Dysthymia

Dysthymia and major depressive disorder - Spanemberg & Juruena
Review Article
Dysthymia: historical and nosological characteristics and its relationship with
major depressive disorder
Lucas Spanemberg * Mario Francisco Juruena **
INTRODUCTION dysthymia is a chronic form of depression, non-episodic, less sever
e symptomatology than those called major depression 1-4. The basic pattern of th
ese patients is a low degree of symptoms, which appear insidiously in most cases
before 25 years.5. Despite the milder symptoms, chronicity and lack of recognit
ion of the disease causes the loss of quality of life of patients is considered
greater than in other types of depression 6. Patients with dysthymic disorder ar
e often sarcastic, nihilistic, grumpy, demanding, and complainants. They may be
tense, rigid and resistant to therapeutic interventions, although regularly atte
nd to queries. As a result
* Medical Student Foundation Federal School of Medical Sciences of Porto Alegre
(FFFCMPA). ** Psychiatrist, Visiting Professor at the Institute of Psychiatry, K
ing's College School of Medicine, University of London, Associate Specialist, So
uth London Maudsley Trust, UK.
addition, the doctor may feel angry with the patient and even disregard their qu
eixas7. Although the disorder present with a relatively stable social functionin
g, this stability is relative, since many of these patients who have invested en
ergy in work, nothing left for pleasure and family activities and social, leadin
g to marital friction característico8. In evolutionary terms, dysthymia may be a
n adaptive subtype of humor that was developed to address states of stress or de
privation 9. Thus, certain characteristics of depressed mood might confer evolut
ionary advantages under specific conditions (where the lack of action and initia
tive would be more appropriate to avoid danger to life) 10, being beneficial in
certain subpopulations and settings, selecting them over time. As a condition ma
ladaptive, dysthymia is clinically manifested as a departure from routine daily
activities rather than face them. Differences gênero11, 12 - female dominance -
in dysthymia and major depression may also have a reason evolucionária9, 13.
300
Received on 24/08/2004. Revised on 19/10/2004. Approved em 09/11/2004.
R. Psiquiatr. RS, 26 '(3): 300-311, Sep. / Dec. 2004
The prevalence of dysthymia is approximately 3-6% of the general population 4-6,
14,15, one of the conditions most commonly encountered in practice médica5. Thes
e patients do not seek help or support 2,3,6 for a long period and their symptom
s usually consult clinicians with ill-defined complaints such as malaise, lethar
gy and fadiga5, 16. About 50% of these patients will not be recognized by clínic
os1, 2.17, and most will present a series of comorbidades3, 5.14. Just as major
depressive disorder (MDD), dysthymia is twice as common in women than in homens1
,6,11-13, and is also more common in people solteiras18-20. When married, these
people have unsatisfactory relationships. Poliqueixosas and are also dissatisfi
ed with vida16. The etiology of dysthymia is complex and multifactorial, being i
nvolved biological and psychological etiological mechanisms. These multiple fact
ors - heredity, predisposition, temperament, lifestyle factors, biological stres
sors, gender, etc.. - Converge in the production of deregulation of the reward s
ystem in August. Stressful life events in childhood 20-23 are frequent. As dysth
ymia is associated with an increased use of health services and also to increase
d consumption of psychotropic drugs, huge financial costs can be attributed to t
his transtorno14, 17.24. Decreased productivity at work and an increased risk of
hospitalização14, 19 and physical illnesses (such as increased risk of cardiova
scular and respiratory diseases) 14 also increase the economic and social cost o
f this pathology, making it a public health problem that needs to be identified
more efficiently. The high rate of comorbidity with other psychiatric disorders
(about 77% of dysthymic have comorbidities) 25 makes it even more important to t
he diagnosis of dysthymia for the appropriate management of comorbid psychopatho
logy. This article aims to review the major historical and nosological aspects o
f this disorder, as well as its relationship with the TDM. We will discuss their
subtypes, controversies regarding the categorical versus dimensional distinctio
n of dysthymia and its relationship with other mood disorders. For this,were se
lected for convenience, the most relevant articles in the databases
LILACS and MEDLINE. In the end, we discuss the relevance of the topic and its im
portance in the practice of psychiatry today. The terms "dysthymic disorder" and
"dysthymia" are used interchangeably, since both are widely used at present. HI
STORICAL FEATURES The term "dysthymia" is from Ancient Greek and means "bad mood
" 1.26. Hippocratic Greek at school, she was considered as part of the concept o
f melancholia, a term derived from the temperament or character typical of intox
ication or influence of "black bile", one of four "humors fundamental" 1,27,28.
Thus, individuals lethargic, anxious and insecure were prone to a temper melancó
lico1. Galen of Pergamum (128-201 AD) describes the melancholy and introspective
, pessimistic and bodily magros27 - "if fear or depression lasts a long time, th
is state is very melancholy," said Galeno29. He established melancholy as a chro
nic and recurrent condition, which could be a primary disease of the brain or se
condary to other doenças30. Sorano of Ephesus describes melancholic patients wit
h symptoms of injury, and paranoid depressivos27. From Ancient Greece to the Mid
dle Ages, mental illness was cared for by clerics and religious, since it has to
be attributed to magic, sin and demonic possession, Santa Inquisição30 target.
At the same time, the Arab world was important readings and descriptions of the
concept of melancholy, by Avicenna (980-1037), Maimonides (1135), Averroes (1126
) and Constantine (1019-1087), among outros27. During the Renaissance, Robert Bu
rton publishes The Anatomy of Melancholy (1621). In this work, Burton's list amo
ng the causes of melancholy, advanced age, temperament and heritage, and also es
tablishes it as a secondary cause of disease corpo27. In the 18th century, Willi
am Cullen (1710-1790), influenced the Enlightenment, the melancholy associated w
ith a primary instability of the brain and suggests "restrictions" as the best r
emedy to reduce excitação27. The 19th century brings an increasing interest in m
inor forms of mood disorders (folie round), which, according Falret (18,241,902)
, a trained observer would perceive as a continuum of disease maior28. Falret wr
ites about ways
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302
attenuated disease circular, and later, in 1863, Karl Ludwig Kahlbaum uses the t
erm "cyclothymia" to the milder forms of mood fluctuations and "dysthymia" to th
e forms of the disease (melancholia) that show only one depressed atenuada26 28.
The description in 19th century Germany, seems to have been the first approach
to the meaning of the term of mild chronic depression, not a psychopathic temper
ament depressivo28. The term "depression" begins to appear in medical dictionari
es em1860, being widely accepted and increasingly restricting the term 'melancho
ly' 27. Esquirol (1772-1840) suggests that the word "melancholy" is left to the
use of poets. Berrius scholar of the history of psychiatry shows that the term "
depression" has supplanted the ancient "melancholy" in the light of the apparent
physiological and metaphorical impression of the functions that fall sugeria27.
Emil Kraepelin described in 1921, the relationship between temperament and depr
essive manic-depressive insanity, suggesting that the first would be an attenuat
ed form, but belonging to the same constellation of pathologic disease plena18,
26,28, a model of continuum5, 7. The characteristics of the depressive temperame
nt would be the constant presence, though fluctuating, sadness, anxiety, pessimi
sm and lack of pleasure 28. Kraepelin advocated a sort of mental illness grounde
d in the natural history of patients and the evolutionary course of their disord
ers, psychiatric symptoms before their 26th. He therefore developed the concept
of nosological status and mood disorders grouped under the aegis of manic-depres
sive insanity, separating them from dementia praecox (schizophrenia) 7.27. This
proposed dichotomy is still the strongest force in psiquiatria27 taxonomic conce
pt. In 1923, Kurt Schneider, in his monograph, described the 26 or dysthymic dep
ressive psychopathy, linking it to mix the etiology of hereditary factors, neona
tal and early environmental influences - and not a disease of mood (depression)
18. Using the term "personality," Schneider defined as abnormal personalities so
me variants of the constitutional standard, considering thus psychopathy in the
field of depressive disorders personalidade31. Kretschmer, 1936,strengthened th
e idea of continuity between the basic temperament and disease, leading it to it
s utmost importance. He opposed the concept of unity
Kraepelin's nosological and introduced the so-called dimensional diagnosis, as o
pposed to categorical kraepeliniano27. Under the influence of psychoanalytic the
ories and schneiderian, the American official classifications (Diagnostic and St
atistical Manual of Mental Disorders - DSM-II, 1968) and worldwide (Internationa
l Classification of Diseases - ICD9, 1978) spread the idea of chronic depression
as equivalent to neuroses character, deviating from mood disorders and linking
it to the 18 personality disorders. Thus, in the 60s and 70s, the DSM-II include
d "Neurotic Depression," and ICD-9, "depressive neurosis", but both episodes enc
ompassed non-crônicos26. However, the view that personality disorders were not t
reatable represent an insurmountable conceptual problem, becoming more complex b
y the fact that the existence of normal personality traits with abnormal variant
s did not represent necessarily a disorder psiquiátrico26. Thus, in 1978, Akiska
l et al. published a follow-up study 3-4 years with 100 neurotic depression, she
found no clinical significance in diagnosis of neurotic depression. The monitor
ing of patients showed a wide variety of nosological diagnoses, both from other
forms of mood disorder as other patologias18, 26.27. The many nosological diagno
ses found by Akiskal et al. did conclude that the diagnosis of neurotic depressi
on had no phenomenological features themselves sufficient to constitute a distin
ct nosological entity 18. This represented an important support in establishing
the empirical basis of dysthymia in the sense atual26 and was a landmark in the
history nosological of mood disorders. Under the influence of new discoveries in
the DSM-III, chronic depression is now referred to by the term "Dysthymic Disor
der" to replace "neurotic depression" in DSMII, and is included in the chapter o
n affective disorders. Despite the descriptive model called "atheoretical" as th
e aetiology (operationalized), this position marks the expulsion of chronic depr
essions in the field of disorders of character and personality. Despite these de
velopments, dysthymic disorders has encompassed a wide variety of entities such
as primary depressions with residual chronicity, chronic dysphoria, and secondar
y depressions
characterological (personality disorder and dysthymic disorder itself) 18. The D
SM-III-R and DSM-IV incorporated some of these definições26, and, in the appendi
x to DSM-IV, already appears depressiva1 personality disorder, 32,33. The ICD-10
does not establish a concept of dysthymia that is essentially different from de
pressive neurosis or neurotic depression 26, ie it is a broader concept than the
DSM-IV. The differences between the diagnostic criteria of both manuals reflect
, among other things, the fact that the DSM-IV is intended also for research, wh
ile the ICD-10 is intended for clinical application. Moreover, the political com
position of the ICD-10 is much more complex, because he wants to embrace the who
le world, not just a país32, 34. Both, despite their differences, consider dysth
ymia as an affective disorder, unipolar, chronic (at least 2 years) with early o
r late, with symptoms less intense than that observed in a depressive episode, w
ith symptoms including insomnia, Low energy and fatigue, low self-esteem, decrea
sed ability to concentrate and loss of interest and prazer34. Today, like Kraepe
lin described 100 years ago, it is accepted that dysthymia is an attenuated vari
ant of the spectrum of affective disorders. Nowadays, dysthymia may be regarded
as a less severe form of depression that increases the risk for depression maior
3. Its main features are chronicity of symptoms of low intensity (for at least t
wo years), insidious onset and early course and intermittent persistente8. The c
urrent nosologic aspects nosography officer ranks dysthymia as a mood disorder,
differing from TDM to be chronic and less severa3, 4.8. The profile of dysthymic
disorder shows a tendency to a predominance of symptoms on the signs (hollows m
ore subjective than objective), another difference from TDM2, 7. Serretto et al.
4 in a study with 512 dysthymic without MDD, found cognitive and emotional sympt
oms as more typical than vegetative and psychomotor symptoms. Low self-esteem, a
nhedonia, fatigue,irritability and poor concentration were present in more than
half of patients 4. So, there stood out the
marked disturbances in appetite and libido or observed psicomotor2 agitation or
retardation. Since the patients who seek treatment often float in and out of a m
ajor depressive episode, the essence of DSM-IV criteria for dysthymic disorder t
ends to emphasize the vegetative dysfunction, whereas the alternative criterion
B for dysthymic disorder in appendix of DSM-IV symptoms cognitivos8 list. This a
lternative classification for dysthymia aims to stimulate further characterizati
on of the disorder in relation to other disorders humor14. The essential standar
ds of dysthymic disorder usually include sadness, lack of enjoyment of life and
concern for the inadequacy. The disorder is best considered as a depression of l
ow intensity, buoyant and durable, experienced as part of the usual self and rep
resents an intensification of depressive temperament traits observed in the (sub
liminal) 2.8. The dysthymic disorder can therefore be seen as a more symptomatic
(or injunction) of temperament (depressive personality disorder) 8. This speaks
in favor of the model spectrum of severity of depression, where the different f
orms of depression exist along a continuum between the disease and subsyndromal
forms plena25. Akiskal is the best contemporary author who has studied the hypot
hesis of dimensional relationship between personality disorders and humor25, 35.
This model, originally conceived by Kraepelin, suggests that subthreshold depre
ssive symptoms may in fact represent the most common expressions of the disorder
depressivo8. Some authors have made important contributions on the subject. Ang
st & Merikangas36 in a longitudinal study of 15 years of follow-up with 591 indi
viduals, investigated the application of diagnostic criteria for preliminary cat
egories (MDD and dysthymia) and subthreshold depression. The main conclusions af
ter the end of follow-up reinforces the idea of a depressive spectrum. Prevalenc
e of categories of injunctions and subthreshold depression were similar, with ap
proximately 17% of the general population meeting criteria for any category of d
epression over time. Few individuals with depression met criteria for only one s
ubtype of depression after 15 years - that is, there were few subtypes "pure." S
ubthreshold depressions associated
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304
with a greatly increased risk of subsequent development of MDD (strong predictor
for depression), with approximately half of the subjects eventually develop maj
or depression. TDM was also associated with increased risk of developing subthre
shold depression, with half of individuals with MDD meeting criteria for subthre
shold categories of depression during follow-up. During follow-up, dysthymic had
a higher rate of hospitalization (11% versus 7%) and were treated more often fo
r depression (77.8% versus 54.7%) than patients with episodes of MDD. Patients w
ith recurrent brief depression also had a higher rate of treatment (60.6%) than
patients with episodes of TDM36. Angst was the introducer of the term "psychiatr
y injunction", which refers to the classification categories used in psychiatric
diagnostic manuals like DSM-IV, which he said did not take sufficient account o
f the depressive dimension. Based on epidemiological studies, Angst justifies so
me disorders that fail to meet the diagnostic criteria bring contemporary levels
of subjective distress and substantial disability, highlighting the importance
of "subliminal psychiatry." Thus, careful observations of patients after years s
how substantial changes in the subtypes of depression over time. The superpositi
on of a categorical diagnostic classification on the dash constantly changing ca
n lead to a diagnostic system that fails to adequately represent the depressive
spectrum subjacente36. Klein compared 37 relatives of patients with dysthymia, w
ith episodes of MDD and normal controls in relation to the existence of depressi
ve personality disorder (depression subliminal). The results showed that relativ
es of dysthymic patients had a significantly higher rate of depressive personali
ty disorder (TPD) that relatives of normal controls. Relatives of patients with
episodes of MDD had a rate intermediate between the other groups. The author con
cludes that this finding strengthens the argument that the DPT is part of the sp
ectrum of mood disorders,suggesting that this link is particularly strong in ch
ronic forms of depression such as dysthymia and depression dupla37.
In the same vein, Kwon et al. 33, a follow-up study three years, they found sign
ificantly higher rates of development of dysthymic disorder in women with TPD th
an in women in the control group. The development of MDD was not statistically s
ignificativo33. compared Flament et al. 38 Phenomenology, psychosocial correlate
s and seeking treatment in adolescents with episodes of MDD, dysthymic and contr
ol subjects. Patterns of affective symptoms were similar in patients with dysthy
mic and MDD episodes, and the latter had more comorbid conditions. Dysthymic had
significantly worse family relationships. Patients with MDD and dysthymic few e
nvironments also sought treatment for their condições38. According to Akiskal 5,
data from the electroencephalogram (EEG) during sleep and abnormalities in the
TRH-TSH tests, among others, indicate that many people with dysthymic disorder e
xhibit, as baseline, the neurophysiological pattern found in acute MDD, confirmi
ng yet more in the nature of the constitutional transtorno5. These data are simi
lar to those found by Akiskal et al. 39, who, reviewing clinical data and polyso
mnographic of depressive conditions less-than-syndromic (or subliminal), a decre
ase in latency during REM (rapid eye movements) sleep, positive response to anti
depressants and sleep deprivation, high rates of disorders mood in the family an
d longitudinal course triggering TDM. The findings, thus supporting the existenc
e of the depressive spectrum, reinforcing the idea that these subthreshold depre
ssions 39 are part of the spectrum, since they are similar to those found in dys
thymia and major depression. Another area of study involves the relationship wit
h the spectrum of dysthymia bipolar9 0.40 to 43. In this regard, dysthymia is in
serted in the current discussion between the nosological classification of depre
ssion as dimensional versus categorical one side and the unipolar-bipolar dichot
omy of the other. The dysthymia reflects this controversy in that it represents
a possible stroke or depression dimensional on one side and a depressive conditi
on subsintomática dial with bipolarity (soft bipolar) from outro40. Brunello et
al. suggest that despite the typical presentation of dysthymia to be unipolar in
shape, about one third of cases could be linked to the bipolar spectrum. This s
ubtle connection with bipolarity may explain, in part, as
asthenia, lethargy and low energy characterize a subgroup of distímicos40. Nicol
escu & Akiskal September, describing anxious and anergic subtypes of dysthymic (
discussed later), both with the possibility of bipolar processing, suggest a mor
e complex conceptualization of dysthymia within the affective spectrum can inclu
de it within the bipolar spectrum 9. Angst et al. 42 suggest the term "bipolar d
isorder minor", which can include symptoms associated with dysthymia hipomaníaco
s42. The so-called "bipolar dysthymia" was characterized by a tendency to states
of elation and family history of bipolar disorder 43. In the bipolar spectrum,
like Kraepelin described in the early 20th century, would be included and also a
ttenuated forms much of the area of TDM, and current nosology (ICD-10 and DSM-IV
) is insufficient to adequately reflect this espectro41, 42 .
Subtypes of dysthymia
Despite the differences between the DSM-IV and ICD-10 for early and late onset o
f dysthymic disorder and 32.34 of the controversy regarding the relevance of thi
s distinção4, this classification is accepted, and many studies have shown diffe
rences 44-48 significant between the two groups. The early-onset dysthymia is co
nsidered the prototypical disorder 19-21,45,49, 15,19,46,48 being more prevalent
. One of the most characteristic findings is the increased incidence of comorbid
axis II (personality disorders) in dysthymic disorder of early precoce45-48. Ea
rly-onset dysthymia also has higher rates of comorbid depression maior14, 50 and
anxiety disorders and a greater propensity for family history of affective diso
rders 14.51. Barzega et al. studied clinical characteristics of dysthymia in the
age of onset, no relationship between stressful life events (illness, separatio
n) prior to the disorder and late-onset dysthymia, suggesting a link etiológica4
4. The authors found, also, the relationship between early onset of dysthymia an
d comorbid conditions such as MDD, panic disorder and social phobia, and a longe
r duration of illness 44. Bellino et al., A similar study 47,also found a relat
ionship between stressful life events and late-onset dysthymia. The authors foun
d a higher rate of personality disorders in early onset dysthymic, suggesting th
at this type of
dysthymia is more related to personality abnormalities, whereas dysthymia would
be related to late events (triggers) estressores47. In another study on the issu
e, Klein et al. 48 found an association between early onset with substance abuse
and family history of affective disorders. Furthermore, early-onset dysthymic w
ere less likely to be married. The author suggests that early-onset dysthymia is
a severe condition that can result in maladaptive states that predispose to the
development of personality disorders and abuse of substâncias48. Corroborating
the hypothesis of a reaction to stressful events as etiological factor of late-o
nset dysthymia, Migliorelli et al. found a rate of 28% in a sample of dysthymic
patients with Alzheimer's, and, in more than 80% of these, dysthymia began after
the doença52. Other subtypes of dysthymia have been proposed by others3-5, 9. S
erretto et al., A study of 512 dysthymic without TDM, delineated subtypes within
the distímico4 disorder. The results showed that dysthymic subtypes are more su
bdued and slow, but without marked difficulties in concentration, activity or en
ergy, and also subtypes with a predominance of these features, but on the other
hand, do not experience much sadness (subtype "hipped"). The authors speculate t
hat the different degrees in clinical construct of dysthymia may partly explain
why different classes of antidepressants have been observed to be effective in d
ysthymia, supporting the hypothesis that the possible neurochemical substrate of
dysthymia systems involves noradrenergic, serotonergic and dopamine. Another im
portant finding is that the characteristics anxious, very present in dysthymia,
appear divided into somatic and psychic types, the latter being more prevalent i
n dysthymia. A significant limiting factor of the work of Serretto et al. is the
double depression as an exclusion criterion, making it the most were late-onset
dysthymic, which goes against the majority of trabalhos4. More recently, Nicule
scu III & Akiskal9 endophenotypes suggested a new classification, with two types
of dysthymia. The first type, called "anxious dysthymia, is characterized by lo
w self-esteem and insecurity. Its etiology is related to deficiency of serotonin
, and it is related to the response to a perceived stress (loss or
305
past trauma, stress a sensitizer for the future). These individuals are more imp
ulsive and often commit more suicide attempts (but with lower mortality), tendin
g to seek help. This type is more common in women, who tend to self-medicate wit
h anxiolytic drugs such as benzodiazepines, marijuana, alcohol and, most commonl
y, excessive eating (bulimic behavior and / or weight gain). Some of these patie
nts exhibit transformation to bipolar disorder type II9. The second type of dyst
hymia proposed is the "anergic dysthymia, characterized by low energy, low react
ivity, and anhedonia. This psychomotor inertia is etiologically related to lower
levels of dopamine. These patients are more often male, have less interest in s
ex, are less impulsive, have hypersomnia and decreased REM sleep and tend not to
seek help. A portion of these patients tend to self-medication with stimulant d
rugs of abuse such as methamphetamine, cocaine, nicotine and caffeine. Some pati
ents exhibit transformation to bipolar disorder type I9. Within this hypothesis,
the biological mechanisms involved in these two distinct types of dysthymia may
respond differently to different types of antidepressants. Thus, Niculescu III
& Akiskal proposed that anxious dysthymia, related to low serotonin levels, resp
ond better to specific reuptake inhibitors (SSRI). Already anergic dysthymia, re
lated to low levels of dopamine, is more responsive to dopaminergic and noradren
ergic medications such as bupropion, venlafaxine, stimulants and antidepressants
tricíclicos9. Comorbidity with Major Depressive Disorder The term comorbidity h
as been used by Feinstein (1970) to mean "any distinct additional clinical entit
y that exists or may occur during the clinical course of a disease '25. Despite
the different classes of existing comorbidities, we will use the class "medical
comorbidity,As regards the difference in course and response to treatment of a
disorder. The importance of identifying a clinical comorbidity in dysthymic diso
rder is, among other things, the possibility of predicting the prognosis and the
need to establish strategies
306
differentiated treatment for each condition mórbidas25. The TDM is the most comm
on psychiatric disorder that is associated with distimia25 and confirmed that it
increases the risk of a depressive episode maior5, 14,15,19,20,40,45,53. Most d
ysthymic patients will develop at some point in life, episodes of MDD 14,15,45,5
3, and some studies show that almost all the terão2, 19.20. An estimated further
that 40% of patients with episodes of MDD also meet the criteria for dysthymic
disorder 5.7. The concomitance of these two diseases is called "double depressio
n" (DD) 19,20,25,54. Stressful life events are important triggers of DD in patie
nts distímicos53. Patients with DD have more severe depressive symptoms 45.55, m
ore chronic course and more comorbidities compared with patients with MDD or dys
thymia pure 55 pure 45. The level of functional disability in these patients is
higher than in patients with both pathologies isoladas20 as well as the rate of
hospitalization and recurrence of TDM54 50. The rate of comorbidity with anxiety
disorders, substance abuse, personalidade54 disorders and irritable bowel syndr
ome 25 is also higher in DD compared with major depression alone. The rate of re
covery from an episode of MDD is lower in patients with DD than in those with si
ngle episode of MDD 14.18, and when recovery occurs, in most cases is not comple
ta18. The prognosis is worse, and treatment should be directed to both transtorn
os7. Pepper et al.45 found a recurrence rate for MDD significantly higher in pat
ients with DD (82.1%) than in patients with single episode of MDD (62.2%) 45. Mo
st dysthymic had a history or current DD, and the patients with DD had a poor le
vel of functioning that dysthymic puros45. Tucci et al.50 studied levels of soci
al adjustment in various subcategories of affective disorders (bipolar, unipolar
, dysthymia and DD) 50. Patients with DD, along with bipolar, presented the wors
t levels of social adjustment. Patients with DD had also the worst record in fam
ily relations. Stressful events were related to the onset and recurrence of all
categories of affective disorders. The emotional quality of
family environment was considered as predictive of the course afetivos50 disorde
rs. A diagnostic system can influence the degree of comorbidity found. The more
classes a diagnostic system has, the greater the possibility that a patient rece
ives more than one diagnosis. Comorbidity may just reflect the excessive subdivi
sion 25. In this regard, the discussion categorical versus dimensional becomes e
ssential especially in the distinction between dysthymia and MDD. As noted earli
er, recent research on dysthymia emphasize its connection with other forms of su
bsyndromal and full disease (MDD), suggesting that, within a dimension or depres
sive spectrum, these different forms may only reflect different degrees of the s
ame disease continuum, ie differences quantitative rather than qualitative 15,16
,19,36,44,45,56. Despite doubts about the various subtypes of depression are suf
ficiently distintos16, 57, the DD remains an accepted diagnosis. Keller et al. r
eviewed the distinctions between dysthymia, episodes of MDD and DD, DD hypothesi
zing as a subtype of unipolar depression. The authors concluded that it is not p
ossible to define DD as a subtype of major depression, suggesting that a separat
e classification of DD and MDD is still justificada54. Goodman et al. 58 studied
discriminating factors (and their consequences) in children and adolescents wit
h MDD and dysthymia. The findings did not support strong discriminant between MD
D and dysthymia in this sample, but suggested that the combination of the two le
ads to more disability and lower social competence, and higher propensity to anx
iety. Thus, children with DD are more likely to be seriously compromised in seve
ral areas of functioning, to have more symptoms and greater impairment in social
and familiar58. compared Flament et al. 38 Phenomenology, psychosocial correlat
es and seeking treatment in adolescents with an episode of MDD with dysthymia an
d controls.Patterns of affective symptoms were similar in patients with dysthym
ic and MDD episodes, and the latter had more comorbid conditions. And dysthymic
patients with MDD also sought some treatment settings for your conditions. The a
uthors highlight the severity of both condições38. Klein et al. 49 disorders ass
essed
mood and personality in 1st degree relatives of dysthymic patients with MDD and
controls. The results showed that there is a strong familial relationship betwee
n dysthymia and MDD. However, dysthymia is also slightly different because it is
specifically aggregate in relatives of patients with dysthymia. Lastly, dysthym
ia and MDD present themselves as having a family association with personality di
sorder, although this connection is somewhat stronger for distimia49. Kovacs et
al.57 in a prospective naturalistic study of 12 years of follow up, compared cha
racteristics of childhood-onset dysthymia and MDD with first episode also in chi
ldhood. The dysthymia was associated with younger age at which the TDM, as well
as greater overall risk for any subsequent affective disorder, particularly MDD
and bipolar57 disorder. Riso et al. 23 reviewed six factors implicated as determ
inants of chronic depression (dysthymia well as chronic major depression). The a
uthors found no qualitative differences between acute and chronic forms of depre
ssion. Developmental factors (childhood adversity) were the most important findi
ngs related to chronicity of depression. Thus, the development of chronic depres
sion involves increased levels of childhood adversity, protracted stress environ
ments and increased reactivity to estresse23. In simple comparison with episodic
MDD, dysthymia appears to be an entity of greater severity. Klein et al. In a p
rospective naturalistic study of 5 years of follow-up, described some results on
the course of the disorder distímico19. The estimated recovery of dysthymic dis
order at 5 years was 53.9%. Among those who recovered, the estimated risk of rel
apse was 45.2%. Patients with dysthymia were approximately 70% of follow-up meet
ing all the criteria for a mood disorder. During the course of follow-up, patien
ts with dysthymia exhibited significantly higher levels of symptoms and lower fu
nctioning and were significantly more likely to attempt suicide and be hospitali
zed than patients with episodic MDD. The risk estimate for the first episode of
MDD in dysthymic patients at 5 years was 76.9%. The authors conclude that dysthy
mia is a chronic condition with a prolonged course and a high relapse rate. Almo
st all patients with dysthymia
307
eventually develop MDD superimposed. Although patients with dysthymic disorder t
end to produce mild to moderate symptoms in a longitudinal perspective is the co
ndition severa19. DISCUSSION Much of modern thinking about mood disorders dates
back to the old concepts gregos8. These concepts have evolved over several centu
ries and form the fundamental basis for the evolution of psychiatry. However, th
ey were postulated random. As pointed out by Lopes 59, the concepts of nosologic
al entities that were consolidated itself (more solidly with Kraepelin, Freud an
d Schneider, among others) were not established arbitrarily. They are all produc
ts of an accumulation of observations, reflections and relationships with patien
ts. Currently, many articles incorporate these works, which, particularly with K
raepelin, were fundamental to the current concept of dysthymia. Kraepelin's idea
of a continuum model within a spectrum of depressive disorders is now a major f
ocus of study of contemporary authors, showing how important may be the historic
al contributions in the evolution of psychiatry. The historical and nosological
study of dysthymia was fundamental practical importance in clinical developments
that entity. Once considered a personality disorder, with a range of therapeuti
c limitations, today dysthymia is classified as a mood disorder, which extended
its therapeutic and altered their prognosis. Moreover, this evolution has also e
xtended the findings about their clinical and paved the way for promising theori
es about its etiology, contributing also to better understand the spectrum of mo
od disorders. Despite the high morbidity and even the 80 had little researched a
lternative treatment of dysthymia: it was considered a personality disorder unre
sponsive to treatment antidepressivo7.Today there seems no doubt that her inclu
sion among the mood disorders represent a major advance in the treatment of pati
ents chronically deprimidos60. They now approached within a therapeutic perspect
ive of affective disorders, resulting in an increase
interest in pharmacological treatment 40.60. Studies show that 50-60% of patient
s with dysthymia respond to treatment with antidepressants 61.62. The monoamine
oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs) and SSRIs are effec
tive in the treatment of dysthymia 40,61,63,64. Manipulations and hormone replac
ement studies are needed of 65.66. The treatment of currently accepted and consi
dered more effective is the combination of pharmacotherapy with psychotherapy, e
specially cognitive and behavioral 6,7,40. The many studies that have been made
about the lack dysthymia, however, greater methodological standardization. Almos
t all clinical studies reviewed in this article reported methodological limitati
ons that make it difficult to generalize the results. These limitations, and pec
uliarities of each study may be attributed to the current difficulty of adopting
a standard concept of dysthymic disorder. Even the official classifications (IC
D-10 and DSM-IV) have different diagnostic criteria. Moreover, these differences
are not that many results to be repeated and give, and gradually the "new face"
of dysthymia. More detailed studies, with concepts and standardized criteria ar
e necessary for this disorder, so prevalent and costly, is better understood and
better treated. CONCLUSION dysthymic disorder is an important cause of morbidit
y, very prevalent in our environment and increasing the financial costs and the
use of the health system. The concept of dysthymia, originally broad and unspeci
fic, has undergone many changes over time and is now included among the mood dis
orders, the spectrum of chronic depressions. This new nosological classification
represented a major step towards a better understanding of the entity, and to a
pharmacological approach in its treatment. The relationship between dysthymia a
nd other mood disorders, particularly MDD, is now the subject of many studies an
d controversies. Current studies are still methodologically limited, the result
also of the lack of standardization in the description of the disorder. Given it
s importance, further studies with careful methodology and substantial samples s
hould be
308
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ABSTRACT dysthymic disorder is a chronic and disabling depression, occurring in
a substantial portion of the population (3-6%) and increasing risks of major dep
ressive disorder. It is associated with considerable disability and high comorbi
dity. The nosological status of dysthymia has aroused considerable controversy o
ver the past decades, and some investigations to consider as a mood disorder, an
d others as a personality disorder. Ranked among nosography current mood disorde
rs, dysthymia is now a treatable entity and needs to receive greater attention b
ecause of its morbidity. This article reviews the main historical aspects of dys
thymia, nosological characteristics, subtypes and their relationship with major
depressive disorder. Finally, we conclude that further studies are needed to val
idate the concept of dysthymia and the spectrum of chronic depressions, for bett
er understanding the etiology and therapy based on evidence.
Keywords: Dysthymia, depression, mood disorders, comorbidity, historical and nos
ological aspects.
56. Klein DN, Kocsis JH, McCullough JP, Holzer CE III, Hirschfeld RMA, Keller MB
. Symptomatology in major depressive and dysthymic disorder. Psychiatr Clin N Am
1996; 19 (1) :41-53. 57. Kovacs M, Akiskal HS, Gatsonis C, Parron PL. Childhood
-onset dysthymic disorder. Arch Gen Psychiatry 1994; 51:365-74. 58. Goodman SH,
Schwab-Stone M, Lahey BB, Shaffer D, Jensen P.Major depression and dysthymia in
children and adolescents: differential discriminant Validity and Consequences i
n a community sample. J Am Acad Child
ABSTRACT Dysthymia is a chronic and incapacitating form of depression That Affec
ts a Substantial Portion of the population (3-6%) and Increase The major risk fo
r depressive disorder. It is Associated with Significant Disabilities and high c
omorbidity. The nosological
310
status of dysthymia Has Been Associated with considerable controversy over the p
ast decades: some investigators Regard it as a mood disorder, and others as a pe
rsonality disorder. Currently Classified among the mood disorders, dysthymia is
a treatable disorder and now Should receive more attention in view of ITS Associ
ated morbidity. The present article reviews the main historic Aspects of dysthym
ia, ITS nosological features and Its relationship with major depressive disorder
. We conclude That Further studies are Necessary in order to validate the concep
t of dysthymia and the spectrum of chronic diseases, in order to Provide a bette
r understanding of the disorder as well as evidence-based guidelines.
Keywords: Dysthymia, depression, mood disorders, comorbidity, historical and nos
ological aspects. Title: Dysthymia: historical / nosological Characteristics and
Its relationship with major depressive disorder
decades pasadas, siendo algunas Investigations that consideraron as siendo la un
trastorno del humor y otras como un trastorno de personalidad. La la clasifica
nosography current between them trastornos del humor, siendo hoy y una Entidad t
ratable Just Need the cause of bad atención de su morbilidad. Este artículo los
principales reviews historical aspects of her dysthymia, sus characteristics nos
ological subtypes y su relación con el trastorno Depresivo mayor. Al final, we c
onclude that If you get stuck to validate nuevos estudios el concepto y el of dy
sthymia spectrum of chronic depresion for una mejor comprensión y for etiologica
l con base en una terapéutica evidence.
Palabras clave: Dysthymia, depresión, trastornos del cheer, comorbilidad, y noso
logical historical aspects. Title: Dysthymia: historical features nosological y
y su relación con el trastorno Depresivo mayor Correspondence: Lucas Spanemberg
Rua José do Patrocinio, 382/82 - CEP 90050-000 Cidade Baixa - Porto Alegre - RS
Fone: (51) 3224.7365 / 9175.6131 Email: Copyright © lspanemberg@yahoo.com.br Rev
ista de Psiquiatria do Rio Grande do Sul - SPRS
RESUMEN El trastorno es una dysthymic chronic and disabling form of depresión, w
hich ocurre en una población de la significant portion (3-6%) y los riesgos incr
eases of trastorno Depresivo mayor. You incapacitaciones considerables y asociad
o a high comorbilidad. El nosological status of dysthymia viene la provoking con
troversy muchas a lo Largo de las
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