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Psychological and Psychiatric Aspects of Oral Health
J. Tim Newton, PhD
Beth J. Guildford, DClinPsy, PGDip
Patients seen in oral medicine departments commonly have conditions with features that can be challenging to live with and can be associated with distress. Examples of such features include pain or other unpleasant sensations, fatigue, chronicity, and altered facial appearance. Healthcare professionals working in this specialty have a vital role to play in taking a holistic approach to assessment and treatment. This chapter has five sections. In the first, the psychological management of patients with chronic orofacial pain is discussed in detail. Patients in pain (such as those with chronic orofacial pain and with burning mouth syndrome [BMS]) are among the most common presentations in dentistry and oral medicine. An understanding of the psychological processes involved in patients’ interpretation of their pain, as well as the impact of chronic pain on mood and behavior, is critical to the care of these patients. The second section will outline psychological approaches applicable to people with orofacial pain, as well as to other long‐term orofacial conditions commonly seen in oral medicine. The next section describes the psychological impact of changes in appearance, such as can occur in conditions including orofacial granulomatosis (OFG). The penultimate section deals with communicating difficult news to the patient (such as a diagnosis of oral cancer). The final section will provide an overview of those psychiatric conditions likely to present among the population of patients with orofacial conditions and the implications of each diagnosis for patient management.
PSYCHOLOGICAL ASSESSMENT AND MANAGEMENT OF INDIVIDUALS WITH OROFACIAL PAIN
The Biopsychosocial Model and Relationship to the Gate Control Theory of Pain
The biopsychosocial model is the most useful in clinical dentistry. The model suggests that the development and experience of illness are the result of the interplay of three broad groups of factors: biologic, psychological, and social (Table 24‐1).1 The biologic grouping includes genetic predispositions, evolutionary vulnerabilities, infective agents, and other biologic processes. The psychological factors include both behaviors and thoughts (cognitions) that influence the onset of disease (for example health‐related behaviors, the experience of psychosocial stress, beliefs about disease, and symptom interpretation) and the course of the disease.
Table 24‐1 The biological, psychological and social factors that need to be taken into account in assessing a patient’s clinical response to pain (the biopsychosocial model).
| Biologic | Psychological | Social |
|---|---|---|
| Genetic predispositions | Behaviors | Living circumstances |
| Evolutionary vulnerabilities | Thoughts (cognitions) | Economic factors |
| Infective agents | Experience of psychosocial stress | Interpersonal factors |
| Other biologic processes | Beliefs about disease | Social support |
| Symptom interpretation |
Examples of thoughts that would have an impact on disease perceptions include beliefs about the ability to control symptoms, the extent to which symptoms are perceived as “normal” or “abnormal,” coping strategies, and so on. Social factors cover living circumstances, economic factors, but also interpersonal factors that operate at the level of the person’s immediate social group, including social support and engagement with the “sick role.” Most illness is socially distributed—that is, related to the social gradient in society—with the experience of illness being more common in those who are most economically deprived, who may also have the fewest resources to address their illness. Furthermore, social support may ameliorate the impact of biologic disease processes.
The gate control theory of pain was proposed over 50 years ago by Melzack and Wall,2 but has stood the test of time. The theory incorporates the biopsychosocial approach just detailed, with the assumption that the experience of pain is the result of a combination of physical, emotional, and cognitive components. The gate control theory is underpinned by an essentially physiological model of pain experience through the interaction of the peripheral and central nervous systems.
Melzack and Wall proposed that the dorsal horn on the spinal cord acts as a “gate” between the peripheral fibers and communication with the pain centers of the brain via the spinal cord. When the gate is open, the nerve fibers can transmit messages to the brain and thus pain is experienced. When the gate is closed, these pain messages are blocked. The gate can be opened and closed both locally and centrally; small fibers at the location of injury may inhibit or excite the gate, which can also be modulated by descending signals from the brainstem. As the brainstem is affected by cortical activity, then cortical activity can indirectly open and close the gate.3
Concordant with the biopsychosocial model, the gate control theory identifies three components of the pain experience. First, there is the sensory–discriminative component that gives information about the location, type, and intensity of the pain stimuli. The second is that the affective–motivational component characterizes the emotional responses to pain (such as anxiety, fear, or distress). Finally there is the cognitive–evaluative component, which refers to the interpretation or meaning that the individual ascribes to the sensory experience, and which is related to their characteristic pattern of thinking about their pain, their beliefs, expectations, and other cognitions concerning the pain, as well as the presence of psychological comorbidities such as depression. Together these interact to determine the individual experience of pain. Figure 24‐1 summarizes the interaction of the sensory–discriminative component, the affective–motivational component, and the cognitive–evaluative component to form the experience of pain.
Assessments of the different dimensions have found that pain of different origins can be distinguished according to these dimensions. Melzack et al.2 report that the pattern of reporting of the pain experience using the McGill Pain Questionnaire (MPQ; see later) was different for patients presenting with atypical facial pain compared with those with trigeminal neuralgia. Similarly, while the sensory component of toothache and the pain of BMS were reported to be similar, the affective–motivational and cognitive–evaluative components were different according to the two sources of pain.4
Figure 24‐1 The components of pain as identified by gate control theory.
Psychological Assessment of Individuals with Chronic Orofacial Pain
The initial assessment of an individual with chronic pain should encompass the following areas:
- The pain experience.
- Psychological wellbeing (including the most common manifestations of psychological disturbance: depression and anxiety, as well as significant risks such as suicidal ideation).
- The impact of pain on functioning and wellbeing.
The Experience of Pain
The three broad components of pain as identified in gate control theory have implications for the comprehensive assessment and management of chronic pain. The McGill Pain Questionnaire was designed to assess all three components of the pain experience.5 Patients are asked to select from a list of 78 pain‐related adjectives (arranged in 20 groups) those that most accurately reflect their pain experience. Sections 1–10 explore the sensory component of the pain, sections 11–15 the affective component, and the evaluative dimensions are covered in section 16. There is also a miscellaneous set of sections (16–20). A single Pain Intensity item asks the patient to rate their pain on a six‐point Likert scale (Present Pain Index, PPI), and finally there is a picture of a human figure facing forward and backward, and the patient is asked to shade those areas where they experience pain. The full MPQ takes approximately 15 minutes to complete. A short form is available that takes approximately 5 minutes to complete. The short form comprises 15 descriptive words taken from the MPQ, each of which is scored on a four point Likert scale, as well as the PPI and a Visual Analogue Scale to assess pain intensity. The short form correlates highly with the full McGill Pain Scale.
Psychological Wellbeing
The identification of coexisting negative impacts on psychological wellbeing, such as low mood or anxiety, is important in the assessment of an individual with chronic orofacial pain, since such issues may have an impact on adherence to medical advice, as well as exacerbating the negative impact of pain on everyday functioning and pursuit of valued goals by the patient. An impact on psychological wellbeing, although not inevitable, has been found to be increased above general population rates in orofacial pain, including temporomandibular dysfunction (TMD)6 and BMS.7
Depression and Suicidal Ideation
Depression and depressive disorders are characterized by a disturbance in mood that is marked and of prolonged duration. It differs from the regular changes in mood that are experienced every day by duration and intensity. The disturbance in mood may take the form of sadness, flat mood, or an unusual degree of irritability. Depression is often accompanied by the experience of changes in the way in which the body is experienced: those affected may report increased aches and pains or a feeling of slowness, excessive sleep, and poor quality of sleep. Depression is accompanied by distinctive changes in the way the person thinks (cognitions), which are often characterized as being negative thoughts about themselves or their situation, and are perceived to be personal (the result of their own actions or character, rather than the situation in which they find themselves) and fixed (not susceptible to change).
The lifetime prevalence of depression and depressive symptoms is about 25% for women and 12% for men, though at any one time it is estimated that approximately 7% of the population will be experiencing marked symptoms of depression.8 There are many questionnaire measures of depression available, and in considering which measure to adopt a key factor should be consideration of the extent to which the measure includes items relating to the somatic aspects of depression (aches, pains, difficulty sleeping, etc.). Such items may overlap with the individual’s experience of pain and as such give an elevated score for the “depression” construct.
The most useful is the Patient Health Questionnaire (PHQ‐9),9 which is a brief measure that assesses nine diagnostic features of depression as identified in the Diagnostic and Statistical Manual of Diseases (DSM‐5). The nine items also include a single item relating to suicidal ideation, which is an important risk to assess as part of the identification and management of depression. The scale can be administered over the phone and takes only a few minutes for the patient to self‐complete. Scores range from 0 to 27, with higher scores indicating a greater severity of depressive symptoms. Where mild or moderate depressive illness is identified, the patient should be referred to psychological and/or psychiatric services for management. If suicidal ideation is identified during the risk assessment (i.e., the score for the single item on suicidal ideation is “more than half the time”), then an urgent referral should be made for assessment by a psychiatric team.
Anxiety
A patient faced with the uncertainty of the diagnosis of a chronic condition will inevitably be concerned for their future wellbeing and the impact socially in terms of family, friends, and work. Where the degree of anxiety becomes debilitating, this may have an impact on the individual’s wellbeing and functioning. Anxiety disorders are manifest when the anxiety experienced is such as to have an impact on the individual’s wellbeing; they are associated with high levels of autonomic arousal, hypervigilance, and avoidance behaviors, such as withdrawal from activities that might increase the person’s anxiety level. Panic attacks are a particular manifestation of anxiety whereby the physiologic and cognitive response to the fear becomes overwhelming.
A range of questionnaire measures of anxiety exist. The authors recommend the use of the Generalized Anxiety Disorder Assessment (GAD‐710). Developed by the same team as the PHQ‐9, the GAD‐7 is easy and quick to complete and gives a score in the range of 0–21, with higher scores indicating higher levels of anxiety. The scale has high levels of sensitivity and specificity in detecting anxiety disorders presenting in nonpsychiatric populations.11 Where a moderate or marked level of anxiety is identified, the patient should be referred for psychological and/or psychiatric assessment.
Impact of Pain on Functioning and Wellbeing
An assessment of the impact of pain and any associated psychological changes on the individual’s functioning is an essential part of the evaluation of chronic pain. People experiencing chronic pain conditions will often make adjustments to their lifestyle in order to incorporate their perceived limitations as a result of the pain experience. Some patients may benefit from a referral to a multidisciplinary pain rehabilitation program. A primary goal of any pain rehabilitation program is the recovery of physical and social functioning and psychological wellbeing, even in the absence of change in the sensory experience of pain. Measures of quality of life, health‐related quality of life, and specific assessments of oral health‐related quality of life are all available. The West Haven‐Yale Multidimensional Pain Inventory (WHYMPI12) is a 52‐item, 12‐scale measure of three dimensions of the experience of chronic pain. Part I assesses the perceived interference of pain in vocational, social/recreational, and family/marital functioning; support or concern from spouse or significant other; pain severity; perceived life control; and affective distress. Part II assesses patients’ perceptions of the degree to which spouses or significant others display solicitous, distracting, or negative responses to their pain behavior. Part III explores patients’ report of the frequency of common everyday activities: household chores; outdoor work; activities away from home; and social activities. The WHYMPI provides a comprehensive assessment of the social and psychological impact of the individual’s chronic pain, together with an identification of the thoughts, behaviors, and contingencies that may be maintaining the pain behavior.
As part of the overall clinical evaluation, it is important to explore any valued activities that the patient may have decreased or ceased as a result of their pain, since these can form the target of psychological interventions in the pain rehabilitation program.
PSYCHOLOGICAL INTERVENTIONS IN CHRONIC OROFACIAL PAIN AND OTHER LONG‐TERM CONDITIONS
Psychological approaches are widely recommended for long‐term health conditions, including chronic pain, in order to help people live with their condition more effectively. These approaches combine techniques to address the cognitive and behavioral manifestations associated with long‐term health conditions. Appreciation of psychological techniques will help oral medicine clinicians to better manage these patients. Examples of common presentations in which it is helpful to have an appreciation of psychological techniques include those in which there is:
- Anxiety about the condition and/or its progression.
- Avoidance of activity, leading to reduced quality of life.
- Continued requests for further investigations or a cure, despite the condition being chronic and/or further investigations not being indicated.
Some patients may additionally benefit from referral to a psychologist for further assessment and a course of psychological therapy to address these issues in more depth.
Cognitive behavioral therapy (CBT) is an example of a brief psychological therapy with proven effectiveness. It uses both behavior modification techniques and cognitive restructuring procedures to change maladaptive beliefs and behaviors. Behavioral aspects of CBT include learning relaxation skills, conducting mini‐experiments, pacing (building an awareness of cycles of energy and fatigue and arranging activity around those cycles), and behavioral activation (encouraging patients to engage in activities that they have previously avoided).
Cognitive aspects of the approach are based primarily in the analysis of people’s cognitions (e.g., thoughts, beliefs, interpretations). The central concept is that the way people think about events plays a central role in their emotions (e.g., anxiety) and physiological responses and paves the way to establishing and maintaining unhelpful behaviors such as avoidance. Cognitive therapy therefore aims to facilitate a new understanding (cognitive restructuring) by the patient.
An important principle underlying CBT is its focus on the “here and now,” as the origin of any behavior may differ from the factors that maintain it. For example, while pain may have originally arisen in response to a physical trauma, pain‐related behavior such as avoiding housework or social isolation may be maintained by a fear of increased pain or by the secondary gain of avoiding an unpleasant activity. In contrast to other psychotherapies, CBT is a short‐term therapy, with treatment typically lasting 6–10 sessions. Other characteristics of CBT that set it apart from other therapies include the collaborative nature and structured approach of therapeutic sessions, and asking clients to spend time each day working on specific tasks in order to practice and establish the skills they have learned in their CBT sessions. The cognitive components of a CBT approach may include psychoeducation: learning more about the nature of their health condition and ways to manage it, challenging beliefs about their health condition (such as that the chronic pain they experience is not an indication of ongoing damage), and small‐scale experiments to test beliefs, for example the patient testing for themselves in a small and systematic way whether increased activity would result in increased pain.
Acceptance and commitment therapy (ACT) is an advanced form of CBT that has been used successfully with patients with various long‐term health conditions. Central to this form of therapy is the notion of “psychological flexibility,” which is a concept that explores how flexible our thoughts and actions are in relation to the demands of the current situation. For many people everyday behavior is habitual and unreflective. This allows many of the day‐to‐day decisions about what to do to be made easily, without too much thought. However, when faced with an unusual situation or challenge (such as the experience of a long‐term health condition), habitual and established patterns of thoughts and behavior may not be helpful. ACT uses notions of acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility. Rather than concentrate on trying to change their situation, patients are encouraged to accept the current state of things and seek flexible strategies to move toward their valued goals. The great benefit of ACT for patients with long‐term health conditions is acceptance of the current situation and an emphasis on return to activities that may have been suspended or avoided.
APPEARANCE‐RELATED ISSUES
Psychosocial Issues Experienced by People with a Visible Difference
Some conditions such as oral cancer and OFG can be associated with changes in appearance, also commonly termed visible difference. Rumsey and Harcourt13,14 give a detailed account of the psychosocial issues related to visible difference. In summary, visible difference can be associated with:
- Anxiety and depression.
- Negative self‐perceptions and self‐esteem.
- Challenging encounters with other people (e.g., staring), which can contribute to distress.
- Behaviors such as avoiding social situations. In the longer term, avoidance can compound distress.
Importantly, the level of psychosocial distress experienced by an individual is not related to the severity of the visible difference.15 Factors that are associated with more positive psychosocial outcomes in people with visible difference include having good social support and effective communication skills.13
It should also be noted that the treatments for some of the conditions in which visible difference occurs can be demanding. Furthermore, physical functioning can be affected and the patient may be in pain. These factors can present additional challenges and sources of distress, alongside a visible difference.
Identification and Management of Psychosocial Issues
It is important for oral medicine clinicians to include assessment of psychosocial concerns as part of their consultation. Since clinicians’ judgment of the severity of the visible difference is not an accurate predictor of psychosocial adjustment, it is important that clinicians do not make assumptions based on this; for example, referring somebody for psychological support simply because they have an objectively large visible difference. Example questions that can be used to identify patients’ psychosocial needs are included in Box 24‐1. Including questions about how patients feel about their appearance is an important part of normalizing their concerns, as well as recognizing when further support may be required. Organizations such as the UK charity Changing Faces can provide training and resources for health professionals in this regard.
As part of the consultation, questionnaires such as the PHQ‐9 and GAD‐7 can be used to screen for psychological distress. More specifically, the Derriford Appearance Scale‐24 (DAS2416) is a widely used measure that assesses distress and dysfunction related to visible difference (such as distress at one’s reflection and avoidance of social situations). The information from the questionnaires, in conjunction with discussion with the patient, can inform recommendations about psychosocial interventions (Bessell and Moss offer a review of psychosocial interventions for visible difference17). Self‐help resources and support groups are among the interventions to which the clinician may direct patients. A smaller proportion of patients may require referral for psychological therapy, including CBT, and/or social interaction skills training. Social interaction skills training involves helping patients to feel more confident when interacting with others. For example, patients with facial alterations due to surgery or OFG learn ways to prepare for challenging social situations, such as when a stranger asks “What’s wrong with your face?”
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