Pain Medicine 2011; 12: 1132–1133
Wiley Periodicals, Inc.
Response to “Maldynia as a Moral Judgment?”
by Quintner et al.
pme_1175
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Quintner and his colleagues express dismay over pain
terminology cited in recent literature [1]. They seem to
base their umbrage on theological arguments and
Hamlet’s reflective Sophistry. Nevertheless, they afford
me an opportunity to address the scientific basis for
the introduction of the terminology and the underlying
concepts of eudynia and maldynia.
Quintner quite correctly notes that in 1998, my intent in
proposing new pain terminology was twofold: to address
a conceptual ambiguity about pain and to resolve a
semantic confusion about pain taxonomy. Happily, the
conceptual ambiguity about pain has all but been
resolved. Sadly, the ambiguity of taxonomy persists.
Pain indeed is a complex phenomenon, but it is also a
medical condition that demands a scientific biomedical
approach. Pain can no longer be relegated to the categories of being a mere symptom or syndrome. Only when
pain is considered in the context of an illness, rather than
a symptom or a disease, can one properly speak of pluralistic concepts amplified by epiphenomena as would be
appropriate for any other chronic illness. The concept that
pain is a neurobiological disease is widely accepted in
current literature [2].
The classical definition proposed by the International
Association for the Study of Pain (IASP) defines pain as
“an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage.” While this definition
remains valid, it is overly broad. Subsequent attempts to
classify pain in a concise and consistent manner have
failed. A perusal of the pain literature, echoed by “public
speak”, readily discloses a cacophony of terminology that
describes various pain states. This confusion in taxonomy
detracts from an understanding of what already is a
complex issue.
Pain terminology all too often is vexed by ill-defined denotations and contradictory connotations bordering on
cognitive dissonance. Literature refers to pain in terms
of acute, subacute, chronic, intermittent, persistent,
peripheral, central, nociceptive, neuropathic, physiological, pathological, somatic, visceral, autonomic. Often
these designations are used interchangeably. In order to
remedy this confusion the terminology of eudynia and
maldynia was proposed and adopted.
Nociceptive pain refers to a normal physiological response
to a noxious stimulus. The resultant afferent response—
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transduction, transmission, modulation, perception—and
the efferent reaction are a manifestation of a physiological
process of an intact nervous system. The stimulus and
the resultant pain are usually chronologically congruent.
Pain in this context is a symptom. Eudynia refers to this
process.
Often pain persists long after the nociceptive stimulus is
no longer present. This is the result of a neuropathological process. Central and peripheral sensitization are
expressed by a dysplastic nervous system at the cellular
and molecular levels. Pain in this context is a disease.
Maldynia refers to this process.
It is important to recognize that the gateway to maldynia
is twofold. An insult to the nervous system resulting in
maldynia is readily observable. The progression of inadequately managed eudynia to maldynia is somewhat more
ambiguous.
“Eu-” is a prefix of Greek derivation meaning good, well, or
normal. In this context, eudynia, it is intended to reflect a
normal or physiological response, not to connote a moral
judgment of sanctity. Eugenic, euphonic, eupnoea, euthyroid, euthermic, eutherapeutic are words incorporating the
same prefix. “Mal-” is a prefix of French or Latin derivation
meaning bad, wrong, ill, or abnormal. In this context it
refers to a pathological process, not to a moral judgment of
evil. Malady, maladjusted, malignant, malpractice, malodorous are words incorporating the same prefix.
Such terminology is useful in medicine. For example, the
term “heart failure” indicates to physicians, patients, and
the public a pathophysiologic condition that threatens
morbidity and mortality, and demands medical attention.
Even though the complexity of its biological causes is not
described in great detail, it signifies a point in the course of
heart disease that requires a different level of clinical care
and attention. No one blames the patient for being a
failure. The same can be said for the use of the term
“maldynia”—it defines a state or process that indicates a
higher level of morbidity and mortality risk (yes, maldynia is
an independent risk factor for suicide) and demands more
urgent and sophisticated level of medical care to prevent
these health consequences.
The introduction of eudynia and maldynia was an exercise
in sound etymology designed to advance pain taxonomy
and clarify the physiology and pathology inherent in neurobiological pain concepts. The intent was to facilitate
dialogue and improve education, research, and patient
Letters to the Editor
care in the field of pain medicine. It was never the intent to
stigmatize patients with pain as “good” or “evil” nor was it
the object to engage in a theological or teleological
exercise.
PHILIPP M. LIPPE, MD, FACS, FAANS, FACPM
Executive Vice President, American Board
of Pain Medicine
Executive Medical Director (ret),
American Academy of Pain Medicine
San Jose, CA, USA
References
1 Dickenson BD, Head CA, Gitlow S, Osbahr AJ. Maldynia: Pathophysiology and management of neuropathic and maladaptive pain—a report of the AMA
Council on Science and Public Health. Pain Med
2011;11:1635–53.
2 Siddall PJ, Cousins MJ. Persistent pain as a disease
entity. Implications for critical management. Anesth
Analg 2004;99:510–20.
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