Intergenerational transmission of gastrointestinal illness behavior.

OBJECTIVE: Previous research, based on retrospective reporting, suggests that parental reinforcement and modeling may be important mechanisms in the development of gastrointestinal illness behavior in children and adults. The aim of this study was to determine the relationship between the illness behavior of parents, in the form of health care use for irritable bowel symptoms, and the illness behavior of their children, without relying on retrospective recall. METHODS: A comparison of two matched groups was made. Groups included 631 children of parents who were diagnosed with irritable bowel syndrome during 1 calendar yr and 646 children of parents matched by parental age, gender, and number of children in the family who did not receive an IBS diagnosis during the same 1 yr. Health care use and costs over a 3-yr calendar period for all children and their parents collected from the health care database of a large health maintenance organization were evaluated. RESULTS: Case children had significantly more ambulatory care visits for all causes (mean 12.26 vs. 9.81, p = 0.0001) and more ambulatory visits for gastrointestinal symptoms (0.35 vs. 0.18, p = 0.0001). Outpatient health care costs over the 3-yr period were also significantly higher for case than control children ($1979 vs. $1546, p = 0.0001). Controlling for the total number of ambulatory visits of the parents, excluding gastrointestinal visits, did not alter the findings. Gender of the IBS parent was not related to children's gastrointestinal visits. CONCLUSION: This study extends previous research by showing that specific types of illness behavior may be learned through modeling.

Use of exogenous hormones and risk of temporomandibular disorder pain.

Temporomandibular disorders (TMD) are common pain conditions that have their highest prevalence among women of reproductive age. The higher prevalence of TMD pain among women, pattern of onset after puberty and lowered prevalence rates in the post-menopausal years suggest that female reproductive hormones may play an etiologic role in TMD. Two epidemiologic studies were designed to assess whether use of exogenous hormones is associated with increased risk of TMD pain. Both used data from automated pharmacy records of women enrolled in a large health maintenance organization to identify prescriptions filled for post-menopausal hormone replacement therapies (Study 1) or for oral contraceptives (OCs) (Study 2). Study 1 employed an age-matched case-control design to compare post-menopausal hormone use among 1291 women over age 40 referred for TMD treatment and 5164 controls not referred. After controlling for health services use, the odds of being a TMD case were approximately 30% higher among those receiving estrogen compared to those not exposed (P = 0.002); a clear dose-response relationship was evident. The relationship of progestin use to TMD was not statistically significant. Study 2 used a similar design to examine the relationship of OC use to referral for TMD care, drawing on data from 1473 cases and 5892 controls aged 15-35. Use of OCs was also associated with referral for TMD care, with an increased risk of TMD of approximately 20% for OC users, after controlling for health services use (P < 0.05). These results suggest that female reproductive hormones may play an etiologic role in orofacial pain. This relationship warrants further investigation through epidemiologic, clinical and basic research.

Diagnostic studies of temporomandibular disorders: challenges from an epidemiologic perspective.

UNLABELLED: Adequate data on the incidence, prevalence, natural history, and clinical course of temperomandibular disorders (TMD) and other chronic pain conditions are largely lacking, though the need to derive such basic data is recognized by clinicians, researchers, and public health agencies. This paper discusses challenges to the epidemiologic study of TMD diagnosis. These challenges include:• CASE DEFINITION: There is currently poor agreement regarding which combinations of clinical and psychosocial findings differentially define cases of TMD• Differentiation of normal variation v pathophysiologic signs: To what extent do commonly gathered clinical measurements constitute pathophysiologic signs of TMD v reflect normal biologic variation• Reliability of clinical measurement: Factors influencing reliability of clinical signs and reliability of examiners have not been adequately assessed• Progressive v self-limiting disease activity: Do TMD subtypes represent a continuum of pathologic disease activity, or nonmutually exclusive categories describing largely symptomatic pain conditions that are selflimiting or stable.It is recommended that epidemiologic studies not be constrained by a priori definitions of TMD subtypes, but continue to gather data on clinical signs and symptoms that have theoretical and clinical relevance to mandibular dysfunction and psychosocial status. An approach is proposed for development of reliable and valid criteria of TMD subtypes suitable for epidemiologic research.

Temporomandibular disorders. Variation in clinical practice.

This research describes the extent of variability in diagnosis and treatment of temporomandibular disorders (TMD) and relates this variability to treatment outcomes. A health maintenance organization sequentially referred 145 patients with orofacial pain and dysfunction to two TMD clinics. The two clinics differed substantially in their use of tomography (applied to 28% vs. 64% of all patients), and varied moderately in diagnoses assigned to the patient groups. There was large variation in selection of treatments including appliances for bruxism (64% vs. 5%), mandibular repositioning (10% vs. 25%), and joint stabilization (3% vs. 30%); anti-inflammatory medications (44% vs. 19%) and analgesics (16% vs. 2%); and subsequent referral for dental or orthodontic treatment (1% vs. 42%). The differences in diagnostic and therapeutic practice that were found were not associated with important differences in patient-reported pain and dysfunction at 1-year follow-up. These data indicate the need for systematic approaches to identifying, evaluating, and modifying variation in health care practices for common presenting problems lacking reliable methods of evaluation and generally accepted clinical standards for choice of treatments.

The epidemiology of panic attacks and panic disorder. Results of three community surveys.

The authors report findings pertaining to panic disorder from the first three sites of the National Institute of Mental Health Epidemiologic Catchment Area Program. Probability samples of about 3,000 persons aged 18 years or older were interviewed in the New Haven, Connecticut area, eastern Baltimore City, Maryland, and the greater St. Louis, Missouri area in 1980-1982. Information on panic attacks and panic disorder was obtained using the Diagnostic Interview Schedule. The prevalence rate of panic attacks in the prior six months was found to be about 3% at each of the sites, while the prevalence of panic disorder varied from 0.6 to 1.0%. Age at onset was found to peak at 15-19 years. Simple panic attacks, severe and recurrent panic attacks, and panic disorder were found to be characterized by similar symptom profiles and age at onset distributions, and to have similar distributions by demographic factors.

Comparison of the lay Diagnostic Interview Schedule and a standardized psychiatric diagnosis. Experience in eastern Baltimore.

We studied DSM-III diagnoses made by the lay Diagnostic Interview Schedule (DIS) method in relation to a standardized DSM-III diagnosis by psychiatrists in the two-stage Baltimore Epidemiologic Catchment Area mental morbidity survey. Generally, prevalence estimates based on the DIS one-month diagnoses were significantly different from those based on the psychiatric diagnoses. Subjects identified as cases by each method were often different subjects. Measured in terms of kappa, the chance-corrected degree of agreement between the DIS and psychiatrists' one-month diagnoses was moderate for DSM-III alcohol-use disorder (abuse and dependence combined), and lower for other mental disorder categories. The unreliability of either the DIS or psychiatric diagnoses is one potential explanation for the observed disagreements. Others include the following: insufficient or inadequate information (on which to base a diagnosis); recency of disorder; incomplete criterion coverage; overinclusive DIS questions; and degree of reliance on subject symptom reports. Further study of the nature and sources of these discrepancies is underway. This work should produce a more complete understanding of obstacles to mental disorder case ascertainment by lay interview and clinical examination methods in the context of a field survey.

Screening for delirium on a general medical ward: the tachistoscope and a global accessibility rating.

With a psychiatrist's standardized clinical diagnosis as the criterion, the "Hand-Held Tachistoscope" was 100% sensitive, but only 45% specific in detecting delirium among hospital patients on a general medical ward. For each true positive in this sample of 97 patients, there were almost 5 false positives. The 10 patients with clinically diagnosed delirium could not see the stimulus. This was also true for 24 of the 87 nondelirious patients. Performance on the tachistoscope was related to age and education. This was not true for another method of delirium case detection, the global accessibility rating. This rating was 90% sensitive and 95% specific when compared with the psychiatric diagnosis, and was stable across two days of ratings. The global accessibility rating warrants further evaluation as a simple screening test for delirium.

The NIMH diagnostic interview schedule modified to record current mental status.

The National Institute of Mental Health Diagnostic Interview Schedule (DIS) was modified to record detailed information on current mental status in addition to the lifetime symptom history. Use of the modified DIS in a field survey indicates that information on current symptoms is required to distinguish persons who meet all DSM-III criteria for Major Depressive Episode at or around the time of interview from former cases who fail to meet all criteria at interview. Thus, the unmodified DIS may overestimate the 1-month period prevalence rates for Major Depressive Episode, by counting symptomatic former cases as having the disorder at or around the time of the interview. An analysis of symptom count data also suggests that the unmodified DIS count of lifetime depressive symptoms is not a good measure of current symptom status.

Limits of the 'Mini-Mental State' as a screening test for dementia and delirium among hospital patients.

With a psychiatrist's standardized clinical diagnosis as the criterion, the 'Mini-Mental State' Examination (MMSE) was 87% sensitive and 82% specific in detecting dementia and delirium among hospital patients on a general medical ward. The false positive ratio was 39% and the false negative ratio was 5%. All false positives had less than 9 years of education; many were 60 years of age or older. Performance on specific MMSE items was related to education or age. These findings confirm the MMSE's value as a screen instrument for dementia and delirium when later, more intensive diagnostic enquiry is possible; they reinforce earlier suggestions that the MMSE alone cannot yield a diagnosis for these conditions.