By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.
Depression.
Photo courtesy of Pixabay.com
Dysthymic Disorder, a forgotten Mood Disorder.
Mood disorders are separated into two groups, Depressive Disorders, and Bipolar Disorders.
Major Depressive Disorder gets all the press while it’s craftier and more insidious cousin Dysthymia gets almost none.
In Dysthymia the person feels pessimistic and “down in the dumps” but the condition is not yet severe enough to be recognized as full-fledged Major Depressive Disorder. In children, this disorder is likely to be missed or to be misdiagnosed as a learning disability, attention problem, or poor behavior.
In adults, we call these people pessimists or grumpy old men. People often have been suffering from dysthymia for so long they come to believe this is simply the way they are. They think the sadness is a part of their personality, and don’t know that dysthymia is a treatable condition. They can’t imagine feeling happy as others do.
Diagnosable Dysthymia is a long-term overall sadness that interferes with having a happy life. As a Cognitive Behavioral Therapist, I am sure a faulty belief system either creates or perpetuates this disorder.
Dysthymia is not an occasional “BAD HAIR DAY.’ It involves someone who, while not always depressed, is sad and down more of the days each week than not. It is also not just a rough patch in the road. We may all have weeks or even months of tough times that make us sad. People with Dysthymia have at least two straight years of mostly sad, depressed days but somehow they keep trudging on. If they would just give in and stop trying they might get the diagnosis of Major Depressive Disorder.
For kids, we reduce the two-year requirement to one year, if the child can avoid the “ADHD, heavy meds, hits someone and become a bad kid” trap. In kids, the mood is more likely to be irritable all the time than obviously sad or depressed. Kids show pain by being irritable. They may also become pessimistic and stop trying to complete their work. Their grades drop and their sad mood leads to missed school days and few friends.
This is a chronic condition and without treatment, it rarely goes away. About half the time Dysthymia deepens and becomes Major Depressive Disorder. The combination of both is sometimes referred to as Double Depression and even when the Major depression lifts the person may still have the overall sad mood of dysthymia. This makes it important that they get treated not just for the Major Depression but for the Dysthymia also.
Just being down, depressed, or irritable for two years is not enough to get you this diagnosis. This disorder will also probably not get you disability, as people with Dysthymia keep trying and are able to go to school or work even when they hate life and are chronically unhappy.
People with Dysthymia will also have features similar to Major Depressive Disorder in being rather Melancholy or having atypical symptoms. They either eat-and-sleep like bears hibernating for the winter or they can’t eat and can’t sleep.
One common characteristic of people who have dysthymia is low self-esteem. They don’t have much self-confidence and they don’t think they can accomplish much; as a result, they give up trying. This can be the result of a difficult childhood, bullying, or simply a lack of having had the experience of succeeding at little things in life.
People with dysthymia are often hypercritical of themselves, others, and the world in general. They may complain a lot and have difficulty having fun. This leads to low productivity and a lack of positive relationships with others.
People who failed a lot or who were never told that what they did was good enough are prone to Dysthymia. Lack of praise was supposed to make for more accomplishment. Some parents ask me why they should praise a child just for doing what they should be doing anyway? The answer is that without praise kids begin to think that no matter what they do, or how hard they try, it will never be good enough. Eventually, they stop trying.
People with Dysthymia don’t get much pleasure out of life. As a result, they avoid doing anything that might be stressful or involve a risk of failure. They become increasingly sad and withdrawn. They find it difficult to make decisions and to start or finish projects. No use in trying if “nothing is going to turn out all right anyway.”
This may be hard to spot, as people with dysthymia avoid social situations and lack of social support is a factor in perpetuating dysthymia. It is hard to make new friends when you are sad, feel bad about yourself, and don’t have a belief in your ability to succeed.
Families tend to share their mental illnesses. If one member of the family has depression, major or minor, then other members of that same family may have dysthymia. This suggests that there is either a hereditary risk factor for Dysthymia or an environmental risk factor. Families provide both.
Dysthymia is extremely common among alcoholics and substance abusers. People who are sad a lot are more likely to abuse substances and people who abuse substances have plenty of reasons to be sad. What brings these people to treatment is an out of control addiction or when the dysthymia becomes Major Depressive Disorder. Many people with Dysthymia have psychical illnesses and conditions also.
Dysthymia frequently starts in childhood and affects both functioning and development. It is important for a child’s healthy development that they know it is possible to succeed and achieve. Having good, positive, and close friends is also an antidote.
The elderly are at increased risk to develop Dysthymia as they lose family and friends, become more isolated, and may have difficulty providing self-care. Changes in appetite, fatigue, sleeping problems, and isolation can all be mistaken for the usual results of aging instead of being recognized as symptoms of Dysthymia or depression in the elderly.
Treatment for Dysthymia is possible and has been shown to be highly effective. Group counseling and support groups are helpful. Individual therapy and medication are useful, though medication appears to be less effective with Dysthymia than with Major Depressive Disorder.
Because of the chronic nature of Dysthymia and the high risk, this will turn into Major Depressive Disorder early treatment is important.
Related articles: Mood Disorders, Depressive Disorders,
Major Depressive Disorder, Bipolar Disorder or Depression?, Bipolar or moody?, Am I Bipolar?, Hyperthymia, Are you hyperthymic?
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I have been seeing a psychiatrist with my mom since I was 18 years old. O would go along with my mother for support because she was a very sickk person. I always wondered why I always felt unhappy, looked angry unable to mile genuinely without looking crazy. I had subjects in school that I enjoyed and loved to learn about. History is still a passion of mine. My mother was an angry violent women. She was never happy even when she drank. she destoryed everyone around her. Now that I know why I couldn’t keep a job, a friend, finish a task that I knew I could do but could not finish it because i had no self confidence. Always second guessing my out come. All these years of hoplessness self loathing didn’t know how to be happy. Loud out rageous ranting. attention drawn to me to exspress my opinion because i didnot know how to have a difference of view point without agreeing to disagree. My mother carried the gen i believe, my granda mother always said that she was suck. My mother had several personalities, my brother was paranoid schizophrenia he was on a very very high dose of medicine. Yes I have tried to commit suicide. I have SAD, I CAN’T THINK ON ONE SUBJECT I JUMP AROUND MIND RACES.
OK NOW THAT I KINDA SEE WHAT WAS HAPPWNING TO MY MOTHER I SEE ME. I CAN’T REMEMBER ALOT OF MY LIFE. I DON’T KNOW HOW TO BE SOCIALLY CORRECT. I NEVER LEARNT HOW HOLD A JOB. DON’T know how to ask the right information to help me to grow need assistance someone to hold my hand walk me through task. This manic depression shows all over my face to my body movement. Help me. I’ve been on Lithium for a long while now. Dysthymic Disorder. HELP ME.
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I would suggest that you talk to the doctor or psychiatrist that is prescribing your medication and let them know everything you’ve written here. It’s quite possible that your medication needs to be adjusted or they may need to try you on a different medication. Please don’t be afraid to advocate for yourself if your current treatment is not controlling your symptoms. Thanks for your comment.
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Also thought you might find this interesting too with regards to dysthymic disorder causing more disability than MDD: http://www.clinicalpsychiatrynews.com/views/fink-still-at-large-by-dr-paul-j-fink/blog/rethinking-the-dysthymic-disorder-diagnosis/29ae59c205.html
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Thanks for sending this link. Part of this is just terminology. I think under-diagnosing depression and not getting treatment results in a lot of disability. Dysthymia, depression or any other mental illness should not keep you from having a happy life.
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I have ADHD (inattentive type) as well as dysthymia and have, at times, also had double depression. Diagnosed with major depression and ADHD in high school. Currently 36, but I think I’ve had symptoms since at least 7th grade if not earlier. I’m mildly gifted with some subclinical learning disabilities with high subtest scatter on the adult Wechsler taken before my senior year of college and a few years later. (The second test was also done with an achievement scale [Woodcock-Johnson, I think?], but the standard deviation between the scores on that test and the IQ test only reached about 1.5, I think, which is why I say subclinical.) Anyway, processing speed, working memory, and sequencing are the primary deficits. There’s definitely some sort of executive function problem going on, which makes sense with the ADHD. I’ve also experienced verbal abuse from my mother (who possibly has an undiagnosed PD); and, unfortunately, I’m currently living at home with my parents.
I preface this with all of that because I’m meeting with a counselor now, and it isn’t really working for me. (I think I’m a bit treatment resistant.) Currently on bupropion and adderall and really don’t want to change my meds. I don’t believe my counselor’s treatment modality is the right one for me since she practices gestalt therapy, and I think I need more structure. I’m not that unhappy lately, though the change of seasons is tough, and I have a tendency towards seasonal affective in the winter. I’ve had no motivation to look for and apply for better jobs to change my situation whatsoever, have trouble initiating tasks on my own, and frequently engage in what I’ll call “numbing” activities like playing a game on my cell phone or compulsively browsing Facebook or the internet. I don’t use drugs, but will drink (with great caution) once or twice every month or two. I’ve been getting up later and later in the morning and will get up and go back to bed. I’m lucky that I have a flexible job, but I’m sure even that has its limits.
I expressed to my therapist that I believe gestalt therapy isn’t the right mode of treatment for me, and that lately I feel like I’ve just been complaining about my mom and not making progress on the things I need to change. Last session, she said she talked to her instructor or mentor that is working with her on gestalt therapy who said that she thinks I have some major problems going on in my frontal lobes from under treated depression (um, executive dysfunction, duh!) and that she thinks it might be time for me to start intensive outpatient treatment. I just looked into the hours required for that, and I don’t have the time or money for it. I don’t want to increase my meds right now, either.
I did just start to take N-acetylcysteine because I have a mild scalp picking issue and remembered that my psychiatrist suggested it a while back. (I had stopped but have recently started again.) I’m hoping that also helps for the motivation and executive dysfunction issues since it also helps for the negative symptoms of schizophrenia (which I do not have, of course).
I need to look for a new therapist because I’m not ready for IOT. I think I need someone who specializes in adult ADHD but also someone who knows how to deal with “gifted” individuals. I feel like someone who knows how to deal with the giftedness might be able to get past my resistance easier. I need a weird combination of structure and assignments while ALSO helping me learn to solve problems on my own to get around my resistance and help me take ownership. I like the idea of CBT and maybe CBMT or DBT because of the skill-building aspect, because I think mindfulness is probably good for ADHD, and because there’s some evidence behind those treatments. I’m open to suggestions to other evidence-based treatments I could consider. Do you have any tips on how I could find such a therapist?
I’m also willing to accept that maybe something else is wrong that I haven’t figured out yet that’s contributing to this issue. I was tested for celiac in case that is causing issues (because my IgA deficiency increases risk) and was both seronegative and negative on the biopsy. My thyroid levels were checked by my primary care doc last year, and they were normal. (I haven’t explored more thorough testing with a specialist. If I see evidence from a source other than alternative-health types, I might consider looking into that because I believe my birth mother had some sort of thyroid condition, and the IgA def. increases risk of autoimmune stuff.) Iron and B12 were fine. Calcium was slightly below normal on one test. If there are other medical things I should look for, I’ll explore that.
I’ve been living with my parents for five, almost six years now; and it’s killing me. I don’t want to live here the rest of my life. My movements are restricted in terms of whether or not I’m permitted to go out, and my mom tries to “help” by guiding me around with constant reminders, which does nothing to help me rebuild skills on my own. (I had lived on my own for 4 years but did have a couple of major depressive episodes and some job issues. Some of the time was successful, though it can be hard to remember that.) I didn’t mean to write you a book, and I should be working, so I’m going to get back to work now. (My sense of time is off, and I didn’t realize I would write that much or wind up writing for about an hour and a half.)
To sum up my questions:
What should I look for in a therapist for my particular profile, and what modes of therapy would this person use?
Are there other possible physical causes that I have not considered that you may know of?
Do you think that intensive outpatient treatment could be warranted after all?
Thanks so much for your help.
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I am not a big fan of Gestalt therapy for your kind of problem. I think CBT or DBT would be a better fit for what you are describing. My view is that once you meet criteria for one episode you should be given the major depressive disorder as a diagnosis. Once you get a diagnosis of asthma or diabetes even if it is under control the diagnosis stays on the file. You Major Depression may be in early partial remission but it could easily come back. Best way to find a good therapist is to call around and interview them. Try a test visit just like you might try a first date. You don’t have to get married to the therapist after one session. Since I have not seen you I cant say about the intensive outpatient but it is worth getting a second opinion before you commit. Working on life skills, managing relationships with your family as an adult would also benefit you. As long as your doctor has ruled out the common medical issues I do not think continued tests are productive, especially since you have clear life stressors. Ask your medical doctor what they think about more tests or different therapy. Hope those suggestions get you started on a path to getting the help you need.
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The symptoms described in this blog so accurately describe my condition that I’m almost stunned. A cause of dysthymia mentioned here, childhood, applies to me as well. I have been feeling sad and unhappy for ten years. I used to be able to function, although I always had to struggle. My symptoms have become worse and worse over the years. Recently I have been wanting to give up and end it once and for all. But my mother pushed me to see a psychiatrist. He diagnosed me with major depression. I know that my symptoms fit dysthymia much more than major depression. Probably because of the difficulty in diagnosing dysthymia and the length of time required for such a diagnosis, my psychiatrist hasn’t done so. After taking antidepressants for two weeks, he prescribed me lithium. I’m just wondering if that’s too extreme. I have never had a manic episode, so I don’t think I’m bipolar. I’m very concerned with the side effects of lithium, and my impression of lithium is that it’s prescribed for very very serious cases, and probably the last resort before starting ECT. So is it really necessary to start with lithium to treat depression or dysthymia?
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Thanks for reading and commenting. To give you a good answer on your situation I or another professional would need to spend a chunk of time with you making sure we were aware of all your symptoms and history. These issues are certainly things you should talk with your prescribing doctor or get a second opinion. If you had thoughts of suicide then it is likely your dysthymia (now called Persistent Depressive Disorder) has progressed and become something more serious. People can have Major Depressive disorder superimposed on Dysthymia which is sometimes called “double depression.” An overly quick response to an anti depressant would cause the doctor to take a look for Bipolar disorder and there are several types of this. Someone on Lithium should get periodic blood tests but that does not mean it is an extreme treatment and certainly, in my opinion, it is not the last stop before ECT. Talk more with your provider and thanks for the comment.
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i am glad i read this. i am 16 and have been diagnosed with dysthymia. i believe ive had it the past six years but ive only been diagnosed for a year and half. due to many family problems i believe my depression has increased. the past two years have been the worst of my life. losing family and not being allowed to talk to other family. it breaks me down especially since it was some of the family i was closest to. my grades have dropped. i used to be an honor roll student. last year i failed four classes. last night i didnt sleep at all and i havent eaten since monday at breakfast. i didnt know that dysthymia caused the eating and sleeping problems and the schooling.
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Someone with Dysthymic Disorder can also go on to develop Major Depressive Disorder. I would encouraged you to try ot find someone locally you cant talk with. Possibly a school counselor or religious leader if you have a particular religion. You may also be able to seek out professional mental health. Thanks for reading and for the comment and take care of yourself.
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I have a question: How do you find a professional who specializes in the treatment of Dysthymia? Someone who is really good. Searching for such a person in Macomb County, Michigan. Medications by the way are a waste of time. They don’t work for me. Can you suggest someone for me. Thanks!
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Great question. Let me make some suggestions. I am out in California and do not know professionals back there in your area. But the process is likely the same everywhere.
1. If you have not done so see a medical doctor first, there are some medical conditions that can look like depression or Dysthymia.
2. If you have a history of substance abuse, alcohol or drugs, get that treated first or concurrently with the Dysthymia. Even after people stop using they still have the old thinking and it does not change without help.
3. Interview the counselor you are considering seeing. Picking a therapist is kind of like dating, you may find the right person the first time, but you need to get to know them a little before you make the commitment. Progress in therapy is all about the relationship.
4. Look for someone who treats depression. The process is very similar in treating depression and Dysthymia. If the depression comes from a recent bad event this is more like adjustment disorder. If you are depressed because you lost your job you need someone who can work on career counseling. Dysthymia is generally more long term and you may need to look at things you learned as a child that no longer are helpful. I prefer to work from a Cognitive Behavioral or Rational Emotive perspective. Narrative therapy can also work.
5. Avoid a counselor who advertises things that do not fit you. Men should generally avoid a therapist that advertises they use a “feminist” perspective. Don’t see a Muslim counselor if you are a Christian or vice verse. Most good counselors work with everyone and do not put that sort of thing in their advertising.
6. Expect to do A lot of work on yourself. A good therapist is like a good tour guide, they can tell you about the trail but you need to take the hike.
This might make a good post for others thanks for the idea.
Best wishes on finding a professional who can help you.
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I have been diagnosed as having Dysthymic Disorder, however, with every article I read saying it is “low grade” or “mild” depression, I’m wondering if this is a correct diagnosis. I have all the symptoms and meet all the criteria for major depression, yet I have been like this constantly for at least 10 years. I find this condition to be very disabling, although articles say it is not disabling.
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Hi Allan. Thanks for the question. Without seeing you and doing an assessment I can’t be sure about your particular condition but here are some suggestions and my feelings about this.
If you feel that it is disabling for you, then I think it sounds disabling. I would suggest you discuss this with your treatment provider. You may need more aggressive treatment or a change in the way you are being treated. If you have been getting meds only consider seeing a therapist to work on issues that are causing the depressed mood.
Having it constantly for ten years does sound like Dysthymia. Major Depression often is more episodic. Major Depressive Disorder comes in Mild, Moderate and Severe varieties. It is possible you have mild or even moderate depression. Your provider would need to take another look at the symptoms.
The diagnosis of Minor depression has been proposed for people like you whose symptoms are more than dysthymia but don’t quite fit Major Depressive Disorder. I do not think it got included in the new DSM-5.
Labels for mental illnesses are just that, labels. Some professionals minimize the diagnosis for fear of labeling you and causing you problems. Other providers go for the high end and treat aggressively. The diagnosis should fit the symptoms, but the provider should never lose site of the client and their impairment.
Psychiatry started with two diagnosis and we are approaching 500 or more different diagnosis. Clearly the labels never exactly match the problems the client is having.
Regardless of what you have, you shouldn’t have to live with a disabling mental illness. Recovery can and does happen.
I know that was not an exact answer to your question but hope that helped.
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my husband of almost 37 yrs. sustained a m/c accident 7 yrs ago..he suffers now with truamatic brain injury/stroke, ptsd, agent orange from viet nam, joe is paralyzed on the right side he lives at home with me, for the 7 yrs..ive lost my best friend, and its hard to reconcile the fact, like the dr’s said..the joe you knew isnt there anymore..ther’sa part of me that wont accept it..he is my best friend..i have no-one else that i cant lean on ..i have to do everything…im lonely and imiss him so much…alot of the times in my head..i think about my demise..and what will happen to my joe..and i get more upset..we have two sons..the elsest lives 400 miles away from us..and our youngest who as of lately just finished with the u.s. marine corp, with one tour in iraq, and another in afghansitan..have also been dealing with my moms’ passing 4 yrs ago..my older sister took care of her up until her death ..ive tried to be as strong as i can but its not easy..ive taken care of all legal crap that i had to regarding what happens after im gone..but its the here and now..i miss joe and love him aboev all else..and my hear tbreaks ..i get about 3-4 hrs of sleep if im lucky….im tryin gto be everything joe was like..suck it up..and move on..its hard to move on..when you cant get anyplace with ut transportation..im firm believer of not leaving “my vet behind”..thank you for letting me vent
many blessings
joann(aka tish)
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My thoughts and prayers go out to you. It is in times like this that caregivers need to take care of themselves also. Consider reaching out for professional help in your area. David
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Interesting post. As I read this, it pretty much summed up my state of being for the majority of my life. I’ve been diagnosed with Major Depression and am being medicated to help with it at the moment. The end of the article kind of leaves me hanging a bit as far as treatment options go. I’ve read about this specific disorder in the past and even brought it up with my doctor, but they didn’t seem to think it fit as well as major depression did in my case. Would you happen to know if ECT has been helpful for some with dysthymic disorder? If the medication I’m on loses its effectiveness the next step will be to try lithium, and ECT if that doesn’t work. I’m also searching for a therapist/counselor/psychologist and am wondering if cognitive behavioral therapy may be useful. I’ve not reached the point of no longer trying to fight the depression, but in practical terms it seems I’m running out of options. Any thoughts or suggestions would be welcomed. Thank you for posting this and trying to raise awareness.
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Thanks for your comment. It reminded me I need to talk more about treatment. A post on treatments for Depression and Dysthymia is on its way. I can’t be sure about your specific condition not having met you or done a full assessment, treatment always needs to be done in person. The suggestion that you may need lithium makes me think the professional who is treating you is considering some form of Bipolar Disorder. Absolutely – CBT and Group treatment would be at the top of my list if I were in your shoes. ECT would be the last thing on my list and only after getting a second through nineteenth opinion.
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Thank you for the insight and the follow-up post about treatment options. The professional I’m seeing I’ve been going to for nearly 6 years now and we’ve tried just about every medication to help with the major depression. In between episodes I will usually get a few weeks of relief, but even then it doesn’t seem possible for me to really feel happy or joyful, but rather neutral at best. This seems to be getting worse as I get older (I’m a few weeks shy of turning 35). I’m not sure if my psychiatrist is thinking along the lines of Bipolar Disorder or not, but I’m willing to try anything (with guidance and care of a professional) to get some relief from this.
I’ll certainly try to seek out help from someone who specializes in CBT and give that an honest effort. ECT is kind of a last resort if all else fails. When that was being seriously considered a few months ago I was at the end of my ability to tolerate the depression and would have been going in-patient for the treatment.
I’ll also see if there’s any group treatment options in this area or within reasonable travel distance.
Thank you for the reply and other info.
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