- Email: [email protected]
Mood Instability in Women With Premenstrual Syndrome
Women’s Health
Mood Instability in Women With Premenstrual Syndrome Rudy Bowen, MDCM, FRCPC,1 Angela Bowen, PhD,1,2 Marilyn Baetz, MD, FRCPC,1 Jason Wagner, MA,1 Roger Pierson, PhD3 1
Department of Psychiatry, University of Saskatchewan, Saskatoon SK
2
College of Nursing, University of Saskatchewan, Saskatoon SK
3
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Saskatchewan, Saskatoon SK
Abstract
Résumé
Objective: Most women of reproductive age experience premenstrual symptoms. Mood swings within a day and from day to day are a common complaint of people with mood problems (mood instability). We investigated whether mood instability was higher in women with premenstrual syndrome (PMS) than in a control group with no PMS.
Objectif : La plupart des femmes en âge de procréer connaissent des symptômes prémenstruels. Les sautes d’humeur se manifestant pendant une journée et d’une journée à l’autre constituent une plainte courante signalée par les gens qui présentent des troubles de l’humeur (instabilité de l’humeur). Nous nous sommes penchés sur la question de savoir si l’instabilité de l’humeur était plus accentuée chez les femmes qui présentent le SPM que chez les femmes d’un groupe témoin ne présentant pas ce dernier.
Methods: We prospectively studied mood and physical symptoms over two menstrual periods in 29 women with self-identified PMS and 31 women without PMS. We excluded women on hormonal birth control or with a history of past or current diagnoses of depression. We used the mean square successive difference derived from twice daily visual analogue scale ratings of mood as the measure of mood instability. Results: The women with PMS showed more irritable and depressed mood instability than the women without PMS. These differences were present whether or not the late luteal phase (seven days before the start of menstruation) was included in the data. On visual inspection of mood ratings, typically irritable and depressed moods increased in the late luteal phase. However, women with self-identified PMS showed a variety of mood patterns throughout the cycle. Conclusion: Women with PMS have increased mood instability within the seven day premenstrual phase and at other times as well. This supports the premise that PMS may represent a manifestation of an underlying problem of mood dysregulation in common with other mood disorders.
Key Words: Depression, irritability, mood instability, premenstrual, premenstrual syndrome Competing Interests: None declared.
Méthodes : Nous avons étudié, de façon prospective, les symptômes physiques et de l’humeur au cours de deux cycles menstruels chez 29 femmes présentant un SPM auto-signalé et chez 31 femmes ne présentant pas le SPM. Nous avons exclu les femmes qui prenaient une contraception hormonale ou qui présentaient des antécédents (ou un diagnostic courant) de dépression. Nous avons utilisé le carré moyen des différences successives tiré des scores d’humeur (établis deux fois par jour selon l’échelle visuelle analogue) à titre de mesure de l’instabilité de l’humeur. Résultats : Les femmes présentant le SPM connaissaient une instabilité de l’humeur plus penchée vers l’irritabilité et la dépression que les femmes ne présentant pas le SPM. Ces différences étaient présentes, et ce, peu importe si la phase lutéale tardive (sept jours avant le début des règles) était incluse ou non dans les données. Selon les scores d’inspection visuelle de l’humeur, la fréquence des humeurs typiquement irritables et déprimées connaissaient une hausse au cours de la phase lutéale tardive. Toutefois, les femmes présentant un SPM auto-signalé connaissaient une variété de profils d’humeur tout au long du cycle. Conclusion : Les femmes présentant le SPM connaissent une instabilité accrue de l’humeur au cours des sept jours de la phase prémenstruelle, ainsi qu’à d’autres moments au cours du cycle. Cela soutient l’hypothèse selon laquelle le SPM pourrait représenter l’une des manifestations d’un problème sous-jacent de dérèglement de l’humeur que l’on constaterait également dans le cadre d’autres troubles de l’humeur.
Received on February 8, 2011 Accepted on May 9, 2011
J Obstet Gynaecol Can 2011;33(9):927–934
SEPTEMBER JOGC SEPTEMBRE 2011 l 927
Women’s Health
INTRODUCTION
M
ost women of reproductive age experience premenstrual symptoms. Twenty to fifty percent have a broad variably defined premenstrual syndrome, but only 1.3% to 5% meet the diagnostic criteria for premenstrual dysphoric disorder established by the American Psychiatric Association in the DSM-IV.1–6 PMS occurs only during the reproductive years (not before menarche, during pregnancy, or after menopause) and is improved by bilateral oophorectomy, treatment with oral contraceptives containing drospirenone and ethinyl estradiol, or treatment with GnRH analogues that suppress ovulation.3,7,8 Despite its frequency, the etiology and pathophysiology of PMS are poorly understood.2,3 Several recent general reviews of PMS have been published.5,9,10 Key characteristics of PMS include a lack of symptoms during the follicular phase, a peak of symptoms during the late luteal or premenstrual phase, and a sudden decrease of symptoms with the onset of menses.11 It is difficult to distinguish PMS from worsening of previously existing mood disorders in the luteal phase because of the overlap and similarity of symptoms in the luteal phase.12 However, depression associated with PMS has been described typically as involving more anxiety, agitation, and mood lability than melancholic change.13 The most commonly reported and bothersome mood symptom of PMS is irritability.11,12,14–16 The most common physical symptoms are fatigue, a sense of bloating, breast tenderness, and food cravings.17 Typically, the rank ordering of symptoms tends to be stable across menstrual cycles in the same woman,5,17 but the day of onset and offset of symptoms is variable.11 In the search for causes of PMS, mean serum levels of ovarian steroids have been found to be within normal limits in women with PMS, but there seems to be greater variation in the levels of luteinizing hormone, estradiol, and 5-HIAA (a metabolite of serotonin) in these women.18 One theory is that PMS shares vulnerability traits with mood or
ABBREVIATIONS BDI
Beck Depression Inventory
DRSP
Daily Record of Severity of Problems
DSM-IV Diagnostic and Statistical Manual of Mental Disorders, fourth edition MINI
Mini International Neuropsychiatric Interview
MSSD
mean square successive difference
PMS
premenstrual syndrome
SEM
standard error of the mean
VAS
visual analogue scales
928 l SEPTEMBER JOGC SEPTEMBRE 2011
anxiety disorders, but the support for this idea is mainly from retrospective studies.7,19 On the basis of these reports and the description of mood lability13 we hypothesized that there is a common proclivity to mood dysregulation between PMS and other mood disorders.20 This indicates a need to determine whether women complaining of PMS show evidence of mood instability in other phases of the menstrual cycle, excluding the premenstrual phase. We hypothesized that a group of women with PMS but without any psychiatric disorder would show greater mood instability than a control group of women without PMS. To show a general tendency towards mood dysregulation, we anticipated that mood instability in the study group would be higher in other phases of the menstrual cycle, i.e., with the late luteal (premenstrual) phase excluded. Approval for the study was obtained from the University of Saskatchewan Behavioural Research Ethics Board. Participants gave signed informed consent and were paid a small stipend after each month of the study. METHODS
Sixty-two women between the ages of 18 and 40 years, who were medically healthy and who had regular menstrual cycles and intermenstrual intervals lasting approximately one month, were recruited. We excluded women who were presently using hormonal birth control or any hormonal treatment, were pregnant or lactating, were taking any psychiatric medication, had ever been treated for any psychiatric or psychological disorder, or had any medical or endocrine condition that might affect mood. We recruited through advertisements around the university, local gymnasiums, and family physician clinics but focused on recruitment from women’s gymnasiums since we presumed that these women were more likely to be healthy. Potential participants were not informed about the study hypothesis but were told that the study would explore symptoms during the menstrual cycle. All potential participants denied having suffered from clinical depression. They completed the Beck Depression Inventory, and anyone with a score of 20 or greater was excluded from participation.21 This threshold score excluded women with clinical depression but allowed the inclusion of women with mild depressive symptoms, because we wished to assess these as symptoms of PMS. The women then underwent the Mini International Neuropsychiatric Interview administered by a trained research assistant. Any ambiguities in the MINI findings were clarified with a psychiatrist.22
Mood Instability in Women With Premenstrual Syndrome
Table 1. Demographic characteristics of the PMS and non-PMS groups
Age, mean (SD)
PMS n = 29
Non-PMS n = 31
30.2 (6.2)
29.6 (6.8)
Marital status
0.697* 0.515†
Single
11 (37.9)
16 (51.6)
Common law/married
16 (55.2)
14 (45.2)
2 (6.9)
1 (3.2)
9 (31.0)
5 (16.1)
Divorced/separated Annual income, $ < 20 000
P
0.160‡
20 000 to 39 000
6 (20.7)
6 (19.4)
40 000 to 59 000
4 (13.8)
5 (16.1)
60 000 to 79 000
5 (17.2)
4 (12.9)
≥ 80 000
3 (10.3)
7 (22.6)
Rather not say
2 (6.9)
4 (12.9)
Grade 12 or GED
2 (6.9)
3 (9.7)
Some post-secondary
8 (27.6)
14 (45.2)
Post-secondary
19 (65.5)
14 (45.2)
Education
0.282†
GED: General Education Development Data shown as mean (SD) or n (%). *Student t test †Pearson chi-square ‡Mann-Whitney U test, excluding “Rather not say”
The PMS group (n = 30) included women who identified at least one mood symptom during the premenstrual phase as moderately severe, causing impairment in at least one area of daily living, and improving with the onset of menses. The premenstrual phase was defined as one week before menstruation.1 The criteria were deliberately broad to include women who might complain of PMS symptoms to a physician. The non-PMS control group (n = 32) were women who specifically denied on direct questioning that they suffered from PMS symptoms. Because prospective rating has been shown to be superior to retrospective reporting,23 participants recorded symptoms for two complete menstrual cycles beginning on the fifth day of a menstrual cycle. The research assistant contacted participants regularly by telephone to address potential questions about data recording and to ensure ongoing data collection. For data collection, we used visual analogue scales, the Beck Depression Inventory, the Altman SelfRating Mania Scale, the Affective Lability Scale, and the Daily Record of Severity of Problems.
bed.24–27 The VAS mood scales have been validated against observer-rated and self-rated scales for premenstrual tension symptoms and have also been shown to be sensitive to change.28,29
Four visual analogue scales measured “depressed,” “anxious/tense,” “enthusiastic/bursting with energy,” and “angry/irritable” moods. Participants completed these scales in the morning after rising and in the evening before
The Affective Lability Scale consists of 18 items that measure mood switches between depression, high mood, anxiety, and anger. A one-week time frame was used. This short form correlates highly (r = 0.94) with the longer
The Beck Depression Inventory is a widely used 21-item self-completed questionnaire that emphasizes cognitive symptoms of depression over the past two weeks. It is reliable and correlates well with other measures of depression.21,30 The two-week time frame was used for initial screening to approximate criteria for major depression in DSM-IV,1 but the time frame was one week when participants used this questionnaire for data recording during the study data collection phase. The Altman Self-Rating Mania Scale consists of five items that assess symptoms of hypomania: feeling cheerful, having more self-confidence, needing less sleep, talking more than usual, and being more active. A one-week time frame was used. We chose the scale because it is brief, uses common words, and correlates well with other scales for hypomania.31
SEPTEMBER JOGC SEPTEMBRE 2011 l 929
Women’s Health
Table 2. Comparisons between PMS and non-PMS groups using data from the follicular phase to the subsequent menses, excluding the late luteal phase Variable
PMS, n = 29 Mean (SD)
Non-PMS, n = 31 Mean (SD)
t (df = 58)
P
VAS Depressed instability
01.48 (1.08)
00.91 (0.91)
2.23
0.029
VAS Irritable instability
01.83 (1.22)
01.17 (0.86)
2.44
0.018
VAS depressed mean
01.31 (1.13)
00.93 (0.94)
1.39
0.170
VAS irritable mean
01.81 (1.58)
01.16 (1.06)
1.91
0.062
BDI mean
08.51 (6.45)
04.73 (4.37)
2.67
0.010
ALS mean
29.87 (9.77)
27.03 (7.95)
1.24
0.219
ASRM mean
04.21 (2.80)
03.73 (2.69)
0.69
0.496
BDI instability
04.93 (3.38)
03.14 (2.37)
2.39
0.020
DRSP mean
16.71 (5.55)
13.89 (5.42)
1.99
0.052
DRSP instability (MSSD)
02.82 (2.01)
02.15 (1.39)
1.51
0.137
DRSP variability (SEM)
01.25 (0.70)
00.82 (0.46)
2.86
0.006
Number of days follicular + menstrual
19.59 (4.37)
19.90 (4.41)
−0.28
0.781
ALS: affective lability scale; ASRM: Altman Self-Rating Mania Scale.
(54 item) version. The three main factors measure anxiety/ depression, depression/elation, and anger switches.32 The Daily Record of Severity of Problems assesses 11 physical and psychological symptoms associated with the menstrual cycle. We used eight of the items to assess daily psychological (mood swings, less interest, difficulty concentrating, lethargy, feeling overwhelmed) and physical (sleep, appetite, breast tenderness) symptoms, omitting depression, anxiety, and irritability because these moods were assessed by the VAS. The whole scale has good internal consistency, test-retest reliability, and concurrent validity compared with other mood and quality of life scales.33 We measured mood instability by using the VAS ratings to calculate the mean square successive difference statistic for each mood.34,35 The MSSD assesses point-to-point variability and temporal dependency in a time series.34 Visual inspection of the symptom daily ratings revealed that participants showed gradual oscillations in some symptoms over the menstrual cycle. The standard error of the mean is more suitable for capturing gradual variation in responses than the MSSD.34 We used the terms “instability” when the MSSD was calculated and “variability” when the SEM was used. Demographic characteristics between the groups were compared by t tests, Mann-Whitney U-tests, and chi-square tests where appropriate. We first did a preliminary comparison of the two groups that showed some differences in mood symptoms and mood instability (MSSD). This was expected because the selection of the PMS group was based on mood 930 l SEPTEMBER JOGC SEPTEMBRE 2011
symptoms during the premenstrual phase. We then tested the hypothesis by excluding the premenstrual phase (seven days before the start of menstruation) from the data. RESULTS
One participant from each group had missing data, which left 29 women in the PMS group and 31 in the non-PMS group. The women in the PMS and non-PMS groups did not differ in any measured demographic characteristics, including age, income, education, and marital status (Table 1), and there were no differences in any of the diagnostic categories. Three participants in the non-PMS group met symptom criteria but not full diagnostic criteria for past major depression on the MINI standard psychiatric interview. Two women in the non-PMS group and one woman in the PMS group reported symptoms of past hypomania. These participants were retained because they denied past histories of mood disorders, and if anything these findings would bias the results against the hypotheses. We first performed an exploratory comparison of the PMS and non-PMS groups on the mood scales. Across the whole menstrual cycle the groups were different in mean scores for VAS irritable mood (PMS 1.95 [SD 1.56], no PMS 1.17 [SD 1.05] ; P = 0.026) and for DRSP (PMS 18.46 [SD 5.99], no PMS 14.00 [SD 5.21]; P = 0.006). When the seven days of the late luteal phase were excluded from the data as shown in Table 2, the PMS group scored higher on both depressed mood instability and irritable
Mood Instability in Women With Premenstrual Syndrome
Figure 1. Representative mood, sleep, and breast tenderness charts from participants in the PMS group with typical PMS pattern. Dark squares represent menstruation. Participant 3 Depressed
10 5 0
Irritable
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
10 5 0
Sleep
6 4 2 0
6
Breast tenderness
4 2 0
Figure 2. Representative mood, sleep, and breast tenderness charts from participants in the PMS group with unstable mood throughout the cycle. Dark squares represent menstruation and dark circles show spotting. Participant 2 Depressed
10 5 0
Irritable
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
10 5 0
Sleep
6 4 2 0
Breast tenderness
6 4 2 0
SEPTEMBER JOGC SEPTEMBRE 2011 l 931
Women’s Health
Figure 3. Representative mood, sleep, and breast tenderness charts from participants in the PMS group with high depression throughout the cycle. Dark squares represent menstruation and dark circles show spotting. Participant 6 Depressed
10 5 0
Irritable
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
14
21
28
35
42
49
56
10 5 0
Sleep
6 4 2 0
6
Breast tenderness
4 2 0 0
7
mood instability. The standard error of the mean for depression (BDI) and for severity of symptoms (DRSP) was also higher in the PMS group. Visual inspection of the symptom graphs showed that there are a variety of patterns of physical and psychological symptoms that women refer to as PMS.19 Several women reported that they had PMS but recorded depression or variable depression during most of the luteal phase or throughout the cycle, with no discernible premenstrual peak (Figures 1 to 3). Several women reported that symptoms continued into the first few days of menstruation and gradually decreased during the menstrual phase.16 The individual symptoms also varied to some extent from cycle to cycle.15 DISCUSSION
The main findings of this study are the significant differences between women with and without PMS when the data from the late luteal (premenstrual) phase were excluded from analysis. Women with PMS report more irritable and depressed mood instability on the VAS (MSSD), more weekly depressed symptom instability on the BDI (MSSD), and more variability in severity of 932 l SEPTEMBER JOGC SEPTEMBRE 2011
symptoms on the DRSP (SEM) than women without PMS. That is, women with PMS show more unstable moods through all phases of the menstrual cycle, suggesting an underlying mood dysregulation. Presumably, the symptoms that are most prominent during the premenstrual phase occur because of hormonal changes during this phase. This is consistent with the view that mood symptoms at other phases of a woman’s life and her premenstrual mood symptoms have in common a tendency towards mood dysregulation, but the precipitants may differ.36,37 One criterion for inclusion in our study was a score of < 20 on the initial BDI, because 20 is the generally accepted cut-off level for clinical depression on the BDI.21 The BDI mean scores were within normal limits in both groups (Table 2).21 A few women (mostly in the non-PMS group) reported mood symptoms in the past during the MINI interview. All of these women denied any history of a mood disorder. It is likely that standard interviews done by lay interviewers (such as the MINI) are overinclusive.38 It is unlikely, therefore, that we measured premenstrual exacerbations of depressive symptoms that were part of a diagnosable mood disorder.
Mood Instability in Women With Premenstrual Syndrome
There is considerable similarity between mood disorders in psychiatric patients and mood symptoms in PMS.10,39 Also, several10,40 but not all41 studies have found an association between PMS symptoms and depression at other times in women’s lives. In contrast, PMS is different from typical mood disorders because of the inclusion of physical symptoms such as breast tenderness and bloating, the disappearance of symptoms with pregnancy and menopause, and the immediate treatment response to low-dose specific serotonin reuptake inhibitor antidepressants.10 Because of the description of high moods in postpartum depression, we examined the individual mood graphs for a pattern of high moods or hyperthymia in the premenstrual phase.42,43 None of the women in our study showed this, although several women recorded high moods on the VAS, but with no discernible pattern.23,44 The broad syndrome of high moods comprises components of euphoria, activation, and anger that are notoriously difficult to elicit reliably.45 As in bipolar spectrum disorders, it is possible that the instruments we used were not adequate to elicit symptoms of hypomania or that women did not recognize these symptoms when they occurred.46 There have been many attempts to define premenstrual syndrome more precisely, but there is no universal agreement.5 Suggested criteria are difficult to apply clinically either because they are vague or because they are specific but have not been tested clinically.5 For this reason we chose to study the inclusive syndrome of self-defined PMS. The major limitation of this study is that we recruited a sample of women with self-identified premenstrual syndrome. If we were to repeat the study, we would apply the clinically relevant criteria developed by Halbreich.5 Strictly defined premenstrual dysphoric disorder (as specified in DSM-IV) affects only 1.3% of women of reproductive age.6 The DSM criteria have changed with different editions and may change again with DSM-5.15 It is possible that increased mood instability in the PMS group was caused by the women in our study reporting on an extended PMS phase (i.e., outside the seven days that we excluded). It would be possible to screen a large number of women prospectively to select a group who had symptoms only in a strictly defined premenstrual phase, but this group would then be so carefully selected that any data derived from them could not be generalized to women seen in clinical practice. The paper and pencil VAS scales that we used do not have the advantage of electronic scales that that record the time of entries. However, all of the participants were committed to the study, and they were contacted regularly to answer any questions or concerns
about completing the measures.47 Finally, we assessed symptoms comprehensively, and this resulted in a number of tests being used. We did not correct for the number of tests, and so the results must be regarded as preliminary. CONCLUSION
Women with complaints of PMS have more irritable and depressed moods both during the premenstrual phase and at other times. The irritable and depressed moods in these women vary in intensity and are changeable within a day and from day to day in contrast to the perception that anger or depression is steady throughout the premenstrual phase. A conclusion of these findings is that mood instability is similar between PMS and other mood syndromes. REFERENCES 1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994. 2. Steiner M, Born L. Psychiatric aspects of the menstrual cycle. In: Women’s mental health: a comprehensive textbook. Kornstein S, Clayton A, eds. New York (NY): The Guilford Press; 2002:48–69. 3. Ismail KMK, O’Brien S. Premenstrual syndrome. Curr Obstet Gynaecol 2005;15:25–30. 4. Pearlstein T. Prevalence, impact on morbidity, and disease burden. In: The premenstrual syndromes: PMS and PMDD. O’Brien S, Rapkin A, Schmidt PJ, eds. London: Informa Healthcare; 2007:37–47. 5. Halbreich U, Backstrom T, Eriksson E, O’Brien S, Calil H, Ceskova E, et al. Clinical diagnostic criteria for premenstrual syndrome and guidelines for their quantification for research studies. Gynecol Endocrinol 2007;23:123–30. 6. Gehlert S, Song IH, Chang CH, Hartlage SA. The prevalence of premenstrual dysphoric disorder in a randomly selected group of urban and rural women. Psychol Med 2009;39:129–36. 7. Halbreich U. Premenstrual dysphoric disorders, anxiety, and depressions: vulnerability traits or comorbidity. Arch Gen Psychiatry 1995;52:606. 8. Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev 2009; 15:CD006586. 9. Yonkers KA, O’Brien S, Eriksson E. Premenstrual syndrome. Lancet 2008; 371:1200–10. 10. Cunningham J, Yonkers KA, O’Brien S, Eriksson E. Update on research and treatment of premenstrual dysphoric disorder. Harv Rev Psychiatry 2009;17:120–3 11. Pearlstein T, Yonkers KA, Fayyad R, Gillespie JA. Pretreatment pattern of symptom expression in premenstrual dysphoric disorder. J Affect Disord 2005;85:275–82. 12. Landen M, Eriksson E. How does premenstrual dysphoric disorder relate to depression and anxiety disorders? Depress Anxiety, 2003;17:122–9. 13. Endicott J, Halbreich U. Clinical significance of premenstrual dysphoric changes. J Clin Psychiatry 1988;49:486–9. 14. Yonkers KA, Davis LL. Premenstrual dysphoric disorder. In: Comprehensive textbook of psychiatry. Sadock SV, Sadock BJ, Ruiz, P, eds. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 1994:1952–8. 15. Endicott J. History, evolution, and diagnosis of premenstrual dysphoric disorder. J Clin Psychiatry 2000;61(Suppl 1):5–8.
SEPTEMBER JOGC SEPTEMBRE 2011 l 933
Women’s Health
16. Angst J, Sellaro R, Merikangas K, Endicott J. The epidemiology of perimenstrual psychological symptoms. Acta Psychiatr Scand Suppl 2001;104:110–6. 17. Bloch M, Schmidt PJ, Rubinow DR. Premenstrual syndrome: evidence for symptom stability across cycles. Am J Psychiatry 1997;154:1741–6. 18. Clayton AH, Keller AE, Leslie C, Evans W. Exploratory study of premenstrual symptoms and serotonin variability. Arch Women Ment Health 2005;9:51–7. 19. Rubinow DR, Schmidt P. Menstrual and formal mood disorders. In: Premenstrual, postpartum, and menopausal mood disorders. Demers LM, Mcguire JL, Philips A, Rubinow DR, eds. Baltimore: Urban & Schwarzenberg, Inc; 1989:35–51. 20. Ebner-Priemer UW, Kuo J, Kleindienst N, Welch SS, Reisch T, Reinhard I, et al. State affective instability in borderline personality disorder assessed by ambulatory monitoring. Psychol Med 2007;37:961–70. 21. Beck AT, Steer RA, Brown GK. BDI-II: Beck Depression InventoryManual. 2nd ed. San Antonio: The Psychological Corporation, Harcourt Brace; 1996. 22. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 (Suppl 20);22–33. 23. Halbreich U, Endicott J. Methodological issues in studies of premenstrual changes. Psychoneuroendocrinology 1985;10:15–32. 24. Faravelli C, Albanesi G, Poli E. Assessment of depression: a comparison of rating scales. J Affect Disord 1986;11:245–53.
32. Oliver MNI, Simons JS. The affective lability scales: development of a short-form measure. Pers Individ Dif 2004;37:1279–88. 33. Endicott J, Nee J, Harrison W. Daily Record of Severity of Problems (DRSP): reliability and validity. Arch Women Ment Health 2005;9:41–9. 34. Jahng S, Wood PK, Trull TJ. Analysis of affective instability in Ecological Momentary Assessment: indices using successive difference and group comparison via multilevel modeling. Psychol Methods 2008;13:354–75. 35. Ebner-Priemer UW, Eid M, Kleindienst N, Stabenow S, Trull TJ. Analytic strategies for understanding affective (in)stability and other dynamic processes in psychopathology. J Abnorm Psychol 2009;118:195–202. 36. Halbreich U. Premenstrual dysphoric disorders: a diversified cluster of vulnerability traits to depression. Acta Psychiatr Scand 1997;95:169–76. 37. Schnurr P, Hurt S, Stout A. Consequences of methodological decisions in the diagnosis of late luteal phase dysphoric disorder. In: Premenstrual dysphorias: myths and realities. Gold JH, Severino, SK, eds. Washington DC: American Psychiatric Press; 1994:19–46. 38. Patten SB. Major depression prevalence is very high, but the syndrome is a poor proxy for community populations’ clinical treatment needs. Can J Psychiatry 2008;53:411–9. 39. Steiner M, Pearlstein T. Premenstrual dysphoria and the serotonin system: pathophysiology and treatment. J Clin Psychiatry 2000;61 (Suppl 12):17–21. 40. Yonkers KA. Comorbidity of premenstrual syndrome and premenstrual dysphoric disorder with other psychiatric conditions. In: The premenstrual syndromes: PMS and PMDD. O’Brien S, Rapkin A, Schmidt PJ, eds. London: Informa Healthcare; 2007:49–54.
25. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 1988; 54:1063–70.
41. Haywood A, Slade P, King H. Is there evidence of an association between postnatal distress and premenstrual symptoms? J Affect Disord 2007;99:241–5.
26. Steiner M, Streiner DL. Validation of a revised visual analog scale for premenstrual mood symptoms: results from prospective and retrospective trials. Can J Psychiatry 2005;50:327–32.
42. Glover V, Liddle P, Taylor A, Adams D, Sandler M. Mild hypomania (the highs) can be a feature of the first postpartum week. Association with later depression. Br J Psychiatry 1994;164:517–21.
27. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med 1988;18:1007–19.
43. Heron J, Haque S, Oyebode F, Craddock N, Jones I. A longitudinal study of hypomania and depression symptoms in pregnancy and the postpartum period. Bipolar Disord 2009;1:410–17.
28. Dhingra V, O’Brien S. Quantification of premenstrual syndrome and premenstrual dysphoric disorder. In: The premenstrual syndromes: PMS and PMDD. O’Brien S, Rapkin A, Schmidt PJ, eds. London: Informa Healthcare; 2007:27–36. 29. Steiner M, Streiner DL, Steinberg S, Stewart D, Carter D, Berger C, et al. The measurement of premenstrual mood symptoms. J Affect Disord 1999;53:269–73. 30. Beck AT, Steer RA. Beck Depression Inventory (BDI). In: Handbook of psychiatric measures. Washington: American Psychiatric Association; 2000:519–23. 31. Altman E, Hedeker D, Peterson J, Davis J. The Altman self-rating mania scale. Biopsych 1997;42:948–55.
934 l SEPTEMBER JOGC SEPTEMBRE 2011
44. Akiskal H, Mallya G. Criteria for the “soft” bipolar spectrum: treatment implications. Psychopharmacol Bull 1987;23:68–73. 45. Metcalf MG, Livesey JH. Distribution of positive moods in women with the premenstrual syndrome and in normal women. J Psychosom Res 1995;39:609–18. 46. Ghaemi SN, Ko JY, Goodwin FK. “Cade’s disease” and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry 2002;47:125–34. 47. Tennen H, Affleck G, Coyne JC, Larsen RJ, DeLongis A. Paper or plastic? Data equivalence in paper and electronic diaries. Psychol Methods 2006;11:87–105.
Mood Instability in Women With Premenstrual Syndrome Rudy Bowen, MDCM, FRCPC,1 Angela Bowen, PhD,1,2 Marilyn Baetz, MD, FRCPC,1 Jason Wagner, MA,1 Roger Pierson, PhD3 1
Department of Psychiatry, University of Saskatchewan, Saskatoon SK
2
College of Nursing, University of Saskatchewan, Saskatoon SK
3
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Saskatchewan, Saskatoon SK
Abstract
Résumé
Objective: Most women of reproductive age experience premenstrual symptoms. Mood swings within a day and from day to day are a common complaint of people with mood problems (mood instability). We investigated whether mood instability was higher in women with premenstrual syndrome (PMS) than in a control group with no PMS.
Objectif : La plupart des femmes en âge de procréer connaissent des symptômes prémenstruels. Les sautes d’humeur se manifestant pendant une journée et d’une journée à l’autre constituent une plainte courante signalée par les gens qui présentent des troubles de l’humeur (instabilité de l’humeur). Nous nous sommes penchés sur la question de savoir si l’instabilité de l’humeur était plus accentuée chez les femmes qui présentent le SPM que chez les femmes d’un groupe témoin ne présentant pas ce dernier.
Methods: We prospectively studied mood and physical symptoms over two menstrual periods in 29 women with self-identified PMS and 31 women without PMS. We excluded women on hormonal birth control or with a history of past or current diagnoses of depression. We used the mean square successive difference derived from twice daily visual analogue scale ratings of mood as the measure of mood instability. Results: The women with PMS showed more irritable and depressed mood instability than the women without PMS. These differences were present whether or not the late luteal phase (seven days before the start of menstruation) was included in the data. On visual inspection of mood ratings, typically irritable and depressed moods increased in the late luteal phase. However, women with self-identified PMS showed a variety of mood patterns throughout the cycle. Conclusion: Women with PMS have increased mood instability within the seven day premenstrual phase and at other times as well. This supports the premise that PMS may represent a manifestation of an underlying problem of mood dysregulation in common with other mood disorders.
Key Words: Depression, irritability, mood instability, premenstrual, premenstrual syndrome Competing Interests: None declared.
Méthodes : Nous avons étudié, de façon prospective, les symptômes physiques et de l’humeur au cours de deux cycles menstruels chez 29 femmes présentant un SPM auto-signalé et chez 31 femmes ne présentant pas le SPM. Nous avons exclu les femmes qui prenaient une contraception hormonale ou qui présentaient des antécédents (ou un diagnostic courant) de dépression. Nous avons utilisé le carré moyen des différences successives tiré des scores d’humeur (établis deux fois par jour selon l’échelle visuelle analogue) à titre de mesure de l’instabilité de l’humeur. Résultats : Les femmes présentant le SPM connaissaient une instabilité de l’humeur plus penchée vers l’irritabilité et la dépression que les femmes ne présentant pas le SPM. Ces différences étaient présentes, et ce, peu importe si la phase lutéale tardive (sept jours avant le début des règles) était incluse ou non dans les données. Selon les scores d’inspection visuelle de l’humeur, la fréquence des humeurs typiquement irritables et déprimées connaissaient une hausse au cours de la phase lutéale tardive. Toutefois, les femmes présentant un SPM auto-signalé connaissaient une variété de profils d’humeur tout au long du cycle. Conclusion : Les femmes présentant le SPM connaissent une instabilité accrue de l’humeur au cours des sept jours de la phase prémenstruelle, ainsi qu’à d’autres moments au cours du cycle. Cela soutient l’hypothèse selon laquelle le SPM pourrait représenter l’une des manifestations d’un problème sous-jacent de dérèglement de l’humeur que l’on constaterait également dans le cadre d’autres troubles de l’humeur.
Received on February 8, 2011 Accepted on May 9, 2011
J Obstet Gynaecol Can 2011;33(9):927–934
SEPTEMBER JOGC SEPTEMBRE 2011 l 927
Women’s Health
INTRODUCTION
M
ost women of reproductive age experience premenstrual symptoms. Twenty to fifty percent have a broad variably defined premenstrual syndrome, but only 1.3% to 5% meet the diagnostic criteria for premenstrual dysphoric disorder established by the American Psychiatric Association in the DSM-IV.1–6 PMS occurs only during the reproductive years (not before menarche, during pregnancy, or after menopause) and is improved by bilateral oophorectomy, treatment with oral contraceptives containing drospirenone and ethinyl estradiol, or treatment with GnRH analogues that suppress ovulation.3,7,8 Despite its frequency, the etiology and pathophysiology of PMS are poorly understood.2,3 Several recent general reviews of PMS have been published.5,9,10 Key characteristics of PMS include a lack of symptoms during the follicular phase, a peak of symptoms during the late luteal or premenstrual phase, and a sudden decrease of symptoms with the onset of menses.11 It is difficult to distinguish PMS from worsening of previously existing mood disorders in the luteal phase because of the overlap and similarity of symptoms in the luteal phase.12 However, depression associated with PMS has been described typically as involving more anxiety, agitation, and mood lability than melancholic change.13 The most commonly reported and bothersome mood symptom of PMS is irritability.11,12,14–16 The most common physical symptoms are fatigue, a sense of bloating, breast tenderness, and food cravings.17 Typically, the rank ordering of symptoms tends to be stable across menstrual cycles in the same woman,5,17 but the day of onset and offset of symptoms is variable.11 In the search for causes of PMS, mean serum levels of ovarian steroids have been found to be within normal limits in women with PMS, but there seems to be greater variation in the levels of luteinizing hormone, estradiol, and 5-HIAA (a metabolite of serotonin) in these women.18 One theory is that PMS shares vulnerability traits with mood or
ABBREVIATIONS BDI
Beck Depression Inventory
DRSP
Daily Record of Severity of Problems
DSM-IV Diagnostic and Statistical Manual of Mental Disorders, fourth edition MINI
Mini International Neuropsychiatric Interview
MSSD
mean square successive difference
PMS
premenstrual syndrome
SEM
standard error of the mean
VAS
visual analogue scales
928 l SEPTEMBER JOGC SEPTEMBRE 2011
anxiety disorders, but the support for this idea is mainly from retrospective studies.7,19 On the basis of these reports and the description of mood lability13 we hypothesized that there is a common proclivity to mood dysregulation between PMS and other mood disorders.20 This indicates a need to determine whether women complaining of PMS show evidence of mood instability in other phases of the menstrual cycle, excluding the premenstrual phase. We hypothesized that a group of women with PMS but without any psychiatric disorder would show greater mood instability than a control group of women without PMS. To show a general tendency towards mood dysregulation, we anticipated that mood instability in the study group would be higher in other phases of the menstrual cycle, i.e., with the late luteal (premenstrual) phase excluded. Approval for the study was obtained from the University of Saskatchewan Behavioural Research Ethics Board. Participants gave signed informed consent and were paid a small stipend after each month of the study. METHODS
Sixty-two women between the ages of 18 and 40 years, who were medically healthy and who had regular menstrual cycles and intermenstrual intervals lasting approximately one month, were recruited. We excluded women who were presently using hormonal birth control or any hormonal treatment, were pregnant or lactating, were taking any psychiatric medication, had ever been treated for any psychiatric or psychological disorder, or had any medical or endocrine condition that might affect mood. We recruited through advertisements around the university, local gymnasiums, and family physician clinics but focused on recruitment from women’s gymnasiums since we presumed that these women were more likely to be healthy. Potential participants were not informed about the study hypothesis but were told that the study would explore symptoms during the menstrual cycle. All potential participants denied having suffered from clinical depression. They completed the Beck Depression Inventory, and anyone with a score of 20 or greater was excluded from participation.21 This threshold score excluded women with clinical depression but allowed the inclusion of women with mild depressive symptoms, because we wished to assess these as symptoms of PMS. The women then underwent the Mini International Neuropsychiatric Interview administered by a trained research assistant. Any ambiguities in the MINI findings were clarified with a psychiatrist.22
Mood Instability in Women With Premenstrual Syndrome
Table 1. Demographic characteristics of the PMS and non-PMS groups
Age, mean (SD)
PMS n = 29
Non-PMS n = 31
30.2 (6.2)
29.6 (6.8)
Marital status
0.697* 0.515†
Single
11 (37.9)
16 (51.6)
Common law/married
16 (55.2)
14 (45.2)
2 (6.9)
1 (3.2)
9 (31.0)
5 (16.1)
Divorced/separated Annual income, $ < 20 000
P
0.160‡
20 000 to 39 000
6 (20.7)
6 (19.4)
40 000 to 59 000
4 (13.8)
5 (16.1)
60 000 to 79 000
5 (17.2)
4 (12.9)
≥ 80 000
3 (10.3)
7 (22.6)
Rather not say
2 (6.9)
4 (12.9)
Grade 12 or GED
2 (6.9)
3 (9.7)
Some post-secondary
8 (27.6)
14 (45.2)
Post-secondary
19 (65.5)
14 (45.2)
Education
0.282†
GED: General Education Development Data shown as mean (SD) or n (%). *Student t test †Pearson chi-square ‡Mann-Whitney U test, excluding “Rather not say”
The PMS group (n = 30) included women who identified at least one mood symptom during the premenstrual phase as moderately severe, causing impairment in at least one area of daily living, and improving with the onset of menses. The premenstrual phase was defined as one week before menstruation.1 The criteria were deliberately broad to include women who might complain of PMS symptoms to a physician. The non-PMS control group (n = 32) were women who specifically denied on direct questioning that they suffered from PMS symptoms. Because prospective rating has been shown to be superior to retrospective reporting,23 participants recorded symptoms for two complete menstrual cycles beginning on the fifth day of a menstrual cycle. The research assistant contacted participants regularly by telephone to address potential questions about data recording and to ensure ongoing data collection. For data collection, we used visual analogue scales, the Beck Depression Inventory, the Altman SelfRating Mania Scale, the Affective Lability Scale, and the Daily Record of Severity of Problems.
bed.24–27 The VAS mood scales have been validated against observer-rated and self-rated scales for premenstrual tension symptoms and have also been shown to be sensitive to change.28,29
Four visual analogue scales measured “depressed,” “anxious/tense,” “enthusiastic/bursting with energy,” and “angry/irritable” moods. Participants completed these scales in the morning after rising and in the evening before
The Affective Lability Scale consists of 18 items that measure mood switches between depression, high mood, anxiety, and anger. A one-week time frame was used. This short form correlates highly (r = 0.94) with the longer
The Beck Depression Inventory is a widely used 21-item self-completed questionnaire that emphasizes cognitive symptoms of depression over the past two weeks. It is reliable and correlates well with other measures of depression.21,30 The two-week time frame was used for initial screening to approximate criteria for major depression in DSM-IV,1 but the time frame was one week when participants used this questionnaire for data recording during the study data collection phase. The Altman Self-Rating Mania Scale consists of five items that assess symptoms of hypomania: feeling cheerful, having more self-confidence, needing less sleep, talking more than usual, and being more active. A one-week time frame was used. We chose the scale because it is brief, uses common words, and correlates well with other scales for hypomania.31
SEPTEMBER JOGC SEPTEMBRE 2011 l 929
Women’s Health
Table 2. Comparisons between PMS and non-PMS groups using data from the follicular phase to the subsequent menses, excluding the late luteal phase Variable
PMS, n = 29 Mean (SD)
Non-PMS, n = 31 Mean (SD)
t (df = 58)
P
VAS Depressed instability
01.48 (1.08)
00.91 (0.91)
2.23
0.029
VAS Irritable instability
01.83 (1.22)
01.17 (0.86)
2.44
0.018
VAS depressed mean
01.31 (1.13)
00.93 (0.94)
1.39
0.170
VAS irritable mean
01.81 (1.58)
01.16 (1.06)
1.91
0.062
BDI mean
08.51 (6.45)
04.73 (4.37)
2.67
0.010
ALS mean
29.87 (9.77)
27.03 (7.95)
1.24
0.219
ASRM mean
04.21 (2.80)
03.73 (2.69)
0.69
0.496
BDI instability
04.93 (3.38)
03.14 (2.37)
2.39
0.020
DRSP mean
16.71 (5.55)
13.89 (5.42)
1.99
0.052
DRSP instability (MSSD)
02.82 (2.01)
02.15 (1.39)
1.51
0.137
DRSP variability (SEM)
01.25 (0.70)
00.82 (0.46)
2.86
0.006
Number of days follicular + menstrual
19.59 (4.37)
19.90 (4.41)
−0.28
0.781
ALS: affective lability scale; ASRM: Altman Self-Rating Mania Scale.
(54 item) version. The three main factors measure anxiety/ depression, depression/elation, and anger switches.32 The Daily Record of Severity of Problems assesses 11 physical and psychological symptoms associated with the menstrual cycle. We used eight of the items to assess daily psychological (mood swings, less interest, difficulty concentrating, lethargy, feeling overwhelmed) and physical (sleep, appetite, breast tenderness) symptoms, omitting depression, anxiety, and irritability because these moods were assessed by the VAS. The whole scale has good internal consistency, test-retest reliability, and concurrent validity compared with other mood and quality of life scales.33 We measured mood instability by using the VAS ratings to calculate the mean square successive difference statistic for each mood.34,35 The MSSD assesses point-to-point variability and temporal dependency in a time series.34 Visual inspection of the symptom daily ratings revealed that participants showed gradual oscillations in some symptoms over the menstrual cycle. The standard error of the mean is more suitable for capturing gradual variation in responses than the MSSD.34 We used the terms “instability” when the MSSD was calculated and “variability” when the SEM was used. Demographic characteristics between the groups were compared by t tests, Mann-Whitney U-tests, and chi-square tests where appropriate. We first did a preliminary comparison of the two groups that showed some differences in mood symptoms and mood instability (MSSD). This was expected because the selection of the PMS group was based on mood 930 l SEPTEMBER JOGC SEPTEMBRE 2011
symptoms during the premenstrual phase. We then tested the hypothesis by excluding the premenstrual phase (seven days before the start of menstruation) from the data. RESULTS
One participant from each group had missing data, which left 29 women in the PMS group and 31 in the non-PMS group. The women in the PMS and non-PMS groups did not differ in any measured demographic characteristics, including age, income, education, and marital status (Table 1), and there were no differences in any of the diagnostic categories. Three participants in the non-PMS group met symptom criteria but not full diagnostic criteria for past major depression on the MINI standard psychiatric interview. Two women in the non-PMS group and one woman in the PMS group reported symptoms of past hypomania. These participants were retained because they denied past histories of mood disorders, and if anything these findings would bias the results against the hypotheses. We first performed an exploratory comparison of the PMS and non-PMS groups on the mood scales. Across the whole menstrual cycle the groups were different in mean scores for VAS irritable mood (PMS 1.95 [SD 1.56], no PMS 1.17 [SD 1.05] ; P = 0.026) and for DRSP (PMS 18.46 [SD 5.99], no PMS 14.00 [SD 5.21]; P = 0.006). When the seven days of the late luteal phase were excluded from the data as shown in Table 2, the PMS group scored higher on both depressed mood instability and irritable
Mood Instability in Women With Premenstrual Syndrome
Figure 1. Representative mood, sleep, and breast tenderness charts from participants in the PMS group with typical PMS pattern. Dark squares represent menstruation. Participant 3 Depressed
10 5 0
Irritable
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
10 5 0
Sleep
6 4 2 0
6
Breast tenderness
4 2 0
Figure 2. Representative mood, sleep, and breast tenderness charts from participants in the PMS group with unstable mood throughout the cycle. Dark squares represent menstruation and dark circles show spotting. Participant 2 Depressed
10 5 0
Irritable
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
10 5 0
Sleep
6 4 2 0
Breast tenderness
6 4 2 0
SEPTEMBER JOGC SEPTEMBRE 2011 l 931
Women’s Health
Figure 3. Representative mood, sleep, and breast tenderness charts from participants in the PMS group with high depression throughout the cycle. Dark squares represent menstruation and dark circles show spotting. Participant 6 Depressed
10 5 0
Irritable
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
0
7
14
21
28
35
42
49
56
14
21
28
35
42
49
56
10 5 0
Sleep
6 4 2 0
6
Breast tenderness
4 2 0 0
7
mood instability. The standard error of the mean for depression (BDI) and for severity of symptoms (DRSP) was also higher in the PMS group. Visual inspection of the symptom graphs showed that there are a variety of patterns of physical and psychological symptoms that women refer to as PMS.19 Several women reported that they had PMS but recorded depression or variable depression during most of the luteal phase or throughout the cycle, with no discernible premenstrual peak (Figures 1 to 3). Several women reported that symptoms continued into the first few days of menstruation and gradually decreased during the menstrual phase.16 The individual symptoms also varied to some extent from cycle to cycle.15 DISCUSSION
The main findings of this study are the significant differences between women with and without PMS when the data from the late luteal (premenstrual) phase were excluded from analysis. Women with PMS report more irritable and depressed mood instability on the VAS (MSSD), more weekly depressed symptom instability on the BDI (MSSD), and more variability in severity of 932 l SEPTEMBER JOGC SEPTEMBRE 2011
symptoms on the DRSP (SEM) than women without PMS. That is, women with PMS show more unstable moods through all phases of the menstrual cycle, suggesting an underlying mood dysregulation. Presumably, the symptoms that are most prominent during the premenstrual phase occur because of hormonal changes during this phase. This is consistent with the view that mood symptoms at other phases of a woman’s life and her premenstrual mood symptoms have in common a tendency towards mood dysregulation, but the precipitants may differ.36,37 One criterion for inclusion in our study was a score of < 20 on the initial BDI, because 20 is the generally accepted cut-off level for clinical depression on the BDI.21 The BDI mean scores were within normal limits in both groups (Table 2).21 A few women (mostly in the non-PMS group) reported mood symptoms in the past during the MINI interview. All of these women denied any history of a mood disorder. It is likely that standard interviews done by lay interviewers (such as the MINI) are overinclusive.38 It is unlikely, therefore, that we measured premenstrual exacerbations of depressive symptoms that were part of a diagnosable mood disorder.
Mood Instability in Women With Premenstrual Syndrome
There is considerable similarity between mood disorders in psychiatric patients and mood symptoms in PMS.10,39 Also, several10,40 but not all41 studies have found an association between PMS symptoms and depression at other times in women’s lives. In contrast, PMS is different from typical mood disorders because of the inclusion of physical symptoms such as breast tenderness and bloating, the disappearance of symptoms with pregnancy and menopause, and the immediate treatment response to low-dose specific serotonin reuptake inhibitor antidepressants.10 Because of the description of high moods in postpartum depression, we examined the individual mood graphs for a pattern of high moods or hyperthymia in the premenstrual phase.42,43 None of the women in our study showed this, although several women recorded high moods on the VAS, but with no discernible pattern.23,44 The broad syndrome of high moods comprises components of euphoria, activation, and anger that are notoriously difficult to elicit reliably.45 As in bipolar spectrum disorders, it is possible that the instruments we used were not adequate to elicit symptoms of hypomania or that women did not recognize these symptoms when they occurred.46 There have been many attempts to define premenstrual syndrome more precisely, but there is no universal agreement.5 Suggested criteria are difficult to apply clinically either because they are vague or because they are specific but have not been tested clinically.5 For this reason we chose to study the inclusive syndrome of self-defined PMS. The major limitation of this study is that we recruited a sample of women with self-identified premenstrual syndrome. If we were to repeat the study, we would apply the clinically relevant criteria developed by Halbreich.5 Strictly defined premenstrual dysphoric disorder (as specified in DSM-IV) affects only 1.3% of women of reproductive age.6 The DSM criteria have changed with different editions and may change again with DSM-5.15 It is possible that increased mood instability in the PMS group was caused by the women in our study reporting on an extended PMS phase (i.e., outside the seven days that we excluded). It would be possible to screen a large number of women prospectively to select a group who had symptoms only in a strictly defined premenstrual phase, but this group would then be so carefully selected that any data derived from them could not be generalized to women seen in clinical practice. The paper and pencil VAS scales that we used do not have the advantage of electronic scales that that record the time of entries. However, all of the participants were committed to the study, and they were contacted regularly to answer any questions or concerns
about completing the measures.47 Finally, we assessed symptoms comprehensively, and this resulted in a number of tests being used. We did not correct for the number of tests, and so the results must be regarded as preliminary. CONCLUSION
Women with complaints of PMS have more irritable and depressed moods both during the premenstrual phase and at other times. The irritable and depressed moods in these women vary in intensity and are changeable within a day and from day to day in contrast to the perception that anger or depression is steady throughout the premenstrual phase. A conclusion of these findings is that mood instability is similar between PMS and other mood syndromes. REFERENCES 1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994. 2. Steiner M, Born L. Psychiatric aspects of the menstrual cycle. In: Women’s mental health: a comprehensive textbook. Kornstein S, Clayton A, eds. New York (NY): The Guilford Press; 2002:48–69. 3. Ismail KMK, O’Brien S. Premenstrual syndrome. Curr Obstet Gynaecol 2005;15:25–30. 4. Pearlstein T. Prevalence, impact on morbidity, and disease burden. In: The premenstrual syndromes: PMS and PMDD. O’Brien S, Rapkin A, Schmidt PJ, eds. London: Informa Healthcare; 2007:37–47. 5. Halbreich U, Backstrom T, Eriksson E, O’Brien S, Calil H, Ceskova E, et al. Clinical diagnostic criteria for premenstrual syndrome and guidelines for their quantification for research studies. Gynecol Endocrinol 2007;23:123–30. 6. Gehlert S, Song IH, Chang CH, Hartlage SA. The prevalence of premenstrual dysphoric disorder in a randomly selected group of urban and rural women. Psychol Med 2009;39:129–36. 7. Halbreich U. Premenstrual dysphoric disorders, anxiety, and depressions: vulnerability traits or comorbidity. Arch Gen Psychiatry 1995;52:606. 8. Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev 2009; 15:CD006586. 9. Yonkers KA, O’Brien S, Eriksson E. Premenstrual syndrome. Lancet 2008; 371:1200–10. 10. Cunningham J, Yonkers KA, O’Brien S, Eriksson E. Update on research and treatment of premenstrual dysphoric disorder. Harv Rev Psychiatry 2009;17:120–3 11. Pearlstein T, Yonkers KA, Fayyad R, Gillespie JA. Pretreatment pattern of symptom expression in premenstrual dysphoric disorder. J Affect Disord 2005;85:275–82. 12. Landen M, Eriksson E. How does premenstrual dysphoric disorder relate to depression and anxiety disorders? Depress Anxiety, 2003;17:122–9. 13. Endicott J, Halbreich U. Clinical significance of premenstrual dysphoric changes. J Clin Psychiatry 1988;49:486–9. 14. Yonkers KA, Davis LL. Premenstrual dysphoric disorder. In: Comprehensive textbook of psychiatry. Sadock SV, Sadock BJ, Ruiz, P, eds. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 1994:1952–8. 15. Endicott J. History, evolution, and diagnosis of premenstrual dysphoric disorder. J Clin Psychiatry 2000;61(Suppl 1):5–8.
SEPTEMBER JOGC SEPTEMBRE 2011 l 933
Women’s Health
16. Angst J, Sellaro R, Merikangas K, Endicott J. The epidemiology of perimenstrual psychological symptoms. Acta Psychiatr Scand Suppl 2001;104:110–6. 17. Bloch M, Schmidt PJ, Rubinow DR. Premenstrual syndrome: evidence for symptom stability across cycles. Am J Psychiatry 1997;154:1741–6. 18. Clayton AH, Keller AE, Leslie C, Evans W. Exploratory study of premenstrual symptoms and serotonin variability. Arch Women Ment Health 2005;9:51–7. 19. Rubinow DR, Schmidt P. Menstrual and formal mood disorders. In: Premenstrual, postpartum, and menopausal mood disorders. Demers LM, Mcguire JL, Philips A, Rubinow DR, eds. Baltimore: Urban & Schwarzenberg, Inc; 1989:35–51. 20. Ebner-Priemer UW, Kuo J, Kleindienst N, Welch SS, Reisch T, Reinhard I, et al. State affective instability in borderline personality disorder assessed by ambulatory monitoring. Psychol Med 2007;37:961–70. 21. Beck AT, Steer RA, Brown GK. BDI-II: Beck Depression InventoryManual. 2nd ed. San Antonio: The Psychological Corporation, Harcourt Brace; 1996. 22. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 (Suppl 20);22–33. 23. Halbreich U, Endicott J. Methodological issues in studies of premenstrual changes. Psychoneuroendocrinology 1985;10:15–32. 24. Faravelli C, Albanesi G, Poli E. Assessment of depression: a comparison of rating scales. J Affect Disord 1986;11:245–53.
32. Oliver MNI, Simons JS. The affective lability scales: development of a short-form measure. Pers Individ Dif 2004;37:1279–88. 33. Endicott J, Nee J, Harrison W. Daily Record of Severity of Problems (DRSP): reliability and validity. Arch Women Ment Health 2005;9:41–9. 34. Jahng S, Wood PK, Trull TJ. Analysis of affective instability in Ecological Momentary Assessment: indices using successive difference and group comparison via multilevel modeling. Psychol Methods 2008;13:354–75. 35. Ebner-Priemer UW, Eid M, Kleindienst N, Stabenow S, Trull TJ. Analytic strategies for understanding affective (in)stability and other dynamic processes in psychopathology. J Abnorm Psychol 2009;118:195–202. 36. Halbreich U. Premenstrual dysphoric disorders: a diversified cluster of vulnerability traits to depression. Acta Psychiatr Scand 1997;95:169–76. 37. Schnurr P, Hurt S, Stout A. Consequences of methodological decisions in the diagnosis of late luteal phase dysphoric disorder. In: Premenstrual dysphorias: myths and realities. Gold JH, Severino, SK, eds. Washington DC: American Psychiatric Press; 1994:19–46. 38. Patten SB. Major depression prevalence is very high, but the syndrome is a poor proxy for community populations’ clinical treatment needs. Can J Psychiatry 2008;53:411–9. 39. Steiner M, Pearlstein T. Premenstrual dysphoria and the serotonin system: pathophysiology and treatment. J Clin Psychiatry 2000;61 (Suppl 12):17–21. 40. Yonkers KA. Comorbidity of premenstrual syndrome and premenstrual dysphoric disorder with other psychiatric conditions. In: The premenstrual syndromes: PMS and PMDD. O’Brien S, Rapkin A, Schmidt PJ, eds. London: Informa Healthcare; 2007:49–54.
25. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 1988; 54:1063–70.
41. Haywood A, Slade P, King H. Is there evidence of an association between postnatal distress and premenstrual symptoms? J Affect Disord 2007;99:241–5.
26. Steiner M, Streiner DL. Validation of a revised visual analog scale for premenstrual mood symptoms: results from prospective and retrospective trials. Can J Psychiatry 2005;50:327–32.
42. Glover V, Liddle P, Taylor A, Adams D, Sandler M. Mild hypomania (the highs) can be a feature of the first postpartum week. Association with later depression. Br J Psychiatry 1994;164:517–21.
27. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med 1988;18:1007–19.
43. Heron J, Haque S, Oyebode F, Craddock N, Jones I. A longitudinal study of hypomania and depression symptoms in pregnancy and the postpartum period. Bipolar Disord 2009;1:410–17.
28. Dhingra V, O’Brien S. Quantification of premenstrual syndrome and premenstrual dysphoric disorder. In: The premenstrual syndromes: PMS and PMDD. O’Brien S, Rapkin A, Schmidt PJ, eds. London: Informa Healthcare; 2007:27–36. 29. Steiner M, Streiner DL, Steinberg S, Stewart D, Carter D, Berger C, et al. The measurement of premenstrual mood symptoms. J Affect Disord 1999;53:269–73. 30. Beck AT, Steer RA. Beck Depression Inventory (BDI). In: Handbook of psychiatric measures. Washington: American Psychiatric Association; 2000:519–23. 31. Altman E, Hedeker D, Peterson J, Davis J. The Altman self-rating mania scale. Biopsych 1997;42:948–55.
934 l SEPTEMBER JOGC SEPTEMBRE 2011
44. Akiskal H, Mallya G. Criteria for the “soft” bipolar spectrum: treatment implications. Psychopharmacol Bull 1987;23:68–73. 45. Metcalf MG, Livesey JH. Distribution of positive moods in women with the premenstrual syndrome and in normal women. J Psychosom Res 1995;39:609–18. 46. Ghaemi SN, Ko JY, Goodwin FK. “Cade’s disease” and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry 2002;47:125–34. 47. Tennen H, Affleck G, Coyne JC, Larsen RJ, DeLongis A. Paper or plastic? Data equivalence in paper and electronic diaries. Psychol Methods 2006;11:87–105.