CRITERIA FOR DIAGNOSIS
An estimated 3% to 8% of women of reproductive age suffer from premenstrual dysphoric disorder. Health care providers have made many attempts to define PMDD and its characteristics to help distinguish it from the common and simple symptoms of PMS.
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) defines PMDD as a “depressive disorder not otherwise specified,” emphasizing its emotional and cognitive-behavioral symptoms. To be diagnosed with premenstrual dysphoric disorder, a patient must experience at least five of 11 symptoms given in DSM-IV. Table 2 lists the criteria. According to DSM-IV, the five symptoms must occur during the luteal phase to eliminate diagnosis of PMS.
| Table 2. Research Criteria for PMDD |
| A. |
In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week postmenses, with at least one of other symptoms being either (1), (2), (3), or (4): |
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1. |
Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts |
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2. |
Marked anxiety, tension, feelings of being “keyed up” or “on edge” |
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3. |
Marked affective lability, e.g., feeling suddenly sad, tearful, or experiencing an increased sensitivity to rejection |
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4. |
Persistent and marked anger, irritability, or increased interpersonal conflicts |
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5. |
Decreased interest in usual activities, e.g., work, school, friends, hobbies |
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6. |
Subjective sense of difficulty in concentrating |
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7. |
Lethargy, easily fatigued, or marked lack of energy |
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8. |
Marked change in appetite, overeating, or specific food cravings |
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9. |
Hypersomnia or insomnia |
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10. |
A subjective sense of being overwhelmed or out of control |
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11. |
Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” or weight gain |
| B. |
The disturbance markedly interferes with work or school or with usual social activities and relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work or school). |
| C. |
The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although it may be superimposed on any of these disorders). |
| D. |
Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. (The diagnosis may be made provisionally prior to this confirmation.) |
| Note: In menstruating females, the luteal phase corresponds to the period between ovulation and the onset of menses, and the follicular phase begins with menses. In nonmenstruating females (e.g., those who have had a hysterectomy), the timing of luteal and follicular phases may require the measurement of circulating reproductive hormones. |
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If the timing of symptoms is not considered, patients may be misdiagnosed, or their condition can be confused with psychiatric disorders (e.g., major depression and generalized anxiety). Patients may also have other menstrual disorders such as endometriosis and dysmenorrhea that may be misinterpreted as premenstrual dysphoric disorder if the guidelines are not followed. Regarding complaints of PMDD, it is important to note the cyclic pattern of symptoms that occur during the menstrual cycle. Patients with PMDD most often experience symptoms a week before menstruation, which abate with menses. The timeframe of symptoms is crucial to prevent confusion with other preexisting or comorbid disease states.
In addition to having the required five symptoms during the luteal phase, symptoms must be confirmed for two consecutive menstrual cycles.Unfortunately, there are no clinical laboratory tests or scientific methods to determine a patient’s symptoms aside from subjective data. Laboratory tests (e.g., thyroid function tests, complete blood count, and FSH and estradiol levels) are often only used to rule out other disease states or causes of symptoms. Therefore, symptoms must be carefully recorded to understand menstrual-related conditions. Patients are strongly encouraged to maintain a diary of symptoms before and after menses to determine the time at which these symptoms occurred. It is essential to understand whether the symptoms and symptom-free phases correlate with the patient’s luteal and follicular phases. Once again, this is important to prevent misdiagnosing a patient with PMDD. A written log is also important in establishing baseline symptoms to determine whether they are improving or worsening with treatment and the patient’s age. (See Table 3 for laboratory tests, procedures, and assessments.) Also, a few standardized tests and questionnaires have been developed to measure a patient’s functional impairment, mood dimensions, and quality of life. Some common standardized tests and questionnaires available to rate a patient’s symptoms include PMS Diary, Menstrual Distress Questionnaire, Hamilton Depression Rating Scale, and Quality of Life Questionnaire. Each questionnaire is designed to evaluate a patient’s symptoms throughout the menstrual cycle. When counseling patients on the questionnaires, it is critical to inform them of the importance of recording baseline symptoms. The goal of therapy is to reduce premenstrual symptoms by at least 50% or more. If a patient finds that her premenstrual symptoms are similar to postmenstrual symptoms, the minimum goal of therapy is reached. It is recommended that at least three menstrual cycle symptoms be recorded to determine the effectiveness of treatment and to allow for proper dose and therapy changes.
| Table 3. Evaluation of Menstrual-Related Disorders |
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Psychiatric Evaluation
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Past psychiatric history, e.g., mood disorders and alcohol/substance abuse |
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History of symptoms, i.e., onset, duration, course, precipitating factors, previous treatment, and response |
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Family history for PMS and mood disorders; treatment of other family members |
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Medical Evaluation
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Past and current history for endocrine and gynecological disorders such as dysmenorrhea, endometriosis, fibrocystic breast disease, thyroid abnormalities, abnormal PAP test results, or irritable bowel syndrome |
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Physical and pelvic exam |
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Laboratory Tests
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| • |
Chemistry panel, complete blood count with differential, and thyroid function tests, i.e., R/O anemia, hypothyroidism, or other disease states |
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Other tests: FSH and estradiol, to R/O estrogen deficiency if perimenopausal or symptoms of irregular bleeding or hot flashes |
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Prolactin, to R/O cause of irregular menses or amenorrhea |
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Vitamin B6, B12, folate, magnesium, and calcium, to R/O deficiencies |
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Medication Use
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History of OTC and prescription medications, e.g., psychoactive drugs, those that predispose the patient to psychiatric conditions |
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Social habits (e.g., caffeine, alcohol, and substances/illicit drugs), oral or injectable hormonal contraceptives |
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Nutritional Evaluation |
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Assessment of diet, i.e., protein, complex carbohydrates, phytoestrogens, salt, minerals, calcium, trace elements, and vitamins |
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Exercise and Sleep Evaluation
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Assessment of adequate and regular exercise |
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Good sleep habits |
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Self-Rating PMS
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Two months of prospective daily rating symptoms using the PMS rating scale (e.g., Menstrual Distress Questionnaire, PMS Diary, and Daily Rating Form). Compare average ratings of luteal phase to follicular phase (5 to 7 days postmenses and 5 to 7 days premenses); > 3050% change in severity ratings required for PMS plus a symptom-free week postmenses |
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Other Evaluations
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Daily basal body temperatures to determine ovulation |
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Morning and evening weights to monitor fluid retention |
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