Dysthymia is defined as a reactive nonpsychotic depression of mild to moderate intensity with predominant anxiety. It is characterized by the presence of a depressed mood that lasts most of the day and is present almost continuously. Patients complain that they have always been depressed. It is not a sequela to a major depressive episode as with chronic depression. There are associated feelings of inadequacy, guilt, irritability, and anger; withdrawal from society; loss of interest; and inactivity and lack of productivity. Most cases are of early onset, beginning in childhood or adolescence and certainly by the time patients reach their 20s. The overall prognosis for dysthymia is good with treatment; however, 25 percent of dysthymic patients never attain complete recovery.

Computed tomography (CT) and magnetic resonance imaging (MRI) scans provide sensitive, noninvasive methods to assess the brain, including cortical and subcortical tracts, as well as white matter lesions. The most consistent abnormality observed in the depressive disorders is increased frequency of abnormal hyperintensities in subcortical regions, especially the periventricular area, basal ganglia, and thalamus (Figure 15.2). More common in bipolar I disorder and among the elderly, these hyperintensities appear to reflect the deleterious neurodegenerative effects of recurrent mood episodes. Ventricular enlargement, cortical atrophy, and sulcal widening have also been reported in patients with mood disorders compared with normal control subjects. In addition to age and illness duration, structural abnormalities are associated with increased illness severity, bipolar status, and increased cortisol levels. Some depressed patients also may have reduced caudate nucleus volumes, suggesting a defect in the mesocorticolimbic system. Cerebrovascular factors often involve subcortical frontal and basal ganglia structures and appear particularly relevant to late-life depression.

Confidentiality refers to the therapist’s responsibility to not release information learned in the course of treatment to third parties. Confidentiality is an essential ingredient of psychiatric care because it is a prerequisite for patients to be willing to speak freely to therapists. People would be less likely to go for help and would tend to withhold crucial information if confidentiality was not assured. There is no reason to break doctor–patient confidentiality in situations involving a patient’s sexual preference (e.g., homosexuality) unless there is some threat to the patient’s safety. Confidentiality must give way to the responsibility to protect others when a patient makes a credible threat to harm someone (e.g, a patient threatening to kill his boss) or acts in a way that could harm him- or herself (e.g., a patient who thinks he can fly). Reportable diseases (e.g., syphilis) must also be reported to the proper authorities despite the bond of patient confidentiality. Any suspicion of child abuse must also be reported to the authorities.

Lithium (Eskalith), used for mood stabilization in patients with bipolar disorder, is known for its low margin of safety, making frequent monitoring necessary. Common side effects include gastrointestinal disturbances, nephrotoxicity, hypothyroidism, tremors, leukocytosis, acne, psoriasis flares, hair loss, and edema. Because of these effects, it is important to get thyroid function tests and renal function tests (creatinine) before starting any patient on this medication. Lithium is also teratogenic and has been associated with cardiac defects, so a pregnancy test is necessary before lithium therapy.

Three (not one) out of four patients with acute depression will experience recurrences, with varying degrees of residual symptoms between episodes. Of note, although depressive disorders are more common in women, more men than women die of suicide because of more lethal methods chosen.

Hypersexuality is cardinal sign of mania and usually indicates a mixed episode of bipolar disorder in depressed patients. The small subgroup of depressed persons with increased sexual drive usually exhibit other atypical features; hence, increased sexual drive is considered the fifth reverse vegetative sign (after even worsening mood, initial insomnia, hypersomnia, and weight gain).

The biological concomitants of melancholia include profound reductions in appetite (i.e., anorexia or weight loss), sleep (i.e., insomnia), and sexual functioning, as well as alterations in other circadian rhythms, especially worsening of mood and psychomotor performance. An equally prominent subgroup of depressed persons exhibits a reversal of the vegetative and circadian functions, with increases in appetite and sleep—and sometimes in sexual functioning—and an evening worsening of mood; in this atypical pattern, patients characteristically exhibit mood reactivity and sensitivity to rejection.

Serotoninergic neurons project from the brainstem dorsal raphe nuclei to the cerebral cortex, hypothalamus, thalamus, basal ganglia, septum, and hippocampus. Serotonin (5-HT) pathways have both inhibitory and facilitatory functions in the brain. For example, much evidence suggests that 5-HT is an important regulator of sleep, appetite, and libido. Serotonergic neurons projecting to the suprachiasmatic nucleus of the hypothalamus help to regulate circadian rhythms (e.g., sleep–wake cycles, body temperature, and hypothalamic-pituitary-adrenocortical axis function). Serotonin also permits or facilitates goal-directed motor and consummatory behaviors in conjunction with norepinephrine and dopamine. Moreover, serotonin inhibits aggressive behavior across mammalian and reptilian species.

There is some evidence that serotonin neurotransmission is partly under genetic control. Nevertheless, whereas acute stress increases serotonin release transiently, chronic stress eventually depletes serotonin stores. Chronic stress may also increase synthesis of 5-HT_1A autoreceptors in the dorsal raphe nucleus, which further decrease serotonin transmission. Elevated glucocorticoid levels tend to enhance serotonergic functioning and thus may have significant compensatory effects on chronic stress.

The course of major depressive disorder, recurrent, with no antecedent dysthymic disorder and a period of full remission between the episodes predicts the best future prognosis. This is depicted in graph A.

Graph D depicts double depression, which is characterized by recurrent major depressive disorder and antecedent dysthymic disorder with no period of full remission in between the two most recent episodes. Graph A is the course of major depressive disorder, recurrent, with no antecedent dysthymic disorder and full remission between episodes. Graph B is the course of major depressive disorder, recurrent, with no antecedent dysthymic disorder but with prominent symptoms persisting between episodes (partial remission is attained). Graph C is the rare pattern major depressive disorder, recurrent, with antecedent dysthymic disorder but with full interepisodic recovery.

Double depression is characterized by recurrent major depressive disorder with antecedent dysthymic disorder and no period of full remission between the two most recent episodes. This pattern is seen in approximately 20 to 25 percent of the persons with major depressive disorder.

Despite their contrasts, depression and mania share such symptoms as irritability, anger, insomnia, and agitation. Mania is defined as a mood disorder characterized by elation, agitation, hyperactivity, and hyperexcitability. The clinical features of mania are generally the opposite of those of depression. Depression is defined as a mental state characterized by feelings of sadness, loneliness, despair, low self-esteem, and self-reproach. Depression is commonly associated with cases of lowered mood, thinking, self-esteem, and activity. Mania, on the other hand, is commonly associated with elevated mood, a rush of ideas, psychomotor acceleration, and grandiosity. An excess of the shared symptoms of escalating intensity suggests a mixed phase of mixed episode of mania and depression occurring simultaneously, commonly called bipolar I disorder.

The 19-year-old rape victim is more likely to develop a variation of posttraumatic stress disorder, which is highest among victims of rape, military combat veterans, and survivors of torture. Childhood onset of dysthymia similarly presages extremely high rates of depression and bipolar disorder in adulthood. Monozygotic twins have been shown to have a two- to fourfold increase in concordance rates for mood disorders over dizygotic twins, compelling data for the role of genetic factors in mood disorders.

Parental loss before adolescence is also a well-documented risk factor for adult-onset depression. Medical problems of many types, such as cancer of the pancreas, multiple sclerosis, and space-occupying lesions of the brain, can produce depression.

A hypomanic episode lacks psychotic features, which can sometimes be associated with mania. A manic episode is a distinct period of an abnormally and persistent elevated, expansive, or irritable mood lasting for at least 1 week or less if a patient must be hospitalized. A hypomanic episode lasts at least 4 days and is similar to a manic episode except that it is not sufficiently severe to cause impairment in social or occupational functioning. Patients often believe that they benefit from the energy and confidence of hypomania. Diagnostically, history of hypomania is preferably obtained from significant others who have observed the patient; the experience is often pleasant, and the subject may be unaware of it or may tend to deny it. Both mania and hypomania are associated with inflated self-esteem, decreased need for sleep, distractibility, great physical and mental activity, and overinvolvement in pleasurable behavior.

In Sigmund Freud’s structural theory, introjection of the lost object into the ego leads to the typical depressive symptoms of a lack of energy available to the ego. The superego, which is unable to retaliate against the lost object externally, flails out at the psychic representation of the lost object, now internalized in the ego as an introject. When the ego overcomes or merges with the superego, energy previously bound in the depressive symptoms is released, and mania supervenes with the typical symptoms of excess.

Projection is the unconscious defense mechanism in which a person attributes to another person those generally unconscious ideas, thoughts, feelings, and impulses that are personally undesirable or unacceptable. Sublimation is an unconscious defense mechanism in which the energy associated with unacceptable impulses or drives is diverted into personally and socially acceptable channels.

Undoing is an unconscious defense mechanism by which a person symbolically acts out to reverse something unacceptable that has already been done or against which the ego must defend itself. Altruism is regard for and dedication to the welfare of others.