eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Dysthymic Disorder

Author: Edwin S Rogers, PhD, ABPP, Assistant Director Behavioral Medicine Fellowship, Associate Professor, Department of Family Medicine, University of Tennessee Medical Center at Knoxville
Coauthor(s): Steven L Spalding, MD, Behavioral Medicine Fellowship Director, Assistant Professor, Department of Family Practice, University of Tennessee Medical Center
Contributor Information and Disclosures

Updated: Dec 5, 2008

Introduction

Background

Dysthymic disorder may be diagnosed in children and adolescents when a pervasive depressed or irritable mood is present for at least 1 year. Two additional symptoms of depression must also be present for most of the day at least half of the time during that year to make the diagnosis. Depressive symptoms typical in dysthymic disorder include diminished or increased appetite, insomnia or hypersomnia, low energy or fatigue, poor self-esteem, difficulties with concentration or decision-making, and feelings of hopelessness.

Pathophysiology

Several neurotransmitter systems have been hypothesized to be involved in the emergence of depressive disorders, including the noradrenergic, serotonergic, cholinergic, and dopaminergic systems. Studies of adults with depression have shown blunted responses of cortisol secretion in response to serotonergic challenges. One study's results suggested that depressed children may also show a blunted cortisol secretion response when challenged with serotonergic agents. Studies in adults have also shown that there are lower levels of the serotonin metabolite, 5-hydroxyindoleacetic acid (5-HIAA), in the cerebrospinal fluid (CSF) of both those who attempt suicide and those who complete it. Studies have shown that children with depressive disorders may have blunted growth hormone responses when challenged with adrenergic agents such as clonidine (Catapres).

Among adults with depression, evidence of sleep abnormalities have been reported, including reduced slow wave (delta) sleep, diminished latency to rapid eye movement (REM) sleep, increased REM density, and increased awakening during the night. Sleep disturbance studies in children and adolescents experiencing depression widely vary. Some evidence suggests that children and adolescents with recurrent depression may have shorter REM latency during the period of depression, as well as during periods of remission.

Frequency

United States

Point prevalence rates from 0.6-1.7% in children and 1.6-8.0% in adolescents have been reported.

International

Rates in Europe generally correspond with US rates. Developing countries have higher prevalence of minor psychiatric illnesses in general.

Mortality/Morbidity

• Mortality
  • Dysthymic disorder increases the risk for development of major depressive disorder, with its concomitant possibility for suicidal thoughts and suicide attempts. Children who have dysthymia along with an exacerbation of depressive symptoms, including recurrent suicidal ideation, may be diagnosed with major depression in conjunction with dysthymic disorder. Suicidal thoughts are not uncommon in preadolescent children with depression, although attempts are less common than in adolescents or adults and are less likely to be lethal. Community studies have shown 8.9% of preadolescent depressed children express suicidal ideas and 3% make threats or mild attempts.
  • Among US adolescents, suicide is the third-ranking cause of death (rate of 7.4 cases per 100,000 population for the age range 15-19 y, rate of 1.2 cases per 100,000 population for the age range 10-14 y, rate of 4.3 cases per 100,000 for the age range 10-19 y), after accidents and homicide. Nearly one fourth of high school students in the United States report having considered suicide, approximately 18% acknowledged more serious intent by making a specific suicide plan, and nearly 8% have attempted suicide, with almost 3% requiring medical attention for associated injuries.
  • Suicide rates vary according to sex and ethnicity, with American Indians/Alaska natives having roughly twice the rate of death by suicide than do whites, who have a rate roughly twice that of blacks and Asians/Pacific Islanders (8 cases per 100,000 population compared with 4.7 cases per 100,000 population and 2.5 cases per 100,000 population, respectively). Males outnumber females in terms of death from suicide in all ethnic groups, with ratios ranging from 3:1 in Asian/Pacific Islanders to 4:1 in Native Americans to 5:1 in whites to almost 6:1 in blacks. The gender differences parallel those in adults; men are more likely than women to die from suicide attempts due to use of more lethal means. Although suicidality is not a predominate symptom in dysthymia, mood disorders are considered a spectrum disorder, and suicidal tendencies should be carefully assessed in all patients with depressive symptoms.
• Morbidity
  • Dysthymic disorder causes severe and prolonged social, interpersonal, and academic dysfunction. Children whose parents have depressive disorders are as much as 3 times more likely to develop a mood disorder. In addition to the academic, behavioral, and peer relationship problems associated with childhood mood disorder, unstable homes and exposure to stressful life events increase the risk for dysfunction even further.
  • Childhood dysthymic disorder is associated with increased risk for subsequent major depressive disorder and bipolar disorders and less likely but significant increased risk for substance use disorders and anxiety disorders. Approximately 70% of pediatric patients with dysthymic disorder develop a superimposed major depressive disorder within 5 years; 50% of pediatric patients with dysthymic disorder have other psychiatric disorders as well, including 40% with anxiety disorders, 30% with conduct disorder, 24% with attention deficit hyperactivity disorder (ADHD), and 15% with elimination disorders (ie, enuresis, encopresis). Approximately 15% of pediatric patients with dysthymic disorder have 2 or more comorbid disorders.
  • Comorbid diagnoses increase the risk for recurrence of depression, lengthen the duration of depressive episodes, increase the risk of suicide, and increase the rate of mental health service use. Individuals with additional psychiatric disorders have poorer outcomes, poorer response to treatment, and more severe social impairment.
  • Depressed children are more likely to use tobacco, alcohol, and other substances in adolescence and adulthood. Of course, increased mortality and morbidity are associated with these behaviors as well.

Race

Limited data suggest that the prevalence of dysthymia among ethnic minority pediatric populations is similar to or lower than the prevalence in white pediatric populations in the United States.

Sex

Major depressive disorder has a male-to-female prevalence ratio of 1:1 in prepubertal children and 1:2 in adolescents. In children, dysthymic disorder appears to occur equally in both sexes. Authors have speculated as to why rates of depression go up in adolescence, especially in girls. Biological, psychosocial, and cognitive factors probably contribute. One hypothesis is that girls are more likely to deal with stressors in a ruminative and openly expressive way, in addition to entering puberty earlier than boys (with the concomitant psychosocial and biological consequences). As adolescents, females are more likely to be exposed to sexual abuse, worry about their body image, and feel pressure to conform to restrictive social images than are males.

Age

Studies of depression in the pediatric population show a rise in frequency with age. Rates and gender ratios approach adult levels with older adolescents. These data are subject to interpretation based on changing diagnostic criteria for depression over time.

Years ago, depression was not diagnosed in childhood. According to the Freudian concept that depression is based on the individual's response to loss, children were thought to be incapable of depression because their psychosexual development was thought to be too immature to produce it.

In the 1960s, it was suggested that children suffer "masked depression;" that is, that typical depressive symptoms are expressed as equivalents such as hyperactivity, learning disabilities, and encopresis. However, scrutiny of clinical reports over the last 100 years leads to the conclusion that the same core symptoms of depression observed in adolescents and adults also occur in children.

Children are now widely believed to express depressive symptoms in a manner consistent with their developmental level, including their ability to articulate their feelings and reflect on their mood. Thus, the frequency of various depressive symptoms in children are developmentally linked; depressed prepubertal children may manifest more somatic complaints, self-esteem difficulties, and sad facial expression compared to adolescents and adults. The core depressive symptoms in affective disorders can be shown to be present in children as well as in adults if the assessment tool used is developmentally sensitive.

Clinical

History

The clinical history is crucial in making the diagnosis of dysthymic disorder. Behavioral assessment in pediatric patients must take into account the patient's current developmental stage and often includes information from additional sources, mainly parents and teachers.

In the case of all suspected depressive disorders, suicidal ideation, homicidal ideation, and a history of behavior of harming the self or others must be assessed during the initial presentation and throughout the course of treatment. Although these symptoms are more closely associated with more severe diagnoses than dysthymia, given the comorbidities in psychiatric illness, these factors need to be considered throughout the clinical process.

• Diagnostic criteria taken from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), American Psychiatric Association (APA), are listed below.¹
  • A - Depressed (or irritable) mood for most of the day for more days than not as indicated by subjective account or observation by others for at least 1 year. In children, parental report may emphasize behavioral difficulties expressing depression, whereas the child can give a better account of internalizing symptoms, including suicidal ideation.
  • B - Presence, while depressed, of 2 (or more) of the following: (1) poor appetite or overeating, (2) insomnia or hypersomnia, (3) low energy or fatigue, (4) low self-esteem, (5) poor concentration or difficulty making decisions, and (6) feelings of hopelessness
  • C - During the 1-year period of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time.
  • D - No major depressive episode has been present during the first year of the disturbance; that is, the disturbance is not better accounted for by chronic major depressive disorder or major depressive disorder in partial remission.
  • E - No manic episode, mixed episode, or hypomanic episode are noted, and criteria have never been met for cyclothymic disorder.
  • F - The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or delusional disorder.
  • G - The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, hypothyroidism).
  • H - The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Some symptoms of depressive disorders are more common in children than in adults. For example, irritability, social withdrawal, and somatic complaints (unexplained general medical complaints) are more likely to be observed in children. On the other hand, hypersomnia and psychomotor retardation are more common in adults. Children, particularly younger children, may display aggressive behavior and psychomotor agitation as aspects of dysthymic disorder.
• Other symptoms associated with dysthymic disorder but not included in the formal diagnostic criteria are anger, feelings of being unloved, self-deprecation, anxiety, and disobedience. A considerable overlap of symptoms is observed between dysthymic disorder and major depressive disorder, and the relationship between them is the subject of ongoing debate. Dysthymic disorder and major depressive disorder differ in terms of both chronicity and pervasiveness. In addition, the chronic course of dysthymic disorder can contribute to academic, social, and behavioral disruption, with profound effects on psychological and educational development. Children and adolescents with dysthymic disorder may develop more acute and intense depressive symptoms sufficient to meet criteria for major depression.

Physical

A thorough physical examination is important to rule out medical illness as a cause of symptoms.

Causes

Depressive disorders are etiologically heterogeneous. Genetic, biological, psychological, and environmental factors contribute to depression. Much of the following discussion applies to many depressive disorders including dysthymic disorder. A complex relationship is likely among genetic predisposition, disrupted attachments, internal psychological representations and attributions, dysfunctional social interactions, risk and protective factors, and melancholic endocrine changes in the etiology of dysthymic disorder and depression.

• Genetic factors
  • Such factors are considered to account for approximately 50% of the variance in the transmission of depressive disorders. Children of parents who are depressed are 3 times more likely to experience a depressive episode than children of parents who are not depressed; 20-45% of parents of depressed children have depressive disorders. However, the specificity of these findings is clouded by the fact that psychopathology, in general, is more common in parents of depressed children, and, in general, depressed parents produce children with other psychopathology as well.
  • Transmission of depression in families may occur by means of nongenetic pathways; environmental stressors increase in families with depressed members. Temperament modulates the expression of genetic variance. Temperament is defined as a long-standing behavioral style, mostly inherited, evident early in life, stable during time, and observable in various settings. Some temperamental patterns are likely to make individual children more vulnerable to depression and other disorders.
• Biological factors: The biological substrate of mood disorders is the basis of pharmacologic treatment.
  • As noted above, several neurotransmitters are likely to contribute to mood problems, with noradrenergic, serotoninergic, cholinergic, and dopaminergic systems as candidates. The biogenic amines, norepinephrine and serotonin, regulate mood, sleep, appetite, and activity; they are implicated in dysthymic disorder and are modified by the current antidepressant drugs.
  • Neuroendocrine abnormalities (blunted growth hormone, hypothalamic-pituitary-adrenal problems, hypothalamic-pituitary-thyroid patterns) are thought to be related to the activity of the above-mentioned neurotransmitters; the effects are heterogenous. Sleep architecture changes have been found in depressed adolescents, but inconsistently.
  • Biological measures cannot be used to rule in or out particular mood disorders. It is hypothesized that maturational differences in neurotransmitter systems account for psychobiological differences observed in pediatric and adult depressive disorders.
• Psychological factors: Three main theories have been studied in the etiology of depressive disorders. Psychoanalytic theory relates the origin of depression to loss of love-objects. Behavioral theories focus on the concept of learned helplessness. Cognitive behavioral theories suggest that depressive disorders are related to negative appraisals of the self and of one's competence and abilities. All of the above models suggest that a person vulnerable to depression responds to adversity by withdrawal and inaction.
• Environmental factors: Life events and family functioning are considered to be potential risk factors or protective factors in the development of dysthymia and other depressive disorders. Families with poor coping abilities, low levels of communication within the family, high levels of intrafamilial conflict, and inconsistent emotional response teach children maladaptive affective regulation. If traumatic life events occur, children reared in chaotic environments have increased vulnerability to depressive outcomes. Studies have shown that negative life events are more likely to be associated with the onset of emotional disorders if maternal distress and a poor mother-child relationship are present. Alternatively, good parent-child and good familial relationships can mitigate the effects of traumatic life events.

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