Dysthymic disorder

Bipolar disorder, type llc Dysthymic disorder Cyclothymic disorder ... 

The essential feature of major depressive disorder is a clinical course that is characterized by one or more major depressive episodes without a history of manic, mixed, or hypomanic episodes. Dysthymic disorder is a chronic disturbance of mood involving depressed mood and at least two other symptoms, and it is generally less severe than major depressive disorder. This chapter focuses exclusively on the diagnosis and treatment of major depressive disorder. 

The mood disorders were once called affective disorders and are grouped into two main categories unipolar and bipolar. The unipolar depressive disorders include major depressive disorder and dysthymic disorder the bipolar disorders include bipolar 1, bipolar II, bipolar not otherwise specified, and cyclothymic disorder. Other mood disorders are substance-induced mood disorders and mood disorders due to a general medical condition. In addition, mood disturbance commonly occurs as a symptom in other psychiatric disorders including dementia, post-traumatic stress disorder, substance abuse disorders, and schizophrenia. 

The differential diagnosis of depression is organized along both symptomatic and causative lines. Symptomatically, major depression is differentiated from other disorders by its clinical presentation or its long-term history. This is, of course, the primary means of distinguishing psychiatric disorders in DSM-1V. The symptomatic differential of major depression includes other mood disorders such as dysthymic disorder and bipolar disorder, other disorders that frequently manifest depressed mood including schizoaffective disorder, schizophrenia, dementia, adjustment disorder, and post-traumatic stress disorder, and, finally, other nonpsychiatric conditions that resemble depression such as bereavement and medical illnesses like cancer or AIDS. 

Dysthymic Disorder. Dysthymic disorder differs from MDD by being more chronic and less severe. Yet, two issues can cloud the distinction. First, some patients experience double depression in which an episode of major depression is superimposed on dysthymia. This can make it difficult to assess treatment response when the baseline mood is dysthymia instead of a normal euthymic mood. Second, a few patients may experience a chronic major depressive episode, which, like dysthymic disorder, lasts 2 years or more. In contrast to dysthymic patients whose insidious onset of symptoms leaves them unable to say exactly when the depression started, most patients with chronic major depression can tell when their depression began. 

The current SSRIs in the United States inclnde fluoxetine, fluvoxamine, sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). All effectively treat major depression. In addition, one or more of the SSRIs has been shown effective in the treatment of dysthymic disorder, the depressive phase of bipolar disorder, premenstrual dysphoric disorder, panic disorder, social phobia, obsessive-compnlsive disorder, bnlimia nervosa, and binge-eating disorder. 

Dysthymic disorder, also called dysthymia, is by definition a chronic illness that lasts two or more years. It consists of persistently depressed mood that is not as severe as major depression. However, double depression can occur in which a major depressive episode is superimposed on a preexisting dysthymia. It is unclear whether double depression is actually two illnesses or a single illness that varies in severity over time. Please refer to Table 3.12 for diagnostic criteria of dysthymic disorder. 

Dysthymia affects 3-6% of Americans in their lifetime. Similar to major depression, women have dysthymic disorder two to three times more often than men. Dysthymia usually begins in childhood or early adulthood. 

Untreated, dysthymic disorder is often a persistent, lifelong illness. It leads to significant functional disability, interfering with work productivity and participation in family and social activities. In addition, untreated dysthymic disorder often progresses to chronic or recurrent major depression. 

The assessment of dysthymic disorder is identical to that nndertaken for MDD. Causative factors such as medical illnesses, depression-indncing medications, or abused substances must be ruled out. Mild depressive symptoms in the context of other psychiatric disorders must also be ruled out. 

For many years, antidepressant medication was infreqnently nsed in the treatment of dysthymic disorder. The reasons are not entirely apparent. One possible explanation is the prevalent view of dysthymic disorder as a reactive phenomenon that arises out of psychodynamic conflict in contrast to major depression that is often... 

For whatever reason, few controlled trials of antidepressants have been performed in the treatment of dysthymic disorder. The limited evidence available, however, suggests that the same classes of antidepressants that effectively treat major depression also treat dysthymia. Reported side effects are similar with the newer agents tolerated better than TCAs. 

A trial of antidepressants is highly recommended in the treatment of dysthymic disorder. Although transference attitudes toward medications should always be explored, this may be especially true in treating a dysthymic patient. These patients commonly view their depressive symptoms as an integral part of their personality therefore, an antidepressant may be seen not as a treatment for an illness but as a confirmation of their defectiveness. In addition, the apathetic and pessimistic outlook of the dysthymic patient occasionally compromises treatment compliance. Because of these transference issues, a psychotherapy that does not ignore but explores the meaning of taking medication is indispensable to successful treatment. 

Antidepressants should be titrated to doses equivalent to those used in the treatment of major depression. Titrating to the lower end of the effective dose range should occur within the first 2 weeks. Thereafter, doses can be raised every 2-4 weeks until symptoms improve. Early evidence suggests that dysthymic patients respond more slowly to antidepressants than do patients with major depression. The proper duration of antidepressant treatment for dysthymic disorder is not known. The chronic nature of the disorder perhaps portends that longer term treatment should be anticipated however, this issue has not been well studied. 

These patients will often present with complaints of depressed mood or anxiety. The depression frequently takes the form of dysthymic disorder although these patients are at increased risk for major depressive disorder as well. Anxiety is often a symptom of the personality disorder itself, though comorbid Axis 1 anxiety disorders are occasionally present. Similar to the other personality disorders, there is a differential diagnosis that should be considered in patients who have a Cluster C personality disorder. 

MAPROTILINE HYDROCHLORIDE For the treatment of depressive illness in patients with depressive neurosis (dysthymic disorder) and manic-depressive illness, depressed type (major depressive disorder) also effective for the relief of anxiety associated with depression. 

Daviss, WB. (1999) Efficacy and tolerability of burproprion in boys with ADHD and major depression or dysthymic disorder. Child Adolesc Psychopharmacol Update 1(5) 1,6. 

Bakish D, Saxena BM, Bowen R, et al Reversible monoamine oxidase-A inhibitors in panic disorder. Clin Neuropharmacol 16 (suppl 2 S77-S82, 1993a Bakish D, Lapierre Y, Weinstein R, et al Ritanserin, imipramine and placebo in the treatment of dysthymic disorder. J Chn Psychopharmacol 13 409-414, 1993b Bakish D, Ravindran A, Hooper C, et al Psychopharmacological treatment response of patients with a DSM-111 diagnosis of dysthymic disorder. Psychopharmacol Bull 30 53-59, 1994... 

Personality disorders can complicate management (e.g., borderline disorder with a superimposed MDD). Dual depression occurs in patients who have chronic dysthymic disorder and then experience a superimposed MDD. Substance abuse and dependence are frequently co-morbid with mood disorders and substantially increase depression-related morbidity and mortality rates (see Drug-Induced Syndromes ). 

Akiskal HS, Lemmi H, Dickson H, King D, Yerevanian B, Van Valkenburg C (1984) Chronic depressions. Part 2. Sleep EEG differentiation of primary dysthymic disorders from anxious depressions. J Affect Disord 6 287-295... 

Depressive disorder (major depressive disorder, bipolar disorder, dysthymic disorder)... 

A 47-year-old man with a dysthymic disorder and intermittent panic attacks and rage outbursts took chromium 400 micrograms/day, and after 1 day had strikingly vivid dreams. Over the next several days there was a dramatic improvement in his mood and behavior. The efficacy of chromium was later confirmed by a double-blind, placebo-controlled, n-of-1 trial. 

By virtue of its severity and clinical impact, major depression is the primary focus of this chapter. However, given its prevalence in outpatient settings, dysthymic disorder—a mild but long-lasting depression— merits additional comments as well. Dysthymic disorder receives less attention from clinicians and less intellectual investment by researchers than major depression, although recently this trend has been somewhat reversed. Dysthymia is not as severe and disabling as MDD, yet it inflicts considerable psychological pain and personal and social burdens. 

Treatment for dysthymic disorder is similar to that for major depression. When a specific precipitating or sustaining stressor is present (medical, marital, interpersonal, occupational, etc.), as is often the case with these patients, this stressor must be addressed. Treatment includes specific forms of therapy—cognitive-behavioral and interpersonal, in particular—and medication. The clinicopharmacological concepts and techniques discussed in the treatment of major depression later in this chapter are generally valid as well for dysthymia. 

McLeod MN, Gaynes BN, Golden RN. Chromium potentiation of antidepressant pharmacotherapy for dysthymic disorder in 5 patients. J Clin Psychiatry 1999 60(4) 237 0. 

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