May, 2000. In this issue, Joel Paris takes a critical (and perhaps controversial) look at the evidence (or lack of it) behind the common assumption of “primacy,” i.e., “that events in early childhood have more long-term impact than those occurring later in development.” Emphasizing that most of our beliefs regarding the longitudinal impact of early adversity rely on retrospective studies, Paris argues persuasively for the need for more prospective studies. He underscores the remarkable resilience shown by most individuals who experience early trauma and points out the importance of cumulative risk—that environments containing multiple, repetitive, and persistent stressors are those most likely to predict adult psychopathology. A similar point was made in our May, 1999 issue in an article by Pine and Cohen, who pointed out that, in spite of many epidemiological studies describing stability of behavior problems over time, the longer the time interval of the study, the more likely the study is to show remission of behavior problems of children and adolescents, presumably as a result of moderating factors.
One conclusion that emerges from these considerations is also applicable to cross-sectional studies of adult populations—that “more is worse.” Relentless stress is worse than a single stressful event, and the presence of multiple, co-existing disorders—comorbidity—makes treatment more complicated. In this issue, in the third article in the series on obsessive-compulsive disorder, Fallon and Mathew describe biological therapies for this condition and emphasize combined treatment and augmentation strategies for patients with more complex presentations, particularly those with comorbid neurological and/or psychiatric disorders. Similarly, Ruiz and colleagues outline treatment approaches for patients with HIV/AIDS, pointing out that in particular “comorbid substance abuse greatly complicates the treatment of HIV/AIDS and leads to poor adherence to medical and psychiatric treatment and increased morbidity and mortality.” Gardos presents a compelling effectiveness (versus efficacy) study showing that patients with panic disorder and agoraphobia who have comorbid conditions do worse in long-term treatment than patients with this condition alone. Finally, Weiden reviews the important problem of comorbid cardiovascular pathology in patients with schizophrenia, often related to risk factors such as smoking and weight gain, and presents useful strategies to help patients reduce these risks.
In previous editorials, I have stressed the importance of carefully tailored assessment (March, 2000) and of flexible (May, 1998) and comprehensive (March, 1999) treatment planning. The importance of ascertaining not just that stress has occurred in the past, but how much and for how long, is an example of these principles, as is the importance of a systematic and thorough diagnostic evaluation to identify the presence of all comorbid conditions.
John Oldham MD