Dysthymia

Dysthymia, defined in the DSM-5 as persistent depressive disorder, is a mood disorder that falls within the depressive disorders. Dysthymia is a disorder characterized by chronic mood swings, but unlike major depression, it is characterized by a lower intensity of symptoms. It involves impairment in social relationships and often in work activity.

Dysthymia is a relatively common disorder. In fact, the lifetime prevalence of persistent depressive disorder is estimated to be between 2.5% and 6% (Kessler et al, 2005). Dysthymia often begins in adolescence, before the age of 21, and affects women more than men. (Klein et al, 2003).

The term dysthymia or dysthymic disorder used to mean any form of altered mood, whether depressive or manic. Currently, however, the definition of dysthymic syndrome applies to any situation in which symptoms of depression occur continuously. Even if the symptoms are less severe than those of major depression.

Dysthymia is probably the most commonly observed disorder in clinical psychiatric settings. In fact, it is estimated that between 22% and 36% of patients referred to outpatient psychiatric services also meet the criteria for dysthymic disorder.

Dysthymia can present alone, although it is often observed in comorbidity with other psychiatric disorders. In particular, it is not uncommon to observe dysthymic disorder in patients who also present with:

  • Anxiety disorders;
  • Substance abuse;
  • Personality disorders.

Symptoms and characteristics of dysthymia

The essential feature of dysthymia is a chronically depressed mood on most days over a long period of time (at least two years).

The onset of dysthymia can occur at any age, from childhood to geriatric age, although it is more common in early adulthood. The age of onset of the disorder, which varies from patient to patient, often identifies different causes and developmental patterns. For example, the onset of dysthymia in adolescence or childhood is often associated with a family history of mood disorders, greater childhood adversity (e.g., abuse or neglect), and a greater likelihood of developing other Axis I and Axis II psychiatric disorders. In particular, the early onset of major depressive disorder is often associated with cluster B and cluster C disorders.

Late-onset dysthymia, on the other hand, seems to be more closely associated with bereavement, separation, and the onset of multiple health problems. For more information, read our article on depression in the elderly.

The lesser intensity and pervasiveness of symptoms also often leads to an underestimation of the true prevalence of dysthymia. In fact, many patients do not recognize their chronically depressed mood as a disorder, but rather as a personality trait that has been with them since adolescence and does not require special intervention.

A diagnosis can be made when at least two of the classic symptoms of depression are present:

  • Cognitive symptoms (e.g., low self-esteem, feelings of hopelessness)
  • Loss of appetite or hyperphagia
  • Insomnia or hypersomnia
  • Low energy or asthenia
  • Low self-esteem
  • Difficulty making decisions or concentrating
  • Affective symptoms (depressed mood)
  • Feelings or experiences of hopelessness
  • Motivational symptoms (loss of interest, social withdrawal)

In order for dysthymia to be truly diagnosable, it is important that the person has not been without the dysthymic symptoms for a period of two months (each time) during the two years in question. There must also be no history of major depressive episodes, cyclothymic disorder, manic or hypomanic episodes. In the case of pure dysthymic syndrome, the criteria for a major depressive episode must not have been fully met in the previous 2 years.

Double depression

However, there is a close relationship between major depression and dysthymia. In fact, people with persistent depressive disorder may experience a worsening of psychopathology over time, meeting the criteria for major depressive disorder. Such cases are referred to as dual depression (Keller e Shapiro, 1982).

Dual depression is not a specific DSM-5 disorder and is therefore not considered a disorder in its own right. DSM-5 invites the use of both diagnoses (dysthymia and major depression) as comorbid disorders in such cases.

Despite this distinction, some authors hypothesize that in cases of dual depression, these pictures do not so much represent two different disorders in comorbidity, but rather two phases of the same syndromic picture (Klein & Santiago, 2003).

Dysthymia diagnosis and DSM-5

In DSM-5, dysthymia is precisely defined by the term persistent depressive disorder. This diagnosis is a consolidation of what was called a major chronic disorder in DSM-IV.

Criteria for the diagnosis of persistent depressive disorder include the presence of depressed mood for at least two years (for children and adolescents, the criterion changes and one year is sufficient). In addition, the DSM-5 requires the presence of at least two of the following symptoms to make the diagnosis:

  • Poor or increased appetite
  • Insomnia or hypersomnia
  • Low energy or excessive fatigue
  • Low self-esteem
  • Poor concentration or difficulty making decisions
  • Feeling of hopelessness

Dysthymia medications and treatment

Dysthymia is a chronic disorder that requires long-term treatment. Like other depressive spectrum disorders, dysthymia is characterized by alterations in serotonin and norepinephrine circuits. (Bellino et al., 2000).

The most commonly used medications for the treatment of dysthymia are antidepressants, especially SSRIs (selective serotonin reuptake inhibitors) and SNRIs (selective norepinephrine reuptake inhibitors). However, the choice of the right medication is variable and a prescription from a psychiatric specialist is required.

Psychotherapy for dysthymia

In addition to medication, a course of psychotherapy may be added to the treatment of dysthymia. For example, NICE (the British National Institute for Health and Care Excellence) guidelines recommend targeted psychological interventions in addition to medication for patients with residual symptoms or at risk of relapse (NICE, 2011).

Finally, a recent review (Jobst et al., 2016) of treatments for persistent depressive disorder concludes by advocating the importance of modulating treatment (psychopharmacological, psychotherapeutic, and rehabilitative) according to the specific characteristics of each patient.

In fact, the best treatment for dysthymia is one in which care is modulated over time according to the symptoms manifested and the progressive needs of each individual patient. For this reason, it is advisable to be followed by one’s own doctor and to avoid do-it-yourself solutions.

References

  1. Brunello, N., Akiskal, Boyer, P., Gessa, G. L., Howland, R. H., Langer, S. Z., Mendlewicz, J., Paes De Souza, M., Placidi, G. F., Racagni, G., & Wessely, S. (1999). Dysthymia: Clinical picture, extent of overlap with chronic fatigue syndrome, neuropharmacological considerations, and new therapeutic vistas. Journal of Affective Disorders52(1–3), 275–290. https://doi.org/10.1016/S0165-0327(98)00163-3
  2. Ventriglio, A., Bhugra, D., Sampogna, G., Luciano, M., de Berardis, D., Sani, G., & Fiorillo, A. (2020). From dysthymia to treatment-resistant depression: evolution of a psychopathological construct. International Review of Psychiatry32(5–6), 471–476. https://doi.org/10.1080/09540261.2020.1765517
  3. Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications. The Lancet Psychiatry7(9), 801–812. https://doi.org/10.1016/S2215-0366(20)30099-7
  4. Schmauß, M., & Messer, T. (2005). Dysthymie. Fortschritte Der Neurologie Psychiatrie73(7), 415–426. https://doi.org/10.1055/s-2004-830141
  5. Gureje, O. (2011). Dysthymia in a cross-cultural perspective. Current Opinion in Psychiatry24(1), 67–71. https://doi.org/10.1097/YCO.0b013e32834136a5
  6. Moore, J. D., & Bona, J. R. (2001). Depression and dysthymia. Medical Clinics of North America85(3), 631–644. https://doi.org/10.1016/S0025-7125(05)70333-3
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