Premenstrual dysphoric disorder

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Premenstrual dysphoric disorder
MedlinePlus	007193

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Synonyms and keywords: Late luteal phase dysphoric disorder; LLPDD; PMDD

Overview

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome, affecting 1.8%-5.8% of menstruating women. It is a mood disorder associated with the luteal phase of the menstrual cycle.

Historical Perspective

Originally called late luteal phase dysphoric disorder, the disorder was renamed PMDD by the American Psychiatric Association in its May 1993 revision of the DSM-IV. PMDD was moved from a position in the appendix of the manual to a "disorder requiring further study." While few would prefer to leave disabling and treatable symptoms untreated, some groups of psychiatrists and women's groups object to the labeling of a severe form of PMS as a psychiatric disorder.

PMDD is accepted as illness by the Food and Drug Administration (FDA) but has not as been listed as a separate disorder in the World Health Organization's International Classification of Diseases. In 2003, the manufacturer of Prozac (fluoxetine) was required by the Committee for Proprietary Medicinal Products to remove PMDD from the list of indications for fluoxetine sold in Europe. The committee found that PMDD is not a well-established disease entity across Europe. There was considerable concern that women with less severe pre-menstrual symptoms might erroneously receive a diagnosis of PMDD resulting in widespread inappropriate short and long-term use of fluoxetine. PMDD is not listed on the Australian Pharmaceutical Benefits Scheme.

Some commentators suggest that PMDD (along with social anxiety disorder, restless leg syndrome, and female sexual dysfunction) has been marketed by pharmaceutical companies in order to increase the demand for treatments. Of course the marketing of a cure is no proof that the underlying condition does not exist, or that the distress of the sufferers is not real.

Pathophysiology

There is, in fact, significant evidence of a neurological foundation in PMDD. The self-rated cardinal mood symptoms of women suffering premenstrual dysphoria was found to be strongly correlated with the concomitant worsening of their brain serotonin function measured objectively by positron emission tomography (PET).

While the underlying pathophysiology of PMDD has not been definitively established, a leading theory suggests it is due to the lack of serotonin (a neurotransmitter) and mediated by the fluctuations of the levels of sex hormones (progesterone, estrogen, and testosterone) in the luteal phase of the menstrual cycle.

Supporting the hypothesized important role of serotonin, a number of selective serotonin reuptake inhibitors (SSRIs) have been proven in clinical trials to effectively treat the mood component of PMDD when taken during the dysphoric phase.

Differential Diagnosis

• Premenstrual syndrome
• Dysmenorrhea
• Bipolar disorder
• Major depressive disorder
• Persistent depressive disorder (dysthymia)
• Use of hormonal therapy

PMDD is similar to premenstrual syndrome (PMS), but differs from it in severity and in that it requires treatment, because it interferes with the sufferer's ability to function in her environment. The cardinal symptom--surfacing between ovulation and menstruation, and disappearing within a few days after the onset of the bleeding--is irritability. Anxiety, anger, and depression may also occur. The main symptoms, which can be disabling, include

Epidemiology and Demographics

Prevalence

The prevalence of premenstrual dysphoric disorder is 1,800-5,800 per 100,000 (1.8%-5.8%) of menstruating women.

Risk Factors

• History of interpersonal trauma
• Seasonal changes
• Socio-cultural aspects of female sexual behavior
• Stress

Natural History,Complications,and Prognosis

Good prognostic factors include:

• Use of oral contraceptives

Diagnosis

DSM-V Diagnostic Criteria for Premenstrual Dysphoric Disorder

“

A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses. AND B. One (or more) of the following symptoms must be present: 1. Marked affective lability (e.g., mood swings: feeling suddenly sad or tearful, or increased sensitivity to rejection). 2. Marked irritability or anger or increased interpersonal conflicts. 3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 4. Marked anxiety, tension, and/or feelings of being keyed up or on edge. AND C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above. 1. Decreased interest in usual activities (e.g., work, school, friends, hobbies). 2. Subjective difficulty in concentration. 3. Lethargy, easy fatigability, or marked lack of energy. 4. Marked change in appetite; overeating; or specific food cravings. 5. Hypersomnia or insomnia. 6. A sense of being overwhelmed or out of control. 7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain. Note:The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year.. AND D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home). AND E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders). AND F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles.(Note:The diagnosis may be made provisionally prior to this confirmation .) AND G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).

”

Symptoms

• Feelings of sadness or despair, or possibly suicidal thoughts
• Feelings of tension or anxiety
• Panic attacks
• Mood swings, crying
• Lasting irritability or anger that affects other people
• Disinterest in daily activities and relationships
• Trouble thinking or focusing
• Tiredness or low energy
• Food cravings or binge eating
• Having trouble sleeping
• Feeling out of control
• Physical symptoms, such as bloating, breast tenderness
• Headaches
• Joint or muscle pain

Treatment

Lifestyle changes may ameliorate some of the effects of PMDD, and certain SSRIs provide relief as well. The U.S. Food and Drug Administration (FDA) has approved three medications for the treatment of PMDD: Fluoxetine (also known as Prozac), was approved by the U.S. Food and Drug administration for PMDD in 2000. Sertraline (Zoloft) was approved in 2002, and Paroxetine HCI (Paxil) has also been approved by the FDA. The patent for Fluoxetine has expired, but Eli Lilly was able to obtain a new patent for its use in the treatment of PMDD, which has since marketed heavily under the trade name Sarafem. However, fluoxetine is now available as a generic in the same doses used in Sarafem, with the generic price generally a fraction of the cost for branded Sarafem.