Dysthymic Disorder

Dysthymic Disorder is the term for what used to be called depressive neurosis. The essential criterion for diagnosis of dysthymia is a depressed mood for most of the day, for more days than not, for at least two years. In addition, there must be at least two of the following symptoms while feeling depressed:

1.  Poor appetite or overeating
2.  Insomnia or hypersomnia
3.  Low energy or fatigue
4.  Low self-esteem
5.  Poor concentration or difficulty making decisions
6.  Feelings of hopelessness

Note that the secondary symptoms are very similar to those for major depression, except that psychomotor agitation/retardation and thoughts of death or suicide are not listed, and low self-esteem is. The distinction between major depression and dysthymia is rather arbitrary, a matter of degree rather than kind. When Prozac or interpersonal psychotherapy is reported to be successful with 70 percent of patients with major depression but only 50 percent of patients with dysthymia, it's quite likely that many patients who didn't improve were misdiagnosed.

Tammy fits the picture of dysthymia. A bright, intelligent woman with a forceful manner and a terrific sense of humor, she has been unhappy most of her life. Raised by an alcoholic mother and a critical father, as a child she tried to make them both happy-an impossible task. She rebelled in adolescence, getting in all kinds of trouble. Her first marriage was to a man who was an alcoholic and abusive. Having found a lot of strength through Al-Anon, Tammy is determined to get her life together. But she and her present husband can't communicate. Tammy is very quick to anger and her husband withdraws. She struggles constantly with her sense of having a grievance against life-she knows this, along with her angry expression, drives people away, but she can't control herself.

Tammy speaks of her depression as a big soft comforter. It's not really comforting, but it's safe and familiar. Sometimes she feels as if she's entitled to be depressed, to quit struggling, to snuggle down and watch old movies and feel sorry for herself.

People with dysthymia are sometimes called the "worried well," but nothing could be further from the truth. Imagine spending the better part of two years feeling depressed, having trouble functioning, unable to enjoy life, feeling lousy about yourself, sleeping poorly, and feeling powerless to do anything about it. These people are more accurately described as "walking wounded." They get through life, but life tends to be nasty.

We often see the effects on children of having a mother who functions like this. Frequently, the children are anxious, tense, and have difficulty getting along with their peers and keeping up with schoolwork. They know all too well that something scary is going on with mom, and they feel that they should be able to do something about it. These children often adapt and become "pseudoadults," who appear tough and independent. They may actually take care of mom by assuming adult responsibilities-meals, housecleaning, baby-sitting the younger siblings.

Often when mom recovers, there is a backlash. With a functioning mother again, the child is able to feel the anger he has suppressed at having been emotionally abandoned. He becomes rebellious and tests mom to see if she can really be relied on. Mom, still vulnerable, has difficulty understanding why her child isn't grateful to see her functioning again and may revert to her depressed stance. Depression then becomes a vicious circle in the family.

On the next page we will discuss Depressive Disorder NOS.