The Research Diagnostic Criteria for Temporomandibular Disorders. IV: Evaluation of Psychometric Properties of the Axis II Measures

Aims: To evaluate the psychometric properties of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) biobehavioral (Axis II) screening instruments. Methods: Participants with Axis I TMD diagnoses (n = 626) com-pleted the Axis II instruments (Depression, Nonspecific Physical Symptoms, Graded Chronic Pain) and other instruments assessing psychological distress, pain, and disability at three study sites. Internal consistency, temporal stability, and convergent/discriminant validity of the Axis II measures were assessed. To assess criterion validity of Nonspecific Physical Symptoms and Depression instruments as screeners, 170 participants completed a structured psychiatric diagnostic interview. Results: The Axis II instruments showed very good to excellent internal consistency (Cronbach’s alpha coefficients = 0.80 to 0.95). Their convergent (correlation range 0.3 to 0.9) and discriminant (range 0.0 to 0.6) validity were generally supported, although Nonspecific Physical Symptoms was more strongly associated with depressive than with somatic symptoms. Temporal stability was high for characteristic pain intensity (Lin’s correlation concordance coefficient [CCC] = 0.91), interference (CCC = 0.89), and chronic pain grade (weighted kappa = 0.87), and fair to good for Depression and Nonspecific Physical Symptoms (CCC = 0.63 to 0.78). The Depression instrument normal versus moderate to severe cutoff point was good at identifying current-year depression and dysthymia diagnoses (sensitivity 87%, specificity 53%). Nonspecific Physical Symptoms did not have high utility for detecting psychiatric disorders (sensitivity 86%, specificity 31%). Conclusion: The Axis-II Depression and Graded Chronic Pain instruments have clinically relevant and acceptable psychometric properties for reliability and validity and utility as instruments for identifying TMD patients with high levels of distress, pain, and disability that can interfere with treatment response and course of Axis I disorders.

biobehavioral;RDC/TMD;screening;sensitivity;specificity

1. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord Facial Oral Pain 1992;6:301–355.

2. Gatchel RJ, Peng YB, Peters M, et al. The biopsychocial approach to chronic pain: Scientific advances and future directions. Psychol Bull 2007;133:581–624.

3. Waddell G. Preventing incapacity in people with muscu-loskeletal disorders. Br Med J 2006;78:55–69.

4. Brage S, Sandanga I, Nygard JF. Emotional distress as a predictor for low back disability. Spine 2007;32:269–274.

5. Turner JA, Franklin G, Turk D. Predictors of chronic dis-ability in injured workers: A systematic literature synthesis. Am J Ind Med 2000;38:707–722.

6. Von Korff M, Ormel J, Keefe FJ, et al. Grading the severity of chronic pain. Pain 1992;50:133–149.

7. Gatchel RJ, Garofalo JP, Ellis E, et al. Major psychological disorders in acute and chronic TMD: An initial examination. J Am Dent Assoc 1996;127:1365–1374.

8. Kinney RK, Gatchel RJ, Ellis E, et al. Major psychological disorders in chronic TMD patients: Implications for successful management. J Am Dent Assoc 1992;123:49–54.

9. Wright AR, Gatchel RJ, Wildenstein L, et al. Biopsychosocial differences between high-risk and low-risk patients with acute TMD-related pain. J Am Dent Assoc 2004;135:474–483.

10. Garofalo JP, Gatchel RJ, Wesley AL, et al. Predicting chronicity in acute temporomandibular joint disorders using the research diagnostic criteria. J Am Dent Assoc 2007;129:438 –447.

11. Dworkin SF, Sherman JJ, Mancl L, et al. Reliability, validity, and clinical utility of RDC/TMD Axis II scales: Depression, non-specific physical symptoms, and graded chronic pain. J Orofac Pain 2002;16:207–220.

12. Ohrbach R, Granger CV, List T, et al. Pain-related functional limitation of the jaw: Preliminary development and validation of the jaw functional limitation scale. Community Dent Oral Epidemiol 2008;36:228–236.

13. Ohrbach R, Larsson P, List T. The jaw functional limitation scale: Development, reliability, and validity of 8-item and 20-item versions. J Orofac Pain 2008;22:219–230.

14. Kight M, Gatchel RJ, Wesley L. Temporomandibular disorders: Evidence for significant overlap with psy-chopathology. Health Psychol 1999;18:177–182.

15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: IV. Washington, DC: American Psychiatric Association, 1994.

16. Scott VM, Von Korff M, Alonso J, et al. Mental-physical comorbidity and its relationship to disability: Results from the world mental health surveys. Psychol Med 2009;39:33–43.

17. Conner TS, Tennen H, Zautra AJ, et al. Coping with rheumatoid arthritis pain in daily life: Within-person analyses reveal hidden vulnerability for the formerly depressed. Pain 2006;126:198–209.

18. Tennen H, Affleck G, Zautra A. Depression history and coping with chronic pain: A daily process analysis. Health Psychol 2006;25:370–379.

19. Banks SM, Kerns RD. Explaining high rates of depression in chronic pain: A diathesis stress framework. Psychol Bull 1996;119:95–110.

20. Schiffman EL, Truelove E, Ohrbach R, et al. The research diagnostic criteria for temporomandibular disorders. I: Overview and methodology for assessment of validity. J Orofac Pain 2010;24:7–24.

21. Goldberg DP, Gater R, Sartorius N, et al. The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med 1997;27:191–197.

22. Benjamin S, Lennon S, Gardner G, et al. The validity of the general health questionnaire for first-stage screening for mental illness in pain clinic patients. Pain 1991;47:197–202.

23. Look JO, John MT, Tai F, et al. The research diagnostic criteria for temporomandibular disorders. II: Reliability of axis I diagnoses and selected clinical measures. J Orofac Pain 2010;24:25–34.

24. Cardenas DD, Turner JA, Warms CA, et al. Classification of chronic pain associated with spinal cord injuries. Arch Phys Med Rehabil 2002;83:1708–1714.

25. Wright KD, Asmundson GJ, McCreary DR. Factorial validity of the short-form McGill pain questionnaire (SFMPQ). Eur J Pain 2001;5:279–284.

26. Dworkin SF, Von Korff M, Whitney CW, et al. Measurement of characteristic pain intensity in field research. Pain 1990;(suppl 5):S290.

27. Visser M, Leentjens AF, Marinus J, et al. Reliability and validity of the Beck depression inventory in patients with Parkinson’s disease. Mov Disord 2006;21:668–672.

28. Von Korff M. Epidemiologic and survey methods: Chronic pain assessment. In: Turk DC, Melzack R (eds). Handbook of Pain Assessment. New York: Guilford,1992:389–406.

29. Derogatis LR, Lipman RS, Covi L. SCL-90: An outpatient psychiatric rating scale preliminary report. Psychopharmacology 1973;9:13–28.

30. Derogatis LR. SCL-90-R: Administration, Scoring and Procedures Manual-II, for the Revised Version. Towson, MD: Clinical Psychometric Research, 1983.

31. Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. App Psych Measurement 1977;1:385–401.

32. Knight RG, Williams S, McGee R, et al. Psychometric properties of the Centre for Epidemiologic Studies Depression Scale (CES-D) in a sample of women in middle life. Behav Res Ther 1997;35:373–380.

33. Haringsma R, Engels GI, Beekman AT, et al. The criterion validity of the center for epidemiological studies depression scale (CES-D) in a sample of self-referred elders with depressive symptomatology. Int J Geriatr Psychiatry 2004;19:558–563.

34. Geisser ME, Roth RS, Robinson ME, et al. Assessing depression among persons with chronic pain using the center for epidemiological studies-depression scale and the Beck depression inventory: A comparative analysis. Clin J Pain 1997;13:163–170.

35. Turk DC, Okifuji A. Detecting depression in chronic pain patients: Adequacy of self-reports. Behav Res Ther 1994;32:9–16.

36. Werneke U, Goldberg DP, Yalcin I, et al. The stability of the factor structure of the general health questionnaire. Psychol Med 2000;30:823–829.

37. Rudy TE, Turk DC, Zaki HS, et al. An empirical taxometric alternative to traditional classification of temporomandibular disorders. Pain 1989;36:311–320.

38. Flor H, Turk DC. Chronic back pain and rheumatoid arthritis: Predicting pain and disability from cognitive variables. J Behav Med 1988;11:251–265.

39. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale multidimensional pain inventory (WHYMPI). Pain 1985; 23:345–356.

40. Turk DC, Rudy TE. Toward an empirically derived taxonomy of chronic pain patients: Integration of psychological assessment data. J Consult Clin Psych 1988;56:233–238.

41. The robustness of an empirically derived taxonomy of chronic pain patients. Pain 1990;43:27–35.

42. Rudy TE. Multidimensional Pain Inventory Version 3.0 User’s Guide. Pittsburgh, PA: University of Pittsburgh, 2005.

43. Ware JE Jr, Kosinski M, Turner-Bowker DM, et al. How to Score Version 2 of the SF12 Health Survey. Lincoln, RI: Quality Metric, 2002.

44. Ware JE Jr, Kosinski M, Keller SD. A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220–233.

45. Luo X, Lynn George M, Kakouras I, et al. Reliability, validity, and responsiveness of the short form 12-item survey (SF-

12) in patients with back pain. Spine 2003;28:1739–1745.

46. Robins LN, Helzer JE, Croughan J, et al. National institute of mental health diagnostic interview schedule. Its history, characteristics, and validity. Arch Gen Psychiat 1981;38:381–389.

47. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: III. Washington, DC: American Psychiatric Association, 1980.

48. Bucholz KK, Robins LN, Shayka JJ, et al. Performance of two forms of a computer psychiatric screening interview: Version I of the DISSI. J Psychiat Res 1991;25:117–129.

49. Williams JB, Gibbon M, First MB, et al. The structured clinical interview for DSM-III-R (SCID). II. Multisite testretest reliability. Arch Gen Psychiat 1992;49:630–636.

50. Robins LN, Cottler LB, Bucholz KK, et al. Diagnostic Interview Schedule for the DSMIV (DIS-IV). St Louis, MO: Washington University School of Medicine, 2000.

51. Escobar JI, Rubio-Stipec M, Canino G, et al. Somatic symptom index (SSI): A new and abridged somatization construct. Prevalence and epidemiological correlates in two large community samples. J Nerv Ment Dis 1989;177:140–146.

52. Escobar JI, Golding JM, Hough RL, et al. Somatization in the community: Relationship to disability and use of services. Am J Public Health 1987;77:837–840.

53. Escobar JI, Rubio-Stipec M, Canino G, et al. Somatic symptom index (SSI): A new and abridged somatization construct. Prevalence and epidemiological correlates in two large community samples. J Nerv Ment Dis 1989;177:140–146.

54. Katon W, Line E, Von Korff M, et al. Somatization: A spectrum of severity. Am J Psychiat 1991;148:34–40.

55. DeVellis RF. Scale Development: Theory and Application. Thousand Oaks: Sage Publications, 2003.

56. Lin LI. A concordance correlation coefficient to evaluate reproducibility. Biometrics 1989;45:255–268.

57. Escobar JI, Manu P, Matthews D, et al. Medically unexplained physical symptoms, somatization disorder and abridged somatization: Studies with the diagnostic inter-view schedule. Psychiat Dev 1989;7:235–245.

58. Fava GA, Wise TN. Issues for DSM-V: Psychological factors affecting either identified or feared medical conditions: A solution for somatoform disorders. Am J Psychiatry 2007;164:1002–1003.

59. Kroenke K, Sharpe M, Sykes R. Revising the classification of somatoform disorders: Key questions and preliminary recommendations. Psychosomatics 2007;48:277–285.

60. Mayou R, Kirmayer LJ, Simon G, et al. Somatoform disorders: Time for a new approach in DSM-V. Am J Psychiatry 2005;162:847–855.

61. Fink P. Somatization: Beyond symptom count. J Psychosom Res 1996;40:7–10.

62. Simon GE, Von Korff M, Piccinelli M, et al. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999;341:1329–1335.

63. Wilson L, Dworkin SF, Whitney C, et al. Somatization and pain dispersion in chronic temporomandibular disorder pain. Pain 1994;57:55–61.

64. Nettleton S. “I just want permission to be ill”: Towards a sociology of medically unexplained symptoms. Soc Sci Med 2006;62:1167–1178.

65. Brown RJ. Introduction to the special issue on medically unexplained symptoms: Background and future directions. Clin Psych Rev 2007;27:769–780.

66. Houtveen JH, van Doornen LJP. Medically unexplained symptoms and between-group differences in 24-h ambulatory recording of stress physiology. Biol Psychol 2007; 76:239–249.

67. Hartman TC, Borghuis MS, Lucassen PL, et al. Medically unexplained symptoms, somatisation disorder, and hypochondriasis: Course and prognosis. A systematic review. J Psychosom Res (in press).

68. Salmon P. Conflict, collusion or collaboration in consultations about medically unexplained symptoms: The need for a curriculum of medical explanation. Patient Educ Coun 2007;67:246–254.

69. Frohlich C, Jacobi F, Wittchen HU. DSM-IV pain disorder in the general population. An exploration of the structure and threshold of medically unexplained pain symptoms. Eur Arch Psychiatry Clin Neurosci 2006;256:187–196.

70. Cella D, Chang CH. A discussion of item response theory and its applications in health status assessment. Med Care 2000;38(9, suppl):66–72.

71. Hambleton RK. Emergence of item response modeling in instrument development and data analysis. Med Care 2000;38(9, suppl):60–65.

72. Embretson SE, Reise SP. Item Response Theory for Psychologists. Mahwah,NJ: Lawrence Erlbaum, 2000.