Dysthymia

Published on 03/03/2015 by admin

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28 Dysthymia

Kenneth Lakritz

Clinical Vignette

A 47-year-old woman was referred to psychiatry by her internist who was caring for her chronic fatigue and diffuse achiness. He was uncertain of her diagnosis and wondered if the patient was depressed. Although the patient resented this referral, she agreed to a single consultation. This lady was experiencing inadequate and poor-quality sleep, impaired concentration, migratory chest pain, and migraine headaches. Utilizing the web, she had sought out a “Lyme specialist” and subsequently received antibiotic treatment for “chronic Lyme disease.” However, her symptoms continued unabated despite this treatment.

Although she had been clearly depressed on two occasions, at age 19 years after her father’s death and at age 26 years after the birth of her first child, she denied current feelings of sadness, guilt, or hopelessness. She described herself as overworked, justifiably pessimistic, socially isolated, and burdened with an unappreciative and unsympathetic husband. She wondered whether she had chronic fatigue syndrome, fibromyalgia, or multiple chemical sensitivities, but she had no obvious delusions about her health. An extensive medical workup had revealed an iron deficiency anemia and hypothyroidism; however, their treatment was not helpful in resolving her many symptoms. An overnight sleep study was unremarkable, excluding sleep apnea as a potential mechanism. As this woman was generally sedentary, her physician recommended aerobic exercise, but she felt too tired to try it.

She reluctantly acknowledged that her pessimism and low mood might be contributing to her problems. She agreed to a trial of cognitive–behavioral therapy, which she found helpful especially as it induced her to exercise more and change jobs. She also convinced her husband to start marriage counseling.

Clinical Presentation

Mood disorders are extremely common and diverse in their presentation and clinical course. Previously called “minor depression” and “subsyndromal depression,” dysthymia is among the most common and easily overlooked.

Dysthymic patients have fewer and less-intense depressive symptoms than patients with major depression. To establish the diagnosis, the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV) requires at least a 2-year course of predominantly depressed mood, while noting that chronic low mood may be such a fixture of the patient’s life as to be unrecognized by the patient. Two other symptoms must also be present from a list, including sleep disturbance, appetite disturbance, fatigue, hopelessness, low self-esteem, and impaired concentration (Fig. 28-1). Dysthymia usually has an early and insidious onset and a chronic course. Family history of mood disorder is common.

Figure 28-1 Dysthymia.

Because of its restriction to overt and easily observable signs and symptoms, DSM-IV does not recognize the existence of a depressive personality disorder. However, patients who are characterologically prone to depression but not classically presenting with active symptoms of a mood disorder are extremely common. These individuals have an underlying conception (misconception) of themselves as defective or inadequate and are prone to feelings of guilt and shame. They overlap partially with patients suffering from dysthymia per se.

Although dysthymic patients do not meet the criteria for a diagnosis of major depression, dysthymia is not a benign illness. As a chronic disease, it causes immense suffering and loss of human potential. Dysthymic patients do less well than they should at school, work, and in personal relations. They overuse medical resources and substances, both legal and illegal. They are at high risk for the development of more severe affective disorders; one of the commonest is double depression, a pattern of repeated major depressive episodes with partial recovery to a state of dysthymia.

Most physician practices include a number of patients with poorly characterized pain or other vague but persistent physical complaints. Even after excluding appropriate and specific medical diagnoses, hypochondriasis, malingering, and delusional disorder, certain puzzling cases remain unclassified or specifically diagnosed per se. These are best understood as disguised presentations of dysthymia. Neurologists, rheumatologists, and gastroenterologists are frequently sought out by these relatively common dysthymic patients. Both the patients and the clinicians are usually frustrated and resentful of one another.

Treatment

Patients with dysthymia deserve careful evaluation and intensive treatment. They often respond well to specific counseling techniques such as cognitive–behavioral therapy or interpersonal therapy. Often a combination of psychotherapy and antidepressant medication produces the best outcome.

Additional Resources

Gureje O. The relation between multiple pains and mental disorders: results from the World Mental Health Surveys. Pain. 2008 Mar;135(1-2):82-91.

Ratey J, Johnson C. Shadow Syndromes: The Mild Forms of Major Mental Disorders That Sabotage Us. New York, NY: Pantheon; 1997.

Shedler J, Westen D. Refining personality disorder diagnosis: Integrating science and practice. American J Psych. 2004;161:1350-1365.

Subodh BNJ, Avasthi A, Chakrabarti S. Psychosocial impact of dysthymia: A study among married patients. J Affect Disord.. 2008;109:199-204.

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