About dysthymia (persistent depressive disorder)

What is dysthymia (persistent depressive disorder)?

Dysthymia, now referred to as persistent depressive disorder, is a form of depression that lasts more than two years at a time in adults and more than one year at a time in children and adolescents.

  • Dysthymia can afflict 3%-6% of the United States population -- women more than men and more African Americans than Caucasians and some groups of Hispanic people.
  • Dysthymic disorder usually co-occurs with other disorders, like major depression, anxiety, personality or somatoform disorders, and with substance abuse.
  • People with dysthymia tend to have a number of biological, psychological, and environmental risk factors that contribute to its development rather than one single cause of the illness.
  • In order to meet criteria for the diagnosis of dysthymia, a person must experience symptoms of depression most of every day, more days than not, for at least two years in a row in adults, or one year for children and teens.
  • Health professionals will likely conduct or refer for an extensive medical interview and physical examination and will conduct a thorough mental-health assessment as part of establishing the diagnosis of dysthymia.
  • The treatment of dysthymia is found to be most effective when it includes both medication treatment and several weeks of talk therapy (psychotherapy).
  • Serotonergic medications (SSRIs) are often the first-line medication treatment for dysthymia due to their effectiveness and high tolerability.
  • Cognitive behavioral therapy (CBT) is effective as part of treatment for dysthymia.
  • People with dysthymia are at risk for having a compromised life adjustment, marital problems, and generally having low social support, even more so than people with major depression.
  • Attempts at prevention of dysthymia tend to address both specific and nonspecific risk factors and strengthen protective factors.

What is dysthymia?

Dysthymia, now referred to as persistent depressive disorder, is a form of depression that tends to be characterized by fatigue and other physical symptoms, low energy, low self-esteem, and changes in appetite or sleep. This mood disorder tends to be less severe than major depression. However, dysthymia is chronic, in that despite potential brief periods of normal mood, symptoms last at least two years at a time in adults and more than one year at a time in children and adolescents.

The cost of dysthymic disorder to individuals with dysthymia, their families, and society is significant. For example, people with this illness can be twice as likely to develop dementia and therefore be unproductive and otherwise unable to care for themselves compared to those without dysthymia.

Statistics on dysthymia include its affecting 3%-6% of the population and up to one-third of people receiving outpatient mental-health services in the United States. It tends to afflict women at a higher rate than men. While elderly individuals seem to be less likely to develop major depression compared to younger people, senior citizens are more at risk for developing the less severe but chronic dysthymia. In contrast to the prevalence of major depression in ethnic groups in the United States, dysthymia tends to be more common in African Americans than in Caucasians and some Hispanic Americans.

Dysthymic disorder usually co-occurs (is comorbid) with other disorders, most commonly with major depression, anxiety, personality or somatoform disorders, as well as with alcohol or other drug abuse.

What are the symptoms for dysthymia (persistent depressive disorder)?

Maois symptom was found in the dysthymia (persistent depressive disorder) condition

Symptoms of persistent depressive disorder can cause significant impairment and may include:

  • Loss of interest in daily activities
  • Sadness, emptiness or feeling down
  • Hopelessness
  • Tiredness and lack of energy
  • Low self-esteem, self-criticism or feeling incapable
  • Trouble concentrating and trouble making decisions
  • Irritability or excessive anger
  • Decreased activity, effectiveness and productivity
  • Avoidance of social activities
  • Feelings of guilt and worries over the past
  • Poor appetite or overeating
  • Sleep problems

In children, symptoms of persistent depressive disorder may include depressed mood and irritability.

What are the causes for dysthymia (persistent depressive disorder)?

The exact cause of persistent depressive disorder isn't known. As with major depression, it may involve more than one cause, such as:

  • Biological differences. People with persistent depressive disorder may have physical changes in their brains. The significance of these changes is still uncertain, but they may eventually help pinpoint causes.
  • Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.
  • Inherited traits. Persistent depressive disorder appears to be more common in people whose blood relatives also have the condition. Researchers are trying to find genes that may be involved in causing depression.
  • Life events. As with major depression, traumatic events such as the loss of a loved one, financial problems or a high level of stress can trigger persistent depressive disorder in some people

What are the treatments for dysthymia (persistent depressive disorder)?

For people with mild dysthymia who want to try treatment without medication, there are a number of lifestyle changes and home/natural remedies that may be useful. Healthy lifestyle changes that may help alleviate dysthymia include getting enough sleep, establishing a healthy diet, setting small goals for oneself, limiting alcohol intake, and abstaining from abusing any other drug. Some natural remedies that have found some success in treating mild depression include St. John's wort and SAM-e. However, these treatments have variable results and may result in side effects so should only be taken in cooperation with a physician.

The treatment of moderate to severe dysthymia is found to be most effective when it includes both medication treatment and at least 18 sessions of talk therapy (psychotherapy), but medications tend to be more effective compared to therapy alone.

Medications that increase the amount of the neurochemical serotonin in the brain are the most common group of medications used to address dysthymia since brain serotonin levels are often thought to be low in depression. The selective serotonin reuptake inhibitor drugs (SSRIs) work by keeping serotonin present in high concentrations in the synapses (spaces between nerve cells across which nerve signals are transmitted). These drugs do this by preventing the reuptake of serotonin back into the sending nerve cell. The reuptake of serotonin is responsible for turning off the production of new serotonin. Therefore, the message to continue making serotonin keeps on coming through. It is thought that this, in turn, helps arouse (activate) cells that have been deactivated by dysthymia, thereby relieving the person's symptoms.

SSRIs tend to have fewer side effects than the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), two other classes of antidepressant drugs. SSRIs do not interact with the chemical tyramine in foods, as do the MAOIs, and therefore do not require the dietary restrictions of the MAOIs. Also, SSRIs do not cause orthostatic hypotension (sudden drop in blood pressure when sitting up or standing) and heart-rhythm disturbances, like the TCAs do. Therefore, SSRIs are often the first-line treatment for dysthymia. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), and escitalopram (Lexapro).

SSRIs are generally well tolerated, and side effects are usually mild. The most common side effects are nausea, diarrhea, agitation, insomnia, and headache. However, these side effects generally go away within the first month of SSRI use. Some patients experience sexual side effects, such as decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. Some patients experience tremors with SSRIs. The so-called serotonergic (meaning caused by serotonin) syndrome is a serious neurologic condition associated with the use of SSRIs. It is characterized by high fevers, seizures, and heart-rhythm disturbances. This condition is very rare and tends to occur only in very ill psychiatric patients taking multiple psychiatric medications.

All patients are unique biochemically. Therefore, the occurrence of side effects or the lack of a satisfactory result with one SSRI does not mean that another medication in this group will not be beneficial. However, if someone in the patient's family has had a positive response to a particular drug, that medication may be the preferable one to try first.

Dual-action antidepressants (SNRIs) are thought to affect both serotonin and norepinephrine in the brain. Examples of that class of medications include venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq). While generally well tolerated, side effects of these medications can include flu-like symptoms (body aches, tiredness, dizziness), particularly when doses are missed.

Atypical antidepressants are not TCAs, SSRIs, MAOIs, or SNRIs, but they are effective in treating depression for many people nonetheless. More specifically, they increase the level of certain neurochemicals in the brain synapses. Examples of atypical antidepressants include trazodone (Desyrel) and bupropion (Wellbutrin).

Cognitive behavioral therapy (CBT): This has been found to be effective as part of treatment for depression. This approach helps to alleviate depression and reduce the likelihood it will come back by helping the dysthymia sufferer change his or her way of thinking about certain issues. In CBT, the therapist uses three techniques to accomplish these goals:

  • Didactic component: This phase helps to set up positive expectations for therapy and promote the person's cooperation with the treatment process.
  • Cognitive component: This helps to identify the thoughts and assumptions that influence the dysthymic individual's behaviors, particularly those that may predispose the sufferer to being depressed.
  • Behavioral component: This employs behavior-modification techniques to teach the person more effective strategies for dealing with problems.

What is the prognosis of dysthymia?

People with dysthymia are at risk for complications like having a compromised life adjustment, marital problems, and generally having low social support. It is thought that these risks are greater for dysthymia sufferers than even people with major depression because of the chronic nature of the illness and the greater influence of life stressors in the development of dysthymia. Having another mental-health condition, a history of trauma, or history of poor family relationships during childhood further negatively affects the prognosis of people with dysthymic disorder. The age that someone first develops dysthymia is also important to his or her prognosis. Those who experience their first episode of the illness prior to 21 years of age tend to have a worse prognosis than people who first have dysthymia at 21 years of age or older.

Is it possible to prevent dysthymia?

Attempts at prevention of dysthymia tend to address both specific and nonspecific risk factors and strengthen protective factors. Such programs often use cognitive behavioral and/or interpersonal approaches, as well as family based prevention strategies because research shows that these interventions are the most helpful.

The inverse of most risk factors, protective factors for depression include preventing exposure to neglect, abuse, community violence or other trauma, having the involvement of supportive family, strengthening family and peer relationships, and developing healthy coping skills and skills in emotional regulation. Children of a dysthymic parent tend to be more resilient when the child is more able to focus on age-appropriate tasks in their lives and on their relationships, as well as being able to understand their parent's illness. For depressed adults, their children seem to be more protected from developing the illness when the parent is able to demonstrate a commitment to parenting and to relationships.

What are the risk factors for dysthymia (persistent depressive disorder)?

Persistent depressive disorder often begins early — in childhood, the teen years or young adult life — and is chronic. Certain factors appear to increase the risk of developing or triggering persistent depressive disorder, including:

  • Having a first-degree relative with major depressive disorder or other depressive disorders
  • Traumatic or stressful life events, such as the loss of a loved one or financial problems
  • Personality traits that include negativity, such as low self-esteem and being too dependent, self-critical or pessimistic
  • History of other mental health disorders, such as a personality disorder

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