Jaw pain in a psychiatric patient

A disheveled woman who was talking to herself came into the emergency department yesterday evening complaining that she couldn't eat because her jaw hurt. The resident with whom I was working was more than happy to give me the first go at interviewing and examining her. She said her right jaw hurt and that she was afraid to go to sleep because "the pain is too close to my brain." She also had a strange preoccupation with her ears and told me some story about accidentally inhaling a piece of paper then later pulling that paper out of her ears.

I did a head and neck exam on her but didn't find anything out of the ordinary - her ears were clear, and I didn't feel any creaking in her jaw when she opened it and closed it. After presenting to my resident, she asked me if I had my patient open her jaw all the way. I hadn't. So I went back, and when she opened her jaw wide, I felt a popping on the right side. Classic temporomandibular joint (TMJ) syndrome. We sent her home with ibuprofen.

I learned what TMJ syndrome feels like and how to elicit its sign. I also learned that it can be easy to miss a physical diagnosis in a psychiatric patient. The pain that my patient felt in her jaw and its impact on her life were no less real just because she had fantastical thoughts.