Premenstrual Dysphoric Disorder 

  • Author: Thwe T Htay, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: Jun 6, 2011
 

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.

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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]

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Epidemiology

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 women[9] in their reproductive years worldwide, imposing an enormous burden on women, their families, and the health care system. A study from India reported a frequency of 6%.[10] A population-based sample of women of the entire reproductive age range from Switzerland found that 3% of the sample population fulfilled criteria for PMDD.[11] A cross-sectional study of female medical students from Nigeria showed that 36% of the respondents met the criteria for the diagnosis of PMDD.[12]

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.[13] White women are more likely than black women to report premenstrual mood changes[14] and weight gain. Pain featured most highly in a sample of Chinese women in Hong Kong.[15]

Age

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

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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 at San Antonio; Adjunct Associate 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, Staff Physician Premier Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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 None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

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