How can we make sense of comorbidity?

Comorbidity, defined as the simultaneous occurrence of more than one disorder in a single patient, is commonplace in psychiatry and somatic medicine. In research, as well as in routine clinical settings.

In March 2016 the new H2020 collaborative project “CoCA” (Comorbidity in adult ADHD) was officially launched, with a 3-day kick-off meeting in Frankfurt, Germany. This ambitious project, which is coordinated by professor Andreas Reif and is co-maintaining this shared blog, will investigate multiple aspects of comorbidity in ADHD.

For instance, CoCA will “identify and validate mechanisms common to the most frequent psychiatric conditions, specifically ADHD, mood and anxiety disorders, and substance use disorders (SUD), as well as a highly prevalent somatic disorder, i.e. obesity”.

As reflected in this bold mission, most scientists trained in the biological sciences agree that studies of overlapping and concurrent phenomena may reveal some underlying common mechanisms, e.g. shared genetic or environmental risk factors.

However, particularly in psychiatry and psychology, the origins of comorbidity have been fiercely debated. Critics have argued that observed comorbidities are “artefacts” of the current diagnostic systems (Maj, Br J Psychiatry, 2005 186: 182–184).

This discussion relates to fundamental questions of how much of our scientific knowledge reflects an independent reality, or is merely a product of our own epistemological traditions. In psychiatry, the DSM and ICD classification systems have been accused of actively producing psychiatric phenomena, including artificial diagnoses and high comorbidity rates, rather than being “true” representations of underlying phenomena.  Thus, the “constructivist” tradition argues that diagnostic systems are projected onto the phenomena of psychiatry, while “realists” acknowledge the presence of an independent reality of psychiatric disorders.

In an attempt to explain these concepts and their implications, psychiatric diagnoses and terminology have been termed “systems of convenience”, rather than phenomena that can be shown to be true or false per se (van Loo and Romeijn, Theor Med Bioeth. 2015, 41-60). It remains to be seen whether such philosophical clarifications will advance the ongoing debate related to the nature of medical diagnoses and their co-occurrence.

CoCA will not resolve these controversies. Neither can we expect that our new data will convince proponents of such opposing perspectives.

It is important to acknowledge the imperfections and limitations of concepts and instruments used in (psychiatric) research.

However, it may provide some comfort that similar fundamental discussions have a long tradition in other scientific disciplines, such as physics and mathematics. Rather  than being portrayed as a weakness or peculiarity of psychiatric research, I consider that an active debate, with questioning and criticism is considered an essential part of a healthy scientific culture.

Hereby, you are invited to join this debate on this blog page!Wooden ruler vector



Measuring rewarding aspects of aggression

In his most famous book, Walden, the American author and naturalist Henry David Thoreau wrote that “many men go fishing all of their lives, without knowing it is not fish they are after”. Thus, one of the difficulties encountered when studying behaviour is to understand their underlying motivation. What makes some animals aggressive and other not when faced with the same situation? How does the brain process stimuli to generate an appropriate behavioural response?

A recent study by Golden and colleagues (Golden et al., 2016) has investigated this question in mice. They combined the resident-intruder assay (a rodent aggression test) with a condition place preference (CPP) test for reward behaviour. The resident-intruder test measures the response of a mouse towards an intruder in its home cage. In this case, male CD-1 mice were allowed to interact with a subordinate C57BL/BJ intruder. Aggressive contact was recorded as the latency for CB-1 mice to attack. Interestingly, about 70% of CD-1 mice were aggressive in this setup (AGGs) and 30% were non-aggressive (NONs). The CPP pairs a neutral stimulus (in this case one side of the home cage) with a conditioned stimulus – the intruder mouse. If the conditioned stimulus is rewarding then test animals spend more time on side of the cage where it was encountered. Here, CD-1 were permitted to interact with C57BL/6J intruders on one side of the CPP setup, whereas the non-conditioned side was empty. AGGs show a positive change in preference under these conditions where NONs showed aversion – they kept away from the intruder. This suggests that AGGs find the aggressive stimulation rewarding and actively seek out the interaction with C57BL/6J.

The authors next examined the neural circuits that control this behaviour with a focus on the connection between the basal forebrain and lateral habenula. During formation of aggression mediated-CPP AGGs show increased forebrain activation (in the nucleus accumbens, diagonal band and lateral septum) with a simultaneous reduction in habenula activity. Next, state of the art optogenetic techniques were used to either activate or inhibit the habenula. Stimulation of the forebrain-habenula circuit in NONs caused a positive change in place preference, whereas inhibition of this circuit in AGGs decreased CPP: the valency of the C57BL/6J stimulus mouse had changed! Importantly, optogenetic stimulation did not alter other social behaviours, although both the intensity of aggression and the rewarding properties of cocaine were increased.

This is exciting research that has possible translational potential to other species. The habenula (and in particular its interaction with the forebrain) appears to be important in processing of stimuli that can elicit aggression. In humans, deep brain stimulation of the basal forebrain and habenula has already been achieved suggesting a possible future treatment for pathological aggression.