|Treatment - Dysthymic Disorder|
Table of Contents
All treatment with an individual suffering from dysthymic disorder should occur in a warm, supporting and caring environment. Since this is a chronic disorder, care should be given to not using previous treatment approaches (especially medication) which have proven ineffective in the past. A careful and thorough history should be conducted at the onset of treatment to ensure this is evaluated. Specific attention should also be given to diagnostic issues, such as the existence of an alcohol or substance abuse problem, or social anxiety or other phobia, underlying or causing the dysthymic condition.
Much treatment for this disorder is considered "maintenance." This does not always have to be the case, however, although some people may suffer from multiple episodes of this disorder throughout their lifetime. Often times the individual will present for treatment because of increased stress or personal difficulties which may be situationally-related. Only after a careful diagnostic interview is conducted (or after a few therapy sessions) may the chronic nature of the individual's problem become apparent.
As with many chronic disorders (such as personality disorders), psychotherapy is the recommended treatment of choice. As mentioned above, it is important for the initial clinician to conduct a thorough evaluation to evaluate the individual's current state of functioning, to assess mood type and severity, check for suicidal ideation and plan, etc. No matter which specific type of psychotherapeutic approach is utilized, a supportive, change-oriented environment and good rapport should be established by the therapist. A client-centered approach to therapy should be considered, as it offers a therapy environment tailored to the patient's need for unconditional acceptance and support. Non-specific factors will likely be the most effective component of therapy with this individual. Therapy should be generally conducted with respect to the client's pace and level of functioning. Attempts to focus on change too early in therapy could lead to early termination of therapy. This likely occurs because the patient feels the therapist didn't respect or care enough about him or her to move at their rate.
Psychotherapy approaches for this disorder vary widely. Short-term approaches are preferred, however, because they emphasize realistic, attainable goals in the individual's life which can usually bring them back to their normal level of functioning. This level, however, may be markedly less than what is expected in the average person. A person who suffers from dysthymic disorder has generally learned to live with a fair amount of chronic unhappiness in their lives. Realistic goals should be established early-on and the focus of therapy, instead of focusing on the person's mood state.
Group therapy has been shown to be an effective modality for individuals suffering from this disorder. A group can be more supportive an individual than any one therapist can and help point out inconsistencies in the patient's thinking and behavior. It should be considered, if not initially, then later on in treatment as the client regains his or her own self-confidence and can interact in a social context. Issues of self-esteem often accompany individuals who have dysthymic disorder, so care must be employed not to place the person into a group situation (where failure may be imminent) too soon. Family therapy may also be helpful for some individuals. Couples therapy can bring the individual's spouse or significant other into the therapeutic relationship to create a therapeutic (and more powerful) triad.
Goals will vary according to type of therapy. Cognitive therapy emphasizes changes in one's faulty or distorted way of thinking and perceiving the world. Interpersonal therapy focuses on an individual's relationships with others and how to improve and strengthen existing relationships while finding new ones. Solution-focused therapy looks at specific problems plaguing an individual's life in the present and examines how to best go about changing the person's behavior to solve these difficulties. Social skills training focuses on teaching the client new skills on how to become more effective in social and work relationships. Usually, psychoanalytic and other insight-oriented approaches will be less effective because of their focus on the past and emphasis on lengthy therapy. While incorporation of therapy into a person's chronic condition might be quite financially lucrative for the therapist, it is not the most change-effective and timely approach to help the individual overcome his or her difficulties.
Because the clinician must move at the client's pace, progress with any type of therapy can be slow. Therapists should resist the temptation to try and "speed up" the process or force the client in a direction he or she is not yet ready to try. Closely related to this issue of the pace of therapy is being aware of the clinician's frustration with lack of progress or boredom within the therapy session. It can be an emotionally draining experience for some therapists.
Additionally, Phillip W. Long, M.D. adds,
"The patient's unrealistic and idealistic expectations of himself or herself may, for example, be transmitted to the therapist and give rise to overlying optimistic expectations of progress in therapy. If the patient shows no subjective improvement over time, the therapist may inadvertently respond somewhat in the way significant individuals in the patient's life have responded. Interpretation of such personal experiences by the therapist can, in the proper context, be therapeutic.
Medication is usually not an issue for someone who suffers from this disorder, unless they also have an additional Axis I disorder, such as major depression. Most patients show no additional improvement with the addition of an antidepressant medication, though, unless they are also suffering from suicidal ideation or a major depressive episode. Long-term treatment of this disorder with medication should be avoided; medication should be prescribed only for acute symptom relief. Additionally, prescription of medication may interfere with the effectiveness of certain psychotherapeutic approaches. Consideration of this effect should be taken into account when arriving at a treatment recommendation.
When appropriate to treat a concurrent major depressive episode, tricyclic antidepressants are effective and inexpensive. Phillip W. Long, M.D. suggests that, "a patient should not be considered a failure until the equivalent of 200 mg to 300 mg of imipramine has been evaluated for at least 6 weeks." Selective serotonin reuptake inhibitors may also be appropriate for prescription.
Phillip W. Long, M.D. also states,
"A number of drugs are not of value for long-term treatment. Those drugs include the amphetamines, the barbiturates, and the benzodiazepines. Those drugs are often prescribed for patients with chronic symptoms of insomnia, fatigue, or tension. However, clinical experience and systematic research indicate that they are little better than a placebo and are at times worse."
Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Adjunctive community support groups in concurrence with psychotherapy is usually beneficial to most people who suffer from dysthymic disorder. Caution should be utilized, however, if the person also suffers from social anxiety. A group like A.A. or N.A. may also be appropriate, if the underlying cause of the dysthymia is a substance abuse problem. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.
Patients can be encouraged to try out new coping skills, assertiveness skills, cognitive restructuring, etc within such a support group. They can be an important part of expanding the individual's skill set and develop new, healthier social relationships.
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