14 OPINION AUGUST 2010 • CLINICAL PSYCHIATRY NEWS FINK! STILL AT LARGE A recent study shows that dysthymic disorder leads to more disability than major depressive disorder. How should we think about dysthymic disorder?

ysthymic When I interview a patient who has What I believe is most disabling is the The extent to which this diagnosis is re- disorder been on the inpatient service, there is a chronic nature of the illness, the length of lated to abuse and trauma in childhood Dis one of group of them who respond to my ques- time the person feels bad, the complaints, never has been studied. Whenever a per- those diagnoses tion, “When did you first become de- and, in particular, the unhappiness. son tells me about a lifetime of unhappi- BY PAUL J. in the DSM-IV pressed,” with a quick, “I’ve been de- ness, I inquire about abuse and trauma. FINK, M.D. that seems to be pressed all my life.” When I get that Viewing the Illness as Cyclical What started a life of unhappiness? In the characterized by answer, I search for a history of physical, I am caring for a patient now with bipolar movie “Precious,” the main character ambiguity. I think that many psychia- sexual, and/or emotional abuse early in illness who seemed very depressed for says “no one ever loved me,” a pathetic trists like me do not use this category that person’s life. The person sitting in months and then, with a change in med- moment in the film but true of many chil- very often because we see it as a fall-back front of me might not be clearly de- ication, became manic—loud, disruptive, dren we see today. Alice Miller, Ph.D., the diagnosis. For example, if you don’t think pressed, but between major depres- very talkative, and filled with complaints. researcher on childhood, says a child must that the patient has a serious depression, sions—the sense of a lifetime of depres- That was a real change from his depressive have one person in his life who gives him you might call it dysthymic disorder. sion might actually be dysthymic. state. He started going out, seeing people, unconditional love. The finding of Dr. Jonathan W. Stew- If we were to plot the illness, perhaps it and was overjoyed with his “improvement.” Unconditional love is just what the art and his colleagues that dysthymic dis- would look like a sine curve graph. This Recently, however, this patient has be- name implies: no constant criticism (emo- order causes a “significant public health is just a conjecture, but it might look like come less joyous, filled with physical tional abuse), no constant punishment burden” that carries with it a significant this: dysthymic—MDD—suicide at- complaints of all kinds, and unable to do (physical abuse), and protection from get- amount of disability (“Dysthymic Dis- tempt—dysthymic disorder—MDD—sui- anything. He quit his part time job and ting hurt or further abused by people, at order Causes More Disability Than Ma- cide attempt, and so on. We have all seen now complains of having nothing to do. school, or on the street. Without it, the jor Depression,” p. 1) is in line with what patients like this. Nothing is accomplished; He says repeatedly, “I am not depressed,” child might develop dysthymia. I see peo- I’ve seen over the years. Coming up with the patient has no job and usual- ple gratuitously hitting children in public effective treatment for these patients is ly no attachments; the family is What I believe is most disabling is venues, and being shamed in this way can particularly challenging. not interested. I would like to the chronic nature of the illness, the lead to dysthymia. My approach is to do a careful assess- hear from others who have seen Recently, I attended an alternative high ment of a patient who complains of de- this kind of syndrome or life his- length of time the person feels bad, school graduation. I was sitting next to pression. If I don’t believe that support- tory. We know that when a pa- the complaints, and, in particular, a family in which the mother had a 4- ing evidence of major depressive tient says she has been depressed year-old on her lap, constantly hit the disorder exists (MDD), I will call it dys- her whole life, that is that pa- the unhappiness. boy, and yelled “Shut the &%$# up.” thymic disorder and look for a “major” tient’s impression retrospectively The grandmother eventually rescued the diagnosis for the patient. I always use to what happened between major but he also is not manic. I think he is dys- boy, and he ran to her as fast as he could. dysthymia as a secondary condition. The episodes. I have found that major depres- thymic at this time—although the DSM- Later during the program, he ended up patient talks depressed but doesn’t look sive episodes are aborted by a suicide at- IV would disagree with me. back with his mother and she started her depressed. Since the entire category of tempt, usually with hospitalization and a On some points, the DSM-IV is clear admonition again. Finally, she sat the lit- depression is under affective disorders in discharge. But discharge to what? about dysthymia. It starts early in life, is tle fellow in her chair and stood right in the DSM-IV, I expect a great deal of af- The dysthymic patient needs a support chronic, and must last for 2 years before front of him so that she could see the fective symptomatology for MDD and system that he usually does not have. one can call a patient dysthymic. Other events. All he could look at was the back still some in dysthymic disorder. And he does not know how to reach out symptoms include poor appetite or of her body. I was very upset by wit- and build such a system. overeating, insomnia or hypersomnia, nessing firsthand what this boy was go- Inability to Work Is Key One man I saw who fit this description low energy or fatigue, low self-esteem, ing through. Of course, I have no way of An important component is the degree had had four intense affairs with women poor concentration or difficulty making following up on the child 10 or 15 years of impairment in these patients. They but was unable to consummate any of the decisions, and feelings of hopelessness. from now to see how he is doing. But I can’t get to work and are inconsistent. relationships into marriage. Of course, he All of these symptoms also are seen in can predict that he will either be delin- According to Dr. Stewart, “dysthymia is took no responsibility for the breakdown MDD. This tells us why the diagnosis is quent or dysthymic. what ruins people’s lives.” Work history, between him and any of the women. so difficult to make. From what I’ve al- Those of us who practice in the office history of success, and failure in social In long-term outpatient cases, we see ready said, I don’t agree with the DSM- each day must be vigilant about identify- settings are clearly part of dysthymic the diagnosis changing from year to year. IV about the absence of any full depres- ing dysthymia disorder and finding effec- disorder. These patients also consume In one patient I saw for more than 2 sion in the 2-year period that must tive treatments. ■ more Medicare, Medicaid, and Social Se- decades, his condition varied over time. precede diagnosis, according to the man- curity Disability Insurance than do peo- He was never free of complaint and ual. Most important is the long-term na- DR. FINK is a psychiatrist and consultant ple with other forms of depression. sometimes would talk of his depression, ture of the disorder. For example, the pa- in Bala Cynwyd, Pa., and professor of These patients also had fewer full-time which generally was not visible. Yet, tient who says “I’ve been depressed all psychiatry at Temple University in jobs than did those with other diagnoses. there were times in which he became se- my life” could be a candidate. Philadelphia. These objective findings are impor- riously depressed with a lot of crying and tant, because patients with dysthymic discomfort. Again, at other times, his af- disorder do not have a lot of symptoms. fect was not deeply impaired. Looking EDITORIAL ADVISORY BOARD They know they do not feel good; in- back, I would say that this patient had LEE H. BEECHER, M.D., University of THOMAS W. MEEKS, M.D., University of stead they are sad, not joyous, and have dysthymia at those times. Minnesota, Minneapolis California, San Diego a lot of self-blame and guilt. The pa- We have to keep our eye on the diag- CARL C. BELL, M.D., University of Illinois THERESA M. MISKIMEN, M.D., University tient’s failure in social engagement and nostic ball and not feel constrained to at Chicago Behavioral Healthcare, Piscataway, N.J. poor work history are important factors keep our original diagnosis as a sacred DANIEL E. CASEY, M.D., Oregon Health CLIFFORD K. MOY, M.D., Texas Medical and Science University, Portland and Healthcare Partnership, Austin to note. The patient rarely has a lot of cow. People change over time and as a re- PAUL J. FINK, M.D., Temple University, RODRIGO A. MUÑOZ, M.D., University of vegetative signs. Sleep is the exception. sult of therapy. We see these changes but Philadelphia California, San Diego The dysthymic disorder patient has some usually do not note them. There are nu- MARY ELLEN FOTI, M.D., University of ANTHONY T. NG, M.D., Acadia Community sleep disturbance, but not of the degree merous anxiety disorders, and we do Massachusetts, Worcester Hospital, Bangor, Maine found in MDD or bipolar illness. not find it strange for people to go from CATHERINE A. FULLERTON, M.D., Harvard CYNTHIA R. PFEFFER, M.D., Cornell I was trying to provide a case history one to another. I am suggesting that the Medical School, Boston University, New York for this essay and couldn’t come up with same is true of the depressive spectrum. ANTONIO Y. HARDAN, M.D., Stanford DAVID SPIEGEL, M.D., Stanford (Calif.) a patient who had a pure DD. As I said in Dr. Stewart’s thesis is that dysthymic (Calif.) University University the beginning, the diagnosis reminds me patients have more disability than other THELISSA A. HARRIS, M.D., Private PETER J. WEIDEN, M.D., University of of “not otherwise specified” or the way depressive disorders. We need to assess Practice, Hartford, Conn. Illinois at Chicago in which the ER physician decides that the psychosomatic symptomatology of JAMES W. JEFFERSON, M.D., University of JOHNNY WILLIAMSON, M.D., Hartgrove Wisconsin, Madison Hospital, Chicago the patient has a psychiatric illness—he these patients and other kinds of psychi- SIMON KUNG, Mayo Clinic, Rochester, can’t find anything physiologically defin- atric disability. We already have reviewed Minn. itive to affirm a diagnosis in his mind. some of the major disabling behaviors.