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A MULTIDISCIPLINARY FACIAL PAIN SERVICE

Dr Sarah Barker, Consultant Clinical PsychologistDr Sarah Barker, Consultant Clinical PsychologistKings College HospitalKings College Hospital

Sarah.barker1@nhs.netSarah.barker1@nhs.net

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Posterior fossa: Posterior fossa: entry of trigeminal entry of trigeminal nerve to the brainnerve to the brain

‘‘Trigeminal neuralgia’Trigeminal neuralgia’

‘‘Burning mouth syndrome’Burning mouth syndrome’

‘‘Idiopathic facial pain’Idiopathic facial pain’

‘‘Facial arthromyalgia’Facial arthromyalgia’

‘‘Atypical facial pain’Atypical facial pain’

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Patients referred to the service are Patients referred to the service are often:often:

Those who engage in dentist shoppingThose who engage in dentist shopping Frequent attendees at the emergency Frequent attendees at the emergency

dental clinicdental clinic Multiple treatment modalities with little / Multiple treatment modalities with little /

no resolution of distressno resolution of distress Cosmetic concerns that seem Cosmetic concerns that seem

disproportionate or difficult to pinpoint disproportionate or difficult to pinpoint Unexplained physical symptoms in Unexplained physical symptoms in

multiple systemsmultiple systems

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What non-dental factors are relevant in What non-dental factors are relevant in chronic orofacial pain?chronic orofacial pain?

PPredisposing factorsredisposing factors Genetics (Diatchenko et al 2005 Genetics (Diatchenko et al 2005 Hum Mol GenHum Mol Gen)) Childhood traumaChildhood trauma Anxiety / depression (Aggarwal et al 2010 Anxiety / depression (Aggarwal et al 2010 PainPain)) Chronic widespread pain (John et al 2003 Chronic widespread pain (John et al 2003 PainPain))

PPrecipitating factorsrecipitating factors Life eventsLife events Physical traumaPhysical trauma

PPerpetuating factorserpetuating factors Anxiety / depressionAnxiety / depression Illness beliefsIllness beliefs Unhelpful behavioursUnhelpful behaviours Iatrogenic treatmentsIatrogenic treatments

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Iatrogenesis ‘brought forth by a healer’Iatrogenesis ‘brought forth by a healer’

Over-investigationOver-investigation

Over-treatmentOver-treatment

Failing to treat aspects of health that are Failing to treat aspects of health that are potentially treatablepotentially treatable

In the economically focussed NHS, In the economically focussed NHS, reducing the costs of iatrogenesis is a reducing the costs of iatrogenesis is a prioritypriority

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Preoperative factorsPain, moderate to severe, lasting more than one monthRepeat surgery Psychological vulnerabilityPreoperative anxiety FemaleYounger age (adults) Workers compensationGenetic predispositionInefficient diffuse noxious inhibitory control DNC

Intraoperative factorsSurgical approach with risk of nerve damage

Postoperative factorsPain (acute, moderate to severe) Depression Radiation therapy to area Psychological vulnerabilityNeurotoxic chemotherapy Neuroticism Anxiety

Risk factors for chronic post-surgical pain (Macintyre et al, 2010)

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Multi-disciplinary facial pain Multi-disciplinary facial pain management at King’smanagement at King’s

PersonnelPersonnel Oral surgeonsOral surgeons Oral medicsOral medics PsychiatristPsychiatrist PsychologistPsychologist NeurologistNeurologist NeurosurgeonNeurosurgeon Pain anaesthetistPain anaesthetist (Physiotherapist)(Physiotherapist) (Speech & Language (Speech & Language

Therapist)Therapist)

Easy referral systems Easy referral systems between disciplinesbetween disciplines

Regular MDT clinicsRegular MDT clinics Frequent informal Frequent informal

discussions between discussions between cliniciansclinicians

Excellent secretarial Excellent secretarial supportsupport

Development of group Development of group treatment days for treatment days for specific patient groups specific patient groups

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Management ApproachesManagement Approaches

Dental Dental

Surgical Surgical

Psychological: Individual CBT/ACT/Schema FocusedPsychological: Individual CBT/ACT/Schema Focused

Group based multi-disciplinary daysGroup based multi-disciplinary days

PPharmacologicalharmacological Rationalising / reducing analgesicsRationalising / reducing analgesics TricyclicsTricyclics Pregabalin / GabapentinPregabalin / Gabapentin SSRIs, SNRIsSSRIs, SNRIs

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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 Formulation and collaborative treatment

planningplanning

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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

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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.

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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)

COMPONENTS OF PAINCOMPONENTS 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)

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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

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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

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Topic Facilitator

9.30 Welcome and housekeeping.

Key questions for the day

Liaison psychiatristClinical 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

MULTIDISCIPLINARY NERVE INJURY DAY

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1.30 Understanding neuropathic pain and the use of medication

Pain Society DVDOral 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 PsychologistLiaison PsychiatristClinical Lead for Oral Surgery

2.45 Break

3.15 Getting back to mainstream dental care and other issues

Clinical PsychologistOral Surgeon

3.45 Summary and resources.Feedback

Liaison psychiatristClinical Psychologist

4.30 Finish

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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.

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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.

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Psychological treatment

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

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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

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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.

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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

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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)

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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

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Altered physical feelings/symptoms

(e.g. tingling/crawling

sensation)

Altered thinkingwith 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

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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)

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The Extended Grief Cycle.                                                                                                                                                                              

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Altered physical feelings/symptoms

(e.g. tingling/crawling sensation)

Altered thinkingwith unhelpful thoughts

(e.g.This sensation is unbearable; the dentist should be made to pay)

Altered behaviourreduced 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

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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).

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The three theoretical pathways through which

injury can increase the risk for PTSD

Trauma

Stress- activating factors/systems

Stress- activating factors/systems

Recovery promoting factors/systems

Injury

PTSD

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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.

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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)

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WEBSITES

http://www.tna.org.uk/index.php

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A typical patient at KCH!