Opinion
VIEWPOINT
Neil L. Schechter, MD Chronic Pain Program, Pain Treatment Service, Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts.
Corresponding Author: Neil L. Schechter, MD, Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (neil .schechter@childrens .harvard.edu).
Functional Pain Time for a New Name The beginning of wisdom is to call things by their right names. Chinese Proverb
When a comprehensive search to explain a particular symptom or cluster of symptoms does not identify an organic disease, those symptoms are often described as representing a functional disorder. When that symptom is pain, the patient is diagnosed with a functional pain disorder. Although functional gastrointestinal disorders are perhaps the best known members of this family, other entities (fibromyalgia, interstitial cystitis, and chronic daily headaches) are considered functional and encountered by primary care professionals and specialists on a daily basis. In fact, most medical specialties appear to have a functional disorder that commonly occurs within their scope of practice.1 In a survey of general practitioners in the United Kingdom, functional syndromes accounted for 20% of consultations. Yet, despite their frequency, there is general dissatisfaction with the terminology used to describe them and widespread misunderstanding of their etiology, which is often wrongfully assumed to be solely psychological.2,3 This assumption often leads to a reductionistic and often unsuccessful approach to their treatment and frustration for both the physician and the patient. The term functional disease was originally promulgated in the late 19th century to suggest that the problem the patient was experiencing did not fit into a specific known disease category and was likely the result of organ dysfunction as opposed to anatomic or biochemical pathology. At that time, there was no suggestion that psychogenesis was at the core of functional disorders. This construct began to change by the middle of the 20th century, however, when deep-seated emotional trauma was seen as responsible for a host of physical symptoms including pain. Evidence of the shift toward a psychological explanation for unexplained symptoms is evident in the varying definitions of functional problems found in medical dictionaries. In 1926, Stedman’s Medical Dictionary, already in its ninth edition, defined functional disease as “a disorder in the functions of several organs or tissues in which no lesion or change in structure can be determined.”4 By the 28th edition in 2006, functional disease was defined as “not organic in origin; denoting a disorder with no known or detectable or organic basis to the symptoms; See Neurosis [my emphasis].”5 In reality, in common parlance today, functional disorders are typically assumed to be a product of psychological distress. These definitions reflect both conventional wisdom as well as our practice patterns. At the present time, it is common for a pain problem to be extensively evaluated and if no organic lesion is identified, the patient’s care is
oftentransferredtoamentalhealthcareprofessional.This is highly unsatisfying for patients who had been led to believe that the identification and possible cure for their suffering would be found around the next investigative corner. They are often not prepared and typically not ready to accept a strictly psychological explanation when those investigations prove fruitless. Patients who are so labeled often feel dismissed and as a result are frequently noncompliant with medical advice. Despite this practice, however, we now know that the organic vs psychological dichotomy is both confusing and inaccurate. Multiple streams of evidence have emerged over the past few years that suggest that functional pain disorders represent an alteration of pain signaling that may stem from central sensitization or failure of descending noxious inhibition or both.2 Changes in the nervous system likely emerge from multiple mechanisms, both biological and psychosocial, such as genetic predisposition, anxiety or depression, increased psychosocial stressors, early life adversity, infections, trauma, and/or inflammation. These factors may impact the central nervous system and cause the hyperexcitability, which is the core biological link and final common pathway for the creation of functional pain disorders. This understanding renders the dichotomization of etiology (organic vs psychological) not only overly simplistic but erroneous. In addition to their common etiology (altered nociceptive processing), these various pain entities frequently co-occur and have shared clinical similarities. They are frequently comorbid with anxiety and depression; they occur more frequently in females than males; they often present with associated symptoms such as fatigue and sleep disorders; and they often respond to centrally acting therapies (anticonvulsants and antidepressants, exercise, cognitive behavioral therapy, and acupuncture).2 Given this reconceptualization of our understanding of functional pain disorders, there is all the more reason to discard the term functional pain. Not only is there a common, albeit inaccurate, belief that functional pain is strongly psychological in origin, but in reality, if the nomenclature focused solely on function, this category should be labeled dysfunctional pain. In effect, calling pain “functional” is like calling disease, “ease.” There are other commonly used terms in the literature to explain this phenomenon that are equally unsatisfactory. Medically unexplained pain is a frequent alternative but implies that our lack of knowledge is the issue when, in fact, much is known about functional pain. Somatization and somatoform disorder were terms that were often used as a default when pain could not be medically explained. Fortunately, the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) has
jamapediatrics.com
JAMA Pediatrics August 2014 Volume 168, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Georgia User on 05/24/2015
693
Opinion Viewpoint
eliminated these highly stigmatizing and often inaccurately used terms that implied that mental factors were the sole cause of a physical symptom. The Diagnostic and Statistical Manual of Mental Disorders Committee substituted somatic symptom disorder but this term as well as psychosomatic disorder continue to be too burdened by the specter of psychogenesis to be truly useful. More recent attempts to categorize functional pain include central sensitivity syndrome,3 which itself appears highly reductionistic, and pain amplification disorder, a term frequently used by rheumatologists, which is often interpreted by patients as implying that they are somehow deliberately amplifying or exaggerating their pain. The search for an appropriate term for these pain problems is far more than semantic. Evidence suggests that patients’ understanding of their illness is clearly linked to their compliance with medical advice. If patients with chronic pain are comfortable that the physician understands their problem, does not assume it is solely psychological, and explains it to them in an understandable manner that links logically to a plan for management, it may stem their desire for additional costly investigation and foster willingness to embrace the rehabilitative treatment approach necessary for individuARTICLE INFORMATION
REFERENCES
Published Online: June 2, 2014. doi:10.1001/jamapediatrics.2014.530.
1. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet. 1999; 354(9182):936-939.
Conflict of Interest Disclosures: None reported. Additional Contributions: I thank Deirdre Logan, PhD, and Rachael Coakley, PhD, of the Pain Treatment Service, Boston Children's Hospital for critical review and thoughtful comments regarding the manuscript.
694
als with chronic pain to return to function. There is an evolving literature that, for these individuals, assessment and feedback is a critical part of the intervention; in fact, the use of metaphors to help deepen the patients’ understanding of chronic pain has also been found to be extremely helpful.6 Therefore, a new neutral name is proposed for this category, primary pain disorders. This term arises from the headache field, where headaches are categorized as primary (the head pain itself is the central problem) or secondary (the headache is due to other factors such as increased intracranial pressure or infection, for example).7 The term primary pain disorder implies that the pain itself is the disease. Such terminology allows patients and clinicians to view these disorders in a broader, non–disciplinary-specific context and see and learn from the similarities in presentation and treatment of all of these entities. It may promote the recognition that individuals may have multiple pain problems stemming from heightened nociceptive sensitivity and encourage treatment of the common associated symptoms such as fatigue, sleep disorders, anxiety, and depression that complicate recovery. Unlike Shakespeare’s rose, functional pain would benefit from a new name.
2. Mayer EA, Bushnell MC. Preface. In: Mayer EA, Bushnell MC, eds. Functional Pain Syndromes: Presentation and Pathophysiology. Seattle, WA: IASP Press; 2009:xv. 3. Yunus MB. Central sensitivity syndromes: a new paradigm and group nosology for fibromyalgia and overlapping conditions, and the related issue of disease versus illness. Semin Arthritis Rheum. 2008;37(6):339-352.
4. Stedman’s Medical Dictionary. 9th ed. Philadelphia, PA: Saunders; 1928. 5. Stedman’s Medical Dictionary. 28th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006: 777. 6. Coakley R, Schechter N. Chronic pain is like…: the clinical use of analogy and metaphor in the treatment of chronic pain in children. Pediatric Pain Letter. 2013;15:12-18. 7. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(suppl 1):9-160.
JAMA Pediatrics August 2014 Volume 168, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Georgia User on 05/24/2015
jamapediatrics.com
VIEWPOINT
Neil L. Schechter, MD Chronic Pain Program, Pain Treatment Service, Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts.
Corresponding Author: Neil L. Schechter, MD, Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (neil .schechter@childrens .harvard.edu).
Functional Pain Time for a New Name The beginning of wisdom is to call things by their right names. Chinese Proverb
When a comprehensive search to explain a particular symptom or cluster of symptoms does not identify an organic disease, those symptoms are often described as representing a functional disorder. When that symptom is pain, the patient is diagnosed with a functional pain disorder. Although functional gastrointestinal disorders are perhaps the best known members of this family, other entities (fibromyalgia, interstitial cystitis, and chronic daily headaches) are considered functional and encountered by primary care professionals and specialists on a daily basis. In fact, most medical specialties appear to have a functional disorder that commonly occurs within their scope of practice.1 In a survey of general practitioners in the United Kingdom, functional syndromes accounted for 20% of consultations. Yet, despite their frequency, there is general dissatisfaction with the terminology used to describe them and widespread misunderstanding of their etiology, which is often wrongfully assumed to be solely psychological.2,3 This assumption often leads to a reductionistic and often unsuccessful approach to their treatment and frustration for both the physician and the patient. The term functional disease was originally promulgated in the late 19th century to suggest that the problem the patient was experiencing did not fit into a specific known disease category and was likely the result of organ dysfunction as opposed to anatomic or biochemical pathology. At that time, there was no suggestion that psychogenesis was at the core of functional disorders. This construct began to change by the middle of the 20th century, however, when deep-seated emotional trauma was seen as responsible for a host of physical symptoms including pain. Evidence of the shift toward a psychological explanation for unexplained symptoms is evident in the varying definitions of functional problems found in medical dictionaries. In 1926, Stedman’s Medical Dictionary, already in its ninth edition, defined functional disease as “a disorder in the functions of several organs or tissues in which no lesion or change in structure can be determined.”4 By the 28th edition in 2006, functional disease was defined as “not organic in origin; denoting a disorder with no known or detectable or organic basis to the symptoms; See Neurosis [my emphasis].”5 In reality, in common parlance today, functional disorders are typically assumed to be a product of psychological distress. These definitions reflect both conventional wisdom as well as our practice patterns. At the present time, it is common for a pain problem to be extensively evaluated and if no organic lesion is identified, the patient’s care is
oftentransferredtoamentalhealthcareprofessional.This is highly unsatisfying for patients who had been led to believe that the identification and possible cure for their suffering would be found around the next investigative corner. They are often not prepared and typically not ready to accept a strictly psychological explanation when those investigations prove fruitless. Patients who are so labeled often feel dismissed and as a result are frequently noncompliant with medical advice. Despite this practice, however, we now know that the organic vs psychological dichotomy is both confusing and inaccurate. Multiple streams of evidence have emerged over the past few years that suggest that functional pain disorders represent an alteration of pain signaling that may stem from central sensitization or failure of descending noxious inhibition or both.2 Changes in the nervous system likely emerge from multiple mechanisms, both biological and psychosocial, such as genetic predisposition, anxiety or depression, increased psychosocial stressors, early life adversity, infections, trauma, and/or inflammation. These factors may impact the central nervous system and cause the hyperexcitability, which is the core biological link and final common pathway for the creation of functional pain disorders. This understanding renders the dichotomization of etiology (organic vs psychological) not only overly simplistic but erroneous. In addition to their common etiology (altered nociceptive processing), these various pain entities frequently co-occur and have shared clinical similarities. They are frequently comorbid with anxiety and depression; they occur more frequently in females than males; they often present with associated symptoms such as fatigue and sleep disorders; and they often respond to centrally acting therapies (anticonvulsants and antidepressants, exercise, cognitive behavioral therapy, and acupuncture).2 Given this reconceptualization of our understanding of functional pain disorders, there is all the more reason to discard the term functional pain. Not only is there a common, albeit inaccurate, belief that functional pain is strongly psychological in origin, but in reality, if the nomenclature focused solely on function, this category should be labeled dysfunctional pain. In effect, calling pain “functional” is like calling disease, “ease.” There are other commonly used terms in the literature to explain this phenomenon that are equally unsatisfactory. Medically unexplained pain is a frequent alternative but implies that our lack of knowledge is the issue when, in fact, much is known about functional pain. Somatization and somatoform disorder were terms that were often used as a default when pain could not be medically explained. Fortunately, the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) has
jamapediatrics.com
JAMA Pediatrics August 2014 Volume 168, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Georgia User on 05/24/2015
693
Opinion Viewpoint
eliminated these highly stigmatizing and often inaccurately used terms that implied that mental factors were the sole cause of a physical symptom. The Diagnostic and Statistical Manual of Mental Disorders Committee substituted somatic symptom disorder but this term as well as psychosomatic disorder continue to be too burdened by the specter of psychogenesis to be truly useful. More recent attempts to categorize functional pain include central sensitivity syndrome,3 which itself appears highly reductionistic, and pain amplification disorder, a term frequently used by rheumatologists, which is often interpreted by patients as implying that they are somehow deliberately amplifying or exaggerating their pain. The search for an appropriate term for these pain problems is far more than semantic. Evidence suggests that patients’ understanding of their illness is clearly linked to their compliance with medical advice. If patients with chronic pain are comfortable that the physician understands their problem, does not assume it is solely psychological, and explains it to them in an understandable manner that links logically to a plan for management, it may stem their desire for additional costly investigation and foster willingness to embrace the rehabilitative treatment approach necessary for individuARTICLE INFORMATION
REFERENCES
Published Online: June 2, 2014. doi:10.1001/jamapediatrics.2014.530.
1. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet. 1999; 354(9182):936-939.
Conflict of Interest Disclosures: None reported. Additional Contributions: I thank Deirdre Logan, PhD, and Rachael Coakley, PhD, of the Pain Treatment Service, Boston Children's Hospital for critical review and thoughtful comments regarding the manuscript.
694
als with chronic pain to return to function. There is an evolving literature that, for these individuals, assessment and feedback is a critical part of the intervention; in fact, the use of metaphors to help deepen the patients’ understanding of chronic pain has also been found to be extremely helpful.6 Therefore, a new neutral name is proposed for this category, primary pain disorders. This term arises from the headache field, where headaches are categorized as primary (the head pain itself is the central problem) or secondary (the headache is due to other factors such as increased intracranial pressure or infection, for example).7 The term primary pain disorder implies that the pain itself is the disease. Such terminology allows patients and clinicians to view these disorders in a broader, non–disciplinary-specific context and see and learn from the similarities in presentation and treatment of all of these entities. It may promote the recognition that individuals may have multiple pain problems stemming from heightened nociceptive sensitivity and encourage treatment of the common associated symptoms such as fatigue, sleep disorders, anxiety, and depression that complicate recovery. Unlike Shakespeare’s rose, functional pain would benefit from a new name.
2. Mayer EA, Bushnell MC. Preface. In: Mayer EA, Bushnell MC, eds. Functional Pain Syndromes: Presentation and Pathophysiology. Seattle, WA: IASP Press; 2009:xv. 3. Yunus MB. Central sensitivity syndromes: a new paradigm and group nosology for fibromyalgia and overlapping conditions, and the related issue of disease versus illness. Semin Arthritis Rheum. 2008;37(6):339-352.
4. Stedman’s Medical Dictionary. 9th ed. Philadelphia, PA: Saunders; 1928. 5. Stedman’s Medical Dictionary. 28th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006: 777. 6. Coakley R, Schechter N. Chronic pain is like…: the clinical use of analogy and metaphor in the treatment of chronic pain in children. Pediatric Pain Letter. 2013;15:12-18. 7. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(suppl 1):9-160.
JAMA Pediatrics August 2014 Volume 168, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Georgia User on 05/24/2015
jamapediatrics.com
