«SIGNIFICATION AND PAIN: A SEMIOTIC READING OF FIBROMYALGIA ABSTRACT. Patients with persistent pain who lack a detectable underlying disease challenge ...»
JOHN QUINTNER, DAVID BUCHANAN, MILTON COHEN and ANDREW TAYLOR
SIGNIFICATION AND PAIN: A SEMIOTIC READING OF
ABSTRACT. Patients with persistent pain who lack a detectable underlying disease
challenge the theories supporting much of biomedical body-mind discourse. In this context,
diagnostic labeling is as inherently vulnerable to the same pitfalls of uncertainty that beset any other interpretative endeavour. The end point is often no more than a name rather than the discovered essence of a pre-existent medical condition. In 1990 a Committee of the American College of Rheumatology (ACR) formulated the construct of Fibromyalgia in an attempt to rectify a situation of diagnostic confusion faced by patients presenting with widespread pain. It was proposed that Fibromyalgia existed as a “speciﬁc entity”, separable from but curiously able to co-exist with any other painful condition. Epistemological and semiotic analyses of Fibromyalgia have failed to ﬁnd any sign, clinical or linguistic, which could differentiate it from other diffuse musculoskeletal pain states. The construct of Fibromyalgia sought to deﬁne a discernable reality outside the play of language and to pass it off as a natural phenomenon. However, because it has failed both clinically and semiotically, the construct also fails the test of medical utility for the subject in persistent pain.
KEY WORDS: ﬁbromyalgia, medical epistemology, persistent pain, semiotics
INTRODUCTIONThe practice of modern Western Medicine is in large part based upon the biomedical model of disease. The assumptions underpinning this model are that symptoms are an expression of underlying disease and that there is a reliable connection between pathological changes and clinical features.
It also presumes that each disease has a determinate cause. As Foucault suggests, this model... gave to the clinical ﬁeld a new structure in which the individual in question was not so much a sick person as the endlessly reproducible pathological fact to be found in all persons suffering in a similar way.1 When the relationship between symptoms and signs is uncertain and the cause is not apparent, recurring clinical patterns of disturbed bodily function are assigned the status of syndromes.2 Syndromes are valuable conceptual instruments that permit a degree of diagnostic ﬂexibility as well as constituting the necessary ﬁrst step to further investigation. This Theoretical Medicine 24: 345–354, 2003.
© 2003 Kluwer Academic Publishers. Printed in the Netherlands.
346 JOHN QUINTNER ET AL.
is not the case for diseases, where deﬁnitive knowledge of their cause, pathology and prognosis is more rigidly codiﬁed.3 Although the terms “syndrome” and “disease” are not synonymous, in practice syndromes may be misinterpreted as diseases and instead of remaining useful instruments to guide provisional diagnosis they become “[a] ﬁnal object endowed with attributed reality”.4 Lewis took this problem further by identifying that much of clinical
practice is syndromic:
Diagnosis is a system of more or less accurate guessing in which the end-point achieved is a name. These names applied to disease come to assume the importance of speciﬁc entities, whereas they are for the most part no more than insecure and therefore temporary conceptions.5 This uncertainty inherent in the practice of medical diagnosis is particularly relevant to those patients suffering from chronic pain in the absence of a discernible disease process.6 In such situations diagnostic endeavours invoke theories that attempt to interpret pain and other accompanying sensory phenomena that lie beyond the demands of the disease model which requires externally veriﬁable pathology. This dilemma has long invited dualistic body-mind hypotheses of pathogenesis, on the grounds that if pain is not demonstrably somatic it must be “psychogenic”.7 Such simplistic approaches ignore the current conceptualisation of the lived experience of pain as a biopsychosocial phenomenon rather than merely a symptom of disease.
The syndrome of Fibromyalgia is the latest example of attempts to codify the clinical phenomenon of chronic pain.8 As concepts or constructs in medicine are communicated by language and in texts, so they are no less subject to the vagaries of interpretation than other sources of literature.
In this paper, we examine ﬁrstly the construct of Fibromyalgia and show how it fails epistemologically and consequently has fallen foul of dualistic inference.9,10 Secondly, we look at Fibromyalgia from a semiotic aspect and ﬁnd that it is little more than a linguistic construct which, although it may have a persuasive presence within its own discourse, fails the critical test of clinical utility.
rheumatism, neurasthenia, hysteria, psychogenic rheumatism, and ﬁbrositis. Fibromyalgia happens to be a terminology that has gained linguistic currency.
In 1990, Fibromyalgia was empirically re-deﬁned by the Multicenter Criteria Committee of the American College of Rheumatology (ACR).13 This was an attempt to remedy a situation in which that label to date had resulted in a state of diagnostic confusion; in which Fibromyalgia “seemed to mean something different to every observer”.14 The investigators who constituted this expert panel believed that by deﬁning Fibromyalgia they were revealing a condition distinguishable from other painful conditions and from “somatization and similar psychologic disorders”.15 Fibromyalgia was thereafter promoted as a deﬁnite syndrome of generalized musculoskeletal pain and widespread tenderness, the latter deﬁned as pain on palpation at eleven or more of eighteen speciﬁed sites selfreferentially termed “tender points”.16 The Committee conceded however that Fibromyalgia could occur in association with other “signiﬁcant rheumatic disorders”, including various forms of inﬂammatory arthritis (mainly rheumatoid arthritis), axial skeletal (neck and low back) pain syndromes and osteoarthritis (hand or knee), by proclaiming that “a diagnosis of ﬁbromyalgia remains a valid construct irrespective of [these] other diagnoses”.17 Four years later, the Vancouver Fibromyalgia Consensus Group reafﬁrmed that “[C]lassiﬁcation of the patient as having Fibromyalgia occurs regardless of any other concomitant medical condition. Thus Fibromyalgia is not a disorder of exclusion”.18 This group broadened the purview of Fibromyalgia, allowing the diagnosis to be made if patients presenting with widespread pain were found to have less than eleven tender points, provided that they complained of “characteristic” symptoms, which included “fatigue, sleep disturbance, mood disturbance, headache, irritable bowel symptoms, among others”.19 In effect, this added more features to enable the syndromic diagnosis to be made.
No doubt it was intended that this manoeuvre would replace a previous state of diagnostic confusion with one of diagnostic certainty. However, the only certainty is that a contradiction was created. If Fibromyalgia was distinguishable from all other painful “rheumatic” diseases but at the same time could co-exist with them, how could Non-Fibromyalgia be diagnosed in a clinical setting of widespread pain? Effectively, Fibromyalgia was now so inclusive as to constitute a tautology and thus become meaningless.20 What particular clinical situation was Fibromyalgia to denote?
Furthermore, Fibromyalgia remains extremely problematic in terms of its causality, natural history, prognosis, and treatment.21,22 Taken together 348 JOHN QUINTNER ET AL.
with the failure to link its clinical features to a plausible hypothesis of pathogenesis, Fibromyalgia has been connoted as a “pseudo-disease”. This “prototypical syndrome of diffuse, but palpably physical, pain associated more with distress than disease”23 was seen as fulﬁlling patients’ “psychological need for organicity”.24 Thus, the construct of Fibromyalgia proposed by the ACR Committee not only fell foul of tautology but also by default became prey to the inferences of dualism that had derailed the previous nosological endeavours in this problematic area of chronic pain without lesion.25,26,27
A SEMIOTIC ANALYSIS OF FIBROMYALGIA
In the preceding section we showed that Fibromyalgia was anything but a distinct clinical entity. In this section, we examine the construct of Fibromyalgia in semiotic terms and ﬁnd that it is a label searching for a meaning.
The fundamental premise of the Western empirical approach to literary interpretation has been that language simply reﬂects experience.28 From the 1920s to the 1980s, this traditional view, which carried the portmanteau of centuries of Greco-Judaeo-Christian hermeneutics, saw the advent of the literary interpretative practice, known as New Criticism. This practice widely taught throughout Western universities up until the 1980s had at its heart “a naïve empiricism-idealism which maintains that words stand either for things or for experiences, and that these inhere timelessly in the phenomenal world or in the continuity of human nature”.29 The fundamental tenet of this discourse was that language testiﬁed to the essence in human nature rather than in some way being subject to and paradoxically constitutive of human nature. Perhaps its epistemological certainty, that language is unproblematically transparent and mimetic in function, contributed to its dominance.
One factor in the demise of the New Critical certainty was the gradual acceptance of the linguistic theory of the Swiss linguist Ferdinand de Saussure.30 For Saussure, language was anything but mimetic or transparent in its function. Rather than reﬂecting a pre-existing phenomenal world, language itself constituted our experience and concepts of this world. The movement that was to emerge from Saussure’s linguistics became known as “Structuralism”, a central tenet of which was that meaning is always mediated through the structure of language and does not come to us as a direct perception of non-linguistic “reality”.31 Saussure argued that the study of language should be part of a wider science of signs which he called semiotics. For Saussure, each sign 349
A SEMIOTIC READING OF FIBROMYALGIAconsisted of a signiﬁer and a signiﬁed. The signiﬁer was the word object itself, for example the written letters p+a+i+n or the sound image of these letters when pronounced. The signiﬁed was the corresponding concept of “pain”. Together, like the two sides of a coin, signiﬁer and signiﬁed constituted the sign “pain”. In English the signiﬁed pain has been deﬁned by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” 32 What enables language to work as a system is that each signiﬁer and each signiﬁed is recognisably different from all others. As Saussure argued, “In language there are only differences... A linguistic system is a series of differences of sound combined with a series of differences of ideas”.33 The word “pain” has to be recognisably different from similar words (for example “bane”) to be meaningful. By the same token, its signiﬁed, the experience of pain, has to be recognisably different from other sensory and emotional phenomena.
Saussure also held that this conjunction of signiﬁer and signiﬁed was arbitrary and a product of cultural convention. This seems obvious when one considers how different languages have their own words to signify what in English is called pain or its nearest equivalent. French has douleur, German schmerz; Italian has three common but different words: dolore, male, and sofferenza. There is no natural or immutable reason why only the signiﬁer “pain” should engender the signiﬁed “pain”. But neither is there any reason why these different signiﬁers in English, German, and French, for example, should refer to a single signiﬁed common to all when clearly they do not.
In effect, language functions by identifying the differences between signs rather than by revealing pre-existing truths or essences. This leaves us with convened linguistic rules to govern relationships between the signiﬁer and the signiﬁed. The consequence of Saussure’s theory is that we live in a world conceptually constructed by language rather than viewed through language. Yet as Rice and Waugh noted of the pre-Saussurean idea of language, “We tend to be so accustomed to the world our language system has produced that it comes to seem natural; the correct and inevitable way to view the world.”34 Saussure’s structuralist semiotics viewed the world as anti-essentialist, that is, predicated on differences but not essences. But for Roland Barthes35 and Jacques Derrida,36 there was a problem with the implied ﬁxed relationships of a signiﬁer to its signiﬁed. Rather than each signiﬁer being neatly uniﬁed with one determinate signiﬁed, it bears traces to other signiﬁeds whose difference is required to create meaning. Since words get 350 JOHN QUINTNER ET AL.