Dysthymic Disorder 300.4 DSM-IV
Dysthymic Disorder 300.4 DSM-IV
Dysthymia was first defined in DSM-III, the third edition of the Diagnostic and Statistical Manual of
Mental Disorders, to refer to chronic depressions of mild-moderate severity (DSM-III, APA, 1980). The
term literally means 'ill-humored’ or ‘despondent’ (American Heritage Dictionary, Fourth Edition, 2000).
Although the term is new, Dysthymia is based on several older clinical concepts, such as neurotic
depression, depressive personality, and chronic depression (Kocsis & Klein, 1995; DSM-IV, 1994).
According to DSM-IV (1994) criteria, the core features of the disorder include at least two years of
depressed mood for more days than not, including at least two additional symptoms related to poor
appetite or overeating, insomnia or oversleeping, fatigue or low energy, low self-esteem, poor
concentration or problems in decision making, and hopelessness (DSM-IV, 1994). Dysthymic individuals
tend to be self-deprecating and socially withdrawn. They may feel irritable and unproductive and spend
time brooding about the past. Dysthymia is also characterized by anhedonia, the inability to derive
pleasure from events or stimuli previously found pleasurable (Griffiths and Ravindran, 2000). It describes
a more chronic condition than Major Depression. It is one that is long term and pervasive. It is more
common among females than among males and can begin at any age, though onsets in childhood and
adolescence are more common (Kocsis & Klein, 1995).
Dysthymia usually appears in childhood or adolescence, and affects about three percent of the U.S.
population. Sufferers are functional but impaired, particularly in social and interpersonal relationships.
Antidepressant medications are often quite helpful in treating Dysthymia (Kocsis & Klein,
1995).Dysthymia is a type of depression that is relatively mild but it is chronic in nature. It describes
people who go through life with a mild level of dysphoria, or a state of just not feeling well. These
sufferers are also likely to have superimposed episodes of major depression. If the Dysthymia precedes
the onset of the first episode of major depression, the process is referred to as 'double depression'. If it
develops after the onset of the first major episode, it may be referred to as 'partial remission'. In either
case, it appears to be treatable with drugs or psychotherapy, although the change is usually not as
dramatic or as rapid as it is after episodes of Major Depression alone (Kocsis & Klein, 1995).
It is now generally accepted that Dysthymia belongs to the classification of mood/affective
disorders, rather than representing a depressive temperament. Yet a condition known as double
depression also exists, in which Dysthymia may be superimposed on a Major Depressive episode.
Dysthymia can be further broken down based on age at onset and non-behavioral symptoms, such as
increased or decreased appetite, weight gain or loss, or sleep disruptions. In addition, Dysthymia has
been subclassified, according to clinical symptoms and presence of family history, as subaffective
Dysthymia and character-spectrum Dysthymia (Griffiths and Ravindran, 2000). Subaffective Dysthymics
tend to respond to antidepressant medication and often have a family history of mood disorder, whereas
character-spectrum Dysthymics respond less well to medications and more often report a major loss as
well as family history of substance abuse (Griffiths and Ravindran, 2000).
Knowledge of the causes and origins of Dysthymia remains incomplete. Though it appears to run in
families, it is unclear whether this linkage is due to genetic or environmental factors, or a combination of
both. Dysthymia seems to be closely related to Major Depression, which is a more severe and episodic
form of depression. Most people who have Dysthymia experience exacerbations that meet the criteria for
Major Depression at some point in their lives, and there is a high rate of occurrence of Major Depression
in the families of people with Dysthymia (Kocsis & Klein, 1995).
In terms of treatment, there is evidence that Dysthymia responds to all the major classes of
antidepressant medications, although it may take a longer time to get a positive response than does
major depression. There is evidence that Dysthymia responds to some of the focused, short-term
psychotherapies that have been developed for major depression, such as cognitive therapy and
interpersonal therapy (Kocsis and Klein, 1995).
Though affecting only about three percent of the population, most of these are women, which make
up nearly three fourths of the sufferers. (Griffiths and Ravindran, 2000). It has been described as a mind-
Roger Bruce McNellie 1
Dysthymic Disorder 300.4 DSM-IV
wearing water torture as opposed to dramatic crash that is more associated with an incident of major
depression (McManamy, 1999). The chronic nature of this disorder is grinding, robbing the sufferer of the
will to succeed in life, to interact with others, and to enjoy the things that others take for granted. The
gloom that is generated warns away those who might serve as a social support system (McManamy,
The symptoms are similar to major depression, with feelings of despair and hopelessness, and low
self-esteem. It is often accompanied by chronic fatigue and often the two overlap. An estimated three to
twelve percent of those with Dysthymia opt for suicide as a solution, while a good number turn to alcohol
or drugs to mask its effects. Eventually for most, a bout with Major Depression occurs resulting in state of
double depression (McManamy, 1999).
The same drugs that are used to treat Major Depression are equally as effective for mild to moderate
depression. In addition, the herbal remedy St John's Wort has been found especially useful in treating
mild to moderate depression, without many of the side effects found in other medications. (Griffiths and
Dysthymics also respond well to two types of psychotherapy. Interpersonal therapy, which aims to
boost one's battered self-esteem, seems to be beneficial as does cognitive therapy, which addresses
erroneous thought patterns. Both therapies usually last from ten to twenty sessions (McManamy, 1999).
Early classifications of Dysthymia described it as a character disorder, in which the individual's main
problems stemmed from a depressive personality or temperament. For this reason, and because there
were few systematic studies on the efficacy of antidepressants in the treatment of Dysthymia, the
treatment of choice was psychotherapeutic in approach. The initial negative attitude toward the use of
drugs in treatment was partly the result of the types of medication that were available. The tricyclic
antidepressants were characterized by unpleasant side effects, and the clinicians were hesitant to
prescribe these medications in adequate doses and duration. Because Dysthymia was considered as a
mild form of Mood Disorder, it was usually treated with sub-threshold doses of antidepressants and for
In the past ten years, there has been evidence of Dysthymia's positive response to antidepressant
medication, especially to the newer generation of drugs such as Prozac, Zoloft, Paxil, Effexor and
Serzone (Griffiths and Ravindran, 2000). This evidence has shown that although the symptoms may be
less severe than those of Major Depression, Dysthymia requires just as aggressive, often longer-term
antidepressant treatment (Griffiths and Ravindran, 2000).
The success in treating Dysthymia with antidepressant medication supports the contention that, like
Major Depression, Dysthymia may have biological underpinnings. Research has been under way into the
immunologic, hormonal and neurotransmitter correlates of Dysthymia, as well as its genetic transmission
(Griffiths and Ravindran, 2000).
Although Dysthymia is not a new disorder, the possibility exists that its diagnosis is becoming more
talked about because of the success of the newer generation of antidepressants in treating its symptoms.
When the treatment of choice is more often the prescribing of medication, the disorder enters the realm of
the medical world, lessening the potential stigma that may be associated with a mental disorder once
thought to be a personality disturbance (Griffiths and Ravindran, 2000).
Dysthymic disorder is a chronic condition with a protracted course and a high risk of relapse. In
addition, almost all patients with Dysthymic disorder eventually develop superimposed Major Depressive
episodes. Although patients with Dysthymic disorder tend to show mild to moderate symptoms, from a
longitudinal perspective the condition is severe and equally debilitating. Dysthymic disorder is a low-
grade, chronic, depressive condition that is defined and distinguished from Major Depressive disorder
primarily on the basis of course and pervasiveness in the life of the sufferer (Keller et al., 1995).
Roger Bruce McNellie 2
Dysthymic Disorder 300.4 DSM-IV
Dysthymic disorder is common, affecting not only 3%-6% of individuals in the community (Kessler et al.,
1994; Weissman et al., 1988), but 22%-36% of outpatients in mental health settings (Klein, Dickstein, et
al., 1989; Markowitz et al., 1992). However, given its high prevalence and the central role of chronicity in
its definition, there are surprisingly few data on the naturalistic course of Dysthymic disorder. Of the few
existing prospective longitudinal studies of Dysthymic disorder, most have used small study groups and
short, two years or less, follow-up periods (Barrett, 1984; Gonzales et al., 1985; Keller et al, 1983; Klein
et al., 1998; Kovacs et al., 1994; McCullough, Kasnetz, et al., 1988; McCullough, Mccune et al., 1994).
These studies have indicated that approximately 40% of the individuals with Dysthymic disorder recover
within 24-30 months of study entry (Barrett, 1984; Keller et al, 1983; Klein et al., 1998). By 1999,
whether or not the rate of recovery increased substantially with longer follow-ups, was not known. In
addition, few data are available on the probability of relapse or recurrence among patients who have
recovered from Dysthymic disorder (Ravindran et al., 1999).
In the same study, compared to patients with episodic Major Depressive disorder, patients with
Dysthymic disorder were less severely depressed at initial examination, but exhibit higher levels of
symptoms in follow-ups conducted 6-30 months later (Klein, Norden et al., 1998; Klein, Taylor et al.,
1988; Wells et al., 1992). A small proportion of adults and children with Dysthymic disorder developed
Bipolar Disorder during the course of follow-up, although the risk may not differ from that of individuals
with Major Depressive disorder (Kovacs et al., 1994; Fava et al., 1996). Individuals with Dysthymic
disorder are at high risk of developing superimposed Major Depressive episodes (Kovacs et al., 1994;
Scott and Stradling, 1990). Although there is a high probability of recovering from a superimposed Major
Depressive episode, there is a substantial risk of relapsing into another episode (Gonzales, 1985; Keller
et al., 1983; Klein, Norden, et al., 1998; Kovacs et al., 1994; Wells et al., 1992). Comparisons of the
rates of recovery from, and relapse into, Major Depressive episodes between patients with Dysthymic
disorder and patients with episodic Major Depressive disorder have been inconsistent (Gonzales, 1985;
Keller et al., 1983; Klein, Norden, et al., 1998; Kovacs et al., 1994; Wells et al., 1992).
A long term study completed by Klein, Schwartz, Rose, and Leader in 2000, described a five year
course and outcome of Dysthymic disorder. The authors did a study of 86 outpatients with early-onset
Dysthymic disorder and 39 outpatients with episodic Major Depressive disorder. The long term follow-ups,
conducted 30 and 60 months after entry into the study, rated patients on the Longitudinal Interval Follow-
Up Evaluation and the Modified Hamilton Rating Scale for Depression (Klein, et al. 2000). The estimated
five year recovery rate from Dysthymic disorder was 52.9%. Among patients who recovered, the
estimated risk of relapse was 45.2% during a mean of 23 months of observation. Patients with Dysthymic
disorder spent approximately 70% of the follow-up period meeting the full criteria for a Mood Disorder.
During the course of the follow-up, the patients with Dysthymic disorder exhibited significantly greater
levels of symptoms and lower functioning and were significantly more likely to attempt suicide and to be
hospitalized than were patients with episodic Major Depressive disorder. Finally, among patients with
Dysthymic disorder who had never experienced a Major Depressive episode before entry into the study,
the estimated risk of having a first lifetime Major Depressive episode was 76.9% (Klein, et al. 2000).
Differential Diagnosis Issues
In terms of psychological diagnosis, differentiation should be made between the following conditions
and Dysthymia as some of the symptoms may overlap. Manic, Mixed, or Hypomanic Episode; Mood
Disorder Due to a General Medical Condition; Substance-Induced Mood Disorder; Schizoaffective
Disorder; Schizophrenia; Delusional Disorder; Psychotic Disorder Not Otherwise Specified; dementia;
Major Depressive Disorder; chronic Psychotic Disorders; coexisting personality disturbance (DSM-IV,
The principal difficulty in diagnosis of the disorder is related to its shared symptoms with Major
Depressive Disorder. In obtaining a history of whether or not there have been one or more discrete Major
Depressive Episodes that can be distinguished from the person’s usual functioning, is often quite difficult.
Differentiation between chronic symptoms and an occasional severe episode is often impossible to
ascertain from a patient provided history. Also, similar symptoms are associated with chronic psychotic
disorders such as schizoaffective disorders, schizophrenia, and delusional disorders (DSM-IV, 1994).
Roger Bruce McNellie 3
Dysthymic Disorder 300.4 DSM-IV
Differentiation between symptoms brought on by an underlying medical condition and Dysthymia is
also difficult at times. These are mood disorders due to a general medical condition. A variety of organic
mood syndromes can be caused by Acquired Immune Deficiency Syndrome (AIDS), Adrenal (Cushing's
or Addison's Diseases), Cancer (especially pancreatic and other GI), Cardiopulmonary disease,
Dementias (including Alzheimer's Disease); Epilepsy, Fahr's Syndrome, Huntington's Disease,
Hydrocephalus, Hyperaldosteronism, Diabetes Mellitus, Infections (including HIV and neurosyphilis),
Migraines, Mononucleosis, Multiple Sclerosis, Narcolepsy, Neoplasms, Parathyroid Disorders (hyper- and
hypo-), Parkinson's Disease, Pneumonia (viral and bacterial), Porphyria, Postpartum, Premenstrual
Syndrome, Progressive Supranuclear Palsy, Rheumatoid Arthritis, Sjogren's Arteritis, Sleep Apnea,
Stroke, Systemic Lupus Erythematosus, Temporal Arteritis, Trauma, Thyroid Disorders (hypothyroid and
"apathetic" hyperthyroidism), Tuberculosis, Uremia (and other renal diseases), Vitamin Deficiencies (B12,
C, folate, niacin, thiamine), Substance-Induced Mood Disorder, and Wilson's Disease. (Long, 2000) If the
symptoms are a psychological reaction to having the medical disorder, then Dysthymia would be the
correct diagnosis. If the symptoms are related directly to the medical condition, then Dysthymia would not
be diagnosed (DSM-IV, 1994).
It is also possible that Dysthymia may be present with a personality disturbance. Both diagnoses
would be used in this case, Dysthymia and coexisting personality disturbance (DSM-IV, 1994).
The Center for Epidemiologic Studies-Depression Scale (CES-D) (Radloff, 1977) is a widely used,
psychometrically derived, self-report instrument, consisting of 20 items. It was designed to assess
depressive symptomatology in community samples and has been found to have high reliability with
samples of diverse ages and ethnic backgrounds (Beals et al., 1995; Garrison et al., 1991; Radloff, 1977;
Radloff and Teri, 1986). Several studies have found higher CES-D scores among ethnic minority groups
(Kuo, 1984; Manson et al., 1990; Swanson et al., 1992; Ying, 1988). However, it is unclear whether these
differences reflect actual differences among groups in depressive symptomatology or whether the CES-D
may be a less valid measure of depression for non-Caucasian groups. Noh et al. (1992) found that higher
CES-D total scores among Koreans were attributable to increased scores on items from the Positive
Affect factor. In contrast, Somervell et al. (1993), found the CES-D had high sensitivity (78%) and
specificity (85%) for predicting major depression among a Native American sample.
Most studies of the CES-D have found significant gender differences, with females having higher
scores than males and more likely to exceed cutoff scores for identifying clinical depression (Berganza
and Agular, 1992; Radloff and Rae, 1981; Brown et al., 1992; Gjerde et al., 1988). These differences are
similar to gender differences in the prevalence rates of depressive disorders in national epidemiological
studies (e.g., Kessler et al., 1994). (Prescott et al., 1998)
Several previous studies have examined the predictive validity of the CES-D for identifying
depression among adolescents. Roberts and colleagues (1991) studied the utility of the CES-D in
screening for major depression and Dysthymia in 1,700 clinically interviewed high school students from
Oregon. Using a cross-classification table, they reported that current CES-D had a sensitivity of 85% and
specificity of 76% but positive predictive value (PPV) of only 10% for predicting a combined classification
of major depression and Dysthymia which is in keeping with the known difficulties in making a differential
diagnosis between the two disorders. Garrison and colleagues (1991) used the CES-D in a two-stage
screening study of young adolescents. They reported high sensitivity and specificity, and PPVs of up to
30% for predicting major depression and Dysthymia.
Though not as dramatic an illness as Major Depression, Dysthymia is just as destructive in that it
robs the sufferer of a life of joy, replacing it with despondency and ill temperedness. Fortunately, a
combination of psychotherapy and drugs appear to be effective in its treatment. The more critical question
is whether or not it can be accurately diagnosed and treatment be brought to bear in an effective and
timely manner before a life has been lost to the despair of Dysthymia.
Roger Bruce McNellie 4
Dysthymic Disorder 300.4 DSM-IV
Diagnostic Criteria 300.4 DSM IV (DSM-IV, 1994).
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective
account or observation by others, for at least 2 years. Note: In children and adolescents, mood
can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. poor appetite or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or difficulty making decisions
6. feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has
never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year
for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major
Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive Episode provided there was a full
remission (no significant signs or symptoms for 2 months) before development of the Dysthymic
Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic
Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both
diagnoses may be given when the criteria are met for a Major Depressive Episode.
E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria
have never been met for Cyclothymic Disorder.
F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder,
such as Schizophrenia or Delusional Disorder.
G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning (DSM-IV, 1994).
Roger Bruce McNellie 5
Dysthymic Disorder 300.4 DSM-IV
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