East Asian Arch Psychiatry 2014;24:174-7 Commentary Premenstrual Dysphoric Disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: Contributions from Asia DSM-5診斷的經前煩燥症：亞洲研究現況 N Mehta, S Mehta Abstract Premenstrual dysphoric disorder has been included as a separate diagnostic entity in the chapter of ‘Depressive Disorders’ of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM- 5). The antecedent, concurrent, and predictive diagnostic validators of premenstrual dysphoric disorder have been reviewed by a sub-workgroup of the DSM-5 Mood Disorders Work Group, which includes a panel of experts on women’s mental health. Contributions from the Asian continent have been mainly in the form of prevalence studies. Genetic and neurobiological domains of premenstrual dysphoric disorder largely remain untouched in Asia and offer a potential area for investigation. Key words: Asia; Diagnostic and Statistical Manual of Mental Disorders; Premenstrual syndrome 摘要 經前煩躁症已被精神疾病診斷及統計手冊第五版（DSM-5）列為屬抑鬱症的單獨診斷實體，而 DSM-5情緒障礙工作小組旗下的女性心理健康專家子工作組也根據前期、現行和預測驗證因子 為此症作審查。有關此症的亞洲文獻以現患率研究為主，而涉及基因和神經生物學這些值得研 究的領域則很少。 關鍵詞：亞洲、精神疾病診斷及統計手冊、經前綜合徵 Dr Nidhi Mehta, DGO, Department of Obstetrics and Gynaecology, Bangalore symptoms must be present in the final week before Medical College and Research Institute, Bengaluru, Karnataka 560002, India. Dr Shubham Mehta, MD, Department of Psychiatry, SMS Medical College, the onset of menses, start to improve within a few Jaipur, Rajasthan 302004, India. days after the onset of menses, and become minimal or absent in the week post-menses. Address for correspondence: Dr Shubham Mehta, Room No. 9, N. M. H. P. Trainees Hostel, Psychiatric Centre Campus, Sethi Colony, Jaipur, Rajasthan (B) One (or more) of the following symptoms must be 302004, India. present: Tel: (91) 9799723735; email: [email protected] • Marked affective lability (eg mood swings, feeling Submitted: 20 November 2013; Accepted: 27 January 2014 suddenly sad or tearful, or increased sensitivity to rejection). • Marked irritability or anger or increased interpersonal conflicts. Introduction • Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts. Among all the changes and new inclusions made in the • Marked anxiety, tension, and / or feelings of being Diagnostic and Statistical Manual of Mental Disorders, 5th keyed up or on the edge. edition (DSM-5),1 one significant change has been moving (C) One (or more) of the following symptoms must be the premenstrual dysphoric disorder (PMDD) from the additionally present, to reach a total of 5 symptoms DSM-IV Appendix-B, “Criteria Sets and Axes Provided when combined with symptoms from criterion B for Further Study”2 to the main body of DSM-5. This entity above: now has its own 7 diagnostic criteria as described below1: • Decreased interest in usual activities (eg work, (A) In the majority of menstrual cycles, at least 5 school, friends, and hobbies). 174 © 2014 Hong Kong College of Psychiatrists Premenstrual Dysphoric Disorder • Subjective difficulty in concentration. different measures used by various researchers to assess • Lethargy, easy fatigability, or marked lack of its symptomatology. In a study of 136 patients attending a energy. specialised mental health clinic in gynaecology settings in • Marked change in appetite, overeating, or specific Taiwan, the incidence of DSM-IV PMDD criteria was noted food cravings. to be as high as 16.3%.6 • Hypersomnia or insomnia. The same study6 also examined the individual • A sense of being overwhelmed or out of control. characteristics of women with PMDD. It was found that • Physical symptoms such as breast tenderness 86% of the women had another concurrent psychiatric or swelling, joint or muscle pain, sensation of disorder. In another study that examined the personality of “bloating,” or weight gain (the symptoms in Criteria 142 patients, the investigators found a significant overlap A to C must have been met for most menstrual in overall personality profiles of women with PMDD and cycles that occurred in the preceding year). major depressive disorder (MDD).7 Impulsiveness subscore (D) The symptoms are associated with clinically was significantly higher in women with PMDD versus those significant distress or interference with work, school, with MDD. usual social activities, or relationships with others (eg The possible relationship between environmental avoidance of social activities; decreased productivity factors such as stress and seasonal changes and the onset and efficiency at work, school, or home). or expression of PMDD symptoms, as well as the role of (E) The disturbance is not merely an exacerbation of interpersonal trauma has been investigated in the West8 but the symptoms of another disorder, such as major not in the Asian continent. Also, there is a lack of family depressive disorder, panic disorder, persistent studies from Asia highlighting the role of genetics in the depressive disorder (dysthymia), or a personality aetiogenesis of PMDD as against a longitudinal population- disorder (although it may co-occur with any of these based twin study from the West9 which reported the disorders). heritability of premenstrual symptoms. (F) Criterion A should be confirmed by prospective daily ratings during at least 2 symptomatic cycles. Concurrent Validators (G) The symptoms are not attributable to the physiological Concurrent or biological validators include effects of a substance (eg a drug of abuse, a medication, neuropsychological, neurophysiological, and neuroimaging other treatment) or another medical condition (eg factors. The Asian literature has examined the physiological hyperthyroidism). differences present in PMDD relative to controls. One This move is significant as it reflects international study examined serotonergic functioning in 24 Japanese concerns about betterment of women’s mental health. women who had PMDD, premenstrual symptoms (PMS) or The special panel of experts on women’s mental were healthy (controls), and found significant differences health created by the Mood Disorders Work Group for across these 3 groups as measured by adrenocorticotropic DSM-5 found robust evidence regarding the distinctiveness hormone and cortisol responses to paroxetine challenge.10 of PMDD. The reproductive mood disorder specialists have Subjects with PMDD showed higher serotonergic function thoroughly analysed the diagnostic validators of PMDD in the follicular phase but lower serotonergic function from the literature and recommended PMDD to reside in the luteal phase compared with women in the other 2 as a diagnosis in a newly created chapter of ‘Depressive groups. Matsumoto et al11 examined autonomic function, Disorders’ in DSM-5. as measured by heart-rate variability (HRV) in Japanese We view this move with interest and try to generate a women diagnosed with PMDD or PMS or who were healthy gestalt of research findings regarding PMDD from the Asian (controls). They found that women in the PMDD group had continent. To consider any disorder as a valid diagnostic the greatest decrease in HRV among the 3 groups. entity, it must have separate antecedent, concurrent / Studies from the West12-14 have suggested that biological, and predictive diagnostic validators.3 While we symptom severity in PMDD is correlated with levels scrolled through the literature, we found that there have of oestradiol, progesterone, or neurosteroids such as been quite a few contributions from Asia when analysed in allopregnanolone and pregnenolone sulfate. However, terms of diagnostic validators of PMDD. With the help of we could not find any neuroimaging studies pertaining this article, we intend to provide a gist of these contributions to PMDD, or studies assessing the neuropsychological as this would help in identifying the strengths and lacunas correlates of PMDD in the Asian population. However, even in the Asian literature on PMDD, thus, providing a probable in the West, such studies remain in a stage of infancy and direction for further research in this area. only a few studies have reported specific central nervous system differences in neural network activation, glucose Antecedent Validators metabolism, and neurotransmitter concentration between These include demographic factors, pre-morbid personality women with PMDD and healthy comparison subjects, based traits, family studies, and environmental risk factors or on findings of functional magnetic resonance imaging,15 precipitating factors. The prevalence of PMDD in Asian positron emission tomography,16 and proton magnetic studies ranged from 1.2%4 to 6.4%,5 keeping in mind the resonance spectroscopy,17 respectively. East Asian Arch Psychiatry 2014, Vol 24, No.4 175 N Mehta, S Mehta Predictive Validators Declaration These include course and outcome of disorder and the response to treatment. Assessment of stability of symptom The authors declared no conflict of interest in this study. pattern prospectively, from cycle to cycle, would serve as a guide to establish diagnostic stability and also the course References of PMDD. Furthermore, longitudinal studies are imperative 1. American Psychiatric Association. Diagnostic and Statistical Manual to determine the outcome of PMDD and its response to of Mental Disorders, 5th edition. Washington, DC: American treatment. Psychiatric Association; 2013. 2. American Psychiatric Association. Diagnostic and Statistical Manual There have been some follow-up studies assessing 18 of Mental Disorders, 4th edition. Washington,