Premenstrual dysphoric disorder: How to alleviate her suffering Accurate diagnosis, tailored treatments can greatly improve women’s quality of life pproximately 75% of women experience a premen- strual change in emotional or physical symptoms Acommonly referred to as premenstrual syndrome (PMS). These symptoms—including increased irritability, tension, depressed mood, and somatic complaints such as breast tenderness and bloating—often are mild to moder- ate and cause minimal distress.1 However, approximately 3% to 9% of women experience moderate to severe premen- strual mood symptoms that meet criteria for premenstrual dysphoric disorder (PMDD).2 PMDD includes depressed or labile mood, anxiety, irri- tability, anger, insomnia, difficulty concentrating, and other © IMAGES.COM/CORBIS symptoms that occur exclusively during the 2 weeks before menses and cause significant deterioration in daily func- Laura Wakil, MD tioning. Women with PMDD use general and mental health Third-Year Psychiatry Resident services more often than women without the condition.3 Samantha Meltzer-Brody, MD, MPH They may experience impairment in marital and parental Director, Perinatal Psychiatry Program relationships as severe as that experienced by women with University of North Carolina Center for Women’s 2 Mood Disorders recurrent or chronic major depression. PMDD often responds to treatment. Unfortunately, Susan Girdler, PhD Director, UNC Stress and Health Research Program many women with PMDD do not seek treatment, and up Menstrually Related Mood Disorders Program to 90% may go undiagnosed.4 In this article, we review the University of North Carolina Center for Women’s prevalence, etiology, diagnosis, and treatment of PMDD. Mood Disorders • • • • Department of Psychiatry A complex disorder University of North Carolina at Chapel Hill A distinguishing characteristic of PMDD is the timing of Chapel Hill, NC symptom onset. In women with PMDD, mood symptoms oc- cur only during the luteal phase of the menstrual cycle (ovu- lation until onset of menses) and resolve after menstruation Current Psychiatry 22 April 2012 onset. Women with PMDD report normal mood and function- Table DSM-IV-TR research criteria for PMDD A. In most menstrual cycles of the past year, ≥5 of the following symptoms must be present for most of the time during the last week of the luteal phase, begin to remit within a few days after the onset of the follicular phase, and are absent in the week postmenses, with ≥1 of the symptoms being either 1, 2, 3, or 4: 1. Markedly depressed mood, feelings of hopeless, or self-deprecating thoughts 2. Marked anxiety, tension, feelings of being “keyed up” or “on edge” 3. Marked affectivity lability 4. Persistent and marked anger or irritability or increased interpersonal conflicts 5. Decreased interest in usual activities 6. Subjective sense of difficulty concentrating 7. Lethargy, easy fatigability, or marked lack of energy 8. Marked changes in appetite, overeating, or specific food cravings 9. Hypersomnia or insomnia 10. A subjective sense of being overwhelmed or out of control Clinical Point 11. Physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” weight gain PMS and PMDD B. The disturbance markedly interferes with work or school or with usual social activities and share symptoms, relationships with others (eg, avoidance of social activities, decreased productivity and efficiency at work or school) but more symptoms C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major are required for a depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although it may be superimposed on any of these disorders) PMDD diagnosis, and D. Criteria A, B, and C must be confirmed by prospective daily ratings during ≥2 consecutive symptoms often are symptomatic cycles (The diagnosis may be made provisionally prior to this confirmation) more severe Source: Reference 6 ing during the follicular phase of the men- which represents a significant change from strual cycle (first day of the menstrual cycle DSM-IV-TR, where it is listed in the appen- until ovulation). dix as “research criteria.”8 In addition, in Although PMS and PMDD criteria share oral contraceptive users, a PMDD diagnosis affective and somatic symptoms, more should not be made unless the premenstrual symptoms are required for a PMDD diag- symptoms are reported to be present and as nosis, and symptoms often are more severe.5 severe when the woman is not taking the As defined in DSM-IV-TR (Table),6 PMDD oral contraceptive.8 has a broader range of symptoms than PMS and includes symptoms not included Comorbidity with other axis I disorders in the American College of Obstetrics and such as major depressive disorder (MDD), Gynecology criteria for PMS,7 such as im- bipolar disorder (BD), and anxiety disorders paired concentration, appetite, and sleep is high.9-11 Women with an MDD history (hypersomnia or insomnia); and mood labil- have the highest correlation with PMDD,9 ity. PMDD symptoms must occur only dur- and worsening premenstrual mood symp- ing the 2 weeks preceding menses, although toms are more common in women with Discuss this article at 12 11 on average symptoms last 6 days and sever- BD. Payne et al found that premenstrual www.facebook.com/ ity usually peaks in the 2 days before men- symptoms were reported by twice as many CurrentPsychiatry ses.1 The prevalence of subthreshold PMDD women diagnosed with mood disorders is fairly common; approximately 19% of (68%) than women without a psychiatric women will meet some—but not all—DSM- diagnosis (34%). Moreover, 38% to 46% of IV-TR criteria for PMDD.3 women with PMDD have comorbid season- In a revision proposed for DSM-5, PMDD al affective disorder, and 11% to 38% report Current Psychiatry would be included as a mood disorder, a comorbid anxiety disorder.12 Women with Vol. 11, No. 4 23 Box 1 • greater resting and stress-induced heart rates and systolic blood pressure PMS or PMDD? Charting compared with non-abused PMDD wom- symptoms over menstrual cycles en, an effect that is eliminated by clonidine 18 o distinguish premenstrual syndrome (an α-2 adrenergic receptor agonist). T(PMS) from premenstrual dysphoric One study showed that PMDD wom- disorder (PMDD), premenstrual exacerbation en with abuse histories had higher blood of an underlying psychiatric disorder, general Premenstrual medical conditions, or other disorders with pressure measurements at rest and during dysphoric disorder no association to the menstrual cycle, it is stress and exhibited greater vascular tone necessary to have patients conduct daily than non-abused women; these effects symptom charting over 2 menstrual cycles. This charting should include documentation of were not seen in non-PMDD women with emotional, behavioral, and physical symptoms. similar abuse histories.14 This body of evi- PMDD can be differentiated from PMS by the dence is consistent with the concept that severity and number of symptoms. In PMDD, 1 PMDD is a stress-related disorder,19 and of the symptoms must be a mood disturbance (depressed, anxious, labile, and/or irritable). that a history of abuse is prevalent and For a sample form used for PMDD charting, may identify a clinically distinct subgroup Clinical Point the Daily Record of Severity of Problems, of PMDD women with respect to thyroid see http://pmdd.factsforhealth.org/drsp/ To help distinguish drsp_month.pdf. axis and adrenergic physiology. Screening PMDD patients for abuse histories may PMDD from PMS, help manage the disorder. patients need to For a discussion of the etiology of PMDD, keep a daily diary PMDD and a history of MDD have lower see this article at CurrentPsychiatry.com. of symptoms for ≥2 cortisol concentrations than non-PMDD women.10 Although interventions for PMDD months and a comorbid axis I disorder may be simi- Mood charting aids diagnosis lar, it is important to consider both when A PMDD diagnosis requires prospec- planning treatment. tive daily monitoring of symptoms for ≥2 consecutive months. Because only 25% to Abuse, trauma, and PMDD. An associa- 35% of women who present with PMDD tion between PMS/PMDD and a history of meet diagnostic criteria when prospective sexual and physical abuse is well-document- daily monitoring is used,20 it is important ed.13 Studies have reported abuse histories for patients to keep a daily diary of PMDD among almost 60% of women with PMDD,14 symptoms to distinguish the disorder from although studies comparing abuse and PMS (Box 1). The Prospective Record of trauma in PMDD vs non-PMDD women the Impact and Severity of Premenstrual have been small. A recent study found that Symptoms calendar and the Daily Record trauma and posttraumatic stress disorder are of Severity of Problems (DRSPP)21 may independently associated with PMDD and help make the diagnosis. premenstrual symptoms.15 The widely used DRSPP allows clinicians Evidence suggests that a history of to quantify the severity of physical, emotion- abuse is associated with specific biological al, and behavioral symptoms and may be sequelae in PMDD women, particularly the easiest to use in clinical practice because See this article at with respect to hypothalamic-pituitary- it creates a graphic representation of cyclical CurrentPsychiatry.com thyroid axis measures and noradrenergic symptom changes. The DRSPP includes all 16-18 21 for a discussion of the activity. Women with PMDD and a his- PMDD symptoms and severity ratings and etiology of PMDD tory of sexual abuse show: is recognized as a valid instrument for diag- • markedly elevated triiodothyronine nosing PMDD. Another option is a revised (T3) concentrations (the more biologically visual analogue scale. Lastly, a new revised potent thyroid hormone) that appear to re- Premenstrual Tension Syndrome (PMTS) sult from increased conversion of thyrox- rating scale, which combines the PMTS ine (T4) to T316 Observer rating scale plus multiple visual • lower circulating plasma norepineph- analogue scales, shows promise as a tool to Current Psychiatry 24 April 2012 rine concentrations17 assess PMDD symptoms.