Classification

Barnes derived the term dyspareunia from the Greek term meaning "difficult or painful mating" (1). This definition, based on interference with sexual intercourse, is understandable given that it is this interference that brings many women to clinical attention. Unfortunately, the focus on "difficult mating" has resulted in the classification of dyspareunia as a sexual dysfunction (3), and has deflected attention away from the major clinical symptom of pain. The nosological questions concerning dyspareunia are further complicated by a more general theoretical issue: the distinction between organic and psychogenic. For example, both the DSM-IV-TR (3) and the ICD-10 (4) differentiate between organic (i.e., due to a medical condition) and idiopathic (i.e., no known physical cause, usually attributed to psychogenic origin) dyspareunia. The apparent presumption in the case of psychogenic dyspareunia is that it is a distinct category, though there is little specification of its underlying determinants. In contrast, organic dyspareunia is seen as the result of many underlying types of gynecological pathologies, as well as a symptom of inadequate lubrication or of naturally occurring menopausal vulvovaginal atrophy.

The reality of the situation is that there are no empirically or theoretically valid guidelines to distinguish psychogenic vs. organic dyspareunia. The notion that these terms reflect easily diagnosable qualitative categories is questionable both on empirical and theoretical grounds. The typical presumption made by many health professionals and the general public is that there must be an underlying physical cause for the pain. In clinical practice, this typically results in numerous physical investigations ranging from standard gynecological examinations and tests for infections, to invasive procedures such as colposcopy and laparoscopy. If such investigations yield negative findings, the default is to assume a psychogenic causation ("it is all in your head") and refer the patient to a mental health professional. Depending on the orientation of the mental health professional, dyspareunia may be attributed to factors ranging from inadequate arousal to childhood sexual abuse. Because most women with dyspar-eunia present without an identifiable physical explanation for their pain, rarely is there a primary focus on the pain or on direct pain control in the case of dyspar-eunia. However, other idiopathic pain conditions are afforded this approach. For example, 85% of back pain patients present without identifiable pathology (15), yet they are still provided with treatment alternatives, such as analgesic medication and/or physical therapy.

As in the case of back pain, we recommend a similar multidimensional pain approach to the understanding and treatment of dyspareunia (16). This approach is consistent with current biopsychosocial pain perspectives that evolved from the

Gate Control Theory of Pain, which states that the experience of pain includes sensory and emotional components and that psychological factors play a role in pain control (17). This theory has helped explain the powerful influence of cognitive processes on pain perception via descending modulation from the brain, and scientists have since learned that the complex experience of pain cannot be simply equated with tissue damage (18). The Classification of Chronic Pain manual published by the International Association for the Study of Pain (IASP) (19) has also inspired a new multidimensional approach for dyspareunia treatment and research (16). According to the IASP classification system, pain is defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (italics added; page 210). The italicized portion of this definition is reserved for pain patients without identifiable physical pathology, as in most cases of dyspareunia and other chronic pain conditions. Within this framework, the study of underlying physiology is ascribed great importance, but is not sufficient in order to characterize the whole pain experience. Therefore, pain classification is further organized according to five axes assessing the region affected, system involved, temporal characteristics, intensity, and duration.

Dealing With Back Pain

Dealing With Back Pain

Deal With Your Pain, Lead A Wonderful Life An Live Like A 'Normal' Person. Before I really start telling you anything about me or finding out anything about you, I want you to know that I sympathize with you. Not only is it one of the most painful experiences to have backpain. Not only is it the number one excuse for employees not coming into work. But perhaps just as significantly, it is something that I suffered from for years.

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