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Consumer & Family Information: Premenstrual Dysphoric Disorder
Psychiatric Services 2001; doi: 10.1176/appi.ps.52.8.1019
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A woman who has premenstrual dysphoric disorder (PMDD) experiences severe depression, irritability, and/or mood swings that interfere with relationships, social functioning, and work or school. The symptoms of PMDD start seven to 14 days before menstruation, and they resolve a few days after menstruation starts.

The term premenstrual dysphoric disorder is a medical term that makes sense when broken down into its individual parts. Disorder is a term used to describe a group of symptoms that impair health. The symptoms are described as premenstrual because they occur before menstruation. The word dysphoric is a Greek word, which literally means "ill-being." Dysphoria is the opposite of a more common word, euphoria (or "well-being").

Premenstrual syndrome (PMS) is a condition that affects some women before they menstruate each month. Physical symptoms—such as breast tenderness, cramps, abdominal bloating, headaches, and cravings for starchy foods—are common. Mood symptoms include depression, anger, irritability, and anxiety. Other problems include social withdrawal and difficulty concentrating and thinking.

Many women have one or more of these symptoms before they menstruate, but the symptoms usually are mild and do not interfere with their ability to function. Making lifestyle changes—such as getting regular exercise, quitting smoking, drinking less caffeine, and learning how to manage stress—may help relieve symptoms. For some women who have PMS, physicians may prescribe birth control pills or select a different birth control pill, which can relieve some symptoms. The physician also may prescribe diuretics, which help the body eliminate the excess water that causes bloating.

Although the mood symptoms associated with PMS sound similar to PMDD, they are different in one key respect: PMDD is much more severe. Premenstrual dysphoric disorder should be diagnosed only when mood symptoms seriously impact relationships and impair functioning at work or school. Depending on how broadly it is defined, between 20 percent and 50 percent of women live with PMS, but only 3 percent to 8 percent of women are estimated to have PMDD.

The term PMDD was added to the appendix of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, in 1994. (The DSM-IV is the standard text of mental disorders published by the American Psychiatric Association). The psychiatrists who developed the DSM-IV added PMDD to the appendix to provide a common definition of the problem so scientists could study whether some women with premenstrual symptoms suffer so seriously that their symptoms should be considered a disease. Adding a condition to the appendix of the DSM-IV does not mean it is a disease. Only further study and scientific evidence can establish whether PMDD is a disease.

According to the research criteria in the DSM-IV, a woman may have PMDD if she has five or more of the following symptoms during the week before menstruating for most of her menstrual cycles in the last year. (It is important to note that a woman may have PMDD only if the symptoms are tied to the menstrual cycle. If they are not, then she may have another condition.)

• Depression (hopelessness; more than just feeling sad or blue)

• Anxiety (feeling "keyed up" or "on edge")

• Severe mood swings (feeling suddenly sad or extremely sensitive to rejection)

• Anger or irritability

• Decreased interest in usual activities (work, school, friends, and hobbies)

• Difficulty concentrating

• Decreased energy

• Appetite changes (overeating or cravings for certain foods)

• Sleep problems (insomnia, early morning waking, or oversleeping)

• Feeling overwhelmed or out of control

• Physical symptoms, such as bloating, breast tenderness, and headaches

The symptoms of PMDD end with menopause, when menstruation stops and the levels of hormones in the body that regulate menstruation no longer rise and fall each month.

According to the appendix of the DSM-IV, a psychiatrist or other physician can diagnose PMDD only if the woman has five or more of the symptoms described above for most menstrual cycles and if those symptoms seriously impair her relationships with others and her ability to be productive at work or school.

A psychiatrist or other physician also will need to consider and rule out other possible causes of the symptoms—such as thyroid problems or lupus—or another mental disorder, such as depression or an anxiety disorder. The symptoms of all these conditions may worsen before menstruation and so could be confused with PMDD.

To determine if a woman has PMDD, she will be asked to keep a mood and symptom journal every day for at least two months. It is easy in hindsight to think symptoms occurred around the time of menstruation. For this reason, keeping a journal over time is necessary to show with more certainty if the mood or functioning problems truly began one to two weeks before menstruation and improved within a few days of menstruation starting. Also, without the information provided in the journal, it could be difficult to identify another medical or mental health condition causing the symptoms.

In some cases two separate records may be suggested: a calendar marking the days of menstruation and a journal of mood and behavior throughout the entire month. Keeping these two records separate helps prevent incorrectly associating mood changes with the menstrual cycle.

The same lifestyle changes that sometimes help women with PMS may help relieve the symptoms of PMDD. In most cases, however, PMDD symptoms will persist despite such efforts.

Studies show some women with PMDD may benefit from treatment with antidepressants called selective serotonin reuptake inhibitors (SSRIs). These medications also are prescribed commonly for depression, but for women with PMDD they usually work more quickly and are prescribed in lower dosages to be taken for just part of each month.

The U.S. Food and Drug Administration has approved one SSRI, Sarafem (fluoxetine), for the treatment of PMDD. Sarafem is the same chemical compound as Prozac, but the manufacturer renamed it for the treatment of PMDD. Recent studies have found that other SSRIs used to treat depression—such as sertraline, citalopram, and paroxetine—also are effective for treating PMDD. Because different women will tolerate some medications better than others, a physician might prescribe one of these other SSRIs. It is a legal and common practice for physicians to prescribe medications "off-label," which means that a medicine approved by the FDA to treat one illness can be prescribed to treat another illness.

With treatment, most women with PMDD will be able to lead more satisfying lives, without the cycles of severe distress and limited functioning caused by the disorder.




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