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DysthymiaBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/dysthymia/DS01111
Dysthymia (dis-THIE-me-uh) is a mild but long-term (chronic) form of depression. Symptoms usually last for at least two years, and often for much longer than that. Dysthymia interferes with your ability to function and enjoy life.
With dysthymia, you may lose interest in normal daily activities, feel hopeless, lack productivity, and have low self-esteem and an overall feeling of inadequacy. People with dysthymia are often thought of as being overly critical, constantly complaining and incapable of having fun.
Dysthymia symptoms in adults may include:
- Loss of interest in daily activities
- Sadness or feeling down
- Tiredness and lack of energy
- Low self-esteem, self-criticism or feeling incapable
- Trouble concentrating and trouble making decisions
- Irritability or excessive anger
- Decreased activity, effectiveness and productivity
- Avoidance of social activities
- Feelings of guilt and worries over the past
- Poor appetite or overeating
- Sleep problems
In children, dysthymia sometimes occurs along with attention-deficit/hyperactivity disorder (ADHD), behavioral or learning disorders, anxiety disorders, or developmental disabilities. Examples of dysthymia symptoms in children include:
- Behavior problems
- Poor school performance
- Pessimistic attitude
- Poor social skills
- Low self-esteem
Dysthymia symptoms usually come and go over a period of years, and their intensity can change over time. But typically symptoms don't disappear for more than two months at a time. In general, you may find it hard to be upbeat even on happy occasions — you may be described as having a gloomy personality.
When dysthymia starts before age 21, it's called early-onset dysthymia. When it starts after that, it's called late-onset dysthymia.
When to see a doctor
It's perfectly normal to feel sad or upset sometimes or to be unhappy with stressful situations in your life. But with dysthymia, these feelings last for years and interfere with your relationships, work and daily activities.
Because these feelings have gone on for such a long time, you may think they'll always be part of your life. But if you have any symptoms of dysthymia, seek medical help. If not effectively treated, dysthymia commonly progresses into major depression. Sometimes, a major depression episode occurs in addition to dysthymia — this is called double depression.
Talk to your primary care doctor about your symptoms. Or seek help directly from a mental health provider. If you're reluctant to see a mental health professional, reach out to someone else who may be able to help guide you to treatment, whether it's a friend or loved one, a teacher, a faith leader, or someone else you trust.
The exact cause of dysthymia isn't known. Dysthymia may have causes similar to major depression, including:
- Biochemical. People with dysthymia may have physical changes in their brains. The significance of these changes is still uncertain, but they may eventually help pinpoint causes.
- Genes. Dysthymia appears to be more common in people whose biological (blood) relatives also have the condition.
- Environment. As with depression, environment may contribute to dysthymia. Environmental causes are situations in your life that are difficult to cope with, such as the loss of a loved one, financial problems or a high level of stress.
Certain factors appear to increase the risk of developing or triggering dysthymia, including:
- Having a first-degree relative with dysthymia or major depression
- Stressful life events, such as the loss of a loved one or financial problems
- Interpersonal dependency where the person relies excessively on approval, reassurance and attention from others and then this approval is significantly reduced or no longer occurs
Complications that dysthymia may cause or be linked with include:
- Reduced quality of life
- Major depression
- Substance abuse
- Relationship difficulties and family conflicts
- Social isolation
- School and work problems
- Decreased productivity
- Eating disorders
- Suicidal behavior
Preparing for your appointment
Your doctor may ask about your mood during a routine medical appointment if you seem to be sad or down. Or you may decide to schedule an appointment to talk about your concerns. Because dysthymia often requires specialized mental health care, you may be referred to a mental health provider, such as a psychiatrist or psychologist, for evaluation and treatment.
What you can do
Prepare for your appointment by making a list of:
- Any symptoms you've had, including any that may seem unrelated to the reason for which you scheduled the appointment
- Key personal information, including any major stresses or recent life changes
- All medications, vitamins, supplements or herbal preparations that you're taking
- Questions to ask your doctor
Taking a family member or friend along can help you remember something that you missed or forgot.
Basic questions to ask your doctor include:
- Why can't I get over dysthymia on my own?
- How do you treat dysthymia?
- Will talk therapy (psychotherapy) help?
- Are there medications that might help?
- How long will I need to take medication?
- What are some of the side effects of the medication you're recommending?
- How often will we meet?
- How long will treatment take?
- What can I do to help myself?
- Are there any brochures or other printed materials that I can have?
- What websites do you recommend visiting?
Don't hesitate to ask questions any time you don't understand something.
What to expect from your doctor
During your appointment, your doctor will likely ask several questions about your mood, thoughts and behavior, such as:
- When did you first notice symptoms?
- How is your daily life affected by your symptoms?
- What other treatment have you had?
- What have you tried on your own to feel better?
- What things make you feel worse?
- Have any relatives had dysthymia, major depression or another mental illness?
- What do you hope to gain from treatment?
Tests and diagnosis
If your doctor suspects you have dysthymia, exams and tests may include:
- Physical exam. The doctor may do a physical exam and ask in-depth questions about your health to determine what may be causing your dysthymia. In some cases, dysthymia may be linked to an underlying physical health problem.
- Lab tests. For example, your doctor may order a blood test called a complete blood count, do blood tests to check your folate and Vitamin D levels, or test your thyroid to make sure it's functioning properly.
- Psychological evaluation. This evaluation includes a discussion about your thoughts, feelings and behavior and may include a questionnaire to help pinpoint a diagnosis.
Checking for other conditions
Several other conditions have symptoms that may resemble dysthymia. Your doctor or mental health provider's evaluation will help determine if you have dysthymia or another condition that can affect your mood, such as major depression, bipolar disorder or seasonal affective disorder.
Diagnostic criteria for dysthymia
To be diagnosed with dysthymia, you must meet the symptom criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.
For a diagnosis of dysthymia, the main indication for an adult differs somewhat from that of a child:
- For an adult, depressed mood most of the day for two or more years
- For a child, depressed mood or irritability most of the day for at least one year
In addition to that, you must have at least two of these symptoms, and they must cause distress or interfere with your ability to function in your daily life:
- Poor appetite or overeating
- Sleep problems
- Tiredness or lack of energy
- Low self-esteem
- Poor concentration
- Trouble making decisions
Treatments and drugs
The two main treatments for dysthymia are medications and talk therapy (psychotherapy). Medications appear to be more effective at treating dysthymia than psychotherapy when either is used alone. Using a combination of medications and psychotherapy may be slightly more effective.
Which treatment approach your doctor recommends depends on factors such as:
- Severity of your dysthymia symptoms
- Your desire to address emotional or situational issues affecting your life
- Your personal preferences
- Previous treatment methods
- Your ability to tolerate medications
- Other emotional problems you may have
Medications for dysthymia
Types of antidepressants most commonly used to treat dysthymia include:
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin and norepinephrine reuptake inhibitors (SNRIs)
- Tricyclic antidepressants (TCAs)
Finding the right medication
SSRIs are often the antidepressant of choice because, in general, they work well and their side effects are more tolerable. Which antidepressant or a combination of medications is best for you depends on your individual situation.
If you're bothered by side effects, don't stop taking an antidepressant without talking to your doctor first. Some antidepressants can cause withdrawal symptoms unless you slowly taper off, and quitting abruptly may cause a sudden worsening of depression. Don't give up until you and your doctor find a medication that's suitable for you. Talk with your doctor or pharmacist about possible side effects to weigh the benefits and risks. In some cases, side effects may go away as your body adjusts to the medication.
When you have dysthymia, you may need to take antidepressants long term to keep symptoms under control.
Antidepressants and increased suicide risk
Although antidepressants are generally safe when taken as directed, the FDA requires that all antidepressants carry "black box" warnings, the strictest warnings for prescriptions. In some cases, children, adolescents and young adults under the age of 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. So, people in these age groups must be closely monitored by loved ones, caregivers and health care providers.
Psychotherapy for dysthymia
Psychotherapy can help you learn about your condition and your mood, feelings, thoughts and behavior. Using the insights and knowledge you gain in psychotherapy, you can learn healthy coping skills and stress management. Psychotherapy can also help you:
- Learn to make decisions
- Reduce self-defeating behavior patterns, such as negativity, hopelessness and a lack of assertiveness
- Improve your ability to function in interpersonal social and work situations
You and your therapist can discuss which type of therapy is right for you, your goals for therapy, and other issues, such as the length of treatment.
Lifestyle and home remedies
Dysthymia generally isn't a disorder that you can treat on your own. But, in addition to professional treatment, you can take these steps:
- Stick to your treatment plan. Don't skip therapy sessions or appointments, even if you don't feel like going. Don't skip your medications, even if you're feeling well. If you stop, symptoms may come back, and you could also experience withdrawal-like symptoms.
- Learn about dysthymia. Education about your condition can empower you and motivate you to stick to your treatment plan. Encourage your family members or friends to learn about dysthymia to help them understand and be more supportive of you.
- Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your dysthymia symptoms. Make a plan so that you know what to do if symptoms get worse or return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Consider involving family members or friends in watching for warning signs.
- Get active. Physical activity and exercise may reduce symptoms in depression-related conditions. Consider walking, jogging, swimming, gardening, or taking up another activity or exercise that you enjoy.
- Avoid drugs and alcohol. It may seem like alcohol or drugs lessen depression-related symptoms, but in the long run they generally worsen them. Talk with your doctor or therapist if you need help with alcohol or drug abuse.
Make sure you understand the risks as well as possible benefits if you pursue alternative or complementary therapy. Keep in mind that the Food and Drug Administration (FDA) doesn't regulate herbal supplements, so you can't always be sure of what you're getting or know whether it's safe. Also, some herbal supplements can interfere with certain prescription medications or cause dangerous interactions.
For example, St. John's wort has been used for depression, although in the United States it's not approved by the FDA to treat depression. It may help mild or moderate depression, such as dysthymia, but the overall evidence is not conclusive. However, it should be used with caution — St. John's wort can interfere with many medications, such as antidepressants, birth control pills, blood thinners, chemotherapy drugs, HIV/AIDS medications, and drugs to prevent organ rejection after a transplant.
Talk to your doctor before taking any herbal supplement.
Complementary and alternative medicine practitioners believe the mind and body must be in harmony for you to stay healthy. Examples of mind-body techniques that may be helpful for dysthymia include:
- Yoga or tai chi
- Guided imagery
- Massage therapy
- Relaxation techniques
- Music or art therapy
Relying solely on these therapies is generally not enough to treat dysthymia. However, they may be helpful when used in addition to medication and psychotherapy.
Coping and support
Coping with dysthymia can be challenging since it can have such a strong hold on your life. Dysthymia makes it hard to engage in behavior and activities that can help you feel better. In addition to the treatments recommended by your doctor or therapist, consider these tips:
- Focus on your goals. Dealing with dysthymia is an ongoing process. Stay motivated by keeping your goals in mind.
- Simplify your life. Cut back on obligations when possible, and set reasonable schedules for goals.
- Keep a journal. Use it to express your pain, anger, fear or other emotions.
- Read reputable self-help books recommended by your doctor or therapist. Use them as a discussion tool during therapy.
- Don't become isolated. Try to participate in activities and get together with family or friends regularly.
- Take care of yourself. Eat a healthy diet, get physical activity and get sufficient sleep.
- Join a support group. Many organizations, such as the National Alliance on Mental Illness (NAMI) and the Depression and Bipolar Support Alliance (DBSA), offer education, support groups, counseling and other resources to help with depression. Employee assistance programs and religious organizations may also offer help.
- Learn relaxation and stress management. Try such stress-reduction techniques as meditation, progressive muscle relaxation, yoga or tai chi.
- Structure your time. Plan your day and activities. Try to stay organized. You may find it helpful to make a list of daily tasks.
- Don't make important decisions when you're down. Avoid decision making when you feel depressed or have trouble concentrating or thinking clearly.
There's no sure way to prevent dysthymia. Because dysthymia often starts in childhood, identifying children at risk of the condition may help them get early treatment. Strategies that may help ward off dysthymia symptoms include the following.
- Take steps to control stress, to increase your resilience and to boost your self-esteem.
- Reach out to family and friends, especially in times of crisis, to help you weather rough spells.
- Get treatment at the earliest sign of a problem to help prevent symptoms from worsening.
- Consider getting long-term maintenance treatment to help prevent a relapse of symptoms.
- Dysthymic disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. 4th ed. Arlington, Va.: American Psychiatric Association; 2000. http://www.psychiatryonline.com. Accessed Oct. 23, 2012.
- Ebert MH, et al. Current Diagnosis & Treatment: Psychiatry. 2nd ed. New York, N.Y.: The McGraw-Hill Companies; 2008. http://www.accessmedicine.com/resourceTOC.aspx?resourceID=10. Accessed Oct. 24, 2012.
- Cuijpers P, et al. Psychotherapy for chronic major depression and dysthymia: A meta-analysis. Clinical Psychology Review. 2010;30:51.
- Understanding major depression. National Alliance on Mental Health. http://www.nami.org/Template.cfm?section=Search&Template=Search/SearchDisplay.cfm. Accessed Oct. 24, 2012.
- Depression and complementary health practices: What the science says. National Center for Complementary and Alternative Medicine. http://nccam.nih.gov/health/providers/digest/depression-science.htm. Accessed May 10, 2012.
- Depression. National Institute of Mental Health. http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml. Accessed Oct. 23, 2012.
- Marchand WR. Mindfulness-based stress reduction, mindfulness-based cognitive therapy, and Zen meditation for depression. Journal of Psychiatric Practice. 2012;18:233.
- Tanyi RA, et al. The effects of psychoneuroimmunology (PNI)-based lifestyle intervention in modifying the progression of depression in clinically depressed adults. International Journal of Psychiatry in Medicine. 2011;42:151.
- Cuijpers P, et al. Personalized treatment of adult depression: Medication, psychotherapy, or both? A systematic review. Depression and Anxiety. 2012;29:855.
- VonWolff A, et al. Selective serotonin reuptake inhibitors and tricyclic antidepressants in the acute treatment of chronic depression and dysthymia: A systemic review and meta-analysis. Journal of Affective Disorders. In press. Accessed Oct. 24. 2012.
- Hourani LL, et al. Influence of spirituality on depression, posttraumatic stress disorder, and suicidality in active duty military personnel. Depression Research and Treatment. 2012;2012:1.
- Wu J, et al. Acupuncture for depression: A review of clinical applications. Canadian Journal of Psychiatry. 2012;57:397.
- Chi J, et al. Tai chi and reduction of depressive symptoms for older adults: A meta-analysis of randomized trials. Geriatrics & Gerontology International. In press. Accessed Aug. 28, 2012.
- Chan MF, et al. The effectiveness of music listening in reducing depressive symptoms in adults: A systemic review. Complementary Therapies in Medicine. 2011;19:332.
- McCaffrey R, et al. Garden walking and art therapy for depression in older adults: A pilot study. Research in Gerontological Nursing. 2011;4:237.
- Carpenter DJ. St. John's wort and s-adenosyl methionine as "natural" alternatives to conventional antidepressants in the era of the suicidality boxed warning: What is the evidence for clinically relevant benefit? Alternative Medicine Review. 2011;16:17.
- Hall-Flavin DK (expert opinion). Mayo Clinic, Rochester, Minn. Oct. 26, 2012 & Nov. 18, 2012.
- Kung S (expert opinion). Mayo Clinic, Rochester, Minn. Oct. 26, 2012.