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Psychology & orofacial pain. Dr H Clare Daniel, Consultant Clinical Psychologist. Persistent Pain ‘ vs ’ Persistent Orofacial Pain. Same or different psychological processes and pain processing? M uch of the orofacial pain literature is about 2 decades behind the persistent pain literature.

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Psychology orofacial pain

Psychology & orofacial pain

Dr H Clare Daniel, Consultant Clinical Psychologist

Persistent pain vs persistent orofacial pain
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
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; temporomandibularpain- dysfunction”. 2013

  • “Burning mouth syndrome is a psychosomatic condition” 2014


Functional symptoms



Not real







Psychology orofacial pain

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

Psychology orofacial pain

Normal pain processing





Sensory-discriminative; motivational-affective; cognitive-evaluative


Cutaneous, visceral & musculoskeletal inputs; visual, vestibular inputs


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


Involuntary & voluntary action patterns; action patterns; social communication


Anxiety; depression; fear


Cortisol, noradrenaline, cytokine levels; immune system activity, endorphin levels

Melzack (1999): The NeuromatrixModel

Psychology orofacial pain

Reported pain & stimulus intensity

fMRI studies


“9 out of 10”

Reported pain & fMRI activity

“9 out of 10”

Reported pain intensity correlates with increased limbic activity during pain processing

i.e. cognitive and emotional input

Tracey & Mantyh (2007)

The patient

Cognitive and emotional influences on pain processing &responses to pain

The Patient

Cognitive behavioural model
Cognitive Behavioural Model






Cognitions & cognitive processing




Meanings are subjective idiosyncratic

Healthcare providers





Past learning



Past experiences of pain & illness

About symptoms

About the cause


About what’s needed to make it better

Competing demands

Who’s present

Meanings are subjective & idiosyncratic

Internet searches

Thoughts, beliefs, meanings

Our meanings, interpretations & perceptions about the patient’s pain will be different from the patient’s

B eliefs

Causal beliefs

“My pain must be caused by cancer”

Beliefs about symptoms

“Clicking means that my jaw bone needs surgery”

“My skull is balanced on my spine”

Anatomical beliefs

“My jaw is lose”

Treatment/ investigation beliefs

“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
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)

Psychology orofacial pain

Cognitive Processing: Catastrophising


Erroneous beliefs are not challenged & re-evaluated












Vlaeyen & Linton (2000)

Cognitive processing worry
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 the problem is seen as disability & distress due to pain….

  • Where pain is seen as the whole problem….

  • Attempts to solve the problem are focused on reducing disability & distress….

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

  • There are some answers

  • Often no solution

Cognitive processing mood related biases
Cognitive processing: Mood related biases


Selective for negative information

Anxiety: Selective for threatening 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

I have coped many times with increased pain

The doctor said that my pain might move around a bit, that’s normal

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

My pain has spread

Psychology orofacial pain

  • 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

    • Simmondset al, 2012; Darlow et al., 2013

  • We can helpfully alter patients’ beliefs about the cause, meaning and consequence of pain

Self reflection what do we come into the room with

CONSIDERATIONS and unhelpful

Self reflection: what do we come into the room with?

Psychology orofacial pain

Situation and unhelpful


Cognitions & cognitive processing

Cognitions & cognitive processing







Our model of pain and desire to treat cure

CONSIDERATIONS and unhelpful

Our model of pain and desire to treat & cure

Stop the vicious cycle of referrals distress
Stop the vicious cycle of referrals & distress and unhelpful

  • 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

The language words we use

CONSIDERATIONS and unhelpful

The Language & words we use

Psychology orofacial pain

We often believe that and unhelpfulpatients 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
…Perceptions of what we say and unhelpful

S/he saying the pain is in my mind

“You’re scans are normal”

The nerve is broken in two. I can find someone to attach it back together

“Your pain is caused by nerve damage”

My nerve is sending faulty messages

Things will get more worn & torn. My jaw&pain are going to get worse &worse….

“Wear and tear”

My jawis weak & crumbling…and will fall off

“Your jaw is a bit crumbly”

Finding out what the patient thinks believes

CONSIDERATIONS and unhelpful

Finding out what the patient thinks & believes

Psychology orofacial pain

“Listening and unhelpful, 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
Do we listen…..? and unhelpful

  • 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)

Psychology orofacial pain

  • This results in: and unhelpful

    • 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 secsin 1ocare and 90 secsin 2o 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
Stay curious & open and unhelpful

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?

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

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

Patient understanding

CONSIDERATIONS and unhelpful

Patient understanding

Psychology orofacial pain

Systematic search of PubMed (1961-2006) and unhelpful

Am J Surg. 2009 Sep;198(3):420-35

Aid understanding
Aid understanding and unhelpful

  • 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?”

Cognitive behavioural pain management

The intervention and unhelpful

Cognitive behavioural pain management

Cbt pain management mdt
CBT pain management (MDT) and unhelpful

  • 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
‘About Face’ Pain Management and unhelpfulProgramme

  • 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
Trigeminal Neuralgia and unhelpfulProgramme

Fear of the next attack

“What if…………”


2 hour Information Session (n~14)

  • 50 min psychology assessment (1:1)

  • Six 3.5 hour weekly sessions (n=12)

  • 1 and 9 month FUs

Framework of mindfulness based cognitive therapy

Burning mouth syndrome
Burning Mouth Syndrome and unhelpful

“What is it?”

  • “What medical treatments will help?”

    “Will it go?”

2 hour Information Session (n~14). Medical education about BMS and medication

  • 50 min psychology assessment (1:1)

  • Short group intervention (workshop format)

Summary and unhelpful

  • 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

Thank you