Comorbidity is widely used in psychiatry, although few studies have considered the conceptual and methodological problems deriving from the transposition of this term from medicine to psychiatry. Comorbidity should be defined as two or more diseases, with distinct aetiopathogenesis (or, if the aetiology is unknown, with distinct pathophysiology of organ or system), that are present in the same individual in a defined period of time. In psychiatry, comorbidity is often an artefact for several reasons: (a) different assessment methods; (b) improper utilisation of the term comorbidity to indicate the association of symptoms instead of diseases; (c) number and characteristics of hierarchical exclusion rules used in classification systems; (d) nosologic classification in disorders (a generic term) instead of syndromes (a more precise concept, that allows clinicians to consider the hierarchy and the qualitative specificity of symptoms); (e) excessive splitting of classical syndromes into small disorders with inappropriate and overlapping boundaries; (f) too frequent revision of the diagnostic criteria, that changes diagnostic threshold; (g) number of clinical entities considered. Biological and psychological hypotheses that investigate the complexity of comorbidity findings are here presented; it is underlined that comorbidity should be the epidemiological descriptive starting point to build hypotheses that must be clear and rigorously defined, with specified usefulness and limits. Finally, the hypotheses should be tested with specific methodologies.

The relationship between eating disorders, impulse control disorders and obsessive-compulsive disorder as part of a so-called ‘obsessive-compulsive spectrum’ is discussed, with particular emphasis on the relationship between eating disorders (particularly bulimia) and obsessive-compulsive disorder. The empirical studies on comorbidity, personality and familiarity are briefly reviewed. Both similarities and differences found in personality, body image, mental rumination, fears, physical exercises, rituals, impulses (bulimic binging and obsessive impulses) and purging behaviors of these patients are discussed from a psychopathological point of view. In particular the importance of distinguishing between obsessive thoughts and prevalent (dominant) thoughts is underlined; the distinctions between repetitive weight controls, physical exercises and purging behaviors of eating disorder patients on the one hand and compulsions on the other, and the distinction between binge impulses and obsessive impulses, are also stressed.

Résumé Les secrets sont considérés comme une manœuvre de protection, mais en même temps, ils peuvent causer des dommages et de la souffrance. Puisqu’ils apparaissent seulement dans des contextes relationnels, leur nature relationnelle sera explorée et analysée. L’importance et le poids du secret dans les relations familiales seront examinés afin de comprendre quand et comment ils deviennent nuisibles. En ce sens, la proéminence attribuée au secret par les membres de la famille joue un rôle central. D’autres facteurs comme l’appauvrissement de l’éventail des comportements extérieurs au secret, ou la relation basée sur le secret, contribuent à une évaluation correcte de leur effet nuisible. Une classification des secrets sera proposée.

No abstract

Se sugiere una hipotesis sobre las dinamicas familiares del trastorno depresivo. Se proponen algunos principios generales para la intervencion .