人类大脑进化与“神经进化时间深度原则”:对《精神疾病诊断与统计手册》第五版中恐惧回路相关特质重新分类以及对战区相关创伤后应激障碍恢复力研究的启示

Human brain evolution and the "Neuroevolutionary Time-depth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder.

作者信息

Bracha H Stefan

机构信息

Department of Veterans Affairs, Pacific Islands Health Care System, and Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii, Honolulu 96813-2830, USA.

出版信息

Prog Neuropsychopharmacol Biol Psychiatry. 2006 Jul;30(5):827-53. doi: 10.1016/j.pnpbp.2006.01.008. Epub 2006 Mar 23.

Abstract

The DSM-III, DSM-IV, DSM-IV-TR and ICD-10 have judiciously minimized discussion of etiologies to distance clinical psychiatry from Freudian psychoanalysis. With this goal mostly achieved, discussion of etiological factors should be reintroduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). A research agenda for the DSM-V advocated the "development of a pathophysiologically based classification system". The author critically reviews the neuroevolutionary literature on stress-induced and fear circuitry disorders and related amygdala-driven, species-atypical fear behaviors of clinical severity in adult humans. Over 30 empirically testable/falsifiable predictions are presented. It is noted that in DSM-IV-TR and ICD-10, the classification of stress and fear circuitry disorders is neither mode-of-acquisition-based nor brain-evolution-based. For example, snake phobia (innate) and dog phobia (overconsolidational) are clustered together. Similarly, research on blood-injection-injury-type-specific phobia clusters two fears different in their innateness: 1) an arguably ontogenetic memory-trace-overconsolidation-based fear (hospital phobia) and 2) a hardwired (innate) fear of the sight of one's blood or a sharp object penetrating one's skin. Genetic architecture-charting of fear-circuitry-related traits has been challenging. Various, non-phenotype-based architectures can serve as targets for research. In this article, the author will propose one such alternative genetic architecture. This article was inspired by the following: A) Nesse's "Smoke-Detector Principle", B) the increasing suspicion that the "smooth" rather than "lumpy" distribution of complex psychiatric phenotypes (including fear-circuitry disorders) may in some cases be accounted for by oligogenic (and not necessarily polygenic) transmission, and C) insights from the initial sequence of the chimpanzee genome and comparison with the human genome by the Chimpanzee Sequencing and Analysis Consortium published in late 2005. Neuroevolutionary insights relevant to fear circuitry symptoms that primarily emerge overconsolidationally (especially Combat related Posttraumatic Stress Disorder) are presented. Also introduced is a human-evolution-based principle for clustering innate fear traits. The "Neuroevolutionary Time-depth Principle" of innate fears proposed in this article may be useful in the development of a neuroevolution-based taxonomic re-clustering of stress-triggered and fear-circuitry disorders in DSM-V. Four broad clusters of evolved fear circuits are proposed based on their time-depths: 1) Mesozoic (mammalian-wide) circuits hardwired by wild-type alleles driven to fixation by Mesozoic selective sweeps; 2) Cenozoic (simian-wide) circuits relevant to many specific phobias; 3) mid Paleolithic and upper Paleolithic (Homo sapiens-specific) circuits (arguably resulting mostly from mate-choice-driven stabilizing selection); 4) Neolithic circuits (arguably mostly related to stabilizing selection driven by gene-culture co-evolution). More importantly, the author presents evolutionary perspectives on warzone-related PTSD, Combat-Stress Reaction, Combat-related Stress, Operational-Stress, and other deployment-stress-induced symptoms. The Neuroevolutionary Time-depth Principle presented in this article may help explain the dissimilar stress-resilience levels following different types of acute threat to survival of oneself or one's progency (aka DSM-III and DSM-V PTSD Criterion-A events). PTSD rates following exposure to lethal inter-group violence (combat, warzone exposure or intentionally caused disasters such as terrorism) are usually 5-10 times higher than rates following large-scale natural disasters such as forest fires, floods, hurricanes, volcanic eruptions, and earthquakes. The author predicts that both intentionally-caused large-scale bioevent-disasters, as well as natural bioevents such as SARS and avian flu pandemics will be an exception and are likely to be followed by PTSD rates approaching those that follow warzone exposure. During bioevents, Amygdala-driven and locus-coeruleus-driven epidemic pseudosomatic symptoms may be an order of magnitude more common than infection-caused cytokine-driven symptoms. Implications for the red cross and FEMA are discussed. It is also argued that hospital phobia as well as dog phobia, bird phobia and bat phobia require re-taxonomization in DSM-V in a new "overconsolidational disorders" category anchored around PTSD. The overconsolidational spectrum category may be conceptualized as straddling the fear circuitry spectrum disorders and the affective spectrum disorders categories, and may be a category for which Pitman's secondary prevention propranolol regimen may be specifically indicated as a "morning after pill" intervention. Predictions are presented regarding obsessive-compulsive disorder (OCD) (e.g., female-pattern hoarding vs. male-pattern hoarding) and "culture-bound" acute anxiety symptoms (taijin-kyofusho, koro, shuk yang, shook yong, suo yang, rok-joo, jinjinia-bemar, karoshi, gwarosa, Voodoo death). Also discussed are insights relevant to pseudoneurological symptoms and to the forthcoming Dissociative-Conversive disorders category in DSM-V, including what the author terms fright-triggered acute pseudo-localized symptoms (i.e., pseudoparalysis, pseudocerebellar imbalance, psychogenic blindness, pseudoseizures, and epidemic sociogenic illness). Speculations based on studies of the human abnormal-spindle-like, microcephaly-associated (ASPM) gene, the microcephaly primary autosomal recessive (MCPH) gene, and the forkhead box p2 (FOXP2) gene are made and incorporated into what is termed "The pre-FOXP2 Hypothesis of Blood-Injection-Injury Phobia." Finally, the author argues for a non-reductionistic fusion of "distal (evolutionary) neurobiology" with clinical "proximal neurobiology," utilizing neurological heuristics. It is noted that the value of re-clustering fear traits based on behavioral ethology, human-phylogenomics-derived endophenotypes and on ontogenomics (gene-environment interactions) can be confirmed or disconfirmed using epidemiological or twin studies and psychiatric genomics.

摘要

《精神疾病诊断与统计手册》第三版(DSM - III)、第四版(DSM - IV)、第四版修订版(DSM - IV - TR)以及《国际疾病分类》第十版(ICD - 10)都审慎地减少了对病因的讨论,以使临床精神病学与弗洛伊德精神分析理论保持距离。随着这一目标基本实现,应将病因因素的讨论重新引入《精神疾病诊断与统计手册》第五版(DSM - V)。一份针对DSM - V的研究议程倡导“开发一种基于病理生理学的分类系统”。作者批判性地回顾了关于应激诱导和恐惧回路障碍以及成年人类临床严重程度的相关杏仁核驱动的、物种非典型恐惧行为的神经进化文献。提出了30多个可通过实证检验/证伪的预测。需要注意的是,在DSM - IV - TR和ICD - 10中,应激和恐惧回路障碍的分类既不是基于获得方式,也不是基于大脑进化。例如,恐蛇症(先天性)和恐犬症(过度巩固性)被归为一类。同样,对血液 - 注射 - 损伤型特定恐惧症的研究将两种先天性不同的恐惧归为一组:1)一种可以说是基于个体发生记忆痕迹过度巩固的恐惧(医院恐惧症);2)对自己的血液或尖锐物体刺入皮肤的一种固有(先天性)恐惧。对与恐惧回路相关特征的遗传结构图谱绘制一直具有挑战性。各种基于非表型的结构可作为研究目标。在本文中,作者将提出一种这样的替代遗传结构。本文的灵感来源于以下几点:A)内斯的“烟雾探测器原理”;B)越来越多的怀疑,即复杂精神疾病表型(包括恐惧回路障碍)的“平滑”而非“块状”分布在某些情况下可能由寡基因(不一定是多基因)传递来解释;C)2005年末发表的黑猩猩测序与分析联盟对黑猩猩基因组初始序列的研究以及与人类基因组的比较所获得的见解。呈现了与主要通过过度巩固出现的恐惧回路症状(特别是与战斗相关的创伤后应激障碍)相关的神经进化见解。还介绍了一种基于人类进化的先天性恐惧特征聚类原则。本文提出的先天性恐惧的“神经进化时间深度原则”可能有助于在DSM - V中基于神经进化对压力触发和恐惧回路障碍进行分类重新聚类。基于时间深度提出了四类进化的恐惧回路:1)中生代(全哺乳动物)回路,由中生代选择性清除驱动固定的野生型等位基因所固定;2)新生代(全猿类)回路,与许多特定恐惧症相关;3)旧石器时代中期和晚期(智人特有的)回路(可以说主要是由配偶选择驱动的稳定选择导致);4)新石器时代回路(可以说主要与基因 - 文化共同进化驱动的稳定选择相关)。更重要的是,作者呈现了关于战区相关创伤后应激障碍、战斗应激反应、战斗相关应激、作战应激以及其他部署应激诱导症状的进化观点。本文提出的神经进化时间深度原则可能有助于解释在对自己或后代生存的不同类型急性威胁(即DSM - III和DSM - V创伤后应激障碍A标准事件)后不同的应激恢复水平。接触致命的群体间暴力(战斗、战区暴露或故意造成的灾难如恐怖主义)后的创伤后应激障碍发生率通常比森林火灾、洪水、飓风、火山爆发和地震等大规模自然灾害后的发生率高5 - 10倍。作者预测,故意造成的大规模生物事件灾难以及如非典和禽流感大流行等自然生物事件将是例外,其后续的创伤后应激障碍发生率可能接近战区暴露后的发生率。在生物事件期间,杏仁核驱动和蓝斑驱动的流行性假性躯体症状可能比感染引起的细胞因子驱动症状普遍一个数量级。讨论了对红十字会和联邦应急管理局的影响。还认为医院恐惧症以及恐犬症、恐鸟症和恐蝠症在DSM - V中需要在一个以创伤后应激障碍为核心的新的“过度巩固性障碍”类别中重新分类。过度巩固性谱系类别可以被概念化为跨越恐惧回路谱系障碍和情感谱系障碍类别,并且可能是一个类别,对于该类别,皮特曼的二级预防普萘洛尔方案可能特别适用于作为“事后避孕药”干预。提出了关于强迫症(OCD)(例如,女性型囤积与男性型囤积)和“文化束缚”急性焦虑症状(如恐人症、缩阳症、恐缩症、受惊症、锁阳症、肉跳症、惊恐障碍、过劳死、职业倦怠、巫毒死亡)的预测。还讨论了与假性神经症状以及即将在DSM - V中出现的分离性 - 转换性障碍类别相关的见解,包括作者所称的惊吓触发的急性假性定位症状(即假性麻痹、假性小脑失衡、心因性失明、假性癫痫发作和流行性群体心因性疾病)。基于对人类异常纺锤样小头畸形相关(ASPM)基因、小头畸形原发性常染色体隐性(MCPH)基因和叉头框p2(FOXP2)基因的研究进行了推测,并将其纳入所谓的“血液 - 注射 - 损伤恐惧症的前FOXP2假说”。最后,作者主张利用神经学启发法将“远端(进化)神经生物学”与临床“近端神经生物学”进行非还原论的融合。需要注意的是,可以通过流行病学或双胞胎研究以及精神病基因组学来证实或证伪基于行为生态学、人类系统发育基因组学衍生的内表型以及个体发生基因组学(基因 - 环境相互作用)对恐惧特征重新聚类的价值。

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