Patients suffering from dysthymic disorder have a poor outlook on life and are very pessimistic, with feelings of low self-wealth. They have less dramatic symptoms, when compared with major depressive disorder. The sleep disturbances and neurological symptoms are not as dramatic. Affected individuals may be restless and anxious. These patients also have poor relationships and tend to focus their time and energy to project and work. They have poor social lives and are distant from family members. Many practice substance abuse [7].

It is important to rule out organic and possible medical causes, such as thyroid disorders and nutrient deficiencies such as vitamin B12 or folate. Other conditions such as chronic diseases have to be addressed. There are some experimental imaging studies with functional magnetic resonance imaging, but this is not routine.

First of all, treatment goals have to be made. The major being to put the patient into remission, and prevent relapse. A combination of psychotherapy and medication is usually an effective treatment.

Medications include second generation antidepressants, these include:

• Serotonin modulators
• Serotonin-norepinephrine reuptake inhibitors
• Selective serotonin reuptake inhibitors

Other drugs such as

• Tricyclic antidepressants
• Monoamine oxidase inhibitors (MAOIs)

may also be used. Other modalities such as exercise 4 to 6 times a week is helpful. Those deemed dangerous to themselves (suicidal) or others will require inpatient care until they are deemed safe [8] [9] [10].

The chance of remission is dependent on a number of factors, such as associated risk factors; genetic, social and so forth. It has been noted that patients with certain traits have a poorer prognosis, such as chronic stress and anxiety disorders. There is a risk that some patients may worsen into a major depressive state which has a worse prognosis. These patients are also at increased risk of employment and relationship issues. There is a significant risk of suicide as compared to the rest of the population [5] [6].

The etiology is not clear but most it is likely to be a multifactorial. These factors may include a family history, with genetic factors, underlying medical problems (particularly chronic medical conditions) and social/economic stressors. Underlying personality disorders may also contribute such as antisocial, dependent and depressive traits.

Lifetime risks of this order may reach as high as 25%. Over 35% of mental health patients have this diagnosis [3]. There is a female predominance with women being twice more likely to suffer from this disorder.

There are a number of theories, but the prevailing one states that there are abnormalities in the noradrenergic and serotonin neurotransmitters. This has been suggested due to the response to treatment with serotonin/norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitor and tricyclic antidepressants.

It has been noted that in a subset of depressed and dysthymic patients shows elevated levels of cortisol associated with increased production of corticotrophin-releasing factor from the hypothalamus and perhaps other brain regions. This chronic levels cause damage to the hippocampal regions with loss of their inhibitory effect on the hypothalamic-pituitary-adrenal axis, with more production of cortisol.

Genetic factors have been found, but not yet confirmed, hence the family history being contributory [4].

Good social support systems and a healthy life style are protective, but there is little date to show this.

Dysthymic disorder, also called dysthymia or neurotic depression, is a common mood disorder. By definition the condition has to have been present for a minimum of two years in adults and one year in children. For the diagnosis to be made the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria have to be meet.

The DSM-V requires:

• Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least two years (In children it one year).
• Presence of two or more of the following while depressed:

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

• During the two year period the patient must have not gone for more than two months without the symptoms.
• There has never been a manic episode. 
• 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.
• The symptoms are not attributable to the physiological effects of a substance (a drug of abuse, a medication) or another medical condition.
• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning [1] [2].

• Definition: Dysthymic disorder is a medical condition that causes psychological symptoms. This condition may considered as a milder form of major depression, as it has less dramatic symptoms. The condition has to be there for a minimum of two years in adults and one year in children.
• Cause: There are many suggested causes of this disorder with chronic stress and chronic medical conditions putting your at risk. Also poor coping mechanisms may also be a significant factor. There also appear to be a strong familial links, which may be related to genetics, but no gene has been implicated to date.
• Symptoms: Patients tend to be gloomy and have a negative outlook on the future. They tend to be withdrawn and focus their time and energy to work rather than relationships and family. They have less dramatic symptoms such as mild sleep disturbance as compared to major depression. They are also at risk of suicide.
• Diagnosis: The doctor has to rule out medical conditions such as thyroid disorders, but the diagnosis is made on the basis of clinical grounds. There are specific criteria that has to be meet. Other test for medical conditions may have to be done.
• Treatment: This will include psychotherapy and antidepressant medications. The psychotherapy will include cognitive behavioural therapy and coping techniques. Exercise and a healthy living have been noted to be beneficial.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013
2. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2197.
3. Eaton WW, Shao H, Nestadt G, et al. Population-based study of first onset and chronicity in major depressive disorder. Arch Gen Psychiatry 2008; 65:513.
4. Wallace RJ Jr, Griffith DE. Antimycobacterial agents. In: Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL, eds. Harrison's Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2012:946
5. Shankman SA, Klein DN. The impact of comorbid anxiety disorders on the course of dysthymic disorder: a 5-year prospective longitudinal study. J Affect Disord. Jul 2002;70(2):211-7
6. Hermens ML, van Hout HP, Terluin B, van der Windt DA, Beekman AT, et al. The prognosis of minor depression in the general population: a systematic review. Gen Hosp Psychiatry. Nov-Dec 2004;26(6):453-62.
7. Casement MD, Shestyuk AY, Best JL, Casas BR, Glezer A, Segundo MA, et al. Anticipation of affect in dysthymia: behavioral and neurophysiological indicators. Biol Psychol. Feb 2008;77(2):197-204
8. Markowitz JC, Kocsis JH, Bleiberg KL, Christos PJ, Sacks M. A comparative trial of psychotherapy and pharmacotherapy for "pure" dysthymic patients. J Affect Disord. Dec 2005;89
9. American Psychiatric Association: Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition, 2010. 
10. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder, third edition. Am J Psychiatry 2010; 167 (supplement):1.