Can we call ME/CFS a disease?

@Jonathan Edwards Thanks Prof. I guess Wikipedia is not well informed either but I agree with its definition:

A syndrome is a set of medical signsand symptoms that are correlated with each other and, often, with a particular disease or disorder.[1] The word derives from the Greek σύνδρομον, meaning "concurrence".[2] In some instances, a syndrome is so closely linked with a pathogenesis or cause that the words syndrome, disease, and disorder end up being used interchangeably for them. This is especially true of inherited syndromes. For example, Down syndrome, Wolf–Hirschhorn syndrome, and Andersen syndrome are disorders with known pathogeneses, so each is more than just a set of signs and symptoms, despite the syndromenomenclature. In other instances, a syndrome is not specific to only one disease. For example, toxic shock syndrome can be caused by various toxins; premotor syndrome can be caused by various brain lesions; and premenstrual syndrome is not a disease but simply a set of symptoms.

If an underlying genetic cause is suspected but not known, a condition may be referred to as a genetic association (often just "association" in context). By definition, an association indicates that the collection of signs and symptoms occurs in combination more frequently than would be likely by chance alone.[3]

Sorry, I am on the phone and can’t quote it properly.
 
In the United States, the National Academy of Medicine, CDC, NIH and NY State Department of Health all refer to ME/CFS as a "disease".
National Academy of Medicine said:
"The primary message of this report is that ME/CFS is a serious, chronic, complex, and systemic disease that frequently and dramatically limits the activities of affected patients. In its most severe form, this disease can consume the lives of those whom it afflicts."

"Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome proposes new diagnostic clinical criteria for ME/CFS and a new term for the illness — systemic exertion intolerance disease (SEID)."

https://www.ncbi.nlm.nih.gov/books/NBK274235/

CDC said:
"Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex, chronic, debilitating disease with systemic effects."

https://www.cdc.gov/me-cfs/healthcare-providers/index.html

NIH said:
"Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), sometimes referred to as myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS), is a debilitating disease that lacks a universally accepted case definition, cause, diagnosis, or treatment."

https://www.nih.gov/mecfs/about-mecfs

New York State Dept of Health said:
"Myalgic Encephalomyelitis...(ME), commonly referred to as chronic fatigue syndrome, is a serious, debilitating, chronic disease that affects multiple body systems, including the nervous system, the immune system, and the body's production of energy."

https://health.ny.gov/diseases/conditions/me-cfs/
 
What about Parkinson's disease and Alzheimers' disease? As I understand it, in both cases there is an observable and objective pathology that ME/CFS does not have, but a common causal process seems to be missing in those illnesses as well.

There are well established common causal processes for these as I understand things. In true Idiopathic Parkinson's Disease there is depletion of dopaminergic cells in the substantial nigra. In Alzheimer's Disease there is an increase in amyloid proteins in the brain and neurofibrillary tangles, not to mention cortical shrinkage. It is true that the causal pathway is not worked out in either case but at least some of these features look to be causally linked to clinical features (dopamine deficit especially) and even if these are epiphenomena they provide pretty good circumstantial evidence for a common causal process being involved.

You might say we have the equivalent for ME/CFS but sadly I do not think we yet have anything firmly enough established.
 
I apologize in advance for opening the discussion about whether we can call ME/CFS a disease or not. This topic is discussed sporadically in other threads and I thought it might be useful to make one for it, to collect our thoughts about it in a more structured manner. This subject may seem trivial, but it’s something that comes back a lot, in just about every advocacy move we do, whether you’re making a flyer, doing an interview, contacting a politician or just want to inform some friends.

The prevailing idea is that it’s best not to use the term disease because that implies a reference to a specific pathological state, which is not yet known in ME/CFS. So other terms such as illness or syndrome might be more appropriate. There are others who take a different view, most famously the IOM-report. In the final speech at the NIH conference, Maureen Hanson said: “this is not a syndrome it's a disease.”

I’ve just read this old article titled: “The confusion between disease and illness in clinical medicine.” The impression I’ve got from it is this: in the 19th century when great scientists like Rudolf Virchow were beginning to discover the organic basis of illnesses, they wanted a word for the pathological changes they discovered and a different word for the symptoms that might correspond with it. To me, that makes sense because research was mostly about how these factors relate to each other. In other words: do the symptoms relate to the biological abnormalities; can the former be explained by the latter?

The way we currently use the term disease however is different and obfuscate this distinction, because we use it for both the pathological changes and the symptoms we think correspond with them. When we say multiple sclerosis is a disease we do not only mean the damage to the myelin sheath of neurons, but also the symptoms of muscle weakness or fatigue that are associated with it.

So it seems that the term disease is now used to make a distinction between illnesses where a pathological state corresponds to symptoms (= disease) and others where no such pathological is yet discovered (= not disease). To me, that doesn’t make much sense. There isn’t a line you can draw there. I think that even in illnesses where a pathological state is known, it’s difficult to explain all the symptoms patients have. The fatigue in MS, for example, is still poorly understood and I suspect this is more the rule than the exception. Another problem is that the term disease versus the alternative term, syndrome is not used consistently within medicine. Down syndrome for example has a known pathology, so would be better described as a disease, while little is known about the pathology of Alzheimer’s disease or Parkinson’s disease, so perhaps these could also be described as a syndrome, depending on how you look at it. Depression is occasionally referred to as a disease but hardly ever as a syndrome.

So I don’t think we make a big mistake or that any insight is lost in using the term disease for ME/CFS. It’s true that ME/CFS is probably quite heterogeneous, but perhaps the same is true of Alzheimer’s disease or Parkinson’s disease. The symptoms of lupus patients can vary widely and MS patients have different illness trajectories which scientists cannot yet explain. So these diseases might also be divided into subgroups based on a different underlying pathology somewhere in the future. It’s hard to name a disease where scientists aren’t trying to subgroup the patient population in the hope of better understanding and treatments.

It’s also true that little is known about the pathology of ME/CFS but we do have some clues: observed cytokine aberrations that correspond to illness severity, metabolic changes that have been observed by multiple groups and abnormalities on exercise tests such as chronotropic intolerance or an earlier onset of the ventilatory threshold on a second CPET. None of these is certain, but we’re getting there.

What we usually want to tell people, when we explain what ME/CFS is, is that it's a condition that keeps people terrible ill for decades. That some people suffering from it, are bedbound for years on end and that some parents affected by it are no longer to care for their children or even themselves. We want to say that many people are suffering from this condition and that they not only have similar symptoms, disability and prognosis but that in most cases it started after an infection from which they never recovered. We want to say that scientists are studying the molecular basis of this condition in the hope of finding a treatment.

In my opinion, this description is not covered by the term ‘syndrome’. Most people would use the term ‘disease’ for what I’ve explained above. So if we as ME/CFS advocates emphasize that ME/CFS is not a disease, we might be causing more confusing instead of avoiding it. Also, as explained in this Wikipedia article: ill without being diseased describes a situation where a "person perceives a normal experience as a medical condition, or medicalizes a non-disease situation in his or her life." So by avoiding the term disease, we might give a misleading impression of ME/CFS.

These are just some thoughts. Interested in what others make of this and whether they use the term disease or not for ME/CFS.

No need for an apology. If the Thought Police show up, spray them with Brain Fog.
 
The CDC website under "Diseases & Conditions A-Z Index" calls CFS/ME an 'illness' and Fibromyalgia a 'condition'. Note: There is no entry for Migraine...
The NHS Scotland website A to Z common illnesses and conditions calls CFS/ME a 'condition', Fibromyalgia a 'condition' as well as a 'syndrome' and Migraine a 'health condition'.
The New Zealand Ministry of Health website don't list any of them under 'Diseases and Illnesses'.
The Public Health Agency of Canada website used to call CFS/ME an 'ilness' but the entry has been ARCHIVED. Fibromyalgia is a 'syndrome'. No entry for Migraine...
The NHS England Health A to Z website calls CFS/ME an 'illness', Fibromyalgia a 'syndrome' and 'condition', Migraine is a 'health condition'.

Looks like a real mess to me.
 
I think 'condition' can be used to mean more or less whatever you like - a bit like illness.
A doctor once said to me that what I had was an illness - and by that he said he meant he accepted that I didn’t feel well, not that there was something physically wrong with me. I never know when a doctor uses the term illness, condition, disease or syndrome what they actually mean by it. It seems they can choose their own definitions as it suits them.
 
I am not sure that site is particularly well informed. It obviously assumes that CFS is a syndrome since it uses CFS as an example of syndrome. It also says that a syndrome can be a condition or several diseases... It doesn't fit very well with the usage I know and doesn't seem to explain why the terms are the way they are.

A lot of syndromes are called that at a stage when there is no known cause - probably virtually all of them. A lot now have known causes and they are only still called syndromes because nobody has bothered to change the name. Down's syndrome is probably called trisomy whatever at genetics meetings but most people still think of the family up the road having a Down's syndrome daughter.

I think 'condition' can be used to mean more or less whatever you like - a bit like illness.
I think my illness "Relapsing Polychodritis" is a good example to use in this "disease" vs "syndrome" debate.

Relapsing Polychonditis (RP) has no known biomarker, and is currently thought to be a syndrome that is autoimmune in nature. The etiology of RP is unknown.

Even with all these unknowns RP is still a respected diagnosis in the medical commmunity and considered very "real". RP is being researched by autoimmune research institutes around the world including the NIH which has on ongoing RP research program involving patients. One of the NIH doctor's heading up the NIH RP research program is an RP patient herself (with quite severe symptoms).

The syndrome is taken very seriously by doctors as it is often progressive in nature and can result in death. For many most RP'ers the pharmacologic treatment involves long-term corticosteroids in conjunction with DMARDs and/or biologics.

Just wanted to give an example to show that it can be done by the medical community. They can recognize and respect the serious nature of a condition (in this case a syndrome) in which so little is known about it and for which there is no biomarker.
 
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This recent news story might be of interest to this discussion:

"Researchers define Alzheimer's-like brain disorder. LATE symptoms resembles Alzheimer's disease but has different cause."
https://www.sciencedaily.com/releases/2019/04/190430121800.htm
It has become increasingly clear that in advanced age, a large number of people had symptoms of dementia without the telltale signs of Alzheimer's disease in their brains at autopsy. Emerging research seems to indicate that TDP-43, while not a stand-alone explanation, is a large contributor to that phenomenon.

I hope we'll be at that stage of defining subgroup within ME/CFS, within the next decade.
 
Thought this was interesting:

Do we belittle epilepsy by calling it a disorder rather than a disease? - PubMed (nih.gov)
In the course of this exercise Ms. Resnick [A public relations expert] was distressed to learn that we were all intent on referring to epilepsy as a disorder and not a disease because it is many different diseases. She questioned this position pointing to cancer which, like epilepsy, also is many different diseases, yet advocates for cancer have a highly successful public relations campaign that does not refrain from using the term ‘‘disease’’ to refer to the generic condition. Her point was that you cannot arouse public passion about a ‘‘disorder,’’ you have to call epilepsy a ‘‘disease.’’

[...]

there is a danger of becoming slaves to terminology that is unnecessarily counterproductive when it does not properly educate or engage the general public. In fact our insistence on our terminology can even be so twisted by the public that it feeds the stigma we are trying to avoid. People with heart disease are not offended by the implication that they are diseased, and this condition also consists of many diseases just like epilepsy.

[...]

I would like to suggest that we reverse decades of tradition and agree to call epilepsy a disease.
 

I can see what this guy is trying ti say but I think it would be foolish to muddle up the accepted meanings of terms any further in a desperate attempt to sound cosy for patients.

I think he confuses two different words - the countable noun '(a) disease' and the generic noun 'disease'. They have different meanings, as count and non-count versions of nouns usually do.

I don't think epilepsy is a disease nor is it 'brain disease' in the sense of heart disease.
All cancers are lumped together as 'a disease' because in this count sense a disease implies some common causal mechanism or process. All cancer is the disease of cell overgrowth.

Epilepsy describes recurrent fits. Fits are a process and so one might say that epilepsy is the disease of fits. But fits are the end result of a wide range of processes. When used in this way 'a disease' is expected to imply a causal process rather than the end result.

The distinction might seem artificial but the fact that the great majority of doctors would not want to call epilepsy a disease presumably means that there is a shared accepted meaning that this does not fit, even if it hard to articulate.

I can immediately see a problem with non-epileptic seizures. Would they be a disease too?
I have the strong impression that if one starts shifting the meanings of words for political reasons you rapidly find more political problems coming back to bite you in the leg.
 
In English, I think we can simply use the word illness if people find disorder or syndrome too confusing, so I largely agree with Jonathan (in Dutch we don't have the distinction illness - disease which makes things more complicated).

Just wanted to flag that the 2014 definition of the International League Against Epilepsy (ILAE) describes epilepsy as a disease and no longer as a disorder as the 2005 definition did.
In the definition, epilepsy is now called a disease, rather than a disorder. This was a decision of the Executive Committees of the ILAE and the International Bureau for Epilepsy. Even though epilepsy is a heterogeneous condition, so is cancer or heart disease, and those are called diseases. The word "disease" better connotes the seriousness of epilepsy to the public.
Source: The 2014 Definition of Epilepsy: A perspective for patients and caregivers // International League Against Epilepsy (ilae.org)
 
I think there are potential problems with advocacy groups defining medical terms.
Just to clarify that the International League Against Epilepsy (ILAE) is the organisation of epilepsy specialists and researchers that also prints the scientific journal Epilepsia. So it's not an advocacy group or patient organisation and they have published several case definitions of epilepsy before.
 
Just to clarify that the International League Against Epilepsy (ILAE) is the organisation of epilepsy specialists and researchers that also prints the scientific journal Epilepsia. So it's not an advocacy group or patient organisation and they have published several case definitions of epilepsy before.

I think sometimes there is a bit of a grey area here. Organisations that deal with one illness in this way may be run by health professionals but they are not necessarily representative of the view of the specialty (neurology). I don't know in this case but there are certainly some groups with meetings and journals that have a skewed perspective. Moreover, it looks from the quote that the change in terminology was designed for public image. Not a bad thing in principle but not always without problems.

Some of these organisations get major funding from private individuals, trusts, endowments etc. and I think that can skew things.
 
The guy who was head of the benefits agency then got a chair at Cardiff University (his name flashes into my mind then disappears, sorry) said that a disease is something that is physically wrong in the body but illness is a behaviour which might mean you have a disease or that you just think you do.

Disease meant you were entitled to benefits but illness did not do so automatically. the BPSers use illness as a weasel word as people think someone is telling them they are genuinely sick but it does not.
 
I think changing ME, epilepsy or whatever to a different definition won’t make them less stigmatised. This seems to miss the point. Calling it a different name won’t make the research or care better or peoples attitudes change.

Sometimes the name itself is insulting or belittling ...I don’t think syndrome, condition , illness, disease etc makes a jot of difference in this respect though.

Avoiding ‘fit” and using ‘seizure” though I think has merits since ‘fits’ seems to conjure up a Victorian view of a hysterical person in a “fit”. I.e. infers lack of self control and could be viewed as negative. Personally I don’t care what you call them. It’s more important that the neurologists are held to a higher quality standard in terms of care and research. If they were better at their job I wouldn’t mind what they called seizures or whether epilepsy was renamed “shaking syndrome”.
 
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