CHAPTER 13: Premenstrual Dysphoric Disorder

Introduction Menstrual cycle is a unique aspect of women’s health. Mood fluctuations across the menstrual cycle provide an example of how biological differences between men and women may have impacted social trajectories.

Introduction The negative impacts of premenstrual mood disturbance on quality of life, daily function, and economic burden have been well established.

Diagnosis of PMDD PMS includes mild psychological and/or physical discomfort in the premenstrual period, but does not markedly impair a woman’s ability to function in her daily life. – 80% of women report some form of PMS.

Diagnosis of PMDD PMDD is a more severe form of premenstrual disturbance that specifically requires the presence of at least one psychiatric symptom and must be associated with a marked disturbance in function (i.e., social, occupational, academic performance).

DSM-IV-TR Criterion A for PMDD In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week postmenses, with at least one of the symptoms being either (1), (2), (3), or (4): (1) markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts (2) marked anxiety, tension, feelings of being “keyed up,” or “on edge” (3) marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection) (4) persistent and marked anger or irritability or increased interpersonal conflicts (5) decreased interest in usual activities (e.g., work, school, friends, hobbies) (6) subjective sense of difficulty in concentrating (7) lethargy, easy fatigability, or marked lack of energy (8) marked change in appetite, overeating, or specific food cravings (9) hypersomnia or insomnia (10) a subjective sense of being overwhelmed or out of control (11) other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” weight gain

Physical Disorders as Differential Diagnoses Some physical disorders can be accompanied by premenstrual exacerbation of somatic and psychological symptoms. – Autoimmune disorders – Diabetes mellitus – Anemia – Hypothyroidism – Epilepsy – Migraine

Psychiatric Disorders as Differential Diagnoses Women who report premenstrual mood disturbance should be screened for psychiatric symptoms across the menstrual cycle. – Major depressive disorder – Dysthymic disorder – Anxiety disorders – Bipolar disorder – Various personality disorders

Prospective Symptom Assessment and Rating Scales There is concern that bias of retrospective ratings may result in overdiagnosis of PMDD. Retrospective reports may be influenced by phase of cycle during which reports are made. Visual analog or Likert rating scales are often used.

Prevalence and Demographic Correlates Population prevalence estimates are difficult to obtain. PMDD risk is increased for women with family history of the disorder and personal history of depression. Day-to-day life stress and history of traumatic life experiences are associated with PMDD.

Impact of PMDD Women report impairments in two main areas of psychosocial function: – Interpersonal relationships – Work productivity and absenteeism

Potential Etiologic Factors Biological Factors – Heritability – Hormones – Neurotransmitters

Potential Etiologic Factors Psychosocial Factors – Sociocultural factors – Potential impact of life stress and sexual abuse

Management of PMDD Psychoeducation Healthy lifestyle and dietary supplementation Relaxation skills and structured psychotherapies Herbal, complementary, and other treatments Pharmacotherapy Manipulation of menstruation

Future Directions More work is needed to understand the etiology of premenstrual mood disturbance and to optimize treatment. One significant question that remains unanswered: – Why SSRI/SNRI medications work to alleviate symptoms of premenstrual dysphoria when used cyclically in the luteal phase of the menstrual cycle