Testing hypotheses regarding the causes of comorbidity: examining the underlying deficits of comorbid disorders

Etiological Overlap Between Sex Under the Influence and Number of Lifetime Sexual Partners

Drug and alcohol use is associated with risky sexual behavior (RSB). It is unclear whether this association is due to correlated liabilities (e.g., third variables influencing both traits), or whether use of drugs and alcohol during sexual decision making increases RSB. This study addresses this question by fitting a series of biometrical models using over 800 twin pairs assessed in early adulthood (m = 25.21 years). Measures included an index of sex under the influence (e.g., frequency that drugs or alcohol affect sexual decision making), number of lifetime sexual partners, and a general measure of substance use. Analyses suggest the covariance among these measures is explained by both genetic and environmental correlated liabilities. The overlap was not specific to sex under the influence, but was shared with a measure of general substance use. Models testing necessary but not sufficient parameters for direction of causation suggest that sex under the influence is unlikely to cause an increase in RSB; more evidence for reverse causation was found.

Behavior and Molecular Genetic Approaches to Comorbidity

Purpose of Review

This review provides an overview of studies that used behavioral genetic methods to understand the genetic and environmental influences that lead to comorbidity, the co-occurrence of two or more developmental disorders in the same individual.

Recent Findings

Comorbidity is primarily explained by shared genetic influences for most pairs of disorders that have been studied, including attention deficit hyperactivity disorder (ADHD) and learning disabilities, conduct disorder and ADHD, anxiety and depression, and anxiety and autism spectrum disorder (ASD). Molecular genetic studies indicate that the etiologies of developmental disorders are highly multifactorial, with dozens or even hundreds of genes acting in combination with environmental risk factors to lead to each individual disorder and the extensive comorbidity between disorders. Due to this complexity, current state-of-the-art studies are now combining molecular genetic data from multiple large samples to begin to achieve adequate statistical power to identify the specific genetic polymorphisms that lead to comorbidity.

Summary

An extensive literature demonstrates the pervasiveness and potential importance of comorbidity between developmental disorders, and results of family, twin, and molecular genetic studies indicate that these comorbidities may be largely explained by shared genetic influences. Additional studies are ongoing to identify the specific genetic polymorphisms that increase risk for each developmental disorder and comorbidity between disorders.

Understanding Comorbidity Between Specific Learning Disabilities

Current definitions of specific learning disability (SLD) identify a heterogeneous population that includes individuals with weaknesses in reading, math, or writing, and these academic difficulties often co-occur in many of the same individuals. The Colorado Learning Disabilities Research Center (CLDRC) is an interdisciplinary, multisite research program that uses converging levels of analysis to understand the genetic and environmental etiology, neuropsychology, and developmental outcomes of SLDs in reading (RD), math (MD), and writing (WD), along with the comorbidity between these SLDs and other developmental disorders. The latest results from the CLDRC twin study suggest that shared genetic influences contribute to the significant covariance between all aspects of reading (word reading, reading fluency, and reading comprehension) and math (calculations, math fluency, and word problems), and distinct genetic or environmental influences also contribute to weaknesses in each specific academic domain. RD and MD are associated with a range of negative outcomes on both concurrent measures and measures of functional outcomes completed 5 years after the twins were first assessed. Over the next several years the CLDRC will continue to expand on this work by administering a comprehensive test battery that includes measures of all dimensions of academic achievement that are described in current definitions of SLD and incorporating these measures in new neuroimaging and molecular genetic studies.

Comorbidity Among Dimensions of Childhood Psychopathology: Converging Evidence from Behavior Genetics

In this article, we review evidence from recent behavior genetic studies that examined the covariance among common childhood psychopathological conditions and tested specific hypotheses regarding common and broadband-specific underlying features of childhood psychopathology. Specifically, we review the distinction between internalizing and externalizing disorders, the support for the generalist genes and specialist environments model, negative emotionality as a heritable underlying feature common to both internalizing and externalizing disorders, and daring as a heritable broadband-specific underlying feature that distinguishes externalizing disorders from internalizing disorders. We also discuss the implications of research in the search for specific genes that influence childhood psychopathology and suggest avenues for new research.

Classification and identification of reading and math disabilities: the special case of comorbidity

Much of learning disabilities research relies on categorical classification frameworks that use psychometric tests and cut points to identify children with reading or math difficulties. However, there is increasing evidence that the attributes of reading and math learning disabilities are dimensional, representing correlated continua of severity. We discuss issues related to categorical and dimensional approaches to reading and math disabilities, and their comorbid associations, highlighting problems with the use of cut points and correlated assessments. Two simulations are provided in which the correlational structure of a set of cognitive and achievement data are simulated from a single population with no categorical structures. The simulations produce profiles remarkably similar to reported profile differences, suggesting that the patterns are a product of the cut point and the correlational structure of the data. If dimensional approaches better fit the attributes of learning disability, new conceptualizations and better methods to identification and intervention may emerge, especially for comorbid associations of reading and math difficulties.

Comorbidity between reading disability and math disability: concurrent psychopathology, functional impairment, and neuropsychological functioning

Reading disability (RD) and math disability (MD) frequently co-occur, but the etiology of this comorbidity is not well understood. Groups with RD only (N = 241), MD only (N = 183), and RD + MD (N = 188) and a control group with neither disorder (N = 411) completed a battery of measures of internalizing and externalizing psychopathology, social and academic functioning, and 10 neuropsychological processes. Groups with RD only, MD only, and RD + MD were significantly impaired versus the control group on nearly all measures, and the group with RD + MD was more impaired than the groups with MD and RD alone on measures of internalizing psychopathology, academic functioning, and 7 of 10 neuropsychological constructs. Multiple regression analyses of the neuropsychological measures indicated that deficits in reading and math were associated with shared weaknesses in working memory, processing speed, and verbal comprehension. In contrast, reading difficulties were uniquely associated with weaknesses in phoneme awareness and naming speed, and math deficits were uniquely associated with weaknesses in set shifting. These results support multiple-deficit neuropsychological models of RD and MD and suggest that RD and MD are distinct but related disorders that co-occur because of shared neuropsychological weaknesses in working memory, processing speed, and verbal comprehension.

Behavioral inhibition in children with learning disabilities

Children with reading disabilities (RD, n=17), mathematical disabilities (MD, n=22), combined reading and mathematical disabilities (RD+MD, n=28) and control peers (n=45) were tested on behavioral inhibition with a Go/no-go task in a picture, letter and digit-modality. In contrast to children without RD, children with RD made significantly more commission errors on alphanumeric (letter and digit) modalities compared to the non-alphanumeric picture modality. As compared to children without MD, children with MD made as much commission errors on the picture modality as on the letter modality. No significant interaction-effect was found between RD and MD. These results can be considered as evidence for behavioral inhibition deficits related to alphanumeric stimuli in children with RD but not in children with MD.

Increasing comorbidity with diabetes in the community: diabetes research challenges

BACKGROUND

The purpose of this paper is to discuss the ongoing definitional, measurement and analytic challenges imposed on community-based diabetes researchers examining the experiences and outcomes of home-dwelling adults surviving longer with diabetes and additional comorbid health conditions. When selecting from the still limited number of standard hospital-oriented comorbidity methods, researchers across the world will need to consider a frequently complex series of methodological decisions from their enrolling such adults with increased comorbidity into study samples.

CONCLUSIONS

Three categories of methodological implications from increasing forms of comorbid diabetes are discussed for diabetes researchers. Six sequenced research design strategies with specific examples are offered regarding how to most rigorously incorporate elements of comorbidity into prospective diabetes study designs.

A twin study of depression and nicotine dependence: shared liability or causal relationship?

BACKGROUND

The nature of the relationship between major depression (MD) and phenotypes related to smoking behavior, including nicotine dependence (ND), is complicated. We present results from analyses comparing models wherein MD and ND are influenced by a shared latent factor to one in which causal pathways between phenotypes are examined.

METHOD

Data were collected for 2906 adult male twins from a population-based sample. Structural equation modeling was used to derive path estimates for shared liability and causal models. MD was assessed according to DSM-III-R diagnostic criteria; ND was assessed using the Fagerstrom Test for Nicotine Dependence (FTND).

RESULTS

The best fitting shared liability model included genetic, but not environmental, influences shared between MD and FTND; a small proportion of these shared influences were also common to smoking initiation. The best fitting causal model included a unidirectional causal path from FTND to MD, with no direct genetic correlation between MD and smoking initiation. Model fit statistics indicated that these models provided nearly identical fits to the data, with the causal model providing a slightly superior AIC value.

CONCLUSIONS

The phenotypic association between MD and FTND is likely due to both a causal relationship, wherein increasing levels of nicotine dependence increase one's risk for depression, and to a shared genetic liability between the two.

LIMITATIONS

This sample consists of Caucasian males born in Virginia, and findings might not be generalizable to others. Statistical power was less than ideal.

How common are motor problems in children with a developmental disorder: rule or exception?

BACKGROUND

Few co-morbidity studies have been conducted since the Leeds Consensus Statement on developmental co-ordination disorder (DCD) in 2006. In this Statement, international cut-offs and inclusion criteria were agreed and consequently, the status of DCD changed. Furthermore, most existing co-morbidity studies are small clinical studies, rather than epidemiological studies, resulting in a broad range of co-morbidity rates. DCD has a higher incidence for boys in comparison with girls; questions arise if this preponderance remains the same in combination with other developmental disorders. Therefore, in this study we aimed to determine co-morbidity and gender differences of motor problems in children with a pervasive developmental disorder, a hyperkinetic disorder and/or a speech, language or learning disability.

METHODS

Profiles of 3608 children (mean age: 9 years 1 month) referred to rehabilitation centres for behavioural, developmental and sensorineural disorders were studied.

RESULTS

Motor problems were reported in one-fifth of the total sample. Co-morbidity of motor problems in specific disorders varied from almost one-fourth to more than one-third. The male/female ratio was significantly higher in children with motor problems and two or more other disorders, compared with children with motor problems and less than two other disorders.

CONCLUSIONS

This study indicates that co-morbidity of motor problems with other clinical disorders is not exceptional and developmental deviance is seldom specific to one domain. However, current co-morbidity studies tend to overestimate the number of children with motor problems. In addition, there may be different patterns of symptoms between the genders. These findings stress the importance of assessing motor skills in children with various developmental disorders.

Posttraumatic stress disorder and the genetic structure of comorbidity

This study used structural equation modeling to examine the genetic and environmental architecture of latent dimensions of internalizing and externalizing psychiatric comorbidity and explored structural associations between posttraumatic stress disorder (PTSD) and these dimensions. Data were drawn from the Vietnam Era Twin Registry and included lifetime diagnoses for PTSD and a range of other psychiatric disorders for 3,372 male-male twin pairs. Examination of the phenotypic structure of these disorders revealed that PTSD cross-loaded on both Internalizing and Externalizing common factors. Biometric analyses suggested largely distinct genetic risk factors for the latent internalizing and externalizing comorbidity dimensions, with the total heritability of the Externalizing factor (69%) estimated to be significantly stronger than that for Internalizing (41%). Nonshared environment explained the majority of the remaining variance in the Internalizing (58%) and Externalizing (20%) factors. Shared genetic variance across the 2 dimensions explained 67% of their phenotypic correlation (r = .52). These findings have implications for conceptualizations of the etiology of PTSD and its location in an empirically based nosology.

Clustering of psychiatric and somatic illnesses in the general population: multimorbidity and socioeconomic correlates

The distribution of psychiatric disorders and of chronic medical illnesses was studied in a population-based sample to determine whether these conditions co-occur in the same individual. A representative sample (N = 1464) of adults living in households was assessed by the Composite International Diagnostic Interview, version 1.1, as part of the São Paulo Epidemiological Catchment Area Study. The association of sociodemographic variables and psychological symptoms regarding medical illness multimorbidity (8 lifetime somatic conditions) and psychiatric multimorbidity (15 lifetime psychiatric disorders) was determined by negative binomial regression. A total of 1785 chronic medical conditions and 1163 psychiatric conditions were detected in the population concentrated in 34.1 and 20% of respondents, respectively. Subjects reporting more psychiatric disorders had more medical illnesses. Characteristics such as age range (35-59 years, risk ratio (RR) = 1.3, and more than 60 years, RR = 1.7), being separated (RR = 1.2), being a student (protective effect, RR = 0.7), being of low educational level (RR = 1.2) and being psychologically distressed (RR = 1.1) were determinants of medical conditions. Age (35-59 years, RR = 1.2, and more than 60 years, RR = 0.5), being retired (RR = 2.5), and being psychologically distressed (females, RR = 1.5, and males, RR = 1.4) were determinants of psychiatric disorders. In conclusion, psychological distress and some sociodemographic features such as age, marital status, occupational status, educational level, and gender are associated with psychiatric and medical multimorbidity. The distribution of both types of morbidity suggests the need of integrating mental health into general clinical settings.

Comorbidity of learning disorders: prevalence and familial transmission

BACKGROUND

In order to fully specify the profiles of risk and protective factors of developmental disorders, a better understanding of the conditions under which they co-occur is required. So far, empirical evidence on comorbidities of specific learning disorders in arithmetic, reading and spelling is scarce.

METHODS

Prevalence and gender ratios of specific learning disorders in arithmetic (AD), reading (RD), and spelling (SD) and their co-occurrence were assessed in a large (N = 2586) population-based sample of elementary school children and in a subsample of 293 children with at least one learning disorder (LD-sample). A questionnaire on familial transmission was given to a subsample of 256 parents of children with a learning disorder and 146 typically developing children.

RESULTS

The rates of deficits in arithmetic, reading, or spelling were four to five times higher in samples already experiencing marked problems in one academic domain compared to the full population. Thus, comorbidity of learning disorders was confirmed in a fairly standard school population. Rates of co-occurrence decreased for AD and RD, but not isolated SD when more stringent cutoff criteria were applied, suggesting that the comorbidity of arithmetic and spelling disorder may be more strongly biologically mediated than the comorbidity of arithmetic and reading disorder. We found a preponderance of girls with AD and boys with SD. These imbalanced gender ratios were especially marked for isolated problems, while for comorbid problems gender ratios were mostly balanced with the exception of deficits in arithmetic and reading (but not spelling) which were more typical for girls. The parental questionnaire provided evidence for disorder-specific familial transmission and co-segregation of arithmetic and literacy deficits.

CONCLUSIONS

Comorbidities of learning disorders are not artificial. They are the result of a complex interplay between both general and disorder-specific aetiological factors.

Reinterpreting comorbidity: a model-based approach to understanding and classifying psychopathology

Comorbidity has presented a persistent puzzle for psychopathology research. We review recent literature indicating that the puzzle of comorbidity is being solved by research fitting explicit quantitative models to data on comorbidity. We present a meta-analysis of a liability spectrum model of comorbidity, in which specific mental disorders are understood as manifestations of latent liability factors that explain comorbidity by virtue of their impact on multiple disorders. Nosological, structural, etiological, and psychological aspects of this liability spectrum approach to understanding comorbidity are discussed.

Test of Alternative Hypotheses Explaining the Comorbidity Between Attention-Deficit/Hyperactivity Disorder and Conduct Disorder

There is significant comorbidity between attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD). The conclusions of studies that examined the causes of comorbidity between ADHD and CD conflict, with some researchers finding support for the three independent disorders model and others finding support for the correlated risk factors model. We tested these models and eleven alternative hypotheses using the same analytical approach. The participants were 110 monozygotic twin pairs and 181 dizygotic twin pairs recruited from the Colorado Learning Disabilities Research Center Twin Study. The three independent disorders model did not fit the data, whereas the correlated risk factors model fit the data well. Several other comorbidity models fit the data as well as or better than the correlated risk factors model. The results suggest that correlated risk factors are a better explanation for the comorbidity between ADHD and CD than a third, independent ADHD+CD subtype.

Comorbidity of substance use disorders and other psychiatric disorders among adolescents: evidence from an epidemiologic survey

This paper extends our knowledge of comorbidity of substance use disorders (SUDs) and other psychiatric disorders by examining comorbidity of specific types of SUDs and risk of comorbidity separately for abuse and dependence. The research question is whether there is specificity of risk for comorbidity for different SUDs and whether greater comorbidity is associated with dependence. Data are presented from a probability sample of 4175 youths aged 11-17 assessed with the NIMH DISC-IV and self-administered questionnaires. SUDs outcomes are alcohol, marijuana and other substances in past year. Mean number of other comorbid disorders ranged from 1.9 for marijuana abuse to 2.2 for other substance abuse and 1.9 for marijuana dependence to 2.8 for other substance dependence. None of the abuse SUDs does not increase risk of anxiety disorders, but dependence does. Both abuse and dependence increased risk of comorbid mood disorders. Similar results were observed for disruptive disorders. Patterns of comorbidity varied by substance, by abuse versus dependence, and by category of other psychiatric disorders. In general, there was greater association of comorbidity with other disorders for dependence versus abuse. Marijuana is somewhat less associated with other disorders than alcohol or other substances. The strongest association is for comorbid disruptive disorders, regardless of SUDs category. Having SUDs and comorbid other psychiatric disorders was associated with substantial functional impairment. Females with SUDs tended to have higher rates of comorbid disorders, as did older youths. There were no differences observed among ethnic groups. When comorbidity of SUDs with other disorders was examined, controlling for other non-SUDs disorders for each specific disorder examined, the greater odds for dependence versus abuse essentially disappeared for all disorders except disruptive disorders, suggesting larger number of comorbid non-SUDs in part account for the observed effects for dependence.

The genetic and environmental origins of learning abilities and disabilities in the early school years

Despite the importance of learning abilities and disabilities in education and child development, little is known about their genetic and environmental origins in the early school years. We report results for English (which includes reading, writing, and speaking), mathematics, and science as well as general cognitive ability in a large and representative sample of U.K. twins studied at 7, 9, and 10 years of age. Although preliminary reports of some of these data have been published, the purpose of this monograph is to present new univariate, multivariate, and longitudinal analyses that systematically examine genetic and environmental influences for the entire sample at all ages for all measures for both the low extremes (disabilities) and the entire sample (abilities). English, mathematics, and science yielded similarly high heritabilities and modest shared environmental influences at 7, 9, and 10 years despite major changes in content across these years. We draw three conclusions that go beyond estimating heritability. First, the abnormal is normal: Low performance is the quantitative extreme of the same genetic and environmental influences that operate throughout the normal distribution. Second, continuity is genetic and change is environmental: Longitudinal analyses suggest that age-to-age stability is primarily mediated genetically, whereas the environment contributes to change from age to age. Third, genes are generalists and environments are specialists: Multivariate analyses indicate that genes largely contribute to similarity in performance within and between the three domains--and with general cognitive ability--whereas the environment contributes to differences in performance. These conclusions have far-reaching implications for education and child development as well as for molecular genetics and neuroscience.

Literacy and mental disorders

PURPOSE OF REVIEW

This review examines recent evidence on the comorbidity between literacy problems and psychiatric disorder in childhood and discusses possible contributory factors.

RECENT FINDINGS

Recent studies confirm the substantial overlap of literacy problems with a range of emotional/behavioural difficulties in childhood. Literacy problems and inattention may share genetic influences, contributing to associations with attention deficit hyperactivity disorder. To an extent, links with conduct problems may be also mediated by attentional difficulties. In addition, findings suggest bidirectional influences whereby disruptive behaviours impede reading progress and reading failure exacerbates risk for behaviour problems. Associations between literacy problems and anxiety disorders are not entirely mediated by inattentiveness. Rather, comorbid anxiety disorders seem likely to arise from the stressors associated with reading failure. Findings in relation to depression are less consistent, but suggest that poor readers may be vulnerable to low mood. Children with autism seem more likely to face problems in reading comprehension than the decoding difficulties more prominent in other disorders.

SUMMARY

Literacy problems are associated with increased risks of both externalizing and internalizing disorders in childhood, with different mechanisms likely to be implicated in each case. When comorbid problems occur, each is likely to require separate treatment.