DYSTHYMIA AND OTHER MOOD DISORDERS
THE HARVARD MENTAL HEALTH LETTER, MAY 1991
The word "depression" can be used to describe anything from a passing
mood to a chronic illness with severe physical as well as psychological
symptoms. Depression is regarded as a psychiatric disorder when it is deep and
persistent enough to interfere with
work, friendships, family life, and physical health.
Common symptoms of major, or severe, depression are inconsolable misery,
despair, guilt, suicidal thoughts, low self-esteem, irritability, a sense of
helplessness, inability to concentrate or make decisions, loss of interest in
life and incapacity for pleasure. Some
depressed patients have expressionless faces, move slowly,
and speak tonelessly. Others pace, weep, and wring their hands in agitation.
Disordered mood also takes the form of physical symptoms -- chronic fatigue,
loss of appetite, insomnia (or sometimes oversleeping and overeating), upset
stomachs, constipation, backaches, headaches, and other pains. Episodes of major
depression usually last several months and may recur throughout a lifetime. A
disorder with similar but longer-lasting
and milder symptoms is Dysthymia (the Greek roots of the word mean "bad
state of mind" or ("ill humor").
By the standard psychiatric definition, this disorder lasts for at least two
years, but is less disabling than major depression; for example, victims are
usually able to go on working and do not need to be hospitalized. About 3
percent of the population will suffer from Dysthymia at some time -- a rate
slightly lower than the rate of major depression. Like major depression,
Dysthymia occurs twice as often in women as it does in men. It is also more
common among the poor and the unmarried. The symptoms usually appear in
adolescence or young adulthood but in some cases do not emerge until middle age.
At first the disorder may take the form of poor school performance, social
withdrawal, shyness, irritable hostility, and conflicts with parents. Sometimes
the symptoms include
physiological abnormalities that also occur in major depression, such as short
REM latency (dreaming that starts unusually early in the night) and other sleep
irregularities.
Dysthymia is common in the children of parents with major depression,
and the rate of mood disorders in the families of people with the early-onset
variety is as high as 50 percent. The high rate of family transmission suggests,
although it does not prove, that the disorder has a genetic basis.
It is also a serious illness that often becomes worse. Most persons with
Dysthymia eventually develop major depression; nearly half of patients treated
for depression are suffering from this "double depression." They
differ very little from other patients
with major depression in biological, social, and psychological functioning, or
in the rate of mood disorders in their families. After recovery from major
depression, a milder chronic condition often persists for years, heightening the
danger of relapse. This
residual depression is not diagnosed as Dysthymia unless the patient had
Dysthymia before developing major depression.
DIAGNOSTIC AMBIGUITY
Similar symptoms may arise not only from primary Dysthymia and residual
depression but also in connection with anxiety and panic disorders, drug and
alcohol dependence, eating disorders, attention deficit disorder, and chronic
physical illnesses. At
least three-quarters of patients with Dysthymia have some other psychiatric or
medical disorder as well. If it can be determined that the other illness came
first, Dysthymia is regarded as secondary, but often the effort to sort out the
symptoms and
disentangle cause and effect is futile.
Diagnostic confusion and ambiguity are even greater when personality is taken
into account. Many symptoms of this long-lasting disorder can be interpreted as
personality traits, especially when they appear early in life. Timidity,
brooding, low self-esteem, submissiveness, and social maladroitness are typical
characteristics of dependent, obsessive-compulsive and avoidant personality
disorders as well as Dysthymia. Until 1980, when it was removed from the
official manual of the American Psychiatric
Association, the diagnosis of depressive personality was given to many cases of
what is now called Dysthymia. That term, or the related "characterological
depression," is still favored by many European and some American
psychiatrists. They argue, for example,
that depressive personality can be distinguished from Dysthymia because it is
more common in men and less often associated with depression in family members.
But now the majority opinion is simply that many people have both Dysthymia and
a quiet, passive, gloomy personality.
Other persons vulnerable to chronic depression are moody, demanding,
self-dramatizing, complaining, and impulsive. Their symptoms may include
alcoholism and other drug abuse, intense anger and anxiety, hypersensitivity to
both criticism and praise, and constantly changing psychosomatic complaints.
Alcoholism and criminal activity, rather than mood disorders, are common in
their families. Their personalities are often described as histrionic,
borderline, or antisocial. Some patients in whom these symptoms
are combined with others (oversleeping, overeating, a leaden feeling that
overcomes the body in waves) may be suffering not from Dysthymia but from a
distinct disorder known as atypical depression or hysteroid dysphoria. Still
another name for related conditions is "depressive spectrum disorder"
-- a term that deliberately blurs the distinction between personality and mood
disorders.
Cyclothymia is a mood disorder related to both personality disorders and
Dysthymia. In this illness the alternating mania (uncontrolled elation) and
depression of bipolar disorder take a milder and less disabling form.
Cyclothymic persons endure short and irregular cycles of energetic activity and
lethargy, optimism and pessimism, insomnia and oversleeping, jocularity and
tearfulness, arrogance and self-pity, passionate involvement and sudden loss of
interest. Their marriages fail; they periodically abuse alcohol and other drugs
and repeatedly change jobs and homes. Just as people with dysthymia usually have
episodes of major depression, people with cyclothymia are vulnerable to both
major depression and mania. But ordinarily their erratic behavior and troubled
family lives are more obvious than any underlying mood cycle. Many of their
symptoms resemble borderline or histrionic personality, and at one time they
were given the
diagnosis of cyclothymic personality disorder. This diagnostic indecisiveness results from the complicated
relationship between personality and mood. It is an
oversimplification to say that personality is enduring and mood is episodic, or
even to say that personality is more fundamental and pervasive than mood. A
personality trait, by definition, is a susceptibility to certain states of mind
and an inclination to
certain kinds of behavior, so the symptoms of personality and mood disorders
overlap. There is no sharp distinction between emotional weather and emotional
climate in individuals.
Certain personality types are more vulnerable to mood disorders. People
are more likely to become depressed and slower to recover if they are
either withdrawn, submissive, and unreasonably self-critical, or unstable,
impulsive, and hypersensitive to loss. On the other
hand, defective mood regulation may cause disturbances in a person's social and
emotional life that resemble character pathology. Another possibility is that
personality and mood disorders often coincide simply because both are so common.
TREATMENT
The choice of treatment may be influenced by these difficult distinctions
between personality and mood disorders and among the various types of mood
disorder. Psychiatrists now find Dysthymia and other mood disorders in many
cases where they would once have diagnosed a personality disorder, mainly
because they have
discovered that mood-regulating drugs are an effective treatment for a wider
range of symptoms than they once suspected. Tricyclic antidepressants, the
standard treatment for major depression, are also useful for both Dysthymia and
residual depression.
In one study 13 percent of patients recovered from Dysthymia with a placebo and
59 percent with Imipramine (Tofranil ®) at the same dose used to treat major
depression. The newer non-tricyclic antidepressant Fluoxetine (Prozac ®) may
work even better, with
fewer side effects. According to some authorities, the best treatment for
symptoms identified as atypical depression or Hysteroid Dysphoria is another
type of antidepressant drug, an MAO (monoamine oxidase) inhibitor. Lithium, the
standard treatment for
bipolar illness, can also be used for Cyclothymia. Most psychiatrists would
prescribe one of these drugs to patients with a diagnosis of primary or
secondary Dysthymia, Cyclothymia, atypical depression, depressive spectrum
disorder, or even some
personality disorders.
But drugs are often ineffective when the depressed patient is angry,
self-dramatizing, hypersensitive, "mood-reactive" rather than
exhausted and inconsolably gloomy; and even when drugs provide some relief,
social and psychological problems must
usually be addressed in psychotherapy. Patients without serious personality
disturbances can make use of supportive psychotherapy, which offers advice,
reassurance, and sympathy. Counseling
on the management of stress is also important.
Cognitive therapy is used to alter patients' self-defeating
thoughts; behavioral treatment may help them unlearn learned helplessness.
Psychodynamic therapists identify and resolve unconscious conflicts derived
largely from childhood experience. Interpersonal psychotherapists concentrate on
restoring self-esteem and improving communication with friends, families, and co-workers.
Social skills training may be important for people with early-onset Dysthymia
who have never learned how to cope with the adult world. Successful treatment of
alcoholism, panic disorder, or eating disorders usually relieves the associated
Dysthymia.
But in many cases the symptoms are hard to recognize and classify, and the
response to treatment is unpredictable. Most people with Dysthymia and related
disorders see only their family doctors, who may misdiagnose them, especially if
the main complaints are
physical. Many patients do not think of themselves as depressed and are relieved
when told they have a treatable illness. Unfortunately, mental health
professionals are usually consulted only when major depression develops,
although Dysthymia alone may
lead to alcoholism or suicide. Even when it is recognized, Dysthymia, like
personality disorders, is difficult to treat. The longer a depression lasts, the
slower the recovery. One study found that two years after treatment, according
to their own reports, 75 percent of patients with major depression but only 43
percent of patients with Dysthymia had recovered. Another study found that on
the average Dysthymia lasted five-and-a-half years.
FOR FURTHER READING
Hagop S. Akiskal and Radwan F. Haykal. Dysthymic, "atypical," and
residual depressive disorders. In Anastasios Georgotas and Robert
Cancro, eds. Depression and Mania. New York: Elsevier, 1988.
James H. Kocsis and Allen J. Frances. A critical discussion of
DSM-III dysthymic disorder. American Journal of Psychiatry,
144:1534-1542 (December 1987). Katharine A. Phillips, John G.
Gunderson, Robert M. A. Hirschfeld, and Lauren E. Smith. A review
of the depressive personality. American Journal of Psychiatry,
147:830-837 (July 1990).
Myrna M. Weissman, Philip J. Leaf, Martha Livingston Bruce, and
Louis Florio. The epidemiology of dysthymia in five communities:
rates, risks, comorbidity, and treatment. American Journal of
Psychiatry, 145:815 819 (July 1988). R. Alnaes and S. Torgensen.
Personality and personality disorders among patients with major
depression in combination with dysthymic or cyclothymic disorders.
Acta Psychiatrica Scandinavica, 79:363-369 (1989).
President and Fellows of Harvard College, 1991
Reprinted with permission.