A case of dysthymia

Note: since the DSM-5, dysthymia has been included under persistent depressive disorder. In this article I’ve kept the term “dysthymia” because it’s the one many people still use.

Pablo, in his mid-forties and in the middle of a separation, came to therapy to work on a hand tremor of psychological origin that had been making his social life and day-to-day life difficult for several years. This was his main reason for seeking help; however, Pablo also showed other behaviours that caught my attention:

• Constant rumination about the past.
• A disproportionate sense of nostalgia (things were always better in the old days).
• A persistently low mood that didn’t amount to depression and that Pablo said he’d had “forever”. In other words, it wasn’t triggered by the separation or any other external event.
• A gradual dropping of all the behaviours that used to be positively reinforcing. Little by little, Pablo had given up the activities he used to enjoy.
• An inner voice marked by low self-esteem, in which Pablo was always comparing himself with his past self and with the people around him.
• A deteriorating social life that made his low mood worse.
• Lack of appetite, trouble sleeping, feelings of hopelessness…

Even so, Pablo carried on with his daily responsibilities as normal, and his sadness seemed to go unnoticed by those around him. It was as if he had accepted that he “was just like that” and that sadness was part of his character. When Pablo first came to see me, he wasn’t taking any medication.

After a couple of sessions, I told him that in my view he had a dysthymic picture that needed treating separately from the tremor and his various insecurities. Dysthymia, or dysthymic disorder (persistent depressive disorder in the DSM-5), is a mood disorder similar to depression, generally milder and long-lasting. In terms of duration, the person must have been in this state for at least two years for it to be classed as dysthymia. The clinical features are similar to those of major depression, but usually less severe and therefore less disabling: a person with dysthymia will find it easier to carry on with daily life. Medication-wise, it is also treated with antidepressants, and the usual first choice are the selective serotonin reuptake inhibitors. So dysthymia is usually milder but chronic: unlike depression, which is often temporary, dysthymia tends to last for years. Even so, that doesn’t mean it has to stay with the patient for life: with treatment it can improve considerably and even go into remission.

Dysthymia is hard to diagnose because the levels of sadness are lower, and so are all the symptoms that come with it. That’s why it often goes unnoticed, unlike major depression, which is easily diagnosed because it produces more serious clinical signs.

So how is it treated in therapy, and why bother if it’s chronic? It is treated like depression, and the aim is for it to go into remission or, at least, for the patient to learn to manage it as well as possible so that it affects daily life as little as possible and doesn’t turn into major depression.

In Pablo’s case, on the one hand we worked on the tremor using exposure. If you’re not quite sure what that is, in short it could be defined as gradually facing all the situations the patient avoids, in order to progressively reduce the anxiety they cause, while also putting to the test the catastrophic consequences they imagine would happen in those situations (for example: they’ll make fun of me for shaking, once I start I won’t be able to stop, they’ll think something’s wrong with me, everyone will focus on me and my shaking hands…). On the other hand, we began treating the dysthymia with behavioural activation and cognitive therapy together.

What is behavioural activation? As I mentioned earlier, people in this state tend to gradually stop doing things, including rewarding or enjoyable activities. As I told Pablo at the time: the emptier your present is, the stronger that constant feeling of nostalgia will be. It’s a vicious circle we need to break by improving your quality of life now, and we’re going to start by adding activities to your day that give you the most reward for the least effort. To do this, we first drew up a list of activities, rating the level of effort and reward each one involved, and worked from there. As for the cognitive side, we’ve started by identifying and pinpointing cognitive biases, using Socratic dialogue and behavioural experiments.

In my view, the order of the strategies is essential: behavioural activation first, then the cognitive part. Why? Because there’s no point working on thoughts and schemas, which are usually deeply rooted, if the patient’s daily life is completely empty of positive reinforcement (pleasant things). Their mood will be very low and they’ll be barely receptive, if at all, to cognitive work, which is demanding in itself. So first we lay the foundations with the behavioural part, and once we see some minimal improvement in mood, we start on the cognitive side. After that, we work on both together.

Pablo started taking medication, and that gave him the boost he needed to face the challenges therapy posed for him. We’re still working together today, bearing in mind that it’s a long-standing problem and aiming for the best possible quality of life.