My choice of Dysthymic Disorder for purposes of this essay was both personal and professional. First and foremost, I was attracted to this disorder because it resides in the gray area somewhere between an Axis I disorder and a personality disorder. Because of this unique diagnostic positioning I feel as though I could reasonably justify techniques that are traditionally associated with all of the major schools of psychotherapy I have studied to date: Behavior Therapy, Cognitive Behavior Therapy, Schema Therapy, Existential Psychotherapy, and/or (perhaps most importantly) my own personal brand of psychotherapy that shall remain unnamed. With some amalgamation of techniques derived from the above, as dictated by individual client needs, I have confidence I would have a reasonable chance of having “success” (however we mutually choose to define that) with the majority of clients that present with Dysthymic Disorder. Secondly, it seems to me a young clinician’s time is best spent on the disorders he is mostly likely to encounter. Prevalence rates of Dysthymic Disorder could be as high as 6% in a nationally representative sample, and as high as 22% in outpatient mental health settings. (Dougherty, Klein, & Davila, 2004) It’s extremely unlikely that I will not encounter Dysthymic Disorder during the course of my professional life. Third and finally, this disorder is close to me because someone I love endured it for the better part of 10 years. Thankfully – I can report at this time that it is in full remission. The journey to full remission was one that tested all of our capacities for change and growth. This essay represents a personal and professional journey that is has led to significant gains in my own understanding of mood disorders. Successfully navigating through the dark forest that is Dysthymic Disorder is no easy task. It is my hope that my clients don’t have to endure the dark thoughts any longer than is absolutely necessary.
The essential feature of Dysthymic Disorder is a chronically depressed mood that occurs for most of the day, more days than not, for at least two years. (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 376) During periods of depressed mood, at least two of the following additional symptoms are present: poor appetite or overeating, insomnia (sleep too little?) or hypersomnia (sleep too much?), low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 377) In my example case the individual was laden with hypersomnia, fatigue, and poor concentration. It is noteworthy that are over 700 different combinations of symptoms that any single individual could potentially present with and still have the same diagnosis of Dysthymic Disorder. As a result, it bears mentioning that the following analysis is in no way suggesting that this is the only right way to treat the disturbance. Manualized treatment is probably doomed to failure when it comes to treating Dysthymic Disorder. Any reasonable attempt to work toward complete remission of Dysthymic Disorder should be guided by a professional.
Differential diagnosis can be a challenge with Dysthymic Disorder. “This is the way it’s always been” is not an unexpected response from patients whom suffer from Dysthymic Disorder. There is no rest for the wicked: During the two year period of the disturbance, the individual may not have been without the qualifying symptoms in for more than 2 consecutive months. Furthermore, no major depressive episode should be present during the first two years of the disturbance and the disturbance cannot be better accounted for by the diagnoses of chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission. (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 380) Double depression, or the comorbid combination of Major Depressive Disorder and Dysthymia, is also a very real consideration since major depressive episodes are often superimposed on mild chronic depression. (Dougherty et al., 2004, p. 1012; Morrison, 2007, p. 139) There should never have been a manic, hypomanic, or mixed episode that would be contraindicative of Dysthymic Disorder and indicative of either Cyclothymic Disorder or Bipolar Disorder (I or II). The disturbance should not occur exclusively during the course of a chronic psychotic disorder (like schizophrenia, for example) or be the direct physiological effects of a substance (like methamphetamine, for example) and/or general medical condition (like a traumatic brain injury, for example). As is the case with most DSM diagnoses, the disturbance should cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 381) This differential diagnosis quandary is further exacerbated by the fact that depression “shares borderlands with bereavement and other losses, problems of living, and adjustment disorders.” (Morrison, 2007, p. 127) A thorough investigation of antecedents and mitigating factors is absolutely critical to accurately “anchor your boat” so you can “wade into the river” with a correct diagnosis.
Family history is an important consideration when determining the hypothetical etiology of a disturbance, especially in the case of mood disorders. “Family history is more useful in starting the train of diagnostic thought than in determining its final destination.” (Morrison, 2007, p. 133) Research suggests that the strongest predictors for Dysthymic Disorder include a history of sexual abuse, quality of the patient’s relationship with both parents, and higher familial loadings for drug abuse and ‘Cluster A’ personality disorders. Unfortunately, we could use that same laundry list of antecedent events for just about every personality disorder in the DSM-IV-TR… so that doesn’t tell us much. Childhood adversity and familial psychopathology and have greater predictive utility for Dysthymic Disorder when compared with demographic and clinical variables. (Durbin, Klein, & Schwartz, 2000) Translation: nurture appears to trump nature. Nature continues to play a significant role in the development and maintenance of the disturbance, however. A patient with a parent (or parents) with unipolar depression exhibited significantly higher rates of Affective/Mood Disorders including Major Depressive Disorder and Dysthymic Disorder – yet another marker that can guide the patient-clinician dyad in the right direction. (Klein, Clark, Dansky, & Margolis, 1988)
A full exploration of the potential therapeutic interventions is beyond the scope of this paper, but there are a few empirically supported treatments that are noteworthy. Supportive therapies, coupled with cognitive behavioral interventions, have been effective in extinguishing negative verbalizations and normalizing daily functioning. (Elligan, 1997) This is consistent with my “necessary but not sufficient” position when it comes to person centered therapies practiced by the late great Carl Rogers (1902-1987). Although I concede that the research I found doesn’t specifically point to Schema Therapy as a potential treatment modality for Dysthymic Disorder, I would consider it based in part on event-related brain potential research. (Yee, Deldin, & Miller, 1992) Processing deficits including selective attention may be modified and corrected vis-à-vis Schema therapy. Since research suggests that resource allocation is the issue, not resource capacity, the goal of Schema Therapy would be to allow for attention resources to be more effectively and efficiently focused on task performance. (Yee & Miller, 1994) Pharmacological interventions have been less effective on Dysthymic Disorder when compared with other mood disorders, so I would not consider this to be a first line of defense except in cases of Double Depression or in cases where talk therapy would be otherwise unproductive without the value added by antidepressant medications. Other noteworthy psychological treatments that have garnered empirical support for the treatment of clinical depression include Behavior Therapy (Behavioral Activation), Cognitive Therapy, Cognitive Behavioral Analysis System of Psychotherapy, Interpersonal Therapy, Problem-Solving Therapy, Self-Management/Self-Control Therapy, Acceptance and Commitment Therapy, Behavioral Couples Therapy, Emotion-Focused Therapy (Process-Experiential), Reminiscence/Life Review Therapy, Self-System Therapy, and Short-Term Psychodynamic Therapy. (Hayes & Strunk, n.d.) In the end, the choice is one that will be made based on the training and expertise of the respective therapist and the needs of the individual patient. Not all therapists are created equal. In the end, every clinician should know a little about most of the treatment options above so they can make a referral if your particular variant of Dysthymia will not be well served by the treatment modalities that your clinician is versed in.
Knowing nothing about my potential client, I would begin the treatment from a cognitive behavioral perspective because I believe that it is the “best bang for the buck” in a brief therapy environment. The most likely scenario for a first session could be summed up in the word “triage.” Something brought the client into therapy and we need to “stop the bleeding.” Behavioral activation in the form of cognitive behavioral homework is absolutely critical to get the ball rolling. Although we can only speculate without a specific case study to reference, we would likely begin with some simple behavioral activation like “going on a walk with a friend for one hour, once a week.” Ideally the target behavior would be specific, measurable, and relatively easy to complete (at least at the beginning). Reversing that “downward spiral” as soon as is possible is an important first step in the treatment of Dysthymic Disorder. (Beck, 2011, p. 80) After identifying avoidance behaviors and potential reinforcing activities, I would endeavor to implement some form of self-reinforcement whereby transfer, generalization, and long-term maintenance of the desired behavior can be established and maintained. (Spiegler & Guevremont, 2010, p. 135) It should be a foregone conclusion but it bears mentioning that the homework should be customized for the specific patient and, if deemed necessary, “contracted” to increase the likelihood of compliance.
Furthermore, I would work to identify chronic stressors that appear to be contributing to the maintenance and onset-recurrence of the disturbance. (Dougherty et al., 2004, p. 1012) I typically engage in a series of assessments including interviews, behavioral checklists, assessments (ex: Beck Depression Inventory), and direct ecological observation to obtain both direct and indirect data regarding the antecedent variables and functional relations that serve to perpetuate the disturbance. (Cooper, Heron, & Heward, 2007, p. 50) I would pay particular attention to social, medical, family circumstances in the past, present, and anticipated future. I would also make certain to note any vested friends and family without whom behavior change cannot be successful. (Cooper et al., 2007, p. 51) Parallel to that search for natural supports, I would engage in a systematic search for pool of appropriate people whom the individual could potentially model. (Cooper et al., 2007, p. 413) Finally, it bears mentioning that the continued inclusion of data from multiple sources (people) and situations (cultural contexts and mediating factors) makes the process of culturally competent cognitive behavioral therapy a possible since “identification of important, controllable, causal functional relationships” is an intimately subjective process laden with unique cultural issues and challenges. (Hays & Iwamasa, 2006, p. 255-256)
The next logical step after the aforementioned behavioral interventions is a series of cognitive interventions that help the patient establish a bridge between automatic thoughts and behavior. The cognitive elements of belief modification may need to be undertaken in parallel with behavioral interventions if the patient isn’t “buying the rationale” or is repeatedly unable to traverse unforeseen cognitive obstacles. (Beck, 2011, p. 295) The process of teaching a patient to identify and monitor automatic thoughts is of paramount importance for long term success and maintenance. If the patient-clinician dyad comes to consensus about a longer treatment course, Schema Therapy would be my personal tool of choice since we can reasonably anticipate it will take at least 12-24 months to modify an individual’s core belief system.
There are a number of anticipated complications that we can reliably predict before treatment commences. The first and most obvious complication is that negative self talk and poor self image are so much a part of the typical patient with Dysthymic Disorder that compliance is likely to be a huge issue. Resistance is likely to be moderate to high, especially once core issues are identified. Metaphorically, we are talking about convincing someone that gravity doesn’t exist… it’s sure to be an uphill battle. By virtue of the fact that I have endured the disorder myself, countertransference is a real and pertinent issue. I would personally address this by attending my own individual sessions to ensure that I don’t get in the way of the best interest of my patient. Finally, it must be noted that an individual with Dysthymic Disorder should be considered extremely vulnerable and handled with the utmost care. For example, individuals with Dysthymic Disorder often exhibit symptoms such as fatigue and low self-esteem. These symptoms may lead to tension in interpersonal relationships, thereby increasing the probability of terminating therapy. Although these life events may appear to be the “cause” a major depressive episode, the episode is often predated by deficits in informational processing that lead to pre-morbid deterioration of the relationship. (Harkness & Luther, 2001)
Because Dysthymic Disorder is largely defined and distinguished by its protracted course, longitudinal studies are uniquely positioned to investigate the prognosis of the disorder. Due to the staggering costs associated with longitudinal studies, few have been conducted on the naturalistic course of Dysthymic Disorder. (Klein, Norden, Ferro, Leader, & Kasch, 1998) The overall consensus is that success treating Dysthymic Disorder is better addressed on a case by case basis – making a generalization about expected treatment outcomes and prognosis is probably ill advised. However, we can reasonably expect that there will be some measure of improvement in cognitive functioning, motivation, mood, and affect. I would be cautious about setting expectations for full recovery or total remission until the underlying core beliefs are identified. Assuming I could obtain permission from the patient, I would endeavor to track relevant data over the course of treatment as we consider the transition to schema therapy together, if applicable. Individuals whom suffer from Dysthymic Disorder often find that the minor daily hassles that happen to everyone may spiral into more serious life events that trigger depression. (Harkness & Luther, 2001, p. 570) Tracking those hassles seems to a reasonably simple way to measure the effectiveness of the therapy being provided and adjusting it if necessary.
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