Psychology & orofacial pain

Dr H Clare Daniel, Consultant Clinical Psychologist

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

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”. 2012 • “Pain with possible psychogenic causes are chronic idiopathic facial pain (atypical facial pain); burning mouth syndrome; temporomandibular pain dysfunction”. 2013 • “Burning mouth syndrome is a psychosomatic condition” 2014

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

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

INPUTS SENSORY INPUT

Cutaneous, visceral & musculoskeletal inputs; visual, vestibular inputs

COGNITIVE INPUT

Memories; past experience; attention; meaning; learning; catastrophising

Normal pain processing

EMOTIONAL INPUT

Anxiety; depression; fear Melzack (1999): The Neuromatrix Model

OUTPUTS 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

Reported pain & stimulus intensity “ 9 out of 10 ”

X

fMRI studies Reported pain intensity correlates with increased limbic activity during pain processing i.e. cognitive and emotional input Reported pain & fMRI activity “ 9 out of 10 ” ✔ Tracey & Mantyh (2007)

Cognitive and emotional influences on pain processing & responses to pain

THE PATIENT

Cognitive Behavioural Model

Beliefs Thoughts Meanings

Meanings are subjective & idiosyncratic Internet searches Media Healthcare providers CULTURE Past learning Past experiences of pain & illness Competing demands SOCIETY PAST RELIGION PAIN BELIEFS CONTEXT Who ’s present Thoughts, beliefs, meanings About symptoms About the cause About what ’s needed to make it better Our meanings, interpretations & perceptions about the patient’s pain will be different from the patient’s

Beliefs Causal beliefs Beliefs about symptoms Anatomical beliefs Treatment/ investigation beliefs “My pain must be caused by cancer” “Clicking means that my jaw bone needs surgery” “My skull is balanced on my spine” “My jaw is lose” “Treatments failed because they weren’t done correctly” Patients may do something that appears to be ‘odd’………. due to underlying fears and beliefs

Cognitive Processing: Catastrophising • Focus on threat • Overestimate threat • Underestimate resources to deal with it • • 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)

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

• • Cognitive Processing: Worry Eccleston & Crombez, 2007 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 Where pain is seen as the whole problem….

Where the problem is seen as disability & distress due to pain….

Attempts to solve the problem are focused on pain reduction….

Often no solution Attempts to solve the problem are focused on reducing disability & distress….

There are some answers

Cognitive processing: Mood related biases Anxiety: Selective for threatening information Depression: Selective for negative information I can’t understand scans, and the doctor told me it was fine I remember that time when my pain was awful & I didn’t cope well My scan looked awful The doctor said that my pain might move around a bit, that’s normal I have coped many times with increased pain My pain has spread I’m sure that headache is linked to my face pain…it’s just all getting worse I used to have headaches every one or two weeks before my face pain

Cognitive and emotional influences on pain processing & responses to pain

HCPS

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Worry Catastrophising HCPs Depression Anxiety Beliefs & meanings

• 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

CONSIDERATIONS

SELF REFLECTION: WHAT DO WE COME INTO THE ROOM WITH?

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

CONSIDERATIONS

OUR MODEL OF PAIN AND DESIRE TO TREAT & CURE

Stop the vicious cycle of referrals & distress Search for a cure Psychological & physical impact Hope Distress ‘Failed’ treatment • 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

CONSIDERATIONS

THE LANGUAGE & WORDS WE USE

We often believe that patients want confident certainty & reassurance from us. But this may not help • 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)

…Perceptions of what we say “You’re scans are normal” S/he saying the pain is in my mind “Your pain is caused by nerve damage” The nerve is broken in two. I can find someone to attach it back together My nerve is sending faulty messages “Wear and tear” “Your jaw is a bit crumbly” Things will get more worn & torn. My jaw & pain are going to get worse & worse….

My jaw is weak & crumbling…and will fall off

CONSIDERATIONS

FINDING OUT WHAT THE PATIENT THINKS & BELIEVES

“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)

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)

• • 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)

Stay curious & open What do you think is happening when your pain increases?

We’ve talked about what is causing your (symptoms). What are your thoughts about them now ?

What do you think is causing your pain?

Many people have concerns or worries when they have this condition, what are yours?

This may sound an odd question, but what’s the worst thing for you about having this condition?

CONSIDERATIONS

PATIENT UNDERSTANDING

Systematic search of PubMed (1961-2006) Am J Surg. 2009 Sep;198(3):420-35

Surgery

Adequate overall understanding of the information provided Risks associated with surgery Satisfaction by the amount of the given information The aim of the study

Clinical research

The process of randomization Voluntarism Withdrawal The risks of treatment The benefits of treatment Satisfaction by the amount of the given information 6/21 (29%) 5/14 (36%) 7/12 (58%) 14/26 (54%) 4/8 (50%) 7/15 (47%) 7/16 (44%) 8/16 (50%) 4/7 (57%) 12/15 (80%)

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?

”

The intervention

COGNITIVE BEHAVIOURAL PAIN MANAGEMENT

35

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

‘About Face’ Pain Management Programme TMD, trigeminal neuropathic pain, persistent idiopathic facial pain 2 hour Information Session (n~20) 50 min psychology assessment (1:1) Six 3.5 hour weekly sessions (n=12) 1 and 9 month FUs

Trigeminal Neuralgia Programme

2 hour Information Session (n~14) 50 min psychology assessment (1:1) Fear of the next attack “What if…………” Avoidance Six 3.5 hour weekly sessions (n=12) Framework of mindfulness based cognitive therapy 1 and 9 month FUs

Burning Mouth Syndrome

2 hour Information Session (n~14). Medical education about BMS and medication 50 min psychology assessment (1:1) “What is it?” “What medical treatments will help?” “Will it go?” Short group intervention (workshop format)

Measures

About Face clinical outcomes

N Pre - Post Mean diff (SD) 95% CI d N Pre- One Month FU Mean diff (SD) 95% CI Pain intensity (BPI) Pain Self Efficacy Scale (PSEQ) Depression (DAPOS) 30 39 49 0.58(5.37) -4.92(8.52) 1.69(3.23) -1.42-2.59

0.76-2.62

0.22

-7.68-2.15

1.14

* 1 *

21 2.43(5.18) 26 -2.82(7.05) 32 1.53(3.21) Anxiety (DAPOS) Pain Catastrophsing Scale (PCS) Pain Interference (BPI: Face) Illness Perceptions Questionnaire (IPQ) 49 46 29 1.54(2.57) 7.99(8.95) 0.61(1.35) 34 7.12(7.51) * = p<0.007 following Bonferroni Correction 0.80-2.28

5.36-10.62

1.04

*

33 7.09(7.77) 0.09-1.12

4.49-9.73

1 *

0.91

1.24

*

32 1.66(2.22) 17 0.17(1.16) 19 7.53(6.91) 0.07-4.78

0.94

-5.67-0.02

0.81

0.37-2.69

0.96

0.85-2.46

1.29

*

4.39-9.81

1.26

*

-0.43-0.77

0.31

4.19-10.86

1.82

*

d

Summary

• 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