69 Dysthymic Disorder

Name: Bill Dauterive, born Gillaume Fontaine de la Tour D’Haute Rive
Source: King of the Hill (Television series, 1997-2010)

Background Information

Bill Dauterive is a Caucasian male around the age of 42. This age estimate is based on his friends, including Hank Hill, who has been stated to be 42 years old, and that he was in the same school grade as his friends. Bill is from an upper-class family in Louisiana, around New Orleans. His family is not present very often and the only remaining relative he has is a male cousin. His self-reports of childhood hardships caused by his father could be fictitious because there is no way to verify this. He has almost no family so genetic factors are hard to account for. His cousin is in good shape and healthy. Bill is the opposite. He was told by a doctor that he would become diabetic if he did not change his lifestyle.
He was a high school athlete, nicknamed the “Billdozer”. He was very popular, had many friends and even held the school touchdown record. He was drafted into the military his senior year of high school and never graduated. He has remained in the Army and is now a Sergeant barber. He is not particularly poor or wealthy. He is a simple person and does not have any extravagant tastes or interests that he has reported.
He met his wife, Lenore, at a concert. She cheated on him and subsequently they divorced. This is reportedly when the depressive symptoms began appearing. He could not heal from the divorce and claims he still loves her. He became overweight and started losing his hair. His friends Dale Gribble, Jeff Boomhauer, and Hank Hill constantly comment on his depression and try to help him. He has had this core group of friends from a young age. They all live on the same street and get together in the alley to have a beer often. Bill is obsessed with Hank’s wife and believes she is the perfect picture of a woman. She is the complete opposite of Bill’s ex-wife. Even though he has a core group of these 3 friends, they often make fun of him and sometimes exclude him. He has a very poor sense of hygiene and his house is often very dirty. His friends and their wives often make remarks about this.
He is in a depressive state most of the time. The only time he is out of a depressive state is when he is with a woman (who always later rejects him) or gets very involved in a project, such as an instance where he turned his home into a halfway house. He enjoyed the company and enjoyed being needed, but the occupants took advantage of him and he missed so many days at work the Army almost reported him Absent Without Leave, or AWOL. He clings to women he gets into relationships with very quickly. He will be overly dedicated to the women but they always end up taking advantage of him and ending the relationship. He perceives relationships to be more serious than they are in reality. This behavior inevitably drives them away.

Description of the Problem

Bill often states that he is depressed. This depression has lasted since his divorce, which is estimated to be 7-9 years ago. He is in a depressed state most of the time. Others describe him as very depressed and down. He has some periods of normality, but usually he is just depressed. He believes no one loves him or will love him and gets into relationships in which he is very likely to be rejected. He overeats and does not take care of himself very well. He has a very poor image of himself but does not seem to care enough to attempt to better himself.
He often speaks of his ex-wife and the divorce and of still loving her. If he is not working, he is at home eating and watching TV or in the alley having a beer with his friends. He does not do much else. His friends often remark on his bringing up of his divorce and try to set him up with women, but the women usually reject him. There have been a few relationships he has ended himself, but the majority are not his choice. His friends attempt to tell him he is too good for his ex-wife and that she is not coming back.
Bill gets particularly depressed around the holidays. He usually spends Thanksgiving with Hank Hill’s family, which is very intrusive to them. He went through a period of suicidal actions and thoughts but never completed or repeated these behaviors. His friends were constantly watching him.

Diagnosis

The disorder Bill Dauterive most accurately can be diagnosed as having is Dysthymic Disorder (300.4).

A. 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.
Bill is self-described as being depressed a lot of the time. His friends also state that he is depressed all of the time and it has been going on for longer than 2 years. In fact, it is closer to 7 years.

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

Bill experiences overeating, low energy and fatigue, low self-esteem, and feelings of hopelessness. Occasionally he experiences insomnia and poor concentration. Quite often his despair will lead him to overeat which leads to further low self-esteem. The symptoms seem to compound themselves. Bill’s friend Hank is usually the one who makes a lot of Bill’s decisions because he has difficulty doing so himself, whether everyday decisions or more meaningful decisions.

C. During the 2-year period of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
Bill fits this and does not seem to reach the 2 month mark for absence of symptoms. Bill’s symptoms of depression seem to be chronic. He is never out of his depressed state for longer than a few days and this is usually because he has found someone to be in a relationship with for a short time.

D. No Major Depressive Episode has been present during the first 2 years of the disturbance i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
This is hard to account for because Bill is being seen 7 years after the onset. Since it has lasted so long, however, Dysthymic Disorder accounts for it very well.

E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
There has been no evidence of a hypomanic episode. The closest period would be when Bill experiences some type of normalcy does not last very long. He does not have manic episodes or even hypomanic episodes. Sometimes he is obsessive but that does not last very long and he slips back into depression, no period of normalcy is seen. He does not qualify for Cyclothymic Disorder because he does not have periods of hypomanic or manic symptoms.

F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
Bill does not have symptoms of a Psychotic Disorder.

G. 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).
Bill does not present with any substance abuse or other medical conditions. Before the onset of Dysthymic Disorder, he was happy, popular, and content with his life. He does drink a beer in the alley with his friends nearly everyday, but it is usually just one beer. If he is feeling extremely depressed, he will drink to excess, but this is a result of his depression, not a cause.

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
This disorder impacts every portion of Bill’s life. He needs to be needed, and when he is, for short periods of time, it makes him miss work; he was almost listed as AWOL on more than one occasion. In his social life, his depression causes major impairment. All his friends state that he is depressed all the time. He does not take care of himself which leads to low self-esteem. This majorly impacts his attempts at finding a date. He does not make new friends, and he only has the core group of friends he grew up with. When he attempts to meet new people, he is usually rejected and thus, he does not try very often.

Regarding etiology, Bill’s Dysthymia seems to have been caused by his divorce, so the psychosocial causal factor fits. There is no way to determine if genetic factors are possible as his only living relative is a male cousin.

Accuracy of Portrayal

An average person watching Bill in King of the Hill would get a very good idea for what Dysthymic Disorder is. Bill expresses almost all of the symptoms, almost all of the time. The portrayal is accurate in that Bill exhibits almost all of the symptoms of Dysthymic Disorder, nearly all the time. Saying that Bill is depressed all of the time is not an exaggeration. In people with Major Depressive Disorder there are longer periods of normalcy, but in Dysthymic Disorder there are not long periods of normalcy. More often than not, Bill is depressed. Major Depressive Disorder is more about episodes of depression, but Dysthymic Disorder is depression nearly all of the time, and Bill exhibits this. The only inaccuracy was his period of suicidality, but this was a cry for help, not an actual wish of death. It was not repeated.

Treatment

Dysthymia has not been widely studied and this impacts research on treatment. Many findings from Major Depressive Disorder have been applied to Dysthymic Disorder, since it is often referred to as a milder form of Major Depressive Disorder.
One could begin by treating Bill with an antidepressant. After the appropriate dosage was found, he would begin psychotherapy. Bill needs to be taught about the disorder and recognize that he is not in a normal state of mind and begin to come out of it. Since he does not really have any family to speak of to attend therapy with him, his friends should accompany him because they are the individuals he sees most often. They could be shown that their comments to Bill are hurtful and need to end. If Bill’s core group of friends were taught about Dysthymic Disorder they could learn ways to help Bill when he was feeling down and make him feel better about himself and the situations he finds himself in.
A therapist could use cognitive therapy to help Bill change how he sees the world and to think more optimistically. This would show Bill that not every bad thing that happens is a crisis and which events to just let go of. He needs help getting over his divorce and gaining his self-esteem back. Other recommendations that he find a hobby he likes and recommend him to someone to help him with nutritional skills, such as what to eat and what to cook.

Name: Andrew Largeman

Source: Garden State (movie, 2004)

Background Information

Andrew is a 26 year old actor and waiter from New Jersey. He was living in Los Angeles when he got the news that his mother has passed away. Returning to New Jersey for his mother’s funeral, he has to face his psychiatrist father with whom he has no relationship. When Andrew was nine years old a terrible accident occurred where he pushed his mother over a dishwasher door that left her paralyzed. This left him in a depressed and distant state. His mother was a very depressed individual too. Andrew resented the fact that he could never make her happy and that he had pushed her out of anger, leaving her paralyzed.

He appears to be very lost and detached. Drugs such as marijuana and ecstasy have been used by Andrew. He has complaints of reoccurring headaches. Andrew seems to be isolating himself from his father and others. In Los Angeles in particular, he has no friends and no desire to attain any. His general lack of attention is established when he forgets to remove the gas pump from the car when finished getting gas.

Andrew feels like he does not have a problem and for the first time has stopped taking the medication that has been prescribed to him. After meeting a female friend, Andrew feels that he can relate to her and seems less depressed when he is with her. However, this is largely just taking his mind off his problems and his symptoms are still apparent.

Gideon Largeman is Andrew’s father who is a psychiatrist. After his wife’s accident involving Andrew, Gideon tries to suppress a deep loathing towards his son. He blames Andrew for the accident that left his wife paralyzed. To “curb the anger” that he holds towards his son, he heavily medicates him starting at a young age to “protect him from his own feelings”. He puts Andrew on Lithium that has left him in an emotionless haze for many years. He feels that when Andrew was younger he had an anger problem so he decided to place him in boarding school fallowing his mother’s accident. His mother was very depressed and abusing alcohol before her accident. She died while drowning in a bath tub. This was known to be an accident and not a suicide attempt, although it was very suspect.

<h3Description of the Problem

Andrew looks depressed and acts depressed. He zones out and lacks attention to certain important daily functions. There is not any color present in his bedroom, everything is white and sterile. He also experiences terrible dreams of being in a situation where the people around him and himself are about to die, yet he still does not or cannot show any emotion. He is just in a daze, without care of what is going on in the world around him. He has explained that he has not cried in many years. It is apparent that he isolates himself from his family and friends.

Diagnosis

The appropriate disorder after evaluating Andrew is Dysthymia Disorder (300.4)

A. 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.
Andrew has indicated that he has been depressed for as far as he can remember. Before the accident that left his mother paralyzed, Andrew felt depressed by the fact that he couldn’t make his mother happy. After causing his mother to be paralyzed he also become depressed and was sent to boarding school where he was isolated from his family. He shows a great amount of guilt for his mother’s accident and her recent death.

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

Andrew experiences low energy, low self-esteem, poor concentration, and feelings of hopelessness. He seems to have low energy by the way he carries himself. He is late to work, has no interest and lacks energy when talking to people. Not being to work on time seems to be a reoccurring event for Andrew, as his boss mentions his last warning before he is replaced. Andrew expresses low self-esteem by explaining that he has a “fucked up family”. He blames himself for his mother’s accident and remains in isolation most of the time. His concentration on important things is also lacking. He has driven away with the gas pump still attached to his car, and has occasionally not responded to his name being called. Andrew has a sense of hopelessness; he does not have hope in the fact that he can fix the relationship between his father and him.

C. During the 2-year period of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
Andrew meets this by explaining that he has felt this way from at least the age of nine. Before his mother’s accident he felt like he could not make her happy when she was depressed. He is also to blame for his mother’s accident and has been in therapy for depression since the age of 9.

D. No Major Depressive Episode has been present during the first 2 years of the disturbance i.e., the disturbance is not better accounted for by Chronic Major Depressive Disorder, Major Depressive Disorder or in Partial Remission.
The criteria of Dysthymia are met due to the amount of time that Andrew has experienced these depressed symptoms. It is estimated that he has had these symptoms for approximately 17 years. No major depressive episode has occurred. He has successfully carried a job, and has played a major role in a film.

E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
It is not apparent that Andrew has had Manic, Mixed or Hypomanic Episodes. The depression seems to remain at a consistent level over the time period estimated to be depressed. He does not meet the criteria for Cyclothymic disorder because Andrew has not experienced or expressed levels of Hypomanic episodes. He also has not experienced as time period of 2 or more months were he has shown no symptoms of depression.

F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
Andrew shows no symptoms of a chronic Psychotic Disorder such as Schizophrenia or Delusional Disorder.

G. 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).
Andrew shows no symptoms that occur from drug, or medication abuse. The lithium that Andrew has been taking is to help his depression and aggression and he shows no signs of abusing it. He has experienced some drug and alcohol use. However it appears that it is only in social situations and he expressed signs of hesitation and has refused drugs from peers.

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Andrew’s symptoms have significantly impaired his social relationship with peers, friends, co-workers and his father. He shows little interest in having friends around and has been isolating himself for a long period of time. He has no relationship with his father and other family members and has isolated himself from them as well. Andrew’s job as a waiter seems to be coming to an end. He is consistently late and is on his last warning before he job position is replaced.

Early Onset – Occurred before the age of 9 and has continued through his adulthood.

Accuracy of Portrayal

When the average person watches Andrew it is obvious that he is depressed. It is also obvious that this depression has lasted a significant amount of time and has been consistent. He shows that he is suffering with depression more often than not. However, there are times where it seems as if Andrew is not depressed, such as when he is with his newest female friend. Yet, Andrew still shows apparent symptoms of depression and guilt that would categorize him with Dysthymia Disorder. One may inaccurately portray Andrew as someone who has major depressive disorder but, this is not the case. Andrew’s depression has lasted more than two years and he is depressed for most of the time. They may also label him with drug abuse; however, drugs are not a consistent player in his life. He knows to refuse it and to my knowledge has done ecstasy once after pressure from peers.

Treatment

Pharmacotherapy would be the most effective treatment for Andrew’s dysthymia. Andrew has been on anti-depressants and involved in therapy since the age of nine. He has been heavily medicated with Lithium prescribed by his father. From a mental health professional perspective Andrew should not be on Lithium. It is obviously not helping him or eliminating the depression he is feeling. The Lithium dosage is too high and maybe triggering some of the depression he is experiencing. Trying another form of anti-depressants and finding the correct amount needed, with the addition to psychotherapy appears to be the most effective treatment for Andrew.
Psychotherapy should be incorporated with Andrew’s treatment plan once his pharmacotherapy has been correct and is showing significant results in decreasing his depression. Therapy involving his father in attempt to repair their relationship should also be in Andrew’s treatment plan. This could relieve a lot of the stress and guilt built up in the both of them. Talk therapy is shown to benefit those with dysthymia. It will give him an opportunity to talk about his problems and learn ways to deal with him in a healthy manner.
Cognitive behavior therapy could also be helpful in treating Andrew’s dysthymia disorder. Here he can go over and review that his behavior as a child needs to be put in the past. He needs help realizing that what has happened cannot be taken back but, instead needs to be moved on from.