Dysthymic Disorder Clinical Presentation

Updated: Nov 09, 2015
  • Author: Jerry L Halverson, MD; Chief Editor: David Bienenfeld, MD  more...
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Presentation

History

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
  • Depressed mood
  • Restlessness
  • Anxiety
  • 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 [27]

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. [28]

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.

Rating scales

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. [29] However, use in dysthymia may be different from use in major depressive disorder.

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Physical Examination

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, [30] 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

Physical findings

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
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