DYSTHYMIA AND OTHER MOOD DISORDERS

THE HARVARD MENTAL HEALTH LETTER, MAY 1991

The word "depression" can be used to describe anything from a
passing mood to a chronic illness with severe physical as well as
psychological symptoms. Depression is regarded as a psychiatric
disorder when it is deep and persistent enough to interfere with
work, friendships, family life, and physical health. 

Common symptoms of major, or severe, depression are inconsolable misery,
despair, guilt, suicidal thoughts, low self-esteem, irritability,
a sense of helplessness, inability to concentrate or make
decisions, loss of interest in life and incapacity for pleasure.
Some depressed patients have expressionless faces, move slowly,
and speak tonelessly. Others pace, weep, and wring their hands in
agitation. Disordered mood also takes the form of physical
symptoms -- chronic fatigue, loss of appetite, insomnia (or
sometimes oversleeping and overeating), upset stomachs,
constipation, backaches, headaches, and other pains. Episodes of
major depression usually last several months and may recur
throughout a lifetime. A disorder with similar but longer-lasting
and milder symptoms is dysthymia (the Greek roots of the word mean
"bad state of mind" or ("ill humor"). 

By the standard psychiatric definition, this disorder lasts for at least                         two years, but is less disabling than major depression; for example, victims are
usually able to go on working and do not need to be hospitalized.
About 3 percent of the population will suffer from dysthymia at
some time -- a rate slightly lower than the rate of major
depression. Like major depression, dysthymia occurs twice as often
in women as it does in men. It is also more common among the poor
and the unmarried. The symptoms usually appear in adolescence or
young adulthood but in some cases do not emerge until middle age.
At first the disorder may take the form of poor school
performance, social withdrawal, shyness, irritable hostility, and
conflicts with parents. Sometimes the symptoms include
physiological abnormalities that also occur in major depression,
such as short REM latency (dreaming that starts unusually early in
the night) and other sleep irregularities. 

Dysthymia is common in the children of parents with major depression,                   and the rate of mood disorders in the families of people with the early-onset
variety is as high as 50 percent. The high rate of family transmission suggests,               although it does not prove, that the disorder has a genetic basis.

It is also a serious illness that often becomes worse. Most
persons with dysthymia eventually develop major depression; nearly
half of patients treated for depression are suffering from this
"double depression." They differ very little from other patients
with major depression in biological, social, and psychological
functioning, or in the rate of mood disorders in their families.
After recovery from major depression, a milder chronic condition
often persists for years, heightening the danger of relapse. This
residual depression is not diagnosed as dysthymia unless the
patient had dysthymia before developing major depression.

DIAGNOSTIC AMBIGUITY

Similar symptoms may arise not only from primary dysthymia and
residual depression but also in connection with anxiety and panic
disorders, drug and alcohol dependence, eating disorders,
attention deficit disorder, and chronic physical illnesses. At
least three-quarters of patients with dysthymia have some other
psychiatric or medical disorder as well. If it can be determined
that the other illness came first, dysthymia is regarded as
secondary, but often the effort to sort out the symptoms and
disentangle cause and effect is futile.

Diagnostic confusion and ambiguity are even greater when
personality is taken into account. Many symptoms of this long-
lasting disorder can be interpreted as personality traits,
especially when they appear early in life. Timidity, brooding, low
self-esteem, submissiveness, and social maladroitness are typical
characteristics of dependent, obsessive-compulsive and avoidant
personality disorders as well as dysthymia. Until 1980, when it
was removed from the official manual of the American Psychiatric
Association, the diagnosis of depressive personality was given to
many cases of what is now called dysthymia. That term, or the
related "characterological depression," is still favored by many
European and some American psychiatrists. They argue, for example,
that depressive personality can be distinguished from dysthymia
because it is more common in men and less often associated with
depression in family members. But now the majority opinion is
simply that many people have both dysthymia and a quiet, passive,
gloomy personality.

Other persons vulnerable to chronic depression are moody,
demanding, self-dramatizing, complaining, and impulsive. Their
symptoms may include alcoholism and other drug abuse, intense
anger and anxiety, hypersensitivity to both criticism and praise,
and constantly changing psychosomatic complaints. Alcoholism and
criminal activity, rather than mood disorders, are common in their
families. Their personalities are often described as histrionic,
borderline, or antisocial. Some patients in whom these symptoms
are combined with others (oversleeping, overeating, a leaden
feeling that overcomes the body in waves) may be suffering not
from dysthymia but from a distinct disorder known as atypical
depression or hysteroid dysphoria. Still another name for related
conditions is "depressive spectrum disorder" -- a term that
deliberately blurs the distinction between personality and mood
disorders.

Cyclothymia is a mood disorder related to both personality
disorders and dysthymia. In this illness the alternating mania
(uncontrolled elation) and depression of bipolar disorder take a
milder and less disabling form. Cyclothymic persons endure short
and irregular cycles of energetic activity and lethargy, optimism
and pessimism, insomnia and oversleeping, jocularity and
tearfulness, arrogance and self-pity, passionate involvement and
sudden loss of interest. Their marriages fail; they periodically
abuse alcohol and other drugs and repeatedly change jobs and
homes. Just as people with dysthymia usually have episodes of
major depression, people with cyclothymia are vulnerable to both
major depression and mania. But ordinarily their erratic behavior
and troubled family lives are more obvious than any underlying
mood cycle. Many of their symptoms resemble borderline or
histrionic personality, and at one time they were given the
diagnosis of cyclothymic personality disorder.

This diagnostic indecisiveness results from the complicated
relationship between personality and mood. It is an
oversimplification to say that personality is enduring and mood is
episodic, or even to say that personality is more fundamental and
pervasive than mood. A personality trait, by definition, is a
susceptibility to certain states of mind and an inclination to
certain kinds of behavior, so the symptoms of personality and mood
disorders overlap. There is no sharp distinction between emotional
weather and emotional climate in individuals. 

Certain personality types are more vulnerable to mood disorders.                      People are more likely to become depressed and slower to recover                            if they are either withdrawn, submissive, and unreasonably self-critical, or
unstable, impulsive, and hypersensitive to loss. On the other
hand, defective mood regulation may cause disturbances in a
person's social and emotional life that resemble character
pathology. Another possibility is that personality and mood
disorders often coincide simply because both are so common.

TREATMENT

The choice of treatment may be influenced by these difficult
distinctions between personality and mood disorders and among the
various types of mood disorder. Psychiatrists now find dysthymia
and other mood disorders in many cases where they would once have
diagnosed a personality disorder, mainly because they have
discovered that mood-regulating drugs are an effective treatment
for a wider range of symptoms than they once suspected. Tricyclic
antidepressants, the standard treatment for major depression, are
also useful for both dysthymia and residual depression.

In one study 13 percent of patients recovered from dysthymia with
a placebo and 59 percent with imipramine (Tofranil ) at the same
dose used to treat major depression. The newer non-tricyclic
antidepressant fluoxetine (Prozac ) may work even better, with
fewer side effects. According to some authorities, the best
treatment for symptoms identified as atypical depression or
hysteroid dysphoria is another type of antidepressant drug, an MAO
(monoamine oxidase) inhibitor. Lithium, the standard treatment for
bipolar illness, can also be used for cyclothymia. Most
psychiatrists would prescribe one of these drugs to patients with
a diagnosis of primary or secondary dysthymia, cyclothymia,
atypical depression, depressive spectrum disorder, or even some
personality disorders.

But drugs are often ineffective when the depressed patient is
angry, self-dramatizing, hypersensitive, "mood-reactive" rather
than exhausted and inconsolably gloomy; and even when drugs
provide some relief, social and psychological problems must
usually be addressed in psychotherapy. Patients without serious
personality disturbances can make use of supportive psychotherapy,
which offers advice, reassurance, and sympathy.

Counseling on the management of stress is also important.
Cognitive therapy is used to alter patients' self-defeating
thoughts; behavioral treatment may help them unlearn learned
helplessness. Psychodynamic therapists identify and resolve
unconscious conflicts derived largely from childhood experience.
Interpersonal psychotherapists concentrate on restoring self-
esteem and improving communication with friends, families, and co-
workers. Social skills training may be important for people with
early-onset dysthymia who have never learned how to cope with the
adult world. Successful treatment of alcoholism, panic disorder,
or eating disorders usually relieves the associated dysthymia.

But in many cases the symptoms are hard to recognize and classify,
and the response to treatment is unpredictable. Most people with
dysthymia and related disorders see only their family doctors, who
may misdiagnose them, especially if the main complaints are
physical. Many patients do not think of themselves as depressed
and are relieved when told they have a treatable illness.
Unfortunately, mental health professionals are usually consulted
only when major depression develops, although dysthymia alone may
lead to alcoholism or suicide. Even when it is recognized,
dysthymia, like personality disorders, is difficult to treat. The
longer a depression lasts, the slower the recovery. One study
found that two years after treatment, according to their own
reports, 75 percent of patients with major depression but only 43
percent of patients with dysthymia had recovered. Another study
found that on the average dysthymia lasted five-and-a-half years.

FOR FURTHER READING

Hagop S. Akiskal and Radwan F. Haykal. Dysthymic, "atypical," and
residual depressive disorders. In Anastasios Georgotas and Robert
Cancro, eds. Depression and Mania. New York: Elsevier, 1988.

James H. Kocsis and Allen J. Frances. A critical discussion of
DSM-III dysthymic disorder. American Journal of Psychiatry,
144:1534-1542 (December 1987). Katharine A. Phillips, John G.
Gunderson, Robert M. A. Hirschfeld, and Lauren E. Smith. A review
of the depressive personality. American Journal of Psychiatry,
147:830-837 (July 1990).

Myrna M. Weissman, Philip J. Leaf, Martha Livingston Bruce, and
Louis Florio. The epidemiology of dysthymia in five communities:
rates, risks, comorbidity, and treatment. American Journal of
Psychiatry, 145:815 819 (July 1988). R. Alnaes and S. Torgensen.
Personality and personality disorders among patients with major
depression in combination with dysthymic or cyclothymic disorders.
Acta Psychiatrica Scandinavica, 79:363-369 (1989).

President and Fellows of Harvard College, 1991
Reprinted with permission.