Understanding Persistent Depressive Disorder and Dysthymia

You’re lying in bed with no energy, even after sleeping all day. You wonder why you should even get up. You spend all day feeling hopeless, you’ve lost all interest in things you once enjoyed and you would rather just be alone. For many, these are clear symptoms of depression.  However, for those who have experienced these symptoms for quite some time, this could be classified persistent depressive disorder (PDD), also known as dysthymia.

With PDD, individuals live with persistent low mood, lack of interest and other depressive symptoms with no episodic onset or offset.  Unlike major depressive disorder (MDD), these symptoms are incessant and do not fluctuate. Instead, they remain consistent and are detrimental to daily mood and liveliness. With symptoms such as these, individuals often seek treatment for what they think is MDD. Although the two disorders are similar and similarly treatable, there are marked differentials in onset and duration.

Diagnosing Persistent Depressive Disorder

Prior to the introduction of the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 in 2013, the DSM-III and DSM-IV conceptualized the symptoms described above as either dysthymia or chronic major depressive disorder. Dysthymia was characterized by symptoms milder than those of major depressive disorder that lasted at least two years.

In the DSM-5, chronic major depressive disorder and dysthymia were merged into the diagnosis of PDD, since there were no scientifically meaningful differences between the two diagnoses.  The PDD diagnostic criteria emphasized the duration of depressive symptoms over their severity. To receive a diagnosis of PDD, an individual must live with a depressed mood throughout the day for a period of two years. Children and adolescents with the same symptoms can be diagnosed with PDD after a period of one year.

Individuals with PDD will experience at least two of the following symptoms on a mostly day-to-day basis:

• Feelings of hopelessness
• Low self-esteem
• Low energy or fatigue
• Insomnia or hypersomnia
• Poor concentration or difficulty making decisions
• Poor appetite or overeating

An individual with PDD may seem as though their depressive mood is a part of their personality. These individuals may even report, “I’ve have always been this way.”

A PDD diagnoses excludes depressive symptoms caused by other medical conditions (including strokes) or substance use. Additionally, an individual will not receive a diagnosis of PDD if they've had a manic, mixed or hypomanic episode or if they meet the criteria for cyclothymic disorder (Bressert, 2016).

Persistent Depressive Disorder and Major Depressive Disorder

Individuals diagnosed with PDD have not necessarily experienced a  full major depressive episode.  However, MDD may precede PDD or major depressive episodes can occur while an individual has PDD. Having PDD increases the risk of developing MDD. Individuals who meet the duration criteria of the PDD diagnosis and show the symptoms of major depressive disorder should be given both diagnoses. Having both diagnoses at the same time is often referred to as “double depression.” Ten percent of individuals with PDD will develop MDD (Price, 2016).

PDD affects between 3 and 6 percent of the population each year (Price, 2016). Women are twice as likely to be diagnosed as men (Bressert, 2014).

Treatment

Those seeking treatment from a behavioral health professional may have had PDD for a number of years prior to seeking help.  Most individuals delay treatment for 10 years or so (Bressert, 2014). These symptoms may have developed early on in the person’s life, giving them reason to believe that it is very normal to feel this way all the time. It goes unnoticed and therefore, untreated.

If a child exhibits symptoms of depression, it is important for them to be seen by a behavioral health provider as early as possible.  Early intervention may help such children avoid serious chronic mood disorders and issues with school, social and even substance use issues as they get older. The sooner an individual seeks treatment, the sooner they can find relief and avoid further distress. PDD is also associated with substance abuse, since people with chronic depression may use alcohol or drugs as a means of coping with symptoms. Remaining vigilant to an individual's poor coping habits is an important portion any treatment.

Prescribed antidepressants along with cognitive-behavioral therapy (CBT) have been shown to be an effective treatment plan for many individuals struggling with chronic depression. Overall, psychotherapy or talk therapy, in general, offers an environment of unconditional support and acceptance. Short-term approaches are preferred, and can vary based upon the individual’s needs and overall functioning. Individual psychotherapy and group psychotherapy are effective approaches to treating an individual with this disorder.  Topics such as self esteem and self-confidence are explored. Additionally, family therapy and even couples therapy can be helpful for some individuals.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

American Psychiatric Association (2013). Highlights of Changes from DSM-IV-TR to DSM-5. DSM-5. Retrieved from http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf.

Bressert, S. (2013). Major Depressive Episode Symptoms. Psych Central. Retrieved  from http://psychcentral.com/disorders/major-depressive-episode-symptoms/

Bressert, S. (2014). Persistent Depressive Disorder (Dysthymia) Symptoms.  Psych Central. Retrieved from http://psychcentral.cm/disorders/dysthymic-disorder-symtoms/.

Price, Prentiss. (May 2016). Dysthymic Disorder: All About Self Help. Retrieved from http://www.allaboutdepression.com/dia_04.html.

Uher, Rudolf.  (July 2014). Persistent Depressive Disorder, Dysthymia, and Chronic Depression:  Update on Diagnosis, Treatment. Retrieved from http://www.psychiatrictimes.com/special-reports/persistent-depressive-disorder-dysthymia-and-chronic-depression