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Recognizing the importance of childhood maltreatment as a critical factor in psychiatric diagnoses, treatment, research, prevention, and education
Open accessAbstract
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.
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Metadata
- Authors
- Teicher, M. H., Gordon, J. B., & Nemeroff, C. B.
- Affiliations
- Harvard University (US)
- California Department of Social Services (US)
- The University of Texas at Austin (US)
- Corresponding author
- Nemeroff, Charles B.
- Venue
- Molecular Psychiatry
- Published
- 2021-11-04
- Volume
- 27
- Issue
- 3
- Pages
- 1331-1338
- ISSN
- 1359-4184 (ISSN-L)
- 1476-5578
- PMC
- PMC8567985
- OpenAlex
- W3211215709
- Cited by
- 325
- References
- 104
- Citations by year
- 2026: 59 · 2025: 84 · 2024: 89 · 2023: 57 · 2022: 35 · 2021: 1
- FWCI
- 6.04
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Molecular Psychiatry (publishedVersion, public-domain)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Health & Human Services | National Institutes of Health (MH-117293, AA-024933, HD-079484, DA-017846)
- ANS Foundation
- Topics
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- child abuse, developmental trauma disorder, DSM-5, psychiatric classification, early life stress, psychological maltreatment, attachment disruption, hypothalamic-pituitary-adrenal axis, neuroinflammation, comorbidities, treatment response, major depressive disorder, ecophenotypes
- MeSH terms
- Mental Disorders, Brain, Child, Child Abuse, Major Depressive Disorder, Depressive Disorder, Major, Humans, Diagnostic and Statistical Manual of Mental Disorders
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