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Dysthymia

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Depression has a varied spectrum of severity, from minor feelings of discomfort and sadness to major and severe depression. Dysthymia, also called persistent depressive disorder, is a “depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years¨ (American Psychiatric Association [APA], 2013, p. 168). This chronic state of depression is not severe as the ones experienced in Major Depression, but they are significant enough to cause problems and obstacles on everyday lives. According to Psychiatric Times about 2.5% of the American population fulfill the criteria to be diagnosed with Dysthymia (Uher, 2014). Dysthymia is a mood disorder that is characterized by many symptoms. According to the DSM-V by the American Psychiatric Association, people suffering from Dysthymia will have a poor appetite or they will overeat, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and finally feelings of hopelessness (2013, p. 168). Dysthymia in more severe cases can also cause people to lose interest in daily activities and sometimes even withdraw completely from engaging in them. In children, “dysthymia sometimes occurs along with attention-deficit/hyperactivity disorder (ADHD), behavioral or learning disorders, anxiety disorders, or developmental disabilities.” (Mayo Clinic, 2012). Some symptoms that may appear in children with Dysthymia are irritability, poor school performance, pessimistic attitude, poor social skills and low self-esteem. In order to be diagnosed with Dysthymia, a specialist must examine the patient and make a decision based on their symptoms. The main criteria that a patient must pass is the list of symptoms listed in the DSM-V. An important step that doctors must make while doing a diagnosis is making sure that the symptoms that a patient is suffering from are not a result of a physical condition. For example “some medical conditions such as viruses or a thyroid disorder may cause the same symptoms as Dysthymia” (“Depression,” 2015) and these possibilities can be eliminated by performing a physical exam. If no physical condition seem to be causing the symptoms then psychological evaluation can begin with a mental health professional. The discussion between the patient and the doctor will include when the symptoms started, how long they have been present, how severe are they, and whether they have occurred before and past treatment of it. Diagnosis in children and adults differs in the duration the symptoms have been present. For adults symptoms must be present “for at least 2 years” but only “for one year for children and adolescents” (APA, 2013). Once all the tests have been made and a patient meets the criteria for Dysthymia, they are diagnosed with the disorder. Although the success of treatment for the chronic depressive state of Dysthymia is lower that the non-chronic depression, it is a treatable disorder. To treat Dysthymia, doctors use medications and psychotherapy. Treatment with medication is mainly antidepressants, which “primarily work on brain chemicals called neurotransmitters, especially serotonin and norepinephrine.” (“Depression,” 2015). These neurotransmitters regulate mood and thus affecting those transmitters will help with mood disorders such as Dysthymia. Some of the antidepressants used are called serotonin reuptake inhibitors (SSRIs). Fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Prozac) are some of the most commonly prescribed SSRIs for depression. Another medication is serotonin and norepinephrine reuptake inhibitors (SNRIs) which include venlafaxine (Effexor) and duloxetine (Cymbalta). When they are first taken, SSRIs and SNRIs can have side effects that include headaches, nausea, jitters or insomnia but these symptoms fade with time. Another antidepressant medication that could be prescribed for patients with Dysthymia are Tricyclics. They are an older type of antidepressants that include imipramine and nortriptyline. Tricyclics are not used commonly today due to their potential side effects. They can cause dizziness and have negative effects on the hearts of people with heart diseases. The other way of treatment for Dysthymia is through psychotherapy through which patients learn about their condition, mood, thoughts and behavior. There two main types of psychotherapy used that are effective in treating depressive symptoms which are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). “CBT helps people with depression restructure negative thought patterns” (Depression, 2015). It also helps patients recognize things that may be contributing to their depressive symptoms and interpret their environment in positive ways. The other type of psychotherapy is IPT, which is more centralized and focused on relationships that may contribute to having the disorder. “Many clinicians assumed that because of its long-standing nature and strong role of environmental factors, persistent depression may require a primarily psychological treatment “(Uher, 2014). However, it has been found that IPT was actually “significantly less effective than antidepressants and added only marginally significant benefits combined with antidepressant treatment” (Uher, 2014) and the most effective treatment for this disorder was a combination of both high quality psychotherapy and antidepressant medications. Humans have been suffering from mood disorders like Dysthymia throughout history and its treatment evolved with time. Depression was first called “melancholia” and the earliest accounts were in ancient Mesopotamian texts from the second millennium B.C. At that time, all mental illnesses, including depression were attributed to demonic spirits and possessions and thus people suffering from such disorders were treated with exorcism. Then came the ancient Romans who believed that these type of disorders were caused not by spirits but by biological and psychological causes. They treated depression with massage, special diets, music and baths to try and alleviate the depressive symptoms. The Greek physician Hippocrates suggested that mental illness was “related to balanced or imbalanced body fluids called humours. There were four of these humours: yellow bile, black bile, phlegm and blood” (Nemade, Reiss & Dombeck) and believed that melancholia (depression) was caused by too much black bile in the spleen. This view caused treatments of depression to include exercise and diets. During the enlightenment period, doctors gained scientific insight on psychological disorders and began to suggest that depression was caused by aggression. Treatment then started to stress the importance of talking with friends or doctor, which is the first step in psychotherapy becoming a leading treatment for mood disorders today. The term depression was derived from the Latin verb “deprimere” which meant to bring down spirits but the use of the term for psychological symptoms was by the French psychiatrist Louis Delasiauve in the middle of the 19th century around 1856. During this same period, psychodynamic theory was gaining popularity as a treatment for depression. The leading psychodynamic psychologist Sigmund Freud suggested that depressive symptoms were due to loss in one’s life. He “believed that a person's unconscious anger over loss weakened the ego, resulting in self-hate and self-destructive behavior” (Nemade et al.). According to Freud, the treatment then was by psychoanalysis, which he called the “talking cure” in order to resolve unconscious conflicts and better understand oneself. Then, in the mid-20th century, researchers theorized that depression was caused by a chemical imbalance in neurotransmitters in the brain which sparked the treatment by medications and antidepressants. Today, Dysthymia and other mood disorders are not considered to have a single cause and treatments are not fixed on only one method.
In the psychological journal Psychiatric Times (Uher, 2014), a case study of woman suffering from Dysthymia and other psychological disorders is described that shows the effects of them on her life. It is stated that Caroline, a 50-year-old divorced mother of 2 adult children, is referred because of chronic depression, insomnia, and anxiety that has not responded to a number of antidepressants, augmentation attempts, and psychotherapy. During the assessment, she is tense, unable to relax, and anhedonic, with low energy and reduced affective reactivity. She states, "I have been depressed for 40 years." Her score is 24 on the Montgomery-Asberg Depression Rating Scale (MADRS) and 35 on the Beck Depression Inventory (BDI). She meets DSM-5 criteria for Persistent Depressive Disorder, generalized anxiety disorder, and social anxiety disorder. She is currently taking 10 mg/d of escitalopram, 100 mg/d of lamotrigine, and 25 mg of quetiapine at bedtime.Titration of lamotrigine and quetiapine to therapeutic doses (250 mg and 200 mg, respectively) proves unsuccessful. Escitalopram is discontinued and after a washout period of 3 weeks, phenelzine is introduced and titrated to 15 mg 3 times daily (the last dose taken at 4 pm to reduce sleep problems and following dietary restrictions for MAOIs). After taking phenelzine for 8 weeks, Caroline has partial improvement (with new scores of MADRS 14, BDI 23). Caroline is assessed by a clinical psychologist and CBT is initiated, with a focus on activity scheduling, problem solving, and rumination. It is then followed by a course of CBT for generalized anxiety disorder and for social anxiety disorder, including behavioral experiments and video feedback. After 8 months of treatment with phenelzine and CBT, Caroline's depression (MADRS 5, BDI 9) and social anxiety symptoms remit. She is able to return to full-time employment and enjoy sports activities.

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association. 169-171
Depression. (2015), Retrieved from http://www.nimh.nih.gov/health/topics/depression/index.shtml
Mayo Clinic. (2012, December 20). Dysthymia. In Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/dysthymia/
Nemade, R., Reiss, N., & Dombeck, M. (n.d.). Historical Understandings of Depression. In Gracepoint. Retrieved from http://www.gracepointwellness.org/5-depression/article/12995-historical-understandings-of-depression Uher, R. (2014, August). Persistent depressive disorder, dysthymia, and chronic depression: update on diagnosis, treatment. Psychiatric Times, 46. Retrieved from Academic OneFile.…...

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