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. Due to its chroncity and lesser severity, most of the patients suffering from dysthymia believe that it is a part of their character and do not seek treatment till it gets extremely disabling.dysthymia is

Historical Perspective

  • The historical origin of the term 'dysthymia' is basically Greek. In 1844, it 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 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.

Classification

  • Diagnostic and Statistical Manual of Mental Disorders (DSM-II) characterized chronic depression in the form of personality disorder.[3]
  • 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. [4]
  • 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.[5]
  • 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.[6]
  • Dysthymia and chronic major depression are both included under the new term 'Persistent depressive disorder' in DSM-5.[7]
  • 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.[8]
  • 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.[9]

Pathophysiology

  • Brain-derived neurotropic factors (BDNF) has been found to play a major role in the long- term potentiation, functioning of neurons and therefore, it can affect neuroplasticity. [10]
  • It has been found that BDNF is significantly lower in individuals with dysthymia, compared to control subjects. [11]
  • Interleukin-6 (IL-6) levels were observed to be higher in dysthymic patients than controls. Individuals with major depressive disorder also have higher levels of IL-6. [12]
  • Cytokines and their expressions have also been found to have a significant role in the pathophysiology of dysthymia. Macrophage inflammatory protein-1α and Interferon-γ-induced protein 10 have been found to have a correlation with the clinical response to treatment.[13]

Clinical Features

  • The symptoms of dysthymia are similar to those of major depression, though they tend to be less intense and persist for a longer duration. 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.
  • 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"[14] because the intense episode exists with the underlying 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. 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.

Differential Diagnosis

The differential diagnosis of dysthymia includes the following: [15]

Epidemiology and Demographics

Prevalence

  • The 12 month prevalence of dysthymia is 500 per 100,000 (0.5%) of the overall population.[16]

Age

  • Based on the age of onset, the etiology of dysthymia varies.
  • The individuals with early-onset dysthymia have a history of physical or sexual abuse. They have also been found to have poor relationship with both the parents.[17]
  • Compared to adolescents, the children display lesser symptoms of dysthymia. 'Anhedonia' has been observed to be more common in adolescents. [18]
  • In younger adults, dysthymia is related to the abnormalities of personality whereas in the elderly, there is a strong association with losses in life and other health related issues. [19]

Gender

  • The prevalence of dysthymia is more in women compared to men.[20]
  • The symptomatic profile is similar between males and females in adolescent population. While comparing the symptoms of dysthymia in both genders, no specific symptom predominance has been observed. [21]
  • Gender differences have been noted for the development of dysthymia in the elderly population.
  • In elderly men, dysthymia was more related to lower educational level and in those receiving nursing home/ institutional care. No relation was found based on occupation or marital status.[22]
  • As opposed to this, in elderly females dysthymia was predominant in older individuals (70 years +), married and in those with higher education level. It was not found to be related to marital status, occupation or form of health care received. [23]

Race

  • Dysthymia has higher lifetime prevalence in individuals of Mexican American and African American background. This can be explained by lower education level, poverty, hesitancy in seeking help, lesser utilization of mental health services and non-compliance to the treatment. The cultural beliefs may have played an important role in this observation. [24]

Risk Factors

Common risk factors in the development of Dysthymia are the following:

  • Parental loss or separation
  • Physical or sexual abuse
  • Lower education level
  • Polysomnographic abnormalities[16]

Natural History,Complications, and Prognosis

Prognosis

Poor prognostic factors include: [16][25]

Diagnostic Criteria

DSM-5 Diagnostic Criteria for Dysthymia

  • Dysthymia can be diagnosed using DSM-5 Diagnostic Criteria.[16]


“

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

AND

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.[26] Other anti-depressants that can be used are bupropion (Wellbutrin), venlafaxine (Effexor), mirtazapine (Remeron), and duloxetine (Cymbalta).

Side Effects of Medications

Some side effects for SSRIs are "sexual dysfunction, nausea, diarrhea, sleepiness or insomnia, short-term memory loss, and tremors." Sometimes SSRIs don’t work for patients. Older antidepressants, such as a tricyclic antidepressant (TCAs) or an MAOI can be tried in such cases. TCAs have anticholinergic side-effects like "weight gain, dry mouth, urinary retention, constipation, blurry vision, sexual dysfunction, and low blood pressure". These medications should be avoided in elderly patients.

Psychotherapy

Some evidence suggests the combination of medication and psychotherapy may result in the greatest improvement. 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 on the education about the disease model. 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 (IPT)can help a person sort out conflicts in important relationships or explore the history behind the symptoms. IPT emphasizes on resolving the conflict in current relationships that are exacerbating the depressive symptoms. Both CBT and IPT are effective for adolescents. An adapted version for IPT is used because these individuals are in conflict with their parents as well as peers, limiting the outlet options for their emotional burden.

References

  1. ↑ Brieger, Peter; Marneros, Andreas (1997). "Dysthymia and cyclothymia: historical origins and contemporary development". Journal of Affective Disorders. 45 (3): 117–126. doi:10.1016/S0165-0327(97)00053-0. ISSN 0165-0327.
  2. ↑ Freeman HL (1994). "Historical and nosological aspects of dysthymia". Acta Psychiatr Scand Suppl. 383: 7–11. doi:10.1111/j.1600-0447.1994.tb05877.x. PMID 7942068.
  3. ↑ Freeman, H. L. (1994). "Historical and nosological aspects of dysthymia". Acta Psychiatrica Scandinavica. 89 (s383): 7–11. doi:10.1111/j.1600-0447.1994.tb05877.x. ISSN 0001-690X.
  4. ↑ Freeman, H. L. (1994). "Historical and nosological aspects of dysthymia". Acta Psychiatrica Scandinavica. 89 (s383): 7–11. doi:10.1111/j.1600-0447.1994.tb05877.x. ISSN 0001-690X.
  5. ↑ Klein DN, Santiago NJ (2003) Dysthymia and chronic depression: introduction, classification, risk factors, and course. J Clin Psychol 59 (8):807-16. DOI:10.1002/jclp.10174 PMID: 12858423
  6. ↑ Klein DN, Santiago NJ (2003) Dysthymia and chronic depression: introduction, classification, risk factors, and course. J Clin Psychol 59 (8):807-16. DOI:10.1002/jclp.10174 PMID: 12858423
  7. ↑ "StatPearls". 2020. PMID 31082096.
  8. ↑ Rhebergen D, Graham R (2014). "The re-labelling of dysthymic disorder to persistent depressive disorder in DSM-5: old wine in new bottles?". Curr Opin Psychiatry. 27 (1): 27–31. doi:10.1097/YCO.0000000000000022. PMID 24270481.
  9. ↑ Lopez Ibor, J. J.; Frances, A.; Jones, C. (1994). "Dysthymic disorder: a comparison of DSM-IV and ICD-10 and issues in differential diagnosis". Acta Psychiatrica Scandinavica. 89 (s383): 12–18. doi:10.1111/j.1600-0447.1994.tb05878.x. ISSN 0001-690X.
  10. ↑ Cao G, Harris KM (2012) Developmental regulation of the late phase of long-term potentiation (L-LTP) and metaplasticity in hippocampal area CA1 of the rat. J Neurophysiol 107 (3):902-12. DOI:10.1152/jn.00780.2011 PMID: 22114158
  11. ↑ Yoshimura R, Umene-Nakano W, Hoshuyama T, Ikenouchi-Sugita A, Hori H, Katsuki A; et al. (2010). "Plasma levels of brain-derived neurotrophic factor and interleukin-6 in patients with dysthymic disorder: comparison with age- and sex-matched major depressed patients and healthy controls". Hum Psychopharmacol. 25 (7–8): 566–9. doi:10.1002/hup.1155. PMID 21312291.
  12. ↑ Yoshimura R, Umene-Nakano W, Hoshuyama T, Ikenouchi-Sugita A, Hori H, Katsuki A; et al. (2010). "Plasma levels of brain-derived neurotrophic factor and interleukin-6 in patients with dysthymic disorder: comparison with age- and sex-matched major depressed patients and healthy controls". Hum Psychopharmacol. 25 (7–8): 566–9. doi:10.1002/hup.1155. PMID 21312291.
  13. ↑ Lopez Ibor, J. J.; Frances, A.; Jones, C. (1994). "Dysthymic disorder: a comparison of DSM-IV and ICD-10 and issues in differential diagnosis". Acta Psychiatrica Scandinavica. 89 (s383): 12–18. doi:10.1111/j.1600-0447.1994.tb05878.x. ISSN 0001-690X.
  14. ↑ Double Depression: Hopelessness Key Component Of Mood Disorder retrieved July 17 2008
  15. ↑ Lopez Ibor, J. J.; Frances, A.; Jones, C. (1994). "Dysthymic disorder: a comparison of DSM-IV and ICD-10 and issues in differential diagnosis". Acta Psychiatrica Scandinavica. 89 (s383): 12–18. doi:10.1111/j.1600-0447.1994.tb05878.x. ISSN 0001-690X.
  16. ↑ 16.0 16.1 16.2 16.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  17. ↑ Lizardi, Humberto; Klein, Daniel N.; Ouimette, Paige Crosby; Riso, Lawrence P.; Anderson, Rochelle L.; Donaldson, Shauna K. (1995). "Reports of the childhood home environment in early-onset dysthymia and episodic major depression". Journal of Abnormal Psychology. 104 (1): 132–139. doi:10.1037/0021-843X.104.1.132. ISSN 1939-1846.
  18. ↑ Masi, Gabriele; Favilla, Letizia; Mucci, Maria; Poli, Paola; Romano, Roberta (2001). "Depressive Symptoms in Children and Adolescents with Dysthymic Disorder". Psychopathology. 34 (1): 29–35. doi:10.1159/000049277. ISSN 0254-4962.
  19. ↑ Bellino, Silvio; Patria, Luca; Ziero, Simona; Rocca, Giuseppe; Bogetto, Filippo (2001). "Clinical features of dysthymia and age: a clinical investigation". Psychiatry Research. 103 (2–3): 219–228. doi:10.1016/S0165-1781(01)00274-8. ISSN 0165-1781.
  20. ↑ Beekman, A.T.F.; Deeg, D.J.H.; Smit, J.H.; Comijs, H.C.; Braam, A.W.; de Beurs, E.; van Tilburg, W. (2004). "Dysthymia in later life: a study in the community". Journal of Affective Disorders. 81 (3): 191–199. doi:10.1016/S0165-0327(03)00138-1. ISSN 0165-0327.
  21. ↑ Masi, Gabriele; Favilla, Letizia; Mucci, Maria; Poli, Paola; Romano, Roberta (2001). "Depressive Symptoms in Children and Adolescents with Dysthymic Disorder". Psychopathology. 34 (1): 29–35. doi:10.1159/000049277. ISSN 0254-4962.
  22. ↑ Kivelä, Sirkka-Liisa; Pahkala, Kimmo (1989). "Dysthymic disorder in the aged in the community". Social Psychiatry and Psychiatric Epidemiology. 24 (2): 77–83. doi:10.1007/BF01788630. ISSN 0933-7954.
  23. ↑ Kivelä, Sirkka-Liisa; Pahkala, Kimmo (1989). "Dysthymic disorder in the aged in the community". Social Psychiatry and Psychiatric Epidemiology. 24 (2): 77–83. doi:10.1007/BF01788630. ISSN 0933-7954.
  24. ↑ Riolo SA, Nguyen TA, Greden JF, King CA (2005). "Prevalence of depression by race/ethnicity: findings from the National Health and Nutrition Examination Survey III". Am J Public Health. 95 (6): 998–1000. doi:10.2105/AJPH.2004.047225. PMC 1449298. PMID 15914823.
  25. ↑ Beekman, A.T.F.; Deeg, D.J.H.; Smit, J.H.; Comijs, H.C.; Braam, A.W.; de Beurs, E.; van Tilburg, W. (2004). "Dysthymia in later life: a study in the community". Journal of Affective Disorders. 81 (3): 191–199. doi:10.1016/S0165-0327(03)00138-1. ISSN 0165-0327.
  26. ↑ National Institute of Mental Health

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