Dysthymic Disorder Clinical Presentation
- Author: Jerry L Halverson, MD; Chief Editor: David Bienenfeld, MD more...
Patients with dysthymia often have a gloomy or negative outlook on life with an underlying sense of personal inadequacy. Compared with major depression, patients' histories tend to include more subjective symptoms, with fewer dramatic psychomotor disturbances or neurovegetative symptoms such as abnormal sleep, appetite, and libido. Some note a diurnal variation, with low energy, inertia, and anhedonia worst in the morning. People with dysthymia may exhibit decreased mental flexibility on neuropsychological testing.
To summarize, the most common symptoms include the following:
A negative, pessimistic, or gloomy outlook
Neurovegetative symptoms - Eg, disturbed sleeping and feeding behaviors, lethargy; usually less marked than those seen in a major depressive episode
Loss of pleasurable feelings (anhedonia)
Tendency to spend little time engaged in leisure activities
Tendency to anticipate that future events and future affective experiences will be negative 
Alternative research criteria for dysthymic disorder also include irritability, excessive anger, and guilty brooding about the past.
A family history of a mood disorder is supporting evidence for the diagnosis. Of note, patients with dysthymia are more likely than patients with episodic major depression to have relatives with dysthymia or major depression.
Although people with dysthymia often have social relationships, some research suggests that this population tends to invest most of their expendable energy into work, leaving little for social life or family and placing a strain on personal relationships.
As many as 15% of persons with dysthymia may have comorbid substance dependence. Since substance dependence can lead to symptoms similar to those caused by dysthymia, a detailed substance abuse history should always be obtained.
A physical and mental status examination is needed to confirm the diagnosis and to determine if comorbid diagnoses are present.
Although psychological tests, such as the Minnesota Multiphasic Inventory or the Rorschach, are not administered routinely in current clinical practice, these tests can be quite helpful for diagnostic purposes, ie, differential diagnosis.
The use of depression rating scales is recommended. Many rating scales, both self administered and clinician rated, are available. The clinician-administered, 17-item Hamilton Rating Scale of Depression (HAM-D) and the self-report scales known as the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16), the Patient Health Questionnaire-9 (PHQ-9), and the Beck Depression Inventory (BDI) are all commonly used.
Simple enough to use on a routine basis, these scales offer diagnostic confirmation and provide a baseline against which change can be evaluated. Studies have emphasized the importance of these rating scales in detecting small changes that may indicate the initial phases of a treatment response. However, use in dysthymia may be different from use in major depressive disorder.
The mental status examination findings in a person with dysthymic disorder are similar to those seen in major depressive episodes.
Some depressed people are less attentive to their appearance, with decline in attention to dress or grooming. Speech may be slowed or show diminished emotional prosody. Mood is likely to be low, with a congruent affect.
Some observable signs of depressed affect include decreased eye contact, slumped posture, and diminished range of facial expression.
With dysthymia alone, one would expect the patient to retain the ability to convey his or her thoughts in a linear and logical manner and would not expect disorganization in speech or behavior.
Hallucinations or delusions would not be explained by dysthymia and should prompt consideration of other diagnoses.
A safety evaluation is an essential part of any mental status examination; the clinician should inquire about suicidal and homicidal thoughts and plans in persons with dysthymia as they would during any psychiatric examination.
Other thought content could be consistent with sad, hopeless, or guilty themes. One would not expect disruption of intellect, orientation, memory, or abstraction from dysthymia alone.
A mental status examination for a person with dysthymia might include the following:
Patient is alert, attentive, and fully oriented
She appears her stated age and is appropriately and casually dressed, although slightly unkempt, with wrinkled clothing
Her mood is stated as depressed and her affect is mood congruent, with avoidant eye contact, less spontaneous movement and gesture, and occasional tearfulness
Her thoughts are linear and logical, with themes reflecting low self-esteem
She expresses guilt that does not rise to a delusional level; she denies paranoid, religious, grandiose, and bizarre delusions and none are apparent
She denies hallucinations and does not appear to respond to internal stimuli
She denies current suicidal and homicidal ideation, intent, and plan and demonstrates good judgment, as evidenced by her seeking treatment for her depressed mood
She has good impulse control
Her intellect is estimated to be average
No deficits are detected in her immediate, short-term, and long-term memory and she is able to interpret proverbs appropriately
Although no physical findings are pathognomonic for dysthymia, an examination may reveal the following:
Evidence of weight gain or loss
Low body temperature, brittle nails and hair, slow reflexes, and other symptoms suggestive of thyroid dysfunction
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.
Niculescu AB 3rd, Akiskal HS. Proposed endophenotypes of dysthymia: evolutionary, clinical and pharmacogenomic considerations. Mol Psychiatry. 2001 Jul. 6(4):363-6. [Medline].
McCullough JP Jr, Klein DN, Borian FE, Howland RH, Riso LP, Keller MB, et al. Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2. J Abnorm Psychol. 2003 Nov. 112(4):614-22. [Medline].
Kessing LV. Epidemiology of Subtypes of Depression. Acta Psychiatr Scand. 2007. 115 (Suppl 433):85-89.
Murphy JA, Byrne GJ. Prevalence and correlates of the proposed DSM-5 diagnosis of Chronic Depressive Disorder. J Affect Disord. 2012 Feb 29. [Medline].
Keller MB, Harrison W, Fawcett JA, Gelenberg A, Hirschfeld RM, Klein D, et al. Treatment of chronic depression with sertraline or imipramine: preliminary blinded response rates and high rates of undertreatment in the community. Psychopharmacol Bull. 1995. 31(2):205-12. [Medline].
Klein DN, Schwartz JE, Rose S, Leader JB. Five-year course and outcome of dysthymic disorder: A prospective, naturalistic follow-up study. Am J Psychiatry. 2000 Jun. 157(6):931-9. [Medline].
Klein DN, Shankman SA, Rose S. Ten-year prospective follow-up study of the naturalistic course of dysthymic disorder and double depression. Am J Psychiatry. 2006 May. 163(5):872-80. [Medline].
Laptook RS, Klein DN, Dougherty LR. Ten-year stability of depressive personality disorder in depressed outpatients. Am J Psychiatry. 2006 May. 163(5):865-71. [Medline].
Ryder AG, Schuller DR, Bagby RM. Depressive personality and dysthymia: evaluating symptom and syndrome overlap. J Affect Disord. 2006 Apr. 91(2-3):217-27. [Medline].
Markowitz JC, Skodol AE, Petkova E, Xie H, Cheng J, Hellerstein DJ, et al. Longitudinal comparison of depressive personality disorder and dysthymic disorder. Compr Psychiatry. 2005 Jul-Aug. 46(4):239-45. [Medline].
Kelly O, Matheson K, Ravindran A, Merali Z, Anisman H. Ruminative coping among patients with dysthymia before and after pharmacotherapy. Depress Anxiety. 2007. 24(4):233-43. [Medline].
Hermens ML, van Hout HP, Terluin B, van der Windt DA, Beekman AT, et al. The prognosis of minor depression in the general population: a systematic review. Gen Hosp Psychiatry. 2004 Nov-Dec. 26(6):453-62. [Medline].
Johnson JG, Cohen P, Kasen S, Brook JS. Personality disorder traits associated with risk for unipolar depression during middle adulthood. Psychiatry Res. 2005 Sep 15. 136(2-3):113-21. [Medline].
Riolo SA, Nguyen TA, Greden JF, King CA. Prevalence of depression by race/ethnicity: findings from the National Health and Nutrition Examination Survey III. Am J Public Health. 2005 Jun. 95(6):998-1000. [Medline].
Masi G, Millepiedi S, Mucci M, Pascale RR, Perugi G, Akiskal HS. Phenomenology and comorbidity of dysthymic disorder in 100 consecutively referred children and adolescents: beyond DSM-IV. Can J Psychiatry. 2003 Mar. 48(2):99-105. [Medline].
Shankman SA, Klein DN. The impact of comorbid anxiety disorders on the course of dysthymic disorder: a 5-year prospective longitudinal study. J Affect Disord. 2002 Jul. 70(2):211-7. [Medline].
Hayden EP, Klein DN. Outcome of dysthymic disorder at 5-year follow-up: the effect of familial psychopathology, early adversity, personality, comorbidity, and chronic stress. Am J Psychiatry. 2001 Nov. 158(11):1864-70. [Medline].
Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006 Nov. 163(11):1905-17. [Medline].
Rush AJ, Kraemer HC, Sackeim HA, et al. Report by the ACNP Task Force on response and remission in major depressive disorder. Neuropsychopharmacology. 2006 Sep. 31(9):1841-53. [Medline].
Adler DA, Irish J, McLaughlin TJ, Perissinotto C, Chang H, Hood M, et al. The work impact of dysthymia in a primary care population. Gen Hosp Psychiatry. 2004 Jul-Aug. 26(4):269-76. [Medline].
Lerner D, Adler DA, Chang H, Lapitsky L, Hood MY, Perissinotto C. Unemployment, job retention, and productivity loss among employees with depression. Psychiatr Serv. 2004 Dec. 55(12):1371-8. [Medline].
Barbui C, Motterlini N, Garattini L. Health status, resource consumption, and costs of dysthymia. A multi-center two-year longitudinal study. J Affect Disord. 2006 Feb. 90(2-3):181-6. [Medline].
Bernal M, Haro JM, Bernert S, Brugha T, de Graaf R, Bruffaerts R, et al. Risk factors for suicidality in Europe: results from the ESEMED study. J Affect Disord. 2007 Aug. 101(1-3):27-34. [Medline].
Bakken K, Vaglum P. Predictors of suicide attempters in substance-dependent patients: a six-year prospective follow-up. Clin Pract Epidemol Ment Health. 2007. 3:20. [Medline].
Casement MD, Shestyuk AY, Best JL, Casas BR, Glezer A, Segundo MA, et al. Anticipation of affect in dysthymia: behavioral and neurophysiological indicators. Biol Psychol. 2008 Feb. 77(2):197-204. [Medline].
Klein DN, Shankman SA, Lewinsohn PM, Rohde P, Seeley JR. Family study of chronic depression in a community sample of young adults. Am J Psychiatry. 2004 Apr. 161(4):646-53. [Medline].
Keitner GI, Ryan CE, Solomon DA. Realistic expectations and a disease management model for depressed patients with persistent symptoms. J Clin Psychiatry. 2006 Sep. 67(9):1412-21. [Medline].
Airaksinen E, Larsson M, Lundberg I, Forsell Y. Cognitive functions in depressive disorders: evidence from a population-based study. Psychol Med. 2004 Jan. 34(1):83-91. [Medline].
Leichsenring F, Hiller W, Weissberg M, Leibing E. Cognitive-behavioral therapy and psychodynamic psychotherapy: techniques, efficacy, and indications. Am J Psychother. 2006. 60(3):233-59. [Medline].
Leichsenring F, Leibing E. Psychodynamic psychotherapy: a systematic review of techniques, indications and empirical evidence. Psychol Psychother. 2007 Jun. 80:217-28. [Medline].
Markowitz JC, Bleiberg KL, Christos P, Levitan E. Solving interpersonal problems correlates with symptom improvement in interpersonal psychotherapy: preliminary findings. J Nerv Ment Dis. 2006 Jan. 194(1):15-20. [Medline].
Markowitz JC, Kocsis JH, Bleiberg KL, Christos PJ, Sacks M. A comparative trial of psychotherapy and pharmacotherapy for "pure" dysthymic patients. J Affect Disord. 2005 Dec. 89(1-3):167-75. [Medline].
Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty KF, Wickramaratne P. Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA. 2003 Jun 18. 289(23):3117-24. [Medline].
Johnson JE, Zlotnick C. A pilot study of group interpersonal psychotherapy for depression in substance-abusing female prisoners. J Subst Abuse Treat. 2008 Jun. 34(4):371-7. [Medline].
Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression. Accessed: May 19, 2009. AHRQ: Agency for Healthcare Research and Quality. Jan. 24, 2007. Available at http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=61.
Carvalho AF, Cavalcante JL, Castelo MS, Lima MC. Augmentation strategies for treatment-resistant depression: a literature review. J Clin Pharm Ther. 2007 Oct. 32(5):415-28. [Medline].
Lifschytz T, Segman R, Shalom G, Lerer B, Gur E, Golzer T, et al. Basic mechanisms of augmentation of antidepressant effects with thyroid hormone. Curr Drug Targets. 2006 Feb. 7(2):203-10. [Medline].
Tuunainen A, Kripke DF, Endo T. Light therapy for non-seasonal depression. Cochrane Database Syst Rev. 2004. CD004050. [Medline].
Hellerstein DJ, Batchelder S, Miozzo R, Kreditor D, Hyler S, Gangure D. Citalopram in the treatment of dysthymic disorder. Int Clin Psychopharmacol. 2004 May. 19(3):143-8. [Medline].