Pain and Addiction: Words, Meanings, and Actions in the Age of the DSM-5
Over the past years, I have focused this column on how the nature of pain—as a symptom, disorder and manifest illness—gives rise to both certain moral responsibilities of care and ethical, legal and social issues, questions and problems that affect the pain patient, clinician and profession and the practice of pain management. Intrinsic to my position is that pain reflects (and perhaps is resultant from) the proverbial “mind-body” problem, at least in part, in that a description and explication of the physiological mechanisms and processes of pain fails to completely capture the subjective experience of the pain patient. To be sure, the subjectivity-objectivity gap is manifest in attempts to assess and treat pain and its resultant effects.1
The Nosology of Pain
Nosological descriptions and categorizations of pain and pain syndromes provide important insights to the pathophysiological substrates that contribute to, and are involved in, particular types of pain and so recent efforts to sharpen these classifications are noteworthy and important.2,3 Yet, the clinical and existential benefit of such nosologies and taxonomies (to the clinician and perhaps, most importantly, the patient) remain limited without further explanation of the potential biological, psychological—and perhaps social—manifestations that any pain disorder can, and often will, incur.
Our group and others have posed the viability of a “spectrum construct” that depicts the complexity of substrates and mechanisms that contribute to and evoke pain as a co-morbid constellation of physical and psychological features, signs and symptoms.4-6 Our hope is that clarification of these variables will create a more salient description of pain that enables a more meaningful approach to assessment and therapeutics. But however useful such a nosological nomenclature may be to pain care, it is still situated within more encompassing descriptive frameworks of medicine and, ultimately, society at-large. Thus, it becomes important to consider if—and how—certain terminologies and descriptors are aligned or misaligned with extant terms, concepts and constructs, and the ideas and implications that they generate and/or sustain.
The Language Game and Diagnosis
The philosopher Ludwig Wittgenstein argued that words, in and of themselves, do not have meaning, per se, but rather, assume meaning through the way(s) in which they are used: “…in the practice of the use of language, one party calls out the words, the other acts on them. I shall…call the whole, consisting of language and the actions into which it is woven, the ‘language-game.’ Now what do the words of this language signify? What is supposed to show what they signify, if not the kind of use that they have?”7 Diagnosis—stemming from the antiquarian Greek diagignoskein (to distinguish)—ascribes to and enables this game. In essence, diagnosis applies the language game to the context and activities of medicine. The act of diagnosis links a name to a set of features, frames the term within the boundaries of that set of features, and makes particular claims about what these features “mean.” Such “meaning” is imparted by the signification of the diagnostic term to the clinician (i.e., “What is wrong with this patient and what can and should be done to treat her?”), the patient (i.e., “How will this condition affect my life; what do I know of others with this condition?”), and to society (i.e., “Patients with this condition are called X, and are viewed in particular ways”).8,9
Physician-philosopher John Z. Sadler states that in this way, diagnosis (as a verb) is an epistemic act that reveals and interprets information and, as a noun, is a denotative-signifier that fosters classification.10 In relating these dimensions of diagnosis to the dynamic relationship between knowing and doing, Jay Rosenberg has argued that “diagnosis demands action” which, in the medical context, is actualized through the reciprocity of treatment and prognostication (i.e., a “knowing ahead” to speculate upon the effects of care upon the future course of illness).11 However, I have stated before, and re-claim here, that medicine is not enacted in a social vacuum and therefore we must ask and reflect upon the ways that current and proposed diagnostic schemas can affect, and are affected by, social and legal meanings, values and attitudes.12,13
The Fifth Edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (i.e., the DSM-5) is currently in phase I field trials, with phase II trials scheduled for 2011 and 2012. Pending university and solo practitioner-setting field trials’ revision, the DSM-5 is scheduled to be released for open use in mid-2013. The DSM-5 is the culmination of a 10-year planning process that conjoined the American Psychiatric Association, National Institutes of Health (NIH), World Psychiatric Association (WPA) and the World Health Organization (WHO) in evaluating the relative merits, limitations, and weaknesses of the DSM-IV toward developing and implementing a new series of assessment and diagnostic criteria that would be coordinated with International Classifications of Disease (ICD) categories. While the planning committee(s) recognized the benefit of (some level of) continuity with the prior edition of the DSM, it was deemed equally important to not limit the formulation of clinically useful, research-based new criteria, and thus the scope and extent of changes from the DSM-IV were not restrained, a priori.14
In the main, the DSM-5 aims to establish clearer boundaries between normal and pathologic states, assume a more biologically-based, nosological categorization of psychiatric disorders, recognize disorders’ spectra, and thereby (1) appreciate signs and symptoms that cut across various conditions, and (2) institute dimensional classifiers that better describe presentation of characteristic features of spectrum pathology. While many classifications of the DSM-IV remain unchanged, several categories have been revised, a number have been eliminated and new classifications added. While a complete review of the DSM-5 is beyond the scope of this essay,15 two diagnostic categories of the DSM-IV that will be revised are of particular importance to pain medicine, namely Pain Disorder, and Substance Abuse/Dependence.
Pain Disorder (Associated with Psychological Factors and with Psychological Factors and General Medical Condition; see DSM-IV descriptions provided in Table 1) will be subsumed under the new broad category of Complex Somatic Symptom Disorder (see Table 2).