Noah Sanders Case Study: Dysthymia

For Noah Sanders, life had never seemed much fun. He was 18 when he first noticed that most of the time he “just felt down.” Although he was bright and studied hard, throughout college he was often distracted by thoughts that he didn’t measure up to his classmates.

He landed a job with a leading electronics firm, but turned down several promotions because he felt that he could not cope with added responsibility. It took dogged determination and long hours of work to compensate for this “inherent second-rateness.” The effort left him chronically tired. Even his marriage and the birth of his two daughters only relieved his gloom for a few weeks at a time, at best. His self-confidence was so low that, by common consent, his wife always made most of their family’s decisions.

“It’s the way I’ve always been. I am a professional pessimist,” Noah told his family doctor one day when he was in his early 30s. The doctor replied that he had a depressive personality.

For many years, that description seemed to fit. Then, when Noah was in his early 40s, his younger daughter left home for college; after this, he began to feel increasingly that life had passed him by. Over a period of several months, his depression deepened. He had worsened to the point that he now felt he had never really been depressed before. Even visits from his daughters, which had always cheered him up, failed to improve his outlook.

Usually a sound sleeper, Noah began awakening at about 4 A.M. and ruminating over his mistakes. His appetite fell off, and he lost weight. When for the third time in a week his wife found him weeping in their bedroom, he confessed that he had felt so guilty about his failures that he thought they’d all be better off without him. She decided that he needed treatment.

Noah was started on an antidepressant medication. Within 2 weeks, his mood had brightened and he was sleeping soundly; at 1 month, he had “never felt better” in his life. Whereas he had once avoided oral presentations at work, he began to look forward to them as “a chance to show what I could do.” His chronic fatigue faded, and he began jogging to use up some of his excess energy. In his spare time, he started his own small business to develop and promote some of his engineering innovations.

Noah remained on his medication thereafter. On the two or three occasions when he and his therapist tried to reduce it, he found himself relapsing into his old, depressive frame of mind. He continued to operate his small business as a sideline.

Evaluation of Noah Sanders

For most of his adult life, Noah’s mood symptoms were chronic, rather than acute or recurring. He was never without these symptoms for longer than a few weeks at a time (criterion C for dysthymia), and they were present most of the day, most days (A). They included general pessimism, poor self-image, and chronic tiredness, though only two symptoms are required by criterion B. His indecisiveness encouraged his wife to assume the role of family decision maker, which suggests social impairment (H).

The way he felt was not different from his usual self; in fact, he said it was the way he had always been. (The extended duration is one of two main features that differentiate dysthymia from major depressive disorder. The other is that the required dysthymia symptoms are neither as plentiful nor as severe as for major depression.) Noah had had no manic or psychotic symptoms that might have us considering bipolar or psychotic disorders (E, F).

The differential diagnosis of dysthymia is essentially the same as that for major depressive disorder. Mood disorder due to another medical condition and substance-induced mood disorder must be ruled out (G). The remarkable chronicity and poor self-image invite speculation that Noah’s difficulties might be explained by a personality disorder, such as avoidant or dependent personality disorder. The vignette does not address all the criteria that would be necessary to make those diagnoses. However, an important diagnostic principle holds that the more treatable conditions should be diagnosed (and treated) first.

If, despite relief of the mood disorder, Noah continued to be shy and awkward and to have a negative self-image, only then should we consider a personality diagnosis.

Now to the specifiers (Table 3.3). Though lacking psychotic symptoms, Noah had quite a number of depressive symptoms (including thoughts about death), which would suggest that he was severely ill. His dysthymia symptoms began when he was young (he first noticed them when he was just 18), so we’d say that his onset was early. Noah’s recent symptoms would also qualify for a major depressive episode, which had begun fairly recently and precipitated his evaluation; DSM-5 notes that a dysthymic patient can have symptoms that fulfill criteria for such an episode (D).

We would therefore give him the specifier with intermittent major depressive episodes, with current episode. None of the course specifiers would apply to Noah’s dysthymia, but the following symptoms would meet the criteria for an episode specifier for the major depression—with melancholic features: He no longer reacted positively to pleasurable stimuli (being with his daughters); he described his mood as a definite change from normal; and he reported guilt feelings, early morning awakening, and loss of appetite.

Once treated, Noah seemed to undergo a personality change. His mood lightened and his behavior changed to the point that, by contrast, he seemed almost hypomanic. However, these symptoms don’t rise to the level required for a hypomanic episode; had that been the case, criterion E would exclude the diagnosis of dysthymia. (Also, remember that a hypomanic episode precipitated by treatment that does not extend past the physiological effects of treatment does not count toward a diagnosis of bipolar II disorder.

It should not count against the diagnosis of dysthymia, either.) I thought his GAF score would be about 50 on first evaluation; his GAF would be a robust 90 at follow-up. In the summary, I’d note the possibility of avoidant personality traits.

My full diagnosis for Noah Sanders would be as follows:

F34.1 [300.4]

Persistent mood disorder, severe, early onset, with intermittent major depressive episode, with current episode, with melancholic features (whew!)

Noah Sanders Case Study: Dysthymia