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Chapter: Essentials of Psychiatry: Mood Disorders: Depression

Dysthymic Disorder

Dysthymic disorder is defined by the presence of chronic de-pressive symptoms most of the day, more days than not, for at least 2 years.

Dysthymic Disorder




Dysthymic disorder is defined by the presence of chronic de-pressive symptoms most of the day, more days than not, for at least 2 years. While chronic depressive conditions were tradi-tionally conceptualized as characterological and amenable to psychotherapy and resistant to pharmacotherapy, recent phar-macologic trials of antidepressants as well as depression-spe-cific psychotherapy have demonstrated effectiveness in the overall treatment of DD. Both focused interpersonal and varia-tions of cognitive–behavioral psychotherapy have demonstrated response in dysthymia. Individuals with DD have a substantial risk for the development of MDD. This highlights the impor-tance of early assessment and treatment to minimize subsequent long-term complications.


If signs and symptoms of DD follow a MDD, then a diag-nosis of MDD, in partial remission, is made. A diagnosis of DD can be made if the individual develops full remission of MDD for 6 months and subsequently develops signs and symptoms of DD which then last a minimum of 2 years. In contrast, the diagnosis of chronic MDD is made when an episode of MDD meets full criteria for MDD continuously for at least 2 years. If DD has been present for at least 2 years in adults (or 1 year in children and ado-lescents) and is subsequently followed by a superimposed MDD, then both DD and MDD are diagnosed, which is often referred to as “double depression”. The following specifiers apply to DD as noted in DSM-IV:


·   Early onset – if the onset of dysthymic symptomsoccurs be-fore age 21.


·    Late onset – if the onset of dysthymic symptoms occurs at age 21 or older, and with atypical features.


Atypical features refer to a pattern of symptoms which include mood reactivity and two of the additional atypical symp-toms (i.e., weight gain or increased appetite, hypersomnia, leaden paralysis, or interpersonal rejection sensitivity). Early-onset DD is usually associated with subsequent episodes of MDD. DD with atypical features may herald a bipolar I or II course.


Ongoing studies have not completely clarified the distinc-tion between DD and depressive personality disorder. Depressive temperaments may predispose an individual to a condition within the spectrum of Axis I mood disorders. However, it may not be specifically associated with MDD. This depressive temperament may also be associated with vulnerability to bipolar disorder.




A lifetime prevalence of 4.1% for women and 2.2% for men was reported for DD (Weissman et al., 1988). In adults, DD is more common in women than in men. In children DD occurs equally in both sexes. Across both women and men, DD has a 2.5% 12-month prevalence (Kessler et al., 1994, 2005).


Comorbidity Patterns


Individuals with early-onset DD are at substantial risk for de-velopment of other psychiatric conditions including alcohol or substance dependence, MDD and personality disorders. Up to 15% of patients with DD may also have a substance use pattern that meets criteria for comorbid alcohol or substance dependence diagnosis. The most common associated personality disorders include mixed, dependent and borderline. Childhood and ado-lescent-onset DD is associated with a substantial risk for later occurrence of both MDD and bipolar disorder.


Etiology and Pathophysiology


Biological Findings


Sleep abnormalities demonstrate reduced REM latency, increased REM density, reduced slow wave sleep and impaired sleep con-tinuity in 25 to 50% of individuals with DD. There are minimal data on cortisol or thyroid abnormalities in individuals with DD. Other neurobiological studies have not yielded consistent results.


Diagnosis and Differential Diagnosis


The diagnosis of DD cannot be made, if depressive symptoms occur during the course of a nonaffective psychosis such as schizophrenia, schizoaffective disorder, or delusional disorder. Diagnosis of depressive disorder NOS is made if there are symp-toms which meet criteria for MDD during the residual phase of a psychotic disorder. If DD is determined to be etiologically related to a chronic medical condition, then one diagnoses secondary mood disorder due to a general medical condition. If substance dependence is judged to be the etiologic factor, then a substance-induced mood disorder is diagnosed. Individuals with DD often have cooccurring personality disorders and in these situations separate diagnoses on Axis I and II are made.


Course and Natural History


Dysthymic disorder often begins in late childhood or early ado-lescence and by definition takes a chronic course. The risk for development of MDD among children who have DD is significant because childhood onset of DD is an early marker for recurrent mood disorder, both recurrent MDD and bipolar disorder.

The course of DD suggests impairment in functional sta-tus including social and occupational, and physical function-ing. Patients who have both DD and MDD have more severe functional impairment. Untreated DD contributes to significant occupational and financial burden. There is substantial reduc-tion in activity, more days spent in bed, more complaints of poor general medical health, and more disability days than reported in the general population.


The treatment goals in DD are similar to those in MDD. They include full remission of symptoms and full psychosocial recovery.


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