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Psychosocial aspect of orofacial pain

Pain is complex

Most people regard pain as a physical protective phenomenon which it is in health, pain is a symptom of tissue damage and calls the body not action to seek resolution of this problem. However, chronic pain is no longer a symptom of disease, there is no ongoing tissue damage, however, the brain continues to relay pain reception often to specific parts of the body, when no injury or continued tissue damage is occurring. This is pain as a disease in itself and no longer a symptom. No one can experience pain without engagement of the whole emotional parts of the brain. You could say pain is like Love in that the complex significant emotional response is often indescribable, purely subjective and unique to the beholder. Thus, when we experience long term pain, we must acknowledge not just the biological or environmental aspects but the key role of psychological repercussions, which not only maintain the ‘bad elements of pain, but also place a patient at risk of developing chronic pain.

The biopsychosocial model incorporates psychological and social factors in order more comprehensively to understand, and manage, both disease (as related to traditional medical factors) and illness across time and circumstance. Major psychological factors associated with pain disorders include anxiety, catastrophizing, depression, physical symptom reporting and fear-avoidance; major social factors include access to medical care, stigma, and support from family and friends. Each of these factors has extensive empirical support for their association with pain disorders, and evidence clearly supports the significance of the biopsychosocial model as crucial for understanding the complexity of pain processing in general

The issues specific to trigeminal pain include the complexity of the region, the problematic impact on daily function and significant psychological impact (More here). By nature of the geography of the pain (affecting the face, eyes, scalp, nose, mouth), it may interfere with just about every social function we take for granted and enjoy (More here). The trigeminal nerve is the largest sensory nerve in the body, protecting the essential organs that underpin our very existence (brain, eyes, nose, mouth). It is no wonder that pain within the trigeminal system in the face is often overwhelming and inescapable for the affected individual.

I was astounded at the psychological impact of these iatrogenic nerve injuries during my PhD 1997-2003 which concentrated on patients with post traumatic neuropathy related to dental interventions. hence i had a co supervisor Prof John Weinman (clinic psychologist) who assisted in my interest and drive to assess this aspect of these patients.

The psychological impact related to nerve injuries caused by surgeons is large and likely due to the iatrogenic aspect and the related loss of trust in a chosen and trusted professional. Another factor is the considerable investment monetary and otherwise in taking the decision to have this treatment undertaken by this clinician. The additional debilitating neuropathic pain seen in 70% of patients with nerve injuries which is life changing and massively impactful on enjoyment of life? In addition, the trigeminal nerve underpins all continued daily function and all the senses that underpin our identify and very survival?

Another confounding issue is that patients with mood disorders, fear of pain or surgery, catastrophic or narcissistic tendencies, introverted tendencies or previous significant life events are upwards of 40% to experience chronic post-surgical pain or widespread pain in later life!

Chronic pain is associated with distress and adverse psychological outcomes in a bidirectional manner:

More information in these links:

The stress–diathesis and biopsychosocial models help inform the interplay of medical conditions, psychological inputs, and social factors in the presentation and experience of pain. There is limited evidence examining psychological experiences and quality of life for patients with trigeminal neuralgia. A few studies have shown that the condition is associated with an increased risk for depressive, anxiety, and insomnia disorders. In a retrospective study, trigeminal neuralgia was found to account for 25% of suicide attempts reported in chronic pain conditions. The side effects of medications for trigeminal neuralgia are potential contributors to psychological distress and social and occupational functioning. There are a limited amount of randomized controlled trials evaluating cognitive-behavioral therapies in neuropathic pain and no studies thus far for trigeminal neuralgia. However, general pain studies provide evidence to support their use.

We compared the impacts of trigeminal neuralgia (TN) and painful posttraumatic trigeminal neuropathy (PPTTN) on psychologic function and health-related quality of life (HRQoL) using a comprehensive quantitative assessment.

Methods: This was a comparative cross-sectional study. A total of 97 patients diagnosed with PPTTN and 40 patients diagnosed with TN who sought treatment at an orofacial pain clinic completed standardized self-report measures of pain intensity, neuropathic symptoms, pain self-efficacy, mood, and indicators of general and oral HRQoL. Differences between the PPTTN and TN groups were tested, and associations of each condition with pain severity, psychologic function, and HRQoL were examined.

Results: The majority of PPTTN (66%) and TN patients (80%) were affected by orofacial pain. Pain attacks were more frequent in TN (71%) than PPTTN (28%) patients, while numbness was more common in PPTTN (51%) than TN (12%) patients. Pain intensity was higher in TN for intermittent and affective pain dimensions. Both PPTTN and TN had a significant, but comparable, impact on patients’ oral HRQoL. The burden of condition on overall health was significantly more pronounced in patients with TN than PPTTN, with evident differences in the mobility and self-care domains. There was a trend showing that more TN (54%) than PPTTN (36%) patients reported signs of depression, but clinically significant anxiety was comparably high in both groups (34% to 39%). Anxiety and pain self-efficacy were closely related to oral and general health statuses in both groups.

Conclusions: Both TN and PPTTN are associated with significant psychosocial burden and reduced HRQoL, indicating a need to develop effective treatments for neuropathic orofacial pain that target functional restoration (link3).

There are Levels of psychosocial assessment
  • Pain- and function-related constructs and instruments for Orofacial pain conditions
  • Pain intensity and pain-related disability
  • Functional limitation.
  • Overuse behaviours
  • Psychosocial constructs and instruments for OFPs
  • Depression and anxiety
  • Somatoform disorders
  • Catastrophizing
  • Fear avoidance
  • And others

We use an extensive psychological screening questionnaire which is accessible online prior to the consultation and this has significantly improved our patient management by identifying associated psychological comorbidity including; disorders of sleep, functional, somatic, mood and post-traumatic stress. All these factors impact on the individual experiencing chronic pain and by addressing them alongside making correct pain diagnoses, the holistic care of the patient is improved and optimised. In the future, online access to questionnaires may facilitate patient care.

Psychological therapies to address chronic pain and related disorders include; cognitive behavioural therapy, acceptance commitment therapy and mindfulness. Often a combination is used tailored to the individual. All these interventions aim to ‘redirect’ negative thoughts about the persons pain condition. More can be learnt about how psychological interventions work for chronic pain (link to virtual pain day – coming soon).

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