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

2. ‘Trigeminal neuralgia’
‘Idiopathic facial pain’
Posterior fossa: entry of trigeminal nerve to the brain
Trigeminal Neuralgia is a condition that affects one of the large nerves in your head, called the trigeminal nerve. It is characterised by a sudden brief, severe, electric shock-like or stabbing pain typically felt on one side of your face, provoked by light touch, which may remit for varying periods. It is more common in women than in men and usually affects people aged 50 and older. It is a rare disease affecting around 0.7% of the population.
There are 12 major nerves on each side of your head. These are called cranial nerves. Each one has a different function. The trigeminal nerve is the fifth cranial nerve. It is responsible for sending impulses of touch, pain, pressure, and temperature to your brain, from your face, jaw, gums, forehead, and around your eyes. They also supply the muscles that help you to eat. Although you have two trigeminal nerves, almost always only one of them is affected, in trigeminal neuralgia. Only 3% of patients get bilateral pain and it is rare to get it at the same time.
There are three main branches to each of the trigeminal nerves. The area that each branch receives signals from is labelled on the diagram. In trigeminal neuralgia it is typically one or both of the lower two branches that are affected. The pain may be felt on the outside of the face or it may feel like toothache and be felt inside your mouth.
‘Burning mouth syndrome’
‘Atypical facial pain’
‘Facial arthromyalgia’

3. Patients referred to the service are often:
Those who engage in dentist shopping
Frequent attendees at the emergency dental clinic
Multiple treatment modalities with little / no resolution of distress
Cosmetic concerns that seem disproportionate or difficult to pinpoint
Unexplained physical symptoms in multiple systems
Cosmetic: e.g.: my jaw is sticking out and requires surgery; dentist disagrees

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

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

6. Intraoperative factors Postoperative factors
Risk factors for chronic post-surgical pain (Macintyre et al, 2010)
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
Neurotoxic chemotherapy Neuroticism Anxiety

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

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

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

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. 3. Neuropsychology of pain
Descending pathways represent the individual’s 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.
Explanation of how psychological factors are understood to impact on chronic pain

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)
However, increasingly we are understanding that chronic pain is located within the central nervous system, and this needs to be communicated to the patient in a way that faciliates a move from a cure based model of medicine, to one of management.

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

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

17. 1.30
Understanding neuropathic pain and the use of medication
Pain Society DVD
Oral Surgeon
2.00
How 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
2.45
Break
3.15
Getting back to mainstream dental care and other issues
3.45
Summary and resources.
Feedback
Liaison psychiatrist
4.30
Finish

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

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

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 can’t fight anymore’).
Different from catastrophising in that it focuses on the person’s perception of themselves.

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

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. The Extended Grief Cycle.
                                                                                                                                                                           

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

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

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. 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. WEBSITES

35. A typical patient at KCH!.