eMedicine Specialties > Psychiatry > Psychosomatic

Premenstrual Dysphoric Disorder

Author: Thwe T Htay, MD, Assistant Professor, Department of Medicine, University of Texas Health Science Center at San Antonio
Coauthor(s): KoKo Aung, MD, MPH, FACP, Associate Professor, Department of Medicine, University of Texas Health Science Center; Adjunct Assistant Professor of Public Health, University of Texas School of Public Health; John Carrick, MD, Consulting Staff, Department of Psychiatry, Flagstaff Medical Center; Romeo Papica II, MD, Research Associate, Department of Internal Medicine, Texas Tech University Health Sciences Center
Contributor Information and Disclosures

Updated: Sep 29, 2009

Introduction

Background

Premenstrual dysphoric disorder (PMDD) is a diagnosis used to indicate serious premenstrual distress with associated deterioration in functioning. PMDD is characterized by depressed or labile mood, anxiety, irritability, anger, and other symptoms occurring exclusively during the 2 weeks preceding menses. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the symptoms must be severe enough to interfere with occupational and social functioning, as opposed to the more common premenstrual syndrome (PMS). PMDD is a severely distressing and disabling condition that requires treatment.

Clinically significant premenstrual problems with mood and behavior have been recognized since ancient times.1 Hippocrates described a group of conditions that occurred prior to the onset of menses, in which women might develop suicidal ideation and other severe symptoms. In 1931, Frank described 15 women experiencing severe premenstrual symptoms and coined the term premenstrual tension syndrome.2 Although Frank first described PMS 70 years ago, PMDD is a relatively new concept.

In 1987, the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) included criteria for late luteal phase dysphoric disorder (LLPDD).3 In the DSM-IV, published by the American Psychiatric Association, the name was changed from LLPDD to PMDD, with criteria that were almost identical to those of LLPDD (only 1 item was added). The DSM-IV included PMDD as an example of a depressive disorder not otherwise specified. In October 1998, a panel of experts evaluated the evidence then available, and a consensus was reached that PMDD was a distinct clinical entity. Subsequently, in November 1999, the US Food and Drug Administration (FDA) Neuropharmacology Advisory Committee supported this concept. Several treatment options for PMDD have been investigated and developed in the past few years.

Clinical study

 Ms. A is a 25-year-old single woman living by herself. She comes to a family practitioner's office seeking help for feeling down and irritable before menses.

Ms. A experienced menarche at age 13 years and is gravida 0, para 0, abortas 0. She reports irritability, feeling depressed, feeling on edge and having mood swings approximately a week preceding menses. She says, "It seems like I have been like this for as long as I can remember." The symptoms begin to resolve within a few days after the onset of her menses. Symptoms are normally absent in the week after menses. She graduated from college a few years ago and began working as an elementary school teacher in local independent school district. At times, her symptoms are accompanied by marked anxiety, tension, and anger to the point that she experiences increased interpersonal conflicts at work. She is so overwhelmed that she has to take a few days off from school days before menses. She decides to seek medical help since her symptoms are severely distressing and debilitating and she runs out of her allowable sick days at work.

Pathophysiology

Major theories to explain the pathophysiology of PMDD are the (1) ovarian hormone hypothesis, (2) serotonin hypothesis, (3) psychosocial hypothesis, (4) cognitive and social learning theory, and (5) sociocultural theory.4

The ovarian hormone theory hypothesizes that PMDD is caused by an imbalance in the ratio of estrogen to progesterone, with a relative deficiency in progesterone. Based on this theory, Dalton treated her PMS patients with progesterone suppositories in the 1960s. However, recent studies of the level of estrogen and progesterone among women with PMS were inconclusive because of methodological difficulties. The current consensus seems to be that the normal fluctuations in gonadal hormones trigger central biochemical events related to PMDD symptomatology in some predisposed women.

The serotonin theory hypothesizes that normal ovarian hormone function (rather than hormone imbalance) is the cyclical trigger for PMDD-related biochemical events within the central nervous system and other target tissues.5 PMDD shares many of the phenomenologic features of depression and anxiety states that have been linked to serotonergic dysregulation. Increasing evidence suggests that 5-hydroxytryptamine also may be important in the etiology of PMDD. Decreased serotonergic activity in women with PMDD has also been implied by the observation of reduced platelet uptake of serotonin and serotonin levels in peripheral blood. The sensitivity to perturbations of the central serotonin system in women with PMDD is altered premenstrually. The administration of the serotonin agonist m -chlorophenylpiperazine may induce mood elevation.6 Agents that transiently diminish serotonin activity have been associated with behavioral changes, including irritability and social withdrawal.

The psychosocial theory hypothesizes that PMDD or PMS is a conscious manifestation of a woman's unconscious conflict about femininity and motherhood. Psychoanalysts proposed that premenstrual physical changes reminded the woman that she was not pregnant and, therefore, was not fulfilling her traditional feminine role. Obviously, proving this theory through scientific evidence is quite difficult.

The cognitive and social learning theory hypothesizes that the onset of menses is an aversive psychological event for women susceptible to PMDD. Moreover, these women might have had negative and extreme thoughts that further reinforce the aversiveness of premenstrual symptoms. They then develop maladaptive coping strategies, such as lability of mood, absence from school or work, and overeating in an attempt to reduce the immediate stress. The immediate reduction of stress acts as a reinforcement, leading to the regular recurrence of symptoms during the premenstrual period.

The sociocultural theory hypothesizes that PMDD is a manifestation of the conflict between the societal expectation of the dual role of women as both productive workers and child-rearing mothers. PMDD is postulated to be a cultural expression of women's discontent with the traditional role of women in the society.

Among the theories described above, the serotonin theory is increasingly popular. Although genetic predisposition and societal expectations may play a role, the strongest scientific data implicate serotonin as the primary neurotransmitter whose levels are affected by ovarian steroid levels. Other neurotransmitter systems that have been implicated include the opioid, adrenergic, and GABA systems.7

Frequency

United States

Epidemiological studies indicate that as many as 80% of women experience emotional, behavioral, or physical premenstrual symptoms.8 From 3-8% of women meet the diagnostic criteria for PMDD.

International

PMDD affects 3-8% of women9 in their reproductive years worldwide, imposing an enormous burden on women, their families, and the health care system. A recent study from India reported a similar frequency.10

Mortality/Morbidity

PMDD is a multifactorial syndrome that affects 3-8% of women in their reproductive years and has varying degrees of severity that interfere with work, social activities, or interpersonal relationships.

Race

Although premenstrual clinics are reported to be almost exclusively attended by white women, community-based studies found no difference in the prevalence or severity of premenstrual symptoms between black women and white women. Some isolated reports indicate varying individual symptoms but not the overall prevalence of premenstrual symptoms among different racial groups. Black women tend to have a higher prevalence of food cravings than white women.11 White women are more likely than black women to report premenstrual mood changes12 and weight gain. Pain featured most highly in a sample of Chinese women in Hong Kong.13

Age

Apparently, women in the late third to middle fourth decades of life are most vulnerable to experiencing PMDD.

Clinical

History

The most common primary symptom in PMDD is irritability. The common symptoms of breast pain and bloating differ from those of women with a major depressive disorder.

The PMDD criteria of the DSM-IV-TR require the presence of 5 of 11 symptoms to make the diagnosis of PMDD. At least 1 of the first 4 symptoms must occur during the last week of the luteal phase, begin to remit within a few days of the onset of menstrual flow, and be absent in the week after menses. The symptoms must be severe enough to interfere with social, occupational, sexual, or scholastic functioning. Symptoms must be discretely related to the menstrual cycle and must not merely be a worsening of preexisting depression, anxiety, or personality disorder.14 All of the above criteria must be confirmed prospectively by daily ratings of at least 2 consecutive menstrual cycles. The diagnosis may be made provisionally before this confirmation.

Of the symptoms listed in the DSM-IV-TR, 10 of 11 are emotional and behavioral in nature. Only one includes multiple common physical symptoms. As such, PMDD defines a narrow group of women with the most severe premenstrual emotional symptoms, with functional impairment, and without a concurrent Axis I or Axis II disorder that is exacerbated premenstrually. Women who meet the PMDD criteria are coded on Axis I as depressive disorder not otherwise specified. Obviously, this criterion excludes many women presenting with predominantly physical premenstrual symptoms and women with premenstrual exacerbation of underlying Axis I or II disorders. Interestingly, DSM-IV-TR criteria state that PMDD may be superimposed on Axis I or II disorders. However, how to differentiate between exacerbation of and superimposition on symptoms of an Axis I or II disorder is unclear. DSM-IV-TR criteria for diagnosis of PMDD are as follows:

Research criteria for premenstrual dysphoric disorder15

A. In most menstrual cycles during the past year, at least 5 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 1 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 (eg, 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 (eg, 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, or weight gain

B. The disturbance markedly interferes with work or school or with usual social activities and relationships with others (eg, avoidance of social activities, decreased productivity and efficiency at work or school).

C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although it may be superimposed on any of these disorders).

D. Criteria A, B, and C must be confirmed by prospective daily ratings during at least 2 consecutive symptomatic cycles. (The diagnosis may be made provisionally prior to this confirmation.)


Since depression is one of the common symptoms of PMDD, suicide may be possible in women with PMDD. A case-control study16 of fertile females with regular menstrual cycles who have attempted suicide (and using blood donors as controls) showed that attempts during the luteal phase were not more frequent in females with PMDD than in those without PMDD. There was, however, a significantly higher frequency of PMDD in those who attempted suicide than in the controls. This suggests that PMDD may not be associated with suicidal acts during the luteal phase, when premenstrual symptoms are present.

Several scoring systems are available for symptom quantification. A recent suggestion is that a within-cycle increase from follicular to luteal phase score (demonstrating "on-offness") of at least 50% is necessary to confirm the diagnosis of PMDD and to merit psychopharmacologic intervention. The within-cycle percentage change is calculated by subtracting the follicular score from the luteal score, divided by the luteal score, and multiplied by 100.

(luteal - follicular / luteal) X 100

More than 60 instruments have been used for symptom recording. Visual analog scales have been used in some studies. The scoring of symptoms on a Likert scale from anchor points of "not present" to "severe" is also commonly used. A 24-item form called the Daily Record of Severity of Problems incorporates all DSM-IV symptoms of PMDD. As one may expect from this large number of instruments, a review of scoring methods used in most studies failed to identify a uniquely favorable method.

Physical

The physical examination findings are usually unremarkable. Mild swelling of the ankles, feet, and fingers may occur secondary to fluid retention. Breast tenderness may be present.

A Mental Status Examination could be abnormal only during the later part of luteal phase as described below. These findings are usually not apparent during other phases of menstrual cycle.

  • General appearance may be affected. Patients may appear anxious or frustrated.
  • Behavior may be altered. Patients may appear irritable.
  • Orientation is normal.
  • Memory is normal.
  • Concentration may be affected.
  • Impulse control may be normal or poor.
  • Speech rate and flow may be slow if the depressive symptoms are predominant.
  • Mood and affect changes such as depression, anxiety, tension, self-depreciation, and anger are common.
  • Thoughts and perception are not affected.
  • There is theoretical danger of suicidal ideation and behaviors in patients with severe depression.

Causes

Risk factors for PMDD include the following:

  • Personal history of a major mood disorder
  • A family history of mood disorder
  • Premenstrual depression
  • Premenstrual mood changes
  • Past history of sexual abuse
  • Past, present, or current domestic violence

More on Premenstrual Dysphoric Disorder

Overview: Premenstrual Dysphoric Disorder
Differential Diagnoses & Workup: Premenstrual Dysphoric Disorder
Treatment & Medication: Premenstrual Dysphoric Disorder
Follow-up: Premenstrual Dysphoric Disorder
References
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Further Reading

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Keywords

PMDD, premenstrual dysphoria, late luteal phase dysphoric disorder, LLPDD, depression, labile mood, anxiety, irritability, anger, premenstrual syndrome, PMS, premenstrual tension syndrome, premenstrual distress, menstrual depression, menstrual cramping, menstrual bloating

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Contributor Information and Disclosures

Author

Thwe T Htay, MD, Assistant Professor, Department of Medicine, University of Texas Health Science Center at San Antonio
Thwe T Htay, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

KoKo Aung, MD, MPH, FACP, Associate Professor, Department of Medicine, University of Texas Health Science Center; Adjunct Assistant Professor of Public Health, University of Texas School of Public Health
KoKo Aung, MD, MPH, FACP is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

John Carrick, MD, Consulting Staff, Department of Psychiatry, Flagstaff Medical Center
John Carrick, MD is a member of the following medical societies: American Association for Geriatric Psychiatry
Disclosure: Nothing to disclose.

Romeo Papica II, MD, Research Associate, Department of Internal Medicine, Texas Tech University Health Sciences Center
Disclosure: Nothing to disclose.

Medical Editor

Ronald C Albucher, MD, Chief Medical Officer, Westside Community Services; Consulting Staff, California Pacific Medical Center
Ronald C Albucher, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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