Premenstrual Dysphoric Disorder (PMDD)

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What is Premenstrual Dysphoric Disorder?

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Premenstrual dysphoric disorder or PMDD is a condition associated with severe emotional and physical problems that are linked closely to the menstrual cycle.

Symptoms occur regularly in the second half of the cycle and end when menstruation begins or shortly thereafter. PMDD is not just a new name for Premenstrual syndrome (PMS), a condition that affects as many as 75% of menstruating women. It is considered to be a very severe form of PMS that affects about 5% of menstruating women.

Who gets Premenstrual Dysphoric Disorder?

Epidemiological studies indicate that as many as 80% of women in the US experience emotional, behavioral, or physical premenstrual symptoms.

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

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.

Some isolated reports indicate varying individual symptoms but not the overall prevalence of premenstrual symptoms among different racial groups. 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. Black women tend to have a higher prevalence of food cravings than white women. White women are more likely than black women to report premenstrual mood changes and weight gain.

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

Predisposing Factors

Strange as it may seem, PMDD does not appear to be caused simply by an imbalance of female ovarian hormones. Research measuring oestrogen and progesterone levels across the menstrual cycle found no difference between women with PMDD and those without the disorder. On the other hand, hormones must play some role because PMDD symptoms disappear if the ovaries are removed or not functioning (e.g. menopause).

Current theories suggest that normal ovarian function may trigger changes in brain chemistry in women predisposed to PMDD. One brain chemical that may be especially important is serotonin, a neurotransmitter. The serotonin system has a close relationship to the female hormones, and imbalances of the serotonin system may play an important role in causing PMDD. Another tie-in is that medications most effective for treating PMDD are those with specific effects on serotonin.

PMDD may also be inherited. Studies have shown that identical twins are more likely to share the disorder (93%) than non-identical twins (44%), and daughters of mothers with PMDD are more likely to have it themselves. However, no specific genes have been identified to account for PMDD. Therefore there may be a genetic predisposition to developing the disorder.

Psychological, social and cultural factors also may be involved in causing PMDD or at least in the expression of PMDD symptoms. These factors alone, however, are inadequate to explain the disorder, which almost certainly has a biological basis.

Progression

PMDD symptoms begin sometime after the middle of a monthly cycle (after ovulation), usually get worse during the week before menses, and then usually disappear within a few days of the start of menses. The symptoms follow this pattern every month or almost every month.

The following list includes the symptoms that make up the diagnosis of PMDD. All of the symptoms do not need to be present, and they may vary from month to month. At least 5 are required to make the diagnosis, including at least one of the first four (according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition):

1) Very depressed mood, feeling hopeless
2) Marked anxiety, tension, edginess
3) Sudden mood shifts (crying easily, extreme sensitivity)
4) Persistent, marked irritability, anger, increased conflicts
6) Loss of interest in usual activities (work, school, socializing, etc.)
6) Difficulty concentrating and staying focused
7) Fatigue, tiredness, loss of energy
8) Marked appetite change, overeating, food cravings
9) Insomnia (difficulty sleeping) or sleeping too much
10) Feeling out of control or overwhelmed
11) Physical symptoms such as weight gain, bloating, breast tenderness or swelling, headache, and muscle or joint aches and pains

PMDD symptoms are not always present. Symptoms disappear during or by the end of menses, and return at about the same time during following cycles. If symptoms are present every day, then they are unlikely to be due to PMDD.

To be considered PMDD, symptoms must be severe enough to impact on the functioning of daily life, that is, to interfere with work, school, social activities or interpersonal relationships.

Women with PMDD may have associated medical or psychiatric disorders. Some of the more commonly associated conditions are mood (depression and bipolar [manic-depressive] disorder) and anxiety disorders. Sometimes, these conditions begin before the onset of PMDD. Sometimes, they appear later. If there is a co-existing condition, it may get worse in the premenstrual phase of the cycle.

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