Dysthymia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Kiran Singh, M.D. [2]

Synonyms and keywords: Dysthymic depression; persistent depressive disorder; dysthymic mood; dysthymic period

Overview

Dysthymia is a mood disorder that falls on the depression spectrum. It is typically characterized by a 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 less disabling. Dysthymia can prevent a person from functioning effectively, disrupt sleep patterns, and interfere with activities of daily living (ADLs). Dysthymia sufferers exhibit fairly mild symptoms on a day-to-day basis. Over a lifetime the disorder may have more severe effects, such as a high rate of suicide, work impairment, and social isolation. The psychiatric term describing a personality with opposite characteristics to dysthymia is hyperthymia.

Historical Perspective

• The historical origin of the term 'dysthymia' is basically Greek. In 1844, it was used first in psychiatry by C.F. Flemming.
• In 1882, dysthymia was further described by Kahlbaum, and he differentiated it from the fluctuating mood of cyclothymia.
• In Diagnostic and Statistical Manual of Mental Disorders (DSM), dysthymia as a clinical entity has undergone a complex evolution from being considered a personality disorder to an affective disorder.
• Diagnostic and Statistical Manual of Mental Disorders (DSM-II) characterized chronic depression in the form of personality disorder.
• According to DSM-III, depression present for more than two years was defined as 'Dysthymic disorder'. Later, DSM-III-R classified it under the affective category.
• Dysthymia and chronic major depression are both included under the new term 'Persistent depressive disorder' in DSM-5.
• Since the introduction in DSM-III, the diagnostic validity of dysthymia has been 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, further adversely affecting the preferred treatment modality.

Classification

• DSM-IV has classified chronic depression into dysthymic disorder and major depressive disorder, chronic type.
• Based on age of onset (before or after 21 years), DSM-IV has divided dysthymic disorders into early and late-onset subtypes, respectively. Early- onset dysthymic disorder is related to 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.
• 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 diagnosis instead of phases of a single disorder that fluctuates in severity over time.
• Inspite 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.
  

Pathophysiology

• It is understood that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].

Differential Diagnosis

The differential diagnosis of dysthymia includes-

• Mood disorder secondary to General Medical Condition
• Major depressive disorder
• Recurrent depressive disorder
• Personality disorders
• Generalised Anxiety Disorder
• Mixed anxiety and depressive disorder
• Substance/medication-induced mood disorder
• Neurasthenia
• Adjustment disorder
• Psychotic disorders

Epidemiology and Demographics

Prevalence

The 12 month prevalence of dysthymia is 500 per 100,000 (0.5%) of the overall population.

Risk Factors

• Genetic predisposition

• First-degree relatives with persistent depressive disorder

• Parental loss or separation
• Polysomnographic abnormalities

Natural History,Complications, and Prognosis

Prognosis

Poor prognostic factors include:

• Anxiety disorders
• Conduct disorder
• Increased severity of the symptoms
• Higher levels of neuroticism
• Poorer global functioning

Symptoms

The symptoms of dysthymia are similar to those of major depression, though they tend to be less intense. In both conditions, a person can have a low or irritable mood, lack of interest in things most people find enjoyable, and a loss of energy (not all patients feel this effect). Appetite and weight can be increased or decreased. The person may sleep too much or have trouble sleeping. He or she may have difficulty concentrating. The person may be indecisive and pessimistic and have a negative self-image.

The symptoms can grow into a full-blown episode of major depression. This situation is sometimes called "double depression" because the intense episode exists with the usual feelings of low mood. People with dysthymia have a greater-than-average chance of developing major depression. While major depression often occurs in episodes, dysthymia is more constant, lasting for long periods, sometimes beginning in childhood. As a result, a person with dysthymia tends to believe that depression is a part of his or her character. The person with dysthymia may not even think to talk about this depression with doctors, family members or friends. Dysthymia, like major depression, tends to run in families. It is two to three times more common in women than in men. Some sufferers describe being under chronic stress. When treating diagnosed individuals, it is often difficult to tell whether they are under unusually high environmental stress or if the dysthymia causes them to be more psychologically stressed in a standard environment.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Dysthymia

“

This disorder represents a consolidation of DSM-lV-defined chronic major depressive disorder and dysthymic disorder. A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year. AND B. Presence, while depressed, of two (or more) of the following: 1. Poor appetite or overeating. 2. Insomnia or hypersomnia. 3. Low energy or fatigue. 4. Low self-esteem. 5. Poor concentration or difficulty making decisions. 6. Feelings of hopelessness. AND C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time. AND D. Criteria for a major depressive disorder may be continuously present for 2 years. E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder. AND F. The disturbance is not better explained by a persistent schizoaffective disorder,schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. AND G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism). AND H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted. Specify if: With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-in congruent psychotic features With peripartum onset Specify if: In partial remission In full remission Specify if: Early onset: If onset is before age 21 years. Late onset: If onset is at age 21 years or older. Specify if (for most recent 2 years of persistent depressive disorder): With pure dysthymic syndrome: Full criteria for a major depressive episode have not been met in at least the preceding 2 years. With persistent major depressive episode: Full criteria for a major depressive episode have been met throughout the preceding 2-year period. With intermittent major depressive episodes, with the current episode: Full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode. With intermittent major depressive episodes, without current episode: Full criteria for a major depressive episode are not currently met, but there have been one or more major depressive episodes in at least the preceding 2 years. Specify current severity: Mild Moderate Severe

”

Treatments

Medications

The most commonly prescribed anti-depressants for this disorder are the selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa). SSRIs are easy to take and relatively safe compared with older forms of anti-depressants. Other new anti-depressants include bupropion (Wellbutrin), venlafaxine (Effexor), mirtazapine (Remeron), and duloxetine (Cymbalta).

Sometimes two different anti-depressant medications are prescribed together, or a doctor may prescribe a mood stabilizer or anti-anxiety medication in combination with an anti-depressant.

Side Effects of Medications

Some side effects for SSRI’s are "sexual dysfunction, nausea…diarrhea, sleepiness or insomnia, short-term memory loss, and tremors." Sometimes antidepressants don’t work for patients. Older antidepressants, such as a tricyclic antidepressant or an MAOI can be tried in such cases. Tricyclic antidepressants are more effective but have worse side effects. Side effects for tricyclic antidepressants are "weight gain, dry mouth, blurry vision, sexual dysfunction, and low blood pressure".

Psychotherapy

Some evidence suggests the combination of medication and psychotherapy may result in the greatest improvement. The type of psychotherapy that will help depends on a number of factors, including the nature of any stressful events, the availability of family and other social support, and personal preference. Therapy should include education about depression. Support is essential. Cognitive-behavioral therapy is designed to examine and help correct faulty, self-critical thought patterns and correct the cognitive distortions that persons with mood disorders commonly experience. Psychodynamic, insight-oriented, or interpersonal psychotherapy can help a person sort out conflicts in important relationships or explore the history behind the symptoms.

References

Mental and behavioral disorders