Comorbidity pp 23-41 | Cite as

Models of Comorbidity

  • Rhonda BrownEmail author
  • Einar Thorsteinsson


Most existing theories of disease comorbidity provide only a broad overview of the manner in which comorbidity is likely to arise, although these broad overarching theories have, for the most part, not been tested empirically. Further, there are few comorbidity theories that are comprehensive yet specific enough to help guide the exploration of the relationships between specific comorbid disorders and the likely role played by intervening factors. As a result, we know little about the extent to which comorbidity is relevant to our understanding of single disorders and conditions; the mechanisms likely to underpin the development of the comorbidities; and the nature of the interactions between specific risk factors and comorbid disorders.


  1. 1.
    Borsboom D, Cramer AOJ, Schmittmann VD, Epskamp S, Waldorp LJ. The small world of psychopathology. PLOS ONE. 2011;6(11):e27407. Scholar
  2. 2.
    Schoevers RA, Deeg D, Van Tilburg W, Beekman A. Depression and generalized anxiety disorder: Co-occurrence and longitudinal patterns in elderly patients. The American Journal of Geriatric Psychiatry. 2005;13(1):31–39. Scholar
  3. 3.
    Degenhardt L, Hall W, Lynskey M. What is comorbidity and why does it occur? In: Teesson M, Proudfoot H, eds. Comorbid mental disorders and substance use disorders: Epidemiology, prevention and treatment. Sydney, Australia: National Drug and Alcohol Research Centre; 2003:10–25.Google Scholar
  4. 4.
    Jansson-Fröjmark M, Lindblom K. A bidirectional relationship between anxiety and depression, and insomnia? A prospective study in the general population. Journal of Psychosomatic Research. 2008;64(4):443–449. Scholar
  5. 5.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). 5th ed. Washington, DC: American Psychiatric Association; 2013.Google Scholar
  6. 6.
    Brady EU, Kendall PC. Comorbidity of anxiety and depression in children and adolescents. Psychological Bulletin. 1992;111(2):244–255. Scholar
  7. 7.
    Sartorius N, Üstün TB, Lecrubier Y, Wittchen H-U. Depression comorbid with anxiety: Results from the WHO study on psychological disorders in primary health care. The British Journal of Psychiatry. 1996;168(S30):38–43. Scholar
  8. 8.
    Thorsteinsson EB, Brown RF, Owens MT. Modelling the effects of stress, anxiety, and depression on rumination, sleep, and fatigue in a nonclinical sample. The Journal of Nervous and Mental Disease. 2019;207(5):355–359. Scholar
  9. 9.
    Thomsen DK, Mehlsen MY, Christensen S, Zachariae R. Rumination—Relationship with negative mood and sleep quality. Personality and Individual Differences. 2003;34(7):1293–1301. Scholar
  10. 10.
    Drake CL, Pillai V, Roth T. Stress and sleep reactivity: A prospective investigation of the stress-diathesis model of insomnia. Sleep. 2014;37(8):1295–1304. Scholar
  11. 11.
    Allison KC, Lundgren JD, O’Reardon JP, et al. Proposed diagnostic criteria for night eating syndrome. International Journal of Eating Disorders. 2010;43(3):241–247. Scholar
  12. 12.
    Colles SL, Dixon JB, O’brien PE. Night eating syndrome and nocturnal snacking: Association with obesity, binge eating and psychological distress. International Journal of Obesity. 2007;31(11):1722. Scholar
  13. 13.
    Schmittmann VD, Cramer AOJ, Waldorp LJ, Epskamp S, Kievit RA, Borsboom D. Deconstructing the construct: A network perspective on psychological phenomena. New Ideas in Psychology. 2013;31(1):43–53. Scholar
  14. 14.
    Finelli LA, Baumann H, Borbély AA, Achermann P. Dual electroencephalogram markers of human sleep homeostasis: Correlation between theta activity in waking and slow-wave activity in sleep. Neuroscience. 2000;101(3):523–529. Scholar
  15. 15.
    Cramer AOJ, Waldorp LJ, van der Maas HLJ, Borsboom D. Comorbidity: A network perspective. Behavioral and Brain Sciences. 2010;33(2–3):137–150. Scholar
  16. 16.
    Maser JD, Cloninger CR. Comorbidity of mood and anxiety disorders. Washington, DC: American Psychiatric Press; 1990.Google Scholar
  17. 17.
    Thorsteinsson EB, Brown RF. Mediators and moderators of the stressor—Fatigue relationship in non-clinical samples. Journal of Psychosomatic Research. 2009;66:21–29. Scholar
  18. 18.
    Kim NS, Ahn WK. Clinical psychologists’ theory-based representations of mental disorders predict their diagnostic reasoning and memory. Journal of Experimental Psychology: General. 2002;131(4):451. Scholar
  19. 19.
    Yeh SSS, Brown RF. Disordered eating partly mediates the relationship between poor sleep quality and high body mass index. Eating Behaviors. 2014;15(2):291–297. Scholar
  20. 20.
    Rooke SE, Thorsteinsson EB. Examining the temporal relationship between depression and obesity: Meta-analyses of prospective research. Health Psychology Review. 2008;2(1):94–109. Scholar
  21. 21.
    van Strien T, Konttinen H, Homberg JR, Engels RCME, Winkens LHH. Emotional eating as a mediator between depression and weight gain. Appetite. 2016;100:216–224. Scholar
  22. 22.
    Brown RF, Thorsteinsson EB, Smithson M, Birmingham CL, Aljarallah H, Nolan C. Can body temperature dysregulation explain the co-occurrence between overweight/obesity, sleep impairment, late-night eating, and a sedentary lifestyle? Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. 2017;22(4):599–608. Scholar
  23. 23.
    Banks S, Dinges DF. Behavioral and physiological consequences of sleep restriction. Journal of Clinical Sleep Medicine. 2007;3(5):519–528.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Lack LC, Lovato N, Micic G. Circadian rhythms and insomnia. Sleep and Biological Rhythms. 2017;15(1):3–10. Scholar
  25. 25.
    Lack LC, Gradisar M, Van Someren EJW, Wright HR, Lushington K. The relationship between insomnia and body temperatures. Sleep Medicine Reviews. 2008;12(4):307–317. Scholar
  26. 26.
    Campbell SS, Broughton RJ. Rapid decline in body temperature before sleep: Fluffing the physiological pillow? Chronobiology International. 1994;11(2):126–131. Scholar
  27. 27.
    Gillberg M, Åkerstedt T. Body temperature and sleep at different times of day. Sleep: Journal of Sleep Research & Sleep Medicine. 1982;5(4):378–388. Scholar
  28. 28.
    Murphy PJ, Campbell SS. Nighttime drop in body temperature: A physiological trigger for sleep onset? Sleep. 1997;20(7):505–511. Scholar
  29. 29.
    Weinert D, Waterhouse J. The circadian rhythm of core temperature: Effects of physical activity and aging. Physiology & Behavior. 2007;90(2):246–256. Scholar
  30. 30.
    Morris M, Lack L, Dawson D. Sleep-onset insomniacs have delayed temperature rhythms. Sleep. 1990;13(1):1–14. Scholar
  31. 31.
    Buguet A. Sleep under extreme environments: Effects of heat and cold exposure, altitude, hyperbaric pressure and microgravity in space. Journal of the Neurological Sciences. 2007;262(1):145–152. Scholar
  32. 32.
    Dijk D-J, Czeisler CA. Contribution of the circadian pacemaker and the sleep homeostat to sleep propensity, sleep structure, electroencephalographic slow waves, and sleep spindle activity in humans. The Journal of Neuroscience. 1995;15(5):3526–3538. Scholar
  33. 33.
    Mistlberger RE. Circadian regulation of sleep in mammals: Role of the suprachiasmatic nucleus. Brain Research Reviews. 2005;49(3):429–454. Scholar
  34. 34.
    Kräuchi K. How is the circadian rhythm of core body temperature regulated? Clinical Autonomic Research. 2002;12(3):147–149. Scholar
  35. 35.
    Lushington K, Dawson D, Lack L. Core body temperature is elevated during constant wakefulness in elderly poor sleepers. Sleep. 2000;23(4):504–510. Scholar
  36. 36.
    Candas V, Libert JP, Muzet A. Heating and cooling stimulations during SWS and REM sleep in man. Journal of Thermal Biology. 1982;7(3):155–158. Scholar
  37. 37.
    Haskell EH, Palca JW, Walker JM, Berger RJ, Heller HC. The effects of high and low ambient temperatures on human sleep stages. Electroencephalography and Clinical Neurophysiology. 1981;51(5):494–501. Scholar
  38. 38.
    Daurat A, Aguirre A, Foret J, Gonnet P, Keromes A, Benoit O. Bright light affects alertness and performance rhythms during a 24-h constant routine. Physiology & Behavior. 1993;53(5):929–936. Scholar
  39. 39.
    Fletcher A, van den Heuvel C, Dawson D. Sleeping with an electric blanket: Effects on core temperature, sleep, and melatonin in young adults. Sleep. 1999;22(3):313–318. Scholar
  40. 40.
    Okamoto-Mizuno K, Tsuzuki K, Ohshiro Y, Mizuno K. Effects of an electric blanket on sleep stages and body temperature in young men. Ergonomics. 2005;48(7):749–757. Scholar
  41. 41.
    Karacan I, Thornby JI, Anch AM, Williams RL, Perkins HM. Effects of high ambient temperature on sleep in young men. Aviation, Space, and Environmental Medicine. 1978;49(7):855–860.PubMedGoogle Scholar
  42. 42.
    Obermeyer Z, Samra JK, Mullainathan S. Individual differences in normal body temperature: Longitudinal big data analysis of patient records. British Medical Journal. 2017;359:j5468. Scholar
  43. 43.
    Muzet A, Ehrhart J, Candas V, Libert JP, Vogt JJ. REM sleep and ambient temperature in man. International Journal of Neuroscience. 1983;18(1–2):117–125. Scholar
  44. 44.
    Auld F, Maschauer EL, Morrison I, Skene DJ, Riha RL. Evidence for the efficacy of melatonin in the treatment of primary adult sleep disorders. Sleep Medicine Reviews. 2017;34:10–22. Scholar
  45. 45.
    Brown GM. Light, melatonin and the sleep-wake cycle. Journal of Psychiatry and Neuroscience. 1994;19(5):345–353.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Malkani R, Zee PC. Basic circadian rhythms and circadian sleep disorders. In: Chokroverty S, Thomas RJ, eds. Atlas of sleep medicine. 2nd ed. Philadelphia, PA Saunders; 2014:119–126.Google Scholar
  47. 47.
    Brzezinski A, Vangel MG, Wurtman RJ, et al. Effects of exogenous melatonin on sleep: A meta-analysis. Sleep Medicine Reviews. 2005;9(1):41–50. Scholar
  48. 48.
    Ehlers CL, Frank E, Kupfer DJ. Social zeitgebers and biological rhythms: A unified approach to understanding the etiology of depression. Archives of General Psychiatry. 1988;45(10):948–952. Scholar
  49. 49.
    Grandin LD, Alloy LB, Abramson LY. The social zeitgeber theory, circadian rhythms, and mood disorders: Review and evaluation. Clinical Psychology Review. 2006;26(6):679–694. Scholar
  50. 50.
    Monk TH, Reynolds CF, Kupfer DJ, Hoch CC, Carrier J, Houck PR. Differences over the life span in daily life-style regularity. Chronobiology International. 1997;14(3):295–306. Scholar
  51. 51.
    Kräuchi K, Wirz-Justice A. Circadian rhythm of heat production, heart rate, and skin and core temperature under unmasking conditions in men. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology. 1994;267(3):R819–R829. Scholar
  52. 52.
    Van Someren EJW. More than a marker: Interaction between the circadian regulation of temperature and sleep, age-related changes, and treatment possibilities. Chronobiology International. 2000;17(3):313–354. Scholar

Copyright information

© The Author(s) 2020

Authors and Affiliations

  1. 1.Australian National UniversityCanberraAustralia
  2. 2.University of New EnglandArmidaleAustralia

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