Teicher Martin H, Gordon Jeoffry B, Nemeroff Charles B
Developmental Biopsychiatry Research Program, McLean Hospital, Belmont, MA, 02478, USA.
Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, USA.
Mol Psychiatry. 2022 Mar;27(3):1331-1338. doi: 10.1038/s41380-021-01367-9. Epub 2021 Nov 4.
Childhood maltreatment is the most important preventable risk factor for psychiatric disorders. Maltreated individuals typically develop psychiatric disorders at an earlier age, have a more pernicious course, more comorbidities, greater symptom severity, and respond less favorably to treatments than non-maltreated individuals with the same primary DSM-5 diagnosis. Furthermore, maltreated individuals have alterations in stress-susceptible brain regions, hypothalamic-pituitary-adrenal response, and inflammatory marker levels not discernible in their non-maltreated counterparts. Hence, maltreated and non-maltreated individuals with the same primary DSM-5 diagnoses appear to be clinically and neurobiologically distinct. The failure to embody this distinction in DSM-5 has interfered with our ability to discover novel treatments, to recommend currently available treatments most likely to be efficacious, and has been a largely unrecognized confound that has thwarted our ability to identify the biological basis for major psychiatric disorders. Incorporating this distinction into DSM will help transform this sign and symptom-based classification system to a more etiologically informed nosology. We discuss several diagnostic alternatives and recommend the inclusion of a Developmental Trauma Disorder diagnosis for severely dysregulated individuals, of all ages, with numerous comorbidities, who experienced interpersonal victimization and disruptions in attachment, such as emotional maltreatment or neglect. For less severely affected maltreated individuals, we suggest using conventional diagnostic categories, such as major depression, but with an essential modifier indicating a history of childhood maltreatment, or early life stress, to delineate the ecophenotypic variant. Implementing this strategy should improve our ability to effectively diagnose and treat individuals with psychiatric disorders and to accelerate discovery.
童年期受虐是精神障碍最重要的可预防风险因素。与未受虐个体相比，受虐个体通常在更早的年龄患上精神障碍，病程更凶险，共病更多，症状更严重，对治疗的反应也更差，即便二者具有相同的首要DSM-5诊断。此外，受虐个体在应激易感性脑区、下丘脑-垂体-肾上腺反应以及炎症标志物水平方面存在改变，而在未受虐的同龄人中则未发现这些改变。因此，具有相同首要DSM-5诊断的受虐个体与未受虐个体在临床和神经生物学上似乎存在差异。DSM-5未能体现这种差异，这妨碍了我们发现新治疗方法的能力，妨碍了我们推荐最有可能有效的现有治疗方法，并且在很大程度上是一个未被认识到的混淆因素，阻碍了我们确定主要精神障碍生物学基础的能力。将这种差异纳入DSM将有助于把这个基于症状的分类系统转变为一个更具病因学依据的疾病分类学。我们讨论了几种诊断替代方案，并建议对所有年龄段、患有多种共病、经历过人际创伤和依恋关系中断（如情感虐待或忽视）且严重失调的个体纳入发育性创伤障碍诊断。对于受虐程度较轻的个体，我们建议使用传统诊断类别，如重度抑郁症，但需添加一个基本修饰词，表明童年期受虐或早期生活应激史，以描述生态表型变异。实施这一策略应能提高我们有效诊断和治疗精神障碍患者的能力，并加速研究发现。
