The Journal of Pain, Vol 15, No 11 (November), 2014: pp 1199-1200 Available online at www.jpain.org and www.sciencedirect.com
Letters to the Editor Multidimensional Approach to Classifying Chronic Pain Conditions—Less Is More To the Editor: Our team received with enthusiasm the proposal from the ACTTION-APS Pain Taxonomy (AAPT),1 which claims an evidence-based and multidimensional approach to classifying chronic pain conditions. Attempting to approach an ideal diagnostic system that aims to systematize, organize, and standardize the biopsychosocial assessment of chronic pain patients, a 5dimension taxonomy was proposed. This perspective drew inspiration from the Diagnostic and Statistical Manual of Mental Disorders (DSM), Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), and International Classification of Headache Disorders diagnostic systems.1 Of these, the DSM is probably the most widely used system in multidisciplinary settings and an essential requirement in the care of pain patients. The evolution of the taxonomies is both necessary and inherent to the progress of science, which develops together with patients’, clinicians’, researchers’, and third-party payers’ needs. However, the DSM-5 (the latest version) has significantly changed its multiaxial diagnostic system in favor of a less complicated nonaxial documentation of diagnoses.2,3 The multiaxial approach was not universally informative or helpful for patient care.3 The major goals for this transformation were to improve compatibility between the DSM-5 and WHO’s International Classification of Diseases 11th Revision3 (other nonpsychiatry specialties prioritize clinically relevant findings without using an axial distribution); to stimulate a dimensional (more process- and pathogenesis-oriented) rather than a categorical diagnostic approach5; to minimize neglecting application and registry of some axes; to be more feasible for both pediatric and adult settings4; and to avoid segregation and reduction of therapeutic efforts toward patients with ‘‘less treatable’’ disorders (eg, personality disorders). The authors declare that there are no financial or other relationships that might lead to conflicts of interest. Address reprint requests to Alexandre Annes Henriques, MD, Psychiatry and Pain Program (PRODOR), Pain and Palliative Care Service, Hospital de Clınicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350-CEP 90035-003, Bairro Rio Branco, Porto Alegre, Rio Grande do Sul, Brazil. E-mail: [email protected] 1526-5900/$36.00 ª 2014 by the American Pain Society http://dx.doi.org/10.1016/j.jpain.2014.08.008
In the same way, we believe that this pentadimensional approach1 for classifying chronic pain might face significant limitations in its applicability for clinicians and researchers. In the practice setting, excessive categories in the analysis of a clinical case tend to create confusion and negligence of some of these categories. Also, this could turn into an obstacle for fluid communication between multidisciplinary professionals at the expense of health care team synchronization and integration. Further, adopting an exclusive multidimensional diagnostic system for chronic pain may hinder the harmonization with acute pain care teams. We support the systematic use of assessment, followup, and prognostic tools that have been validated in the various dimensions of a biopsychosocial approach, as long as their relationships with the mechanisms of disease are clear and evidence based. Likewise, it should be required that these tools present an established association with hard and clinically relevant outcomes, and sanctioned consensus by clinicians, researchers, and third-party payers. In this way, we suggest considering the field experience and evolution of the DSM system.4 The use of 2 or 3 dimensions may represent a more feasible and practical solution, reducing the complexity and improving the clinical decision making for all involved actors in the pain patients’ integrated care pathway, through primary to quaternary health care settings.
Alexandre Annes Henriques Psychiatry and Pain Program Laboratory of Pain and Neuromodulation Pain and Palliative Care Service Hospital de Clınicas de Porto Alegre Porto Alegre, Brazil Post-Graduate Program in Medical Sciences School of Medicine Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil Jairo A. Dussan-Sarria Post-Graduate Program in Medical Sciences School of Medicine Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil 1199
1200
The Journal of Pain
Laboratory of Pain and Neuromodulation Hospital de Clınicas de Porto Alegre Porto Alegre, Brazil Leonardo M. Botelho Post-Graduate Program in Medical Sciences School of Medicine Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil Laboratory of Pain and Neuromodulation Pain and Palliative Care Service Hospital de Clınicas de Porto Alegre Porto Alegre, Brazil Wolnei Caumo Post-Graduate Program in Medical Sciences School of Medicine Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil Laboratory of Pain and Neuromodulation Pain and Palliative Care Service Hospital de Clınicas de Porto Alegre Porto Alegre, Brazil
Letter to the Editor
References 1. Fillingim RB, Bruehl S, Dworkin RH, Dworkin SF, Loeser JD, Turk DC, Widerstrom-Noga E, Arnold L, Bennett R, Edwards RR, Freeman R, Gewandter J, Hertz S, Hochberg M, Krane E, Mantyh PW, Markman J, Neogi T, Ohrbach R, Paice JA, Porreca F, Rappaport BA, Smith SM, Smith TJ, Sullivan MD, Verne GN, Wasan AD, Wesselmann U: The ACTTION-American Pain Society Pain Taxonomy (AAPT): An evidence-based and multidimensional approach to classifying chronic pain conditions. J Pain 15:241-249, 2014 2. Kupfer DJ, Kuhl EA, Wulsin L: Psychiatry’s integration with medicine: The role of DSM-5. Annu Rev Med 64: 385-392, 2013 3. Kupfer DJ, Regier DA: Why all of medicine should care about DSM-5. J Am Med Assoc 303:1974-1975, 2010 4. Moscicki EK, Clarke DE, Kuramoto SJ, Kraemer HC, Narrow WE, Kupfer DJ, Regier DA: Testing DSM-5 in routine clinical practice settings: Feasibility and clinical utility. Psychiatr Serv 64:952-960, 2013 5. Musalek M, Scheibenbogen O: From categorical to dimensional diagnostics: Deficiency-oriented versus personcentred diagnostics. Eur Arch Psychiatry Clin Neurosci 258(Suppl 5):18-21, 2008
Letters to the Editor Multidimensional Approach to Classifying Chronic Pain Conditions—Less Is More To the Editor: Our team received with enthusiasm the proposal from the ACTTION-APS Pain Taxonomy (AAPT),1 which claims an evidence-based and multidimensional approach to classifying chronic pain conditions. Attempting to approach an ideal diagnostic system that aims to systematize, organize, and standardize the biopsychosocial assessment of chronic pain patients, a 5dimension taxonomy was proposed. This perspective drew inspiration from the Diagnostic and Statistical Manual of Mental Disorders (DSM), Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), and International Classification of Headache Disorders diagnostic systems.1 Of these, the DSM is probably the most widely used system in multidisciplinary settings and an essential requirement in the care of pain patients. The evolution of the taxonomies is both necessary and inherent to the progress of science, which develops together with patients’, clinicians’, researchers’, and third-party payers’ needs. However, the DSM-5 (the latest version) has significantly changed its multiaxial diagnostic system in favor of a less complicated nonaxial documentation of diagnoses.2,3 The multiaxial approach was not universally informative or helpful for patient care.3 The major goals for this transformation were to improve compatibility between the DSM-5 and WHO’s International Classification of Diseases 11th Revision3 (other nonpsychiatry specialties prioritize clinically relevant findings without using an axial distribution); to stimulate a dimensional (more process- and pathogenesis-oriented) rather than a categorical diagnostic approach5; to minimize neglecting application and registry of some axes; to be more feasible for both pediatric and adult settings4; and to avoid segregation and reduction of therapeutic efforts toward patients with ‘‘less treatable’’ disorders (eg, personality disorders). The authors declare that there are no financial or other relationships that might lead to conflicts of interest. Address reprint requests to Alexandre Annes Henriques, MD, Psychiatry and Pain Program (PRODOR), Pain and Palliative Care Service, Hospital de Clınicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350-CEP 90035-003, Bairro Rio Branco, Porto Alegre, Rio Grande do Sul, Brazil. E-mail: [email protected] 1526-5900/$36.00 ª 2014 by the American Pain Society http://dx.doi.org/10.1016/j.jpain.2014.08.008
In the same way, we believe that this pentadimensional approach1 for classifying chronic pain might face significant limitations in its applicability for clinicians and researchers. In the practice setting, excessive categories in the analysis of a clinical case tend to create confusion and negligence of some of these categories. Also, this could turn into an obstacle for fluid communication between multidisciplinary professionals at the expense of health care team synchronization and integration. Further, adopting an exclusive multidimensional diagnostic system for chronic pain may hinder the harmonization with acute pain care teams. We support the systematic use of assessment, followup, and prognostic tools that have been validated in the various dimensions of a biopsychosocial approach, as long as their relationships with the mechanisms of disease are clear and evidence based. Likewise, it should be required that these tools present an established association with hard and clinically relevant outcomes, and sanctioned consensus by clinicians, researchers, and third-party payers. In this way, we suggest considering the field experience and evolution of the DSM system.4 The use of 2 or 3 dimensions may represent a more feasible and practical solution, reducing the complexity and improving the clinical decision making for all involved actors in the pain patients’ integrated care pathway, through primary to quaternary health care settings.
Alexandre Annes Henriques Psychiatry and Pain Program Laboratory of Pain and Neuromodulation Pain and Palliative Care Service Hospital de Clınicas de Porto Alegre Porto Alegre, Brazil Post-Graduate Program in Medical Sciences School of Medicine Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil Jairo A. Dussan-Sarria Post-Graduate Program in Medical Sciences School of Medicine Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil 1199
1200
The Journal of Pain
Laboratory of Pain and Neuromodulation Hospital de Clınicas de Porto Alegre Porto Alegre, Brazil Leonardo M. Botelho Post-Graduate Program in Medical Sciences School of Medicine Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil Laboratory of Pain and Neuromodulation Pain and Palliative Care Service Hospital de Clınicas de Porto Alegre Porto Alegre, Brazil Wolnei Caumo Post-Graduate Program in Medical Sciences School of Medicine Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil Laboratory of Pain and Neuromodulation Pain and Palliative Care Service Hospital de Clınicas de Porto Alegre Porto Alegre, Brazil
Letter to the Editor
References 1. Fillingim RB, Bruehl S, Dworkin RH, Dworkin SF, Loeser JD, Turk DC, Widerstrom-Noga E, Arnold L, Bennett R, Edwards RR, Freeman R, Gewandter J, Hertz S, Hochberg M, Krane E, Mantyh PW, Markman J, Neogi T, Ohrbach R, Paice JA, Porreca F, Rappaport BA, Smith SM, Smith TJ, Sullivan MD, Verne GN, Wasan AD, Wesselmann U: The ACTTION-American Pain Society Pain Taxonomy (AAPT): An evidence-based and multidimensional approach to classifying chronic pain conditions. J Pain 15:241-249, 2014 2. Kupfer DJ, Kuhl EA, Wulsin L: Psychiatry’s integration with medicine: The role of DSM-5. Annu Rev Med 64: 385-392, 2013 3. Kupfer DJ, Regier DA: Why all of medicine should care about DSM-5. J Am Med Assoc 303:1974-1975, 2010 4. Moscicki EK, Clarke DE, Kuramoto SJ, Kraemer HC, Narrow WE, Kupfer DJ, Regier DA: Testing DSM-5 in routine clinical practice settings: Feasibility and clinical utility. Psychiatr Serv 64:952-960, 2013 5. Musalek M, Scheibenbogen O: From categorical to dimensional diagnostics: Deficiency-oriented versus personcentred diagnostics. Eur Arch Psychiatry Clin Neurosci 258(Suppl 5):18-21, 2008
