Pediatric Persistent Depressive Disorder (Dysthymia) Clinical Presentation

Updated: Oct 14, 2016
  • Author: Jeffrey S Forrest, MD; Chief Editor: Caroly Pataki, MD  more...
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Presentation

History

The clinical history is crucial in making the diagnosis of persistent depressive disorder (PDD). 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 addition to taking the patient’s history, conducting a thorough physical examination is important, to rule out medical illness as a cause of symptoms.)

In the case of all suspected depressive disorders, suicidal ideation, homicidal ideation, and a history of behavior in which the patient has harmed himself/herself 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.

DSM-5 criteria

Diagnostic criteria taken from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), from the American Psychiatric Association (APA) are as follows [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, the parental report may emphasize behavioral difficulties expressing depression, whereas the child can give a better account of internalizing symptoms, including suicidal ideation
  • B - The 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 - Criteria for a major depressive disorder may be continuously present for 2 years
  • E - No manic episode, mixed episode, or hypomanic episode is 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, schizoaffective disorder, or delusional disorder
  • G - The symptoms are not due to the direct physiologic 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

Additional symptoms

Symptoms associated with PDD but not included in the formal diagnostic criteria are anger, feelings of being unloved, self-deprecation, anxiety, and disobedience.

The chronic course of PDD can contribute to academic, social, and behavioral disruption, with profound effects on psychological and educational development. Children and adolescents with PDD may develop more acute and intense depressive symptoms sufficient to meet the criteria for major depression.

Symptoms found primarily in children

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 PDD.

Persistent depressive disorder versus major depressive disorder

A considerable overlap of symptoms is observed between PDD and major depressive disorder, and the relationship between them is the subject of ongoing debate. However, PDD and major depressive disorder differ in terms of chronicity and pervasiveness.