224 Dysthymic Disorder (300.4)

DSM-IV-TR criteria

• 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. NOTE: In children and adolescents, mood can be irritable and duration must be at least 1 year. The individual must have been depressed for at least 22 months during the past 2 years. This type of disorder is classified as unipolar, where there is only severe depression.
• B. Presence, while depressed, of two (or more) of the following:
  • poor appetite or overeating
  • insomnia or hypersomnia
  • low energy or fatigue
  • low self-esteem
  • poor concentration or difficulty making decisions
  • feelings of hopelessness
• C. 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.
• D. 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, 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 Disorder
• E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
• F. The disturbance does not occur exclusively during the course 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).
• H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Specify If:
  • Early Onset: if onset is before age 21 years
  • Late Onset: if onset is age 21 years or older

Specify (for most recent 2 years of Dysthymic Disorder):

• With Atypical Features

Associated features

Many of the associated features of Dysthymic Disorder are similar to features of Major Depressive Disorder. Changes in sleep patterns, appetite, significant weight gain or loss, and psychomotor symptoms are seen less than in those patients with Major Depressive Disorder. Some of the most common symptoms to be associated with Dysthymic Disorder are feelings with inadequacy; social withdrawal; general loss of interest or pleasure; feelings of guilt or brooding about the past; excessive anger; decreased activity; productivity; or effectiveness. Around 75 percent of people who develop Dysthymic Disorder without ever having Major Depressive Disorder will develop Major Depressive Disorder within the next five years. Problems can occur when treatment becomes necessary, as the individual at that time may have become so accustomed to his depressed mood, he may not see anything that needs discussing. Some researchers say that the studies show that the spontaneous remission rate for Dysthymic Disorder could be as low as 10%. Some evidence found over the last ten years suggests that the with active treatment the plausible outcome is significantly increased (meaning there is a higher chance of a spontaneous recovery.) Dysthymic Disorder is often comorbid with Borderline, Histrionic, Narcissistic, Avoidant, and Dependent personality disorders in adults. In children, it can be comorbid with Attention Deficit/Hyperactive Disorder, Conduct Disorder, Anxiety Disorders, Learning Disorders, and Mental Retardation.

Child vs. adult presentation

In children, Dysthymic Disorder occurs consistently equal in both sexes. Both Children and adolescents, who have Dysthymic Disorder, display moods of irritability, crankiness, and depression. These attributes of Dysthymic Disorder usually impair the individual’s school performance and most social interaction. Children who display Dysthymic Disorder also show to have low self esteem, tend to be pessimistic and, have poor social skills. Most patients with dysthymia recall having feelings of unhappiness during their childhood but do not know why. First onset occurs during adolescence or early adulthood. Some people that develop dysthymia do not get treated if it occurs during adolescence because they do not know happiness, and they believe that is just the way life is. Symptoms in children may present as feelings of irritability rather than being depressed, and these symptoms only need occur for one year.

Gender and cultural differences in presentation

Women are 2 to 3 times more likely to develop this disorder. However, before puberty and after menopause, men and women are affected about the same. Females outnumber males 2:1 during childbearing years. Little research has been done to show differences between races, however, it is more common among African Americans and Mexican Americans.

Epidemiology

Dysthymic disorder, lifetime prevalence for many people, affects about 6% of the general population. In a year, about 3% of the general population has this disorder.

Etiology

The cause of dysthymia is unclear but there are several factors that may cause it. They are

• Genetic predisposition
  • Dysthymic Disorder is most prevalent among first-degree biological relatives of people with Major Depressive Disorder or Dysthymic Disorder then people out in the general population.
• Biological factors
• Chronic stress
• Chronic medical illness
• Psychosocial factors, such as isolation, loss

Empirically supported treatments

There has been little research conducted on Dysthymic Disorder. Medications that are used to treat Dysthymic Disorder have originated from studies that studied Major Depressive Disorder. Dysthymic Disorder is a milder but longer lasting form of Major Depressive Disorder. Researchers have carried over the findings from the studies of Major Depressive Disorder to Dysthymic Disorder. Furthermore this treatment taken from Major Depressive Disorder has been shown to be very effective in treating and managing Dysthymic Disorder. The most effective treatments that have shown success are as follows: antidepressants, MAOI, and SSRI antidepressants. The only other treatments that have been found to be effective in the fight against Dysthymic Disorder are supportive psychotherapy and psychoeducation. This helps the patient and the patient’s family to understand the illness, helps improve the patient’s compliance and allows the family to be more cooperative with their loved one’s recovery. Cognitive therapy is used to change the pessimistic ideas. It also helps a person realize which problems are truly problems and which ones are minor. Problem solving helps individuals identify which areas of life need to be changed so one can better cope with this disorder instead of sustain it.

Additional Information:

Dysthymia is a milder form of major depression. Periods of feeling normal can last up to a couple of months but usually go back to feelings of depression (2009). People who are diagnosed with this disorder before age 21 tend to have a higher rate of developing a personality disorder (2009). Dysthymic symptoms can often go unnoticed so this population becomes untreated as well. Some medical conditions, including neurological disorders (such as multiple sclerosis and stroke), hypothyroidism, fibromyalgia, and chronic fatigue syndrome, are associated with dysthymia. Investigators believe that, in these cases, developing dysthymia is not a psychological reaction to being ill but rather is a biological effect of these disorders (2009). People who have recently encountered a high level of stress such as losing a spouse or divorce can increase the risk for dysthymia (2009).