A MULTIDISCIPLINARY FACIAL PAIN SERVICE

1. A MULTIDISCIPLINARY FACIAL PAIN SERVICE Dr Sarah Barker, Consultant Clinical Psychologist Kings College Hospital Sarah.barker1@nhs.net

2. ‘Trigeminal neuralgia’ ‘Idiopathic facial pain’ Posterior fossa: entry of trigeminal nerve to the brain ‘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

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

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. 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 2. Formulations contain..

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.

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. 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

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. Life situation, relationship or practical problems(e.g. lingual nerve injury) Altered thinkingwith 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. Life situation, relationship or practical problems(e.g. nerve injury) Altered thinkingwith 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 behaviourreduced 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 functioningAcceptance 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 • http://www.tna.org.uk/index.php

35. A typical patient at KCH!