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The clinician's perspective provided by Dr Mark Alcock1 on the Williams and Craig proposal5 to update the definition of pain to reflect 50 years of changing emphasis on the nature of pain is most appreciated. Dr Alcock's observations encourage deeper thinking when considered in the context of the initial topical review,5 Wright and Aydede's critique,6 and our response to this critique.3 We hope others will find the discussion stimulating and join the conversation to generate a more satisfactory definition. The following comments address Dr Alcock's specific observations.
Caution is recommended in replacing the word “unpleasant” with “distressing”. Dr Alcock notes that while distress characterizes pain, it is also a feature of many nonpainful experiences. We agree that distress is a feature of pain that is shared with many nonnoxious but aversive states. Unfortunately, there is no unique word that characterizes the emotional distress that is a defining feature of pain; as per the existing and proposed definitions of pain, the distress must be associated with actual or potential tissue damage. This delineates the unique nature of painful distress. We note this concern applies equally to the use of “unpleasant” and “distressing”.
Dr Alcock refers to an Oxford dictionary definition of distress that focuses on distress as a cause of anxiety, sorrow, or pain, ie, as a verb. We use the word to refer to the negatively valenced psychological state of the person experiencing pain, ie, a noun, an option that was available to Dr Alcock. The word “unpleasant” fails to capture the variability in this state, which can vary from mild to agonizing. The term distress seems to better reflect this potential.
The description of social interventions and contexts capable of ameliorating (or aggravating) painful distress arising from an injury or musculoskeletal exertion (eg, psychotherapeutic interventions such as acceptance commitment therapy, battle, or motivation to excel in athletic competitions) encourages reflection on the important role of cognitive and social mechanisms that are implicated or can be mobilized in the interest of controlling pain. To the extent to which these are not wholly effective in eliminating distress or lead to voluntary exposure to pain, the pain would remain an issue for the person. The social or cognitive states could be seen as encouraging pain tolerance. If distress is eliminated (or the experience is no longer unpleasant), the term pain would no longer seem suitable to describe the experience. Nondistressing pain seems an oxymoron (as is neutral or pleasant pain). Furthermore, although we agree that threat is central in pain, it is broader than tissue damage: we do not believe that the chronic headache sufferer, or the individual with painful indigestion, is necessarily distressed by anxieties about tissue damage: she or he just wants the pain to stop.
Dr Alcock argues against removal of the phrase “or described in terms of such damage,” concluding that this would “exclude a large number of patients seen in the chronic pain clinic who are experiencing pain yet have no current or past evidence of tissue damage on clinical assessment.” We too have clinical experience with a large number of patients who can be characterized in this manner—they are legion. As we elaborated in the topical review, there is no exclusion of people reporting pain on the basis of established or putative cause, only of the requirement that they describe it as such, because that does exclude those without the verbal skills to do so. The review proposes that the complex assessment issues should be addressed in the accompanying note through consideration of multiple sources of relevant information.
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