Psychology & orofacial pain

Dr H Clare Daniel, Consultant Clinical Psychologist

Persistent Pain ‘vs’ Persistent Orofacial Pain

• Same or different psychological processes and pain processing?

• Much of the orofacial pain literature is about 2 decades behind the persistent pain literature

The literature: 2012 onwards

• “Burning mouth syndrome (BMS) has been considered an enigmatic condition because the intensity of pain rarely corresponds to the clinical signs of the disease”. 2012

• “Pain with possible psychogenic causes are chronic idiopathic facial pain (atypical facial pain); burning mouth syndrome; temporomandibular pain- dysfunction”. 2013

• “Burning mouth syndrome is a psychosomatic condition” 2014

Medical

Psychological

Mind

Body

Not real

Real

Mad

Sane

Dualism

Somatising

Functional symptoms

Viewing many orofacial pains as having a ‘psychosomatic’ or ‘psychogenic’

component is keeping the door of some pain services shut to facial pain

Normal pain processing

Melzack (1999): The Neuromatrix Model

COGNITIVE INPUT

Memories; past experience; attention;

meaning; learning; catastrophising

INPUTS

EMOTIONAL INPUT

Anxiety; depression; fear

PAIN

Dimensions:

Sensory-discriminative; motivational-

affective; cognitive-evaluative

ACTION (MOTOR RESPONSE)

Involuntary & voluntary action patterns;

action patterns; social communication

STRESS

Cortisol, noradrenaline, cytokine levels;

immune system activity, endorphin levels

OUTPUTS

SENSORY INPUT

Cutaneous, visceral & musculoskeletal

inputs; visual, vestibular inputs

Reported pain intensity correlates with increased limbic

activity during pain processing

i.e. cognitive and emotional input

“9 out of 10”

Reported pain & stimulus intensity

XReported pain & fMRI activity

“9 out of 10”

Tracey & Mantyh (2007)

✔

fMRI studies

THE PATIENT

Cognitive and emotional influences on pain processing & responses to pain

Cognitive Behavioural Model

Body

Cognitions & cognitive

processing

Behaviour

Emotions

Situation

Beliefs

Thoughts

Meanings

Thoughts, beliefs,

meanings

RELIGION

CONTEXT

Who’s present

Competing demands

CULTURE

PAIN BELIEFS

About the causeAbout symptoms

About what’s needed to make it

better

Past learning

Past experiences of pain &

illness

PAST

SOCIETY

Healthcare providers Media

Our meanings, interpretations & perceptions

about the patient’s pain will be different from the

patient’s

Meanings are subjective & idiosyncratic

Internet searches

“My pain must be caused by cancer”Causal beliefs

Treatment/ investigation beliefs “Treatments failed because they weren’t done correctly”

Beliefs about symptoms “Clicking means that my jaw bone needs surgery”

“My jaw is lose”

Anatomical beliefs

“My skull is balanced on my spine”

Beliefs

Patients may do something that appears to be ‘odd’………. due to underlying fears and beliefs

Cognitive Processing: Catastrophising

• In healthy subjects: predicts pain intensity & tolerance

• At acute stage: predicts chronicity & disability

• In chronic pain: predicts mood & avoidance

• Associated with greater sleep disturbance in TMD. Catastrophising was mediated by sleep disturbance to increase pain severity & pain-related interference – (Buenaver et al, 2012)

• Associated with the progression of chronic TMD pain & disability– (Velly et al, 2010)

• Focus on threat

• Overestimate threat

• Underestimate resources to deal with it

RECOVERYDISUSE

DISABILITY

DEPRESSION

INJURY/STRAIN

FEAR OF MOVEMENT

(RE)INJURY, PAIN

AVOIDANCE

EXPOSUREPAIN EXPERIENCE

LOW FEARCATASTROPHIZE

Vlaeyen & Linton (2000)

Erroneous beliefs are not

challenged & re-evaluated

Cognitive Processing: Catastrophising

Cognitive Processing: Worry

• We worry when we perceive that a situation could have a negative outcome

• Worry is an attempt to find a solution to a problem– It can help solve problems...but only if the problem is soluble

• Worry & problem solving with pain can be misdirected

Eccleston & Crombez, 2007

Where the problem is seen as disability & distress due to

pain….

Where pain is seen as the whole problem….

Often no solution

Attempts to solve the problem are focused on reducing

disability & distress….

Attempts to solve the problem are focused on

pain reduction….

There are some answers

Anxiety: Selective for threatening information

I have coped many times with

increased pain

The doctor said that my pain

might move around a bit, that’s

normal

My scan looked awful

I remember that time when my pain was awful & I didn’t cope

well

My pain has spread

I can’t understand scans, and the doctor told me it

was fine

I’m sure that headache is linked to my face

pain…it’s just all getting worse

Cognitive processing: Mood related biasesDepression:

Selective for negative information

I used to have headaches every one

or two weeks before my face pain

HCPS

Cognitive and emotional influences on pain processing & responses to pain

16

HCPs

Worry

Depression

Beliefs & meaningsAnxiety

Catastrophising

• HCPs are powerful co-creators of beliefs about pain (helpful and unhelpful)– Eccelston et al, 2013

• We have the strongest influence upon patients attitudes & beliefs about the cause, meaning of symptoms & expectations of prognosis– Simmonds et al, 2012; Darlow et al., 2013

• We can helpfully alter patients’ beliefs about the cause, meaning and consequence of pain

SELF REFLECTION: WHAT DO WE COME INTO THE ROOM WITH?

CONSIDERATIONS

Cognitions & cognitive processing

Behaviour

Emotions

Body

Situation

Cognitions & cognitive processing

Behaviour

Emotions

Body

Situation

OUR MODEL OF PAIN AND DESIRE TO TREAT & CURE

CONSIDERATIONS

Stop the vicious cycle of referrals & distress

Search for a cure

Hope

‘Failed’ treatmentDistress

Psychological & physical

impact

• Well meaning medical interventions can reinforce searches for a cause & cure

• The ability to say enough is enough is difficult but can be extremely helpful & stop damaging

cycles

THE LANGUAGE & WORDS WE USECONSIDERATIONS

• HCPs using ‘certainty language’

• More likely to prematurely close their assessment of pain and less likely to assess thoroughly (Shields et al,

2013)

• Can increase patient anxiety (Linton et al, 2008)

We often believe that patients want confident certainty & reassurance from us. But this may not help

…Perceptions of what we say

“You’re scans are normal”

“Your pain is caused by nerve damage”

“Wear and tear”

S/he saying the pain is in my mind

Things will get more worn & torn. My jaw & pain

are going to get worse & worse….

The nerve is broken in two. I can find someone

to attach it back together

“Your jaw is a bit crumbly” My jaw is weak & crumbling…and will fall off

My nerve is sending faulty messages

FINDING OUT WHAT THE PATIENT THINKS & BELIEVES

CONSIDERATIONS

“Listening, without judgment, to patients’ beliefs about the cause of pain, which can seem

outlandish, gives valuable insight into what is causing distress and halting progress”

(Eccleston et al, 2013)

Do we listen…..?

• 77% of patients are interrupted after 12 seconds (Dyche, 2005)

• 69% of patients are interrupted and directed toward a specific concern (Beckman & Frankel, 1984)

• 37% of patients are not asked about their agenda for the appointment

• 70% of patients want to ask more questions (Salmon, 2000)

• Female patients are interrupted more often than male patients (Rhaodes, 2001)

• Male HCPs interrupt more frequently than female HCPs (Rhaodes, 2001)

• This results in:– The loss of relevant information– 24% reduction in HCP understanding of the patient

• Myths– “Patients will go on and on and on…..”

• On average, uninterrupted patients stop in less than 30 secs in 1o care and 90 secs in 2o care

– “We haven’t got time & they’re so complex”• Assessment of time pressure or medical complexity

were not associated with rates of interruption

Beckman & Frankel (1984); Rhoades et al (2001); Dyche & Swiderski (2005); Salmon, (2006)

What do you think is causing your

pain?

We’ve talked about what is causing your

(symptoms). What are your thoughts about them

now ?

This may sound an odd question, but what’s the worst

thing for you about having this condition?Many people have concerns or worries when they have this

condition, what are yours?

Stay curious & open

What do you think is happening when your

pain increases?

PATIENT UNDERSTANDINGCONSIDERATIONS

Surgery

Adequate overall understanding of the information provided

6/21 (29%)

Risks associated with surgery 5/14 (36%)

Satisfaction by the amount of the given information 7/12 (58%)

Clinical research

The aim of the study 14/26 (54%)

The process of randomization 4/8 (50%)

Voluntarism 7/15 (47%)

Withdrawal 7/16 (44%)

The risks of treatment 8/16 (50%)

The benefits of treatment 4/7 (57%)

Satisfaction by the amount of the given information 12/15 (80%)

Am J Surg. 2009 Sep;198(3):420-35

Systematic search of PubMed (1961-2006)

Aid understanding• The average reading age of the UK population is…

– 9 years – Use plain, non-medical language

• Use pictures (show or draw)– Collaborative– Visual images can improve recall

• Limit the amount of information provided– Information is best remembered when given in small pieces

• Check understanding– But not with “Do you understand what I’ve said?”

COGNITIVE BEHAVIOURAL PAIN MANAGEMENT

The intervention

35

CBT pain management (MDT) • Aims

– Increase the patient’s understanding of persistent pain• Pain processing• Pain does not equal damage

– Reduce disability

– Reduce pain related distress

– Improve sleep

– Achieve greater independence in health care

‘About Face’ Pain Management Programme

TMD, trigeminal neuropathic pain, persistent idiopathic facial pain

Six 3.5 hour weekly sessions

(n=12)

1 and 9 month FUs

2 hour Information Session

(n~20)

50 min psychology assessment

(1:1)

Trigeminal Neuralgia Programme

Six 3.5 hour weekly sessions

(n=12)

1 and 9 month FUs

2 hour Information Session

(n~14)

50 min psychology assessment

(1:1)

Fear of the next attack

“What if…………”

Avoidance

Framework of mindfulness based cognitive therapy

Burning Mouth Syndrome

“What is it?”

“What medical treatments

will help?”

“Will it go?”

Short group intervention

(workshop format)

2 hour Information Session (n~14). Medical

education about BMS and medication

50 min psychology assessment

(1:1)

Measures Pre - Post Pre- One Month FU

N Mean diff (SD) 95% CI d N Mean diff (SD) 95% CI d

Pain intensity (BPI) 30 0.58(5.37) -1.42-2.59 0.22 21 2.43(5.18) 0.07-4.78 0.94

Pain Self Efficacy Scale (PSEQ) 39 -4.92(8.52) -7.68-2.15 1.14* 26 -2.82(7.05) -5.67-0.02 0.81

Depression (DAPOS) 49 1.69(3.23) 0.76-2.62 1* 32 1.53(3.21) 0.37-2.69 0.96

Anxiety (DAPOS) 49 1.54(2.57) 0.80-2.28 1* 32 1.66(2.22) 0.85-2.46 1.29*

Pain Catastrophsing Scale (PCS) 46 7.99(8.95) 5.36-10.62 1.04* 33 7.09(7.77) 4.39-9.81 1.26*

Pain Interference (BPI: Face) 29 0.61(1.35) 0.09-1.12 0.91 17 0.17(1.16) -0.43-0.77 0.31

Illness Perceptions Questionnaire (IPQ) 34 7.12(7.51) 4.49-9.73 1.24* 19 7.53(6.91) 4.19-10.86 1.82*

* = p<0.007 following Bonferroni Correction

About Face clinical outcomes

• Psychological processes are a normal part of facial pain processing

• In order to develop a non-pathological formulation of the patient we need to understand the patient’s

– Understanding of pain

– Responses to pain

– Beliefs about what is needed to help them

• Attend to our communication with the patient

• Evidence based psychological pain management is effective in reducing the psychological and physical impact of persistent orofacial pain

Summary

Thank you