Atypical Facial Pain and Depression

R. G. LASCELLES

Abstract

Ninety-three patients suffering from prolonged facial pain have been studied in detail from the general medical and psychiatric aspects. Review of the literature has shown the wide diversion of opinion over the significance of the various aetiological factors claimed to be involved in the production of facial pain and over the efficacy of the measures that have been employed for its relief.

Careful questioning revealed a background of depressive illness in the majority of patients in this survey. This illness was "atypical" in that the classical features of a depressive state—melancholia, retardation, weight loss and self-reproach were replaced by intense fatigue, agitation and sleep disorders as the most prominent symptoms. It was considered significant that most of the patients appeared to have good previous personalities and tended to be "obsessive" in that they were meticulous and over-conscientious in their approach to life.

In 53 patients, the treatment of underlying depressive illness by modern physical methods produced excellent results. Of these, 29 lost their pain completely and were symptom-free at the end of a follow-up period which averaged seven months. The best results were obtained in those patients who had the shortest clinical histories, who had good previous personalities, and who displayed well-marked "obsessive" features.

A control study, conducted on the "double-blind" basis was carried out on the remaining 40 patients. Each patient received one month of active and one month of placebo therapy, and was assessed at intervals as regards both the degree of facial pain and the depth of depression. For the latter a modification of the Hamilton rating scale was employed. Statistical analysis of the results showed that patients receiving active therapy were significantly improved in both facial pain and depression as compared with those receiving placebo. The improvement in facial pain was shown to be associated with an improvement in depression.

The dangers of surgical intervention, especially in those patients whose history of pain bore a resemblance to that found in trigeminal neuralgia, have been stressed. The value of a searching inquiry into the patients' psychiatric background has been emphasized.