Persistent Depressive Disorder

A Combination of Dysthymia and Chronic Major Depression

Persistent depressive order - always in a dark fog
Persistent depressive order - always in a dark fog. Echo's WebMagic, Ltd.

Dysthymic Disorder and chronic Major Depressive Disorder used to be two different illnesses, with Dysthymia the less severe of the two. In the latest edition of the American Psychiatric Association’s diagnostic handbook, the DSM-5, published in 2013, these two conditions have been combined under the heading of Persistent Depressive Disorder.

This illness is not the same as Major Depressive Disorder, which has episodes of depression alternating with periods without depression.

Chronic Major Depressive Disorder was diagnosed when a major depressive episode continued without a break for at least two years (one year in children and adolescents).

In Dysthymic Disorder, the condition also had to last continually for two years (again, one year in children and adolescents), but several of the more serious symptoms of a major depressive episode were left out of the definition.

Persistent Depressive Disorder (Dysthymia)

This new combination diagnosis can be made when the following criteria are present:

A. Depressed mood most of the day, most days, for at least two years. For children and adolescents, the mood can be irritable and only has to last for one year or more.

B. During depression, at least two of these symptoms must be present:

  • Fatigue or lack of energy
  • Low self-esteem
  • Difficulty making decisions or inability to concentrate
  • Feeling hopeless

C. During the entire period (1 or 2 years, depending on age), the symptoms have not gone away for more than 2 months at a time.

D. Full criteria for a major depressive episode (see above) may be present for the entire period.

In this case, the illness would be specified as with “persistent major depressive episode.”

Note: If the full criteria for a major depressive episode have not been met at any point throughout the preceding two years, the condition may be specified as “with pure Dysthymic syndrome.”

And if the full criteria for a major depressive episode have been present part of the time during a two-year period, the condition may be specified as “with intermittent depressive episodes.”

E. There has never been a manic or hypomanic episode, nor has the patient ever had Cyclothymia.

F. The symptoms aren’t explained better by any of these other conditions:

G. The symptoms aren’t the result of another medical condition or a substance such as a drug of abuse or a medication.

H. The symptoms cause clinically significant distress in social, occupational or other important functioning areas.

NOTE: This distress can be as bad as or worse than in Major Depressive Disorder.

Some other specifiers can be attached to the diagnosis of Persistent Depressive Disorder, including:

Notes on Persistent Depressive Disorder

  • There is a higher risk for comorbid anxiety disorders and substance abuse disorders in people with this condition than in individuals with Major Depressive Disorder.
  • Those who first exhibit signs of Persistent Depressive Disorder before the age of 21 are at a higher risk for having certain personality disorders as well.

Regarding Bipolar Disorder

Criterion E above specifies that to be diagnosed with Persistent Depressive Disorder, an individual can never have had any manic or hypomanic episodes and can’t have been diagnosed with Cyclothymia. By contrast, in the previous edition of the diagnostic manual, the DSM-IV-TR, it was possible to diagnose chronic Major Depressive Disorder if a major depressive episode of Bipolar I or II lasted two years or more.

This means that there is no longer an additional diagnosis to make, or even a specifier to add, if a person with bipolar has a long-lasting depressive episode of two years or more.

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