Lifetime prevalence of psychiatric disorders in women with perimenstrual difficulties

Affective Risk Associated With Menstrual Cycle Symptom Change

In the present study we test whether cyclical changes in affective symptoms of the menstrual cycle are associated with higher mean levels of those same symptoms. Using prospective daily reports across two full menstrual cycles, from two samples of female University students (n = 213; n = 163), we applied both quartic polynomial regressions and cosine regressions to model cyclical change in symptoms, and to test for mean-level differences in symptoms across the resulting trajectory patterns. Counter to prior findings, but consistent with theoretical expectations, these results show that females who experience menstrual cycle-related changes in affect (whether a perimenstrual or mid-cycle increase) are at risk for higher average levels of affective symptoms. These results suggest that the mid-cycle group should be recognized as a target for future research that is associated with increased risk for chronic negative affective symptoms.

Roles of childhood maltreatment, personality traits, and life stress in the prediction of severe premenstrual symptoms

BACKGROUND

About 3% to 8% of women of fertile age are thought to have premenstrual dysphoric disorder (PMDD), which is regarded as a serious form of premenstrual syndrome (PMS), although the details of this common condition remain unclear. The aim of this study was to analyze the interrelations of childhood maltreatment, personality traits, and life stress in the etiology of PMS/PMDD.

METHODS

A total of 240 adult female volunteers from a community in Japan were investigated, using the following 5 questionnaires: Patient Health Quesstionaire-9, Child Abuse and Trauma Scale, Temperament and Character Inventory (TCI), Life Experiences Survey, and premenstrual dysphoric disorder (PMDD) scale. The questionnaire data were subjected to path analyses to clarify the association between childhood maltreatment and the severity of premenstrual symptoms, mediated by personality traits and life stress.

RESULTS

The 2 path analysis models showed that high harm avoidance (HA) on the TCI and low self-directedness (SD) on the TCI had significant direct effects on the severity of premenstrual symptoms. Moreover, childhood maltreatment was associated with the severity of premenstrual symptoms, both directly and indirectly through personality traits.

CONCLUSION

Our findings suggest that HA on the TCI might be a risk factor for severe premenstrual symptoms among general women and furthermore that SD on the TCI may be a protective factor. In addition, childhood maltreatment is associated with severe premenstrual symptoms both directly and indirectly through personality traits.

History of postpartum depression in a clinic-based sample of women with premenstrual dysphoric disorder

OBJECTIVE

Overlapping comorbidities between premenstrual dysphoric disorder (PMDD) and postpartum depression (PPD) suggest that these disorders represent a continuum of vulnerability with shared pathophysiology. We report the past histories of PPD (and other Axis I psychiatric illnesses) in a clinic-based sample of women meeting criteria for PMDD.

METHODS

215 women, ages 19 to 51 years, who attended the National Institute of Mental Health Mood Disorders Clinic between 1988 and 2013 seeking treatment for PMDD and in whom we confirmed the diagnosis of PMDD (DSM-IV), were identified. All were administered the Structured Clinical Interview for DSM-III-R or -IV. The frequency of PPD (major or minor) was established in the subgroup of women (n = 137) who had delivered at least 1 child.

RESULTS

Ninety-three women (43.3%) had a past history of a mood disorder (ie, either major [n = 67; 31.2%] or minor [n = 10; 4.7%] depression or PPD [n = 16; 7.4%; 11.7% of parous women]). Nine of the 16 women with PMDD and a past PPD had either a past major depressive episode (MDE) or subsyndromal anxiety disorder. Thirty-three women (15.3%) had a past history of an Axis I anxiety disorder. A total of 40 women (18.6%) met criteria for past alcohol or drug abuse, 3 (1.4%) met criteria for bulimia nervosa, and 2 (0.9%) met criteria for anorexia nervosa.

CONCLUSIONS

Our data demonstrate that PMDD and PPD do not frequently co-occur. These data do not suggest that PMDD and PPD share similar pathophysiology beyond being ovarian-steroid-triggered mood disorders. The high comorbidity of past MDE could contribute to the increased risk both for future MDE and for PPD in some women with PMDD.

Rapid cycling mood disorder: A review

Objectives: Rapid cycling mood disorder is an important clinical phenomenon. The concept of rapid cycling has evolved since it was first described in 1974. The purpose of this review is to summarise current diagnostic criteria, postulated risk factors and suggested management strategies.

Method: A Medline and Psych-Lit computerised literature search was supplemented by tracing back through the references from existing review work.

Results: Over 80 papers were identified which discussed diagnosis and management of rapid cycling.

Conclusions: DSM-IV provides a useful but narrow definition of rapid cycling. Standard treatment of affective disorder may exacerbate rapid cycling. If a rapid cycling course develops, discontinuation of antidepressants and use of mood stabilisers is recommended.

Premenstrual dysphoric disorder: evidence for a new category for DSM-5

Premenstrual dysphoric disorder, which affects 2%–5% of premenopausal women, was included in Appendix B of DSMIV, "Criterion Sets and Axes Provided for Further Study." Since then, aided by the inclusion of specific and rigorous criteria in DSM-IV, there has been an explosion of research on the epidemiology, phenomenology, pathogenesis, and treatment of the disorder. In 2009, the Mood Disorders Work Group for DSM-5 convened a group of experts to examine the literature on premenstrual dysphoric disorder and provide recommendations regarding the appropriate criteria and placement for the disorder in DSM-5. Based on thorough review and lengthy discussion, the work group proposed that the information on the diagnosis, treatment, and validation of the disorder has matured sufficiently for it to qualify as a full category in DSM-5. A move to the position of category, rather than a criterion set in need of further study, will provide greater legitimacy for the disorder and encourage the growth of evidence-based research, ultimately leading to new treatments.

Update on research and treatment of premenstrual dysphoric disorder

Many women in their reproductive years experience some mood, behavioral. or physical symptoms in the week prior to menses. Variability exists in the level of symptom burden in that some women experience mild symptoms, whereas a small minority experience severe and debilitating symptoms. For an estimated 5%-8% of premenopausal women, work or social functioning are affected by severe premenstrual syndrome. Many women in this group meet diagnostic criteria for premenstrual dysphoric disorder (PMDD). Among women who suffer from PMDD, mood and behavioral symptoms such as irritability, depressed mood, tension, and labile mood dominate. Somatic complaints, including breast tenderness and bloating, also can prove disruptive to women's overall functioning and quality of life. Recent evidence suggests that individual sensitivity to cyclical variations in levels of gonadal hormones may predispose certain women to experience these mood, behavioral, and somatic symptoms. Treatments include: antidepressants of the serotonin reuptake inhibitor class, taken intermittently or throughout the menstrual cycle; medications that suppress ovarian cyclicity; and newer oral contraceptives with novel progestins.

Premenstrual syndrome

Most women of reproductive age have some physical discomfort or dysphoria in the weeks before menstruation. Symptoms are often mild, but can be severe enough to substantially affect daily activities. About 5-8% of women thus suffer from severe premenstrual syndrome (PMS); most of these women also meet criteria for premenstrual dysphoric disorder (PMDD). Mood and behavioural symptoms, including irritability, tension, depressed mood, tearfulness, and mood swings, are the most distressing, but somatic complaints, such as breast tenderness and bloating, can also be problematic. We outline theories for the underlying causes of severe PMS, and describe two main methods of treating it: one targeting the hypothalamus-pituitary-ovary axis, and the other targeting brain serotonergic synapses. Fluctuations in gonadal hormone levels trigger the symptoms, and thus interventions that abolish ovarian cyclicity, including long-acting analogues of gonadotropin-releasing hormone (GnRH) or oestradiol (administered as patches or implants), effectively reduce the symptoms, as can some oral contraceptives. The effectiveness of serotonin reuptake inhibitors, taken throughout the cycle or during luteal phases only, is also well established.

Personality disorders and depressive symptoms in late luteal phase dysphoric disorder

BACKGROUND

Although many significant studies of late luteal phase dysphoric disorder (LLPD) have been carried out, some conflicting findings on the relationships between personality disorders, depressive symptoms, hostility and LLPD deserve further investigation.

METHODS

Forty-three LLPD patients and 85 control subjects, evaluated by prospective daily ratings during two symptomatic cycles, received a detailed psychiatric evaluation, including the sections for psychotic, affective and anxiety disorders of the Structured Clinical Interview for DSM-III-R nonpatient version and the section for personality disorders; the Buss Durkee Inventory for Assessing Different Kinds of Hostility and the Montgomery-Asberg Depression Rating Scale.

RESULTS

The odds of suffering from LLPD are about nine-fold (crude odds ratio, OR = 9.23, 95% confidence interval, CI 3.98-21.39) among women with mild or moderate depressive symptoms. When two age strata (below and above 30) are analyzed separately, the association between LLPD and depressive symptoms is strong and positive in both strata, while the association between LLPD and avoidant personality disorder is found only among older women (adjusted OR = 8.26, p < 0.05, 95% CI 1.03-66.35).

CONCLUSIONS

The major finding from this preliminary study is the association between LLPD and depressive symptoms. Conversely, the association between LLPD and avoidant personality disorder remains controversial and seems to be dependent on age. Our findings support the hypothesis that LLPD and avoidant personality disorder may be considered as part of the spectrum of recurrent mood disorder rather than as qualitatively distinct nosological entities. Future studies are needed, adopting prospective, longitudinal assessments of personality prior to the onset of LLPD.

Steroid regulation of tryptophan hydroxylase protein in the dorsal raphe of macaques

BACKGROUND

Tryptophan hydroxylase (TPH) is the rate-limiting enzyme for the synthesis of serotonin, and serotonin is a pivotal neurotransmitter in the regulation of mood, affective behavior, pituitary hormone secretion, and numerous autonomic functions. We previously demonstrated that estradiol (E) and progesterone (P) increase TPH mRNA levels in the dorsal raphe of macaques.

METHODS

This study employed western blotting and densitometric quantitation to determine whether the changes observed at the level of gene expression were manifested by changes in TPH protein expression and whether modified estrogens or progestins had actions similar to the native ligands. In addition, the effect of the antiestrogen tamoxifen was examined. Ovariectomized (ovx) rhesus and cynomolgus macaques were untreated or treated with E, P, E+P, equine estrogens (EE), medroxyprogesterone (MPA), EE+MPA, or tamoxifen. The dorsal raphe region was subjected to Western analysis.

RESULTS

E treatment for 28 days increased TPH protein mass four to six fold over ovariectomized controls. Addition of P to the E regimen or treatment with P for 28 days after E priming did not alter TPH from E treatment alone. Treatment of ovx macaques with a low dose of P caused a two-fold increase in TPH protein. Treatment of ovariectomized macaques for 30 months with EE alone or MPA alone significantly increased TPH protein; however, unlike P, the addition of MPA to the EE regimen blocked the stimulatory effect of EE. Tamoxifen treatment significantly reduced TPH protein compared to EE and ovariectomized control animals.

CONCLUSION

The stimulatory effect of E and P on TPH protein in the dorsal raphe of macaques correlates with the previously observed effect at the level of mRNA expression. P had no effect on the stimulatory action of E, whereas MPA blocked the stimulatory effect of EE. Tamoxifen acted as a potent antiestrogen on TPH protein expression. If TPH protein mass influences serotonin synthesis, then these steroids will impact many autonomic systems that are regulated by serotonin.

Salivary cortisol in women with and without perimenstrual mood changes

An increase in the activity of the hypothalamic-pituitary-adrenal axis (HPA axis) is frequently associated with major depression. During the premenstrual phase of their reproductive cycle some women experience depressive mood changes that are proposed to be of similar intensity to that experienced during periods of major depression. This study examined the secretion of cortisol, the end-product in the HPA axis, at different stages of the menstrual cycle in women with and without premenstrual depression. Women who experienced only mild physical and emotional changes in the premenstrual phase of their cycle had a significantly higher cortisol secretion on a premenstrual day (measured hourly) compared to a postmenstrual day. Those who were significantly more depressed premenstrually showed the opposite pattern of cortisol secretion with significantly lower levels on the premenstrual day compared with the postmenstrual day. Across the menstrual cycle, women who were significantly more depressed premenstrually also had lower evening cortisol levels in their premenstrual phase. The results of this study indicate that, unlike major depression where the underlying neurological changes are manifest as overactivity of the HPA axis, premenstrual depressive changes are associated with reduced HPA axis activity. Premenstrual depression may, therefore, be similar neurologically to seasonal affective disorder, which is associated with underactivity of the HPA axis.

Social subordination stress, behavior, and central monoaminergic function in female cynomolgus monkeys

BACKGROUND

Social subordination in female cynomolgus monkeys is stressful and activates the hypothalamic-pituitary-adrenal axis. In a previous experiment behavioral depression was observed in a subset of subordinates.

METHODS

In the experiment reported here behavioral and physiological indicators of stress were evaluated in dominant and subordinate female cynomolgus monkeys, and brain dopaminergic activity was assessed, as reflected in the prolactin response to haloperidol, a dopamine2 (D2) receptor antagonist.

RESULTS

Subordinates were aggressed more, spent more time in fearful scanning of the social environment, spent less time as the recipients of the active affiliative behavior of being groomed, had more variable heart rates in response to a novel environment, and were hypercortisolemic compared to dominants. Prolactin responses to haloperidol challenge were lower in subordinates than dominants, an observation consistent with the hypothesis that subordinate females have decreased D2 receptor function.

CONCLUSIONS

These observations suggest that social subordination is stressful and may alter brain dopaminergic function in primates. The neurophysiological characteristics of social subordinates may contribute to their susceptibility to depression.

Behavior and physiology of social stress and depression in female cynomolgus monkeys

The hypothesis that social subordination is stressful, and results in a depressive response in some individuals, was examined in socially housed female cynomolgus monkeys. Social status was manipulated such that half of the previously subordinate females became dominant and half of the previously dominant females became subordinate. Current subordinates hypersecreted cortisol, were insensitive to negative feedback, and had suppressed reproductive function. Current subordinates received more aggression, engaged in less affiliation, and spent more time alone than dominants. Furthermore, they spent more time fearfully scanning the social environment and displayed more behavioral depression than dominants. Current subordinates with a history of social subordination were preferentially susceptible to a behavioral depression response. The results of this experiment suggest that the stress of social subordination causes hypothalamic-pituitary-adrenal and ovarian dysfunction, and support the hypothesis that chronic, low-intensity social stress may result in depression in susceptible individuals.

Temperature circadian rhythms during the menstrual cycle and sleep deprivation in premenstrual dysphoric disorder and normal comparison subjects

The aim of this study was to test the hypothesis that the circadian rhythm of core body temperature is altered in premenstrual dysphoric disorder (PMDD) subjects compared to that in normal comparison (NC) subjects and that it is normalized in PMDD subjects after treatment with early night partial sleep deprivation (ESD) or late night partial sleep deprivation (LSD). A total of 23 subjects meeting DSM-IV criteria for PMDD and 18 NC subjects had 24-h core body temperature recordings taken during the following conditions: (1) baseline midfollicular (preovulatory) and (2) late luteal (postovulatory) menstrual cycle phases and after a randomized crossover trial in subsequent luteal phases of (3) ESD, in which subjects slept from 03:00 to 07:00 h, followed by (4) a night of recovery sleep (ESD-R: sleep 22:30 to 06:30 h), and (5) LSD, in which subjects slept from 21:00 to 01:00 h, also followed by (6) a night of recovery sleep (LSD-R: sleep 22:30 to 06:30 h). Temperature amplitudes were significantly decreased in the luteal phase compared to those in the follicular menstrual cycle phase and increased after nights of recovery sleep. Compared to the baseline late luteal phase, during LSD, temperature amplitude increased in PMDD subjects but decreased in NC subjects. During ESD, the temperature acrophase was delayed in PMDD subjects but was advanced in NC subjects; during LSD, the temperature acrophase was advanced in PMDD subjects but was delayed in NC subjects compared to the late luteal baseline. Nocturnal temperature and temperature maxima and mesors tended to be higher in PMDD subjects than in NC subjects; when not reduced during sleep deprivation interventions, these were not associated with therapeutic effects. Alterations in both phase and amplitude of temperature circadian rhythms characterize PMDD subjects as contrasted with NC subjects in response to sleep deprivation. The changes in phase reflected more shifts in temperature acrophase in response to shifts in sleep in PMDD subjects. This realignment of the timing of sleep and temperature in addition to the enhancement of blunted amplitude rhythms during recovery nights of sleep may provide corrective mechanisms that contribute to the therapeutic effects of sleep deprivation.

Circadian rhythms of prolactin and thyroid-stimulating hormone during the menstrual cycle and early versus late sleep deprivation in premenstrual dysphoric disorder

The present study extended previous work by examining whether disturbances in the circadian rhythms of prolactin (PRL) and thyroid-stimulating hormone (TSH) distinguish patients with premenstrual dysphoric disorder (PMDD) from normal volunteers. In addition, the effects of therapeutic interventions with early and late partial sleep deprivation were explored. Both PRL and TSH levels were measured every 30 min from 18:00 h to 09:00 h during midfollicular and late luteal menstrual cycle phases in 23 PMDD patients and 18 normal volunteers. Hormone levels were measured again after a randomized crossover trial of early (sleep 03:00-07:00 h) versus late (sleep 21:00-01:00 h) partial sleep deprivation administered in two separate luteal phases. Compared with normal volunteers, PMDD patients had higher PRL concentrations, consistent with previous findings. TSH rhythms occurred earlier in PMDD than in normal subjects. PRL levels decreased and TSH levels increased with sleep deprivation compared with baseline conditions. The timing of PRL secretion shifted earlier with late sleep deprivation and later with early sleep deprivation. Although circadian disturbances of PRL and TSH were found in PMDD patients compared with normal volunteers, the therapeutic effects of early and late sleep deprivation do not appear to be mediated by correcting these disturbances.

Personality traits in LLPDD and normal controls during follicular and luteal menstrual-cycle phases

In 15 women with Late Luteal Phase Dysphoric Disorder (LLPDD) and in 15 normal control subjects, personality traits were assessed using the Millon Clinical Multiaxial Inventory (MCMI) during follicular and luteal menstrual-cycle phases. Compared with controls, LLPDD subjects had less compulsive but more passive/aggressive and borderline/cycloid traits, and more depression and hypomania. Menstrual-cycle phase did not significantly affect personality variables in either group. In particular, depression and hypomania in LLPDD subjects suggests a relationship with affective disorders.

Do premenstrual pain and edema exhibit seasonal variability?

This study tested whether symptoms of pain and edema associated with change during the premenstrual phase of the monthly menstrual cycle exhibit a seasonal pattern. Menstruating chronic myofascial face pain cases (N = 99) and acquaintance controls (N = 100) were questioned about their premenstrual symptoms during the prior month in each of 10 consecutive months. Unlike myofascial face pain and psychological distress, premenstrual symptoms of general discomfort and edema did not show an exacerbation in the dark months for either cases or controls. The positive results for distress and facial pain and the negative results for the premenstrual symptoms occurred whether or not respondents met an algorithmic diagnosis of DSM-IV premenstrual dysphoric syndrome.

Perimenstrual depression: its relationship to pain, bleeding, and previous history of depression

Daily ratings of depression, pain, and menstrual blood loss, as well as past history of treated depression, were analyzed in 210 women attending a Premenstrual Syndrome Clinic. Severity and duration of perimenstrual depression was strongly associated with the severity of premenstrual and menstrual pain, raising the possibility of a causal relationship. It is not yet clear whether the occurrence of depression alters a woman's perception of pain, pain aggravates a tendency to perimenstrual depression, or some common factor aggravates both. A relationship between depression and subjective ratings of blood loss was also observed but was less marked than the relationship with pain. Both relationships had been reported in an earlier study using retrospective ratings. A relationship between past history of treated depression and severity and timing of current perimenstrual depression, observed previously, was not found in this study. This discrepancy was not due to differences between retrospective and prospective methods of assessment, but may have partly resulted from differences in the reporting of premenstrual pain in the two studies. Further studies of this association should control for the confounding effect of pain.

Suicidal ideas during premenstrual phase

The aim of the present study was to determine the frequency of suicidal ideas and death wish among 296 women from urban, rural, industrial and college populations. Suicidal ideas and/or death wish during premenstrual period were reported by 30 (10%) subjects, more so among college students and industrial working women and less among housewives. Premenstrual symptoms, like depression, irritability, mood swings, sense of losing control and water retention, were significantly more often reported by women who had suicidal ideas as compared with women without suicidal ideas.

Intermenstrual affect in women with symptomatic premenstrual change

To determine whether women seeking treatment for symptomatic premenstrual change have ongoing psychological disturbance, we undertook a cross-sectional, comparative study across four groups of reproductive-age women. Subjects were 35 patients with symptomatic premenstrual change and no psychiatric history, 35 women without symptomatic premenstrual change, 35 patients with affective disorders, and 35 women from the community at large. All women except those in the community sample were tested in the intermenstrual phase (after menses but before the 12th cycle day). Psychological tests administered were Profile of Mood States, State-Trait Anxiety Inventory, Institute for Personality and Ability Testing (IPAT) Anxiety Scale, IPAT Depression Scale, General Health Questionnaire and the Family Inventory of Life Events (FILE). Demographic data and information concerning present and past stresses were also collected. Women with symptomatic premenstrual change were distinguishable from psychiatric patients on assessment of intermenstrual mood state. They were no different from women within the community at large or from non-symptomatic women. When symptomatic women reported on time periods, which include the premenstrual phase of the cycle, we found results at variance with those obtained in relation to current state mood. While not unlike the women from the community at large in longer term affective characteristics, they were consistently different from non-symptomatic women and sometimes indistinguishable from psychiatric patients. Women with symptomatic premenstrual change also reported higher levels of past external stresses than women taken from the community at large.

The premenstrual syndrome--a reappraisal of the concept and the evidence

The Premenstrual Syndrome (PMS) remains a controversial issue. As a clinical concept it is surrounded by confusion. Attempts to establish a consensus definition have resulted in the majority of women seeking help for such problems excluded from the diagnosis. Furthermore, there is no consensus about how such problems should be treated, with a variety of methods being advocated usually on very uncertain scientific grounds. The issue also has its political implications; there are those who see PMS as a way of reducing the status of women, by linking the normal ovarian cycle to a phenomenon which, on the face of it, impairs women's ability to cope. Yet there are a substantial number of women who experience significant negative changes which vary with the menstrual cycle, and produce long-term effects on their well being and family relationship which can be serious. There is also a real possibility that recurrent perimenstrual mood changes of this kind may increase the likelihood of chronic depressive illness in susceptible individuals. In most respects the features of depression which occurs perimenstrually are essentially similar to those of major depressive disorder, except for the short duration and recurrent pattern. PMS, therefore, remains an issue not only of clinical importance, but of considerable potential relevance to our understanding of major depressive disorder, which is substantially more common in women of reproductive age than in their male counterparts. In this review the concept of PMS, and some prominent operational definitions of it, are critically evaluated; it is now questionable whether the concept, as currently applied, still carries any heuristic or clinical value. Some current theoretical and aetiological issues are considered: e.g. the role of the corpus luteum, the effects of hormonal regimes which block ovulation, such as oral contraceptives, and the possibility that cyclical mood change represents an entrained rhythm in the brain. The conclusions reached at this stage in the review lead to a 'paradigm shift' with the proposal of a three-factor model to account for the complexities of menstrual cycle-related problems.(ABSTRACT TRUNCATED AT 400 WORDS)

General health, health care utilization, and medical comorbidity in dysthymia

OBJECTIVE

This article reviews the literature on the general health, health care utilization, prevalence, medical comorbidity, and treatment of dysthymia in medical settings.

METHOD

The literature was searched by using MEDLINE and by reviewing the bibliographies of recent publications. Studies were selected that included health data on patients with dysthymia or chronic depression according to DSM-III, DSM-III-R, ICD-9, or RDC criteria, or patients who were described as having persistent depressive symptoms.

RESULTS

This review shows that dysthymic patients are at increased risk for poor general health and frequently use medical services. Compared to the general population, dysthymia is more prevalent in primary care and among patients with various medical and neurological conditions, sleep disorders, chronic fatigue, hypothyroidism, and somatoform disorders. Pharmacotherapy is effective, but has not been well studied. Non-tricyclic antidepressants might be especially useful. Psychotherapy studies are virtually non-existent.

CONCLUSIONS

Although dysthymia is considered a minor depressive condition, these findings show that it is a significant public health problem, comparable to major depression. Recent efforts to improve the recognition and treatment of major depression in medical settings, therefore, should be extended to include the entire spectrum of depressive disorders. Future studies should investigate the type and pattern of medical comorbidity and health care utilization, different antidepressant and psychosocial therapies, and the clinical and biological correlates of treatment response in different chronic depressive subtypes in medical settings and compare them to major depressive and subsyndromal depressive conditions.

A psychosocial profile of women with premenstrual dysphoria

Sixty women from the community were used in this study to identify a profile of women who experience premenstrual dysphoria. Women with prospectively confirmed premenstrual dysphoria (PMD +; N = 24) were compared to women with prospectively unconfirmed premenstrual dysphoria (PMD -; N = 15) and controls (PMD control; N = 21). Over one menstrual cycle daily records of physical, emotional and behavioural symptoms were completed on the Daily Ratings Form. Other self report measures obtained were the Premenstrual Assessment Form, Rotter's Internal External Locus of Control, the Locke-Wallace Marital Adjustment Scale, and the State-Trait Anxiety Inventory. A psychiatric history was obtained during an interview. Analyses showed that premenstrually, PMD + and PMD - groups could be significantly differentiated from controls on reports of premenstrual dysphoric changes and levels of state and trait anxiety. Postmenstrually, they could be significantly differentiated from controls firstly, by history of affective disorder and locus of control and secondly, by premenstrual dysphoric changes. There were no significant differences between the PMD+ and PMD- women on most of the self report measures either at pre or post menstrual assessments. The present findings suggest that the characteristic profile of PMD+ and PMD- women is one of being symptomatic premenstrually in relation to dysphoric changes and levels of state and trait anxiety. Postmenstrually these symptoms appear to be superimposed on a background of a history of affective disorder and an external locus of control orientation.

The relationship between perimenstrual depressive mood and depressive illness

In a study of 144 women, mainly self-designated PMS sufferers, the premenstrual depression experienced was, apart from its shorter duration, quantitatively and qualitatively similar to major depressive disorder for a substantial proportion of subjects. The associations with previous history of depression were complex: the severity of premenstrual depression was related to previous history of postnatal depression, whereas its duration (i.e., whether it persisted through longer) was related to a history of treatment with antidepressants. Two independent dimensions are proposed. (i) A menstrual cycle-related factor which in vulnerable women can results in severe and disabling premenstrual dysphoria, and which may be aetiologically related to a subgroup of postnatal depression. (ii) In a minority of women a more general propensity for depressive illness evidence as a tendency for any premenstrual depression to be prolonged.

Blunting of neuroendocrine responses to infusion of L-tryptophan in women with perimenstrual mood change

The neuroendocrine response to L-tryptophan infusion was measured at two stages of the menstrual cycle, premenstrually and postmenstrually, in 13 women with and 13 women without premenstrual depression (the MC and NMC groups respectively). Previous studies have shown that in non-depressed women, this challenge test results in an increase in circulating prolactin and growth hormone. In depressed women both responses are blunted. In this study the growth hormone and cortisol responses were smaller in the MC group than the NMC group on both occasions. The prolactin response was blunted premenstrually compared with postmenstrually in both groups. These findings suggest that women who experience premenstrual depression may have neuroendocrine abnormalities throughout the cycle. The neurotransmitter abnormalities reflected in these altered endocrine responses appear to interact with neuroendocrine changes that normally occur premenstrually resulting in a vulnerability to depression at that phase of the cycle.

Atenolol in premenstrual syndrome: a test of the melatonin hypothesis

Eleven patients with prospectively documented premenstrual depression were given 100 mg atenolol or placebo daily to suppress melatonin secretion during the symptomatic premenstrual phase of the menstrual cycle. There was no significant improvement in mood following treatment with atenolol vs. placebo. These findings suggest that bright light may exert antidepressant effects in patients with premenstrual syndrome through mechanisms other than melatonin suppression and that atenolol does not appear to be a viable treatment modality for the majority of patients with premenstrual depression.

Sexual dysfunction, social maladjustment, and psychiatric disorders in women seeking treatment in a premenstrual syndrome clinic

The NIMH Diagnostic Interview Schedule (n = 43), and the Hopkins Symptom Checklist and Weissman Social Adjustment Scale (n = 35) was administered to assess the prevalence of psychiatric disorders and psychosocial maladjustment present in women seeking treatment in a multidisciplinary Premenstrual Syndrome Clinic. We found a 67 percent lifetime prevalence of DIS/DSM-III psychiatric disorders: 50 percent Major Affective Disorder (primarily Depression), 53 percent Anxiety Disorder (primarily Phobias or Generalized Anxiety Disorder), and 40 percent Psychosexual Dysfunction (notably Inhibited Sexual Desire or Excitement). Our group had significantly greater Major Depression, Dysthymia, and any one psychiatric disorder compared with female general population samples. Two-thirds of women with premenstrual symptoms had true Premenstrual Syndrome. In our sample, social maladjustment as well as psychiatric symptomatology was significantly greater than in normals and closer to that in psychiatric out-patient norms, and was independent of cycle phase. Presence or absence of PMS, social maladjustment and sexual dysfunction was each not significantly different in women with or without psychiatric disorder.

Prevalence of axis I and axis II disorders in women with late luteal phase dysphoric disorder

The authors interviewed 78 female patients with late luteal phase dysphoric disorder and found a 78% lifetime prevalence of axis I disorders but only a 10% prevalence of axis II disorders. A prior depression was the predominant axis I disorder found, and 29% of parous patients had a prior postpartum depression. A comparison of Global Assessment Scale scores obtained at both the follicular and luteal phases of the menstrual cycle confirmed luteal increases in symptoms and role impairment.

Premenstrual depression predicts future major depressive disorder

To assess the power of premenstrual changes as a risk factor for future major depressive disorder (MDD), we conducted a follow-up study of 36 women who had volunteered for menstrual cycle studies. Scores on the depressive subscale of the Premenstrual Assessment Form (PAF) at initial evaluation were found to be significantly correlated (r = 0.35) with the occurrence of MDD during the follow-up period. Moreover, multiple regression analysis indicated that the PAF scores had predictive value above and beyond 2 known risk factors for MDD, family history of depression and prior personal history of depression. The Premenstrual Change Index, a score derived from prospective daily self-ratings of severity of dysphoric symptoms, was also correlated with interval MDD, but did not enhance the predictive power of the PAF score. We conclude that the assessment of premenstrual depression has validity in identifying women at risk for future MDD, even when a retrospective instrument, PAF, is utilized for such assessment.

Longitudinal sleep EEG, temperature, and activity measurements across the menstrual cycle in patients with premenstrual depression and in age-matched controls

After a 2-month evaluation period, eight women with moderate to severe premenstrual depression and eight age- and sex-matched controls underwent sleep electroencephalographic (EEG) and temperature recordings 2 nights a week over the course of one menstrual cycle. Overall, patients had more Stage 2 (%) sleep and less rapid eye movement (REM) sleep (% and minutes) than normal controls. Stage 3 sleep and number of intermittent awakenings varied with phases of the menstrual cycle. Temperature minima were earlier in patients compared with controls, but this difference was not statistically significant, and there was no significant effect of menstrual cycle phase on the timing of temperature minima. Wrist motor activity did not change during the menstrual cycle in patients or controls. Thus, in this sample of women with premenstrual depression, we did not find sleep EEG alterations similar to those reported in some patients with major depressive disorder. In light of the small number of subjects and the large individual variability, the absence of marked changes with the menstrual cycle may be a function of a Type II error.

Premenstrual syndrome. A practical approach to management

Management of premenstrual syndrome (PMS) includes psychosocial as well as medical therapy. Nonmedical treatment involves patient education, physician and family support, stress reduction, and dietary changes. If these methods do not alleviate symptoms, drug therapy may be necessary. Because the exact cause of PMS is unknown, treatment is largely empirical. More research is imperative to improve therapy for patients with PMS.

Correlates of confirmed premenstrual dysphoria

This study found that women with prospective reports of premenstrual dysphoria could be significantly differentiated from others on self-report measures of anxiety, depression and negative self-statements. Women who reported premenstrual dysphoria retrospectively but not prospectively did not significantly differ from controls on any of these measures using the State-Trait Anxiety Inventory, the Beck Depression Inventory and the Automatic Thoughts Questionnaire. Issues for further investigation are highlighted.

Premenstrual syndrome and locus of control

Seventy-six women completed a three-month prospective evaluation for premenstrual syndrome (PMS). As a part of the evaluation, they completed Rotter's Locus of Control (LOC) form in the follicular phase and premenstrually. It was found that the LOC scores of women meeting criteria for PMS rose significantly (became more "external") premenstrually, while scores of women without PMS did not show significant change. In addition, the premenstrual LOC scores of women meeting criteria for PMS were significantly higher than were scores of the non-PMS women. The results are consistent with the idea that cycle related changes in self-perception occur in women demonstrating PMS symptomatology.