Persistent Depressive Disorder

What is Persistent Depressive Disorder?

Persistent depressive disorder (PDD), also known as dysthymia, is a chronic form of depression that affects millions of people worldwide. It is characterized by a low or sad mood that lasts for at least two years, along with other symptoms such as low self-esteem, poor appetite, sleep problems, fatigue, hopelessness, and difficulty concentrating. PDD can interfere with your daily functioning, relationships, work and quality of life. However, it can also be treated effectively with a combination of psychotherapy and medication. In this article, I will explain what causes PDD, how it is diagnosed and treated, and how you can manage your condition.

What are the symptoms of Persistent Depressive Disorder?

The main symptom of PDD is a depressed mood that occurs for most of the day, for more days than not, for at least two years. In children and adolescents, the mood may be irritable rather than sad. The depressed mood must be accompanied by at least two of the following symptoms:

• Poor appetite or overeating
• Insomnia or hypersomnia (sleeping too much)
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

The symptoms of PDD are usually mild to moderate in severity, but they can vary over time and from person to person. Some people may experience periods of normal mood interspersed with periods of depression. Others may have a constant low-level depression that never lifts. Some people may also have episodes of major depression on top of their persistent depressive disorder. This is called double depression and it requires more intensive treatment.

What causes Persistent Depressive Disorder?

The exact causes of PDD are not fully understood, but they may involve a combination of biological, psychological, and environmental factors. Some possible factors include:

• Genetics: PDD may run in families, suggesting that some people may inherit a vulnerability to developing the condition.
• Brain chemistry: PDD may be associated with imbalances in certain brain chemicals called neurotransmitters, such as serotonin and norepinephrine, that regulate mood and other functions.
• Personality: PDD may be more common in people who have certain personality traits, such as pessimism, low self-confidence, perfectionism, or chronic stress.
• Life events: PDD may be triggered or worsened by stressful or traumatic events in life, such as loss, abuse, illness, or conflict.
• Medical conditions: PDD may co-occur with or result from other medical conditions that affect the brain or the body, such as thyroid disorders, diabetes, chronic pain, or cancer.

How is Persistent Depressive Disorder diagnosed?

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the Diagnostic Criteria for Persistent Depressive Disorder is as follows:

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.

Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:

1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.

C. During the 2 year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for 2 years.

E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

G. The symptoms are not attributable to the physiological effects 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.

Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.

How is Persistent Depressive Disorder treated?

The treatment of PDD usually involves a combination of psychotherapy and medication. The goals of treatment are to reduce the symptoms of depression, improve the functioning and quality of life of the person, and prevent relapse or recurrence of depression.

• Psychotherapy: Psychotherapy is a form of counseling that helps the person understand and cope with their depression, identify and change negative thinking patterns, develop coping skills and strategies, enhance self-esteem and confidence, and improve interpersonal relationships. There are different types of psychotherapy that can be effective for PDD, such as:
  • Cognitive-behavioural therapy (CBT): CBT focuses on identifying and challenging distorted or irrational thoughts and beliefs that contribute to depression, and replacing them with more realistic and positive ones. CBT also teaches behavioural techniques to increase pleasant activities, cope with stress, and solve problems.
  • Interpersonal therapy (IPT): IPT focuses on improving the quality of the person’s relationships with others, especially those that may be causing or worsening their depression. IPT helps the person identify and resolve interpersonal conflicts, role transitions, grief, and social isolation.
  • Psychodynamic therapy: Psychodynamic therapy explores the unconscious motives, conflicts, and patterns that underlie the person’s depression. It helps the person gain insight into their past experiences, emotions, and needs, and how they affect their present behaviour and mood.
  • Other types of therapy: Other types of therapy that may be helpful for PDD include supportive therapy, mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), and group therapy.
• Medication: Medication is often used in conjunction with psychotherapy to treat PDD. The most commonly prescribed medications for PDD are antidepressants, which work by affecting the levels of neurotransmitters in the brain. There are different classes of antidepressants that have different mechanisms of action, such as:
  • Selective serotonin reuptake inhibitors (SSRIs): SSRIs increase the availability of serotonin in the brain by blocking its reabsorption by nerve cells. Examples of SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and fluvoxamine (Luvox).
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs increase the availability of both serotonin and norepinephrine in the brain by blocking their reabsorption by nerve cells. Examples of SNRIs include venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq), and levomilnacipran (Fetzima).
  • Tricyclic antidepressants (TCAs): TCAs increase the availability of serotonin and norepinephrine in the brain by blocking their reuptake by nerve cells as well as other receptors. Examples of TCAs include amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil), desipramine (Norpramin), doxepin (Sinequan), clomipramine (Anafranil), and trimipramine (Surmontil).
  • Monoamine oxidase inhibitors (MAOIs): MAOIs increase the availability of serotonin, norepinephrine, and dopamine in the brain by inhibiting an enzyme called monoamine oxidase that breaks them down. Examples of MAOIs include phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), selegiline (Emsam), and moclobemide (Manerix).

The choice of antidepressant depends on several factors, such as the severity and type of symptoms, the response and side effects to previous medications, the presence of other medical conditions or medications, and the preference of the person. Antidepressants usually take several weeks to show their full effect, so it is important to continue taking them as prescribed even if there is no immediate improvement. Antidepressants may also cause some side effects, such as nausea, headache, insomnia, weight changes, sexual dysfunction, anxiety, agitation, drowsiness, dry mouth, constipation, or sweating. These side effects usually subside over time or can be managed by adjusting the dose or switching to another antidepressant. It is important not to stop taking antidepressants abruptly without consulting your healthcare provider, as this may cause withdrawal symptoms or a relapse of depression.

How can you manage your Persistent Depressive Disorder?

In addition to psychotherapy and medication, there are some self-help strategies that can help you cope with PDD and improve your mood and well-being. Some of these strategies include:

• Physical activity: Regular exercise can have positive effects on your mood, energy, sleep, appetite, and self-esteem. Aim for at least 30 minutes of moderate physical activity on most days of the week. Choose an activity that you enjoy and that suits your level of fitness and health. You can also break up your exercise into shorter sessions throughout the day.
• Healthy diet: Eating a balanced and nutritious diet can help you maintain your physical and mental health. Avoid skipping meals or overeating, as this can affect your mood and energy levels. Try to limit your intake of caffeine, alcohol, and sugar, as these can worsen your depression symptoms or interfere with your medication. Include foods that are rich in omega-3 fatty acids, such as fish, nuts, seeds, and flaxseed oil, as these may have anti-inflammatory and antidepressant effects.
• Sleep hygiene: Getting enough quality sleep can help you feel more rested and refreshed. Poor sleep can aggravate your depression symptoms and affect your concentration and memory. To improve your sleep hygiene, follow these tips:
  • Stick to a regular sleep schedule. Go to bed and wake up at the same time every day.
  • Avoid napping during the day, as this can disrupt your night-time sleep.
  • Avoid caffeine, nicotine, alcohol, and heavy meals close to bedtime.
  • Make your bedroom comfortable, dark, quiet, and cool.
  • Avoid using electronic devices such as TV, computer/tablet, or phone before bed or in bed.
  • Develop a relaxing bedtime routine. You can read a book, listen to soothing music, meditate, or do some gentle stretches.
  • If you have trouble falling asleep or staying asleep, don’t check the clock or worry about it. Get up and do something relaxing until you feel sleepy again.
• Social support: Having a strong network of supportive people can help you cope with PDD and reduce your feelings of loneliness and isolation. Reach out to your family members, friends, co-workers, or other people who care about you. Share your feelings and thoughts with them and ask for help when you need it. You can also join a support group for people with depression or other mental health conditions. A support group can provide you with emotional support, practical advice, and a sense of belonging.
• Stress management: Chronic stress can worsen your depression symptoms and affect your physical health. Learning to manage your stress levels can help you feel more calm and in control of your life. Some effective stress management techniques include:
  • Breathing exercises: Deep breathing can help you relax your body and mind. To practice deep breathing, sit comfortably in a quiet place. Breathe in slowly through your nose for four seconds, filling your belly with air. Hold your breath for two seconds. Breathe out slowly through your mouth for six seconds, emptying your belly of air. Repeat this cycle for several minutes.
  • Progressive muscle relaxation: This technique involves tensing and relaxing different muscle groups in your body. To practice progressive muscle relaxation, start by lying down or sitting comfortably in a quiet place. Close your eyes and focus on your breathing. Then tense one muscle group (such as your feet) for five seconds while breathing in. Relax the muscle group for 10 seconds while breathing out. Move on to the next muscle group (such as your calves) and repeat the process until you have relaxed all the major muscle groups in your body.
  • Mindfulness meditation: Mindfulness is the practice of paying attention to the present moment without judgment or distraction. Mindfulness meditation can help you cultivate awareness of your thoughts, feelings, sensations, and surroundings, and accept them as they are. To practice mindfulness meditation, sit comfortably in a quiet place. Close your eyes and focus on your breathing. Notice how it feels to breathe in and out, and how it affects your body. If any thoughts, feelings, or sensations arise, simply acknowledge them without judging them or trying to change them. Then gently bring your attention back to your breathing. Continue this practice for 10 to 20 minutes. [Check out this article on two mindful mantram practices that you could use]
• Other stress management techniques: You can also try other activities that help you relax and enjoy yourself, such as listening to music, reading a book, watching a movie, playing a game, gardening, cooking, or doing a hobby. Find what works for you and make time for it in your daily or weekly schedule.

Conclusion

Persistent depressive disorder is a chronic form of depression that can affect your mood, functioning, and quality of life. However, it is not a permanent or hopeless condition. With proper treatment and self-care, you can overcome your depression and live a fulfilling and satisfying life. If you think you may have PDD, don’t hesitate to seek professional help. There are many resources and options available to help you cope and recover from PDD. Remember that you are not alone and that there is always hope.

I hope this article has helped you understand more about persistent depressive disorder and how to manage it. If you have any questions, please feel free to ask.