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Psychology & orofacial pain Dr H Clare Daniel, Consultant Clinical Psychologist.

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Presentation on theme: "Psychology & orofacial pain Dr H Clare Daniel, Consultant Clinical Psychologist."— Presentation transcript:

1 Psychology & orofacial pain Dr H Clare Daniel, Consultant Clinical Psychologist

2 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

3 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” “Pain with possible psychogenic causes are chronic idiopathic facial pain (atypical facial pain); burning mouth syndrome; temporomandibular pain- dysfunction” “Burning mouth syndrome is a psychosomatic condition” 2014

4 Medical Psychological Mind Body Not real Real Mad Sane Dualism Somatising Functional symptoms

5 Viewing many orofacial pains as having a ‘psychosomatic’ or ‘psychogenic’ component is keeping the door of some pain services shut to facial pain

6 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

7 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 X Reported pain & fMRI activity “9 out of 10” Tracey & Mantyh (2007) ✔ fMRI studies

8 THE PATIENT Cognitive and emotional influences on pain processing & responses to pain

9 Cognitive Behavioural Model Beliefs Thoughts Meanings

10 Thoughts, beliefs, meanings RELIGION CONTEXT Who’s present Competing demands CULTURE PAIN BELIEFS About the cause About 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

11 “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

12 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

13 RECOVERY DISUSE DISABILITY DEPRESSION INJURY/STRAIN FEAR OF MOVEMENT (RE)INJURY, PAIN AVOIDANCE EXPOSURE PAIN EXPERIENCE LOW FEAR CATASTROPHIZE Vlaeyen & Linton (2000) Erroneous beliefs are not challenged & re-evaluated Cognitive Processing: Catastrophising

14 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

15 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 biases Depression: Selective for negative information I used to have headaches every one or two weeks before my face pain

16 HCPS Cognitive and emotional influences on pain processing & responses to pain 16

17 HCPs WorryDepression Beliefs & meanings AnxietyCatastrophising

18 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


20 Cognitions & cognitive processing Behaviour Emotions Body Situation Cognitions & cognitive processing Behaviour Emotions Body Situation


22 Stop the vicious cycle of referrals & distress Search for a cure Hope ‘Failed’ treatment Distress 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


24 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

25 …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


27 “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)

28 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)

29 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 1 o care and 90 secs in 2 o 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)

30 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?


32 Surgery Adequate overall understanding of the information provided 6/21 (29%) Risks associated with surgery5/14 (36%) Satisfaction by the amount of the given information7/12 (58%) Clinical research The aim of the study14/26 (54%) The process of randomization4/8 (50%) Voluntarism7/15 (47%) Withdrawal7/16 (44%) The risks of treatment8/16 (50%) The benefits of treatment4/7 (57%) Satisfaction by the amount of the given information12/15 (80%) Am J Surg Sep;198(3): Systematic search of PubMed ( )

33 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?”


35 35

36 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

37 ‘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)

38 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

39 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)

40 Measures Pre - PostPre- One Month FU N Mean diff (SD)95% CId N Mean diff (SD)95% CId Pain intensity (BPI)300.58(5.37) (5.18) Pain Self Efficacy Scale (PSEQ) (8.52) * (7.05) Depression (DAPOS)491.69(3.23) *1*321.53(3.21) Anxiety (DAPOS)491.54(2.57) *1*321.66(2.22) * Pain Catastrophsing Scale (PCS)467.99(8.95) *337.09(7.77) * Pain Interference (BPI: Face)290.61(1.35) (1.16) Illness Perceptions Questionnaire (IPQ)347.12(7.51) *197.53(6.91) * * = p<0.007 following Bonferroni Correction About Face clinical outcomes

41 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

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