Abstract
Dysthymic disorder is one of those disorders of the psyche that has been under-recognised and, even when recognised, undertreated. That has changed. Its inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM) since 1980 has enabled epidemiological surveys to determine incidence, morbidity and comorbidity. It is common (3% of American adults), has high levels of comorbidity (particularly with Axis I major depression, panic disorder and substance abuse, and Axis II self-defeating, avoidant and borderline personality disorders), and is the cause of years of misery, sustained by low self-esteem, pessimism and feelings of inadequacy. A growing body of clinical studies, summarised in the book, supports, however, the hope that it can respond to time-limited intervention.
A manifest reluctance to investigate treatment of dysthymic disorder had derived from a common perception that dysthymia was a way of life, the expression of a miserable view of the world about which, as with personality disorders, little could be done. Markowitz relates how clinicians, alienated by the self-defeating and pessimistic interpersonal styles of their patients, have found a sense of hopelessness developing within the therapeutic relationship, with a consequent lowering of therapeutic goals. He is at pains throughout to stress the necessity for the clinician to maintain practical optimism for the patient.
To encourage optimism in therapist and patient, Markowitz gives anecdotal and research evidence of successful interventions with patients and sets out a theoretical rationale for interpersonal psychotherapy for dysthymic disorder (IPT-D). He summarises studies of IPT-D, cognitive-behavioural therapy, and admittedly limited accounts of psychodynamic psychotherapy. He describes their limitations and makes suggestions for future research. One recommendation is for use of antidepressant medication followed by IPT-D. Another is for refinement of the DSM diagnostic criteria, with the prediction that they and those for major depressive disorder will converge. The concerns of clinicians for patients who may then slip through the diagnostic net and miss inclusion in clinical trials are not addressed, however. The recommendation contains the uncomfortable elements of a self-fulfilling prophecy.
This book was designed by Markowitz for use in a large-scale comparative study of IPT-D and sertraline in dysthymic disorder at Cornell University Medical College where he is Associate Professor of Psychiatry. He recommends that it be read in conjunction with the original IPT manual, developed in 1984 by his mentors, Gerald Klerman and Myrna Weissman, other colleagues and himself. Certainly, clinicians and researchers would find it difficult to institute or standardise therapy solely from the present manual. What it does well is encourage understanding of individual sufferers through their own words and how the therapist can use them to assist the patient. It also gives a detailed account of the elements of therapy which the author considers to be essential to successful application of IPT-D.
The therapy, with its focus on the present, is based on Sullivan's interpersonal school of psychoanalysis. Intercurrent life events are held to affect mood, which influences social functioning. In dysthymic patients, the tendency to blame themselves for interpersonal difficulties masks the recognition of the adverse effects of depression. Interpersonal psychotherapy for dysthymic disorder provides psychoeducation to reattribute blame from the self to a medical model of depression, therapy for depression and the opportunity to resolve interpersonal issues. The four issues crucial to IPT-D are grief, role dispute, role transition and interpersonal deficits. Specific elements of each are itemised and practical intervention strategies are described. Like the therapy itself, the manual section is organised into three stages, rather unimaginatively designated as the initial, middle and termination phases. Each catalogues its major purposes and techniques. Versions of the Inventory of Interpersonal Problems as aids to formulation and assessment, and standardisation of IPT-D, are given as appendices. There is sufficient detail to enable clinicians unfamiliar with IPT to gain an understanding of its rationale but not to institute it with confidence nor to mount a research trial based on it. This is a book about, not for, therapy for dysthymia.
The author's reliance on the medical model to understand depression and the sickness role to prepare the patient for change is interesting. By differentiating between the person and the depression, patients’ beliefs that their suffering is due to their nature and can't be changed is challenged. Once free of depression, the work of building up under-developed interpersonal skills can begin, establishing an interpersonal style that will maintain a satisfying life free of depression. The stance certainly should assist patients who have lost belief in change. It does, however, promote the view that personality characteristics are resistant to change. It is ironic that this belief that grew initially from the combined failure of the medical and psychoanalytic models to effect positive, rapid change in personality disordered patients has helped forge a society in which the belief in the inability to change personality traits helps perpetuate it. The effectiveness of some time-limited therapies, such as cognitive and behavioural interventions and brief psychodynamic psychotherapies, however, illuminates possibilities for changing our fundamental perceptions of human nature.
A slightly disconcerting aspect of the book is the inconsistent and repetitious voice of the author, probably stemming from the impossibility of satisfying the two main aims of the book simultaneously. One was to provide, for the clinician, an empathic clinical description of dysthymic disorder followed by an experimentally and experientially based formula for effective therapy. The other was to provide, for the sufferer, the hope the author holds essential for recovery. Both aims are laudatory but limit the effectiveness of each when combined in such a slim volume. Even though each aim is only partially achieved, the book will be of value to clinicians and researchers interested in ensuring breadth of understanding of tested therapies. The more sophisticated sufferer of dysthymic disorder would find it sympathetic to them and may assist the process of psycho-education. It will certainly form a solid basis for evaluating the published results of the outcome study for which the book was developed.