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Imagine a middle-aged woman who has been depressed for most of her life but doesn’t realize it. Her sad feelings started so long ago – possibly in childhood or adolescence – that gradually they became “normal” to her. Only when her friends finally ask her to get help does it cross her mind that she might be depressed.
Persistent depressive disorder (PDD) or “dysthymia” is essentially a chronic mild depression. A person with this condition suffers from a depressed mood most of the day, more days than not, for at least two years and often longer. The person also may notice changes in sleep patterns and eating habits, low energy or fatigue, difficulty concentrating and making decisions, poor self-esteem or feelings of hopelessness. There may be little relief from depressed thoughts and feelings.
This is different from the major depression that is depicted in television commercials for antidepressants. A person suffering from major depression usually is seen as struggling to make it through the day. He often cannot perform at work and may be very socially isolated. Although there is much overlap in the symptoms of major depression and persistent depressive disorder, to a certain extent, it is a matter of degree.
A person with PDD will have milder symptoms and his depression may go unnoticed because he seems to be functioning well in his work or ministry. Nevertheless, he is suffering inside, and may even lose hope that he can ever feel any better.
A person may develop PDD either early in life or later in adulthood. He may remember the depression starting following a loss or a trauma in his life. The loss might have been the death of a parent, sibling or grandparent. It could have been a divorce between parents, a near-fatal illness or a chronic form of abuse – emotional, physical or sexual.
Often people with PDD turn to maladaptive addictive behaviors in an attempt to ward off their sadness. Alcohol and drug abuse is quite common. Overeating, bingeing and purging food, or severely restricting food, as with anorexia, may occur. Internet pornography use and sexually acting out with others are often seen, and compulsive gambling may be present.
During the course of treatment for addictive behaviors, underlying dysthymia may become more apparent as the addictive behaviors subside. The next phase of treatment then focuses on this depression.
Psychotherapy is usually the first line of treatment for PDD. A person works with a psychotherapist in an effort to reverse the pattern of negative thoughts, feelings and perceptions. Sometimes effects due to unresolved grief or trauma also need to be addressed. Talking with a trained therapist to work through these issues is often helpful. Cognitive-behavioral, interpersonal and psychodynamic psychotherapies may all be used to treat PDD.
Because PDD is a condition that often affects a person for years before being detected, it can become embedded in one’s outlook on life. Recovery from this chronic depression usually will take weeks, months or even longer. In order to reduce the recovery time so the person will begin to feel better sooner, medications may be suggested along with the psychotherapy.
Antidepressants are typically recommended for treatment of persistent depressive disorder. An antidepressant can reduce sad-ness and negativity as well as alleviate some of the physical symptoms, such as changes in sleep, appetite and energy. Optimally, a person will be able to more effectively use psychotherapy sessions toward recovery when antidepressants are taken.
The antidepressants that are often recommended initially for PDD are selective serotonin reuptake inhibitors (SSRI’s). Serotonin dysregulation has been implemented as a biological cause in depression. The SSRI’s are commonly known by their trade names: Zoloft, Lexapro, Celexa, Prozac and Paxil. Another group of antidepressants that may be recommended are serotonin-norepinephrine reuptake inhibitors (SNRI’s). These include Effexor, Pristiq and Cymbalta. Other antidepressants such as Wellbutrin and Remeron can also be helpful.
Persistent depressive disorder is a chronic condition that may be present for years without the depressed person being aware of it. It is often masked by maladaptive and addictive behaviors and can have a detrimental effect on personal relation-ships and work. However with proper treatment, usually beginning with psychotherapy, and often including anti-depressants, relief from this debilitating condition is possible.
Dr. Joseph Collins is a board-certified psychiatrist and director of medical services for Saint Luke Institute.
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