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1 A MULTIDISCIPLINARY FACIAL PAIN SERVICE Dr Sarah Barker, Consultant Clinical Psychologist Kings College Hospital

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Presentation on theme: "1 A MULTIDISCIPLINARY FACIAL PAIN SERVICE Dr Sarah Barker, Consultant Clinical Psychologist Kings College Hospital"— Presentation transcript:

1 1 A MULTIDISCIPLINARY FACIAL PAIN SERVICE Dr Sarah Barker, Consultant Clinical Psychologist Kings College Hospital

2 2 Posterior fossa: entry of trigeminal nerve to the brain Trigeminal neuralgia Burning mouth syndrome Idiopathic facial pain Facial arthromyalgia Atypical facial pain

3 3 Patients referred to the service are often: Those who engage in dentist shopping Those who engage in dentist shopping Frequent attendees at the emergency dental clinic Frequent attendees at the emergency dental clinic Multiple treatment modalities with little / no resolution of distress Multiple treatment modalities with little / no resolution of distress Cosmetic concerns that seem disproportionate or difficult to pinpoint Cosmetic concerns that seem disproportionate or difficult to pinpoint Unexplained physical symptoms in multiple systems Unexplained physical symptoms in multiple systems

4 4 What non-dental factors are relevant in chronic orofacial pain? Predisposing factors Predisposing factors Genetics (Diatchenko et al 2005 Hum Mol Gen) Genetics (Diatchenko et al 2005 Hum Mol Gen) Childhood trauma Childhood trauma Anxiety / depression (Aggarwal et al 2010 Pain) Anxiety / depression (Aggarwal et al 2010 Pain) Chronic widespread pain (John et al 2003 Pain) Chronic widespread pain (John et al 2003 Pain) Precipitating factors Precipitating factors Life events Life events Physical trauma Physical trauma Perpetuating factors Perpetuating factors Anxiety / depression Anxiety / depression Illness beliefs Illness beliefs Unhelpful behaviours Unhelpful behaviours Iatrogenic treatments Iatrogenic treatments

5 5 Iatrogenesis brought forth by a healer Over-investigation Over-investigation Over-treatment Over-treatment Failing to treat aspects of health that are potentially treatable Failing to treat aspects of health that are potentially treatable In the economically focussed NHS, reducing the costs of iatrogenesis is a priority In the economically focussed NHS, reducing the costs of iatrogenesis is a priority

6 6 Preoperative factors Pain, moderate to severe, lasting more than one month Repeat surgery Psychological vulnerability Preoperative anxiety Female Younger age (adults) Workers compensation Genetic predisposition Inefficient diffuse noxious inhibitory control DNC Intraoperative factors Surgical approach with risk of nerve damage Postoperative factors Pain (acute, moderate to severe) Depression Radiation therapy to area Psychological vulnerability Neurotoxic chemotherapy Neuroticism Anxiety Risk factors for chronic post-surgical pain (Macintyre et al, 2010)

7 7 Multi-disciplinary facial pain management at Kings Personnel Personnel Oral surgeons Oral surgeons Oral medics Oral medics Psychiatrist Psychiatrist Psychologist Psychologist Neurologist Neurologist Neurosurgeon Neurosurgeon Pain anaesthetist Pain anaesthetist (Physiotherapist) (Physiotherapist) (Speech & Language Therapist) (Speech & Language Therapist) Easy referral systems between disciplines Easy referral systems between disciplines Regular MDT clinics Regular MDT clinics Frequent informal discussions between clinicians Frequent informal discussions between clinicians Excellent secretarial support Excellent secretarial support Development of group treatment days for specific patient groups Development of group treatment days for specific patient groups

8 8 Management Approaches Dental Dental Surgical Surgical Psychological: Individual CBT/ACT/Schema Focused Psychological: Individual CBT/ACT/Schema Focused Group based multi-disciplinary days Group based multi-disciplinary days Pharmacological Pharmacological Rationalising / reducing analgesics Rationalising / reducing analgesics Tricyclics Tricyclics Pregabalin / Gabapentin Pregabalin / Gabapentin SSRIs, SNRIs SSRIs, SNRIs

9 9 1. Assessment Presenting problem and medical history (often pain is the primary problem) Impact of problem on function and quality of life Psychological function and past mental health history and treatment Social issues Goals of treatment and expectations of therapy Formulation and collaborative treatment planning Formulation and collaborative treatment planning

10 10 2. Formulations contain.. Symptoms and problems Predisposing life events or stressors Precipitating stressors or events; An explanatory mechanism that links the preceding categories together and offers a description of the precipitants and maintaining influences of the person's problems

11 11 3. Neuropsychology of pain Descending pathways represent the individuals state of mind - memories & experience, fears & expectations, and mood. These modulate transmission from the first synapse onwards. Cortical processing also draws on memories, learning, current state, potential action, etc. These systems are complex, plastic and recursive.

12 12 Definitions of Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain)

13 COMPONENTS OF PAIN A sensory or nociceptive component. An affective component – i.e. patients feelings about the pain (Anxiety/depression/anger etc) An evaluative (cognitive) component (i.e. patients beliefs, attitudes and expectations about pain and its treatment)

14 14 CBT model of chronic pain (Tang, 2008) Negative appraisal of pain/health relevant information Negative appraisal of self in relation to pain (mental defeat) Bodily variations (including pain) Automatic attentional processes Effortful attentional deployment Anxiety frustration depressed mood Sleep disturbance Mental elaboration (worry, rumination) Seeking reassurance/ medical information Selective attention Safety seeking behaviour

15 15 4. Treatment options within oral surgery Information sheets about nerve injury and direction to patient support website Multidisciplinary group for nerve injury patients (Plan is to run bi- annually Individual psychological therapy

16 16 TopicFacilitator 9.30Welcome and housekeeping. Key questions for the day Liaison psychiatrist Clinical Psychologist 10.00Nerve injury; medical information Oral Surgeon 10.45Break 11.15Mechanical symptoms and how to improve these Speech Therapist 12.30Lunch MULTIDISCIPLINARY NERVE INJURY DAY

17 Understanding neuropathic pain and the use of medication Pain Society DVD Oral Surgeon 2.00How nerve injury affects you and others; the psychological effects of disability, loss and pain. The role of the complaints system. Clinical Psychologist Liaison Psychiatrist Clinical Lead for Oral Surgery 2.45Break 3.15Getting back to mainstream dental care and other issues Clinical Psychologist Oral Surgeon 3.45Summary and resources. Feedback Liaison psychiatrist Clinical Psychologist 4.30Finish

18 18 Nerve injury group programme Pilot 1 day programmes run for patients with trigeminal neuralgia and burning mouth syndrome. Opportunity to meet others with a rare condition was reported to be very helpful.

19 19 Evaluation Quantitative data: EQ-5D-5L Pain Detect scale Hospital Anxiety and Depression Scale Pain Catastrophising Scale Pain Self Efficacy Questionnaire Qualitative data to cover patient satisfaction with the workshop.

20 20 Psychological treatment Shared formulation Setting a contract Goal specific therapy Regular review and reformulation

21 21 CBT model of chronic pain (Tang, 2008) Negative appraisal of pain/health relevant information Negative appraisal of self in relation to pain (mental defeat) Bodily variations (including pain) Automatic attentional processes Effortful attentional deployment Anxiety frustration depressed mood Sleep disturbance Mental elaboration (worry, rumination) Seeking reassurance/ medical information Selective attention Safety seeking behaviour

22 22 Mental defeat (Tang, 2008) Conceptualised as a form of self-defeating cognitions where people believe that the pain has taken away their former identity and autonomy (e.g. the pain has destroyed me as a person and I cant fight anymore). Different from catastrophising in that it focuses on the persons perception of themselves.

23 23 The importance of attention Pain interrupts and demands attention. Interruptive function of pain depends on the relationship between pain-related characteristics (e.g., the threat value of pain) and the characteristics of the environmental demands (e.g., emotional arousal). Chronic pain can be viewed as chronic interruption

24 24 Rumination and chronic pain Rumination can be seen as a repetitive style of thinking where individuals go over and over the same thoughts in their mind Tendency to be past-focused with an emphasis on searching for meanings and causes (Segerstrom et al, 2003) Rumination is an important cognitive process, which has been implicated in a number of disorders including depression, social phobia and post-traumatic stress disorder (e.g. Nolen- Hoeksema et al, 1993; Rachman et al, 2000; Michael et al, 2007)

25 25 Thinking about thinking about pain: A qualitative study investigating rumination in chronic pain (Edwards et al,2010) A reciprocal relationship was found between rumination and pain. Nineteen participants reported that pain triggered rumination. Twelve participants reported that rumination increased their pain, even during episodes of non-pain related rumination. … when you spend time thinking about things that are not so great, then the pain does feel worse – Participant 12 A reciprocal relationship was also found between rumination and mood. Nine participants reported that they ruminated when they felt low, anxious or stressed. Eighteen reported that rumination had negative effects on their mood including low mood, anxiety and frustration. … you go into a bit of a spiral where everything just starts to become terribly doom and gloom. – Participant 2

26 26 Altered physical feelings/symptoms (e.g. tingling/crawling sensation) Altered thinking with unhelpful thoughts (e.g. what if this pain means further damage is occurring?) Altered behaviour (reduced activity, avoidance or unhelpful behaviour e.g. excessive checking with tongue Altered emotional feelings e.g. anxiety Life situation, relationship or practical problems (e.g. lingual nerve injury) THE COGNITIVE-BEHAVIOURAL MODEL

27 27 Depression and pain Pain and depression are often linked, but depression in pain patients has been shown to be qualitatively different to patients with clinical depression (Rusu et al, in press) On BDI II somatic items do not accurately identify patients with depression (Wesley et al, 1999)

28 28 The Extended Grief Cycle.

29 29 Altered physical feelings/symptoms (e.g. tingling/crawling sensation) Altered thinking with unhelpful thoughts (e.g.This sensation is unbearable; the dentist should be made to pay) Altered behaviour reduced activity, avoidance or unhelpful behaviour (e.g. repeated phone calls to dentist demanding remedial work) Altered emotional feelings (e.g. anger) Life situation, relationship or practical problems (e.g. nerve injury) THE COGNITIVE-BEHAVIOURAL MODEL

30 30 Physical trauma and PTSD Physical injury increases the risk for PTSD The relationship between injury and trauma is complex, and is not correlated with the degree of injury. Complex neurobiological and psychological interactions mediate the effect of trauma. (Koren et al, 2006).

31 31 The three theoretical pathways through which injury can increase the risk for PTSD Trauma Stress- activating factors/systems Recovery promoting factors/systems Injury PTSD

32 32 Sleep modulates pain response Tiede et al (2010) found that sleep restricted participants found it harder to attend to but also disengage from a painful stimuli. They proposed a positive feedback cycle can occur, where reduced prefrontal control leads to higher pain.

33 33 Alternatives to CBT:strong evidence that mindfulness and acceptance can modulate chronic pain Acceptance decreases experienced pain and increases tolerance (Gutiérrez-Martínez et al, 2004) Acceptance-oriented responses are associated with better physical, social, and emotional functioning Acceptance improves functioning whilst attempting to control pain reduces it (Vowles et al, 2007). Struggling to control pain is related to pain, disability, depression and avoidance (McCracken et al, 2007)

34 34 WEBSITES

35 35 A typical patient at KCH!


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