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. At-
tempting to approach an ideal diagnostic system that
aims to systematize, organize, and standardize the bio-
psychosocial assessment of chronic pain patients, a 5-
dimension 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 pa-
tients. The evolution of the taxonomies is both neces-
sary and inherent to the progress of science, which
develops together with patients’, clinicians’, re-
searchers’, and third-party payers’ needs.
However, the DSM-5 (the latest version) has signifi-
cantly changed its multiaxial diagnostic system in favor
of a less complicated nonaxial documentation of diagno-
ses.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 Classifica-
tion 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 neglect-
ing 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: zeaah1918@gmail.com
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 penta-
dimensional 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 syn-
chronization 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, follow-
up, 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 associa-
tion 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 ac-
tors 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
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