Depressive disorders have a high prevalence in the world today. Among them, dysthymic disorder is one of the most frequent, being one of the disorders of high frequency in our times. Although dysthymia is a mild disorder in relation to the other affective pictures, its characteristics affect the quality of life in chronic form of those who suffer it.
In the DSM IV (1994), the term «dysthymia» was changed to «dysthymic disorder». A new change appears in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is the categorical modification of dysthymia, whose name has been replaced by that of persistent depressive disorder.
Dysthymia is used to describe an alteration of mood, a mild depression, chronic, which usually begins in late childhood or adolescence and whose evolution is prolonged. There are people who have been like this practically all their lives. Some authors speak of «depressive personality» in these cases. Many people with dysthymia come to believe that «they are like that», and do not identify dysthymia as a pathological condition, but as a normal state of their way of being.
Dysthymia is a frequent cause of personal discomfort and family troubles. People with dysthymia are often irritated, aggressive, easily to enter into discussions, have a tendency to self-reproach, little ability to enjoy and a low tolerance for frustrations.They are often described as «bitter», or as pessimistic, sad or introverted.
In most cases their sexual area is significantly affected, in many cases, the libido has decreased noticeably or no longer exists. If we begin to investigate reasons for this area may be affected and in many cases, what is behind is a dysthymia disorder.
People tend to suffer that their life has been invaded by a lot of stress and tension and people who suffer from it feel very tired, fall asleep, arrive late to work, their sex life is not very active and have no interest in socializing This could bring other consequences such as loss of work, marital difficulties, low self-esteem or, simply, frustration themselves.
It is also possible that people with dysthymic disorder have periods of normal mood that last up to two months and that their family and friends do not know that their loved one is depressed, because the dysthymic person is functional, that is to say, they carry out an activity habitual even with reluctance.
However, despite being a frequent disorder in the population, generally young, it is much less identified than other depressive disorders, in medical practice, dysthymia is not usually diagnosed or treated, due to many causes, including inadequate medical education, or time restrictions in the medical consultation.
Some define it as «bad mood» and because, the individual is usually sad, introverted, melancholic, excessively conscious, incapable of joy and worried about his personal inadequacy.What characterizes dysthymia are low-grade depressive symptoms, mainly subjective (humor and cognition) and the absence of objective signs (psychomotor and vegetative).
The term «dysthymia» means mood disease, it implies a temperamental dysphoria, that is, an innate tendency to experience depressed mood. On the contrary, «depressive neurosis» implies a pattern of thought and maladaptive and repetitive behavior that leads to depression. Patients in this second group are often described as anxious, obsessive, and prone to somatization.
Two types of dysthymic disorder can be seen: the sporadic one, with 85% of the cases, in which the patient has more depressed days than no, there is no sustained euthymia of more than 2 months, there are not depressive symptoms during 2 weeks or more. They are patients whose mood changes from depressed to normal sporadically.
The other type of dysthymia is less frequent: more chronic, with depressive symptoms every day, but without being a major depression. Depressive mood most of the day, almost every day, (feels sad or empty or sometimes cries).
Dysthymia occurs in 5-6% of the general population. It is more frequent in women under 64 years of age compared to men of any age. Other population groups where it is common are singles, young people and people with low incomes.
On the other hand, it can be a comorbid diagnosis of other mental illnesses such as major depressive disorder, anxiety disorders (especially panic disorders), substance abuse and borderline personality disorder.
A study published in 2012 found that, worldwide, the annual prevalence of dysthymia exceeds 105 million people (about 1.53% of the world population). In this sense, it is slightly more common in women (1.81%) than in men (1.26%)
An essential issue concerning the cause of dysthymic disorder is whether it is related to other psychiatric disorders, including major depressive disorder and borderline personality disorder, and keep numerous evolutionary, familiar, biological and even therapeutic coincidences with major depressions.
The category of dysthymia has been very heterogeneous, some biological aspects of dysthymic disorder support its inclusion in the group of mood disorders; other studies question this association. One hypothesis that is derived from the available data is that the biological basis for the symptoms of this disorder and for those of major depressive disorder are similar; however, the biological bases for the underlying illness in both disorders are different.
Sleep studies. One of the most studied aspects has been the REM latency (time elapsed from the beginning of sleep until the beginning of the phase of rapid eye movements). In normal subjects this time is around 90 minutes (70-120 minutes). However, it has been found that this latency is reduced in primary depressions.
Neuroendocrine studies. The two most studied neuroendocrine axes in major depressive disorder and dysthymic disorder are the adrenal and thyroid axis, which have been examined using the dexamethasone suppression test (DST), and the stimulation test of the release of the hormone thyrotropin (TRH), respectively.
Although the studies are not all uniform, most indicate that patients with a dysthymic disorder are less likely to have abnormal results on the DST than patients with a major depressive disorder.
The criteria require the presence of a depressed mood most of the time for at least two years (one year for children and adolescents). To meet the diagnostic criteria, the patient should not have symptoms that would allow diagnosing a major depressive disorder. The patient must never have suffered a manic or hypomanic episode.
DSM-V criteria (classification of the APA: American Psyshiatric Association) for the diagnosis of dysthymic disorder:
Chronically depressed mood communicated by the subject, or observed by others, which occurs most of the day on most days for at least 2 years. Note: In children and adolescents the mood may be irritable and the duration must be at least 1 year.
During depressive periods, at least two of the following symptoms are present:
Loss or increase of appetite.
Insomnia or hypersomnia.
Lack of energy or fatigue.
Decreased sexual performance
Lack of concentration or difficulty in making decisions.
Feelings of hopelessness
There are never been a manic episode, a mixed episode or a hypomanic episode and the criteria for cyclothymic disorder have never been met.
The alteration does not appear exclusively during the course of a chronic psychotic disorder, such as schizophrenia or a delusional disorder.
The symptoms are not due to the direct physiological effects of a substance (a drug, a medication) or medical illness (hypothyroidism).
Symptoms cause clinically significant discomfort or impairment in social, occupational or other important areas of the individual’s activity.
ICD-10 criteria (WHO classification) for the diagnosis of dysthymic disorder:
Presence of a period of at least 2 years of depressed mood continuously or constantly recurring.The periods of depression are not serious enough to meet criteria for depressive disorder.
At least in some periods, three or more of the following symptoms must be found:
Decrease in vitality or activity.
Loss of confidence or feelings of inferiority.
Difficult to focus.
Loss of interest in sexual or other pleasurable activities.
Feelings of hopelessness
Feelings of disability with respect to habitual responsibilities.
Pessimism about the future or pondering about the past.
Less loquacity than usual.
Propensity to the anhedonia (lack of capacity for the enjoyment of pleasurable situations)
Tendency to somatize in the form of dizziness or headache.
Lack of sexual desire and sexual fantasies, that is known medically under the name of: hypoactive sexual desire.
These include changes between appetite or sleep patterns. Low self-esteem, loss of energy, psychomotor retardation, decreased sex drive, and obsessive concern about health issues. Pessimism, despair and helplessness make these patients look like masochistic people. However, if pessimism is directed abroad, patients can rant about the world and complain that they are mistreated by family members, children, parents, friends, and throughout the system.
They can also present Alexitimia, which is a disorder in the way emotions are processed; is the inability of a subject to identify their emotions and, therefore, express them. The individual does not understand what he feels or knows how to describe it.
Between the 1950s and the 1960s, psychiatrists Peter E. Sifneos and John C. Nemiah, of Beth Israel Hospital, at Harvard, observed that many of their patients had serious difficulties talking about their emotions, were rigid, squared and did not use the fantasy. In 1972, Sifneos coined the term Alexitimia, from Greek A: «missing»; LEXIS: «word», THYMOS: «affection», which literally means «absence of verbalization of affections».
Alexithymia can be a curious disorder, but it is widespread among the population, affecting one in seven people. About 8% of men and 1.8% of women are alexithymic, as well as 30% of people with psychological problems and 85% of those with autism.
The deterioration of social functioning is sometimes the reason why patients with a dysthymic disorder consult. In fact, divorce, unemployment, and social difficulties are common problems in these patients.
They may complain of difficulties in concentrating and that their work and academic performance be affected by. Due to physical complaints, patients may miss work days and occasions in which to enjoy social contact.
Patients with this disorder may have problems of a couple that result from a sexual dysfunction, or the inability to maintain emotional intimacy.
COURSE AND PROGNOSIS
Approximately 50% of patients with a dysthymic disorder experience an early onset, patients suffer these symptoms for decades before consulting with the psychiatrist. Affected people may consider the early onset of their disorder simply as part of life. These patients have a higher risk of later developing a major depressive disorder or a bipolar I disorder.
If present, symptom-free periods do not exceed two months in a row and if they persist for more than two years, they can meet the criteria for a major depressive disorder and have never had manic or hypomanic episodes and do not meet the criteria for cyclothymia.
The prognosis for patients with a dysthymic disorder is variable, only 25% of patients with a dysthymic disorder never achieve a complete remission.
It is important that patients come to understand how they try to satisfy an excessive need for approval from others to strengthen low self-esteem, and how they try to satisfy an overly demanding superego.
The current trend in psychological treatments is more eclectic and uses all the previous paradigms, as well as elements of Gestalt, humanistic and group therapy in some cases, in an attempt that the patient changes his life story, his repetitive narrative, his way of seeing things and focus more on the here and now, so that you do not always resort to the same pattern, as entering «in a loop».
They must change the round and round without being able to establish contact with your surroundings in a satisfactory way so as not to repeat, once again, the rigid forms that were learned in the past, behaviors that might be useful in yesterday but that become inadequate at the current time
In people with sexual dysfunction, one must be especially careful in the choice of the drug, since the selective serotonin reuptake inhibitors (SSRIs) are the ones that can have the most side effects in this type of person.
Initial research indicates that bupropion, which acts via the dopamine and noradrenaline pathway can be an effective treatment for patients with dysthymic disorder, another candidate may be agomelatine that has a mechanism of action on melatonin, dopamine and noradrenaline, others to consider would be duloxetine and trazodone. Sympathomimetics can also be used in certain patients.
When an antidepressant is used in the treatment of dysthymic disorder, the maximum tolerated doses should be used for a minimum of eight weeks, before the specialist concludes that the treatment was not effective.
If a treatment was not effective, the specialist should reconsider the diagnosis, especially in regard to the possibility of an underlying medical condition (eg, a thyroid disorder) or an adult attention deficit disorder. If after a reconsideration of the differential diagnosis the dysthymic disorder is maintained as the most probable, the specialist should follow the same therapeutic strategy that would follow in the case of a major depressive disorder.