Comorbidity Between Facial Pain, Widespread Pain, and Depressive Symptoms in Young Adults

Aims: To assess, firstly, the prevalence of facial pain associated with widespread pain and the prevalence of high levels of depres-sive symptoms (ie, “depressiveness”) among subjects with this pain condition, and secondly, the association between depressive-ness and a facial pain condition. Methods: This study forms part of the Northern Finland Birth Cohort study. The original material consisted of all people whose expected birthdate was in 1966 in Northern Finland. Of these, 5,696 participated in a follow-up study at the age of 31. As part of it, data on facial pain, pain in other areas of the body, depressiveness (measured using the Symptom Checklist-25 depression subscale) and sociodemographic background data were gathered using questionnaires. Prevalence proportion ratios were estimated using log-binomial regression models. Results: Facial pain and simultaneous widespread pain were reported by 8.3% of the subjects (6.6% of men and 9.9% of women), and 27.4% of those with widespread pain were depres-sive. Comorbidity between facial pain, widespread pain, and depressiveness was found to be particularly prevalent among women. Conclusion: Comorbidity should be taken into account in clinical practice. A multidisciplinary approach is needed, especially for patients with complex pain conditions.

facial pain; depression; widespread pain

1. American Academy of Orofacial Pain. Okeson JP (ed). Orofacial Pain. Guidelines for Assessment, Diagnosis, and Management. Chicago: Quintessence, 1996.

2. Dworkin SF, LeResche L. Research Diagnostic Criteria for Temporomandibular Disorders: Review, criteria, examinations and specifications, critique. J Craniomand Disord 1992;6:301–355.

3. American Academy of Craniomandibular Disorders. McNeill C (ed). Temporomandibular Disorders. Guidelines for Evaluation, Diagnosis, and Management. Chicago: Quintessence, 1990.

4. Von Korff M, Dworkin SF, LeResche L, Kruger A. An epidemiologic comparison of pain complaints. Pain 1988;32:173–183.

5. Rauhala K, Oikarinen KS, Järvelin MR, Raustia AM. Facial pain and temporomandibular disorders—An epidemiological study of the Northern Finland 1966 Birth Cohort. J Craniomandib Pract 2000;18:40–46.

6. Hagberg C, Hagberg M, Kopp S. Musculoskeletal symptoms and psychosocial factors among patients with craniomandibular disorders. Acta Odontol Scand 1994;52:170–177.

7. Turp JC, Kowalski CJ, O’Leary N, Stohler CS. Pain maps from facial pain patients indicate a broad pain geography. J Dent Res 1998;77:1465–1472.

8. Rantakallio P. The longitudinal study of the northern Finland birth cohort of 1966. Paediatr Perinat Epidemiol 1988;2:59–88.

9. Sipilä K, Veijola J, Jokelainen J, et al. Association between facial pain, temporomandibular disorders and depression—An epidemiological study of the Northern Finland 1966 Birth Cohort. J Craniomandib Pract 2001;19:183–187.

10. Magni G. On the relationship between chronic pain and depression when there is no organic lesion. Pain 1987;31:1–21.

11. Gallagher RM, Marbach JJ, Raphael KG, Dohrenwend BP, Cloitre M. Is major depression comorbid with tem-poromandibular pain and dysfunction syndrome? A pilot study. Clin J Pain 1991;7:219–225.

12. Gatchel R, Garofalo J, Ellis E, Holt C. Major psychological disorders in acute and chronic TMD: An initial examination. J Am Dent Assoc 1996;127:1365–1374.

13. Korszun A, Hinderstein B, Wong M. Comorbidity of depression with chronic facial pain and temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:496–500.

14. Carlson CR, Reid K, Curran SL, et al. Psychological and physiological parameters of masticatory muscle pain. Pain 1998;76:297–307.

15. Madland G, Feinmann C, Newman S. Factors associated with anxiety and depression in facial arthromyalgia. Pain 2000;84:225–232.

16. Dworkin SF, Von Korff MR, LeResche L. Multiple pains and psychiatric disturbance: An epidemiologic investigation. Arch Gen Psychiatr 1990;47:239–244.

17. Vimpari SS, Knuuttila MLE, Sakki TK, Kivelä S-L. Depressive symptoms associated with symptoms of the temporomandibular joint pain and dysfunction syndrome. Psychosom Med 1995;57:439–444.

18. Rantala MAI, Ahlberg J, Suvinen TI, et al. Temporomandibular joint related painless symptoms, orofacial pain, neck pain, headache, and psychosocial factors among non-patients. Acta Odontol Scand 2003; 61:217–222.

19. Raphael KG, Marbach JJ, Klausner J. Myofascial face pain. Clinical characteristics of those with regional vs. widespread pain. J Am Dent Assoc 2000;131:161–171.

20. Macfarlane TV, Blinkhorn AS, Davies RM, Kincey J, Worthington HV. Predictors of outcome for orofacial pain in the general population: A four-year follow-up study. J Dent Res 2004;83:712–717.

21. Carlsson GE. Epidemiology and treatment need for tem-poromandibular disorders. J Orofac Pain 1999; 13:232–237.

22. White KP, Speechley M, Harth M, østbye T. The London fibromyalgia epidemiologic study: Direct health care costs of fibromyalgia syndrome in London, Canada. J Rheumatol 1999;26:885–889.

23. Fink P, Jensen J, Borgquist L, et al. Psychiatric morbidity in primary public health care: A Nordic multicentre investigation. Part I: Method and prevalence of psychiatric morbidity. Acta Psychiatr Scand 1995;92:409–418.

24. Derogatis LR, Lipman RS, Covi C. SCL-90: An outpatient psychiatric rating scale—Preliminary report. Psychopharmacol Bull 1973;9:13–28.

25. Lehtinen V, Joukamaa M, Karlsson H, Rouhe E. Agreement on diagnoses of mental disorder in the primary health care of Turku, Finland. Eur Psychiatry 1995;10:11–16.

26. Winokur A, Winokur DF, Rickels K, Cox DS. Symptoms of emotional distress in a family planning service: Stability over a 4-week period. Br J Psychiatry 1984;144:395–399.

27. Nettelbladt P, Hansson L, Stefansson C-G, Borgquist L, Nordström G. Test characteristics of the Hopkins Symptom Check List-25 (HSCL-25) in Sweden, using the Present State Examination (PSE-9) as a caseness criterion. Soc Psychiatry Psychiatr Epidemiol 1993;28:130–133.

28. Skov T, Deddens J, Petersen MR, Endahl L. Prevalence proportion ratios: Estimation and hypothesis testing. Int J Epidemiol 1998;27:91–95.

29. SAS Institute SAS/STAT User’s Guide, Version 8. Cary, NC: SAS Institute, 1999.

30. Yap AU, Chua EK, Dworkin SF, Tan HH, Tan KB. Multiple pains and psychosocial functioning/psychologic distress in TMD patients. Int J Prosthodont 2002;15: 461–466.

31. Velly AM, Philippe P, Gornitsky M. Heterogeneity of tem-poromandibular disorders: Cluster and case-control analyses. J Oral Rehabil 2002;29:969–979.

32. Delgado PL. Common pathways of depression and pain. J Clin Psychiatry 2004;64 (suppl 12):16–19.

33. Stahl S, Briley M. Understanding pain in depression. Hum Psychopharmacol 2004;19:9–13.

34. Korszun A, Papadopoulos E, Demitrack M, Engleberg C, Crofford L. The relationship between temporomandibular disorders and stress-associated syndromes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:416–420.

35. Korszun A. Facial pain, depression and stress—Connections and directions. J Oral Pathol Med 2002;31:615–619.

36. Gold PW, Chrousos GP. The endocrinology of melan-cholic and atypical depression: Relation to neurocircuity and somatic consequences. Proc Assoc Am Physicians 1999;111:22–34.

37. Demitrack MA. Chronic fatigue syndrome and fibromyalgia. Psychiatr Clin North Am 1998;21:671–693.

38. Crofford LJ. Neuroendocrine abnormalities in fibromyalgia and related disorders. Am J Med Sci 1998; 315:359–366.

39. Zubieta J-K, Heitzeg MM, Smith YR, et al. COMT val158met genotype affects µ-opioid neurotransmitter responses to a pain stressor. Science 2003;299: 1240–1243.

40. Kim H, Neubert JK, San Miguel A, et al. Genetic influence on variability in human acute experimental pain sensitivity associated with gender, ethnicity and psychological tem-perament. Pain 2004;109:488–496.

41. Bassols A, Bosch F, Campillo M, Canellas M, Banos JE. An epidemiological comparison of pain complaints in the general population of Catalonia (Spain). Pain 1999;83:9–16.

42. Young EA. Sex differences and the HPA axis: Implications for psychiatric disease. J Gend Specif Med 1998;1:21–27.

43. Sipilä K, Zitting P, Siira P, et al. Temporomandibular disorders, occlusion and neck pain in subjects with facial pain—A case control study. J Craniomandib Pract 2002;20:158–164.

44. Carlsson GE. Epidemiology and treatment need for tem-poromandibular disorders. J Orofac Pain 1999;13: 232–237.