We have to keep our eye on the diagnostic ball and not feel constrained to keep our original diagnosis as a sacred cow. People change over time and as a result of therapy. We see these changes but usually do not note them. There are numerous anxiety disorders, and we do not find it strange for people to go from one to another. I am suggesting that the same is true of the depressive spectrum.
Dr. Stewart's thesis is that dysthymic patients have more disability than other depressive disorders. We need to assess the psychosomatic symptomatology of these patients and other kinds of psychiatric disability. We already have reviewed some of the major disabling behaviors. What I believe is most disabling is the chronic nature of the illness, the length of time the person feels bad, the complaints, and, in particular, the unhappiness.
Viewing the Illness as Cyclical
I am caring for a patient now with bipolar illness who seemed very depressed for months and then, with a change in medication, became manic–loud, disruptive, very talkative, and filled with complaints. That was a real change from his depressive state. He started going out, seeing people, and was overjoyed with his “improvement.”
Recently, however, this patient has become less joyous, filled with physical complaints of all kinds, and unable to do anything. He quit his part time job and now complains of having nothing to do. He says repeatedly, “I am not depressed,” but he also is not manic. I think he is dysthymic at this time–although the DSM-IV would disagree with me.
On some points, the DSM-IV is clear about dysthymia. It starts early in life, is chronic, and must last for 2 years before one can call a patient dysthymic. Other symptoms include poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.
All of these symptoms also are seen in MDD. This tells us why the diagnosis is so difficult to make. From what I've already said, I don't agree with the DSM-IV about the absence of any full depression in the 2-year period that must precede diagnosis, according to the manual. Most important is the long-term nature of the disorder. For example, the patient who says “I've been depressed all my life” could be a candidate.
The extent to which this diagnosis is related to abuse and trauma in childhood never has been studied. Whenever a person tells me about a lifetime of unhappiness, I inquire about abuse and trauma. What started a life of unhappiness? In the movie “Precious,” the main character says “no one ever loved me,” a pathetic moment in the film but true of many children we see today. Alice Miller, Ph.D., the researcher on childhood, says a child must have one person in his life who gives him unconditional love.
Unconditional love is just what the name implies: no constant criticism (emotional abuse), no constant punishment (physical abuse), and protection from getting hurt or further abused by people, at school, or on the street. Without it, the child might develop dysthymia. I see people gratuitously hitting children in public venues, and being shamed in this way can lead to dysthymia.
Recently, I attended an alternative high school graduation. I was sitting next to a family in which the mother had a 4-year-old on her lap, constantly hit the boy, and yelled “Shut the [expletive] up.” The grandmother eventually rescued the boy, and he ran to her as fast as he could. Later during the program, he ended up back with his mother and she started her admonition again. Finally, she sat the little fellow in her chair and stood right in front of him so that she could see the events. All he could look at was the back of her body. I was very upset by witnessing firsthand what this boy was going through. Of course, I have no way of following up on the child 10 or 15 years from now to see how he is doing. But I can predict that he will either be delinquent or dysthymic.
Those of us who practice in the office each day must be vigilant about identifying dysthymia disorder and finding effective treatments.