Dysthymia: when the greyness became your character

“I’m not depressed. I’m just like that.”

I have heard this sentence in many forms. Sometimes someone says it with a smile, as if describing the colour of their eyes. Sometimes with a weariness that says more than the words. I’m just a pessimist. In our family we’re all on the serious side. I’ve never been someone who looks forward to things. And when I ask how long it has been like this, the answer is almost always the same: “For as long as I can remember.”

That very answer hides a trap. When something has been with us for as long as we can remember, we do not experience it as a condition but as ourselves. It does not occur to us that things could be different, because we have never lived differently. This post is about dysthymia — a form of depression so quiet and so long-lasting that people often mistake it for their character.

Let me say at the outset: dysthymia cannot be identified by an online questionnaire, nor by this post. The diagnosis is made by a psychiatrist or a clinical psychologist. But this post may help you consider, perhaps for the first time, that the greyness you carry might not be your fate.

What dysthymia is

Dysthymia is a long-lasting depressive disorder. Since 2013 the American diagnostic manual DSM-5 has called it persistent depressive disorder, bringing together under that name what used to be dysthymia and chronic major depression. The essence is duration: low mood for most of the day, on more days than not, for at least two years. In children and adolescents the threshold is one year, and in them mood often shows as irritability rather than sadness. During this time the person has not been free of symptoms for more than two months in a row.

Alongside low mood, at least two of the following are present: poor appetite or overeating, insomnia or sleeping too much, low energy, low self-esteem, poor concentration or difficulty making decisions, and a sense of hopelessness.

When I read this list, I am struck again and again by how ordinary it sounds. None of it is dramatic. Nobody lies in bed for weeks. People with dysthymia go to work, look after their children, pay their bills. They just do all of it under a low grey sky that never really clears.

It is not as rare as you might think. In a large American epidemiological study led by Ronald Kessler (2005), around 2.5 per cent of adults had had dysthymia at some point in their lives. And because people so often explain it away as personality, many of them probably never get as far as talking to a doctor.

Why we mistake it for character

With an episode of major depression it is usually clear that something has changed. The person was different before; now they cannot sleep, cannot eat, cannot cope. Those around them notice, and so do they. I wrote about the difference between sadness and depression in Depression is not sadness: how to tell them apart and why it matters.

With dysthymia there is no such clear line. It often starts early — in childhood, in the teenage years or in early adulthood. The DSM therefore has a specific label for early onset, before the age of 21. If the greyness has been with you since you were fifteen, it is almost impossible to tell where the disorder ends and the person begins. Dysthymia weaves itself into your identity: “I’m the one who sees the bad side. I’m the one who doesn’t know how to be happy.”

Something else contributes to this. Each of us is born with a certain temperament — some of us are calmer, others livelier, some more sensitive to anything unpleasant. So the explanation “that’s just my nature” seems plausible. And it is true that not every serious or reserved person is depressed. But the difference lies in whether your “nature” includes constant tiredness, a feeling that you are worthless and hopelessness about the future. That is not temperament. Those are symptoms.

And finally: the people around you get used to it. They say “oh, he’s always like that” and stop asking. So dysthymia lives in a silence that everyone respects, because it has become part of the furniture.

Double depression

People with dysthymia are not protected from worse periods. On the contrary: often, at some point, an episode of major depression settles on top of the constant greyness. In 1982 the psychiatrists Martin Keller and Robert Shapiro named this double depression — an acute episode superimposed on a chronic one.

Double depression is particularly treacherous. When the more severe episode passes — with treatment or on its own — the person does not return to feeling well but to the old greyness. And because that greyness is “normal”, it seems to them that they have recovered. Those around them think so too. Treatment ends, even though half the work remains.

Research by Daniel Klein and colleagues, who followed people with dysthymia over many years, has shown that recurrences are common in chronic forms of depression. That is why it matters not to stop treatment at “it’s not so bad any more”. The goal is not a return to grey but real improvement. You can read more about why a recurrence is not a defeat in When depression comes back: why a recurrence is not a failure.

What it looks like from the inside

People living with dysthymia often do not describe their state as sadness. They describe it differently:

• As a lack of flavour. Things are not terrible, it is just that nothing is really good. A holiday passes like any other day. I wrote more about what it is like when nothing brings joy in Anhedonia: when nothing brings joy any more.
• As constant tiredness. Not the kind that sleep fixes, but tiredness of life itself.
• As a quiet inner critic. A voice that says “that’s nothing” after every success and “I knew it” after every mistake.
• As low expectations. You do not dare to want much, because it seems it will not work out anyway.
• As a sense that everyone else knows something you do not — how to live lightly.

Many function very well with it. They are reliable, hard-working, responsible. And that is exactly why nobody asks how they are. I wrote about how depression stays hidden behind successful functioning in High-functioning depression: when everything works outside and it is empty inside.

Where it comes from

Dysthymia has no single cause. Research speaks of an interweaving of inherited tendencies, temperament and experience. Among experiences, early adversity stands out. A 2012 meta-analysis by Valentina Nanni, Rudolf Uher and Andrea Danese showed that maltreatment in childhood is linked to a more persistent and recurrent course of depression and to a poorer response to treatment.

But childhood does not have to have been dramatic. Sometimes it is enough to have grown up in a family where feelings were unwelcome, joy was suspect, or one of the parents was themselves low for a long time. A child learns that hoping does not pay, because hope does not pay off. This is close to what psychology calls learned helplessness.

In relational family therapy, in which I am training, we understand such patterns as something that was once learned in a relationship — and that can therefore also begin to change in a relationship. Greyness is often not just a mood but also a way of protecting yourself from disappointment. What matters, though, is this: it is not about finding someone to blame. Parents often gave what they had. Understanding the origin is not an accusation but a map.

Who makes the diagnosis

Dysthymia is identified by a psychiatrist or a clinical psychologist, not by a psychotherapist and not by an online test. Physical causes also need to be ruled out — thyroid problems, anaemia, the effects of medication and so on — so a good first step is a conversation with your GP. I explained who in Slovenia may make a diagnosis and who may prescribe medication in Who may diagnose, who may prescribe, and who leads the process.

When talking to the doctor, it often helps people to say how long things have been like this. Many mention only the last few weeks, because before that it seemed “normal”. But it is precisely the long duration that the doctor needs to hear.

This is how a conversation might go when someone says it for the first time (composite example, not a real person):

“How long have you been feeling like this?”
“It’s been worse these last few months. But really … I don’t know. I think I’ve always been like this.”
“Can you remember a time when it was different? When you looked forward to things?”
“Maybe in primary school. Not after that. I thought that was just being an adult.”
“What you’re describing is important information. Let’s talk about it in more detail.”

Treatment

The good news is that dysthymia can be treated. The less good news is that treatment often takes longer than for a short episode and calls for patience — partly because something that has been with us for a long time needs to change.

Psychotherapy helps. A 2010 meta-analysis by Pim Cuijpers and colleagues showed that psychotherapy is effective for chronic depression and dysthymia, although the effect was somewhat smaller than with medication; a combination of the two proved best. For chronic depression the American psychologist James McCullough developed a specific form of therapy called CBASP, which focuses precisely on how a person has learned that their actions have no effect on others. You can read about which forms of psychotherapy have the most support in depression in Which psychotherapy helps with depression.

Medication can help. Decisions about antidepressants are made by a psychiatrist or doctor. With chronic forms of depression it often takes longer for the effect to show, and a conversation about how long to take the medication is needed.

A combination works best. In a large study published in 2000 by Martin Keller and colleagues, the combination of medication and psychotherapy proved more effective in people with chronic depression than either approach alone.

Exercise: separating yourself from the greyness

This exercise does not replace treatment. But it can help you create a first small gap between who you are and what dysthymia says about you.

1. Write down three sentences that begin with “I’m just …”. For example: “I’m just a pessimist”, “I just don’t know how to be happy”, “I’m just always tired”.
2. Rewrite each sentence so that it begins with “The greyness tells me that …”. “The greyness tells me that I don’t know how to be happy.” Notice whether anything shifts.
3. For each sentence, find one exception. One moment, however small, when it was not entirely so: an afternoon when you laughed, a conversation that woke you up.
4. Ask yourself: when did I first hear or feel this? Do not look for someone to blame. Just notice whether the sentence has a history.
5. Choose one sentence and take it to your doctor or therapist. A sentence written down is often easier to say than starting from nothing.

If the exercise brings up more sadness than you expected, that is understandable. When you first consider that things could be different, there may also be grief for the years that passed under the greyness. That grief, too, belongs in a conversation with a professional.

Where this does not apply

When I write about dysthymia, I worry that someone might read every kind of seriousness as an illness. So here are a few limits.

Not every reserved or serious person is depressed. People are different. Someone may be introverted, prefer observing to joining in, not show enthusiasm out loud — and be entirely content. The difference is not in how cheerful you seem from the outside but in whether you are suffering: whether tiredness, hopelessness and a sense of worthlessness go with you.

Not every long-lasting low mood comes from within. Someone who has spent two years living in poverty, with a violent partner, alongside a seriously ill family member or in an unbearable job often has very understandable reasons for the greyness. Then treating the mood is not enough; the circumstances need to change too, as far as possible. If you are living with violence, in Slovenia you can call the SOS helpline for women and children victims of violence on 080 11 55 or the police on 113.

Dysthymia is no less serious for being quieter. Precisely because it lasts so long, it can shape the whole course of a life — the choice of career, of partner, what a person even dares to want. If you recognise yourself as you read, do not reassure yourself that “it’s not that bad”.

And if, amid the greyness, there are ever thoughts that it would be better if you were not here, in Slovenia call the crisis line Klic v duševni stiski on 01 520 99 00 (7 pm to 7 am) or the Samaritans helpline on 116 123 (24 hours), and in an emergency 112.

What to remember

• Dysthymia (persistent depressive disorder) is low mood on most days that lasts at least two years.
• Because it often starts early, people mistake it for their character — “I’m just like that”.
• Double depression is an episode of major depression on top of dysthymia; afterwards the aim is to return to wellbeing, not just to the old greyness.
• The diagnosis is made by a psychiatrist or clinical psychologist; your GP can be the first step.
• Dysthymia can be treated — with psychotherapy, medication or a combination of both, which has proved most effective in research.