Dysthymia and premenstrual dysmorphic disorder

1. WOLLO University
College Of Medicine and Health Science
Department of Psychiatry
Dysthymia and PDD
By; Mohammed Ahmed
January,2023
Dessie,Ethiopia
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2. Outlines of presentation
Objectives
Definition
Epidemiology
Clinical features
Diagnosis
Management
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3. Learning objectives
After completion of this class, the we should be able
to:
 Define what dysthymia is
 Discuss
Dysthymia
Premenstrual Dysphoric Disorder
Deal with pharmacologic and non pharmacologic
management of Dysthymia and Premenstrual Dysphoric
Disorder No Health With out Mental Health 3

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DYSTHYMIA
(PERSISTENT DEPRESSIVE DISORDER)

5. DYSTHYMIA (persistent depressive disorder)
Is defined as low grade, intermittent & protracted
depression.
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6. DYSTHYMIA…
The most typical features is persistent depressive
disorder i.e the presence of a depressed mood that
lasts most of the day and is present almost
continuously.
The essential features of such primary dysthymic
disorder include :
Habitual gloom/brooding
Lack of joy in life, and lack of productivity
Preoccupation with inadequacy , guilt, irritability,
and anger
withdrawal from society
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7. DYSTHYMIA…
Dysthymic disorder then is best characterized as:
 Long-standing,
Fluctuating,
Low-grade depression,
Experienced as part of the habitual self and
Representing an accentuation of traits observed in the
depressive temperament.
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8. DYSTHYMIA…
Dysthymia is distinguished from MDD :
1. low-grade chronicity for at least 2 years;
2. insidious onset, with origin often in childhood or
adolescence
3. a persistent or intermittent course.
dysthymia can occur as a secondary complication of
other psychiatric disorders.
Dysthymia is associated with hx of depressive and
bipolar disorder
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9. Epidemiology
is common among the general population and affects 5
to 6 percent of all persons.
it affects between half and one-third of all patients in
general psychiatric clinics.
No gender differences are seen for incidence rates.
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10. DYSTHYMIA…
 is more common in women younger than 64 years
of age than in men of any age .
 is more common among unmarried and young
persons and in those with low incomes.
frequently coexists with other mental disorders,
particularly major depressive disorder,
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11. DYSTHYMIA…
may also have coexisting anxiety disorders
(especially panic disorder), substance abuse, and
borderline personality disorder.
there is less likelihood of full remission between
episodes.
Chronic course; <10% remission per year
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12. DYSTHYMIA…
is more common among those with first-degree
relatives with major depressive disorder
Can respond to treatment – may need higher
doses, longer duration of treatment
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13. DSM-5 Diagnostic Criteria for Dysthymia
a. Depressed mood nearly every day for ≥ 2 years
Note: In children and adolescents, mood can be irritable and
duration must be at least 1 year.
b. Associated with ≥ 2 of the following:
• decreased or increased appetite
• decreased or increased sleep
• low energy or fatigue
• low self-esteem
• poor concentration or indecisiveness
• hopelessness
c. No more than 2 months symptom free
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14. DSM-5 Diagnostic Criteria for Dysthymia…
d. No major depressive episode has been present during the first
2 years of the disturbance.
e. There has never been a manic episode, a mixed episode, or a
hypomanic episode, and criteria have never been met for
cyclothymic disorder.
f. The disturbance does not occur exclusively during the course
of a chronic psychotic disorder, such as schizophrenia or
delusional disorder
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15. DSM-5 Diagnostic Criteria for Dysthymia…
g. the symptoms are not attributable to the physiological effect
of a substance (e.g a drug of abuse, a medication) or another
medical condition (e.g, hypothyroidism).
h. the symptoms cause clinically significant distress or
impairment in social, occupational or other important areas of
functioning.
Specify :
Early onset :if onset is before 21 years of age
Late onset : if onset is at age 21 years or older
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16. Differential Diagnosis
minor depressive disorder
recurrent brief depressive disorder
Double Depression
substance-related disorder
The other differentials for MDD
N.B :
Two disorders are particularly important to consider
in the differential diagnosis of dysthymia—
- minor depressive disorder and
- recurrent brief depressive disorder
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17. Differential Diagnosis…
Minor Depressive Disorder-
is characterized by episodes of depressive
symptoms that are less severe than those seen in
major depressive disorder.
The difference between dysthymia and minor
depressive disorder is primarily the episodic nature
of the symptoms in the latter -
- Between episodes, patients with minor depressive
disorder have a euthymic mood, but patients with
dysthymia have virtually no euthymic periods.
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18. Differential Diagnosis…
Recurrent Brief Depressive Disorder
is characterized by brief periods (less than 2 weeks)
during which depressive episodes are present.
Patients with the disorder would meet the
diagnostic criteria for MDD if their episodes lasted
longer.
differ from patients with dysthymia on two counts:
- have an episodic disorder
- symptoms are more severe
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19. Course and Prognosis
About 50 percent of patients experience an
insidious onset of symptoms before age 25 years.
Patients with an early onset of symptoms are at
risk for either MDD or bipolar I disorder in the
course of their disorder.
- about 20 percent progressed to MDD
- 15 percent to bipolar II disorder
- fewer than 5 percent to bipolar I disorder
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20. Course and Prognosis…
Anti-depressive agents and specific types of
psychotherapies (e.g., cognitive and behavior
therapies) have positive effects on the course and
prognosis of dysthymia.
only 10 to 15 percent of patients are in remission 1
year after the initial diagnosis.
About 25 percent of all patients with dysthymia never
attain a complete recovery.
Overall, however, the prognosis is good with treatment.
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21. Risk Factors
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 Environmental:- Childhood risk factors include
parental loss or separation.
• Genetic and physiological:- persistent depressive
disorder will have a higher proportion of first-degree
relatives than MDD.
• A number of brain regions (e.g., prefrontal cortex,
anterior cingulate, amygdala, hippocampus) have
been implicated in persistent depressive disorder.
• Major depressive disorder

22. Treatment
Pharmacotherapy + some form of psychotherapy -
may be the most effective treatment for dsythmia.
Cognitive Therapy
ois a technique in which patients are taught new ways
of thinking and behaving to replace faulty negative
attitudes about themselves, the world, and the
future.
ois a short-term therapy program oriented toward
current problems and their resolution.
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23. Treatment…
Behavior Therapy
oBehavior therapy for depressive disorders is based on the
theory that depression is caused by a loss of positive
reinforcement as a result of separation, death, or sudden
environmental change.
ofocus on specific goals to increase activity, to provide
pleasant experiences, and to teach patients how to relax.
ois often used to treat the learned helplessness of some
patients who seem to meet every life challenge with a
sense of impotence
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24. Treatment…
Insight-Oriented (Psychoanalytic) Psychotherapy
oIndividual insight oriented psychotherapy is the most
common treatment method for dysthymia.
omany clinicians consider it the treatment of choice.
oAttempts to relate the development and
maintenance of depressive symptoms and
maladaptive personality features to unresolved
conflicts from early childhood.
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25. Treatment…
oInsight into depressive equivalents (e.g., substance
abuse) or into childhood disappointments as
antecedents to adult depression can be gained
through treatment.
oAmbivalent current relationships with parents,
friends, and others in the patient’s current life are
examined.
oPatients’ understanding of how they try to gratify an
excessive need for outside approval to counter low
self-esteem and a harsh superego is an important
goal of this therapy.
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26. Treatment…
Interpersonal Therapy
oA patient’s current interpersonal experiences and
ways of coping with stress are examined to reduce
depressive symptoms and to improve self-esteem.
oIPT lasts for about 12 to 16 weekly sessions and
can be combined with antidepressant medication.
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27. Treatment…
Family and Group Therapies
oFamily therapy may help both the patient and the
patient’s family deal with the symptoms of the
disorder, especially when a biologically based sub
affective syndrome seems to be present.
oGroup therapy may help withdrawn patients learn
new ways to overcome their interpersonal
problems in social situations
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28. Treatment…
Pharmacotherapy
Effective drug treatment for patients with
dysthymia-
- SSRIs
- TCAs
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29. Treatment…
Hospitalization
ois usually not indicated for patients with dysthymia
except in particular situations.
indications for hospitalization
- severe symptoms
- marked social or professional incapacitation
- the need for extensive diagnostic procedures
- suicidal ideation
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Premenstrual Dysphoric Disorder

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Premenstrual Dysphoric Disorder
Diagnostic Criteria
A. In the majority of menstrual cycles, at least five
symptoms must be present in the final week before
the onset of menses
 Start to improve within a few days after the onset of
menses, and become minimal or absent in the
week postmenses.
B. One (or more) of the following symptoms must be
present:-

32. Premenstrual Dysphoric Disorder
Diagnostic Criteria…
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1. Marked affective lability (e.g., mood swings:-
 Feeling suddenly sad or tearful, or increased sensitivity
to rejection).
2. Marked irritability or anger or increased interpersonal
conflicts.
3. Marked depressed mood, feelings of hopelessness.
4. Marked anxiety, tension, and/or feelings of being keyed
up or on edge.

33. Premenstrual Dysphoric Disorder DiagnosticCriteria
C. One (or more) of the following symptoms must
to reach a total of five
symptoms when combined with symptoms from
Criterion B above.
1.Decreased interest in usual activities (e.g., work,
school, friends, hobbies).
2. Difficulty in concentration.
3. Easy fatigability, or marked lack of energy.
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Premenstrual Dysphoric Disorder
DiagnosticCriteria…
4. Marked change in appetite, overeating or specific
food cravings.
5. Hypersomnia or insomnia.
6.A sense of being overwhelmed or out of control.
7. Physical symptoms:-
 Such as breast tenderness or swelling
 Joint or muscle pain
 A sensation of ―
b
loating,‖ or weight gain

35. Premenstrual Dysphoric Disorder Diagnostic Criteria..
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D. Clinically significant distress or interference with work,
school, social activities, or relationships with others (e.g.,
avoidance of social activities; decreased productivity and
efficiency at work, school, or home).
E. The disturbance is not symptoms of another disorder, such
as MDD, panic disorder, persistent depressive disorder
(dysthymia), or a personality disorder.

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Premenstrual Dysphoric Disorder
Diagnostic Criteria…
F. Criterion A should be confirmed by prospective daily
ratings during at least two symptomatic cycles.
G. The symptoms are not the physiological effects of
a substance e.g., a drug of abuse, a medication,
other treatment or another medical condition e.g.,
hyperthyroidism.

37. Associated Features
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• Delusions and hallucinations have been
described in the late luteal phase (final phase) of
the menstrual cycle but are rare
• The premenstrual phase has been considered by
some to be a risk period for suicide

38. Prevalence
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• The prevalence of premenstrual dysphoric disorder
is between 1.8% and 5.8% of menstruating women.
• 1.8% for women whose symptoms meet the full
criteria without functional impairment.
• 1.3% with functional impairment.

39. Course of the illness
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• Onset of premenstrual dysphoric disorder can occur
at any point after menarche.
• Many individuals as they came up to menopause
that symptoms worsen.
• Symptoms cease or stop after menopause,
hormone replacement can trigger the re-expression
of symptoms.

40. RiskFactors
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Environmental factors:- associated with the premenstrual
dysphoric disorder include:-
 Stress, history of interpersonal trauma, seasonal changes.
Genetic & physiological:- Heritability of premenstrual
dysphoric disorder is unknown.
 But Premenstrual symptoms, estimates for heritability range
between 30% and 80%.

41. Functionalconsequences
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• Symptoms associated with distress and impairment
in the ability to function socially or occupationally in
the week prior to menses.
 Marital discord and problems with children, other
family members, or friends.
• Chronic marital or job problems are occurs only
with premenstrual dysphoric disorder.

42. Differential Diagnosis
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• Premenstrual syndrome:- Premenstrual syndrome
differs from premenstrual dysphoric disorder in that
a minimum of five symptoms is not required.
 There is no requirement of affective symptoms for
individuals who have premenstrual syndrome.

43. DifferentialDiagnosis…
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 Premenstrual syndrome:- shares the feature of
symptom expression during the premenstrual
phase of the menstrual cycle.
 Premenstrual syndrome:- is less severe than
premenstrual dysphoric disorder.
• Dysmenorrhea:- is a syndrome of painful menses,
but this is distinct from a syndrome characterized by
affective changes.

44. DifferentialDiagnosis…
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• Bipolar disorder
• Major depressive disorder
• Persistent depressive disorder (dysthymia)
• Women with another mental disorder
 May experience chronic symptoms that are unrelated to
menstrual cycle phase.
 The onset of menses symptoms occur only during the
premenstrual period.

45. DifferentialDiagnosis…
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• The overlap
differentiating
from:-
of symptoms is difficult to
premenstrual dysphoric disorder
 Major depressive episodes
 Persistent depressive disorder
 Bipolar disorders
 Borderline personality disorders

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Thank you