive strategies. This al- then the waking procedure. Patients self-scored their
lowed us to assess whether the presence overt and subjective responses to each suggestion in
of an hypnotic induction procedure and a booklet after the waking procedure. The CURSS : O
the definition of treatment as hypnotherapy would increase treatment efficacy beyond that found in a relaxation training
group.
'Thanks to Fran Cosier for conducting this session.
536
Psychosomatic Medicine Vol. 46, No, 6 (Nov./Dec. 1984)
COGNITIVE-BEHAVIOR TREATMENT
and 0-1 dimensions yielded scores ranging from 0 to
7 for each person; the CURSS : S dimension yielded
a score ranging from 0 to 21 (32).
Treatments. After their pretest session, patients
were randomly assigned to one of three treatments
with the exception that each group had approximately equivalent numbers of subjects with high, medium, and low susceptibility to hypnosis: hypnosis
(n = 12), relaxation (n = 15), or waiting list control
(WCL) (n = 14). The hypnosis and relaxation groups
each received four weekly sessions of treatment beginning one week after their pretest session. The two
treatments were identical with the exception that in
the hypnosis group treatment was denned as hypnosis and each session was begun with a standard
hynotic induction procedure. In the relaxation group,
on the other hand, treatment was defined as relaxation; those subjects received standard progressive relaxation instructions at the outset of each session.
The therapist was blind to patients' hypnotic susceptibility scores.
The remainder of each session for both groups consisted of providing patients with coping skills to enable them to deal with painful episodes (33, 34). These
consisted of attention diversion strategies, imagery
training and imaginative reconstruction, and thought
management or the reappraisal of pain-related thoughts
and feelings. Specific strategies included focusing
attention on details of the environment, focusing on
cognitive processes, concentrating on activities, focusing on other, nonpainful sensations, imagining or
recalling pleasant experiences, reinterpreting painful
sensations, and encouraging positive self-statements
(33, 34).
Outcome Measures. After the pretest all patients
had received a "daily pain log" consisting of seven
140-mm visual analog scales (VAS). Each scale was
bounded by "no pain" on one end and "most intense
pain imaginable" on the other. Patients were asked
to make three marks daily along each line to indicate
the intensity of their pain on awakening, during midday, and in the evening. Each mark was labelled for
identification. All patients completed these logs
throughout treatment until their fourth session. Aside
from their function in assessing treatment efficacy,
the logs were used to discuss and isolate situational
variables that preceded or coincided with painful
episodes. They also served to involve patients in the
treatment process
At the beginning of each treatment session, all patients rated the intensity of their pain, the frequency
of any sounds in the temporomandibular joint, and
the extent of limitations (if any) in opening their
mouths on three 140-mm visual analogue scales. The
actual extent to which the mouth could be opened
was measured in millimeters with a caliper by the
therapist.
Two to four weeks after treatment, all patients were
examined by the dental surgeon who had made the
original diagnosis and who was blind to the patients'
treatment status. After a physical examination the
surgeon rated each of the three symptoms in terms
of four categories, worse, same, improved, or completely alleviated.
Waiting List Control Group. Patients assigned to
the WLC group were seen for the pretest session and
then returned four to six weeks later. At that time
they were reexamined by the dental surgeon, who
was blind to their treatment status. In the interval
between examinations they were asked to complete
the daily pain logs, which were returned after testing.
All WLC group patients were then offered relaxation
training.
RESULTS
One-way analyses of variance indicated
that there were no differences between the
groups on any of the dependent measures
before treatment. Thus any posttreatment
differences cannot be attributed to preexisting differences between the groups.
Daily Logs
All of the patients in the hypnosis and
relaxation groups completed the logs and
ten (71%) of the patients in the WLC group
completed theirs. Before examining treatment efficacy, the time course of TMPDS
was determined by examining the logs of
the WLC group. Figure 1 depicts the daily
ratings averaged for each week of the fourweek waiting period during which these
ten patients kept records. A reliable pattern (as denned by at least 6 days in every
week) emerged for seven of the ten WLC
Psychosomatic Medicine Vol. 46, No. 6 (Nov./Dec. 1984)
537
H. J. STAM et al.
Fig. 1. Mean rated pain in mm ( + SEM) presented
by week and time of day and averaged across
days from the daily logs of 10 waiting list
control group patients.
x weeks interaction, however, was significant, F(4, 68) = 2.51, p < 0.05 (covariate F[l, 33] = 174, p < 0.001). Newman-Keuls post hoc multiple comparisons
on the adjusted means involved in the interaction (35) indicated 1) patients in the
hypnosis and the WLC groups did not
change significantly in peak pain across
weeks, 2) patients in the relaxation group
reported significant decrements in peak
pain from the second to fourth week, and
3) relaxation group patients reported significantly less pain by the fourth week than
did WLC group patients, whereas the hypnosis group did not differ from either the
relaxation or WLC group in the fourth week.
The means involved in this interaction are
presented in Table I. 1
patients. As can be seen in Figure 1, pain
Weekly Symptom Ratings
was rated as mild (or not present) on awakening, increased by midday, and most sePain Intensity and Sounds in TMJ. At
vere in the evening. Likewise, nine (75%) each of the four weekly visits, all treatment
of the hypnosis group patients and ten
(66%) of the patients in the relaxation group
TABLE 1.. Mean Covariate and Adjusted Mean
showed the same consistent pattern of
Peak Pain Scores for the Treatment x Weeks
change in reported painfulness within days.
Interaction
Thus, for most patients the most intense
Treatment group
pain was consistently experienced during
Week
Relaxation
Hypnosis
WLC
later portions of the day.
The data from the daily logs were re1a
50.9
61.6
51.3
2
48.1 a
48.6a
43.2 a
duced by summing the greatest of the three
3
45.7 a
39.9 ab
50.7a
daily pain reports during each week and
4
34.9 b
55.1,
44.8a
dividing by seven. Thus, we obtained a
n
12
15
10
"peak pain" score for each patient for each
of four weeks, beginning with the week WLC = waiting list control.
Means within each group sharing the same subscript do
before the first treatment session. This first not differ significantly from each other, p < 0.05.
week was then used as a covariate in a aCovariate.
3 x 3 mixed analysis of covariance (ANCOVA). The between-subjects variable was
treatment group (three levels) and the
"An identical ANCOVA on the mean weekly pain
within-subjects variable was weeks (three
scores for each subject led to similar results, with the
levels). Neither of the main effects ap- exception, of course, that the means were lower than
proached significance. The treatment those of the peak pain scores.
538
Psychosomatic Medicine Vol. 46, No. 6 (Nov./Dec. 1984)
COGNITIVE-BEHAVIOR TREATMENT
group patients had rated their subjectively
experienced pain, sounds, and limitations
of opening on the 140-mm VAS. The subjectively rated pain and sound measures
were each subjected to a 2 x 3 mixed ANCOVA. The between-subjects variable was
treatment (two levels) and the within-subjects variable was weeks (three levels). The
first week was again used as the covariate.
For the ANCOVA on pain, the only effect
to achieve significance was the main effect
for weeks, F (2, 50) = 7.17, p < 0.01, (covariate F[l,24] = 7.35, p < .05). Likewise,
the only effect to approach significance for
the ANCOVA on sounds was the main effect for weeks, F (2, 50) = 4.16 p < 0.05,
(covariate F[l, 24] = 84.44, p < 0.001). The
adjusted means for these main effects are
presented in Table 2. Newman-Keuls post
hoc multiple comparisons on the adjusted
means for rated pain involved in the main
effect for weeks indicated that both thirdand fourth-week ratings were significantly
lower than second-week ratings. For rated
sounds, the multiple comparisons indicated that fourth-week ratings were significantly lower than second-week ratings.
Third-week ratings did not differ from second- or fourth-week ratings.
TABLE 2. Mean Covariate and Adjusted Mean
Weekly Rated Pain Intensity (VAS) and Rated
Frequency of Sounds in the Temporomandibular
Joint (VAS) for the Week's Main Effects
Week
Pain
V
2
3
4
62.5
60.5a
42. %
38.6 b
Sounds
66.7
60.9a
54.5ab
46.7b
VAS = visual analogue scales.
n = 27 for combined treatment groups. Means sharing
the same subscript do not differ significantly from each
other, p < 0.05.
'Covariate.
Limitations of Mouth Opening. Eight
patients in the hypnosis group (67%) and
nine patients in the relaxation group (60%)
had limitations in mouth opening at the
start of treatment. For these patients, differences between the treatment groups in
VAS-rated limitation of opening at any of
the sessions were not significant as determined by t-tests (all ts < 1). However, the
difference between the first and fourth session for all 17 patients combined was significant, t (16) = 3.02, p < 0.01. Thus, patients who reported having limitations in
opening the jaw at the first session
(M = 54.5, SD = 36) rated their limitations as significantly less at the fourth session (M = 29.1, SD = 33).
Maximai Mouth Opening. Measurements of maximal mouth opening (in millimeters) for these same 17 patients were
examined for differences between the
treatment groups. There were no significant differences between the hypnosis and
relaxation groups at any of the sessions (all
ts < 1). The difference between the first
and fourth session for the two groups combined was significant, t (16) = 2.39,
p < 0.05. Maximal mouth opening in millimeters increased significantly from the
first (M = 30.9, SD = 5.7) to the fourth
session (M = 35.4, SD = 5.9).
Posttreatment Evaluation
To overcome the low frequencies in some
of the cells for the following analyses, the
posttreatment ratings by the dental surgeon were combined to form two categories, same or worse, and improved or
completely alleviated. These are presented in Table 3.
Pain. Chi-square analyses for the ratings of pain indicated a significant degree
Psychosomatic Medicine Vol. 46, No. 6 (Nov./Dec. 1984)
539
H. I. STAM et al.
TABLE 3. Frequencies of Posttreatment Physician
Outcome Ratings of TMPDS Symptomatology
Categories
Croup
Pain
Hypnosis
Relaxation
WLC
Sounds
Hypnosis
Relaxation
WLC
Limitations"
Hypnosis
Relaxation
WLC
Same or worse
Improved or alleviated
5
3
10
7
12
4
7
6
11
5
9
3
2
2
9
6
7
3
TMPDS = temporomandibular pain and dysfunction;
WLC = waiting list control.
^Limitation ratings are presented only for patients who
had limitations of mouth opening at the time they entered
the study.
of association between treatment group and
posttreatment pain, x2(2) = 7.81, p < 0.05.
A separate x2 comparing the two treatment
groups was nonsignificant, x2(l) = 1-49.
The two treatment groups combined and
compared with the WLC group, however,
did result in a significant degree of association, x 2 (l) = 7.96, p < 0.01. Thus, the
posttreatment pain of the two treatment
groups was more likely to be rated as improved or alleviated than the ratings for
the WLC group.
Sounds. The rated presence of sound
was not associated with treatment group,
2
X (2] = 4.44, NS. When the treatment
groups are combined and compared to the
WLC group the x2 is also nonsignificant,
X2(l) = 3.52. Although a trend is present
that is consistent with the remaining data,
the overall relationship between treatment
group and rated sounds is nonsignificant.
540
Limitation of Mouth Opening. For patients with limitation of mouth opening,
rated limitations were significantly associated with treatment group, x2(2) = 7.55,
p < 0.05. Further analyses indicated no
differences between the two treatment
groups alone, x2(l) < 1. whereas the combined treatment groups compared to the
WLC group were significantly different,
X2(l) = 7.53, p < 0.01. Like the pain ratings, posttreatment limitations in opening
were more likely rated as improved or alleviated for treatment than no-treatment
patients.
Interrelationships of Outcome
Measures
The dependent measures for the two
treatment groups were intercorrelated for
each week of treatment. They were then
converted using Fisher's Z-transformation, averaged, and converted back to correlation coefficients. The mean correlation
coefficients for the four weeks are presented in Table 4. The only coefficients
that were significantly greater than zero for
each week of treatment were those relating
peak pain and weekly rated pain. The other
measures were weakly to moderately correlated and these correlations were not
consistently significant. Thus it appears that
there is some degree of independence
among the various symptom measures.
Hypnotic Susceptibility
and Outcome Measures
The peak pain scores, the weekly symptom ratings, and the maximal millimeters
of mouth opening taken in the last week
of treatment were subtracted from the same
measures obtained in the first week of
treatment. These difference scores and the
Psychosomatic Medicine Vol. 46, No. 6 (Nov./Dec. 1984)
COGNITIVE-BEHAVIOR TREATMENT
TABLE 4.
Mean Correlation Coefficients Relating Outcome Measures for Four Weeks of Treatment
Peak pain
Rated pain
Rated sounds
Rated limitations
Peak
pain
Rated
paina
Rated
sounds3
Rated
limitations3
Limitation
(mm)
_
0.57*
_
0.36
0.53
—
0.45
0.36
0.32
—
-0.29
-0.22
-0.16
-0.38
n = 27.
•"Weekly visual analogue scales ratings by patients.
*AII four correlations significant, p < 0.05.
posttreatment ratings of the dental surgeon
(worse = 1,
same = 2,
improved = 3, alleviated = 4) were then
correlated with the three measures of hypnotic susceptibility. They are presented in
Table 5 separately for the combined treatment groups and the WLC group.
The objective, subjective, and involuntariness measures of hypnotic susceptibility are highly and significantly correlated
with the reduction in patients' peak pain
scores and the posttreatment pain ratings.
There are no significant correlations between measures of hypnotic susceptibility
and TMPDS symptomatology for the WLC
group, although these correlations are based
on a small sample size. However, the difference scores based on the weekly pain
ratings were not significantly related to any
of the measures of hypnotic susceptibility.
This may have been due to the relative
instability of the global weekly ratings of
pain versus the daily ratings obtained from
the home logs. The correlation between
the peak pain difference scores and the
weekly rated pain difference scores was
0.51.
Age and Duration of Pain
Several reports have indicated that
treatment effectiveness for TMPDS may be
negatively related to both patients' age and
the duration of pain before treatment (36,
37). Age and duration are included in Table 5 and do not correlate significantly with
any of the outcome measures.
Attrition
Attrition was not related to any particular group. Patients were as likely to drop
out of the WLC group (n = 7) as they were
to drop out of the hypnosis (n = 6) or relaxation^ = 7) groups. Although there was
a trend for patients who did not drop out
of treatment to have a slightly longer duration of pain prior to treatment (M = 26.4
months, SD = 32) than dropouts (M = 15.8
months, SD = 21), this difference was not
significant, t (59) = 1.34. Thirteen of the
20 dropouts had completed at least one
treatment session. Their baseline levels of
pain and subjective presence of sounds did
not differ from those of subjects who did
not drop out. However, only five of these
13 patients (38%) complained of interfering limitations in mouth opening, whereas
17 (63%) treatment group patients and 12
(86%) WLC group patients had done so. A
comparison of dropouts with all other patients indicated that dropouts were significantly less likely to have limitations of
mouth opening than those who completed
Psychosomatic Medicine Vol. 46, No. 6 (Nov./Dec. 1984)
541
H. J. STAM et al.
TABLE 5.
Correlation Coefficients between Treatment Outcome Measures and Hypnotic Susceptibility
Scales, Age, and Duration
Difference Scores
Peak pain
Rated pain"
Rated sounds3
Rated limitations8
Limitations (mm)
Posttreatment ratings
Pain
Sounds
Limitations
CURSS.O
CURSS:S
CURSS:O-I
Age
Duration
0 60**(0.36)
0.19
0.25
0.36
-0.35
0.51"(0.19)
-0.01
0.30
0.37
-0.52**
0.44*(-0.21)
0.15
0.33
0.46*
-0.57"
-0.28(-0.10)
0.12
-0.09
-0.15
0.19
-0.08(-0.28)
-0.20
0.10
0.00
-0.15
-0.20(-0.35)
0.03(-0.09)
0.02(-0.39)
0.23I-0.36)
-0.19(-0.27)
0.03(0.26)
0.54"(-0.05)
-O.05(-0.09)
0.20(0.09)
0.58**(0.26)
-0.04(0.07)
-0.02(0.48)
0.58**(0.01)
-0.09(-0.23)
0.00(0.32)
CURSS = Carleton University Responsiveness to Suggestion Scale; WLC = waiting list control.
Correlations in parentheses are for WLC group (n = 14; n = 10 for peak pain); all others are for combined treatment
groups, n = 27.
a
Weekly visual analogue scales ratings by patients.
*p < 0.05.
•*p<0.01.
all aspects of the study x2U) = 4.66,
p < 0.05. A one-way analysis of variance
on baseline VAS ratings of limitation comparing the hypnosis, relaxation, and dropout group approached significance (F (2,
37) = 3.14, p < 0.06). Post-hoc comparisons indicated that the dropouts were significantly lower in rated limitations of
opening (M = 27) than those in the hypnosis (M = 61) or relaxation group
(M = 48), who did not differ from each
other. No other measure was able to predict whether or not a patient would remain
in treatment.
DISCUSSION
Patients in both cognitive behavioral
treatment groups reported less pain, lowered limitations in mouth opening, and a
lower incidence of abnormal sounds from
the first to fourth treatment session. Maximal mouth opening also increased over
the course of treatment. Furthermore, the
two treatment groups did not differ from
each other on these measures. Neither did
542
they differ on the posttreatment ratings of
the dental surgeon. However, both groups
did differ from the WLC group on posttreatment pain and limitations. Although
a similar trend was present for the posttreatment evaluation of sounds, this was
not significant. This coincides with patients' reports that the presence of clicking
or other sounds is often the last symptom
to disappear (38).
The peak pain scores indicated that the
relaxation group was the only group to report reductions in daily ratings relative to
the WLC group. Nevertheless, these groups
did not differ when evaluated after treatment. The reasons for this finding are not
immediately obvious. Overall, however,
our brief treatment program provided significant reductions in TMPDS symptoms.
Furthermore, these results are equivalent
to those obtained in a previously tested
larger group of TMPDS patients who
underwent seven sessions of relaxation
training with or without biofeedback in
the same clinic (15).
With the exception of the peak pain
scores, the hypnosis and relaxation groups
Psychosomatic Medicine Vol. 46, No. 6 (Nov./Dec. 1984)
COGNITIVE-BEHAVIOR TREATMENT
did not differ on any of the outcome measures. However, the reduction in peak pain
and posttreatment examination ratings of
pain were related to hypnotic susceptibility. This was true for all three measures
obtained from the susceptibility scale.
Laboratory studies of hypnotic analgesia
have long demonstrated the importance of
hypnotic susceptibility in predicting the
efficacy of suggested analgesia (25, 26,
29-31, 39). This is true regardless of the
presence or absence of a hypnotic induction procedure (30, 31). Several clinical
studies have likewise noted the importance of hypnotic susceptibility in predicting the efficacy of hypnotic analgesia
(27, 40). However, these studies have not
evaluated the effects of the definition of
the situation as hypnosis and the presence
or absence of a hypnotic induction procedure.
Our results indicated that hypnotic susceptibility was a good predictor of reductions in reported pain for both treatment
groups. These results coincide well with
laboratory studies that have found hypnotic susceptibility to be a good predictor
of responsiveness to suggestions for analgesia in both hypnotized and nonhypnotized subjects. They also suggest that the
skills that are critical for the efficacy of
cognitively based behavior therapies for
pain reduction may be the same skills that
are critical determinants of hypnotic susceptibility, namely, involvement and absorption in one's imaginings. Absorption
has also been implicated as an important
predictor of the efficacy of electromyographic biofeedback for reducing muscle
tension (41, 42). Quails and Sheehan (42)
found that conditions that encouraged a
withdrawal from the external environment (i.e., increased imaginative involvement) led to greater relaxation in high-absorption subjects than low-absorption
subjects. The latter group showed greater
relaxation with biofeedback than did highabsorption subjects. Thus, an important
direction for future research on cognitive
behavior therapies for pain reduction is
the specification of the situational and person variables that most enhance internal,
self-generated control.
One limitation of the present study was
the lack of a follow-up. Patients in the WLC
group received relaxation training after the
study and patients whose symptoms were
the same or worse at the end of treatment
were given the option of further treatment,
usually physiotherapy. Thus any followup would have been severely limited in
scope. It is also worth noting that, in the
study conducted by Brooke and Stenn (15)
on a large group of patients from the same
clinic, the success of relaxation training at
a 6-month follow-up was the same as success immediately after treatment. If these
data are representative, then it is unlikely
that a 6-month follow-up would have altered our results.
An aspect of this study that is rarely
addressed in the literature on TMPDS was
the attempt to account for attrition. Unfortunately, almost none of our measures
was able to discriminate between those who
were likely to drop out and those who were
likely to remain in treatment. The only exceptions were the measures of limitations
in opening from the 13 patients who had
completed at least one treatment session.
Their lower level of limitation may have
led these patients to decide they could deal
with their TMPDS on their own once they
had been diagnosed. Nevertheless, this is
speculative and future studies should examine the nature of attrition from behaviorally based treatment programs more
carefully.
In summary, our study provides further
evidence that relaxation-based psycho-
Psychosomatic Medicine Vol. 46, No. 6 (Nov./Dec. 1984)
543
H. J. STAMetal.
logic treatment programs are effective in
treating TMPDS. Although the study does
not provide direct support for the hypothesis' that stress-induced muscular hyperactivity is related to TMPDS, the success
of psychologic therapies relative to more
traditional conservative therapies (15, 43)
is at least consistent with this hypothesis,
By denning potential stress situations, instructing patients to monitor muscle ten-
sion during and after stressful situations,
and by providing relaxation therapy and
coping strategies, we may reduce the contribution of the stress-hyperactivity cycle
to TMPDS. Furthermore, the efficacy of our
cognitive behavior therapy program, as well
as the correlation of pain reductions with
hypnotic susceptibility indicates that the
treatment effects may be cognitively mediated.
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