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COMMENTARY | GIORDANO
COMMENTARY:
Dolor, Morbus, Patiens:
Maldynia, Pain as
Illness and Suffering
BY JAMES GIORDANO, PhD, MEDICINE AND HUMANITIES EDITOR
AS THE MEDICINE AND HUMANITIES EDITOR for
The Pain Practitioner, I am grateful for the
opportunity to write a commentary on the
papers appearing in this issue on complex
regional pain syndrome (CRPS).
TOGETHER, THESE ARTICLES address this frequently misunderstood
syndrome, convey how an expanding epistemology has
generated enhanced understanding of the mechanistic basis and
existential impact of pain as a complexity-based systems event,
and present the need to develop diagnostic and therapeutic
approaches that reflect this progressive knowledge.
The basic and clinical sciences, humanities, and the
experiential narratives of patients all contribute essential lenses
through which we can examine and de-mystify the enigma
of persistent pain.
I believe that how we come to know about pain
is equally important as, and provides a pediment for, what
we know about pain. It is only through the combination of
distinct domains of knowledge that we can both comprehend
pain as a dysfunction of the dynamical, nonlinear adaptability
of the nervous system, and at the same time apprehend the
manifestations of these changes within the networked-hierarchy
of interacting systems that is the patient as person. 1 Thus,
the study of pain conjoins neuroscience to the burgeoning
discourse of neurophilosophy and, in so doing, may reconcile
issues in the dialectic surrounding the concepts of disease—
illness, brain-mind, and ethical dimensions of care.
Pain as a Spectral Disorder
I POSIT THAT PAIN CAN BE CONSIDERED TO BE A SPECTRAL
DISORDER—one that ranges from a symptom of organic insult
or trauma, to durable, more global pathologic changes occurring
at multiple levels of the nervous system, ultimately affecting
the substrates that are involved in and/or elicit behavior,
emotion, and cognition of the (internal and external) environment
and, thus, some form of the definable “self.” 2
I maintain that with progression across this spectrum, the
disease process of pain increasingly becomes the phenomenal
illness of pain. Classification and diagnoses must acknowledge
pain as disease and manifest illness, recognizing, too, that the
disease process may be durable and immutable (1).
The arbitrary temporal classifications that rested upon the
acuteness or chronicity of pain did little to define the etiologic
and pathophysiologic processes that may cause or perpetuate
the disorder. Hence, these criteria have been replaced by nosologic
distinctions (e.g., nociceptive vs. neuropathic; Type I, II,
III) that have sought to characterize pain according to the
inherent neurological mechanisms. Woolf, Borsook, and
Koltzenburg (2) have recently expanded this schema into an
elegant algorithmic model that thoroughly accounts for stimulus
dependency and neural basis, enabling both mechanistic
identification of types of pain and proof of concept evidenced
in clinical syndrome(s). Certainly, this algorithm can be considered
to be situated along, and/or be representative of, the pain
spectrum, as I have proposed. Yet, the “meaning” and manifestations
of these types of pain still remain implicit in, if not altogether
absent from, the algorithm of Woolf et al. Almost a
decade ago, Lippe (3) proposed the use of the term eudynia to
represent physiologically “normal” or nociceptive pain, and
maldynia to be “abnormal” pain arising from neuropathic
processes. These terms have become increasingly popular, but I
feel that when used alone, they do little to define what “normality”
and “abnormality” actually mean. Similarly, the sole use
of the categorization scheme of Woolf and colleagues is some-
1 These are concepts that are inherent to, and derived from, complexity theory.
I feel that the use of a complexity-based model of pain is important to fully
reconcile the notions of disease and illness, and to fit these within a more
encompassing framework. For a review of complexity theory and its applicability
to neuroscience and medicine, see: Kelso, JS. Dynamic Patterns: The
Self-Organization of the Brain and Behavior, Cambridge, MIT Press, 1995;
Waldrop MM. Complexity: The Emerging Science at the Edge of Order and
Chaos, NY, Touchstone Books, 1992; Dayan P, Abbott LF. Theoretical Neuroscience:
Computational and Mathematical Modeling of Neural Systems. Cambridge,
MIT Press, 2001; and for a straightforward overview, see: Sarder Z,
Abrams I. Introducing Chaos, Cambridge (UK), Icon Books, 2003.
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