A thief crept into Maria’s life and stole one of her most prized possessions: her happiness. It has been ten years and she still does not know it is gone.  She is still able to go to work, cook for her children, and even go to parties when she must. Maria’s husband wonders where the woman that he married is, the one full of energy that was fun to be around, but he just figures that that is what happens after two children and her full-time job.  Maria’s children like to be around their friend’s mother better because she laughs and plays with them, instead of snapping at them.  Maria sometimes thinks that there may be something wrong as she watches her husband watch television at night, she thinks that something may be missing. No, she thinks, that is just the way that she is, a part of her personality.

The perfect crime has taken place: the crime that nobody suspects. The thief’s name is dysthymia.  Even the clinical description of dysthymia, a chronic low-grade depression, is a crime explained Dr. Joseph Henry, a psychiatrist at the University of Miami’s Out-patient Care Clinic.

“When you say someone has a [low-grade] depression,” said Henry, “what you’re implying is that it is something that need not be addressed, need not be taken care of and yet what is minor depression to one person may be significantly affecting their lives.”

Dysthymia encases a person within walls they do not even realize are there and then warps their perception of the world around them.  DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), a book that sits on the shelf of every mental health care professional in the country, describes the onset of dysthymia as insidious. 

“Insidious,” as defined in Webster’s Dictionary, means:  1)  intended to entrap or beguile; 2)  stealthily treacherous or deceitful; 3)  operating or proceeding inconspicuously but with grave effect.  Dysthymia creeps into a person’s life at an early age.  It has no warning signs like its more popularly known cousin, major depression, and its chronicity is completely unlike major depression.  One blue day turns into a blue week, which can turn into years.  It beguiles a person into thinking that that is how they are, just a part of their personality.  Most people that suffer from dysthymia do not even realize that they have a treatable problem.  Over time, the illness reaches out to have a grave effects on every facet of a person’s life.

Dysthymia Uncovered

Dysthymia is best understood by its comparison with major depression.  Dysthymia is like a thief in the night where major depression is like the guy in military fatigues bursting through your door with a shotgun.  Both can ravage a person’s life, steal what is most important to a person: happiness, self-control, self-esteem.

“The symptoms [of dysthymia] are actually very similar to major depression,” said Henry.  “They are cousins.  The difference is that dysthymia lasts a long time without significant remission and the symptoms are not quite as intense in severity.”

For an illustration of dysthymia, imagine a person’s emotional state as a scale from 1 to 100, with the higher range of the scale indicating elevated states of happiness and the lower range indicating sadness and depression.  A normal person’s emotional levels will rarely go beyond the 40 to 60 range, except in traumatic moments.  A person suffering from major depression will plunge down to 10 for periods of weeks to months.  A person suffering from dysthymia, on the other hand, will gradually lower to 35, then continue at that level from two years to a lifetime.

“Depressions lasting two to three years are not uncommon,” wrote Dr. Hagop Souren Akiskal, a leading researcher of dysthymia, “and an unremitting course over decades or even a lifetime has been observed.”

For a diagnosis of major depression, symptoms must be present for at least two months.  For dysthymia, symptoms must be present for two years.  By the time that dysthymia can be diagnosed, the symptoms have already become engrained into a person’s life, becoming part of their habits.

Symptoms of Dysthymia

Up to this day, there is a controversy over whether or not a “pure dysthymia” exists or if dysthymia is merely a part of major depression.  Although dysthymia first entered the mental health care language at the end of the 19th century, it was not until DSM-III, published in 1980, that it attained status as a separate mood disorder apart from major depression.  Before then, it was either classified as a complication of major depression or even as a personality disorder.

“I believe there is a pure dysthymia,” said Henry.  “There are people who have been suffering with depression–we’ll call it dysthymia–for many years and although they have never clearly suffered from an episode of major depression, they have still been depressed for a long period of time.”

Dr. Daniel Kline, a clinical psychologist at the State University of New York at Stony Brook and an expert in chronic depression, said “dysthymia waxes and wanes in severity, sometimes meeting the criteria for major depression.”  He considers “pure dysthymia” almost a mythological thing.

Whatever the case, two things are clear:  1)  A person may suffer for a long time without ever having a major depressive episode and 2)  a major depressive episode, if and when it does occur, can be a blessing.  When the man with the shotgun breaks down the door, it may make a person look into the corner where the thief has been hiding.

DSM-IV lists the following as symptoms of dysthymia that must be met for two years without significant remission.  At least two of the symptoms have to be met.

• Poor appetite or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or difficulty making decisions
• feelings of hopelessness

With major depression, these symptoms are going to have drastic effects on a person’s life.  They will stop eating and/or stay in bed all of the time. With a person suffering from dysthymia, the effects are not going to be as severe.

Kline explained that severity is a combination of intensity and frequency.  He made an example of “low self-esteem” to illustrate the point.  “With a person suffering from major depression, they are going to feel worthless, that they have no value.  A person suffering from dysthymia would not feel worthless but would feel badly about themselves and feel they did not measure up to their own or other’s standards.”

The feeling of worthlessness, explained Kline, is going to be present all of the time with major depression.  The low self-esteem associated with dysthymia is going to fluctuate but be present more than half of the time four days out of the week.

“Anna,” a middle-aged woman who was diagnosed with dysthymia one year ago, responded in a written interview that her symptoms included difficulty making decisions and low self-esteem.  “I suspected I was prone to mild depression once in a while,” she wrote, “until I realized that ‘once in a while’ was way too often.”  She went to see her physician who referred her to a psychiatrist.

Realizing that they have a problem is one of the major difficulties faced by people suffering from dysthymia.

“[Dysthymics] are still functioning within their structure,” said Henry.  “They are still able to go to their job, still able to maintain relationships…unlike the patient with major depression who may not be getting out of bed, may not be showering…so inevitably there is someone else with the person suffering from major depression that sort of says, ‘Hey, there is something wrong here and we need you to go see a doctor.’”

Dysthymia does not cripple in one blow.  It invades a person’s life with stealth, creeps into their habits and personality.  It steals their happiness and then creates a “blue” world.  Their actions and reactions become shaped by the illness. 

A Lifetime of the “Blues”

The insidious onset of dysthymia, and its chronic course, plays a major role in the life of a person.  They are in a continual state of feeling “blue.”  A person comes to believe that feeling blue is a part of their personality.  Akiskal wrote in the American Journal of Psychiatry, “trait (personality) and state (depression) are so interwoven that it is difficult to separate posture or lifestyle from illness or disease.”  Happiness is not stolen all at once; it is stolen in pieces.  A person eventually finds themselves in an empty house–thinking that that is the way it is supposed to be.

DSM-IV reports that the onset of dysthymia is before age 25.  Kline reports a much earlier onset.  “3/4 cases,” he said, “begin before the age of 21.”  He feels that many cases begin before adolescence, but it is hard to determine exactly when because “kids have different lives than adults.”  Without the warning signals, the direct crippling effects of a major depressive episode, there is not a single period that a person can point to and say, “that was when I began to suffer from dysthymia!”

Akiskal wrote that patients in clinics with dysthymia have made such statements as “I was born depressed” and “I am the most miserable creature on earth.”

“Laura,” a middle-aged housewife, wrote, “I was unaware that I was regularly in a minor state of depression…I am not a person who worries much about myself.  My concentration has always been on taking care of my family.  As long as I could do that I didn’t think much about how I felt…part of my problem was I didn’t know that I should or could feel better on a regular basis.”

People with dysthymia, after living without happiness for a long period of time, begin to feel that the depressed state they live in is normal.  It can change how they process thoughts.

Some of the associated features of dysthymia as listed in DSM-IV are:

• feelings of inadequacy
• generalized loss of interest or pleasure
• social withdrawal
• feelings of guilt or brooding about the past
• subjective feelings of irritability or excessive anger
• decreases activity, effectiveness, or productivity

Anna reported that prior to her diagnosis, she had higher levels of irritability, lower motivation, mood swings, and had a tendency to withdraw from social activities.  She also did not have much interest in relationships or social interaction.

“[Dysthymia] can have serious ramifications upon an individual,” said Henry, “because due to this continued lack of interest and lack of enjoyment, they start to withdraw somewhat.  People don’t particularly want to be with them because they’re not much fun to be with and they don’t particularly want to be with other people because they’re not enjoying themselves.  It is not that they don’t want to enjoy themselves, they have this burden.”

A person described a fellow co-worker, who was later diagnosed with dysthymia, as dull and boring.  “He was a nice guy,” she said, “but he never laughed or joked–something that was very abnormal in my office.”

At a study done at the Virginia Commonwealth University, it was found that people suffering from dysthymia developed a depressive lifestyle.  In The Journal of Nervous and Mental Disease researchers described the untreated course of the illness.  The people studied had turned inward.  They were chronically shy and their coping strategies tended to be wishing their problems away, blaming themselves, and/or seeking support from others.  Dysthymics find themselves alone in an empty house without the ability to change the situation by themselves.

Complications associated with dysthymia are also going to extend into the workplace.  “Although they function at work,” said Henry, “they cannot function at their optimal level.  [Dysthymia] will probably hold them back in social engagements or occupational advancement.”

“Most [people with dysthymia],” said Kline, “are underproducing because they just do not have the energy or the initiative to do more.  People with Dysthymia just get through the day.”

Hope–And Advice for Mental Health Care Practitioners

“I think that people should be aware,” said Henry, “that they don’t have to continue living in this continuous depression, this continuous down-feeling.  There are new medications available that are safe, tolerable.”

Both Laura and Anna are taking the anti-depressant Zoloft.

Laura has lived with dysthymia all of her life.  She began treatment only one month ago.  “[With the medications], my ability to go about the day is better.  The rest really remains to be seen.”

Anna began treatment one year ago.  Treatment has lowered her anxiety, made her less irritable and depressed, and “therefore,” she wrote, “I can rationalize my problems more clearly.”

“It is pretty clear anti-depressant drugs are effective,” said Kline.  He continued that there should be a complete recovery from the direct effects of dysthymia after 8 to 12 weeks.  His research has shown, however, that drug therapy should be modified because it takes longer for a patient with dysthymia to respond to medications than a person with major depression.  “In major depression, if there is no response after four to six weeks, medications are switched.”  With dysthymia, it may take up to eight weeks for the person to respond.

There are various anti-depressant drugs including Prozac and Zoloft, two of the most popular.  Kline stated that each drug has a 50 percent chance of working, but that each drug taken afterwards, if the previous has been ineffective, also has a 50 percent chance.

Psychotherapy, or talk therapy, can also be an important aspect of recovering from dysthymia.

“Psyche patterns for dysthymia are passive,” said Kline.  “In coping styles, they tend more on their own feelings (how miserable they are) rather than problem solving (how to make themselves less miserable).”

“There are ongoing studies of psychotherapy with dysthymia,” said Kline.  “My hunch is that psychotherapy will also take longer to be effective.”

“I think that the publicity about [dysthymia] is extremely important,” said Henry, “because I think that many people are just unaware of the existence of this illness…there are no statistics but it would not surprise me if there were many, many people that were suffering from dysthymia who are just not aware of it.”

For people who suffer from dysthymia, somewhere in their past they began to live depressed.  Anti-depressants can return what dysthymia had stolen from them.  It can refill the empty house.  But the person still as to relearn how to live in that world that is not always blue, how to open the front door and let people in, and how to deal with the problems outside that door in a healthy way.  They have to learn how to live with happiness.

For more information on dysthymia, please contact the following organizations:

• National Depressive and Manic Depressive Association (800-826-3632):  Offers free literature and referrals for support groups.
• National Foundation for Depressive Illness (800-248-4344):  provides 24 hour recorded message on symptoms of depression and address for more information and physician referrals.
• Your local university-based psychology department should also be able to answer questions concerning referrals.

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