Persistent Depressive Disorder (Dysthymia) DSM-5 300.4 (F34.1)

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Introduction

Persistent depressive disorder (PDD), also known as dysthymia, is a chronic depression that is present for most days over a period of two years. The symptoms are milder than major depressive disorder but additional symptoms involved in MDD may develop during dysthymia and lead to a diagnosis of MDD. The comorbidity of both these disorders is known as a double depression. About 30% of depressions are classified as chronic.

In DSM-5 (APA 2013), dysthymic disorder and major depressive episode were combined under the umbrella disorder of persistent depressive disorder. Generally, cognitive symptoms are more prevalent in dysthymic such as low self-esteem and social withdrawal while lack of sleep or appetite are more common in major depressive episode. It is not uncommon for PDD to evolve into MDE, triggering the individual to seek medical attention.

Symptoms of  Persistent Depressive Disorder

A diagnosis of persistent depressive disorder must meet all of the following criteria (American Psychiatric Association, 2013):

The individual must be in a depressed mood for most of the day for the majority of days over at least a two year period, indicated either by subjective account or the observation of others. In children and adolescents, the duration must be at least one year, and the mood can be irritable.

While depressed, two or more of the following must be present:

  • Poor appetite or overeating
  • Insomnia or hypersomnia
  • Low energy or fatigue
  • Low self-esteem
  • Poor concentration
  • Feelings of hopelessness
  • During the two year period, the symptoms have not been absent for less than two months at a time.
  • The criteria for a major depressive order may be continuously present for the two years .
  • The individual has never experienced a manic or hypomania episode.
  • The criteria for cyclothymic disorder has never been met.
  • The criteria for schizoaffective disorder, schizophrenia, delusional disorder or other psychotic disorder does not better explain the disorder.
  • Drug abuse or another medical disorder do not explain the symptoms.

Note: Four additional symptoms are included for a diagnosis of major depressive episode. If all of the symptoms of MDE are present during the period of the depression, a diagnosis of major depressive episode should be made.

Persistent Depressive Disorder Therapies and Treatment

Much of the literature on therapies for chronic depression addresses the old criteria treating dysthymia and major depressive disorder under separate rubrics. A January 2014 German metastudy has provided a useful overview of the efficacies of PDD treatments. This study found that interpersonal psychology with medication is more efficacious than medication alone in chronic major depression but not dysthymia. Cognitive behavioral analysis was more effective than interpersonal psychotherapy (Kriston et al, 2014).

A comparison of the efficacy of psychotherapy and pharmacotherapy in treating depression over 67 studies showed that psychotherapy is equally effective as SSRIs, which are widely used. Given the side effects and potential for addiction with pharmacotherapy, the results make a case for the increased use of psychotherapy. In terms of types of psychotherapy, there were some indications that interpersonal psychotherapy is the most effective while psychodynamic and non-directive counselling therapy may be less effective (Cuijpers, 2013). The success of interpersonal therapy may be partly explained by the interpersonal nature of some of the underlying causes or triggers of PDD. Whether using pharmacotherapy, psychotherapy or a combination of both, long-term treatment is associated with positive treatment outcomes.

An ambitious review of the efficacy of mood disorder therapies across 125 studies concluded that interpersonal psychotherapy (IPT), cognitive behavior therapy and behavior therapy are efficacious in the treatment of major depressive disorder. IPT is possibly efficacious in the treatment of dysthymia (Hollon and Ponniah 2010).

Other therapies used to treat dysthymia include couple therapy. Strains in personal relationships often result from the change in mood of those affected. Mindfulness therapy based on cognitive therapy has been shown to have a positive effect on symptoms of dysthymia, including depression, anger and obsessive rumination (Madahi et all, 2013)

Living With Persistent Depressive Disorder on Daily Life

Persistent depressive disorder symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. While dysthmia is sometimes referred to as low-grade depression, its effects especially after two years can have a significant impact on one’s quality of life . An individual experiencing chronic depression may withdrawal from life. He/she may lose enthusiasm for daily activities and work, and experience a lack of energy and appetite. In a more extreme form of dysthymia, the afflicted may withdraw from daily activities. A loss of enjoyment from formerly pleasurable events and feeling of hopelessness are often experienced. As a result of this lack of enthusiasm and energy, performance may decline at work. The person may experience a productivity decline. Performance at school may be lower. Personal relationships may become strained and even break up. The symptoms of PDD are often ignored and the condition undiagnosed, prolonging the negative impact on quality of life.

Family and life circumstances can be a predictor of dysthymia. A person with a first degree relative with dysthymia or major depression is at a higher risk of acquiring it. Loss of a loved one or a breakdown in a relationship may change and create a negative self-perception. A failure such as a change in professional status or financial situation may lead to the development of lower self-esteem.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Kriston, L., Wolff, A., Westphal, A., Hölzel, L. P., & Härter, M. (2014). EFFICACY AND ACCEPTABILITY OF ACUTE TREATMENTS FOR PERSISTENT DEPRESSIVE DISORDER: A NETWORK META‐ANALYSIS. Depression and anxiety.

Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds, C. F. (2013). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta‐analysis of direct comparisons. World Psychiatry, 12(2), 137-148.

Hollon, S. D., & Ponniah, K. (2010). A review of empirically supported psychological therapies for mood disorders in adults. Depression and anxiety, 27(10), 891-932.

Madahi, M. E., Khalatbari, J., Dibajnia, P., & Sharifara, B. (2013). The efficiency of based on mind fullness cognitive therapy upon depression, anger, obsessive rumination in dysthymic patients. HealthMed, 7(3).


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