Dysthymia

Abstract

Dysthymia is described as a disorder that is characterized by smouldering mood disturbance. It also causes transient moods between normal moods. It has been known to affect grownups for periods ranging from at least two years (American Public Health Association, 2011). The disorder appears to be genetically susceptible. In places like the United States, the disorder is not much widespread and represents a population of 3% to 6% and have a representation of 7% in the primary care (Cohen et al., 2013). Its etiology appears to be somehow a mystery, but the disorder has links with some genetic inheritance. The disorder, therefore, seems to be under-recognized in many circumstances. Treatment of dysthymia is done in various ways that include psychotherapy and pharmacotherapy. The overall treatment, however, is determined by the extent and the symptoms exhibited by the disorder.

Dysthymia occurs in 0.5-4.5% of the children and between 1.5-8% of the adults. The condition is chronic and it becomes depressive, However, it has lesser symptoms than in the major depression. It is also called the neurotic depression, and it consists of the same problems as in the depression, and this is from the disorders that it causes on the moods. The condition may last for long periods of up to two years, and mostly it may have the victims experience the symptoms for very long periods. This means that it may go on for a long period without being diagnosed in the victims. Moreover, in around 50% of the patients experience the severe symptoms that may go up to 4 years and third may have effects such as bringing the disabling effects and the abnormal psychosocial functioning or lead to major effects such as the relapse or end up bringing the major depression.

Introduction

Dysthymia is a disorder that has long been characterized by longstanding mood disorder that comes with fluctuating dysphoria and some short periods of common moods. This disorder is far less symptomatic than depression that might be firmly consumed with. It is at times referred to as dysthymic disorder (DD). Dysthymia might be difficult to detect and has a linage with the genetic structure of the victim. The major aims of having to treat the condition are to resolve the symptoms that are attached to the depression. The other major aim is to stop the probability of the advancement of the mood disorder and go ahead to make the psychosocial function better. Since the conditions come with many problems, it is good to have it approached from intervening on the victim’s condition and have the treatment in different levels and measures. The diagnosis is mostly in cases of depression or moods that are noted in the victim. In some cases, where the disorder has been after one year, it is advisable to have the double depression diagnosis (Kaplan, 2007).

From researches and studies it has been seen that the dysthymic disorder that is early onset is a long lasting condition and in most reported cases led to relapse and mood disorders in the later stages. From a study that was done on the follow-up of the patients with the disorder, it was realized that at some point in life the victims had a depressive disorder. Some of the practical effects that have been experienced are such as suicidal evidence. The victims show some threats of committing suicide or they may keep showing suicide ideas, or it may be too bad to have one successful suicide.

It has at time been known as being chronic and a low-grade representation of depression, however, occurs in a substantial population. The disorder might pave the way for depression whatsoever since it shares some characteristics with depression. The common factors might be seen in the process of coping or response to some medication.

Symptoms

Some of the major symptoms are the poor attentive and overeating, low insomnia energy and fastened fatigue, difficulty in making decisions and poor concentration and the lack of hope in all the endeavors. When the patient has two or more of these symptoms, it is a clear indication of the disorder. However, in the children that may indicate fewer symptoms and among the symptoms are having irritable mood and impaired concentration. The other known effect is the impairment of the psychosocial performance (Leatherdale, 2013). According to a sample that was taken on the victims, it shows that they tend to keep themselves from socializing with others. The sample showed that the affected people kept of activities that involved other people such as sports and their relationship with their friends are quite bad. Since it mostly affects the teenagers and at their stage, it is very crucial for them to develop the situation may lead to negative impacts on the education performance. The condition of the improper functioning may also go on even when they recover from dysthymic disorder (Mathews, 2010). This means that in the later stages of life they may still have problems in their social existence. As earlier seen the major symptoms are as follows: –

low self-esteem,
feelings of hopelessness.
poor concentration or difficulty making decisions,
poor appetite or overeating,
low energy or fatigue,
hypersomnia or insomnia

Dysthymia’s clinical and epidemiological features

Since dysthymia is referred to as bad mood it is therefore associated with some characteristics and symptoms that are effective, cognitive and near vegetative. While its severity is less profound than that of depression, symptoms might seem to fluctuate and intensify with time. It has been experienced in the past as explained by Cohen et al., (2013). Several sub-branches of dysthymia have been associated with age, family history and some even base the effects of dysthymia as being more personality-based.

Clinical Assessment

The DSM approach

This approach acknowledges the role of one clinically relevant specifier which is the early and late onset of dysthymia. There are different stages of onset that are associated with this disorder. Early onset and late onset have a broad distinction since both take place at different times and ages. Early onset is seen before the victim gets to 21 years and is characterized with by higher relapse rates while late onset occurs during later times of the victims age (Markowitz, 2008). Early onset has a major role in causing personality disorders and comorbid major depression.

Comorbidity issues.

Psychiatric Comorbidity frequencies are associated with dysthymia in many circumstances. According to (American Public Health Association, 2011), “pure” dysthymia is very in common in many institutes since many cases show related effects such as anxiety disorders, personality disorders, somatoform disorders and mild depression.

Difficulties with the clinical detection of dysthymia

It has been difficult over the years to diagnose dysthymia in the clinics since there is no defined way of doing it. The difficulties are notable since they are similar in almost every institution. In the clinical detection of soft mood symptoms, the seemingly modest nature of the symptoms might make the doctors under-recognize the disorder.

Explicitly, the waning and waxing or seemingly smouldering symptoms course can be easily matched with the patients’ social situations. This makes it harder for the doctors or the family to detect the existence of the disorder in many circumstances (Thande, & Marx, 2009). Additionally, the disorder, compared with other types disorders, show symptoms that are relatively covert. This means that the patient shows low self-esteem and concentration difficulties rather than compulsive behaviors in obsessive-compulsive disorder, hallucinations in schizophrenia, or purging in bulimia nervosa (Markowitz, 2008). Similarly, individuals with mild signs might find themselves being easily overlooked since the dysthymia symptoms have varying amplitudes in different people. They vary from one patient to another.

Risk factors

Some of the conditions are the factors that are associated with the risk of getting the disorder. Some of them are demographic factors. Examples of these factors are such as sex and age. Sex in being female have them at a higher risk of having the disorder. For the age factor the age of around 15 years the risk of getting the same is higher than at older ages (Hooley et al., 2009). The other risk factors may be the psychopathology which is the history of the victim. In this case, man’s is that the people who have had the disorder at some point in their life are at a higher risk of getting it again. Moreover, the factors may be also familial factors. In this case, the factors depend on the genetics of the family. For a family that has a history of some of the family members having the disorders affect the children who are also at a higher side of getting the same. The psychosocial factors are another major affecting risk factors. In this case, it depends on the events that happen in life. For the people who face challenges in life such as lack of support and the lack of proper maternal care may be at a higher risk since they have much that is in their mind that is troubling them.

Distracting psychiatric comorbidity

Dysthymia as earlier said, rarely appears in a pure form. The majority of cases will, therefore, be comorbid psychiatric disorders that many times seem to compete for diagnostic detection. They are associated with various anxiety and mood disorders and somatoform, personality and substance use disorders (Markowitz, 2008). They are all likely to be present in a patient and mostly causes symptoms such as depression in later stages.

Distracting Somatic Comorbidity

Patients with dysthymia who have milder symptoms and lower education often present somatic comorbidity in primary care settings (Markowitz, 2008). These somatic symptoms most of the times cover the underlying mood disorder to appear as if it does not exist.

Lack of patient recognition in early-onset dysthymia stages

When the dysthymia systems have been present for a long time, that is if they started showing during childhood or at adolescence, the victims might fail to acknowledge that the disorder exists and might seem to think that their conditions are personality characteristics. They might fail to identify the mood disturbance as a disorder but might take it as a self-character.

Misdiagnosis of symptoms.

As is the case with most primary care clinicians, detection and diagnosis of major depression are easy since most of them have in depth knowledge in that. The reason behind this is that symptoms of major depression tend to be more dramatic. They are often easily identified since they tend to be linked to alterations in neurovegetative rhythms (Thomas & Hersen, 2010). Patients, therefore, tend to get treatment for depression, instead of dysthymia due to the many similarities that occur in both (dysthymia and major depression).

Discriminating depressive disorders: a simple approach.

It is advisable to test patients with depression for dysthymia. This could be done by presenting the victim with a figure shows the similarities and differences between major depression and dysthymia. Dysthymia is more characterized by an insidious onset, that exhibit waning symptoms that often show for at least two years. Brief periods of normal mood are as well experienced. On the other hand, major depression has a fairly well-defined onset, which shows discrete episodes and sustained symptoms. Having a simultaneous discussion about these syndromes and illustrating them as well for the with patients to see quickens the determination of the dominant disorder.

Treatment

Pharmacotherapy.

According to (Thomas & Hersen, 2010) almost any medication used for depressive mood disorders could be effectively used to treat dysthymia. This has been confirmed by research where a degree of efficacy in treating the disease is experienced. This includes the treatments with newer antidepressants, for instance, duloxetine (Thomas & Hersen, 2010). However, despite statistically significant changes in improving the health status of the patient, the overall responses tend to be modest (Markowitz, 2008). The finding has made health practitioner recommend sufficient drug-evaluation tests and trials that mostly take three months before being fully accredited. Though there is no defined duration of pharmacotherapy in treating dysthymia, a lifelong treatment seems inevitable in many circumstances. Many patients, however, experience relapses as well as loss of medication efficacy after a period of continued treatment. This is characterized by adjustments in augmentation strategies and changes in antidepressants.

Psychotherapy. Psychotherapy has been crucial in many instances of treating dysthymia. However, (Markowitz, 2008) has an opinion that treatment with psychotherapy is somewhat slow and difficult. Different types of psychotherapies include interpersonal psychotherapy (IPT), cognitive behavioral analysis system of psychotherapy (CBASP) (American Public Health Association, 2011), manualized group therapy, (Cohen et al., 2013), cognitive behavioral therapy, (Thomas & Hersen, 2010) and problem-solving therapy. (Markowitz, 2008) psychodynamic or supportive psychotherapies might also be of great help.

Pharmacotherapy vs. Psychotherapy.

According to many studies and research made, pharmacotherapy tends to receive much more support than psychotherapy. In comparing both of them, some studies might seem to hold mixed conclusions. However, the majority of them seem to recommend pharmacotherapy over psychotherapy. (Markowitz, 2008) This does not mean that those individuals with dysthymia who have responded positively to psychotherapy should have opted to prefer otherwise since it is not guaranteed that better outcomes would be achieved. It could even be better if both types of interventions were applied.

General Treatment Way

As earlier established, the main aim of the treatment is to stop the depressive symptoms. The treatment becomes helpful at the younger age because at this age the victims have not fully developed, this helps to save the mood that may be destroyed in later stages. This saves them later mood disorders. However, even after the many numbers of youthful people getting the disorder, there are few studies on the condition that have been carried out. For the treatment of the paediatric dysthymia, it is important to focus more on intervening on the children and the adolescents. Even in the event of the development of the treatment, it is very key to take into account of the peculiar aspects. This is because the improvement of the depressive symptoms does not always help to recover the psychosocial functions. Over the past few years, there have been studies, and they have revealed that the treatment of the dysthymic condition sometimes worsens especially from the comorbid situations. For effective treatment, approaches should include different interview sessions between the parents and the children and the adolescents. This helps since the parents give their view on the behavior while the children will give the internal symptoms.

It should be noted that the treatment should be individual and according to the patient. For example, for the children with the dysthymic condition they should have treatment with individual therapy on the psychological sector, treatment of the pharmacological sector and the psychological education that has proved useful. These components are useful irrespective of the use of medications. However, before starting the treatment, it is important to evaluate the functioning and the symptoms. The evaluation can be done using the depression scales. A good example of the scale is the Children Depression Inventory or the Hamilton Depression Scale Rating. It is good to note that the impairment in the functioning can be evaluated through the Children Global Assessment Scale.

Psychoeducational interventions.

This is a method that should be carried out on the children, parent or the caretaker during the treatment even if the medication is not used. This helps to give more information to the child, family, and the other concerned members about the symptoms. This is the main aim of this way of treatment since it helps to help understand the treatment duration, effects of medication, education guidelines and the consequences of the same. This helps to encourage the child to avoid the bad feeling by staying and trying to function normally (Durand & Barlow, 2010). For the family members it important to have them informed of the aspects since it comes a long way to help them understanding the child’s requirement. This helps in reassuring the child rather than worsening the case by the unusual behaviour that they may come across. This helps even in the observing the symptoms in case the problem comes back. With the education part, it helps to reach to the youth who are having the disorder but do not dare seek treatment (Ayd, 2011). Even in a school setting, it should be ensured that it reduces on the stressful demands.

Supportive Treatment

The main aim of this method of treatment is to provide support to the patients. This assists the people giving the patients expression of feelings by giving them an audience to listen to them. Showing the empathy helps to improve the situation, and this makes the therapist work easier in giving the skills. From the previous studies, it has shown that the supportive group treatment was more helpful than a group that was trying to solve problems to reduce the depression symptoms.

Psychological therapies

The main aim of this way of treatment is to modify the personality, and this may have an effect on the long lasting mood. Improvement of the emotional management skills, the improvement of the behavior and helping the victim to be able to handle stressful life events that may occur are the other main aims of this treatment. This method has proven useful in situations where there is a challenge with the patient not responding to the medication such as the antidepressants. It may also be used in situations where the patient’s family refuses the medication of the pharmacological sector.

It is also important to note that the response to the psychotherapy has a relation to different factors such as the onset age, presence of psychiatric disorder, psychopathology of the parents, stressful events among others. The factors are also most similar to the factors that affect the risk of getting the dysthymia disorder. The quality of treatment and the therapist’s knowledge may also affect the response of the medication. But the factor that depends on the victim is the way of understanding of the moods and the ways that are helpful in managing it. All these are the aspects that should be looked at when establishing the plans on this treatment since they can affect the repetition of the depression.

Reports show that other psychological therapies work in treating the condition. These therapies include family therapy, cognitive-behavioural therapy, and interpersonal psychotherapy. The aim of these is keeping the patient company to help the patient cope and lead a healthy relationship.

The best treatment for dysthymia is a combination of both medication and psychotherapy. This is because the clinical therapies take care of the prevailing condition while the psychological part take care of the victims’ psychology. A review shows that serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs) are all equally effective, but selective serotonin reuptake inhibitors (SSRIs)are better as compared to them. There have been positive results with duloxetine, bupropion, mirtazapine, venlafaxine and nefazodone since they are noradrenergic agents (Thase & Lang, 2014). Second-generation antipsychotics have shown some advantages as compared to placebo in dealing with dysthymia or even other major depressive disorder (Thomas & Hersen, 2010). However, most of them have proven to be worse tolerable, the main reason being due to weight gain, sedation, and prolactin increase (American Public Health Association, 2011). According to Thase & Lang, (2014), there are some beneficial effects of low-dose amisulpride people with dysthymia.

The use of a combination of Psychotherapy and medication is common since both are an effective treatment for dysthymia. There are, however, many different modes of psychotherapy, which include cognitive, psychodynamic, behavioral therapy and insight-oriented psychotherapy. These are the interpersonal intervention they are mostly done. (CBASP) Which is the short form for Cognitive Behavioural Analysis System of Psychotherapy, however, attracted attention for treating chronic depression (Markowitz, 2008). CBASP, according to (Thase & Lang, 2014) is a form of psychotherapy developed for victims of chronic depression. The procedures involved teaches patients on the best ways of handling problematic interpersonal encounters. The method encourages patients to address their interpersonal problems by looking at the consequences caused by their behaviors. They are therefore required to use their social problem-solving algorithm in addressing the difficulties they face.

CBASP is considered to be more directive and structured than interpersonal psychotherapy. It differs from cognitive therapy since it focuses on interpersonal interactions. The combination of both of the methods of treatment, therefore, works best than the application of either of them alone.

Cognitive behavioural therapy

This is a more structured therapy, and it is more effective in the treatment. In this method it is time limited to the intervention and the main aim of the treatment is to look more into the different patterns of behavior and its management skills. It takes the assumption that the coping behavior and the abnormal thoughts are the major reasons for the symptoms of depression. It has techniques of help the patient set goals and to help improve the problem-solving skills. However, having a follow-up treatment for this case has shown more probability of having a relapse (Andrews, 2010). For this matter, it has proven useful to carry out the continuation treatment which reduces the chances of relapse.

Interpersonal therapy

This method is manual based and has time limits. The main aim of this is that the therapist helps the patient to connect the links between the moods and the personal experiences. It has proven effective in the treatment of the acute of depressive disorder in the adolescents. According to recent studies it has shown that this kind if therapy improved the self-esteem in most of the patients who used it.

Family therapy

This method of treatment is mostly suitable for the youths. This is because the youths have a more often association between the family dysfunction and the depressive symptoms. This shows the contributions between the genetic factors and the environments that the patient is surrounded in. Some of the examples that have led to the depressions are the parental criticism, the poor parental communication. Some of these poor relationships and the family burden leads to the disorders of the personality. This requires the family members’ involvement in the treatment plan. Mostly the involvement of the parents in the treatment of the children have proven useful in the recovery (Andrasik, 2006).

Psychodynamic psychotherapy

The method has proven useful in some situations but has not worked in al situations. However, from studies, this approach has been seen time-to consume and quite expensive than others. This is because the approach requires control groups and standardized measures that are added (Akiskal & Cassano, 2007). This method helps to identify their feelings and help them to cope with the conflicts that they face.

Pharmacological treatment

The use of this method should depend on the efficacy of a given drug for a certain disorder. It has also been noted that the use of antidepressants in the treatment that is associated with the impairment that is related to the disorder.

Etiology of Dysthymia

Over the years there has been no consistent, pervasive biological abnormality confirmed among the patients of the disorder. This might be closely related to clinical as well as etiological heterogeneity (Thomas & Hersen, 2010). Some abnormalities associated with patients suffering from then disorder include the following: elevations in interleukin-1, polysomnographic sleep irregularities, lower platelet monoamine oxidase activity in female patients and serotonergic dysfunction. In families that have dysthymic probands, there is a higher possibility of a member suffering from the condition than an individual that comes from a family that does not have a dysthymic history. This proves the point that the condition might be genetic. Other factors that might contribute to suffering from then disorder include exposure to stress as at early stages in life, unfavorable social circumstances such as isolation and lack of support from family or peers and poor conditions of living g as an adult since this might result in depression (Markowitz, 2008).

Medication

Studies have been done and show that treatment of the disorder might be done through the following means: use of monoaminoxidase inhibitors and tricyclic antidepressants. They can be effective in patients who have some sleeping deformities. Some of the tricyclic antidepressants include the following: imipramine (Tofranil), nortriptyline (Aventyl, Pamelor) and amitriptyline(Elavil). On the other hand, examples of monoaminoxidase inhibitors include phenelzine (Nardil) and tranylcypromine (Parnate) (Thomas & Hersen, 2010). However, the most recommended medication for the condition by the physicians is citalopram (Celexa), paroxetine (Paxil) and fluoxetine (Prozac). In conclusion, it has been seen the various treatment methods for this disorder. It has been explored in detail to understand the psychological abnormality.

References

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