Discussion: Premenstrual Dysphoric Disorder

Discussion: Premenstrual Dysphoric Disorder

Discussion: Premenstrual Dysphoric Disorder

A long history of disagreement over the reality of premenstrual dysphoria caused it to languish in the appendices of earlier DSM editions. At last, enough research has been published to bring it forth from the shadows.

Premenstrual symptoms to one degree or another affect about 20% of women of reproductive age. The severe form, premenstrual dysphoric disorder (PDD), affects up to 7% of women, often beginning in the teenage years. Throughout their reproductive years, these symptoms appear for perhaps a week out of each menstrual cycle. These women complain of varying degrees of dysphoric mood, fatigue, and physical symptoms that include sensitivity of breasts, weight gain, and abdominal swelling. Differentiation from major depressive episode and dysthymia relies principally on timing and duration.

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The consequences of PDD can be serious: Such a patient could experience mood symptoms during an accumulated 8 years of her reproductive life. Some patients may be unaware how markedly their anger and other negative moods affect those around them, and many suffer from severe depression; perhaps 15% attempt suicide. Yet the typical patient doesn’t receive treatment until she is 30, sometimes even later. Symptoms may be worse for older women, though menopause offers a natural endpoint (duration is sometimes extended by hormone replacement therapy). Overall, this condition ranks high among the seriously underdiagnosed mental disorders.

Risk factors for PDD include excessive weight, stress, and trauma (including a history of abuse); there appears to be a robust genetic component. Comorbid are anxiety disorders and other mood disorders, including bipolar conditions.

Dating as far back as 1944—the term premenstrual tension dates at least to 1928—the premenstrual syndrome (PMS) has had a long and tempestuous life. It’s dismissed by many as pejorative, ridiculed by would-be comics, and disparaged even by some of those who practice gender politics. It should come as no surprise that it has been so ill received; as disorders go, PMS is remarkably vague and variously defined.

All told, PMS encompasses over a hundred possible symptoms, with no minimum number and no specific symptoms required; it’s all anecdotal. Here are just a few: fluid retention (the symptom most often reported), especially in breasts and abdomen; craving for sweet or salty foods; muscle aches/pains, fatigue, irritability, tension, acne, anxiety, constipation or diarrhea, and insomnia; a change in sex drive; and feeling sad or moody or out of control. Most women will occasionally have one or two of these symptoms around the time of their periods—these symptoms are so common that, individually, they may be considered physiological rather than pathological. This fact causes some people to blame all such symptoms on PMS (it hardly ever goes by its full, nonabbreviated name); all women are in effect tarred with the same brush, when it is of crucial importance to note the exact symptoms, their timing, and their intensity.

Again, the critical difference is the presence of mood symptoms in PDD.

Essential Features of Premenstrual Dysphoric Disorder

For a few days before menstruating, a patient experiences pronounced mood shifts, depression, anxiety, anger, or other expressions of dysphoria. She will also admit to typical symptoms of depression, including trouble concentrating, loss of interest, fatigue, feeling out of control, and changes in appetite or sleep. She may have physical symptoms such as sensitivity of breasts, muscle pain, weight gain, and a sensation of abdominal distention. Shortly after menstruation begins, she snaps back to normal.

The Fine Print

The D’s: • Duration (for several days around menstrual periods, for most cycles during the past year) • Distress or disability (social, occupational, or personal impairment) • Differential diagnosis (substance use—including hormone replacement therapy; physical disorders; major depressive disorder or dysthymia; ordinary grief/sadness)

Coding Note

DSM-5 says that the diagnosis can only be stated as (provisional) until you’ve obtained prospective ratings of two menstrual cycles. What you as a clinician decide to do with this is, of course, your business.

Amy Jernigan

“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.”

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