Persistent Depressive Disorder (dysthymia)

Overview

Persistent depressive disorder (PDD), formerly known as dysthymia (dis-THIE-me-uh) , is a fairly new diagnosis that is characterized by chronic depression. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) consolidated dysthymia and chronic major depressive disorder under the umbrella of persistent depressive disorder, which includes any chronic depression running on a spectrum from mild to severe.

These diagnostic changes were made to reflect the fact that there is no scientifically meaningful distinction between chronic major depressive disorder and what was previously known in the DSM-IV as dysthymic disorder.

The word dysthymia comes from the Greek roots dys, meaning “ill” or “bad,” and thymia, meaning “mind” or “emotions.” The terms dysthymia and dysthymic disorder referred to a mild, chronic state of depression.

You may lose interest in normal daily activities, feel hopeless, lack productivity, and have low self-esteem and an overall feeling of inadequacy. These feelings last for years and may significantly interfere with your relationships, school, work and daily activities.

If you have persistent depressive disorder, you may find it hard to be upbeat even on happy occasions — you may be described as having a gloomy personality, constantly complaining or incapable of having fun. Though persistent depressive disorder is not as severe as major depression, your current depressed mood may be mild, moderate or severe.

Symptoms

Persistent depressive disorder symptoms usually come and go over a period of years, and their intensity can change over time. But typically symptoms don’t disappear for more than two months at a time. In addition, major depression episodes may occur before or during persistent depressive disorder — this is sometimes called double depression.

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.

When to see a doctor

Because these feelings have gone on for such a long time, you may think they’ll always be part of your life. But if you have any symptoms of persistent depressive disorder, seek medical help.

Talk to your primary care doctor about your symptoms. Or seek help directly from a mental health professional. If you’re reluctant to see a mental health professional, reach out to someone else who may be able to help guide you to treatment, whether it’s a friend or loved one, a teacher, a faith leader, or someone else you trust.

Diagnosis

To make an accurate diagnosis, your doctor will first perform a physical examination. Your doctor will also perform blood tests or other laboratory tests to rule out possible medical conditions that may be causing your symptoms. If there’s no physical explanation for your symptoms, then your doctor may begin to suspect that you have a mental health condition.

Your doctor will ask you certain questions to assess your current mental and emotional state. It’s important to be honest with your doctor about your symptoms. Your responses will help them determine whether you have PDD or another type of mental illness.

Many doctors use the symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to diagnose PDD. This manual is published by the American Psychiatric Association. The PDD symptoms listed in the DSM-5 include:

• a depressed mood almost every day for most of the day
• having a poor appetite or overeating
• difficulty falling asleep or staying asleep
• low energy or fatigue
• low self-esteem
• poor concentration or difficulty making decisions
• feelings of hopelessness

For adults to be diagnosed with the disorder, they must experience a depressed mood most of the day, nearly every day, for two or more years.

For children or teens to be diagnosed with the disorder, they must experience a depressed mood or irritability most of the day, nearly every day, for at least one year.

If your doctor believes you have PDD, they’ll likely refer you to a mental health professional for further evaluation and treatment.

Causes

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

Risk factors

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

Complications

Conditions that may be linked with persistent depressive disorder include:

• Reduced quality of life
• Major depression, anxiety disorders and other mood disorders
• Substance abuse
• Relationship difficulties and family conflicts
• School and work problems and decreased productivity
• Chronic pain and general medical illnesses
• Suicidal thoughts or behavior
• Personality disorders or other mental health disorders

Prevention

There’s no sure way to prevent persistent depressive disorder. Because it often starts in childhood or during the teenage years, identifying children at risk of the condition may help them get early treatment.

Strategies that may help ward off symptoms include the following:

• Take steps to control stress, to increase your resilience and to boost your self-esteem.
• Reach out to family and friends, especially in times of crisis, to help you weather rough spells.
• Get treatment at the earliest sign of a problem to help prevent symptoms from worsening.
• Consider getting long-term maintenance treatment to help prevent a relapse of symptoms.

Treatment

Treatment for PDD consists of medication and talk therapy. Medication is believed to be a more effective form of treatment than talk therapy when used alone. However, a combination of medication and talk therapy is often the best course of treatment.

Medications

PDD can be treated with various types of antidepressants, including:

• selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft)
• tricyclic antidepressants (TCAs), such as amitriptyline (Elavil) and amoxapine (Asendin)
• serotonin and norepinephrine reuptake inhibitors (SNRIs), such as desvenlafaxine (Pristiq) and duloxetine (Cymbalta)

You may need to try different medications and dosages to find an effective solution for you. This requires patience, as many medications take several weeks to take full effect.

Talk to your doctor if you continue to have concerns about your medication. Your doctor may suggest making a change in dosage or medication. Never stop taking your medication as directed without speaking to your doctor first. Stopping treatment suddenly or missing several doses may cause withdrawal-like symptoms and make depressive symptoms worse.

Therapy

Talk therapy is a beneficial treatment option for many people with PDD. Seeing a therapist can help you learn how to:

• express your thoughts and feelings in a healthy way
• cope with your emotions
• adjust to a life challenge or crisis
• identify thoughts, behaviors, and emotions that trigger or aggravate symptoms
• replace negative beliefs with positive ones
• regain a sense of satisfaction and control in your life
• set realistic goals for yourself

Talk therapy can be done individually or in a group. Support groups are ideal for those who wish to share their feelings with others who are experiencing similar problems and pychotherapy  may involve a range of different techniques, but two that are often used are cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT).

• CBT: This type of therapy focuses on learning to identify and change the underlying negative thought patterns that often contribute to feelings of depression.
• IPT: This therapy is similar to CBT but focuses on identifying problems in relationships and communication and then finding ways to make improvements in how you relate to and interact with others.

Lifestyle Changes

PDD is a long-lasting condition, so it’s important to participate actively in your treatment plan. Making certain lifestyle adjustments can complement medical treatments and help ease symptoms. These remedies include:

• exercising at least three times per week
• eating a diet that largely consists of natural foods, such as fruits and vegetables
• avoiding drugs and alcohol
• seeing an acupuncturist
• taking certain supplements, including St. John’s wort and fish oil
• practicing yoga, tai chi, or meditation
• writing in a journal