Category talk:Potential comorbidities

Comorbidities must be medical disorders, not symptoms of several disorders

The comorbidities list is excessively long and most are not disorders but symptoms found in many disorders. I am going to look at removing those that are not in the disorders category. Automated list of those that are currently in Comorbidities but not actually disorders is below. notjusttired (talk) 10:28, 5 May 2019 (EDT)
Edit: The issue seems to be with the Wanted Pages, and with less common disorders being stuck in comorbidities when they should only be in disorders. notjusttired (talk) 10:44, 5 May 2019 (EDT)
Comorbidities that are NOT disorders (does this code work???)
No pages meet these criteria.

Considering for removal from comorbidities and leaving in diagnosis

Some of these may be triggers / risk factors or consequences so not comorbidities. There are some very key topics here. If there are good references stating they are comorbidities rather than triggers or consequences they could stay.
Cervical medullary syndrome, Cervical spinal stenosis, Chronic Lyme disease, Hepatitis C, Hypothyroidism, Intracranial hypertension, Lyme disease, Mast cell activation syndrome, Osteoporosis, Premenstrual syndrome, Restless legs syndrome, Rheumatoid arthritis, Sleep apnea, Temporomandibular joint disorder, Thyroid disease

Comorbidities are technically not symptoms

The comorbidities category seems to have grown into a list of the symptoms. There will be no references to use for most of these that refer to them as comorbidities. I looked at the CCC and ICC to check actual comorbidities and found things like POTS aren't listed (!) I presume because it's not an independent condition but a diagnostic symptom as well as a separate disorder - I assume this means it's a dependent disorder. So, should these symptoms that are disorders be listed in the comorbidities category (which isn't accurate)? I have listed them in the category description but perhaps there should be a new subcategory for Disorders that are also symptoms - although this could be fine as a page instead. Info below from ICC and CCC. What do you think? User:JaimeS User:Kmdenmark User:Pyrrhus User:DxCFS User:Hip User:JenB User:MEandCFS notjusttired (talk) 10:28, 5 May 2019 (EDT)

These are all great questions, thanks Njt! Unfortunately, I believe all of these questions fall into grey areas where two doctors can and will disagree on the answer. One doctor will call something a symptom, while a different doctor will call it a comorbidity. Oftentimes, two doctors will disagree on whether a condition should be called a disease, a disorder, or a syndrome. Attempts to come up with a definition for ‘disease’ often hinge on whether a condition should be considered ‘normal’ or ‘abnormal’, without bothering to define ‘normal’ and ‘abnormal’.

It’s great that you looked so closely at the CCC and ICC, then we can just say “well according to the CCC/ICC...” We’ve never before required a reliable reference in order to put a page in a category, but there may be some instances where that might be helpful. POTS wasn’t really a common term back when the CCC was put together, so that’s probably why it wasn’t listed as either a symptom or comorbidity, and there are still many doctors that refuse to recognize POTS as either a symptom or comorbidity of anything.

It would certainly be helpful to know which are independent conditions, and which conditions are causally related. Unfortunately, we have no way of knowing which conditions are independent and which are causally related. Hashimoto’s Thyroiditis is generally considered to be an independent condition from ME. However, many people develop both Hashimoto’s Thyroiditis and ME simultaneously following an enterovirus infection and enteroviruses have been causally implicated in both conditions, so they may well be causally related conditions.

One way we could embrace this uncertainty is to combine the “Signs and symptoms” category with the “Comorbidities” category. I believe this was done with the “Triggers” and “Risk factors” categories, resulting in the “Triggers and risk factors” category, since it was sometimes impossible to distinguish between a trigger and a risk factor. Yes, this would create a very large category, but at least we wouldn’t have to deal with the grey areas.

My 2 cents! Pyrrhus (talk) 19:13, 5 May 2019 (EDT)

I am against combining the categories since signs and symptoms is huge and fully of fairly minor things or rare symptoms, so would mean adding dizziness and double vision to major comorbidities like fibromyalgia - there are hundreds of signs and symptoms already. I think perhaps putting diagnoses ONLY in comorbidities, whether they are regarded as symptoms or not. I just realized the Fukuda criteria (and some other weak ones) don't have any symptoms that are also disorders so POTS and many others are considered unspent. I think going for what people expect to find is best.

A further issue is the very weak suggestion that something is a comorbidity from a single person and without research - eg Carpal Tunnel Syndrome or psychologist and patient Erica Verrillo's list of comorbidities from her book which hasn't got references - those I think should be in signs and symptoms - unless we create a subcategory for "suggested comorbidities"/"possibly comorbiditied". notjusttired (talk) 12:02, 7 May 2019 (EDT)

List of comorbidities from CCC and/or ICC

(not including diagnostic symptoms that are separate conditions eg POTS)

• allergies
• Depression
• Fibromyalgia
• Hashimoto's thyroiditis
• Interstitial cystitis
• Irritable bladder syndrome
• Irritable bowel syndrome
• Migraine
• Multiple chemical sensitivities
• Myofascial pain syndrome
• Prolapsed mitral valve
• Raynaud's phenomenon
• Sicca syndrome
• secondary depression
• Temporomandibular joint syndrome

notjusttired (talk) 07:10, 5 May 2019 (EDT)

I think that we should be considering patients' experiences with comorbidities apart from those listed in the ICC, CCC or other definitions. Most chronic illnesses exhibit comorbidities that are not part of their illness criteria, but are accepted by the medical community.

The overlap between comorbidities and signs and symptoms can be confusing, especially since some symptoms can also be diagnoses, but I don't think the categories should be combined. Both categories could be listed instead. Kmdenmark (talk) 16:39, 11 May 2019 (EDT)

Thanks for the input. These are the ones I'm considering for moving out of the comorbidities category:

Cervical medullary syndrome, Chronic Lyme disease and Lyme disease (ME/CFS usually a misdiagnosis - but should Chronic Lyne stay?), Hepatitis C (blood etc transmission only), Intracranial hypertension - I might leave this in if I can find a reference, Osteoporosis (I think no more a risk than for other bedbound patients?), Premenstrual syndrome, Restless legs syndrome, Rheumatoid arthritis, Sleep apnea (must be ruled out first), Thyroid disease (leaving hypothyroidism in). Any particular ones to keep? User:Kmdenmark user:Sisyphus User:JaimeS user:JenB User:Pyrrhus User:Canele notjusttired (talk) 09:18, July 17, 2019 (EDT)

My 2 cents - except for Rheumatoid arthritis, I would leave them all as cormorbid conditions. Some of these conditions, such as Lyme and Hep C, could be a trigger of ME, and thus exist simultaneously with ME if not resolved. But if you prefer to move them to the 'Potential triggers' category, I'm fine with that.

Several of the other conditions may be triggered by ME, such as, all the conditions that are a result of hormone disruption. Likewise, someone may have a predisposition for a sleep disorder, such as sleep apnea, but their ME exasperates the condition to the point where its more evident to diagnose.

I don't understand what you meant when you said, regarding osteoporosis: "I think no more a risk than for other bedbound patients?" Comorbidities do not have to be unique to an illness to be considered a comorbid condition. That some people with ME are at risk for and consequently develop another chronic condition is the essence of a comorbid condition.

What if the category 'Comorbidities' is changed to 'Potential comorbidities?' Perhaps that may eliminate some debate as to what is or isn't comorbid. Kmdenmark (talk) 16:49, July 17, 2019 (EDT)

I'm going to add 2 cents as well: I think any illness can be seen as a comorbidity to ME/CFS as long as the physicians make sure it doesn't explain the symptoms of ME/CFS. So, for example, sleep apnea is usually advised to look out for in patients with chronic fatigue. But if the patient doesn't improve with treatment, it can be seen as comorbid if the final diagnosis is ME/CFS. These lists of comorbid conditions in case definitions are usually intended to guide clinicians in making the diagnosis of ME/CFS and to preserve only clear cases in research. But if a ME/CFS patient develops cancer, heart disease or whatever many years later, then clearly that is a comorbid condition. For obvious reasons, these patients are excluded from research as cancer may obscure findings. But no clinician will say that such patients no longer have ME/CFS now they've developed cancer many years after a diagnosis of ME/CFS. So pretty much every condition can be a comorbid condition. If we're going to list only a few, then I think it should be those that have been most clearly established as a comorbidity in research: fibromyalgia, irritable bowel syndrome, depression, anxiety disorder etc. - Sisyphus

You have both raised some good points User:Kmdenmark User:Sisyphus Thank you Comorbidities in medical literature rather than in a person's history would mean just common comorbidities. There's a separate category:Triggers and risk factors for things that can cause the illness but don't necessarily continue for any link of time after - I think Lyme conned under that but Chronic Lyme does not (chronic meaning 6 months+, rather than severe but potentially brief). So, since a person can have any possible illness along with ME or CFS which to list? I like the idea of having a Potential Comorbidities category. What about having just the well documented comorbidities in the main category, and less well documented / inconsistent evidence ones in a potential comorbidities category? With a note not to put the same illness in both? When browsing people could use Comorbidities, then go into a Potential comorbidities subcategory for others. I am not sure renaming the whole category is the way forward - plus it links to the Contents page so that would need editing too. notjusttired (talk) 09:01, July 18, 2019 (EDT)

I have already given my 2 cents, so I’ll just add 1.5 more cents. Thanks to Notjusttired for tackling this thorny issue. I like the idea to limit the Comorbidities category to just “common comorbidities”. I also like the idea to limit the Comorbidities category to just “clearly established” comorbidities. Unfortunately, we are in such a grey area that I fear both approaches may be ultimately impractical. Maybe not. Nonetheless, I like the idea of renaming the Comorbidities category to “Potential comorbidities” to acknowledge that we are dealing with a grey area. If we do this, maybe User:Hip can add a bold CSS banner to the top of each “Potential comorbidity” page, in the same way that “Potential treatment” pages and “Medical hypothesis” pages are branded with the bold banner at the top of the page, as a subtle disclaimer to the reader that they are entering a grey area.

Pyrrhus (talk) 21:16, July 18, 2019 (EDT)

It was my idea to put the banner at the top of those pages, but it was implemented by the developers. By the way, Jonathan Edwards once pointed out that the medical term comorbidities is ambiguous. It can mean a second disease that co-exists with the first in a patient, or it can mean a secondary disease which is statistically more prevalent in patients with the primary disease. I believe the MEpedia article on comorbidities of ME/CFS refers to the second meaning (although it's not actually made clear in that article). Hip (talk) 21:31, July 18, 2019 (EDT)

notjusttired, Hip, Pyrrhus: I like the idea of changing the category name to 'Potential comorbidities' for all whether common or not. You are correct in pointing out that the medical term, comorbidities, is very ambiguous. The term is used differently depending on the purpose of why the co-existing conditions need to be listed. For example, a hospitalist will have a much shorter list of comorbidities/secondary diagnoses because his/her priority for the patient is just to get the patient well enough to get out of the hospital. Sometimes, just the potentially dangerous comorbidities are listed to ensure procedures do not exasperate them. A GP's list may include many comorbidities/secondary diagnoses to order to document the need for referrals to other specialists.

If we define our purpose it will help decide what to include. I think MEpedia's purpose is to show all aspects of the illness (as Jen says, "the good, the bad, the ugly"). I believe the reader will be better served if the comorbidities category is broad. I bristle at just listing common comorbidities because research is so scant that we may not know how common a particular comorbid condition is. Some comorbidities are dependent on the severity of ME, some on gender, and some on individual predispositions and thus they may only reach a significant percentage for a subgroup but not the total ME population.

Another aspect to consider as we discuss what is common is that some statistics on frequency of a comorbid condition are based on the comparison to a healthy population and some on the frequency within the patient population. A bit of 'apples to oranges.'

CCC, ICC, etc are case definitions for diagnosis which serve a different purpose than a treatment manual. A list a comorbidities in a definition would naturally be much shorter than one for treatment and should not be considered inclusive.

In summary, I think the answer to what to include in the category should be based on the purpose of MEpedia to inform in an expansive, inclusive way. Whether the comorbid condition is more common or not can be included in the article about that condition as opposed to the category tag. Kmdenmark (talk) 14:23, July 19, 2019 (EDT)

Just looking through the category now, it's not particularly cluttered so I think it would work too keep all together as Potential comorbidities. There's already a main comorbidities article for summarizing the common ones. The code for adding a new banner is in MediaWiki:Common.js and looks extremely simple to change ourselves. A color would need deciding on - Green and blue are already used. notjusttired (talk) 14:40, July 19, 2019 (EDT)

Kmdenmark, to me it makes sense to have this page as a list of comorbid diseases which are statistically more common in ME/CFS (such ME/CFS common comorbidities are listed in the Canadian consensus criteria), but I don't see the logic of including ANY disease that an ME/CFS patient might have alongside their ME/CFS, because there are around 13,000 diseases listed in the ICD-10, and an ME/CFS patient could potentially have any of those 13,000 along with their ME/CFS.

The reason common comorbidities are of interest is twofold, as far as I can see: firstly, from the clinical perspective, since ME/CFS patients are likely to have one or more of these common comorbidities, you would want to make patients aware of these possibilities. For example, POTS is a very common comorbidity in ME/CFS, and so once you make patients aware of that, they may realize that certain symptoms they have may be due to POTS. I did not even know I had POTS, until I learnt that POTS is a common comorbidity in ME/CFS, which promoted me to test myself for POTS, and I tested positive.

The second reason common comorbidities are of interest relates to research on disease etiology: by looking at the common comorbidities of a disease, researchers may uncover common mechanisms which might explain how ME/CFS and its common comorbidities arise. Hip (talk) 10:54, July 21, 2019 (EDT)

Just as a reminder, there are two questions here: (1) Which comorbidity pages to include in the "Comorbidities" category and (2) How to treat comorbidities on the page Comorbidities_of_Myalgic_Encephalomyelitis. This discussion mostly covers the first question, but may be relevant to discussions on the second question. (The page Comorbidities_of_Myalgic_Encephalomyelitis appears to discuss which comorbidities may be considered "common".)

Pyrrhus (talk) 13:38, July 21, 2019 (EDT)

Hip, Pyrrhus What illnesses already in this category do you think do not belong besides the few discussed? I agree that "including ANY disease" is not the purpose. (I don't think anyone else sees the category as such either.) I stand by my reasoning stated earlier that research is so scant that we may not know how common a particular comorbid condition is. Just using those listed in case definitions will miss many valid comorbidities. For example, the CCC does not list endometriosis but a recent study found endometriosis occurs more than twice as often in the ME population than the general population. I think a wider net is better.

I'm amenable to the suggestion to rename the category "Potential comorbidities" as it is more accurate and yet leaves wiggle room for discrepancies. Kmdenmark (talk) 19:16, July 24, 2019 (EDT)

I think any time you find a study which shows a disease is more common in ME/CFS than in the general population, it could be included. So a disease that occurs twice as often in ME/CFS could be included.

Here are some papers which I collected in the past on statistically comorbid diseases to ME/CFS:

https://www.ncbi.nlm.nih.gov/pubmed/9790493 — SAD
https://www.ncbi.nlm.nih.gov/pubmed/17546343 — SAD
https://www.ncbi.nlm.nih.gov/pubmed/22648008 — ADHD
https://www.ncbi.nlm.nih.gov/pubmed/26200644 — ATOPY
https://www.ncbi.nlm.nih.gov/pubmed/20939923 — IBS
https://www.tandfonline.com/doi/abs/10.1080/21641846.2014.978109 — Lists lots of different comorbidities
https://www.ncbi.nlm.nih.gov/pubmed/19788552 — Anxiety and depression
https://www.ncbi.nlm.nih.gov/pubmed/29096528 — Mental health problems in adolescents with ME/CFS
https://www.ncbi.nlm.nih.gov/pubmed/19414619 — Psychiatric comorbidity
https://www.ncbi.nlm.nih.gov/pubmed/25768845 — Mood and anxiety disorders
https://www.ncbi.nlm.nih.gov/pubmed/20102774 — Metabolic syndrome
https://www.ncbi.nlm.nih.gov/pubmed/16396727 — Generalized joint hypermobility
https://www.ncbi.nlm.nih.gov/pubmed/26549386 — Temporomandibular disorders
https://www.ncbi.nlm.nih.gov/pubmed/11251747 — Various conditions including IBS, chronic pelvic pain, MCS, TMJD
Hip (talk) 19:59, July 24, 2019 (EDT)

I'd like to see if we can bring this discussion to a constructive conclusion. I'd like to propose the following:

1. Keep all pages in this category, but rename the category to "Potential comorbidities".
2. Add a banner at the top of all pages in this category that says "This is a Potential Comorbidity page." The banner will link to this category page.
3. A disclaimer can be posted at the top of this category page about the ambiguity of the term "comorbidity", the uncertainty surrounding which conditions are in fact more common in ME/CFS, and the uncertainty regarding whether a condition should be considered a symptom or a comorbidity.
4. Each page in this category can discuss the specific merits of considering its condition a "comorbidity of ME/CFS".
5. The page Comorbidities_of_Myalgic_Encephalomyelitis can summarize the merits of each potential comorbidity.
6. The pages Related conditions and Related diseases can be merged into Comorbidities_of_Myalgic_Encephalomyelitis, leaving redirects.

How does this sound?

Pyrrhus (talk) 21:43, October 25, 2019 (EDT)

Any feedback? User:JenB User:JaimeS User:Kmdenmark User:Notjusttired

Pyrrhus (talk) 19:52, November 4, 2019 (EST)

I thought it was pretty much agreed to keep all in the category but rename it to Potential Comorbidities. We should only be looking at comordibities of ME or CFS, others should go on the page for that topic ~Njt (talk) 10:40, November 5, 2019 (EST)

I favor using Category:Potential comorbidities Kmdenmark (talk) 13:48, November 6, 2019 (EST)

 Done Many thanks to all members of the MEpedia community who participated in this 7-month long discussion.

Pyrrhus (talk) 16:16, December 6, 2019 (EST)

 Thanks to Pyrrhus for updating the category! Kmdenmark (talk) 12:22, December 10, 2019 (EST)