Dysthymia: Difference between revisions

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==Overview==
==Overview==
Dysthymia is a [[mood disorder]] that falls on the [[Clinical depression|depression spectrum]].  It is characterized by the lack of enjoyment or [[pleasure]], clinically referred to as [[anhedonia]], that continues for an extended period. Dysthymia differs from [[major depression]] in that it is both longer-lasting and lesser distressing. The symptoms of dysthymia are often underestimated by the patients and misdiagnosed by [[Clinician|clinicians]]. Dysthymia can have a substantial impact on an individual's life by preventing effective functioning, disrupting sleep patterns, and interfering with activities of daily living (ADLs). It usually presents with mild symptoms on a day-to-day basis. Progressively, the disorder may take a more severe form, resulting in work impairment, social isolation, and high rates of [[suicide]]. Due to its chronicity and lesser severity, most of the patients suffering from dysthymia believe that it is a part of their [[Character (biology)|character]] and do not seek [[treatment]] until it gets extremely disabling.
Dysthymia is a [[mood disorder]] that falls on the [[Clinical depression|depression spectrum]].  It is characterized by the lack of enjoyment or [[pleasure]], clinically referred to as [[anhedonia]], that continues for an extended period. Dysthymia differs from [[major depression]] in that it is both longer-lasting and not as distressing. The symptoms of dysthymia are often underestimated by the patients and misdiagnosed by [[Clinician|clinicians]]. Dysthymia can have a substantial impact on an individual's life by preventing effective functioning, disrupting sleep patterns, and interfering with activities of daily living (ADLs). It usually presents with mild symptoms on a day-to-day basis. Progressively, the disorder may take a more severe form, resulting in work impairment, social isolation, and high rates of [[suicide]]. Due to its chronicity and lesser severity, most of the patients suffering from dysthymia believe that it is a part of their [[Character (biology)|character]] and do not seek [[treatment]] until it gets extremely disabling.


==Historical Perspective==
==Historical Perspective==
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*In 1882, dysthymia was further described by Kahlbaum, and he differentiated it from the fluctuating mood of [[cyclothymia]].<ref name="pmid7942068">{{cite journal| author=Freeman HL| title=Historical and nosological aspects of dysthymia. | journal=Acta Psychiatr Scand Suppl | year= 1994 | volume= 383 | issue=  | pages= 7-11 | pmid=7942068 | doi=10.1111/j.1600-0447.1994.tb05877.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942068  }}</ref>
*In 1882, dysthymia was further described by Kahlbaum, and he differentiated it from the fluctuating mood of [[cyclothymia]].<ref name="pmid7942068">{{cite journal| author=Freeman HL| title=Historical and nosological aspects of dysthymia. | journal=Acta Psychiatr Scand Suppl | year= 1994 | volume= 383 | issue=  | pages= 7-11 | pmid=7942068 | doi=10.1111/j.1600-0447.1994.tb05877.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942068  }}</ref>
*In the Diagnostic and Statistical Manual of Mental Disorders ([[DSM]]), dysthymia as a clinical entity has undergone complex evolution from being considered a [[personality disorder]] to an [[affective disorder]].
*In the Diagnostic and Statistical Manual of Mental Disorders ([[DSM]]), dysthymia as a clinical entity has undergone complex evolution from being considered a [[personality disorder]] to an [[affective disorder]].
*
 


==Classification==
==Classification==


*Diagnostic and Statistical Manual of Mental Disorders ([[DSM-II]]) described chronic [[depression]] as a [[personality disorder]].<ref name="Freeman1994">{{cite journal|last1=Freeman|first1=H. L.|title=Historical and nosological aspects of dysthymia|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=7–11|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05877.x}}</ref>
*The Diagnostic and Statistical Manual of Mental Disorders ([[DSM-II]]) described chronic [[depression]] as a [[personality disorder]].<ref name="Freeman1994">{{cite journal|last1=Freeman|first1=H. L.|title=Historical and nosological aspects of dysthymia|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=7–11|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05877.x}}</ref>
*'Dysthymic disorder' was the term used in [[Diagnostic and statistical manual of mental disorders|DSM]]-III to describe depression present for more than two years.
*'Dysthymic disorder' was the term used in [[Diagnostic and statistical manual of mental disorders|DSM]]-III to describe depression present for more than two years.
*From the [[personality disorder]] of [[DSM-II]],  [[DSM-III-R]] placed it under the affective category. <ref name="Freeman19942">{{cite journal|last1=Freeman|first1=H. L.|title=Historical and nosological aspects of dysthymia|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=7–11|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05877.x}}</ref>
*From the [[personality disorder]] of [[DSM-II]],  [[DSM-III-R]] placed it under the affective category. <ref name="Freeman19942">{{cite journal|last1=Freeman|first1=H. L.|title=Historical and nosological aspects of dysthymia|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=7–11|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05877.x}}</ref>
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*Based on the [[age of onset]], [[DSM-IV]] has divided dysthymic disorders into early (before 21 years) and late-onset (after 21 years) subtypes. <ref name="pmid12858423" />
*Based on the [[age of onset]], [[DSM-IV]] has divided dysthymic disorders into early (before 21 years) and late-onset (after 21 years) subtypes. <ref name="pmid12858423" />
*Early-onset dysthymic disorder is related to a higher familial burden of [[Mood disorder|mood disorders]] and childhood adverse conditions. On the other hand, late-onset has an association with health issues and major losses.<ref name="pmid12858423">Klein DN, Santiago NJ (2003) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12858423 Dysthymia and chronic depression: introduction, classification, risk factors, and course.] ''J Clin Psychol'' 59 (8):807-16. [http://dx.doi.org/10.1002/jclp.10174 DOI:10.1002/jclp.10174] PMID: [https://pubmed.gov/12858423 12858423]</ref>
*Early-onset dysthymic disorder is related to a higher familial burden of [[Mood disorder|mood disorders]] and childhood adverse conditions. On the other hand, late-onset has an association with health issues and major losses.<ref name="pmid12858423">Klein DN, Santiago NJ (2003) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12858423 Dysthymia and chronic depression: introduction, classification, risk factors, and course.] ''J Clin Psychol'' 59 (8):807-16. [http://dx.doi.org/10.1002/jclp.10174 DOI:10.1002/jclp.10174] PMID: [https://pubmed.gov/12858423 12858423]</ref>
*In [[DSM-IV]], individuals having underlying dysthymic disorder who develop [[major depressive episode]] are diagnosed as having both dysthymic disorder and [[major depressive disorder]]. So, DSM-IV has categorized dysthymic disorder and major depressive episodes as separate diagnoses instead of phases of a single disorder that fluctuates in severity over time.<ref name="pmid128584232">Klein DN, Santiago NJ (2003) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12858423 Dysthymia and chronic depression: introduction, classification, risk factors, and course.] ''J Clin Psychol'' 59 (8):807-16. [http://dx.doi.org/10.1002/jclp.10174 DOI:10.1002/jclp.10174] PMID: [https://pubmed.gov/12858423 12858423]</ref>
*In [[DSM-IV]], individuals having underlying dysthymic disorder who develop [[major depressive episode]]s are diagnosed as having both dysthymic disorder and [[major depressive disorder]]. So, DSM-IV has categorized dysthymic disorder and major depressive episodes as separate diagnoses instead of phases of a single disorder that fluctuates in severity over time.<ref name="pmid128584232">Klein DN, Santiago NJ (2003) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12858423 Dysthymia and chronic depression: introduction, classification, risk factors, and course.] ''J Clin Psychol'' 59 (8):807-16. [http://dx.doi.org/10.1002/jclp.10174 DOI:10.1002/jclp.10174] PMID: [https://pubmed.gov/12858423 12858423]</ref>
*In spite of minor differences in the definitions of dysthymic disorder in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition ([[DSM-IV]])  and International Classification of Diseases Tenth Edition (ICD-l0), both the systems are competent to establish the diagnosis.<ref name="Lopez IborFrances1994">{{cite journal|last1=Lopez Ibor|first1=J. J.|last2=Frances|first2=A.|last3=Jones|first3=C.|title=Dysthymic disorder: a comparison of DSM-IV and ICD-10 and issues in differential diagnosis|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=12–18|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05878.x}}</ref>
*In spite of minor differences in the definitions of dysthymic disorder in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition ([[DSM-IV]])  and International Classification of Diseases Tenth Edition (ICD-l0), both the systems are competent to establish the diagnosis.<ref name="Lopez IborFrances1994">{{cite journal|last1=Lopez Ibor|first1=J. J.|last2=Frances|first2=A.|last3=Jones|first3=C.|title=Dysthymic disorder: a comparison of DSM-IV and ICD-10 and issues in differential diagnosis|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=12–18|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05878.x}}</ref>
*Dysthymia and chronic major depression are both included under the new term 'Persistent depressive disorder' in [[DSM|DSM-5]].<ref name="pmid31082096">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=31082096 | doi= | pmc= | url= }}</ref>
*Dysthymia and chronic major depression are both included under the new term 'persistent depressive disorder' in [[DSM|DSM-5]].<ref name="pmid31082096">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=31082096 | doi= | pmc= | url= }}</ref>
*Since the introduction in [[DSM-III]], the diagnostic validity of dysthymia is questioned. It is a [[heterogeneous]] diagnosis including various [[depressive]] and [[anxiety]] conditions. As persistent depressive disorder includes dysthymia as a component, the former is more likely to represent a [[heterogeneous]] domain diagnosis. It limits the identification of the preferred treatment options. <ref name="pmid24270481">{{cite journal| author=Rhebergen D, Graham R| title=The re-labelling of dysthymic disorder to persistent depressive disorder in DSM-5: old wine in new bottles? | journal=Curr Opin Psychiatry | year= 2014 | volume= 27 | issue= 1 | pages= 27-31 | pmid=24270481 | doi=10.1097/YCO.0000000000000022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24270481  }}</ref><br />
*Since the introduction in [[DSM-III]], the diagnostic validity of dysthymia is questioned. It is a [[heterogeneous]] diagnosis including various [[depressive]] and [[anxiety]] conditions. As persistent depressive disorder includes dysthymia as a component, the former is more likely to represent a [[heterogeneous]] domain diagnosis. It limits the identification of the preferred treatment options. <ref name="pmid24270481">{{cite journal| author=Rhebergen D, Graham R| title=The re-labelling of dysthymic disorder to persistent depressive disorder in DSM-5: old wine in new bottles? | journal=Curr Opin Psychiatry | year= 2014 | volume= 27 | issue= 1 | pages= 27-31 | pmid=24270481 | doi=10.1097/YCO.0000000000000022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24270481  }}</ref><br />


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*As compared to the general population, the people with dysthymia have a greater-than-average chance of developing [[major depression]].
*As compared to the general population, the people with dysthymia have a greater-than-average chance of developing [[major depression]].
*While major depressive disorder mostly occurs in episodes, dysthymia lasts for longer periods, is consistent, and sometimes begins in [[childhood]].  Therefore, persons with dysthymia tend to consider depression as a part of their character.
*While major depressive disorder mostly occurs in episodes, dysthymia lasts for longer periods, is consistent, and sometimes begins in [[childhood]].  Therefore, persons with dysthymia tend to consider depression as a part of their character.
*Dysthymia and [[major depression]], both are [[Heritability|heritable]].
*Dysthymia and [[major depression]], both are [[Heritability|inheritable]].
*Some individuals describe dysthymia as being under [[chronic stress]].
*Some individuals describe dysthymia as being under [[chronic stress]].
*When treating the cases, it is often difficult to distinguish if these people are actually under unusually high environmental stress or if the dysthymia causes them to be more psychologically stressed in a standard environment.
*When treating cases, it is often difficult to distinguish if these people are actually under unusually high environmental stress or if the dysthymia causes them to be more psychologically stressed in a standard environment.


==Differential Diagnosis==
==Differential Diagnosis==
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*Based on the [[age of onset]], the [[etiology]] of dysthymia varies.
*Based on the [[age of onset]], the [[etiology]] of dysthymia varies.
*The individuals with early onset dysthymia often have a history of physical or sexual [[abuse]]. They have also been found to have poor relationships with both the parents.<ref name="LizardiKlein1995">{{cite journal|last1=Lizardi|first1=Humberto|last2=Klein|first2=Daniel N.|last3=Ouimette|first3=Paige Crosby|last4=Riso|first4=Lawrence P.|last5=Anderson|first5=Rochelle L.|last6=Donaldson|first6=Shauna K.|title=Reports of the childhood home environment in early-onset dysthymia and episodic major depression.|journal=Journal of Abnormal Psychology|volume=104|issue=1|year=1995|pages=132–139|issn=1939-1846|doi=10.1037/0021-843X.104.1.132}}</ref>
*The individuals with early onset dysthymia often have a history of physical or sexual [[abuse]]. They have also been found to have poor relationships with both the parents.<ref name="LizardiKlein1995">{{cite journal|last1=Lizardi|first1=Humberto|last2=Klein|first2=Daniel N.|last3=Ouimette|first3=Paige Crosby|last4=Riso|first4=Lawrence P.|last5=Anderson|first5=Rochelle L.|last6=Donaldson|first6=Shauna K.|title=Reports of the childhood home environment in early-onset dysthymia and episodic major depression.|journal=Journal of Abnormal Psychology|volume=104|issue=1|year=1995|pages=132–139|issn=1939-1846|doi=10.1037/0021-843X.104.1.132}}</ref>
*Compared to [[Adolescent|adolescents]], the [[children]] display lesser variability in the symptoms of dysthymia.
*Compared to [[Adolescent|adolescents]], [[children]] display lesser variability in the symptoms of dysthymia.
*'[[Anhedonia]]' is a common characteristic in [[Adolescent|adolescents]] with dysthymia. <ref name="MasiFavilla2001">{{cite journal|last1=Masi|first1=Gabriele|last2=Favilla|first2=Letizia|last3=Mucci|first3=Maria|last4=Poli|first4=Paola|last5=Romano|first5=Roberta|title=Depressive Symptoms in Children and Adolescents with Dysthymic Disorder|journal=Psychopathology|volume=34|issue=1|year=2001|pages=29–35|issn=0254-4962|doi=10.1159/000049277}}</ref>
*'[[Anhedonia]]' is a common characteristic in [[Adolescent|adolescents]] with dysthymia. <ref name="MasiFavilla2001">{{cite journal|last1=Masi|first1=Gabriele|last2=Favilla|first2=Letizia|last3=Mucci|first3=Maria|last4=Poli|first4=Paola|last5=Romano|first5=Roberta|title=Depressive Symptoms in Children and Adolescents with Dysthymic Disorder|journal=Psychopathology|volume=34|issue=1|year=2001|pages=29–35|issn=0254-4962|doi=10.1159/000049277}}</ref>
*In younger adults, dysthymia is related to the abnormalities of [[personality]] whereas, [[elderly]] have a strong association with losses in life and other health-related issues. <ref name="BellinoPatria2001">{{cite journal|last1=Bellino|first1=Silvio|last2=Patria|first2=Luca|last3=Ziero|first3=Simona|last4=Rocca|first4=Giuseppe|last5=Bogetto|first5=Filippo|title=Clinical features of dysthymia and age: a clinical investigation|journal=Psychiatry Research|volume=103|issue=2-3|year=2001|pages=219–228|issn=01651781|doi=10.1016/S0165-1781(01)00274-8}}</ref>
*In younger adults, dysthymia is related to the abnormalities of [[personality]] whereas, the [[elderly]] have a strong association with losses in life and other health-related issues. <ref name="BellinoPatria2001">{{cite journal|last1=Bellino|first1=Silvio|last2=Patria|first2=Luca|last3=Ziero|first3=Simona|last4=Rocca|first4=Giuseppe|last5=Bogetto|first5=Filippo|title=Clinical features of dysthymia and age: a clinical investigation|journal=Psychiatry Research|volume=103|issue=2-3|year=2001|pages=219–228|issn=01651781|doi=10.1016/S0165-1781(01)00274-8}}</ref>


===Gender===
===Gender===
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*Gender differences have been noted in the [[elderly]] population.
*Gender differences have been noted in the [[elderly]] population.
*In [[elderly]] [[men]], dysthymia is more related to lower educational levels and in those receiving [[nursing home]]/ institutional care. No relation has been found based on occupation or marital status.<ref name="KiveläPahkala1989">{{cite journal|last1=Kivelä|first1=Sirkka-Liisa|last2=Pahkala|first2=Kimmo|title=Dysthymic disorder in the aged in the community|journal=Social Psychiatry and Psychiatric Epidemiology|volume=24|issue=2|year=1989|pages=77–83|issn=0933-7954|doi=10.1007/BF01788630}}</ref>
*In [[elderly]] [[men]], dysthymia is more related to lower educational levels and in those receiving [[nursing home]]/ institutional care. No relation has been found based on occupation or marital status.<ref name="KiveläPahkala1989">{{cite journal|last1=Kivelä|first1=Sirkka-Liisa|last2=Pahkala|first2=Kimmo|title=Dysthymic disorder in the aged in the community|journal=Social Psychiatry and Psychiatric Epidemiology|volume=24|issue=2|year=1989|pages=77–83|issn=0933-7954|doi=10.1007/BF01788630}}</ref>
*As opposed to this, in [[elderly]] [[Female|females]] dysthymia is predominant in older individuals (70 years +), married, and in those with [[Education|higher education]] levels. It is not related to marital status, occupation, or form of health care received. <ref name="KiveläPahkala19892">{{cite journal|last1=Kivelä|first1=Sirkka-Liisa|last2=Pahkala|first2=Kimmo|title=Dysthymic disorder in the aged in the community|journal=Social Psychiatry and Psychiatric Epidemiology|volume=24|issue=2|year=1989|pages=77–83|issn=0933-7954|doi=10.1007/BF01788630}}</ref>
*As opposed to this, in [[elderly]] [[Female|females]], dysthymia is predominant in older individuals (70 years +), married, and in those with [[Education|higher education]] levels. It is not related to marital status, occupation, or form of health care received. <ref name="KiveläPahkala19892">{{cite journal|last1=Kivelä|first1=Sirkka-Liisa|last2=Pahkala|first2=Kimmo|title=Dysthymic disorder in the aged in the community|journal=Social Psychiatry and Psychiatric Epidemiology|volume=24|issue=2|year=1989|pages=77–83|issn=0933-7954|doi=10.1007/BF01788630}}</ref>


===Race===
===Race===


*Dysthymia has a higher [[lifetime prevalence]] in individuals of Mexican American and African American backgrounds. This can be explained by a number of factors dominating these populations <ref name="pmid15914823">{{cite journal| author=Riolo SA, Nguyen TA, Greden JF, King CA| title=Prevalence of depression by race/ethnicity: findings from the National Health and Nutrition Examination Survey III. | journal=Am J Public Health | year= 2005 | volume= 95 | issue= 6 | pages= 998-1000 | pmid=15914823 | doi=10.2105/AJPH.2004.047225 | pmc=1449298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi
*Dysthymia has a higher [[lifetime prevalence]] in individuals of Mexican American and African American backgrounds. This can be explained by a number of factors dominating these populations: <ref name="pmid15914823">{{cite journal| author=Riolo SA, Nguyen TA, Greden JF, King CA| title=Prevalence of depression by race/ethnicity: findings from the National Health and Nutrition Examination Survey III. | journal=Am J Public Health | year= 2005 | volume= 95 | issue= 6 | pages= 998-1000 | pmid=15914823 | doi=10.2105/AJPH.2004.047225 | pmc=1449298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi
dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15914823 }}</ref>
dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15914823 }}</ref>
**Lower [[education]] level
**Lower [[education]] level
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**Hesitancy in seeking help
**Hesitancy in seeking help
**Lesser utilization of mental health services
**Lesser utilization of mental health services
**Failure to comply with the [[treatment]]
**Failure to comply with [[treatment]]
**Various cultural beliefs
**Various cultural beliefs


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*Parental loss or separation
*Parental loss or separation
*Physical or sexual abuse
*Physical or sexual abuse
*<nowiki/><nowiki/><nowiki/>Lower education l<nowiki/>evels
*<nowiki/><nowiki/><nowiki/>Lower educational l<nowiki/>evels
*<nowiki/><nowiki/><nowiki/>Polysomnographic <nowiki/>abnormalities
*<nowiki/><nowiki/><nowiki/>Polysomnographic <nowiki/>abnormalities


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*Individuals with dysthymia have a higher risk of developing [[major depressive disorder]] in the future.
*Individuals with dysthymia have a higher risk of developing [[major depressive disorder]] in the future.
*Similar to adults, the children and adolescents with dysthymia are also more likely to develop [[depression]]. <ref name="Keller1994">{{cite journal|last1=Keller|first1=M. B.|title=Course, outcome and impact on the community|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=24–34|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05880.x}}</ref>
*Similar to adults, children and adolescents with dysthymia are also more likely to develop [[depression]]. <ref name="Keller1994">{{cite journal|last1=Keller|first1=M. B.|title=Course, outcome and impact on the community|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=24–34|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05880.x}}</ref>
*These children have a [[Scholastic performance|poor scholastic performance]] and deteriorating [[quality of life]].<ref name="Keller19943">{{cite journal|last1=Keller|first1=M. B.|title=Course, outcome and impact on the community|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=24–34|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05880.x}}</ref>
*These children have a [[Scholastic performance|poor scholastic performance]] and deteriorating [[quality of life]].<ref name="Keller19943">{{cite journal|last1=Keller|first1=M. B.|title=Course, outcome and impact on the community|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=24–34|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05880.x}}</ref>
*Dysthymia has an impact on personal relationships, financial state as well as physical and mental well-being.<ref name="Keller19942">{{cite journal|last1=Keller|first1=M. B.|title=Course, outcome and impact on the community|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=24–34|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05880.x}}</ref>
*Dysthymia has an impact on personal relationships, financial state as well as physical and mental well-being.<ref name="Keller19942">{{cite journal|last1=Keller|first1=M. B.|title=Course, outcome and impact on the community|journal=Acta Psychiatrica Scandinavica|volume=89|issue=s383|year=1994|pages=24–34|issn=0001-690X|doi=10.1111/j.1600-0447.1994.tb05880.x}}</ref>
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|-
|-
!''Specify if-''
!''Specify if-''
Early onset (before 21 years)
Early-onset (before 21 years)


Late onset (at or after 21 years)
Late-onset (at or after 21 years)
|-
|-
!''Specify if''-
!''Specify if''-
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With intermittent major depressive episodes, with current episode
With intermittent major depressive episodes, with current episode


With intermittent major depressive episodes, without a ent episode
With intermittent major depressive episodes, without an ent episode
|-
|-
!''Specify if-''
!''Specify if-''
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====Selective Serotonin Reuptake Inhibitors (SSRI)====
====Selective Serotonin Reuptake Inhibitors (SSRI)====


*The most commonly prescribed anti-depressants for dysthymia are the [[selective serotonin reuptake inhibitors]] (SSRI), which include [[fluoxetine]] (Prozac), [[sertraline]] (Zoloft), [[paroxetine]] (Paxil), and [[citalopram]] (Celexa).
*The most commonly prescribed [[Antidepressants|anti-depressants]] for dysthymia are the [[selective serotonin reuptake inhibitors]] ([[SSRI]]), which include [[fluoxetine]] ([[Prozac]]), [[sertraline]] ([[Zoloft]]), [[paroxetine]] ([[Paxil]]), and [[citalopram]] ([[Celexa]]).
*[[Selective serotonin reuptake inhibitor|SSRI]]<nowiki/>s have a very high affinity for [[Serotonin|Serotonin (5-HT) receptors]] whereas low affinity for [[noradrenaline]] uptake receptors. They act by inhibiting the [[reuptake]] of [[5-HT]] from the [[Synaptic cleft|synaptic cleft,]] increasing its [[concentration]] and contributing to the [[therapeutic effect]].<ref name="SangkuhlKlein2009">{{cite journal|last1=Sangkuhl|first1=Katrin|last2=Klein|first2=Teri E.|last3=Altman|first3=Russ B.|title=Selective serotonin reuptake inhibitors pathway|journal=Pharmacogenetics and Genomics|volume=19|issue=11|year=2009|pages=907–909|issn=1744-6872|doi=10.1097/FPC.0b013e32833132cb}}</ref>
*[[Selective serotonin reuptake inhibitor|SSRI]]<nowiki/>s have a very high affinity for [[Serotonin|Serotonin (5-HT) receptors]] whereas low affinity for [[noradrenaline]] uptake [[receptors]]. They act by inhibiting the [[reuptake]] of [[5-HT]] from the [[Synaptic cleft|synaptic cleft,]] increasing its [[concentration]] and contributing to the [[therapeutic effect]].<ref name="SangkuhlKlein2009">{{cite journal|last1=Sangkuhl|first1=Katrin|last2=Klein|first2=Teri E.|last3=Altman|first3=Russ B.|title=Selective serotonin reuptake inhibitors pathway|journal=Pharmacogenetics and Genomics|volume=19|issue=11|year=2009|pages=907–909|issn=1744-6872|doi=10.1097/FPC.0b013e32833132cb}}</ref>
*The different [[Selective serotonin reuptake inhibitor|SSRIs]] have variability in efficacy and side-effect profile, which requires thorough clinical consideration before prescribing them.<ref name="SangkuhlKlein20092">{{cite journal|last1=Sangkuhl|first1=Katrin|last2=Klein|first2=Teri E.|last3=Altman|first3=Russ B.|title=Selective serotonin reuptake inhibitors pathway|journal=Pharmacogenetics and Genomics|volume=19|issue=11|year=2009|pages=907–909|issn=1744-6872|doi=10.1097/FPC.0b013e32833132cb}}</ref>
*The different [[Selective serotonin reuptake inhibitor|SSRIs]] have variability in [[efficacy]] and side-effect profile, which requires thorough clinical consideration before prescribing them.<ref name="SangkuhlKlein20092">{{cite journal|last1=Sangkuhl|first1=Katrin|last2=Klein|first2=Teri E.|last3=Altman|first3=Russ B.|title=Selective serotonin reuptake inhibitors pathway|journal=Pharmacogenetics and Genomics|volume=19|issue=11|year=2009|pages=907–909|issn=1744-6872|doi=10.1097/FPC.0b013e32833132cb}}</ref>
*[[Selective serotonin reuptake inhibitor|SSRIs]] are easy to take and relatively safer compared with the other older forms of anti-depressants.<ref>National Institute of Mental Health</ref>
*[[Selective serotonin reuptake inhibitor|SSRIs]] are easy to take and relatively safer compared with the other older forms of anti-depressants.<ref>National Institute of Mental Health</ref>


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*[[Selective serotonin reuptake inhibitor|SSRI]] are associated with some [[side effects]] like [[sleep disturbances]], [[nausea]], [[vomiting]], [[sexual dysfunction]], [[weight gain]], cognitive disturbances and [[SSRI discontinuation syndrome]].<ref name="Ferguson2001">{{cite journal|last1=Ferguson|first1=James M.|title=SSRI Antidepressant Medications|journal=The Primary Care Companion to The Journal of Clinical Psychiatry|volume=03|issue=01|year=2001|pages=22–27|issn=1523-5998|doi=10.4088/PCC.v03n0105}}</ref>
*[[Selective serotonin reuptake inhibitor|SSRI]] are associated with some [[side effects]] like [[sleep disturbances]], [[nausea]], [[vomiting]], [[sexual dysfunction]], [[weight gain]], cognitive disturbances and [[SSRI discontinuation syndrome]].<ref name="Ferguson2001">{{cite journal|last1=Ferguson|first1=James M.|title=SSRI Antidepressant Medications|journal=The Primary Care Companion to The Journal of Clinical Psychiatry|volume=03|issue=01|year=2001|pages=22–27|issn=1523-5998|doi=10.4088/PCC.v03n0105}}</ref>
*The [[sleep disturbances]] are more prominent initially in the treatment course. These are in the form of earlier onset of [[Rapid eye movement|rapid eye movement (REM) sleep]], increased duration of [[REM sleep|REM]] sleep, and lesser slow-wave sleep.<ref name="Ferguson20012">{{cite journal|last1=Ferguson|first1=James M.|title=SSRI Antidepressant Medications|journal=The Primary Care Companion to The Journal of Clinical Psychiatry|volume=03|issue=01|year=2001|pages=22–27|issn=1523-5998|doi=10.4088/PCC.v03n0105}}</ref>
*The [[sleep disturbances]] are more prominent initially in the treatment course. These are in the form of earlier onset of [[Rapid eye movement|rapid eye movement (REM) sleep]], increased duration of [[REM sleep|REM]] sleep, and lesser slow-wave sleep.<ref name="Ferguson20012">{{cite journal|last1=Ferguson|first1=James M.|title=SSRI Antidepressant Medications|journal=The Primary Care Companion to The Journal of Clinical Psychiatry|volume=03|issue=01|year=2001|pages=22–27|issn=1523-5998|doi=10.4088/PCC.v03n0105}}</ref>
*The immediate [[adverse effects]] of [[SSRIs|SSRI]] is due to increased concentration of [[serotonin]] at particular [[Receptor (biochemistry)|receptor]] subtypes in various parts of the brain. The [[Post-synaptic|post-synaptic receptor desensitization]] in these regions leads to [[tolerance]] to these [[side effects]] after some time. <ref name="Stahl1998">{{cite journal|last1=Stahl|first1=Stephen M.|title=Mechanism of action of serotonin selective reuptake inhibitors|journal=Journal of Affective Disorders|volume=51|issue=3|year=1998|pages=215–235|issn=01650327|doi=10.1016/S0165-0327(98)00221-3}}</ref>
*The immediate [[adverse effects]] of [[SSRIs|SSRI]]s are due to increased concentration of [[serotonin]] at particular [[Receptor (biochemistry)|receptor]] subtypes in various parts of the [[brain]]. The [[Post-synaptic|post-synaptic receptor desensitization]] in these regions leads to [[tolerance]] to these [[side effects]] after some time. <ref name="Stahl1998">{{cite journal|last1=Stahl|first1=Stephen M.|title=Mechanism of action of serotonin selective reuptake inhibitors|journal=Journal of Affective Disorders|volume=51|issue=3|year=1998|pages=215–235|issn=01650327|doi=10.1016/S0165-0327(98)00221-3}}</ref>


====Other medications====
====Other medications====


*Some patients do not respond to [[SSRIs|SSRI]] or have to discontinue them due to inability to tolerate the [[Adverse effect (medicine)|adverse effects]].
*Some patients do not respond to [[SSRIs|SSRI]]s or have to discontinue them due to inability to tolerate the [[Adverse effect (medicine)|adverse effects]].
*Older antidepressants, such as a [[tricyclic antidepressant]] (TCA) or a Monoamine oxidase Inhibitor [[MAOI|(MAOI]]) can be prescribed in such cases.
*Older [[antidepressants]], such as a [[tricyclic antidepressant]] (TCA) or a [[monoamine oxidase inhibitor]] [[MAOI|(MAOI]]) can be prescribed in such cases.
*TCAs have [[anticholinergic]] side-effects like weight gain, [[dry mouth]], urinary retention, [[constipation]], and blurry vision.
*[[Tricyclic antidepressant|TCAs]] have [[anticholinergic]] side-effects like weight gain, [[dry mouth]], urinary retention, [[constipation]], and blurry vision.
*Some individuals on TCA also develop [[sexual dysfunction]], cardiac side-effects and [[orthostatic hypotension]].
*Some individuals on TCA also develop [[sexual dysfunction]], cardiac side-effects and [[orthostatic hypotension]].
*These medications should be avoided in elderly patients.
*These [[Medication|medications]] should be avoided in elderly patients.
*[[MAOI|MAOIs]] can predispose to [[Serotonin Syndrome]] if used with [[SSRIs]] as an [[adjuvant therapy]] or if insufficient time is given for washout of SSRI before switching to MAOI. <ref name="MalikJunglee2015">{{cite journal|last1=Malik|first1=A.|last2=Junglee|first2=N.|title=A Case of the Serotonin Syndrome Secondary to Phenelzine Monotherapy at Therapeutic Dosing|journal=Case Reports in Medicine|volume=2015|year=2015|pages=1–4|issn=1687-9627|doi=10.1155/2015/931963}}</ref>
*[[MAOI|MAOIs]] can predispose to [[serotonin syndrome]] if used with [[SSRIs]] as an [[adjuvant therapy]] or if insufficient time is given for washout of [[Selective serotonin reuptake inhibitor|SSRI]]s before switching to [[Monoamine oxidase inhibitor|MAOI]]s. <ref name="MalikJunglee2015">{{cite journal|last1=Malik|first1=A.|last2=Junglee|first2=N.|title=A Case of the Serotonin Syndrome Secondary to Phenelzine Monotherapy at Therapeutic Dosing|journal=Case Reports in Medicine|volume=2015|year=2015|pages=1–4|issn=1687-9627|doi=10.1155/2015/931963}}</ref>
*A considerable approach to deal with this problem is to give at least a [[Washout|washout period]] of 14 days while switching from SSRI to MAOI or vice-versa.<ref name="Keltner2009">{{cite journal|last1=Keltner|first1=Norm|title=Serotonin Syndrome: A Case of Fatal SSRI/MAOI Interaction|journal=Perspectives in Psychiatric Care|volume=30|issue=4|year=2009|pages=26–31|issn=00315990|doi=10.1111/j.1744-6163.1994.tb00446.x}}</ref>
*A considerable approach to deal with this problem is to give at least a [[Washout|washout period]] of 14 days while switching from [[Selective serotonin reuptake inhibitor|SSRI]]s to [[Monoamine oxidase inhibitor|MAOI]]s or vice-versa.<ref name="Keltner2009">{{cite journal|last1=Keltner|first1=Norm|title=Serotonin Syndrome: A Case of Fatal SSRI/MAOI Interaction|journal=Perspectives in Psychiatric Care|volume=30|issue=4|year=2009|pages=26–31|issn=00315990|doi=10.1111/j.1744-6163.1994.tb00446.x}}</ref>
*[[Fluoxetine Hcl|Fluoxetine]] has a longer [[half-life]] as compared to other SSRIs, therefore a longer washout period (a minimum of 5 weeks) is required to switch from [[Fluoxetine hydrochloride|Fluoxetine]] to another [[MAOI]].<ref name="pmid10598311">{{cite journal| author=Gury C, Cousin F| title=[Pharmacokinetics of SSRI antidepressants: half-life and clinical applicability]. | journal=Encephale | year= 1999 | volume= 25 | issue= 5 | pages= 470-6 | pmid=10598311 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10598311  }}</ref>
*[[Fluoxetine Hcl|Fluoxetine]] has a longer [[half-life]] as compared to other [[Selective serotonin reuptake inhibitor|SSRIs]], therefore a longer washout period (a minimum of 5 weeks) is required to switch from [[Fluoxetine hydrochloride|Fluoxetine]] to another [[MAOI]].<ref name="pmid10598311">{{cite journal| author=Gury C, Cousin F| title=[Pharmacokinetics of SSRI antidepressants: half-life and clinical applicability]. | journal=Encephale | year= 1999 | volume= 25 | issue= 5 | pages= 470-6 | pmid=10598311 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10598311  }}</ref>
*Other antidepressants that can be used for treating dysthymia are [[bupropion]] (Wellbutrin), [[venlafaxine]] (Effexor), [[mirtazapine]] (Remeron), and [[duloxetine]] (Cymbalta).
*Other [[antidepressants]] that can be used for treating dysthymia are [[bupropion]] ([[Wellbutrin]]), [[venlafaxine]] ([[Effexor]]), [[mirtazapine]] ([[Remeron]]), and [[duloxetine]] ([[Cymbalta]]).


===Psychotherapy===
===Psychotherapy===


*Evidence suggests the combination of [[pharmacotherapy]] and [[psychotherapy]] provides the greatest improvement in dysthymia. <ref name="BrowneSteiner2002">{{cite journal|last1=Browne|first1=Gina|last2=Steiner|first2=Meir|last3=Roberts|first3=Jacqueline|last4=Gafni|first4=Amiram|last5=Byrne|first5=Carolyn|last6=Dunn|first6=Edward|last7=Bell|first7=Barbara|last8=Mills|first8=Michael|last9=Chalklin|first9=Lori|last10=Wallik|first10=David|last11=Kraemer|first11=James|title=Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs|journal=Journal of Affective Disorders|volume=68|issue=2-3|year=2002|pages=317–330|issn=01650327|doi=10.1016/S0165-0327(01)00343-3}}</ref>
*Evidence suggests the combination of [[pharmacotherapy]] and [[psychotherapy]] provides the greatest improvement in dysthymia. <ref name="BrowneSteiner2002">{{cite journal|last1=Browne|first1=Gina|last2=Steiner|first2=Meir|last3=Roberts|first3=Jacqueline|last4=Gafni|first4=Amiram|last5=Byrne|first5=Carolyn|last6=Dunn|first6=Edward|last7=Bell|first7=Barbara|last8=Mills|first8=Michael|last9=Chalklin|first9=Lori|last10=Wallik|first10=David|last11=Kraemer|first11=James|title=Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs|journal=Journal of Affective Disorders|volume=68|issue=2-3|year=2002|pages=317–330|issn=01650327|doi=10.1016/S0165-0327(01)00343-3}}</ref>
*On the contrary, some studies point towards the inferiority of psychotherapy in treating dysthymia.<ref name="Cuijpersvan Straten2010">{{cite journal|last1=Cuijpers|first1=Pim|last2=van Straten|first2=Annemieke|last3=Schuurmans|first3=Josien|last4=van Oppen|first4=Patricia|last5=Hollon|first5=Steven D.|last6=Andersson|first6=Gerhard|title=Psychotherapy for chronic major depression and dysthymia: A meta-analysis|journal=Clinical Psychology Review|volume=30|issue=1|year=2010|pages=51–62|issn=02727358|doi=10.1016/j.cpr.2009.09.003}}</ref>
*On the contrary, some studies point towards the inferiority of [[psychotherapy]] in treating dysthymia.<ref name="Cuijpersvan Straten2010">{{cite journal|last1=Cuijpers|first1=Pim|last2=van Straten|first2=Annemieke|last3=Schuurmans|first3=Josien|last4=van Oppen|first4=Patricia|last5=Hollon|first5=Steven D.|last6=Andersson|first6=Gerhard|title=Psychotherapy for chronic major depression and dysthymia: A meta-analysis|journal=Clinical Psychology Review|volume=30|issue=1|year=2010|pages=51–62|issn=02727358|doi=10.1016/j.cpr.2009.09.003}}</ref>
*There are different types of psychotherapies. The type of therapy chosen depends upon a number of factors like the nature of any stressful events, the availability of family and other social support, and personal preference.
*There are different types of [[Psychotherapy|psychotherapies]]. The type of therapy chosen depends upon a number of factors like the nature of any stressful events, the availability of family and other social support, and personal preference.
*Psychotherapy focuses mainly on education about the disease model, correcting the underlying cognitive distortions, and building up support.
*[[Psychotherapy]] focuses mainly on education about the disease model, correcting the underlying [[cognitive]] distortions, and building up support.
*Cognitive-behavioral therapy is designed to examine and help correct the faulty, self-critical thought patterns and correct the cognitive distortions that persons with mood disorders commonly experience.<ref name="Cuijpersvan Straten20102">{{cite journal|last1=Cuijpers|first1=Pim|last2=van Straten|first2=Annemieke|last3=Schuurmans|first3=Josien|last4=van Oppen|first4=Patricia|last5=Hollon|first5=Steven D.|last6=Andersson|first6=Gerhard|title=Psychotherapy for chronic major depression and dysthymia: A meta-analysis|journal=Clinical Psychology Review|volume=30|issue=1|year=2010|pages=51–62|issn=02727358|doi=10.1016/j.cpr.2009.09.003}}</ref>
*[[Cognitive-behavioral therapy]] is designed to examine and help correct the faulty, self-critical thought patterns and correct the [[cognitive]] distortions that persons with mood disorders commonly experience.<ref name="Cuijpersvan Straten20102">{{cite journal|last1=Cuijpers|first1=Pim|last2=van Straten|first2=Annemieke|last3=Schuurmans|first3=Josien|last4=van Oppen|first4=Patricia|last5=Hollon|first5=Steven D.|last6=Andersson|first6=Gerhard|title=Psychotherapy for chronic major depression and dysthymia: A meta-analysis|journal=Clinical Psychology Review|volume=30|issue=1|year=2010|pages=51–62|issn=02727358|doi=10.1016/j.cpr.2009.09.003}}</ref>
*[[Psychodynamic psychotherapy|Psychodynamic]], insight-oriented, or [[interpersonal psychotherapy]] (IPT) can find out the origin of the symptoms, address them appropriately, and explore the conflicts in important relationships which are further deteriorating the illness.<ref name="SchrammZobel2011">{{cite journal|last1=Schramm|first1=Elisabeth|last2=Zobel|first2=Ingo|last3=Dykierek|first3=Petra|last4=Kech|first4=Sabine|last5=Brakemeier|first5=Eva-Lotta|last6=Külz|first6=Anne|last7=Berger|first7=Mathias|title=Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: A randomized pilot study|journal=Journal of Affective Disorders|volume=129|issue=1-3|year=2011|pages=109–116|issn=01650327|doi=10.1016/j.jad.2010.08.003}}</ref>
*[[Psychodynamic psychotherapy|Psychodynamic]], insight-oriented, or [[interpersonal psychotherapy]] (IPT) can find out the origin of the symptoms, address them appropriately, and explore the conflicts in important relationships which are further deteriorating the illness.<ref name="SchrammZobel2011">{{cite journal|last1=Schramm|first1=Elisabeth|last2=Zobel|first2=Ingo|last3=Dykierek|first3=Petra|last4=Kech|first4=Sabine|last5=Brakemeier|first5=Eva-Lotta|last6=Külz|first6=Anne|last7=Berger|first7=Mathias|title=Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: A randomized pilot study|journal=Journal of Affective Disorders|volume=129|issue=1-3|year=2011|pages=109–116|issn=01650327|doi=10.1016/j.jad.2010.08.003}}</ref>
*[[Interpersonal psychotherapy|IPT]] emphasizes on resolving the conflict in current relationships that are exacerbating the depressive symptoms.<ref>{{cite journal|title=Psychotherapy of dysthymia|journal=American Journal of Psychiatry|volume=151|issue=8|year=1994|pages=1114–1121|issn=0002-953X|doi=10.1176/ajp.151.8.1114}}</ref>
*[[Interpersonal psychotherapy|IPT]] emphasizes resolving the conflict in current relationships that are exacerbating the depressive symptoms.<ref>{{cite journal|title=Psychotherapy of dysthymia|journal=American Journal of Psychiatry|volume=151|issue=8|year=1994|pages=1114–1121|issn=0002-953X|doi=10.1176/ajp.151.8.1114}}</ref>
*Both [[Cognitive-behavioral therapy|CBT]] and [[Interpersonal psychotherapy|IPT]] are effective for adolescents. [[Psychoeducation]] and [[Psychosocial|psychosocial support]] provided to the parents of adolescents with dysthymia plays a very important role in the early and satisfactory response to these therapies.<ref name="NobileCataldo2003">{{cite journal|last1=Nobile|first1=Maria|last2=Cataldo|first2=Giulia M|last3=Marino|first3=Cecilia|last4=Molteni|first4=Massimo|title=Diagnosis and Treatment of Dysthymia in Children and Adolescents|journal=CNS Drugs|volume=17|issue=13|year=2003|pages=927–946|issn=1172-7047|doi=10.2165/00023210-200317130-00001}}</ref>
*Both [[Cognitive-behavioral therapy|CBT]] and [[Interpersonal psychotherapy|IPT]] are effective for adolescents. [[Psychoeducation]] and [[Psychosocial|psychosocial support]] provided to the parents of adolescents with dysthymia plays a very important role in the early and satisfactory response to these therapies.<ref name="NobileCataldo2003">{{cite journal|last1=Nobile|first1=Maria|last2=Cataldo|first2=Giulia M|last3=Marino|first3=Cecilia|last4=Molteni|first4=Massimo|title=Diagnosis and Treatment of Dysthymia in Children and Adolescents|journal=CNS Drugs|volume=17|issue=13|year=2003|pages=927–946|issn=1172-7047|doi=10.2165/00023210-200317130-00001}}</ref>
*An adapted version for [[Interpersonal psychotherapy|IPT]] is used for adolescents because they are in conflict with their parents as well as peers, limiting the outlet options for their emotional burden.<ref name="MufsonFairbanks1996">{{cite journal|last1=Mufson|first1=Laura|last2=Fairbanks|first2=Janet|title=Interpersonal Psychotherapy for Depressed Adolescents: A One-Year Naturalistic Follow-up Study|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=35|issue=9|year=1996|pages=1145–1155|issn=08908567|doi=10.1097/00004583-199609000-00012}}</ref>
*An adapted version for [[Interpersonal psychotherapy|IPT]] is used for adolescents because they are in conflict with their parents as well as peers, limiting the outlet options for their emotional burden.<ref name="MufsonFairbanks1996">{{cite journal|last1=Mufson|first1=Laura|last2=Fairbanks|first2=Janet|title=Interpersonal Psychotherapy for Depressed Adolescents: A One-Year Naturalistic Follow-up Study|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=35|issue=9|year=1996|pages=1145–1155|issn=08908567|doi=10.1097/00004583-199609000-00012}}</ref>
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Psychiatry]]
[[Category:Psychiatry]]
[[Category: Up-To-Date]]
[[Category: Up-To-Date]]

Latest revision as of 20:52, 19 February 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vatsala Sharma; M.B.B.S[2]

Synonyms and keywords: Dysthymic disorder; persistent depressive disorder; double depression

Overview

Dysthymia is a mood disorder that falls on the depression spectrum. It is characterized by the lack of enjoyment or pleasure, clinically referred to as anhedonia, that continues for an extended period. Dysthymia differs from major depression in that it is both longer-lasting and not as distressing. The symptoms of dysthymia are often underestimated by the patients and misdiagnosed by clinicians. Dysthymia can have a substantial impact on an individual's life by preventing effective functioning, disrupting sleep patterns, and interfering with activities of daily living (ADLs). It usually presents with mild symptoms on a day-to-day basis. Progressively, the disorder may take a more severe form, resulting in work impairment, social isolation, and high rates of suicide. Due to its chronicity and lesser severity, most of the patients suffering from dysthymia believe that it is a part of their character and do not seek treatment until it gets extremely disabling.

Historical Perspective

  • The historical origin of the term 'dysthymia' is Greek.
  • In 1844, dysthymia was used first in psychiatry by C.F. Flemming. [1]
  • In 1882, dysthymia was further described by Kahlbaum, and he differentiated it from the fluctuating mood of cyclothymia.[2]
  • In the Diagnostic and Statistical Manual of Mental Disorders (DSM), dysthymia as a clinical entity has undergone complex evolution from being considered a personality disorder to an affective disorder.


Classification

  • DSM-IV has classified chronic depression into dysthymic disorder and major depressive disorder, chronic type.
  • Based on the age of onset, DSM-IV has divided dysthymic disorders into early (before 21 years) and late-onset (after 21 years) subtypes. [5]
  • Early-onset dysthymic disorder is related to a higher familial burden of mood disorders and childhood adverse conditions. On the other hand, late-onset has an association with health issues and major losses.[5]
  • In DSM-IV, individuals having underlying dysthymic disorder who develop major depressive episodes are diagnosed as having both dysthymic disorder and major depressive disorder. So, DSM-IV has categorized dysthymic disorder and major depressive episodes as separate diagnoses instead of phases of a single disorder that fluctuates in severity over time.[6]
  • In spite of minor differences in the definitions of dysthymic disorder in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) and International Classification of Diseases Tenth Edition (ICD-l0), both the systems are competent to establish the diagnosis.[7]
  • Dysthymia and chronic major depression are both included under the new term 'persistent depressive disorder' in DSM-5.[8]
  • Since the introduction in DSM-III, the diagnostic validity of dysthymia is questioned. It is a heterogeneous diagnosis including various depressive and anxiety conditions. As persistent depressive disorder includes dysthymia as a component, the former is more likely to represent a heterogeneous domain diagnosis. It limits the identification of the preferred treatment options. [9]

Pathophysiology

Clinical Features

  • The main features of dysthymia are
  • Dysthymia as compared to major depression, tends to be less intense and persists for a longer duration.
  • Other than the variation in magnitude of severity, both these conditions exhibit similar symptomatology.
  • To diagnose major depressive disorder, the symptoms should be present for a minimum duration of 14 days (2 weeks) whereas, dysthymia symptoms should be present for at least 2 years.
  • The symptoms of dysthymia can grow into a full-blown episode of major depression. The intense episode often exists with the underlying feelings of low mood and this resulting condition is called "double depression"[15]
  • As compared to the general population, the people with dysthymia have a greater-than-average chance of developing major depression.
  • While major depressive disorder mostly occurs in episodes, dysthymia lasts for longer periods, is consistent, and sometimes begins in childhood. Therefore, persons with dysthymia tend to consider depression as a part of their character.
  • Dysthymia and major depression, both are inheritable.
  • Some individuals describe dysthymia as being under chronic stress.
  • When treating cases, it is often difficult to distinguish if these people are actually under unusually high environmental stress or if the dysthymia causes them to be more psychologically stressed in a standard environment.

Differential Diagnosis

The differential diagnosis of dysthymia includes the following: [16]

Epidemiology and Demographics

Prevalence

  • The 12-month prevalence of dysthymia is approximately 500 per 100,000 (0.5%) of the overall population.[17]

Age

  • Individuals of all age groups may develop dysthymia.
  • Based on the age of onset, the etiology of dysthymia varies.
  • The individuals with early onset dysthymia often have a history of physical or sexual abuse. They have also been found to have poor relationships with both the parents.[18]
  • Compared to adolescents, children display lesser variability in the symptoms of dysthymia.
  • 'Anhedonia' is a common characteristic in adolescents with dysthymia. [19]
  • In younger adults, dysthymia is related to the abnormalities of personality whereas, the elderly have a strong association with losses in life and other health-related issues. [20]

Gender

  • Dysthymia affects both men and women.
  • The prevalence of dysthymia is more in women compared to men.[21]
  • The symptomatic profile is similar in males and females of the adolescent population. While comparing the symptoms of dysthymia in both genders, no specific symptom predominance has been noticed. [22]
  • Gender differences have been noted in the elderly population.
  • In elderly men, dysthymia is more related to lower educational levels and in those receiving nursing home/ institutional care. No relation has been found based on occupation or marital status.[23]
  • As opposed to this, in elderly females, dysthymia is predominant in older individuals (70 years +), married, and in those with higher education levels. It is not related to marital status, occupation, or form of health care received. [24]

Race

  • Dysthymia has a higher lifetime prevalence in individuals of Mexican American and African American backgrounds. This can be explained by a number of factors dominating these populations: [25]
    • Lower education level
    • Poverty
    • Hesitancy in seeking help
    • Lesser utilization of mental health services
    • Failure to comply with treatment
    • Various cultural beliefs

Risk Factors

Common risk factors in the development of dysthymia are:[17][26]

Natural History, Complications, and Prognosis

Prognosis

Overall, dysthymia has a worse prognosis than major depressive disorder. [31]

Poor prognostic factors related to dysthymia are: [17][32]

Diagnostic Criteria

DSM-5 Diagnostic Criteria for Dysthymia

  • Persistent Depressive Disorder (Dysthymia) is diagnosed using DSM-5 Criteria.[17]
DSM-5 DIAGNOSTIC CRITERIA FOR DYSTHYMIA SPECIFIERS
The following criteria should be fulfilled-



A. For at least 2 years, depression for most of the day as observed by the individual himself/herself or others. Irritable mood lasting at least 1 year for adolescents and children.


B. With depressed mood, presence of two or more of-

1.Reduced appetite or overeating

2. Fatigue or less energy

3.Low self-esteem

4.Indecisiveness or low concentration

5.Hyper or insomnia

6.Hopelessness


C. The person has never been without the symptoms mentioned in Criteria A and B for greater than 2 months at a time.


D. Criteria for major depressive disorder may be present continuously for two years.


E. Criteria have never been met for Cyclothymia and there has never been a hypomanic or manic episode.


F. The condition can not be explained by schizophrenia, delusional disorder, schizoaffective disorder, or other schizophrenia spectrum disorder.


G. The symptomatology is not secondary to the effects of a substance or other medical condition.


H. Presence of clinically significant impairment in occupational, social, and other domains of functioning.

Specify if-

With anxious distress

With mixed features

With atypical features

With mood-incongruent psychotic features

With mood-congruent psychotic features

With melancholic features

With peripartum onset

Specify if-

In partial remission

In full remission

Specify if-

Early-onset (before 21 years)

Late-onset (at or after 21 years)

Specify if-

With pure dysthymic syndrome

With persistent major depressive episode

With intermittent major depressive episodes, with current episode

With intermittent major depressive episodes, without an ent episode

Specify if-

Mild

Moderate

Severe


Treatment

Medications

Selective Serotonin Reuptake Inhibitors (SSRI)

Side Effects of SSRI

Other medications

Psychotherapy

  • Evidence suggests the combination of pharmacotherapy and psychotherapy provides the greatest improvement in dysthymia. [42]
  • On the contrary, some studies point towards the inferiority of psychotherapy in treating dysthymia.[43]
  • There are different types of psychotherapies. The type of therapy chosen depends upon a number of factors like the nature of any stressful events, the availability of family and other social support, and personal preference.
  • Psychotherapy focuses mainly on education about the disease model, correcting the underlying cognitive distortions, and building up support.
  • Cognitive-behavioral therapy is designed to examine and help correct the faulty, self-critical thought patterns and correct the cognitive distortions that persons with mood disorders commonly experience.[44]
  • Psychodynamic, insight-oriented, or interpersonal psychotherapy (IPT) can find out the origin of the symptoms, address them appropriately, and explore the conflicts in important relationships which are further deteriorating the illness.[45]
  • IPT emphasizes resolving the conflict in current relationships that are exacerbating the depressive symptoms.[46]
  • Both CBT and IPT are effective for adolescents. Psychoeducation and psychosocial support provided to the parents of adolescents with dysthymia plays a very important role in the early and satisfactory response to these therapies.[47]
  • An adapted version for IPT is used for adolescents because they are in conflict with their parents as well as peers, limiting the outlet options for their emotional burden.[48]

References

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Mental and behavioral disorders