Academic journal article Journal of Cognitive Psychotherapy

Toward a Cognitive Conceptualization of Dysthymia: Cognitive Behavioral Identification and Treatment of Patients with Dysthymia

Academic journal article Journal of Cognitive Psychotherapy

Toward a Cognitive Conceptualization of Dysthymia: Cognitive Behavioral Identification and Treatment of Patients with Dysthymia

Article excerpt

Archival records of three groups of outpatients, seen in a U.S. behavioral health clinic during 2009 and 2010, were examined. All had taken a battery of tests and measures at admission, including both the Millón Clinical Multiaxial Inventory-Ill (MCMI-III) and a questionnaire representing beliefs, attitudes, and behaviors, believed to be prototypical of dysthymia. The groups, identified on the basis of their MCMI-III profiles, were Dysthymia (η = 84), non- chronic Depression ( /; = 58 ), and Control ( « = 120 ). Significant differences were found among the groups, in that the Dysthymia group had the highest level of agreement on 25 items of the questionnaire; the nonchronic Depression group had the second highest; and the Control group had the lowest level of agreement. Conceptual and therapeutic implications are dis- cussed, as are various modalities considered to be effective in the treatment of patients with dysthymia.

Keywords: dysthymia; chronic depression; cognitive measures; double depression; maladaptive beliefs/attitudes

Studies on chronic depression in general, and dysthymia (a subtype of chronic depression) in particular, are meager. Predominantly studies on dysthymia have focused on identifying the risk factors and conditions that have been associated with dysthymia, and that are be- lieved to influence its course and outcome. These include family history of mood and personality disorders, childhood adversities, parental neglect and rejection, and chronic stress (Hayden & Klein, 2001; Riso & Klein, 2004). Markowitz (1994), viewing dysthymia as a highly prevalent mood disorder, makes the distinction between "pure" dysthymia, a milder form of chronic de- pression, and Double Depression, which involves major depression superimposed on dysthymia. He argues that, although the two differ in several symptoms, the two are more alike than differ- ent. Akiskal and Cassano (1997) state that the pure form of dysthymia might be more prevalent in outpatient psychotherapy practices, whereas those who present in the clinical mental health system typically constitute double depressives. Klein and Vocisano (1999) contend that depressive personality disorder overlaps with dysthymic disorder, although the former is less symptomatic and more trait-oriented than is dysthymic disorder.

Although two of the six symptoms in Section ? of the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-FV) classification for dysthymic disorder (American Psychiatric Association, 1994), that is, low self-esteem and hopelessness, are cognitive in nature, research studies examining cognitive variables associated with the disorder are few. Pössel (2003) examined positive versus negative beliefs, as well as peripheral core beliefs, in participants who are normal, dysthymic, and depressed in an attempt to determine whether or not dysthymia and major depression constitute distinct conditions along a one-dimensional continuum. The data supported his contention that dysthymia and unipolar depression are distinct conditions, rather than a one-dimensional continuum of unipolar depression.

Schmaling, Dimidjian, Katon, and Sullivan (2002), examining such cognitive elements as rumination and distraction in 96 primary care patients with dysthymia or minor depression, sug- gest that rumination maybe a symptom of depression rather than a causal or maintenance factor for depression, as had been suggested by Nolen-Hoeksema (1991).

Airaksinen, Larsson, Lundberg, and Forsell (2004), studying cognitive function in depressive disorders based on their performance on several cognitive tasks, found individuals with dysthy- mia showing pronounced difficulties in mental flexibility. In persons with minor depression, cog- nitive performance was not affected.

Rigidity of attitudes on the part of the patient has long been thought to be a significant stumbling block in the treatment of patients with dysthymia. In this connection, Kelly, Matheson, Ravindran, Merali, and Anisman (2007) found that patients with dysthymia showed a persistent inflexibility in their ability to combine various coping efforts, despite receiving 12 weeks of pharmacotherapy (sertraline); pharmacotherapy did yield a reduction in depressed mood and rumination. …

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