Amy Jernigan Case: Premenstrual Dysphoric Disorder

Amy Jernigan Case: Premenstrual Dysphoric Disorder

Amy Jernigan Case: Premenstrual Dysphoric Disorder

“Look, I don’t need you to tell me what’s wrong. I know what’s wrong. I just need you to fix it.” One ankle crossed over the other, Amy Jernigan slouched in the consultation chair and gazed steadily at her clinician. “I brought a list of my symptoms, just so there won’t be any confusion.” She unfolded a half-sheet of embossed stationery.

“It always starts out 4 or 5 days before my period,” she recited. “I begin by feeling uptight, like I’m waiting to take an exam I haven’t studied for. Then, after a day or two, depression sets in and I just want to cry.” She looked up and smiled. “You won’t catch me doing that now—I’m always just fine after my period starts.”

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Still in her early 20s, Amy had graduated from a college near her home in the Deep South. Now, while waiting for her novel to sell, she did research for a political blogger. With another glance at the paper, she continued. “But before, I’m depressed, cranky, lazy as a hound dog in August, and I don’t really give a shit about anything.”

Amy’s mother, an antifeminist who’d campaigned against the Equal Rights Amendment, had refused to validate Amy’s premenstrual symptoms, though she might have had them herself. Amy’s problems had begun in her early teens, almost from the time of her first period. “I’d be so pissed off, I’d drive away all my friends. Fortunately, I’m pretty outgoing, so they didn’t—don’t—stay lost for long. But reliably every month, my breasts get so sensitive they could read Braille. Then I know I’d better put a lock on my tongue, or the next week I’ll be buying beers for everyone I know.”

Amy tucked her list into her back pocket and sat up straight. “I hate being the feminist with PMS—I feel like a walking cliché.”

Discussion of Amy Jernigan

As Amy said, she didn’t need much discussion about what was wrong, though she didn’t have her terms quite right. Her list of symptoms—depression, irritability, and tension (criterion B) and breast tenderness, lethargy, and loss of interest (C)—exceeds the requirement for a total of five or more. Amy herself indicated just how debilitating she considered the symptoms to be (D). The recurrence, the timing, and the absence of symptoms at times other than before her menses (A) complete a pretty airtight case. The duration of her low moods was too brief for either a major depressive episode or dysthymia (E). Of course, the usual investigation must be made to rule out any lingering thoughts that her symptoms could be due to substance use or another medical condition (E). I should note that, in the absence of a couple of months of prospective symptom recording, Amy’s clinician needs to be extra careful to rule out major depressive disorder. It is awfully easy to ignore depressive symptoms that occur at other times of the month.

Amy’s clinician would have to assess her mood through two subsequent periods to comply with criterion F. When she was ill, her GAF score would be 60, and her diagnosis should be as follows:

The demand for prospective data before a definitive diagnosis can be made is unique in DSM-5, and has never been required in a prior edition of the DSM. The rationale is to ensure that the diagnosis is made with the best data possible; the fact that such a step is not required for more diagnoses may be a nod to the realities of clinical practice. Even so, we may have just experienced the first breeze of a gathering storm.

Discussion: Premenstrual Dysphoric Disorder