We used to call it dysthymic disorder. Now with DSM-5, it's persistent depressive disorder,

but the patients are their same. And today, Ellen Francis shares his top tips on working with them.

Welcome to the Carlet Psychiatry Podcast, keeping psychiatry honest since 2003.

I'm Chris Aiken, the editor-in-chief of the Carlatte Psychiatry Report.

And I'm Kelly Newsom, psychiatric MP and a dedicated reader of every issue.

When we started this interview with Alan Francis, he talked about how structured behavioral

techniques are very effective for simple,

limited problems like primary insomnia, panic disorder, and phobias. But for many patients,

life's not so simple. They have multiple comorbidities or longstanding psychiatric problems

that strip away at their relationships, their physical health, and their identity.

All that reminded me of working with chronic depression. These are the patients who say they

don't know what normal is. You ask them how long they've been depressed, and they'll say,

my whole life. For them, depression is not what they do. It's who they are, it's how they relate to people,

and all this makes it difficult to parse it off as some kind of treatable, separate entity.

Change is more difficult here because these patients don't have a healthy baseline to draw from.

It's harder for them to engage in like the rational thinking

that CBT depends on.

The DSM used to call this dysthymic disorder, which is a long-standing, low-grade

depressive temperament. But two things change that. First, we learned that nearly everyone,

90%, with a dysthymic temperament went on to have full

episodes of depression so-called double depression so it made little sense to parse it off as a

separate disorder when it so often gets intermingled with full depression and with a lot of other

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