Dysthymic Disorder 

  • Author: Sarah C Langenfeld, MD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: May 28, 2011
 

Background

Dysthymia is a depressive mood disorder characterized by a chronic course and an insidious onset. Many people with dysthymia describe life-long depression.

By definition, dysthymia is a chronic mood disorder with a duration of at least 2 years (1 year in adolescents and children). It is manifested as depressed mood for most of the day, occurring more days than not, and accompanied by at least 2 of the following symptoms:

  • Poor appetite or overeating
  • Insomnia or hypersomnia
  • Low energy or fatigue
  • Low self-esteem
  • Poor concentration
  • Difficulty making decisions
  • Feelings of hopelessness

To diagnose dysthymia, any major depressive episodes must not have occurred in the first 2 years of the illness (the first 1 year in children) and history of mania should not exist. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR)[1] allows transient euthymic episodes (periods of normal mood) of up to 2 months during the course of dysthymia.

The DSM-IV-TR categorizes dysthymia according to course specifiers. These include (1) early onset if symptoms began before age 21 years, (2) late onset if symptoms began at age 21 years or later, and (3) dysthymia with atypical features if symptoms include increased appetite or weight gain, hypersomnia, a feeling of leaden paralysis, and extreme sensitivity to rejection.

Dysthymia should be differentiated from major depression. In contrast to dysthymia, a diagnosis of major depression requires that at least 5 or more of the following symptoms have been present most of the day, every day, for the past 2 weeks:

  • Depressed mood
  • Loss of interest or pleasure in usual activities
  • Significant weight loss or gain
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Diminished ability to think or concentrate
  • Recurrent thoughts of death or suicide

A diagnosis of major depression requires depressed mood and/or significant loss of interest or pleasure in activities. Differentiating dysthymia from major depression may be challenging, for example, in cases of major depression with a partial response to treatment.

Major depressive disorder, dysthymia, double depression, and some apparently transient dysphorias may all be manifestations of the same disease process. These varieties of depressive mood states, while distinct diagnostic entities, share similar symptoms and respond to similar pharmacologic and psychotherapeutic approaches.[2, 3]

Although dysthymia was traditionally considered less severe than major depression, the consequences of dysthymia are increasingly recognized as grave and include severe functional impairment, increased morbidity from physical disease, and increased risk of suicide.

The various outcomes of dysthymia. The various outcomes of dysthymia.

Of note, an estimated 75% of people with dysthymia meet criteria for at least 1 major depressive episode, referred to as double depression.[4] Those with dysthymia who have depressive episodes tend to have longer periods of depression and spend less time fully recovered.[5] In a 10-year follow-up study of people with dysthymia, 75% experienced some (at least 2 m) period of recovery from major depression; the mean time to recovery was 52 months from study entry. In this study, most (70%) of those who recovered experienced a relapse into another episode of depression, most commonly in the 3 years following recovery.[6]

The DSM IV-TR also includes research criteria for depressive personality disorder, which may also be considered in the differential diagnosis of chronic low mood. Depressive personality disorder is characterized by a depressive disposition, introversion, a tendency toward self-criticism, and pessimistic cognitive processes, with fewer of the mood and neurovegetative symptoms seen in dysthymia. Dysthymia or depression may be comorbid with depressive personality disorder.[7, 8] See also, eMedicine's article Personality Disorders.

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Pathophysiology

The pathophysiology of dysthymia has not been clearly established.

Involvement of serotonin and noradrenergic systems is suggested by positive clinical responses to serotonergic and noradrenergic medications, such as selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants.

Abnormalities in neuroendocrine systems, especially thyroid and hypothalamo-pituitary-adrenocortical (HPA) systems, have been linked to depressive disorders in general; the HPA axis has not been adequately studied in dysthymic disorder. Cytokines and inflammation have also been implicated in major depression; however, a link to dysthymia has not been clearly established.

EEG and polysomnogram data demonstrate that about 25% of people who have dysthymia have sleep changes similar to those who have major depression, including shortened rapid eye movement (REM) latency, increased REM density, and poor sleep continuity.

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Epidemiology

Frequency

United States

Best estimates are that the lifetime risk of significant depression exceeds 25%, with a point prevalence of about 5%. The lifetime community prevalence of dysthymia is 6%. Dysthymia affects an estimated 36% of patients in outpatient mental health treatment.

Mortality/Morbidity

Mortality is reflected not only in the death rate from suicide but also increased morbidity and mortality from a variety of physical illnesses among patients with dysthymia.

Race

Minimal research has been performed to define differences in frequency and symptoms between races. One study, the National Health and Nutrition Examination Survey III (NHANES III), found that dysthymia is more common among African Americans and Mexican Americans than among Caucasians.[9]

Sex

For major depressive disorders, females outnumber males, with a female-to-male ratio of 2:1 during their childbearing years. Before puberty and after menopause, the 2 sexes appear to be affected about equally. In elderly people, dysthymia is relatively more frequent in females, but dysthymia adversely affects survival in males more than in females.

Age

Most often, patients with dysthymia recall unexplained unhappiness in preadolescent childhood. Whether DSM-IV-TR adequately addresses dysthymia in children and adolescents is a matter of some controversy.[10]

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Contributor Information and Disclosures
Author

Sarah C Langenfeld, MD  Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School; Attending Psychiatrist, Community HealthLink

Sarah C Langenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Rebecca S Lundquist, MD  Consulting Staff, Department of Psychiatry, UMass Memorial Medical Center

Rebecca S Lundquist, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Pfizer Salary Employment; Biogen Salary Employment

Brian R Szetela, MD  Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School; Consulting Psychiatrist, Psychiatric Consultation - Liaison Service, University of Massachusetts Memorial Medical Center

Brian R Szetela, MD is a member of the following medical societies: American Psychiatric Association, American Society of Addiction Medicine, and Association for Convulsive Therapy

Disclosure: Nothing to disclose.

Specialty Editor Board

Alan D Schmetzer, MD  Professor Emeritus, Interim Chairman, Vice-Chair for Education, Associate Residency Training Director in General Psychiatry, Fellowship Training Director in Addiction Psychiatry, Department of Psychiatry, Indiana University School of Medicine; Addiction Psychiatrist, Midtown Mental Health Cener at Wishard Health Services

Alan D Schmetzer, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Clinical Psychiatrists, American Academy of Psychiatry and the Law, American College of Physician Executives, American Medical Association, American Neuropsychiatric Association, American Psychiatric Association, and Association for Convulsive Therapy

Disclosure: Eli Lilly & Co. Grant/research funds Other

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

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The various outcomes of dysthymia.
 
 
 
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