Dysthymic Disorder

“I have taken it upon myself to educate people…. I say I have finally arrested a lifelong disease. And they say, ‘What did you have? What is that?’ [I say] ‘Depression. It is called dysthymia.’ I am not ready to do that publicly, but I say that all the time.”
— Anonymous
On The Edge of Darkness
HISTORY

Dysthymic disorder, also called dysthymia, is a relatively new term in psychiatry, first introduced in 1980. By definition the word means “ill-humored,” and implies that one who is prone to dysthymic disorder possesses an inborn tendency to experience depressed moods.

The disorder has been plagued by a lack of clinical agreement regarding its diagnosis, but nonetheless it was the most common psychiatric diagnosis in the 1970s. During that period, the disease was referred to as depressive neurosis or neurotic depression.

In DSM-III-R, dysthymia was recognized as a depressive disorder, as insidious and debilitating as major depressive disorder, not simply as a personality type.

EPIDEMIOLOGY

Dysthymic disorder, a mild, chronic depression of at least two years duration, is a fairly widespread psychiatric condition, affecting 3 to 5 percent of all persons, and as many as one half of all patients seen in psychiatric clinics. Dysthymic patients often suffer from more than one brain disorder, especially major depressive disorder, anxiety disorders or substance abuse. Because of these multiple associations, dysthymic patients are often prescribed multiple psychiatric medications. The vast majority of patients with dysthymia develop superimposed episodes of major depression, resulting in a state of “double depression.”

The disorder is much more prevalent in women; in fact, it is more common in women up to 64 years of age than in men of any age. However, some studies suggest that the disorder is experienced more by adolescent  boys (8 percent) than girls (5 percent).

ETIOLOGY

DSM-IV contains a description of dysthymic disorder in the section on mood disorders. This suggests similarities with major depressive disorder in cause, genetic bases, prognoses, and treatment responses.

DIAGNOSIS AND CLINICAL FEATURES

The essential difference between dysthymic disorder and major depressive disorder is the intensity and duration of symptoms. Dysthymia is defined as a low-grade, chronic depression. In dysthymic disorder, the presence of a depressed mood for at least two years (with no more than two months of wellness) is required for diagnosis; in major depressive disorder, the diagnosis is based upon the presence of symptoms nearly every day for two weeks. The diagnostic symptoms for the illnesses are similar (see page 9 of this document), but usually the number of depressive symptoms is lower in patients with dysthymic disorder.

Dysthymic individuals, on the surface, may seem to be fairly productive; they may be employed and involved in social and marital relationships. However, impairment of physical and social functioning, a requirement of diagnosis, is often more significant than it appears to be, and is often
the motivate for an individual to seek professional assistance.

COURSE AND PROGNOSIS

Dysthymia is often misdiagnosed and undertreated due to the low-grade severity of the disorder. Because the symptoms of dysthymic disorder have been apparent for so long, many people do not seek treatment, or they delay seeking treatment for 10 or more years. In fact, many patients who delay seeking treatment indicate that they do so because they believe depressive symptoms are part of their inherent personality. Most do not recognize that they are experiencing symptoms of depression. Unfortunately, for those patients with an early onset of symptoms, the disorder may lead to major depressive disorder or bipolar disorder.

Bipolar Disorder
“Manic depression distorts the moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origin, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide.”

— Kay Redfield Jamison, PhD
An Unquiet Mind

HISTORY

Although there are early writings on manic depression–or bipolar disorder–it is primarily during the last 100 years that psychiatrists have fully identified the characteristics of the disease.

In 1686 Bonet described a mental illness that he called maniaco-melancholicus and in 1854 Jules Falret described a condition called folie circulaire, in which the patient experienced alternating moods of depression and mania.

But it was not until 1899, when Emil Kraepelin described a manic-depressive psychosis, that the criteria for the illness were defined. Today, most of the criteria identified by Dr. Kraepelin are used by psychiatrists in establishing the diagnosis for bipolar disorder.

EPIDEMIOLOGY

Bipolar disorder has a lifetime prevalence of 1.2 percent. The onset of bipolar disorder can begin as early as 5 or 6 years of age, with a mean onset of age 30. Manic symptoms are frequently seen in the elderly, but usually these symptoms can be attributed to another medical condition; it is rare for the onset of the disease to occur in this population. Bipolar disorder is equally common in men and women, but interestingly appears
to have a higher than average incidence among upper socioeconomic groups, most likely due to biased diagnostic practices.

ETIOLOGY

Many recent studies have shown that there is a strong genetic connection in the transmission of bipolar disorder; family studies repeatedly have found that first-degree relatives of diagnosed patients are significantly more likely to have bipolar disorder than first-degree relatives of control subjects. Studies also show that about 50 percent of all bipolar disorder patients have at least one parent with a mood disorder.

COURSE AND PROGNOSIS

Bipolar disorder is a recurring mood disorder that most often starts with depression — 75 percent of the time in women and 67 percent in men. In most cases, episodes of depression and mania will occur, but in a small percentage of cases, 10 to 20 percent, only manic episodes are experienced. Manic episodes may evolve over a few weeks, but typically symptoms have a much more rapid onset‹days, or even hours.

Variations in the course of bipolar disorder have led researchers to identify subtypes within the illness. One of these subtypes, rapid cycling, is defined as four or more manic, hypomanic or depressive episodes in any 12-month period. Depressive episodes are defined as lasting two weeks or longer; hypomanic episodes are defined as lasting four days or longer; and manic episodes are defined as lasting one week or longer
or requiring hospitalization. In actual experience, episodes can be much more frequent, and therefore shorter. Episodes are not truly cyclic, but rather occur in a random pattern.

Another subtype, mixed states (also called mixed mania), occurs when an individual has episodes of both mania and depression daily for one week.

Bipolar disorder is recurring, but fortunately the time between episodes increases for most patients. After approximately five episodes, there is generally a six to nine month interval before symptoms reemerge.

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