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Dysthymia: Break Through the Fog

By Josh P. Roberts from www.hopetocope.com

In his 71 years, Powell has never been knocked down and out by a depressive episode. In retrospect, though, he recognizes that he’s had chronic mild depression—officially known as dysthymic disorder or dysthymia—since adolescence.

 Of course, “mild” is a relative term. Dysthymia may not be as well-known as its bully big brother, major depressive disorder, but it can be just as pernicious in the long term. Familiar symptoms of depression—low mood, listlessness, lack of enjoyment, low self-esteem, poor concentration—persist for years at a level that is significant enough to interfere with work and relationships, but low enough that people may not feel it’s worth seeking help.

In dysthymia, “the lingering ‘sniffles’ of depression never get ‘really’ bad,” explains Bill Ashdown, vice president of the Mood Disorders Society of Canada. But left untreated, “it is miserable, and sucks the life out of you for years at a time.”

Low moods and a lack of excitement for life characterized Sheila’s dysthymia. Over the years, dysthymia undermined various ambitions. The Virginia resident studied to go to medical school, but gave up before taking the entrance exam because she was overwhelmed. She became a dietitian.

More recently, after retiring, she applied to and was accepted to study at Princeton Theological Seminary. She didn’t go because, “I felt blah,” says Sheila, 53. “I felt I wasn’t good enough.”

Like Sheila, Powell had a solid career but was left feeling hollow and unfulfilled.

“I’ve held a job,” says Powell, a former insurance adjustor from Georgia. “I’ve done stuff. But I’ve never really done what I wanted to do.”

Dysthymia “sort of robs you of the potential for the things you may have done,” says Powell, who started work on a novel and wishes he’d studied music. “It’s like somebody is pushing me back down in my chair and saying, ‘No, don’t even go there, you’d just make a mess out of that.’”

 

Early stressors

Stories of neglected opportunities and low self-esteem are not unusual for people with dysthymia. Nor is the self-medication—drinking and other substance abuse—Powell resorted to.

After he sobered up around 1980, he sought help, was diagnosed with longstanding dysthymia, and was put on antidepressants. He has seen psychiatrists and psychologists over the years. Now, coupled with a strict regimen of exercise, volunteer activity, and “more insight into the problems of dysthymia,” he finds himself less irritable and “definitely on a better footing.”

Powell also has two contributing factors often found in dysthymia: a family history of depression and a personal history of childhood stress.

There is strong evidence for early stressors and adversity as predisposing conditions of dysthymic disorder, says Daniel Klein, PhD, a professor of clinical psychology at Stony Brook University in New York whose research includes a 10-year study of people with dysthymia.

People with the disorder may wonder, ‘If I’ve felt this way throughout my adult life, is this just who I am, and am I stuck with it?’ The answer is, ‘Not necessarily and not necessarily’…

For David, a 57-year-old business consultant and financial planner from Memphis, Tennessee, early stressors include being abused as a boy. For David, dysthymia can feel like trying to get through molasses. There are workdays when he won’t get out of the house until 10 a.m. “because it’s just hard to move.”

He does have stretches where his mood lightens, he says, but adds, “I don’t know that I see periods of happiness as [happily] as a ‘normal’ person.”

According to his therapist, David relates, the “ups” he feels are a notch or two below what might be considered standard. Therapy helps him from slipping lower.

It helps that on days when he doesn’t have to meet with clients, he has the flexibility to log in and work from home. Also helpful is having a boss who himself went through a period of depression and can understand the symptoms David deals with.

 

Diagnosing dysthymia or major depression

Still, people with dysthymia carry a different burden than people who experience acute or episodic depression, though both disorders have a similar range of symptoms and treatments.

For one thing, points out Ka Rae’ Carey, PhD, a licensed professional counselor based in Cary, North Carolina, for most people with dysthymia the disorder is embedded in their responses and outlook as they go to work, parent, and do all the things people do in their day-to-day lives.

Acute depression, on the other hand, more typically represents a break from someone’s normal life and attitude, is often triggered by a major life event such as a divorce or a child leaving home, and tends to have an “end date” with proper treatment.

I don’t know that I see periods of happiness as [happily] as a normal person.

People with acute depression “might be depressed for a month, three months, six months,” and then recover, says David Hellerstein, MD, a research psychiatrist at the New York State Psychiatric Institute and a professor of clinical psychiatry at Columbia University Medical Center. “That seems to be distinct in many ways from chronically depressed people, even though biologically they may have a lot of commonalities.”

Unfortunately, Hellerstein notes, it’s very likely that someone with dysthymic disorder will experience at least one episode of major depression on top of their chronic condition, something termed “double depression” (as opposed to “pure dysthymia”).

Confused? Although there is some disagreement among practitioners as to the different diagnoses, sorting out dysthymic disorder and acute, episodic, or major depression can be visualized in a simple graph. One axis represents severity—how many symptoms are present. The other axis is duration.

In dysthymia, symptoms are of comparatively mild severity but last a long time. In acute depression, also called episodic depression, symptoms can be of varying severity but they erupt and then subside; they may or may not return. “Major depression” refers to the presence of a greater number of symptoms.

In double depression, someone with dysthymia begins experiencing enough additional symptoms that an episode of major depression is indicated.

To complicate matters, there is also a controversial diagnosis that identifies chronic pessimism, negativity, guilt and low-self-esteem as traits of a personality disorder, rather than symptoms of a mood disorder such as depression. This line of research sees depressive personality disorder (DPD) as a risk factor for dysthymia and major depression.

But Andrew Ryder, PhD, an associate professor of psychology at Concordia University in Montreal who researched depressive personality disorder, says that from a practical point of view the diagnostic distinctions don’t matter.

“In terms of genetics and risk factors, DPD behaves just like a chronic, low-grade mood disorder,” he points out. “If you’re doing psychotherapy, you tend to intervene in similar ways. If you’re giving medication, you tend to pick the same ones.”

 

Dysthymia should be taken seriously

Carey puts it this way: “It’s all depression.”

For dysthymia, she advocates talk therapy focused on changing thought and behavior patterns, perhaps supplemented with journaling and reading assignments between counseling sessions. Although she doesn’t necessarily suggest medication right away, “I do refer people to medication when I find that they’re not responsive to outpatient therapy or if they’re [in crisis] and need medication.”

She says as long as you’re willing to learn from therapy, make needed changes, and take medication if it’s indicated, “you can … elevate your mood and lead a productive life.”

The small body of research on dysthymia suggests that behavioral-based psychotherapy (such as cognitive behavioral therapy and dialectical behavior therapy) and pharmacotherapy (depression medications) are effective treatments, either separately or in conjunction.

In the end, says Hellerstein, what’s most important “is not necessarily whether you have to do this or that, but that [dysthymia] should be something that should be taken seriously and should receive treatment, with the goal of getting the person’s depression into sustained remission.”

When I involve myself with other people… it boost my self-esteem and it keeps me more in a better frame of mind.

A Swedish study published in BMC Journal in July 2008 followed a small group of people with dysthymia for nine years. Researchers found that along with antidepressant medication, “common helpful factors” in remission included greater self-understanding, enhanced flexibility of thinking, and “change from avoidance coping to approach coping”—that is, strategies that focus on solving problems that create distress.

Sheila says she was in denial about her lifelong dysthymia until she completed some depression surveys a few years ago. She went in for a clinical evaluation and started talk therapy. After a few trials, she found medication that works for her. She now feels good enough to go back to school for library science.

She recognizes that she still gets overwhelmed easily, though, so she’s taking one class at a time, online. “I have up to seven years to complete the degree,” she points out.

The Swedish study also found it was important to recognize “a helpful relationship to the health care provider” as a vehicle for change.

That includes not only a good relationship with your psychotherapist—Carey notes that you may need to try on therapists, like shoes, until you find one that fits—but also with your prescribing physician as well.

“If you have a good rapport you’re willing to open up more, say more things; you trust the person’s decisions,” says Ryder. “Even with a family physician who gives you an exercise program to do, who listens to you and is compassionate, and sounds like they’ve thought it through, you’re more likely to follow the program. So that relationship is really the key.”

Speaking of exercise, Klein points out that although physical activity hasn’t been rigorously studied as a treatment for chronic depression, evidence shows it to be a “pretty effective antidepressant, and certainly something one should consider.”

Carey also encourages patients to take time for themselves and do self-nurturing things, even if it’s something as basic as taking a bubble bath.

David, for example, will sometimes take time out to watch a TED talk about one of his many interests or treat himself to a latte. Those simple actions reinforce the fact that he’s “worth it,” counteracting low self-esteem.

Powell finds it helpful to take time for others. He’s on the board of the Northside Atlanta chapter of the National Alliance on Mental Illness and he also drives people to visit their incarcerated relatives.

“When I involve myself with other people in things like that, it boosts my self-esteem and it keeps me more in a better frame of mind,” he says.

 

Feeling wonderfully normal

The chronic nature of dysthymia and the fact that it often appears in late adolescence can make it hard to tease apart symptoms from self. People with the disorder may wonder, “If I’ve felt this way throughout my adult life, is this just who I am, and am I stuck with it?”

The answer is, “Not necessarily and not necessarily,” says Ryder. “Just because something feels like it’s part of who you are and part of your personality doesn’t mean it’s untreatable.”

[Dysthymia] should be… taken seriously and should receive treatment, with the goal of getting the person’s depression into sustained remission.

Lars Petersen’s dysthymia came to the fore during his college years in the early 1970s, “when nobody knew what this was.” For Petersen (not his real name), a 63-year-old retired commercial writer who lives in Minneapolis, Minnesota, dysthymia “felt heavy, like I was wrapped up in cords.”

He tried psychoanalytic counseling several times and “got lots of insights into family, but nothing changed.” When the first selective serotonin reuptake inhibitors (SSRIs) started making news, he got a prescription from his family physician. It worked, opening his eyes to a different kind of life.

He told his wife, “I feel wonderful,” to which she replied, “That’s normal.”

Unfortunately for Petersen, his first medication stopped working after a few months. He lost energy for all but the highest priority tasks, like earning a living. It got to the point, he says, that to an outsider his narrowed-in survival strategy looked like self-obsession.

He went to a specialist who worked with him to find the right class of drug—there were several available then, and more now—and the right dosage that would allow him to feel “wonderful,” aka normal, again. Petersen said it was something of an ordeal, with lots of trial and error, but he stuck with it.

“I had such life-changing results before, I knew it was possible,” he explains. Now, he says, “I feel great, like I have the bandwidth for other things.”

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