Premenstrual Dysphoric Disorder (PMDD) 



 

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, however, considered to be a very severe form of PMS that affects about 5% of menstruating women. PMDD is also a psychiatric term for a major mood disturbance. "Dysphoria" derives from a Greek word meaning "distress" or "hard to bear". It generally refers to a type of depression.


PMDD usually begins when a woman is in her teens to late 20s, although women who seek treatment are usually in their 30s.



PMS vs. PMDD

 

Premenstrual syndrome (PMS) refers to the variation of physical and mood symptoms that appear during the last one or two weeks of the menstrual cycle and disappear by the end of a full flow of menses. This is a diagnosis used by Ob-Gyns and primary care physicians. Psychiatrists and other mental health workers tend to use the diagnosis term of premenstrual dysphoric disorder (PMDD) to describe a specific set of mood symptoms that are also present the week before menses and remit a few days after the start of menses and also interfere with social or role functioning.


PMS looks more at physical symptoms such as bloating, weight gain, breast tenderness, swelling of hands and feet, aches and pains, poor concentration, sleep disturbance, appetite change, and psychologic discomfort.


Premenstrual dysphoric disorder has as part of its definition, symptoms such as depressed mood or dysphoria, anxiety or tension, emotional lability, irritability, decreased interest in usual activities, concentration difficulties, marked lack of energy, marked change in appetite, overeating or food cravings, sleepiness or insomnia, and feeling overwhelmed.


Symptoms of Premenstrual Dysphoric Disorder


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.

For a PMDD diagnosis a woman must regularly experience five or more of the symptoms listed in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) during the premenstrual period, and the symptoms must seriously impair her ability to function on a day-to-day basis.


Physical Symptoms

Some physical discomfort or pain accompany PMDD , including weight gain, bloating and tenderness in the breast, abdomen or groin area, headache, and muscle or joint aches.


Emotional and Psychological Symptoms

 


Causes of PMDD:

 

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.



Genetics may play a role. Studies have shown that identical twins are more likely to share the disorder (93%) than non-identical twins (fraternal) (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.

 

A woman may be more likely to suffer from PMDD if she has had a major depressive disorder or has bipolar disorder, or if someone in her family has suffered from one of these conditions.


The experts recommend that women with severe symptoms use all the above approaches.

But, for women with less severe symptoms, it may not be necessary to use all 3 approaches at once.



Medications for PMDDTo treat the emotional symptoms of PMDD (e.g., depression, tearfulness, mood swings, anxiety, anger, irritability, fatigue, difficulty concentrating), the majority of experts recommend antidepressant medications. One of the most important treatments for PMDD, then, has been to prescribe selective serotonin reuptake inhibitors, commonly known as SSRIs. The better-known SSRIs include such popular brand names as Prozac�, Zoloft�, Paxil�, Celexa�, and Luvox�. SSRIs have been successful in treating the depression of many sufferers and have relatively few side effects.


In case of severe physical symptoms (headache, cramps, bloating, or water retention), the doctor would combine the antidepressant with a medication for these physical symptoms, such as a diuretic, an over-the-counter pain medicine such as ibuprofen (Motrin), or a prescription pain medicine, depending on the particular problems.


Note: Don�t stop or change the dose of your medication without first consulting your doctor.



Nutritional Strategies

  • Limiting consumption of alcohol, caffeine, and salt to minimize their potential adverse effects (eg, nervousness, jitteriness, bloating).

  • Avoiding sugar and eating more complex carbohydrates to avoid symptoms resembling hypoglycemia. One study reported that a commercially available carbohydrate-rich beverage improves mood, appetite, and cognitive function when taken in the late luteal phase.

  • Calcium supplementation during the luteal phase has proven beneficial with regard to bloating, pain, mood, and food cravings.

  • One recent nonrandomized trial found that a low-fat vegetarian diet reduced premenstrual symptoms.


Behavioral Approaches

  • Regular exercise is strongly recommended. Although exercise has not been studied specifically in PMDD, it has shown benefit in PMS- aerobic exercise traditionally is recommended, particularly if depressive or fluid retention symptoms predominate. The efficacy of exercise could be because of raised endorphin levels, physiologic changes, and psychological changes.

  • Relaxation techniques, meditation, and yoga are recommended-Relaxation response is a physiological response that results in decreased metabolism, decreased heart rate, decreased blood pressure, decreased rate of breathing, and slower brain waves. The repetition of a word, a sound, a prayer, a phrase, or a muscular activity is required to elicit the relaxation response. Most studies of relaxation techniques have used them as an adjunct to other modalities of therapy.

  • Psychotherapies may prove helpful like, cognitive-behavioral and interpersonal therapies, supportive counseling-Cognitive treatment teaches the patients about ways to examine these negative patterns and replace them with more adaptive ways of viewing life events. Cognitive-behavioral therapy for PMDD includes anger control, thought stopping, and reduction of negative emotions through cognitive restructuring.

For severe symptoms that have not responded to any other strategies, the doctor may also discuss using medication to block ovulation (creating a �chemical menopause�).Since ovulation appears to be the trigger for PMDD, the cessation of ovulation is clearly warranted for extreme cases. A medical method for causing the cessation of ovulation is the use of gonadotropin-releasing hormone agonists (GnRH agonists). The problem with GnRH agonists, however, is that many women find the side effects unacceptable. They include weight gain, increased facial hair, and acne, among others. Worse yet, the cost of this medication is very high�almost $500 a month.


A second method for stopping ovulation is with hormonal treatments. For example, scientists are studying the use of progestin and estradiol. Results are not available, though, and these approaches have not yet been deemed safe and effective for PMDD.A third strategy for ending ovulation prior to menopause is the surgical removal of the ovaries. Needless to say, this is a drastic and invasive approach that is reserved for extreme cases. The effects of such surgery are similar to the onset of menopause: increased risk of osteoporosis and loss of libido are