As we embark upon a new year, we may do so with a sense of renewal, refueled and refreshed by family gatherings through the holiday season. For those without friends or loved ones, however, or those with disabling psychiatric disorders, the winter season can intensify depression, and the holidays can seem cruel. What can be, for some, a valued time of reunion and expressions of affection is, for others, a time of stress and deprivation. And if there’s a single word that might best guide us in our efforts to prevent illness, that word might be stress, i.e., the importance of protection from stress. The more we learn about stress, whether the acute and non-repeating variety or the persistent, relentless variety, the more we recognize its pathogenic nature. All of us, of course, as a colleague of mine, Nancy Wexler, often remarks, may soon find ourselves uninsurable, since we all have pre-existing conditions—those latent, not-yet-expressed biological and genetic vulnerabilities to become ill in myriad ways. Sometimes the latent illness may become overt because it is genetically programmed to do so, but far more often this transition is precipitated by stress. And we now know that stress not only precipitates latent pathology, it also wreaks biological havoc in its own right, causing effects such as hippocampal atrophy, cognitive impairment, dysregulated cortisol, and many others. How much of this is reversible and how much irreversible is not yet clear, but what is clear is that every effort should be made to minimize stress, in the interest of good health.
In this issue, Corcoran et al. describe the neurobiology of the “stress cascade,” emphasizing its relevance for schizophrenia, but pointing out its importance in many other neuropsychiatric conditions. Weiden, in turn, presents a new scale to facilitate evaluation of patients with schizophrenia, to clarify which of the many side effects of antipsychotic medications are least, and which are most, distressing. Here, we recognize that stress comes from many sources, including our own therapeutic efforts. Welsh and Liberto review the use of medication to prevent relapse in substance dependence disorders, and these medications, too, have secondary side effects that may be stressful in their own right and hence important to identify. It is also widely recognized that those who suffer from substance use disorders frequently relapse when faced with stress, returning to substance use as a form of short-term psychological analgesia. Finally, Casey helps us think carefully about adult adjustment disorder, a condition that, by definition, occurs within 3 months of a stressful event.
All of these concerns reflect the thorny complexity of problems associated with stress. We know that stress is unavoidable. However, our expanded understanding of its crucial role in precipitating pathology truly helps us make progress in the area of prevention. And by preventively minimizing the universal etiological agent, stress, the need for treatment will be reduced.