Dysthymic disorder

Essential (Required) Features:

• Persistent depressed mood (i.e., lasting 2 years or more), for most of the day, for more days than not, as reported by the individual (e.g., feeling down, sad) or as observed (e.g., tearful, defeated appearance). In children and adolescents depressed mood can manifest as pervasive irritability.
• The depressed mood is accompanied by additional symptoms typically seen in a Depressive Episode, though these may be milder in form. Examples include:
• Markedly diminished interest or pleasure in activities
• Reduced concentration and attention or indecisiveness
• Low self-worth or excessive or inappropriate guilt
• Hopelessness about the future
• Disturbed sleep or increased sleep
• Diminished or increased appetite
• Low energy or fatigue
• During the first 2 years of the disorder, there has never been a 2-week period during which the number and duration of symptoms were sufficient to meet the diagnostic requirements for a Depressive Episode.
• While brief symptom-free intervals during the period of persistent depressed mood are consistent with the diagnosis, there have never been any prolonged symptom-free periods (e.g., lasting 2 months or more) since the onset of the disorder.
• There is no history of Manic, Mixed, or Hypomanic Episodes, which would indicate the presence of a Bipolar or Related Disorder.
• The symptoms are not a manifestation of another medical condition (e.g., hypothyroidism) and are not due to the effects of a substance or medication on the central nervous system (e.g., benzodiazepines), including withdrawal effects (e.g., from stimulants).
• The symptoms result in significant distress about experiencing persistent depressive symptoms or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• In children, it may be appropriate to assign the diagnosis of Dysthymic Disorder after a briefer period of initial symptoms (e.g., 1 year).
• Suicide risk is significantly higher among individuals diagnosed with Dysthymic Disorder than among the general population.
• There is a greater risk of Dysthymic Disorder among individuals with a family history of Mood Disorders.
• Co-occurrence with other mental disorders is common, including Anxiety or Fear-Related Disorders, Bodily Distress Disorder, Obsessive-Compulsive or Related Disorders, Oppositional Defiant Disorder, Disorders Due to Substance Use, Feeding or Eating Disorders, and Personality Disorder.

Boundary with Normality (Threshold):

• Some depressed mood is a normal reaction to severe adverse life events and problems, and is common in the community. Dysthymic Disorder is differentiated from this common experience by the severity, range, and duration of symptoms. Assessment of the presence or absence of signs or symptoms should be made relative to typical functioning of the individual.

Course Features:

• Dysthymic Disorder typically has a gradual onset beginning in childhood, adolescence, or early adulthood.
• The course of Dysthymic Disorder may fluctuate between dysthymia and symptoms of Single Episode Depressive Disorder or Recurrent Depressive Disorder.
• Early onset of Dysthymic Disorder is associated with increased likelihood of co-occurring Anxiety or Fear-Related Disorders, Personality Disorder, and Substance Use Disorders.
• In contrast to high rates of co-occurring Mental, Behavioural or Neurodevelopmental Disorders in young adults, Dysthymic Disorder in older adults typically occurs without co-occurrence.
• Greater symptom severity, higher levels of negative affectivity, poorer global functioning, and the presence of Anxiety or Fear-Related Disorders or Conduct-Dissocial Disorder have been associated with poorer long-term outcomes.

Developmental Presentations:

• In young children, Dysthymic Disorder may present as somatic complaints (e.g., headaches, stomachaches), whining, increased anxiety or fearfulness, or excessive crying.
• Adolescents with Dysthymic Disorder may demonstrate low self-esteem, and may be more reactive to negative (or perceived negative) feedback from others.
• Children and adolescents may present with pervasive irritability rather than depressed mood. However, the presence of irritability is not in and of itself indicative of Dysthymic Disorder and may indicate the presence of another Mental, Behavioural or Neurodevelopmental Disorder or be a normal reaction to frustration.
• In children and adolescents, reduced ability to concentrate or sustain attention may manifest as a decline in academic performance, increased time needed to complete school assignments, or an inability to complete assignments.

Culture-Related Features:

• There is little information available about cultural influences on Dysthymic Disorder. The information on Culture-Related Features for Single Episode Depressive Disorder and Recurrent Depressive Disorder may be relevant.

Sex- and/or Gender-Related Features:

• Although Dysthymic Disorder is more common among women in early life, there are no notable gender differences among older adults with late-onset Dysthymic Disorder.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Single Episode Depressive Disorder and Recurrent Depressive Disorder: Dysthymic Disorder is differentiated from Single Episode Depressive Disorder and Recurrent Depressive Disorder by the number of symptoms and the course of the disorder. Dysthymic Disorder is a chronic and persistent condition, and during the initial period of 2 years necessary to establish the diagnosis, the number and duration of symptoms are not sufficient to meet the diagnostic requirements for a Depressive Episode as required for a diagnosis of Single Episode Depressive Disorder or Recurrent Depressive Disorder. After this initial period, if the number and severity of symptoms reaches the diagnostic threshold for a Depressive Episode in the context of an ongoing Dysthymic Disorder, both Dysthymic Disorder and either Single Episode Depressive Disorder or Recurrent Depressive Disorder may be diagnosed. Unlike Dysthymic Disorder, Recurrent Depressive Disorder is episodic in nature. However, long periods of subthreshold depressive symptoms that occur following Depressive Episodes when there has not been an initial 2-year period of subthreshold symptoms are better diagnosed as Single Episode Depressive Disorder in partial remission or Recurrent Depressive Disorder in partial remission.
• Boundary with Bipolar or Related Disorders: Individuals with a pattern of depressive symptoms that resembles Dysthymic Disorder who have a history of Manic or Mixed Episodes should be diagnosed as Bipolar Type I Disorder. A pattern of chronic mood instability that is characterized by periods of both depressive symptomatology that is not sufficiently severe or prolonged to meet the diagnostic requirements for a Depressive Episode and periods of hypomanic symptomatology should be diagnosed as Cyclothymic Disorder.
• Boundary with Schizophrenia or Other Primary Psychotic Disorders: The symptoms are not better accounted for by Schizophrenia, Schizoaffective Disorder, or Other Primary Psychotic Disorder. Depressive symptoms are common in Psychotic Disorders, and these should only be diagnosed as Dysthymic Disorder if they persist for several years after the full remission of psychotic symptoms.
• Boundary with Generalized Anxiety Disorder: Generalized Anxiety Disorder and Dysthymic Disorder can share several features such as somatic symptoms of anxiety, difficulty with concentration, sleep disruption, and feelings of dread associated with pessimistic thoughts. Dysthymic Disorder is differentiated by the presence of low mood or loss of pleasure in previously enjoyable activities and other characteristic symptoms of Dysthymic Disorder (e.g., appetite changes, feelings of worthlessness, recurrent thoughts of death). In Generalized Anxiety Disorder, individuals are focused on potential negative outcomes that might occur in a variety of everyday aspects of life (e.g., family, finances, work) rather than thoughts of worthlessness or hopelessness. Rumination often occurs in the context of Dysthymic Disorder but, unlike in Generalized Anxiety Disorder, is not usually accompanied by persistent worry and apprehension about various everyday aspects of life. Generalized Anxiety Disorder may co-occur with Dysthymic Disorder, but should only be diagnosed if the diagnostic requirements for Generalized Anxiety Disorder were met prior to the onset of Dysthymic Disorder.
• Boundary with Oppositional Defiant Disorder: It is common, particularly in children and adolescents, for patterns of noncompliance and symptoms of irritability/anger to arise as part of mood disturbance. Specifically, noncompliance may result from a number of depressive symptoms (e.g., diminished interest or pleasure in activities, difficulty concentrating, hopelessness, psychomotor retardation, reduced energy). When the behaviour problems occur primarily in the context of mood disturbance, a separate diagnosis of Oppositional Defiant Disorder should not be assigned.
• Boundary with Secondary Mood Syndrome: A chronic depressive syndrome that is a manifestation of another medical condition (e.g., hypothyroidism) should be diagnosed as Secondary Mood Syndrome rather than Dysthymic Disorder.
• Boundary with Substance-induced Mood Disorder: A chronic depressive syndrome due to the effects of a substance or medication on the central nervous system (e.g., benzodiazepines), including withdrawal effects (e.g., from stimulants), should be diagnosed as Substance-Induced Mood Disorder rather than Dysthymic Disorder.