Dysthymic Disorder1 300.4 DSM-IV
Dysthymia was first defined in DSM-III, the third edition of the Diagnostic and Statistical Manual of Mental Disorders, to refer to chronic depressions of mild-moderate severity (DSM-III, APA, 1980). The term literally means 'ill-humored’ or ‘despondent’ (American Heritage Dictionary, Fourth Edition, 2000). Although the term is new, Dysthymia is based on several older clinical concepts, such as neurotic depression, depressive personality, and chronic depression (Kocsis & Klein, 1995; DSM-IV, 1994). According to DSM-IV (1994) criteria, the core features of the disorder include at least two years of depressed mood for more days than not, including at least two additional symptoms related to poor appetite or overeating, insomnia or oversleeping, fatigue or low energy, low self-esteem, poor concentration or problems in decision making, and hopelessness (DSM-IV, 1994). Dysthymic individuals tend to be self-deprecating and socially withdrawn. They may feel irritable and unproductive and spend time brooding about the past. Dysthymia is also characterized by anhedonia, the inability to derive pleasure from events or stimuli previously found pleasurable (Griffiths and Ravindran, 2000). It describes a more chronic condition than Major Depression. It is one that is long term and pervasive. It is more common among females than among males and can begin at any age, though onsets in childhood and adolescence are more common (Kocsis & Klein, 1995).
Dysthymia usually appears in childhood or adolescence, and affects about three percent of the U.S. population. Sufferers are functional but impaired, particularly in social and interpersonal relationships. Antidepressant medications are often quite helpful in treating Dysthymia (Kocsis & Klein, 1995).Dysthymia is a type of depression that is relatively mild but it is chronic in nature. It describes people who go through life with a mild level of dysphoria, or a state of just not feeling well. These sufferers are also likely to have superimposed episodes of major depression. If the Dysthymia precedes the onset of the first episode of major depression, the process is referred to as 'double depression'. If it develops after the onset of the first major episode, it may be referred to as 'partial remission'. In either case, it appears to be treatable with drugs or psychotherapy, although the change is usually not as dramatic or as rapid as it is after episodes of Major Depression alone (Kocsis & Klein, 1995).
It is now generally accepted that Dysthymia belongs to the classification of mood/affective disorders, rather than representing a depressive temperament. Yet a condition known as double depression also exists, in which Dysthymia may be superimposed on a Major Depressive episode. Dysthymia can be further broken down based on age at onset and non-behavioral symptoms, such as increased or decreased appetite, weight gain or loss, or sleep disruptions. In addition, Dysthymia has been subclassified, according to clinical symptoms and presence of family history, as subaffective Dysthymia and character-spectrum Dysthymia (Griffiths and Ravindran, 2000). Subaffective Dysthymics tend to respond to antidepressant medication and often have a family history of mood disorder, whereas character-spectrum Dysthymics respond less well to medications and more often report a major loss as well as family history of substance abuse (Griffiths and Ravindran, 2000).
Knowledge of the causes and origins of Dysthymia remains incomplete. Though it appears to run in families, it is unclear whether this linkage is due to genetic or environmental factors, or a combination of both. Dysthymia seems to be closely related to Major Depression, which is a more severe and episodic form of depression. Most people who have Dysthymia experience exacerbations that meet the criteria for Major Depression at some point in their lives, and there is a high rate of occurrence of Major Depression in the families of people with Dysthymia (Kocsis & Klein, 1995).
In terms of treatment, there is evidence that Dysthymia responds to all the major classes of antidepressant medications, although it may take a longer time to get a positive response than does major depression. There is evidence that Dysthymia responds to some of the focused, short-term psychotherapies that have been developed for major depression, such as cognitive therapy and interpersonal therapy (Kocsis and Klein, 1995).
Though affecting only about three percent of the population, most of these are women, which make up nearly three fourths of the sufferers. (Griffiths and Ravindran, 2000). It has been described as a mind-wearing water torture as opposed to dramatic crash that is more associated with an incident of major depression (McManamy, 1999). The chronic nature of this disorder is grinding, robbing the sufferer of the will to succeed in life, to interact with others, and to enjoy the things that others take for granted. The gloom that is generated warns away those who might serve as a social support system (McManamy, 1999).
The symptoms are similar to major depression, with feelings of despair and hopelessness, and low self-esteem. It is often accompanied by chronic fatigue and often the two overlap. An estimated three to twelve percent of those with Dysthymia opt for suicide as a solution, while a good number turn to alcohol or drugs to mask its effects. Eventually for most, a bout with Major Depression occurs resulting in state of double depression (McManamy, 1999).
The same drugs that are used to treat Major Depression are equally as effective for mild to moderate depression. In addition, the herbal remedy St John's Wort has been found especially useful in treating mild to moderate depression, without many of the side effects found in other medications. (Griffiths and Ravindran, 2000).
Dysthymics also respond well to two types of psychotherapy. Interpersonal therapy, which aims to boost one's battered self-esteem, seems to be beneficial as does cognitive therapy, which addresses erroneous thought patterns. Both therapies usually last from ten to twenty sessions (McManamy, 1999).
Early classifications of Dysthymia described it as a character disorder, in which the individual's main problems stemmed from a depressive personality or temperament. For this reason, and because there were few systematic studies on the efficacy of antidepressants in the treatment of Dysthymia, the treatment of choice was psychotherapeutic in approach. The initial negative attitude toward the use of drugs in treatment was partly the result of the types of medication that were available. The tricyclic antidepressants were characterized by unpleasant side effects, and the clinicians were hesitant to prescribe these medications in adequate doses and duration. Because Dysthymia was considered as a mild form of Mood Disorder, it was usually treated with sub-threshold doses of antidepressants and for inadequate durations.
In the past ten years, there has been evidence of Dysthymia's positive response to antidepressant medication, especially to the newer generation of drugs such as Prozac, Zoloft, Paxil, Effexor and Serzone (Griffiths and Ravindran, 2000). This evidence has shown that although the symptoms may be less severe than those of Major Depression, Dysthymia requires just as aggressive, often longer-term antidepressant treatment (Griffiths and Ravindran, 2000).
The success in treating Dysthymia with antidepressant medication supports the contention that, like Major Depression, Dysthymia may have biological underpinnings. Research has been under way into the immunologic, hormonal and neurotransmitter correlates of Dysthymia, as well as its genetic transmission (Griffiths and Ravindran, 2000).
Although Dysthymia is not a new disorder, the possibility exists that its diagnosis is becoming more talked about because of the success of the newer generation of antidepressants in treating its symptoms. When the treatment of choice is more often the prescribing of medication, the disorder enters the realm of the medical world, lessening the potential stigma that may be associated with a mental disorder once thought to be a personality disturbance (Griffiths and Ravindran, 2000).
Dysthymic disorder is a chronic condition with a protracted course and a high risk of relapse. In addition, almost all patients with Dysthymic disorder eventually develop superimposed Major Depressive episodes. Although patients with Dysthymic disorder tend to show mild to moderate symptoms, from a longitudinal perspective the condition is severe and equally debilitating. Dysthymic disorder is a low-grade, chronic, depressive condition that is defined and distinguished from Major Depressive disorder primarily on the basis of course and pervasiveness in the life of the sufferer (Keller et al., 1995). Dysthymic disorder is common, affecting not only 3%-6% of individuals in the community (Kessler et al., 1994; Weissman et al., 1988), but 22%-36% of outpatients in mental health settings (Klein, Dickstein, et al., 1989; Markowitz et al., 1992). However, given its high prevalence and the central role of chronicity in its definition, there are surprisingly few data on the naturalistic course of Dysthymic disorder. Of the few existing prospective longitudinal studies of Dysthymic disorder, most have used small study groups and short, two years or less, follow-up periods (Barrett, 1984; Gonzales et al., 1985; Keller et al, 1983; Klein et al., 1998; Kovacs et al., 1994; McCullough, Kasnetz, et al., 1988; McCullough, Mccune et al., 1994). These studies have indicated that approximately 40% of the individuals with Dysthymic disorder recover within 24-30 months of study entry (Barrett, 1984; Keller et al, 1983; Klein et al., 1998). By 1999, whether or not the rate of recovery increased substantially with longer follow-ups, was not known. In addition, few data are available on the probability of relapse or recurrence among patients who have recovered from Dysthymic disorder (Ravindran et al., 1999).
In the same study, compared to patients with episodic Major Depressive disorder, patients with Dysthymic disorder were less severely depressed at initial examination, but exhibit higher levels of symptoms in follow-ups conducted 6-30 months later (Klein, Norden et al., 1998; Klein, Taylor et al., 1988; Wells et al., 1992). A small proportion of adults and children with Dysthymic disorder developed Bipolar Disorder during the course of follow-up, although the risk may not differ from that of individuals with Major Depressive disorder (Kovacs et al., 1994; Fava et al., 1996). Individuals with Dysthymic disorder are at high risk of developing superimposed Major Depressive episodes (Kovacs et al., 1994; Scott and Stradling, 1990). Although there is a high probability of recovering from a superimposed Major Depressive episode, there is a substantial risk of relapsing into another episode (Gonzales, 1985; Keller et al., 1983; Klein, Norden, et al., 1998; Kovacs et al., 1994; Wells et al., 1992). Comparisons of the rates of recovery from, and relapse into, Major Depressive episodes between patients with Dysthymic disorder and patients with episodic Major Depressive disorder have been inconsistent (Gonzales, 1985; Keller et al., 1983; Klein, Norden, et al., 1998; Kovacs et al., 1994; Wells et al., 1992).
A long term study completed by Klein, Schwartz, Rose, and Leader in 2000, described a five year course and outcome of Dysthymic disorder. The authors did a study of 86 outpatients with early-onset Dysthymic disorder and 39 outpatients with episodic Major Depressive disorder. The long term follow-ups, conducted 30 and 60 months after entry into the study, rated patients on the Longitudinal Interval Follow-Up Evaluation and the Modified Hamilton Rating Scale for Depression (Klein, et al. 2000). The estimated five year recovery rate from Dysthymic disorder was 52.9%. Among patients who recovered, the estimated risk of relapse was 45.2% during a mean of 23 months of observation. Patients with Dysthymic disorder spent approximately 70% of the follow-up period meeting the full criteria for a Mood Disorder. During the course of the follow-up, the patients with Dysthymic disorder exhibited significantly greater levels of symptoms and lower functioning and were significantly more likely to attempt suicide and to be hospitalized than were patients with episodic Major Depressive disorder. Finally, among patients with Dysthymic disorder who had never experienced a Major Depressive episode before entry into the study, the estimated risk of having a first lifetime Major Depressive episode was 76.9% (Klein, et al. 2000).
Differential Diagnosis Issues
In terms of psychological diagnosis, differentiation should be made between the following conditions and Dysthymia as some of the symptoms may overlap. Manic, Mixed, or Hypomanic Episode; Mood Disorder Due to a General Medical Condition; Substance-Induced Mood Disorder; Schizoaffective Disorder; Schizophrenia; Delusional Disorder; Psychotic Disorder Not Otherwise Specified; dementia; Major Depressive Disorder; chronic Psychotic Disorders; coexisting personality disturbance (DSM-IV, 1994).
The principal difficulty in diagnosis of the disorder is related to its shared symptoms with Major Depressive Disorder. In obtaining a history of whether or not there have been one or more discrete Major Depressive Episodes that can be distinguished from the person’s usual functioning, is often quite difficult. Differentiation between chronic symptoms and an occasional severe episode is often impossible to ascertain from a patient provided history. Also, similar symptoms are associated with chronic psychotic disorders such as schizoaffective disorders, schizophrenia, and delusional disorders (DSM-IV, 1994).
Differentiation between symptoms brought on by an underlying medical condition and Dysthymia is also difficult at times. These are mood disorders due to a general medical condition. A variety of organic mood syndromes can be caused by Acquired Immune Deficiency Syndrome (AIDS), Adrenal (Cushing's or Addison's Diseases), Cancer (especially pancreatic and other GI), Cardiopulmonary disease, Dementias (including Alzheimer's Disease); Epilepsy, Fahr's Syndrome, Huntington's Disease, Hydrocephalus, Hyperaldosteronism, Diabetes Mellitus, Infections (including HIV and neurosyphilis), Migraines, Mononucleosis, Multiple Sclerosis, Narcolepsy, Neoplasms, Parathyroid Disorders (hyper- and hypo-), Parkinson's Disease, Pneumonia (viral and bacterial), Porphyria, Postpartum, Premenstrual Syndrome, Progressive Supranuclear Palsy, Rheumatoid Arthritis, Sjogren's Arteritis, Sleep Apnea, Stroke, Systemic Lupus Erythematosus, Temporal Arteritis, Trauma, Thyroid Disorders (hypothyroid and "apathetic" hyperthyroidism), Tuberculosis, Uremia (and other renal diseases), Vitamin Deficiencies (B12, C, folate, niacin, thiamine), Substance-Induced Mood Disorder, and Wilson's Disease. (Long, 2000) If the symptoms are a psychological reaction to having the medical disorder, then Dysthymia would be the correct diagnosis. If the symptoms are related directly to the medical condition, then Dysthymia would not be diagnosed (DSM-IV, 1994).
It is also possible that Dysthymia may be present with a personality disturbance. Both diagnoses would be used in this case, Dysthymia and coexisting personality disturbance (DSM-IV, 1994).
The Center for Epidemiologic Studies-Depression Scale (CES-D) (Radloff, 1977) is a widely used, psychometrically derived, self-report instrument, consisting of 20 items. It was designed to assess depressive symptomatology in community samples and has been found to have high reliability with samples of diverse ages and ethnic backgrounds (Beals et al., 1995; Garrison et al., 1991; Radloff, 1977; Radloff and Teri, 1986). Several studies have found higher CES-D scores among ethnic minority groups (Kuo, 1984; Manson et al., 1990; Swanson et al., 1992; Ying, 1988). However, it is unclear whether these differences reflect actual differences among groups in depressive symptomatology or whether the CES-D may be a less valid measure of depression for non-Caucasian groups. Noh et al. (1992) found that higher CES-D total scores among Koreans were attributable to increased scores on items from the Positive Affect factor. In contrast, Somervell et al. (1993), found the CES-D had high sensitivity (78%) and specificity (85%) for predicting major depression among a Native American sample.
Most studies of the CES-D have found significant gender differences, with females having higher scores than males and more likely to exceed cutoff scores for identifying clinical depression (Berganza and Agular, 1992; Radloff and Rae, 1981; Brown et al., 1992; Gjerde et al., 1988). These differences are similar to gender differences in the prevalence rates of depressive disorders in national epidemiological studies (e.g., Kessler et al., 1994). (Prescott et al., 1998)
Several previous studies have examined the predictive validity of the CES-D for identifying depression among adolescents. Roberts and colleagues (1991) studied the utility of the CES-D in screening for major depression and Dysthymia in 1,700 clinically interviewed high school students from Oregon. Using a cross-classification table, they reported that current CES-D had a sensitivity of 85% and specificity of 76% but positive predictive value (PPV) of only 10% for predicting a combined classification of major depression and Dysthymia which is in keeping with the known difficulties in making a differential diagnosis between the two disorders. Garrison and colleagues (1991) used the CES-D in a two-stage screening study of young adolescents. They reported high sensitivity and specificity, and PPVs of up to 30% for predicting major depression and Dysthymia.
Though not as dramatic an illness as Major Depression, Dysthymia is just as destructive in that it robs the sufferer of a life of joy, replacing it with despondency and ill temperedness. Fortunately, a combination of psychotherapy and drugs appear to be effective in its treatment. The more critical question is whether or not it can be accurately diagnosed and treatment be brought to bear in an effective and timely manner before a life has been lost to the despair of Dysthymia.
1Diagnostic Criteria 300.4 DSM IV (DSM-IV, 1994).
Depressed mood for most of the day, for more days than not, as indicated either by 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.
Presence, while depressed, of two (or more) of the following:
poor appetite or overeating
insomnia or hypersomnia
low energy or fatigue
poor concentration or difficulty making decisions
feelings of hopelessness
During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode.
There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (DSM-IV, 1994).
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