Dysthymia – Causes, Signs and Symptoms

Dysthymia

Also called: Depressive Neurosis, Dysthymic Episode, Chronic Depression, Depressive Personality Disorder, Dysthymic Disorder

Summary

Dysthymia is a mood disorder characterized by chronic  depression  that lasts for at least two years, but is not as severe as major depression. Although it causes significant distress or some impairment in function of school or work performance, socially or otherwise, it is not as severe as the impairment caused by major depression.

Dysthymia typically begins gradually during early adulthood, and patients usually have trouble pointing out precisely when they first became depressed. It is common for patients to consider their depression normal. Dysthymia may be associated with other mental illnesses (e.g., anxiety disorders, substance abuse).

Improper levels of certain brain chemicals seem to be linked to dysthymia. The disorder is more common in adult women and seems to have a genetic component, making it more common in people closely related to patients with depression. Stressful life situations (e.g., discrimination, poverty, chronic illness) may also be associated with the condition.

The symptoms of dysthymia include sadness, hopelessness, despair or pessimism (believing everything will turn out badly), fatigue or loss of energy, and substantial changes in appetite.

Before an individual can be diagnosed with dysthymia, a physical examination must be performed by a physician to rule out other medical conditions that may be causing the symptoms (e.g., thyroid malfunction). Diagnosis is then made by a mental health evaluation performed either by a physician or another mental health professional. Normal responses to grief need to be ruled out. It is possible for both dysthymia and major depression to be diagnosed, resulting in what is referred to as double depression. Treatment of dysthymia can often completely eliminate symptoms, though it may have to be maintained indefinitely to prevent them from returning. In many cases, dysthymia responds equally to psychotherapy or medication. The primary medications for this disorder are antidepressants.

About dysthymia

Dysthymia –  meaning “bad state of mind” or “ill humor” in Greek – is a mood disorder in which a chronically depressed mood is present on the majority of days for at least two years. Patients often regard the low mood they live with as normal, and many individuals may not realize that anything is wrong at all. Although dysthymia causes significant distress or some impairment in function of school or work performance, socially or otherwise, it is not as severe as the impairment caused by major depression.

The onset of dysthymia is usually gradual. The median age of onset is 31 years, though it may begin much earlier or later. Most patients cannot pinpoint precisely when they first became depressed. In children and adolescents, the altered mood may be irritable instead of depressed, and must last at least one year instead of two.

There is a close relationship between dysthymia and major depression. For instance, many patients with dysthymia will eventually develop major depression, and patients with major depression may eventually develop dysthymia. If an episode of major depression occurs during dysthymia, both dysthymia and major depression may be diagnosed, resulting in what is referred to as double depression. Dysthymia may also be associated with other mental health disorders (e.g., anxiety disorders, substance abuse). Dysthymia in children may be associated with attention deficit hyperactivity disorder and other medical or psychological conditions.

According to the National Institute of Mental Health, about 3.3 million adult Americans ages 18 and older suffer from dysthymia at some point in their lives. Women are about twice as likely to have dysthymia as men.

Risk factors and causes of dysthymia

The cause of dysthymia is not completely understood. It is believed that changes in brain structures and chemistry may cause alterations in mood. Too many or too few neurotransmitters (chemicals that convey messages between nerves), particularly serotonin, are believed to play a key role.

There are many risk factors for dysthymia. These include:

  • Gender. Women have about twice the risk of developing dysthymia as men. Although the reason for this is unknown, it may be due to factors such as differences in hormones in certain life stages, such as after pregnancy and menopause. It should be noted that the disparity between the genders also may be related to women being more willing to report symptoms of depression than men.

  • Family history. Individuals who have relatives with a history of any form of depression, especially dysthymia or major depression, are at a higher risk of developing dysthymia. This is especially true for first-degree relatives (e.g., parents, children, siblings).

  • Long-standing life stresses. Individuals who experience constant sources of major stress, such as from discrimination, poverty, constant abuse or chronic illness, have an increased risk of dysthymia.

  • Marital status and quality. In general, unmarried people have a greater risk of developing dysthymia. However, unhappily married people may also have a higher risk of developing the disorder. Whether these are actual risk factors for developing dysthymia, or if they are due to the fact that people with chronic depression may be less likely to marry and when they do marry are more likely to have unhappy marriages, is unclear. Individuals who feel rejected or depreciated by a loved one or are isolated are also at an increased risk. 

Signs and symptoms of dysthymia

The symptoms of dysthymia may vary greatly from one patient to another. They may result in decreased activity, effectiveness or productivity. Most are similar to the symptoms of major depression, but not as severe. Because patients with dysthymia may consider their symptoms normal, symptoms may be noticed by others before they are recognized by the patient. Signs and symptoms of dysthymia include:

  • Altered mood. The patient will usually experience feelings of sadness, hopelessness, discouragement or apathy (lack of emotion). The patient may be pessimistic (feel that everything in life will turn out badly) or discouraged and may experience crying spells or excessive emotional sensitivity. Excessive anger, irritability or crankiness may also be noticeable, particularly in children.

  • Lack of interests and/or social withdrawal. Patients may have little or no interest in activities they used to find pleasurable, such as food, sex, work, friends, hobbies and entertainment (anhedonia). They may be also socially withdrawn or shy.

  • Self-worth. Poor self-esteem is common in dysthymia. The patient may have feelings of worthlessness, self-reproach, inadequacy or excessive or inappropriate guilt.

  • Fatigue and low energy.

  • Concentration. The patient may be indecisive, have diminished ability to think, pay attention to tasks or concentrate, or have memory problems.

  • Significant change in appetite or weight. Patients with dysthymia may experience reduced or increased appetite or significant weight loss or gain over a relatively short period of time.

  • Changes in sleep patterns. The patient may sleep too much (hypersomnia) or be unable to sleep enough (insomnia).

Diagnosis methods for dysthymia

Before dysthymia is diagnosed, a physical examination needs to be performed by a physician to rule out other medical conditions. Many long-term medications (e.g., corticosteroids) or chronic medical conditions (e.g., hypothyroidism, anemia) can cause symptoms similar to those of dysthymia.

The diagnosis of dysthymia begins with a mental health evaluation performed either by a physician or after a referral to a non-physician mental health professional. This evaluation includes a complete history of symptoms, including when they started, how long they have lasted and how severe they are. It is also noted whether the patient has experienced these symptoms before and, if so, whether and how they were treated. The physician or other mental health professional will also inquire about alcohol and drug use and whether other family members have had a depressive illness, such as dysthymia or major depression. If there is a history of a depression in any family members, the treatment method and effectiveness will need to be reported.

The American Psychiatric Association identifies particular criteria for the diagnosis of dysthymia in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV). These criteria include:

  • Quality and duration of mood. Adults must have a depressed mood for most of the day on the majority of days for at least two years. Children or adolescents must have a depressed or irritable mood for most of the day on the majority of days for at least one year.

  • Symptoms. Two different, overlapping sets of symptoms may be used by different physicians or non-physician mental health professionals. In general, patients must display two or more of the following symptoms during the time that they have an altered mood:

    • Substantial change in appetite (overeating or reduced appetite)
    • Too much or too little sleep (hypersomnia or insomnia)
    • Reduced energy or fatigue
    • Reduced self-image or confidence (poor self-esteem)
    • Indecisiveness or problems with concentration
    • Hopelessness, despair or pessimism

  • Consistency. Symptoms must not be absent for more than two consecutive months in a two-year period in adults or a one-year period in children.

  • Impairment. The symptoms must be severe enough to cause significant distress (as per the DSM-IV) or impairment in function of work or school performance, socially or otherwise.

The diagnosis of dysthymia is only made if the patient has not been diagnosed with other particular mood disorders (e.g., major depression, bipolar disorder). However, there are certain circumstances where both dysthymia and major depression may be diagnosed (double depression). For instance, many patients with dysthymia will eventually develop major depression, and patients with major depression may eventually develop dysthymia. To be diagnosed with either of these conditions, the symptoms must be unrelated to a physical medical condition or use of any prescribed medications or recreational substances. The diagnosis of dysthymia may be described as early or late onset depending on whether it began before or after the age of 20 years. The age of onset may affect treatment options. Patients with early onset dysthymia are more likely to eventually develop a major depressive episode in the future.

Treatment and prevention of dysthymia

There is only about a 10 percent chance per year that the symptoms of dysthymia will go away without treatment. The symptoms of dysthymia can often be completely eliminated, though treatment may have to be maintained indefinitely to prevent them from returning. In many cases, dysthymia responds equally to psychotherapy and medication.

Psychotherapy teaches coping skills and more effective ways to deal with problems in life. It also targets symptoms and addresses any substance use. One form known as cognitive behavior therapy (CBT) is often used. During CBT, the therapist engages the patient with conversation to gain insight into and to change negative patterns of thought or behavior that are associated with dysthymia. Sometimes, the patient will be given “homework” assignments between sessions. CBT teaches patients to gain more satisfaction and rewards from their own actions and resolve problems.

Medications for dysthymia typically offer relatively quick relief of symptoms. The primary medications for this disorder are antidepressants. Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. In addition, the U.S. Food and Drug Administration(FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients, particularly children and adolescents, and all people being treated with them should be monitored closely for unusual changes in behavior. However, the benefits of such medications typically outweigh the risks.

Over-the-counter herbal and dietary supplements may be used by some people for dysthymia. Among the most commonly used of these is the herb St. John’s wort. Although used in Europe for the treatment of many forms of mild to moderate depression, including dysthymia, scientific studies demonstrating their effectiveness are lacking. The National Institute of Mental Health (NIMH) is currently conducting studies on the effectiveness and safety of this herb in the treatment of dysthymia and other forms of depression. It is important for patients to speak with a physician before taking any herbal or dietary supplement because many supplements may cause serious drug interactions.

Questions for your doctor regarding dysthymia

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to dysthymia:

  1. Are you experienced in treating depression and other mood disorders?
  2. Why do you suspect I have dysthymia rather than major depression?
  3. Am I at an increased risk for any other conditions because of my dysthymia?
  4. Is there any chance that my dysthymia will resolve on its own?
  5. Will my treatment for dysthymia include medication?
  6. Which type of medication is most appropriate for me?
  7. For how long will I have to take medication for my dysthymia?
  8. How soon after starting medication will I see improvement in my symptoms?
  9. What is the best therapy for me?
  10. For how long will I have to attend therapy?
  11. How long might it take before I or others notice a difference in my mood?
  12. Do you recommend any lifestyle changes that may help my condition?
  13. How can I prevent dysthymia from returning?
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