Presentation on theme: "A MULTIDISCIPLINARY FACIAL PAIN SERVICE"— Presentation transcript:
1 A MULTIDISCIPLINARY FACIAL PAIN SERVICE Dr Sarah Barker, Consultant Clinical PsychologistKings College Hospital
2 ‘Trigeminal neuralgia’ ‘Idiopathic facial pain’Posterior fossa: entry of trigeminal nerve to the brainTrigeminal 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 shoppingFrequent attendees at the emergency dental clinicMultiple treatment modalities with little / no resolution of distressCosmetic concerns that seem disproportionate or difficult to pinpointUnexplained physical symptoms in multiple systemsCosmetic: e.g.: my jaw is sticking out and requires surgery; dentist disagrees
4 What non-dental factors are relevant in chronic orofacial pain? Predisposing factorsGenetics (Diatchenko et al 2005 Hum Mol Gen)Childhood traumaAnxiety / depression (Aggarwal et al 2010 Pain)Chronic widespread pain (John et al 2003 Pain)Precipitating factorsLife eventsPhysical traumaPerpetuating factorsAnxiety / depressionIllness beliefsUnhelpful behavioursIatrogenic treatments
5 Iatrogenesis ‘brought forth by a healer’ Over-investigationOver-treatmentFailing to treat aspects of health that are potentially treatableIn 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 factorsPain, moderate to severe, lasting more than one monthRepeat surgeryPsychological vulnerabilityPreoperative anxiety FemaleYounger age (adults)Workers compensationGenetic predispositionInefficient diffuse noxious inhibitory control DNCIntraoperative factorsSurgical approach with risk of nerve damagePostoperative factorsPain (acute, moderate to severe) DepressionRadiation therapy to areaNeurotoxic chemotherapy Neuroticism Anxiety
7 Multi-disciplinary facial pain management at King’s PersonnelOral surgeonsOral medicsPsychiatristPsychologistNeurologistNeurosurgeonPain anaesthetist(Physiotherapist)(Speech & Language Therapist)Easy referral systems between disciplinesRegular MDT clinicsFrequent informal discussions between cliniciansExcellent secretarial supportDevelopment of group treatment days for specific patient groups
9 1. AssessmentPresenting problem and medical history (often pain is the primary problem)Impact of problem on function and quality of lifePsychological function and past mental health history and treatmentSocial issuesGoals of treatment and expectations of therapyFormulation and collaborative treatment planning
10 2. Formulations contain.. Symptoms and problems Predisposing life events or stressorsPrecipitating 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 disturbanceAnxiety frustration depressed moodNegative appraisal of pain/health relevant informationNegative appraisal of self in relation to pain (mental defeat)Mental elaboration (worry, rumination)Bodily variations (including pain)Automatic attentional processesSeeking reassurance/medical informationEffortful attentional deploymentSelective attentionSafety seeking behaviour
15 4. Treatment options within oral surgery Information sheets about nerve injury and direction to patient support websiteMultidisciplinary group for nerve injury patients (Plan is to run bi-annuallyIndividual psychological therapy
16 MULTIDISCIPLINARY NERVE INJURY DAY TopicFacilitator9.30Welcome and housekeeping.Key questions for the dayLiaison psychiatristClinical Psychologist10.00Nerve injury; medical informationOral Surgeon10.45Break11.15Mechanical symptoms and how to improve theseSpeech Therapist12.30Lunch
17 1.30Understanding neuropathic pain and the use of medicationPain Society DVDOral Surgeon2.00How nerve injury affects you and others; the psychological effects of disability, loss and pain.The role of the complaints system.Clinical PsychologistLiaison PsychiatristClinical Lead for Oral Surgery2.45Break3.15Getting back to mainstream dental care and other issues3.45Summary and resources.FeedbackLiaison psychiatrist4.30Finish
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-5LPain Detect scaleHospital Anxiety and Depression ScalePain Catastrophising ScalePain Self Efficacy QuestionnaireQualitative data to cover patient satisfaction with the workshop.
20 Psychological treatment Shared formulationSetting a contractGoal specific therapyRegular review and reformulation
21 CBT model of chronic pain (Tang, 2008) Sleep disturbanceAnxiety frustration depressed moodNegative appraisal of pain/health relevant informationNegative appraisal of self in relation to pain (mental defeat)Mental elaboration (worry, rumination)Bodily variations (including pain)Automatic attentional processesSeeking reassurance/medical informationEffortful attentional deploymentSelective attentionSafety 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 mindTendency 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 12A 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 physicalfeelings/symptoms (e.g. tingling/crawling sensation)Altered emotional feelingse.g. anxietyAltered behaviour (reduced activity, avoidance or unhelpful behavioure.g. excessive checking with tongueTHE COGNITIVE-BEHAVIOURAL MODEL
27 Depression and painPain 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)
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 physicalfeelings/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 PTSDThe 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 TraumaInjuryStress- activating factors/systemsStress- activating factors/systemsRecovery promoting factors/systemsPTSD
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)