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 paindysfunction”. 2013
• “Burning mouth syndrome is a psychosomatic condition” 2014
Mad
Functional symptoms
Somatising
Not real
Psychological
Mind
Dualism
Body
Medical
Real
Sane
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
INPUTS
OUTPUTS
PAIN
Dimensions:
Sensorydiscriminative;
motivational-affective;
cognitive-evaluative
SENSORY INPUT
Cutaneous, visceral &
musculoskeletal inputs;
visual, vestibular inputs
COGNITIVE INPUT
Memories; past
experience; attention;
meaning; learning;
catastrophising
ACTION (MOTOR
RESPONSE)
Involuntary & voluntary
action patterns; action
patterns; social
communication
EMOTIONAL INPUT
Anxiety; depression;
fear
Melzack (1999): The Neuromatrix Model
STRESS
Cortisol, noradrenaline,
cytokine levels; immune
system activity,
endorphin levels
Reported pain & stimulus
intensity
“9 out of
10”
X
fMRI studies
Reported pain & fMRI activity
“9 out of
10”
✔
Reported pain intensity
correlates with increased limbic
activity during pain processing
i.e. cognitive and emotional
input
Tracey & Mantyh (2007)
Cognitive and emotional influences on pain processing & responses to
pain
THE PATIENT
Cognitive Behavioural Model
Beliefs
Thoughts
Meanings
Meanings are subjective & idiosyncratic
Internet
searches
Healthcare
providers
Media
CULTURE
RELIGION
SOCIETY
Past learning
PAST
Thoughts,
beliefs,
meanings
Past experiences
of pain & illness
About
symptoms
CONTEXT
Competing
demands
PAIN
BELIEFS
Who’s
present
About the
cause
About what’s needed
to make it better
Our meanings,
interpretations & perceptions
about the patient’s pain will
be different from the
patient’s
Beliefs
Causal beliefs
“My pain must be caused by cancer”
Beliefs about symptoms
“Clicking means that my jaw bone
needs surgery”
“My skull is balanced on my spine”
Anatomical beliefs
“My jaw is lose”
Treatment/ investigation
beliefs
“Treatments failed because they
weren’t done correctly”
Patients may do something that appears to be ‘odd’……….
due to underlying fears and beliefs
Cognitive Processing: Catastrophising
• Focus on threat
• Overestimate threat
• Underestimate resources to deal with it
• 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 & painrelated interference
– (Buenaver et al, 2012)
• Associated with the
progression of chronic TMD
pain & disability
– (Velly et al, 2010)
Cognitive Processing: Catastrophising
INJURY/STRAIN
Erroneous beliefs
are not challenged &
re-evaluated
DISUSE
DISABILITY
DEPRESSION
RECOVERY
AVOIDANCE
FEAR OF MOVEMENT
(RE)INJURY, PAIN
PAIN EXPERIENCE
CATASTROPHIZE
Vlaeyen & Linton (2000)
EXPOSURE
LOW FEAR
Cognitive Processing: Worry
Eccleston & Crombez, 2007
• 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
Where pain is seen as the
whole problem….
Where the problem is seen as
disability & distress due to pain….
Attempts to solve the
problem are focused on
pain reduction….
Attempts to solve the problem
are focused on reducing disability
& distress….
Often no solution
There are some answers
Cognitive processing: Mood related biases
Anxiety: Selective for threatening
information
Depression:
Selective for negative information
I can’t understand scans, and
the doctor told me it was fine
I remember that time when my pain
was awful & I didn’t cope well
My scan looked awful
The doctor said
that my pain might
move around a
bit, that’s normal
My pain has
spread
I have coped
many times with
increased pain
I’m sure that headache is
linked to my face
pain…it’s just all getting
worse
I used to have
headaches every one
or two weeks before
my face pain
Cognitive and emotional influences on pain processing & responses to
pain
HCPS
16
Worry
Depression
Catastrophising
HCPs
Anxiety
Beliefs &
meanings
• 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
CONSIDERATIONS
SELF REFLECTION: WHAT DO WE
COME INTO THE ROOM WITH?
Situation
Cognitions & cognitive
processing
Body
Behaviour
Emotions
Situation
Cognitions & cognitive
processing
Body
Behaviour
Emotions
CONSIDERATIONS
OUR MODEL OF PAIN AND DESIRE
TO TREAT & CURE
Stop the vicious cycle of referrals & distress
Search for a
cure
Psychological &
physical impact
Distress
Hope
‘Failed’
treatment
• 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
CONSIDERATIONS
THE LANGUAGE & WORDS WE USE
We often believe that patients want confident certainty &
reassurance from us. But this may not help
• 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)
…Perceptions of what we say
“You’re scans are normal”
“Your pain is caused by
nerve damage”
S/he saying the pain
is in my mind
The nerve is broken in two.
I can find someone to
attach it back together
My nerve is sending
faulty messages
“Wear and tear”
“Your jaw is a bit crumbly”
Things will get more worn &
torn. My jaw & pain are going
to get worse & worse….
My jaw is weak &
crumbling…and will fall off
CONSIDERATIONS
FINDING OUT WHAT THE PATIENT
THINKS & BELIEVES
“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)
Stay curious & open
What do you think is
happening when your pain
increases?
We’ve talked about what is
causing your (symptoms).
What are your thoughts about
them now ?
What do you think is
causing your pain?
Many people have concerns or
worries when they have this
condition, what are yours?
This may sound an odd
question, but what’s the worst
thing for you about having this
condition?
CONSIDERATIONS
PATIENT UNDERSTANDING
Systematic search of PubMed (1961-2006)
Am J Surg. 2009 Sep;198(3):420-35
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%)
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?”
The intervention
COGNITIVE BEHAVIOURAL PAIN
MANAGEMENT
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
2 hour Information
Session (n~20)
50 min psychology
assessment (1:1)
Six 3.5 hour weekly
sessions (n=12)
1 and 9 month
FUs
Trigeminal Neuralgia Programme
Fear of the next
attack
2 hour Information
Session (n~14)
“What
if…………”
50 min psychology
assessment (1:1)
Avoidance
Six 3.5 hour weekly
sessions (n=12)
Framework of mindfulness
based cognitive therapy
1 and 9 month
FUs
Burning Mouth Syndrome
“What is it?”
2 hour Information
Session (n~14). Medical
education about BMS and
medication
“What medical
treatments will
help?”
“Will it go?”
50 min psychology
assessment (1:1)
Short group
intervention
(workshop format)
About Face clinical outcomes
Pre - Post
Measures
N
Mean diff (SD)
Pre- One Month FU
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
Summary
• 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