An Abridged Psychological Self-rating Questionnaire (APSQ) was taken from the Middlesex Hospital Scale and adapted to the Al-Ahsa colloquial Arabic language. The aim was to develop a simple yet valid screening tool for early detection of  temporomandibular disorder (TMD) patients with psychological problems. It is well known that a considerable number of TMD patients are psychologically dysfunctional  and have  higher rates of anxiety, depression, and health care utilization. This case-control study was done on a systemic random sample of 72 TMD Saudi patients. All subjects were blindly rated on the APSQ during dental assessment, and each followed by a clinical psychiatric assessment consisting of a history and a systemic mental state examination. A cut-off point ranging from 11 to 13 was found acceptable in identifying positive subjects. The best cut-off point was found to be at 12. When using the recommended cut-off point, approximately 15.3% of the subjects were identified by the APSQ form as psychiatric patients as compared to 38.9% being identified by the clinical psychiatric assessment.  The sensitivity ranged from 72.7 to 90.48 % and specificity ranged from 83.87 to 89.7 %. The commonest psychiatric disorder among the subjects was a mixed anxiety-depression disorder. The APSQ was found to be of good validity, thus supporting its usefulness as a screening tool for detecting psychiatric morbidity among TMD patients in the Al-Ahsa area.

Many investigators believe that psychological factors play a significant role in the etiology or persistence of temporomandibular disorders (TMD). Depression and anxiety have been considered the primary focus of attention among many psychological factors contributing to TMD.1-5 About 20-30 % of TMD subjects are psychosocially dysfunctional and have higher rates of depression, somatization and health care utilization.6 Early identification and treatment of psychological problems in persons with TMD can diminish the use and cost of medical services in prepaid medical plans. However, those patients are not likely to respond to conventional dental care7,8 and may seek relief through litigation.9

Screening procedures based on the dentist's global impression does not adequately identify psychological problems in the TMD population.10

In addition, psychological problems may not be obvious or reliably detected by impressions from an initial examination, therefore, many psychological problems will go undetected.

In view of this, Gale and Dixon11 indicated that evaluation of the patient's emotional status is an important part in the diagnosis of TMD. This may affect the clinician's approach in counseling the patient regarding the course of the disorder. A simplified questionnaire composed of two-items was found to be nearly as effective as long and more complex ones in providing evidence regarding the emotional status of TMD patients.11 The aim of this study was to assess the validity of an Abridged Psychological Self-rating Questionnaire (APSQ) in detecting psychiatric problems among TMD patients in a dental clinic.

This study was conducted in the dental department of King Fahad Hospital-Hofuf (KKHH). The KFHH is located in Al-Ahsa province in the Eastern region of Kingdom of Saudi Arabia. The study sample comprised 72 Saudi TMD patients (25 males and 47 females) with a confirmed diagnosis of TMD. The subjects were selected on a random basis (2 cases/week).

A TMD diagnosis was established if the patient demonstrated pain and discomfort in the temporomandibular joint (TMJ), muscles of mastication and/or had masticatory dysfunction for a period exceeding six months.12  The Abridged Self-rating Questionnaire (APSQ)  (Figs. 1 and 2) used in this study was taken from the Middlesex Hospital Scale (MSHS) that was translated into Arabic (Egyptian colloquial) by Al-Rakhawy et al.13 This scale is composed of eight questions with a yes/no response, or with a yes/sometimes/no response. The items of depression and anxiety were selected and adapted to the Al-Ahsa colloquial Arabic language. The score of either depression (total 16 points) or anxiety (total 16 points) was negative for less than 8, doubtful for 8-12 and positive for 13 or more.

The validity of APSQ was tested in a trial to minimize the number of doubtful cases by two approaches:

a) owering the upper limit of the cut-off point to 12, 11 and 10 for anxiety and depression   separately (Table 1).

b) combining the scores of anxiety and depression (32 points) and using a high cut- off point ranging from 19 to 10 (Table 2).

All patients completed an informed consent form before participation, after being briefed about the study and the relationship between physical and psychological problems. One dentist rated all TMD subjects on the completed APSQ forms.

Clinical psychiatric assessment (CPA), consisting of a history and standard mental state examination, was conducted on all TMD subjects by psychiatrists. The psychiatric diagnosis was based on the criteria of the International Classification of Diseases of the World Health Organization 10th revision (ICD-10).14 Data was statistically analyzed using an Epi-6-Info cartilage.15

The mean age of the 28 TMD subjects with psychiatric disorders according to the Clinical Psychiatric Assessment (CPA) was 27.8 ± 7.3 years while that for the 44 psychiatrically free subjects was 26.4 ± 7.8, with no significant difference (t test = 0.715 and P > 0.05).  Using the recommended cut off point of the APSQ (positive 13 and more), 11 subjects (15.3%) were identified as positive psychiatric morbidity (3 anxiety and 8 depression) as shown in Fig. 3. The doubtful subjects whose scores ranged from 8 to 12 were 32 (44.4%), while the negative subjects were found to be 29 (40.3 %) as shown in Fig. 3.

CPA (Fig. 4) revealed higher figures as 28 TMD subjects (38.9%) were positive.  Out of this number 14 (19.4%) were suffering from anxiety-depression disorder, 9 (12.5%) from depression, 3 (4.2%) from anxiety and 2 (2.8%) from other psychiatric disorders. On the other hand, 44 cases (61.1%) were found free of psychiatric disorders. Among the 32 doubtful cases indicated by the APSQ, the CPA showed anxiety in two (6.3%), depression in 6 (18.6%) and anxiety-depression in 10  (31.3%) as shown in Fig. 5.

The validity of the APSQ test was found clinically good in identifying both negative and positive cases with cut-off points 13, 12 and 11 respectively for either anxiety or depression as shown in Table 1 (APSQ doubtful cases were not included). However, cut-off point of 12 had the highest likelihood of a positive ratio (LR+ve  = 7.96) and the likelihood of a negative ratio was clinically good  (LR-ve = 0.2). The validity of the APSQ tested by combined scores of anxiety and depression was shown in Table 2. A clear inverse relationship between sensitivity and specificity was noticed and decreased with increased cut-off points. The clinical decision of the diseased at cut-off points 10 & 11 was poor while it was fair at 12 and more (Table 2).

In this study, females predominated over males in a ratio of 1.8:1. This difference was expected because anxiety, depression and TMD are more common in females than in  males.16-18 Clinical psychiatric assessment (Fig. 4) identified 38.9% to have a psychiatric disorders and this figure lies in the range of previous reports.19,20 Half of them had mixed anxiety-depression disorder. Such disorder was found to be more common than anxiety or depression alone in primary care settings and moreover, two thirds of depressed patients have prominent anxiety symptoms.21 Among the TMD subjects diagnosed as mixed anxiety-depression disorder, four were identified to have experienced definite stressful life events. However, a mixed anxiety-depression disorder could be a presentation of an adjustment disorder.14

The APSQ was found valid with a recommended cut-off point of 13, but more valid with a cut-off point of 12 for either anxiety or depression separately (Table 1). The cut-off point 12 was considered to be valid in making a clinical decision for detection of psychiatric patients (LR +ve 7.96) and psychiatrically free subjects (LR-ve 0.20).  When both anxiety and depression scores were added together (Table 2), the validity of the APSQ was found to be excellent in detection of the psychiatrically free subjects but poor in detection of the psychiatric subjects. However, the later approach of combining both anxiety and depression APSQ scores was found to be of no value, since detection of TMD patients with the psychiatric disorder was the prime aim of the questionnaire.

It is well known that psychological tests have limitations, since the patient may respond falsely or haphazardly to the questionnaire and therefore, the results should be interpreted with caution. In addition, TMD patients are not a homogeneous group; they differ in coping strategies, disease conviction and demonstration of genuine psychiatric disorders. On a psychosocial basis, Suvinen et al.12 identified three subgroups of patients with TMD. These subgroups were termed maladaptive, adaptive and uncomplicated. It has been reported that TMD cases with psychiatric disorders respond poorly to physical treatment alone.22,23 Therefore, the immediate referral of positive cases by a general dental practitioner to the liaison psychiatrist is justified  for further re-evaluation and management. It was found that 56.3% of the doubtful cases (Fig. 5) had psychiatric disorders and this group may be similar clinically to the adaptive group, which was defined by Suvinen12 as moderately distressed and behaviorally functional. Since TMD subjects with psychiatric disorders respond poorly to physical treatment alone,22,23 we suggest that the doubtful cases on APQS should be referred to a liaison psychiatrist if their initial response to physical treatment was found poor.

1. The Abridged Psychological Self-rating  questionnaire (APSQ) had good validity and reliability, was simple to use and not time consuming. This supports its usefulness as a screening tool for psychiatric morbidity among TMD patients.

2. The APSQ describes psychological symptoms in the same terms used by the Al-Ahsa population where illiteracy was not found to be a barrier for  its use.

3. An APSQ cut-off point of 12 for either anxiety or depression is recommended.

4. Mixed anxiety-depression disorder is more common among TMD cases than either anxiety or depression alone.

5. Doubtful cases detected by the APSQ but not responding to physical treatment should be  referred to a liaison psychiatrist.

The authors wish to express their thanks and deep appreciation to Mr. Mubarak M. Al Mulhim (Clinical Psychologist) for his effort in translating the APSQ into the Al-Ahsa colloquial language, Dr. Hashim Abdul Majeed (Psychiatrist) for his help in the psychiatric assessment of  the TMD patients and to Ms. Mercy Joy C. Reyes for her assistance in preparing the manuscript.

Address reprint requests to:

Dr. El Fatih I. El-Amin
Consultant Prosthodontist
Acting Director, Al-Ahsa Dental Center
Al-Ahsa Directorate of Health
P.O. Box 5161 Al-Ahsa 31982  Saudi Arabia