Monday, March 2, 2015

So, what do you think about the new name?

A version of this article first appeared on ProHealth.

Anyone may reprint or repost this article with a link back to the original, and attribution.

By Erica Verrillo

In September 2013, the IOM was contracted by HHS to devise a new definition for chronic fatigue syndrome (CFS), the current CDC definition being considered too broad. It was also charged with providing a new name at its discretion.

The IOM made its recommendations on Tuesday, February 10, 2015 in a report entitled, "Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness.” One of the recommendations of the report was to eliminate CFS and to replace it, as well as myalgic encephalomyelitis, with "systemic exertion intolerance disease" (SEID).

The IOM's report on ME/CFS has generated a tremendous amount of media coverage (Time, CBS, NY Times Blog, The New Yorker), as well as considerable discussion in the ME/CFS community. While many have welcomed the report's emphasis on the serious nature of the disease, there have been some lingering doubts about the appropriateness of the new name.

(You can read and/or download the report as well as watch the video of the announcement HERE.)

A Brief History of the Name “Chronic Fatigue Syndrome”

In 1984, a mysterious illness struck residents of Incline Village, Nevada. At the time it was thought to be caused by Epstein-Barr virus (EBV), the herpesvirus that causes mononucleosis. For several years the disease was referred to as chronic EBV (CEBV). When EBV was disputed as the cause, Steven Straus of the NIH dubbed it “chronic fatigue syndrome” after its main presenting symptom. Straus was apparently unaware when he coined the term in 1988 that the disease already had a name that had been in use in the UK and Europe since 1959, “myalgic encephalomyelitis” (ME).

An outbreak of an illness identical to the one in Incline Village had struck the Royal Free Hospital in 1955. The attending physician of that outbreak was Dr. Melvin Ramsay, a doctor who not only documented the outbreak, but treated those who suffered from the disease for decades. The term he used for the disease was “myalgic encephalomyelitis,” in order to distinguish it from polioencephalomyelitis, the epidemic which had preceded the Royal Free outbreak.

Medical Impact of a Name
What people think we look like.
(Photo from 
thepsychologystudent)


Virtually from the moment of its creation, patients, as well as specialists, voiced reservations about the name “chronic fatigue syndrome.” Not only did the name trivialize an illness that could be devastating for patients, but it departed from medical tradition.

Illnesses are not named after a single non-specific (common to many ailments) symptom. Critics pointed out that there is no “chronic coughing disease” (pneumonia), or “chronic forgetfulness disease” (Alzheimer’s). In addition to these drawbacks, the focus on fatigue drew attention away from one of the cardinal symptoms of the illness, post-exertional malaise (PEM). It also led to confusion and ultimately to the misdiagnosis of patients who had other conditions that present with chronic fatigue, such as MS and leukemia.

What we really look like. (Jessica Taylor)
Public Reaction to SEID

While the ME/CFS community has universally welcomed the abandonment of CFS as a name for the disease, there have been mixed reactions to the IOM’s proposed new name, “systemic exertion intolerance disease” (SEID).

Those who like the new name have offered that “systemic” captures the fact that the disease affects multiple systems, and “exertion intolerance,” or PEM, is one of the cardinal symptoms of the disease. The fact that the IOM has defined the illness as a disease is especially important.

Those who are critical of SEID have pointed out that every disease affects multiple systems, therefore the inclusion of “systemic” is meaningless. They have also pointed out that “exertion intolerance” is non-specific. “Exercise intolerance” - as exertion intolerance is better known in the medical world - is a feature of cardiopulmonary diseases, hypothyroidism, cancer, and many other conditions. To make matters worse, “intolerance” can be easily interpreted by physicians as “aversion,” which increases the likelihood that patients will be referred to therapists and told to exercise. (See my analysis of the report HERE.)

Other Name Choices

Keep in mind that the recommendations of the IOM are not public policy. No federal agency or department is obliged to follow them.

Some of the alternatives to both CFS and SEID that have been suggested are:

Myalgic Encephalomyelitis: This is the long-standing name for the disease.
Cons: 1) CNS inflammation has not been definitively proven. 2) Not all patients experience pain. 
Pros: 1) The fact that inflammation of the CNS has not been definitively proven does not prevent adopting this name for historical continuity, much like the names malaria (which means “bad air”) and cancer (from karkinos, which means “crab” in Greek). 2) The IOM recognized that pain was a definitive symptom of the disease, and that it was experienced in various forms by 94% of patients. 3) Myalgic encephalomyelitis, as opposed to either “chronic fatigue” or “systemic exertion intolerance,” sounds like a serious medical illness. 4) Myalgic encephalomyelitis has been the name for this disease for 60 years.

Ramsay’s Disease: Honors Dr. Melvin Ramsay.
Cons: 1) There already is a Hunt Ramsay Syndrome. 2) The WHO discourages naming illnesses after people.

Pros: 1) There is a longstanding medical tradition of honoring physicians who first describe an illness. 2) Ramsay’s Disease makes no claim about the etiology of the disease, which has yet to be determined.

Nightingale’s Disease: Honors Florence Nightingale, the founder of the Red Cross, and sufferer of a chronic ailment similar to ME.
Cons: 1) Florence Nightingale probably did not have ME, but a chronic bacterial infection. 
Pros: 1) Florence Nightingale is famous. 2) This name skirts the issue of brain inflammation.

Cheney Peterson Disease: Honors the two American physicians who attended the Incline Village outbreak.
Cons: Neither physician has wanted this disease to be named after them. 
Pros: This name skirts the issue of brain inflammation.

Incline Village Disease: Where the illness was formally identified in the US.
Cons: 1) The outbreak in Incline Village was preceded by outbreaks in Los Angeles, London, Iceland, and various other locales, many of which had names associated with them. A clear point of origin is hard to establish. 2) The state of Nevada would not welcome one of their tourist attractions being associated with a disease.  
Pros: This name skirts the issue of brain inflammation.

Why Your Opinion Matters

In a post published on the Oxford University Press blog  Dr. Leonard Jason stressed that input from the community on what to name this illness is crucial. As he has pointed out, names can stigmatize. He proposed that with the publication of the IOM Report we have been provided an opportunity to work together to devise a name that is appropriate.

Adopting an appropriate name for this illness is important because a suitable name is a crucial part of getting recognition, funding, and treatment. As long as this disease is called "chronic fatigue syndrome" no one will take it seriously. No physician will consider it as a potentially life-threatening illness, and no researcher will be able to identify a cohort.

Without a clearly defined cohort of people who actually have the disease (as opposed to people who are chronically tired), there will be no funding, and without funding for clinical trials, there will be no treatment - of any kind.

The IOM got that much right. The question is whether SEID is any better. If it isn't, then we are stuck in the same situation we have been in over the past 27 years of "CFS."

Polls and Surveys

Recent results of polls have not favored SEID. Paradigm Change and MEAdvocacy ran a poll (March 1) that was strongly critical of the IOM's proposed name. Some of the preliminary comments were:
* If you read Ramsay’s definition of ME, it states that ME is multi system disease. This is my experience of the disease. Intolerant indicates that if the patient were given exercise therapy, their tolerance could be improved. The whole name centres around the exercise intolerance view, as CFS centred Round fatigue. There are so any other far more debilitating symptoms to ME and the worse the disease gets, the more symptoms and the more debilitating they are.
* It’s not clearly defined and “intolerance” sounds like exertion is something I’m not interested in as in laziness. I wasn’t lazy before getting this disease and now I don’t know day to day how I’ll feel. If I was a doctor and seeing this name I would think this person has psychological problems. It’s a step up from “CFS” but not by much.
* just change the name to M.E.

Health Rising has conducted a poll as well in which SEID came in last of all preferred names. (Click HERE for the results.)

What do you think?

IOM's name change is not written in stone, It has not been formally adopted by HHS, or by any US Agency. Although the IOM has suggested a WHO code for SEID, the World Health Organization has not yet assigned one.

No matter what you think of the new name, you can still make your voice heard through a variety of ongoing polls and surveys. Some of their results will be distributed to the media, and even more importantly to relevant government organizations (e.g. HHS, CFSAC).
____________________

ProHealth is currently running a three-question poll, "What name would YOU choose for CFS?"

The questions are:
1. Do you have ME or CFS? (Either diagnosis)
2. Do you think CFS should be replaced by a new name?
3. Which name do you prefer for this illness? (Names are listed.)
This poll will be open until March 21. You can take it HERE.

____________________

ME Association has a one-question poll. "Should CFS and/or ME be renamed Systemic Exertion Intolerance Disease (SEID) as recommended in the U.S. Institute of Medicine Report?'

You can take the poll (and see the results) HERE.

____________________

Mass CFIDS and FM Association is running a more comprehensive survey, "What do you think about the IOM report?" 

You may leave as long or short a comment as you wish. The results of this survey will be sent to CFSAC. The deadline is March 20, 2015. Take the survey HERE.

These are the five questions on the survey:

1) What are the positive things in the Report that we can use to move forward?
2) What questions do you have?
3) What goals would you like to see accomplished with regard to this illness in the next 3 - 5 years? Are these goals supported by the Report?
4) What parts of the Report are problematic for you?
5) Do you have other comments you would like to share?


2 comments:

  1. WHO discourages the use of eponyms:

    http://www.who.int/classifications/icd/revision/Content_Model_Reference_Guide.January_2011.pdf

    (Page 59)

    WHO, ICD-11 Content Model Reference Guide

    Use of Name of Noun formed after a person (eponyms)

    The naming of diseases after proper nouns or people (e.g. eponyms) are explicitly discouraged, except in historical cases where the eponym is already well-established (Alzheimer, Parkinson, etc.). However, eponyms can be entered into the tool as synonyms. Eponyms are used without the Genitive “’s”.


    SNOMED CT

    http://www.isb.nhs.uk/documents/isb-0034/amd-26-2006/uktceditprinc.pdf

    Editorial principles for UK Edition of SNOMED CT

    5.1.5 Eponyms

    (Pages 19 and 20)

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  2. "IOM's name change is not written in stone, It has not been formally adopted by HHS, or by any US Agency. Although the IOM has suggested a WHO code for SEID, the World Health Organization has not yet assigned one."

    What code has IOM suggested, please?

    I am not aware of any suggestions for a proposed ICD chapter location and parent class within the report.

    The WHO, Geneva, is not responsible for the U.S.'s version of ICD-10.

    In October 2015, the U.S. is scheduled to implement a "clinical modification" adapted by NCHS from the WHO's ICD-10.

    Revisions, updates, corrections and other modifications to the ICD-10-CM code set is the responsibility of NCHS/CMS via the public ICD-10-CM Coordination and Maintenance Committee meeting process. Meetings are held in March and September.

    ICD-10-CM is currently subject to a partial code freeze, during which only limited additions can be made to incorporate new diseases, like new strains of virus that have wide public health implications (for ICD-10-CM diagnosis codes), and new technologies (for ICD-10-PCS procedure codes). The code freeze lifts in October 2016.

    Revisions and updates for the WHO's ICD-10 is the responsibility of the WHO-FIC Update and Revision Committee. The URC has an annual or 3 yearly update cycle depending on whether any proposed modifcation submitted by WHO-FIC members meets criteria for a minor or major change.

    ICD-11 is being developed by a number of international advisory groups and sub working groups that report to the ICD-11 Revision Steering Group. The ICD-11 RSG sits outside the ICD-10 update process.

    In order for a unique new code to be created for ICD-10-CM (or for a new term to be added as an inclusion term under an existing ICD-10-CM term) proposals would need to be submitted via one of the NCHS/CMS C & M Committee meetings for public scrutiny.

    Meetings are followed by a public comment period. Decisions are then made by the Director of NCHS.

    The IOM report is a U.S. driven initiative with U.S. agency stakeholders and it will be NCHS's responsibility to determine whether to approve any proposals submitted from any source for consideration for additions or other modifications to the ICD-10-CM code set.


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