“This Is Not Me!”: The Debilitating Impact of Premenstrual Dysphoric Disorder

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TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From the Clinic: The Art of Psychiatry, we delve into a case of premenstrual dysphoric disorder (PMDD), a condition that is often underestimated and mistaken for typical premenstrual symptoms or mood swings. Unlike common premenstrual discomfort or emotional fluctuations, PMDD can lead to profound and debilitating mood disturbances that significantly impact daily functioning. Diagnosis can be challenging, as the severity of symptoms may be influenced by individual differences, cultural attitudes, and situational factors such as work or academic pressures.

Case Vignette

“Jennifer,” a 44-year-old woman presents with cyclical episodes of significant premenstrual emotional and physical distress 5 to 7 days before her menstrual periods, which have remained regular and uninterrupted. She reports frequent crying spells, often retreating to the bathroom at work to regain countenance. Her physical symptoms include headache, back pain, breast tenderness, fluid retention in her hands and feet, and bloating.

These symptoms, which were previously manageable, have now begun to interfere with her daily activities. For example, she can no longer enjoy reading novels for extended periods as she once did, finding herself exhausted and unable to concentrate. Specifically, Jennifer notes that during her premenstrual phase, she does more poorly on one her favorite online word games. During these episodes, she experiences an increased need for emotional support, often craving physical affection and reassurance. She also reports heightened sensitivity to noise, and frustration due to her reduced ability to manage minor conflicts with her children, consistently feeling "on edge." She becomes easily irritated, reacting to minor stressors with unusual intolerance, increased irritability, and occasional outbursts of anger.

During these mood episodes, she experiences intense cravings for sweets, particularly cupcakes, which she then consumes in excessive amounts. The severity of her symptoms has also strained her relationships, leading to increased conflicts with both her children and spouse, who commented “next time you are in PMS mode, I am just going to stay out late.” She has lately noticed that these episodes are considerably more disturbing than the premenstrual symptoms she experienced in her twenties, expressing concern that she no longer feels like herself, stating, "This is not me! I am afraid of what I am becoming."

What Is PMDD?

PMDD is a severe and debilitating form of premenstrual syndrome (PMS) that affects women between ovulation and the start of menstruation. PMDD gained official recognition in 2013 when the American Psychiatric Association added it to the DSM-5, classifying it as a psychiatric disorder. In 2019, the World Health Organization also acknowledged PMDD by including it in ICD-11, categorizing it as a disorder of the reproductive system. This concurrent classification in both DSM-5 and ICD-11 emphasizes the complex interplay between the physical and emotional symptoms that characterize PMDD. PMDD affects 3% to 8% women of reproductive age and lacks a definitive ovarian hormone biomarker for diagnosis.^1,2 Symptoms can range from extreme mood swings to suicidal ideation, typically occurring about a week before menstruation. This results in significant stress, functional impairment, and interpersonal conflicts.

Figure 1. Possible Symptoms of PMDD

Symptoms of PMDD encompass depression and potentially intense sadness, suicidal thoughts, panic attacks, anxiety, anger, irritability, sudden mood swings, loss of interest in daily activities, insomnia, trouble concentrating, binge eating, painful cramps, and bloating (Figure 1). Additionally, a family history of PMS, postpartum depression, or other mood disorders can increase the risk of PMDD.³ Many women do not seek help due to the spontaneous cyclical improvement of symptoms after menstruation begins, and instead manage the condition with behavioral and social modifications. Women who do may encounter a lack of knowledge and hence limited support from health care professionals.

Diagnosis

Physicians recommend maintaining a diary to track menstruation and related emotional and physical symptoms for at least 2 menstrual cycles, according to the DSM-5. If symptoms consistently appear during the luteal phase and subside shortly after menstruation begins, PMDD may be diagnosed (Figure 2).

Figure 2. Progression of PMDD Symptoms During Menstrual Cycle

In the diagnostic process of PMDD, accurate differentiation from other mood disorders is critical. Research indicates that women with PMDD are often misdiagnosed with other mood disorders, such as major depressive disorder, bipolar disorder, generalized anxiety disorder, and panic disorder, due to the overlap in mood symptoms. This misdiagnosis can result in missed opportunities for appropriate treatment. Accurate diagnosis requires a thorough understanding of the context, including taking a detailed history and considering the patient's perspective during these complex mood episodes, which can lead to a more accurate diagnosis and an effective treatment plan.⁴

Treatment Selection

A correct and confident management of PMDD lies at the intersection of psychiatry and gynecology, and may require collaboration among a multidisciplinary team including a gynecologist, psychiatrist, and psychologist. A study on patients seeking care for PMDD symptoms found that psychotherapists were rated highest for interpersonal qualities, such as compassion and openness to learning about PMDD, while gynecologists and psychiatrists were rated highest for their knowledge and awareness of the disorder. Gynecologists were more likely than other providers to ask patients to track their symptoms daily. These findings suggest that different providers have unique strengths in assessing and treating PMDD.⁵

For the management of mild to moderate PMDD, several lifestyle modifications and nonpharmacological strategies have been shown to be effective. These strategies include adequate hydration and the consumption of herbal teas, such as chamomile, which may help in stress reduction and irritability, and peppermint tea, which can relieve bloating and digestive discomfort.⁶ Maintaining a balanced diet, particularly by reducing the intake of high-fat and high-sugar foods, is also recommended. Additional interventions include acupuncture and the use of supplements like folic acid and vitamin B6. Enhancing vitamin D levels, ensuring adequate sleep, regular physical activity, and participation in self-care practices such as relaxation techniques, hobbies, and social interactions can further contribute to symptom relief.³

In the treatment of moderate to severe PMDD, psychotropic agents and ovulation suppression therapies can be employed. US Food and Drug Administration approved agents include fluoxetine and sertraline anddrospirenone/ethinyl estradiol. Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to manage both mood-related symptoms, such as irritability, dysphoria, and depression, and physical symptoms, including bloating, appetite changes, and breast tenderness. Notably, SSRIs may produce a more immediate effect on physical symptoms compared with mood symptoms. If SSRIs are chosen, they can only be administered premenstrually, rather than on standing basis as in depression treatment (Figure 3). Ovulation suppression can be effectively achieved through the use of combined oral contraceptive pills or gonadotropin-releasing hormone agonists. Additionally, spironolactone, a diuretic, can be utilized to reduce symptoms of abdominal bloating, breast tenderness, and peripheral edema.

Figure 3. Level of Blockade by SSRIs in PMDD

Combining cognitive-behavioral therapy with pharmacotherapy is considered an optimal approach for addressing PMDD.⁷ This integrated treatment strategy aims to address the patient's core beliefs and align with the expectations of both the patient and her family for prompt relief from irritability and aggressive mood symptoms. This combination helps guide physicians through a comprehensive and long-lasting treatment process.

Two Challenging Time Periods: Adolescence and Perimenopause

PMDD can intensify during perimenopause due to hormonal fluctuations and can become a treatment challenge. While lifestyle changes and minimal treatments like SSRIs may effectively manage PMDD in younger premenopausal women, these approaches may fall short during perimenopause in late forties. Oral contraceptive pills are to be used with care, as depression is reported as an important potential adverse effect, especially in women already struggling with perimenopausal mood disturbances.⁸ Therefore, a comprehensive approach combining both pharmacological and nonpharmacological strategies may be essential for managing PMDD in women during perimenopause.

Adolescents with PMDD present unique challenges in diagnosis and management, requiring a tailored approach to ensure timely and effective treatment. Adolescents are often less likely to monitor their symptoms or seek professional assistance, which can result in delays in both diagnosis and follow-up care.⁹ Additionally, diagnosing PMDD in this population is particularly challenging due to the overlap between PMDD related mood swings and the predictable emotional fluctuations that occur during puberty. Physicians may incorrectly attribute emotional lability to normal pubertal development, leading to a delayed diagnosis. Furthermore, the diagnosis is complicated by irregular ovarian cycles and the variability in the transition from irregular to regular menstrual cycles among adolescents. This complexity raises the question of whether a thorough patient history or a standardized screening tool might be more effective than the traditional 2-month symptom tracking for establishing a timely diagnosis of PMDD in adolescents with irregular cycles.

Concluding Thoughts

PMDD symptoms may necessitate a comprehensive treatment strategy, yet they frequently show significant improvement with appropriate lifestyle and pharmacological interventions. The abundance of tracking smartphone apps is likely to facilitate accurate diagnosis. Consulting with a health care provider can help in crafting a tailored treatment plan that effectively addresses specific needs of patients.

Dr Hashmi is a graduate and house officer in Mayo Hospital, King Edward Medical University, Lahore, Pakistan. Dr Moukaddam is a professor of psychiatry at Baylor College of Medicine, Department of Psychiatry, and the Director of Outpatient Psychiatry at Harris Health System. She also serves on the Psychiatric Times Editorial Board.

References

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2. Lu G, Shiver TM, Blackburn SL, et al. Full remission of long-term premenstrual dysphoric disorder-like symptoms following resection of a pituitary adenoma: case report. Am J Case Rep. 2020;21:e922797.

3. PMS: Premenstrual Syndrome Symptoms, Treatments, and More. Healthline. Updated April 24, 2023. Accessed August 4, 2024. https://www.healthline.com/health/premenstrual-syndrome

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6. 10 effective natural remedies for premenstrual syndrome relief. Continental Hospitals. February 12, 2024. Accessed August 15, 2024. https://continentalhospitals.com/blog/10-effective-natural-remedies-for-premenstrual-syndrome-relief/

7. Adler Nevo GW, Nefsky C. Mind over PMDD: a glimpse into the process of pharmacotherapy-psychotherapy combination treatment. J Can Acad Child Adolesc Psychiatry. 2014;23(2):146-150.

8. Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of hormonal contraception with depression. JAMA Psychiatry. 2016;73(11):1154-1162.

9. Lundin C, Danielsson KG, Bixo M, et al. Combined oral contraceptive use is associated with both improvement and worsening of mood in the different phases of the treatment cycle-a double-blind, placebo-controlled randomized trial. Psychoneuroendocrinology. 2017;76:135-143.