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Premenstrual Syndrome (PMS)
Premenstrual Syndrome (PMS) S T Sigmon, J Craner, K L Yoon, and G L Thorpe, University of Maine, Orono, ME, USA ã 2012 Elsevier Inc. All rights reserved. This article is a revision of the previous edition article by Margaret L Moline, volume 3, pp. 587–599, ã 1994, Elsevier Inc.
Glossary Anxiety sensitivity The tendency to focus on and catastrophize about the meaning of physical sensations that is linked to increased premenstrual distress and the development of panic disorder. Biopsychosocial perspective A theoretical model that includes physical, psychological, and cultural factors in the development of diseases and disorders. Cognitive–behavior therapy A psychotherapy approach that focuses on identifying and challenging negative thinking and schemas in psychological disorders. Late luteal phase Refers to the 5–7 days prior to the onset of menstrual bleeding (menses).
In Western and non-Western cultures, fluctuations in menstrual symptoms have been noted for over 2500 years. Since its introduction to the medical nomenclature in the 1930s, the topic of premenstrual syndrome (PMS) has consistently elicited controversy, and differences in methodologies and small sample sizes have led to inconsistent findings. Research on PMS relied heavily on retrospective reports, which are problematic due to bias and overestimation of symptoms. Furthermore, definitions of PMS have not been consistent in the past, and generalization across studies is limited. However, PMS is an important topic of study, particularly when considering prevalence rates, impact, and societal views relating to PMS. The recent focus on using more standardized criteria for PMS has added greatly to the research literature, and the state of contemporary PMS research represents significant advances in our understanding of this condition.
Symptoms, Epidemiology, and Classification Symptoms of PMS In general terms, PMS refers to a variety of emotional, physical, and behavioral symptoms that occur after ovulation during the late luteal phase (days 21–28 of the menstrual cycle) and end with the onset of menstrual bleeding (day 1). Although over a hundred symptoms have been associated with the premenstrual phase, the following listed symptoms are the most commonly reported. Emotional symptoms may include anxiety, depression, anger, irritability, and mood swings. Physical symptoms can include breast tenderness, water retention, headache, fatigue, acne, joint pain, and gastrointestinal distress. Behavioral symptoms typically include appetite change, sleep disturbance, crying, social withdrawal, agitation, forgetfulness, and poor concentration.
Menstrual reactivity hypothesis A dual vulnerability model including psychological, social, and physical explanations for premenstrual exacerbation of symptoms. Panicogenic task Refers to the administration of substances that increase the symptoms (e.g., intense fear, increase in sympathetic nervous system symptoms) associated with a panic attack. Rumination The tendency to focus on the experience and causes of thoughts, feelings, and sensations associated with dysphoric mood that may lead to increases in depression and anxiety. Social construction perspectives A model that focuses on social processes that influence the discourse surrounding psychological diagnoses.
Epidemiology Approximately 80% of reproductive age women may report some of these premenstrual symptoms, and most of these symptoms occur at a mild level that does not interfere with daily functioning. Approximately 25% of women may experience PMS, which occurs when symptoms are experienced at a moderate-to-severe level and daily functioning becomes impaired. The International Classification of Diseases (ICD10) categorizes PMS as premenstrual tension syndrome. More severe symptoms with significant impairment occur in 2–9% of women and lead to a diagnosis of premenstrual dysphoric disorder (PMDD). Approximately 50% of women may seek medical treatment for their PMS symptoms. Although PMS can be diagnosed in menstruating women of any age who have ovulatory cycles, it is typically diagnosed in women in their thirties and forties. To be diagnosed with PMS, symptoms must be cyclical and not represent the exacerbation of another disorder. Women who suffer from the following psychological disorders may also experience premenstrual exacerbation of their symptoms: depression, bulimia, binge eating disorder, and panic disorder. Also, women with the following health conditions may experience an increase in symptoms or severity: epilepsy, fibromyalgia, asthma, multiple sclerosis, rheumatoid arthritis, and migraines. Women with PMS are more likely to report excessive menstrual flow, abdominal pain, and bleeding during other phases of the menstrual cycle. Current smoking and passive smoke exposure are associated with anxiety, cravings, water retention, breast pain, back pain, and headache in PMS. Increased alcohol consumption and less physical activity are related to more severe premenstrual symptoms. Increased consumption of caffeine is also linked to more severe premenstrual symptoms.
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Classification Issues Unfortunately, there is a continuing lack of consensus regarding definitions, assessment, and treatment of PMS. However, current diagnostic criteria indicate that in order to qualify for a diagnosis of PMS, symptoms must meet the following criteria: occur in the 5 days prior to menstrual bleeding onset and increase by at least 30% from other times in the menstrual cycle, cease by day 4 of menstrual bleeding, and symptoms must remit during the remainder of the menstrual cycle. More strict criteria require that both physical and emotional symptoms must be present during the 5 days before menses. Another issue to consider is the consistency of PMS symptoms over time. In this regard, prospective, daily recording of symptoms for two consecutive menstrual cycles is considered necessary to establish symptom patterns and the symptoms must be distressing as well as cause impairment in normal, daily functioning.
Biopsychosocial Perspective of PMS The most current view of PMS derives from a biopsychosocial perspective. A biopsychosocial approach posits that biological factors, psychological factors, and social factors interact to play a significant role in human functioning. Although the menstrual cycle itself is not considered a disease or illness, the biopsychosocial perspective can be used as a model to better understand the vast array of conditions that may affect a woman’s menstrual experience. Menstruation is a normal and integral biological process for women. However, psychological factors may also play a role in the report, interpretation, and experience of menstrual symptoms. Indeed, research suggests that symptom severity is quite variable and may be more related to psychological factors than biological ones. Social factors, such as age, racial/cultural diversity, and religion, may also play a role. Health care and mental health care providers, thus, need to consider the interaction of these factors in PMS in order to provide the best assessment and treatment for patients. In this article, PMS and PMDD are presented from a biopsychosocial perspective.
Biological Aspects of PMS Current research indicates that ovulation and ovulation-related processes play a central role in the development of premenstrual symptoms. Support for this model comes from research findings that PMS symptoms disappear when ovulation does not occur. Although the exact mechanisms are not clear, reproductive hormones are thought to play a significant role in symptom fluctuation across the menstrual cycle. During the late luteal phase, progesterone metabolites typically decrease and estradiol levels increase. Interestingly, however, reproductive hormone levels in women diagnosed with PMS tend to fall in the normal range. At present, there are no hypotheses concerning what would account for sensitivity in some women to normal changes in hormone levels. Progesterone and estrogen are also hypothesized to modulate neurotransmitters (e.g., serotonin, GABA, dopamine, norepinephrine) that are typically associated with changes in
mood and behavior. Decreased levels of serotonin are linked to sleep disruption, appetite change, fatigue, and depressed mood which are associated with PMS. Research has found that women with PMS have lower levels of serotonin during the last 10 days of the menstrual cycle. One hypothesis is that serotonin deficiency could enhance sensitivity to progesterone changes. Support for serotonin as a contributory factor in PMS is bolstered by the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the alleviation of some PMS symptoms. However, it is not known why some women would be more sensitive to these changes. Allopregnanolone, a metabolite of progesterone, has also been linked to PMS. However, low and high levels of it have been found in women with PMS. Genetic contributions have also been examined in women with PMS. For example, if a woman’s mother had PMS, her chances of having PMS were 70%. If one monozygotic twin had PMS, the other twin had a 90% chance of having PMS. Thus, the role of genetics in PMS deserves more study. Cyclic changes in stress hormone levels (e.g., adrenocorticotropic hormone, cortisol) have also been found in some women with PMS. This type of research represents an emerging area of interest that needs more study. Another promising area of interest relates to cyclic changes in the immune system. During the premenstrual phase, cellmediated immunity is suppressed. This cyclic change is thought to have evolutionary adaptation for the developing embryo. However, there has been no research conducted to test this interesting model of PMS and no hypothesis about why some women would experience symptoms and others dont. Other potential biological causes of PMS posited are differences in prolactin and aldosterone levels (i.e., hormones that affect fluid balance), thyroid imbalances, glucose metabolism, and insulin imbalances. However, there is no confirming evidence for causality for these hormones in the development and maintenance of PMS symptoms. Potential nutritional differences (e.g., vitamin B6, calcium, magnesium, caffeine) have also been mentioned as possible contributions to PMS symptoms. Again, there is no evidence to support these nutritional causes when women with PMS are compared to controls. In addition, there is no explanation of why some women might be more affected by these biological changes during the menstrual cycle than others. Given the lack of support for purely biological causes of PMS, researchers have also investigated the role that psychological factors or trait variables may play in PMS experience.
Psychological Aspects of PMS For women with PMS, quality of life may be significantly impacted. Women with PMS may experience impairment in social relations, personal relationships, hobbies, and household activities. PMS may also result in work disruption, decreased productivity, and increased use of health care. Women with PMS report more daily stress, life stress, perceived stress, and physiological stress than controls. Similarly, women with PMS report experiencing more traumatic events than controls. However, these findings are correlational and do not imply causation. There are several psychological disorders that are comorbid with PMS. In fact, 50% of women with PMS report a history
Premenstrual Syndrome (PMS)
of anxiety or mood disorders. Given that women with PMS often respond to a panicogenic task similar to women with panic disorder, it has been suggested that PMS and panic disorder may share a similar pathophysiological mechanism. According to the menstrual reactivity hypothesis, some women report more severe premenstrual symptoms based on an array of influences: accurate symptom reporting, biases that relate to past premenstrual experience, cultural attitudes and beliefs, and a predisposition to focus on internal bodily sensations and catastrophize about their meaning. This model has been used to explain premenstrual distress differences between women varying in levels of anxiety as well as to women with asthma. In this dual vulnerability model, some women may experience physiological sensations or symptoms and then mood symptoms may develop in response to those symptoms. As yet, this model has not been tested in PMS.
Sociocultural Factors in PMS In any discussion of PMS, the potential for the medicalization of the menstrual cycle needs to be addressed. It is clear that the menstrual cycle itself should not be considered a problem, disease, or illness that needs to be solved or treated. However, it is also clear that some women will experience moderateto-severe premenstrual symptoms that may impair their normal functioning. Does receiving a diagnosis of PMS perpetuate a myth that women are emotionally unstable and captives to raging hormones? Does this diagnosis reinforce traditional beliefs about femininity? For these reasons, sociocultural factors are particularly important to consider. There are inconsistent findings regarding the effect of education, employment, and marital status on PMS prevalence. One study found that work-related stress was a significant predictor of premenstrual symptom severity. Another study found that younger age, high levels of stress, and less education were positively associated with emotional symptoms of PMS. As women age, anxiety, mood changes, and back pain associated with PMS decrease. Women with low BMI tend to report less premenstrual symptoms (possibly due to lower levels of estrogen). Relatedly, women who are obese are three times more likely to suffer from PMS. Preliminary research also suggests that Caucasian women, smokers, and younger women are more at risk for PMS. Clearly, more research on age and weight as they relate to PMS experience is needed. Although PMS is thought to be found worldwide, culture plays a role in the reporting of symptoms. In one large survey, women of Asian descent reported fewer premenstrual symptoms than Caucasian, African American, and Hispanic women. Anxiety and mood changes were reported less by African American and Japanese women. There are, however, too few studies to be able to definitively say that race and culture may play a significant role in PMS experience.
Assessment and Treatment of PMS Assessment Assessment of PMS requires daily monitoring of symptoms for two consecutive menstrual cycles. Given that women may vary in the types of symptoms they experience, symptoms from
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the emotional, behavioral, and physical realms should be included. Women should be able to indicate the severity of the symptoms as well as the level of impairment of the daily symptoms in all life domains. In addition, other medical conditions that have similar symptom presentations, such as menopause, hyperthyroidism, hypothryroidism, and polycystic ovary syndrome, should be ruled out. Recent assessment measures have led to more consistencies in how premenstrual symptoms are measured. For example, the premenstrual symptoms screening tool (PSST), a short survey of 14 items, maps onto current diagnostic criteria for PMDD, and can also be used to screen for PMS symptoms. The daily record of severity of problems (DRSP), a prospective monitoring tool, is completed daily for two consecutive menstrual cycles to obtain a diagnosis of PMS or PMDD. The premenstrual symptoms impact survey (PMSIS), a brief survey of six items, can discriminate between women with clinically significant PMS and controls. With the continued use of such measures in larger samples, study results will be more reliable and generalizable to other populations.
Treatment Typically, women who seek treatment for their PMS symptoms are prescribed medication. Although there is no support for the progesterone deficiency model of PMS, progesterone-based therapies are commonly prescribed. SSRIs (e.g., fluoxetine, sertraline, paroxetine) are also frequently used throughout the menstrual cycle or just during the premenstrual phase (e.g., luteal phase dosing) with demonstrated efficacy compared to placebo. SSRIs may help reduce depression, anxiety, irritability, and fatigue associated with PMS. However, the long-term efficacy of using SSRIs has not been demonstrated for PMS and 40% of women with PMS do not have reduction in symptoms. Another treatment involves the suppression of ovulation and/or menstruation (e.g., GnRH analogs, Danazol, transdermal estradiol patches). However, the long-term use of such medications may include bone loss, menopausal symptoms (e.g., hot flashes, irritability), and cardiac difficulties. Oral contraceptives (OCs) may also be used to suppress ovulation. Research has shown that continuous use of OCs may result in reductions of headaches, fatigue, and water retention. Dietary changes are often suggested for women with PMS such as reducing salt intake, chocolate, caffeine, nicotine, and alcohol. Eating frequent meals high in complex carbohydrates may help reduce binges and cravings. Intake of vitamin B6, calcium, magnesium, and vitamin E is also recommended. Moderate aerobic exercise may also help manage PMS symptoms. Stress management techniques may also be helpful in reducing stress associated with work, school, and relationships. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help some women with PMS in reducing muscle tension and headaches. Yoga, acupuncture, relaxation, and social support are also recommended but have no empirical support or controlled trials. Compared to a wait-list control group, women with PMS who received cognitive–behavioral therapy (CBT) reported a reduction in the negative effects of symptoms and these results were maintained over time. However, the majority of CBT for
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PMS studies were not controlled trials and CBT has not demonstrated greater efficacy compared to SSRIs. More research is necessary to determine the mechanisms and which women with PMS might benefit from this type of treatment.
PMDD Diagnosis, Epidemiology, and Quality of Life Impact Diagnosis of PMDD Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual distress characterized by significant increases in physical and affective symptoms during the premenstrual phase of the menstrual cycle. These symptoms are serious enough to cause clinically significant distress and interfere with functioning (e.g., in work, school, home, daily activities, and/or social relationships). Symptoms of PMDD include depressed mood, anxiety, anger/irritability, mood swings, loss of interest, difficulty in concentrating, lack of energy, appetite changes or cravings, sleep disturbance, feeling overwhelmed or out of control, and physical symptoms (e.g., bloating, breast tenderness, weight gain). In women with PMDD, these symptoms are present during the premenstrual phase, improve within the first few days of the onset of menstruation, and remit during the remainder of the menstrual cycle. In other words, PMDD is characterized by dramatic emotional, physical, and behavioral changes that occur cyclically and are restricted to the premenstrual phase. Thus, PMDD is a separate diagnostic entity, rather than a premenstrual exacerbation of another disorder, such as depression.
Epidemiology PMDD is estimated to impact 2–9% of women in the United States. Similar prevalence rates have been found in several European, African, and Asian countries. However, no research has examined potential differences between racial and ethnic groups in the United States in terms of prevalence rates, symptom expression, or correlates. Regarding onset of PMDD, symptoms typically emerge during the mid- to late twenties and follow a chronic course if left untreated. In women with PMDD, symptoms tend to worsen over time but discontinue during interruptions of the ovulatory cycle (i.e., menopause, pregnancy, and ovariectomy). Lifetime comorbidity rates for PMDD are high (30–70%), particularly with other mood disorders. PMDD may put women at risk for later depression, including perimenopausal and postpartum depression. Conversely, mood or anxiety disorders may put women at risk for later development of PMDD.
Quality of Life Impact Women with PMDD experience significant impairment in quality of life. PMDD is associated with decreased social and parental functioning, as well as occupational performance. Some women with PMDD also report cognitive difficulties (e.g., attention, concentration), although research findings in this area are mixed. PMDD is also related to health-related quality of life impairment in both physical and mental health
domains. Women with PMDD report health-related quality of life burden comparable to individuals with other chronic physical (e.g., arthritis) and mental (e.g., depression) disorders. Although individuals with PMDD are most impaired during the premenstrual phase, they are more impaired in several areas of functioning during other menstrual cycle phases compared to women not diagnosed with PMDD. Overall, it is clear that PMDD has a major impact on the lives of women diagnosed with this disorder.
Biopsychosocial Perspective of PMDD Biological Aspects Most research on the etiology of PMDD has focused on biological explanations. However, research on biological models for PMDD has produced mixed findings. The majority of research has investigated the potential role of gonadal hormones. Support comes from evidence that symptoms are not present during interruptions of the ovarian cycle, and research suggesting that oral contraceptives may be an effective treatment. Symptoms may be related to the declining levels of ovarian steroid hormones during the premenstrual phase of the menstrual cycle. Estrogen and progesterone are elevated during the luteal phase, and then drop dramatically in the late luteal (premenstrual) phase. Estrogen is linked to mood through its influence on the serotonin system. Fluctuations in estrogen may also impact the secretion of corticotrophin releasing hormone (CRH), of which decreased levels have been associated with depression. There is some initial research suggesting that women with PMDD may have higher levels of estrogen during the follicular phase, and that PMDD symptoms may vary as levels of estrogen change. However, research has not confirmed relationships between estrogen levels and PMDD, and research does not support a relationship between progesterone levels and PMDD. Hormone imbalance, rather than fluctuations, may be related to PMDD. For example, a hormonal ratio imbalance between estrogen and progesterone has been implicated. In particular, when estrogen levels are high in relation to progesterone, this may be related to PMDD. In addition, it has been suggested that the pattern of secretion of hormones in women with PMDD may be abnormal. However, some studies have found that levels of ovarian hormones are normal in women with PMDD, and studies have not found differences in hormone levels in women with PMDD compared to controls. Thus, evidence regarding the role of hormones in PMDD is mixed at best. Neurotransmitters have also been studied relating to the etiology of PMDD. Decreased levels of GABA have been associated with depression and anxiety; therefore, it has been suggested that women with PMDD may have low levels of GABA during the premenstrual phase. Serotonin has also been studied in relation to PMDD, due to its links with other mood disorders. Endogenous opiate withdrawal during the premenstrual phase may be associated with fatigue, depression, and pain sensitivity. However, research on the role of neurotransmitters in PMDD has produced inconsistent findings, and many studies lack a comparison control group. At present, there is no confirmed relationship between neurotransmitter deficiencies and PMDD.
Premenstrual Syndrome (PMS)
In sum, biological explanations for PMDD have produced mixed findings. However, given that symptoms coincide with physiological changes, it is important to continue to research these factors. Research that investigates biological factors in relation to psychological and social factors may be particularly valuable in understanding this complex disorder. It is likely that PMDD is multiply determined by a combination of biological, behavioral, and cognitive factors such that attempts to assign primacy to any one of them could be misguided. In other syndromes such as panic disorder, it is now clear that unfamiliar bodily sensations stemming from normal physiological variations can be misinterpreted in ways that amplify the original concern needlessly. A similar formulation has been applied to some chronic pain syndromes. The development of negative expectations, together with the operation of conditioning processes, can create a feedback pattern that escalates manageable discomfort into seemingly unendurable distress. In the context of panic disorder, that formulation has proven to be extremely helpful in clarifying etiology and focusing effective treatment regimens that have been demonstrated to have substantial empirical support.
Psychological Aspects of PMDD Limited research has investigated psychological factors that may play a role in the development of PMDD. Psychoanalytic explanations have focused on the ‘meaning’ of the symptoms for PMDD. For example, premenstrual symptoms could be interpreted as repressed hostility toward males, who are more favored in society. Another view suggests that premenstrual mood symptoms are caused by a woman’s grief over failure to conceive. These explanations are refuted by the pattern of symptom onset and remittance in PMDD, since symptoms actually decrease at the onset of menstruation. The state of the empirical literature on psychological factors related to the etiology of PMDD is severely lacking at present. However, as research has demonstrated in PMS, the role of beliefs, expectations, and interpretations of symptoms may be influential in PMDD (e.g., menstrual reactivity hypothesis). Research on psychological factors involved in PMS has resulted in two important findings that may shed light on our understanding of PMDD: (1) Women with PMS may respond to emotional changes in a manner that is maladaptive (e.g., rumination, self-blame), and (2) Women with PMS may focus inward on physiological sensations and view these as catastrophic, thus increasing these symptoms (e.g., anxiety sensitivity). Therefore, it is possible that the manner in which women with PMDD respond to their symptoms is related to increased distress during the premenstrual phase. That is, biological changes alone do not account for PMDD per se, but rather women’s responses to physiological and emotional changes that result from the menstrual cycle may be related to the experience of PMDD. Given that research on biological factors involved in the etiology of PMDD has yielded mixed findings, incorporating psychological and social factors is likely to provide a more complete explanation of this disorder. Another line of research has examined potential shared etiologies between PMDD and other psychological disorders. Although PMDD involves symptoms of depression, it also shares similarities with anxiety disorders. Interestingly, irritability and
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anxiety are actually reported more often in women with PMDD than sadness or loss of interest. Research in this area has resulted in criticism of the classification of PMDD as a mood disorder. For example, women with PMDD respond more strongly to panicogenic challenges than women with depression, and women with PMDD and panic disorder seem to share underlying etiological factors, such as anxiety sensitivity. Given these findings, it has been suggested that PMDD is particularly similar to panic disorder. Furthermore, there are high rates of comorbidity between PMDD and other psychological disorders, such as anxiety and depression. It is possible that shared vulnerabilities exist between PMDD and these other diagnoses that may make women more susceptible to developing comorbid disorders.
Sociocultural Factors in PMDD Social constructionist perspectives contend that diagnostic categories emerge out of social processes. As such, psychological disorders are social, not natural, categories. In other words, the etiology of PMDD lies with society rather than individuals. Within this framework, feminist critics have raised concerns over the diagnosis of PMDD. In particular, a diagnosis such as PMDD may serve to subjugate women. Labels such as PMS and PMDD may reinforce women’s lower class standing. Furthermore, this classification system can be seen as medicalizing women’s sexuality. Labeling women’s premenstrual symptoms as a disorder may validate the ideas that there is something ‘wrong’ with women’s bodies, and thus underemphasize social and cultural influences on attitudes and beliefs about menstruation. For example, what girls are taught about menstruation and societal views tend to reinforce is that menstruation is painful, debilitating, and something to be embarrassed about, rather than emphasizing that menstruation is healthy and natural. These views may lead to negative attitudes toward menstruation, which could in turn contribute to premenstrual distress. For example, the menstrual reactivity hypothesis suggests that women may respond to cultural stereotypes regarding the menstrual cycle in addition to actual symptoms. Social constructionist and feminist critics have also pointed out the large financial stake in the PMDD diagnosis, particularly through pharmaceutical sales.
Assessment and Treatment of PMDD Assessment of PMDD PMDD is currently listed in the Diagnostic and Statistical Manual of Mental Disorders (APA [DSM-IV-TR], 2000) in the appendix as a set of criteria provided for further study. PMDD is diagnosed as a Mood Disorder Not Otherwise Specified. There has been debate over the classification of PMDD, including the number of symptoms required for diagnosis, as well as the location of PMDD in the manual. The state of the classification of PMDD for the updated version of the diagnostic manual (DSM-V) is unknown at present. According to current diagnostic criteria, PMDD involves five moderate-to-severe symptoms, of which at least one is primarily affective in nature (i.e., depression, anxiety, irritability, loss of interest). Of the ten symptoms listed, only one
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Premenstrual Syndrome (PMS)
involves physical symptoms (e.g., bloating, aches). Symptoms must also cause significant interference in work, school, or social activities/relationships. Additionally, symptoms must not be premenstrual exacerbation of another disorder. Diagnosis of PMDD is made using prospective ratings of symptoms for two consecutive menstrual cycles. This is typically done using a daily rating form (e.g., DRSP) on which women report the severity of each symptom. Prospective rating is particularly important considering the presence of a significant recall bias for premenstrual symptoms. Many women who retrospectively report meeting PMDD criteria do not meet criteria after rating symptoms prospectively, and retrospective and prospective ratings often do not correlate with each other. The requirement of prospective ratings for two menstrual cycles has been criticized in terms of its practicality. However, it is often possible to make a provisional diagnosis prior to obtaining prospective ratings of symptoms, for example by using a screening tool (e.g., PSST). It is particularly important to consider differential diagnoses when assessing for PMDD. For example, women with mood or anxiety disorders may experience premenstrual exacerbation of these disorders, which can present similar to PMDD in the absence of prospective ratings. Similarly, mood or anxiety disorder onset could occur during the premenstrual phase but not follow a cyclical pattern, highlighting the importance of rating two consecutive cycles. Additionally, women with menstrual-cycle-related symptoms (e.g., cramps) that occur during the menstrual phase, after the onset of bleeding, could report increased symptoms on premenstrual screening tools, despite the fact that these symptoms do not occur premenstrually.
Treatment of PMDD In general, treatment of PMDD is similar to that of PMS. Pharmacological treatments for PMDD include psychotropic medications, such as SSRIs and anxiolytics, both of which have demonstrated some success in treating PMDD. Interestingly, some studies show that SSRIs may be effective even when taken only during the premenstrual phase. Oral contraceptives (i.e., birth control pills) have also been used in the treatment of PMDD; however, empirical studies on the success of this intervention have produced mixed findings. Research suggests that oral contraceptives may be most beneficial for physical symptoms compared to the affective symptoms of PMDD. Type of oral contraceptive may also be important. Thus, more research on pharmacological treatments for PMDD is warranted. Research on psychological treatment for PMDD has demonstrated some promising results. In particular, CBT interventions for PMDD indicate that this may be a potentially beneficial treatment for PMDD. However, research in this area is lacking and more studies are necessary to establish empirical support for the treatment of PMDD with CBT.
Conclusions Since the 1990s, considerable research has been conducted on women’s premenstrual experience. Stricter diagnostic criteria
have been proposed for PMS and PMDD. However, there is still no agreed-upon etiology for the two conditions. Most researchers agree that any causal model of PMS/PMDD must be multifactorial, considering biological, psychological, and sociological factors from multidisciplinary fields. More is known about treatment options, even though this research is plagued by small samples and uncontrolled trials. It is important that researchers continue to tease apart premenstrual exacerbation of existing conditions from primary PMS/PMDD.
See also: Hormones and Behavior.
Further Reading Chrisler JC (2008) PMS as a culture-bound syndrome. In: Chrisler JC, Golden C, Rozee PD, Chrisler JC, Golden C, and Rozee PD (eds.) Lectures on the Psychology of Women, 4th edn., pp. 155–171. New York, NY: McGraw-Hill. Clayton A (2008) Symptoms related to the menstrual cycle: Diagnosis, prevalence, and treatment. Journal of Psychiatric Practice 14(1): 13–21. Cohen HB (2008) Premenstrual syndrome and premenstrual dysphoric disorder. In: Clouse AL and Sherif K (eds.) Women’s Health in Clinical Practice, pp. 19–28. Totowa, NJ: Humana Press. Davis L and Yonkers KA (1997) Diagnosis and treatment of premenstrual dysphoric disorder. International Journal of Psychiatry in Clinical Practice 1: 149–156. Denmark F and Paludi M (eds.) (2008) Psychology of Women: A Handbook of Issues and Theories, 2nd edn. Westport, CT: Praeger Publishers/Greenwood Publishing Group. Di Guilio G and Reissing ED (2006) Premenstrual dysphoric disorder: Prevalence, diagnosis considerations, and controversies. Journal of Psychosomatic Obstetrics and Gynecology 27(4): 201–210. Dohi A, Dillon GH, and Singh M (2008) The role of progesterone and its metabolites in premenstrual disorders of affect. In: Ritsner MS, Weizman A, Ritsner MS, and Weizman A (eds.) Neuroactive Steroids in Brain Function, Behavior, and Neuropsychiatric Disorders: Novel Strategies for Research and Treatment, pp. 483–491. New York, NY: Springer Science þ Business Media. Doyle C, Ewald HAS, and Ewald PW (2007) Premenstrual syndrome: An evolutionary perspective on its causes and treatment. Perspectives in Biology and Medicine 50: 181–202. Hunter MS (2007) A biopsychosocial approach to premenstrual problems. In: Cockburn J and Pawson ME (eds.) Psychological Challenges in Obstetrics and Gynecology: The Clinical Management, pp. 255–262. New York, NY: Springer Science þ Business Media. Lustyk MKB, Gerrish WG, Shaver S, and Keys SL (2009) Cognitive–behavior therapy for premenstrual syndrome and premenstrual dysphoric disorder: A systematic review. Archives of Women’s Mental Health 12: 85–96. Macdougall M, Born L, Krasnik CE, and Steiner M (2006) Premenstrual syndromes. In: Fisher JE and O’Donohue WT (eds.) Practitioner’s Guide to Evidence-Based Psychotherapy, pp. 550–566. New York, NY: Springer Science þ Business Media. O’Brien PMS, Rapkin A, and Schmidt PJ (eds.) (2007) The Premenstrual Syndromes: PMS and PMDD. Boca Raton, FL: Taylor & Francis. Offman A and Kleinplatz PJ (2004) Does PMDD belong in the DSM? Challenging the medicalization of women’s bodies. The Canadian Journal of Human Sexuality 13(1): 17–27. Sigmon ST, Dorhofer DM, Rohan K, and Boulard NE (2000) The impact of anxiety sensitivity, bodily expectations, and cultural beliefs on menstrual symptom reporting: A test of the menstrual reactivity hypothesis. Journal of Anxiety Disorders 14: 615–633. Sigmon ST and Schartel JG (2008) Anxiety, anxiety disorders, and the menstrual cycle. In: Zvolensky MJ and Smits JAJ (eds.) Anxiety in Health Behaviors and Physical Illness, pp. 181–206. New York: Springer. Steiner M (2000) Premenstrual syndrome and premenstrual dysphoric disorder: Guidelines for management. Journal of Psychiatry & Neuroscience 25: 459–468.
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Steiner M and Born L (2000) Advances in the diagnosis and treatment of premenstrual dysphoria. In: Palmer KJ and Palmer KJ (eds.) Managing Depressive Disorders, pp. 139–157. Kwai Chung, Hong Kong: Adis International Publications. Ussher JM (2002) Premenstrual syndrome: Fact, fantasy, or fiction? In: Von-Hofsten C and Ba¨ckman L (eds.) Social, Developmental, and Clinical Perspectives. Psychology at the Turn of the Millennium, vol. 2, pp. 497–527. Florence, KY: Taylor & Frances-Routledge. Yonkers K, O’Brien P, and Eriksson E (2008) Premenstrual syndrome. Lancet 371: 1200–1210.
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Relevant Websites http://www.pmsandpmdd.eclipse.co.uk/ – Help and Support for Premenstrual Syndrome. http://www.medicinenet.com/premenstrual_syndrome/article.htm – Premenstrual Syndrome (PMS). http://www.nlm.nih.gov/medlineplus/ency/article/007193.htm – Premenstrual Dysphoric Disorder. http://menstruationresearch.org/ – Society for Menstrual Cycle Research. http://www.mayoclinic.com/health/pmdd/AN01372 – Premenstrual Syndrome (PMS).
Glossary Anxiety sensitivity The tendency to focus on and catastrophize about the meaning of physical sensations that is linked to increased premenstrual distress and the development of panic disorder. Biopsychosocial perspective A theoretical model that includes physical, psychological, and cultural factors in the development of diseases and disorders. Cognitive–behavior therapy A psychotherapy approach that focuses on identifying and challenging negative thinking and schemas in psychological disorders. Late luteal phase Refers to the 5–7 days prior to the onset of menstrual bleeding (menses).
In Western and non-Western cultures, fluctuations in menstrual symptoms have been noted for over 2500 years. Since its introduction to the medical nomenclature in the 1930s, the topic of premenstrual syndrome (PMS) has consistently elicited controversy, and differences in methodologies and small sample sizes have led to inconsistent findings. Research on PMS relied heavily on retrospective reports, which are problematic due to bias and overestimation of symptoms. Furthermore, definitions of PMS have not been consistent in the past, and generalization across studies is limited. However, PMS is an important topic of study, particularly when considering prevalence rates, impact, and societal views relating to PMS. The recent focus on using more standardized criteria for PMS has added greatly to the research literature, and the state of contemporary PMS research represents significant advances in our understanding of this condition.
Symptoms, Epidemiology, and Classification Symptoms of PMS In general terms, PMS refers to a variety of emotional, physical, and behavioral symptoms that occur after ovulation during the late luteal phase (days 21–28 of the menstrual cycle) and end with the onset of menstrual bleeding (day 1). Although over a hundred symptoms have been associated with the premenstrual phase, the following listed symptoms are the most commonly reported. Emotional symptoms may include anxiety, depression, anger, irritability, and mood swings. Physical symptoms can include breast tenderness, water retention, headache, fatigue, acne, joint pain, and gastrointestinal distress. Behavioral symptoms typically include appetite change, sleep disturbance, crying, social withdrawal, agitation, forgetfulness, and poor concentration.
Menstrual reactivity hypothesis A dual vulnerability model including psychological, social, and physical explanations for premenstrual exacerbation of symptoms. Panicogenic task Refers to the administration of substances that increase the symptoms (e.g., intense fear, increase in sympathetic nervous system symptoms) associated with a panic attack. Rumination The tendency to focus on the experience and causes of thoughts, feelings, and sensations associated with dysphoric mood that may lead to increases in depression and anxiety. Social construction perspectives A model that focuses on social processes that influence the discourse surrounding psychological diagnoses.
Epidemiology Approximately 80% of reproductive age women may report some of these premenstrual symptoms, and most of these symptoms occur at a mild level that does not interfere with daily functioning. Approximately 25% of women may experience PMS, which occurs when symptoms are experienced at a moderate-to-severe level and daily functioning becomes impaired. The International Classification of Diseases (ICD10) categorizes PMS as premenstrual tension syndrome. More severe symptoms with significant impairment occur in 2–9% of women and lead to a diagnosis of premenstrual dysphoric disorder (PMDD). Approximately 50% of women may seek medical treatment for their PMS symptoms. Although PMS can be diagnosed in menstruating women of any age who have ovulatory cycles, it is typically diagnosed in women in their thirties and forties. To be diagnosed with PMS, symptoms must be cyclical and not represent the exacerbation of another disorder. Women who suffer from the following psychological disorders may also experience premenstrual exacerbation of their symptoms: depression, bulimia, binge eating disorder, and panic disorder. Also, women with the following health conditions may experience an increase in symptoms or severity: epilepsy, fibromyalgia, asthma, multiple sclerosis, rheumatoid arthritis, and migraines. Women with PMS are more likely to report excessive menstrual flow, abdominal pain, and bleeding during other phases of the menstrual cycle. Current smoking and passive smoke exposure are associated with anxiety, cravings, water retention, breast pain, back pain, and headache in PMS. Increased alcohol consumption and less physical activity are related to more severe premenstrual symptoms. Increased consumption of caffeine is also linked to more severe premenstrual symptoms.
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Classification Issues Unfortunately, there is a continuing lack of consensus regarding definitions, assessment, and treatment of PMS. However, current diagnostic criteria indicate that in order to qualify for a diagnosis of PMS, symptoms must meet the following criteria: occur in the 5 days prior to menstrual bleeding onset and increase by at least 30% from other times in the menstrual cycle, cease by day 4 of menstrual bleeding, and symptoms must remit during the remainder of the menstrual cycle. More strict criteria require that both physical and emotional symptoms must be present during the 5 days before menses. Another issue to consider is the consistency of PMS symptoms over time. In this regard, prospective, daily recording of symptoms for two consecutive menstrual cycles is considered necessary to establish symptom patterns and the symptoms must be distressing as well as cause impairment in normal, daily functioning.
Biopsychosocial Perspective of PMS The most current view of PMS derives from a biopsychosocial perspective. A biopsychosocial approach posits that biological factors, psychological factors, and social factors interact to play a significant role in human functioning. Although the menstrual cycle itself is not considered a disease or illness, the biopsychosocial perspective can be used as a model to better understand the vast array of conditions that may affect a woman’s menstrual experience. Menstruation is a normal and integral biological process for women. However, psychological factors may also play a role in the report, interpretation, and experience of menstrual symptoms. Indeed, research suggests that symptom severity is quite variable and may be more related to psychological factors than biological ones. Social factors, such as age, racial/cultural diversity, and religion, may also play a role. Health care and mental health care providers, thus, need to consider the interaction of these factors in PMS in order to provide the best assessment and treatment for patients. In this article, PMS and PMDD are presented from a biopsychosocial perspective.
Biological Aspects of PMS Current research indicates that ovulation and ovulation-related processes play a central role in the development of premenstrual symptoms. Support for this model comes from research findings that PMS symptoms disappear when ovulation does not occur. Although the exact mechanisms are not clear, reproductive hormones are thought to play a significant role in symptom fluctuation across the menstrual cycle. During the late luteal phase, progesterone metabolites typically decrease and estradiol levels increase. Interestingly, however, reproductive hormone levels in women diagnosed with PMS tend to fall in the normal range. At present, there are no hypotheses concerning what would account for sensitivity in some women to normal changes in hormone levels. Progesterone and estrogen are also hypothesized to modulate neurotransmitters (e.g., serotonin, GABA, dopamine, norepinephrine) that are typically associated with changes in
mood and behavior. Decreased levels of serotonin are linked to sleep disruption, appetite change, fatigue, and depressed mood which are associated with PMS. Research has found that women with PMS have lower levels of serotonin during the last 10 days of the menstrual cycle. One hypothesis is that serotonin deficiency could enhance sensitivity to progesterone changes. Support for serotonin as a contributory factor in PMS is bolstered by the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the alleviation of some PMS symptoms. However, it is not known why some women would be more sensitive to these changes. Allopregnanolone, a metabolite of progesterone, has also been linked to PMS. However, low and high levels of it have been found in women with PMS. Genetic contributions have also been examined in women with PMS. For example, if a woman’s mother had PMS, her chances of having PMS were 70%. If one monozygotic twin had PMS, the other twin had a 90% chance of having PMS. Thus, the role of genetics in PMS deserves more study. Cyclic changes in stress hormone levels (e.g., adrenocorticotropic hormone, cortisol) have also been found in some women with PMS. This type of research represents an emerging area of interest that needs more study. Another promising area of interest relates to cyclic changes in the immune system. During the premenstrual phase, cellmediated immunity is suppressed. This cyclic change is thought to have evolutionary adaptation for the developing embryo. However, there has been no research conducted to test this interesting model of PMS and no hypothesis about why some women would experience symptoms and others dont. Other potential biological causes of PMS posited are differences in prolactin and aldosterone levels (i.e., hormones that affect fluid balance), thyroid imbalances, glucose metabolism, and insulin imbalances. However, there is no confirming evidence for causality for these hormones in the development and maintenance of PMS symptoms. Potential nutritional differences (e.g., vitamin B6, calcium, magnesium, caffeine) have also been mentioned as possible contributions to PMS symptoms. Again, there is no evidence to support these nutritional causes when women with PMS are compared to controls. In addition, there is no explanation of why some women might be more affected by these biological changes during the menstrual cycle than others. Given the lack of support for purely biological causes of PMS, researchers have also investigated the role that psychological factors or trait variables may play in PMS experience.
Psychological Aspects of PMS For women with PMS, quality of life may be significantly impacted. Women with PMS may experience impairment in social relations, personal relationships, hobbies, and household activities. PMS may also result in work disruption, decreased productivity, and increased use of health care. Women with PMS report more daily stress, life stress, perceived stress, and physiological stress than controls. Similarly, women with PMS report experiencing more traumatic events than controls. However, these findings are correlational and do not imply causation. There are several psychological disorders that are comorbid with PMS. In fact, 50% of women with PMS report a history
Premenstrual Syndrome (PMS)
of anxiety or mood disorders. Given that women with PMS often respond to a panicogenic task similar to women with panic disorder, it has been suggested that PMS and panic disorder may share a similar pathophysiological mechanism. According to the menstrual reactivity hypothesis, some women report more severe premenstrual symptoms based on an array of influences: accurate symptom reporting, biases that relate to past premenstrual experience, cultural attitudes and beliefs, and a predisposition to focus on internal bodily sensations and catastrophize about their meaning. This model has been used to explain premenstrual distress differences between women varying in levels of anxiety as well as to women with asthma. In this dual vulnerability model, some women may experience physiological sensations or symptoms and then mood symptoms may develop in response to those symptoms. As yet, this model has not been tested in PMS.
Sociocultural Factors in PMS In any discussion of PMS, the potential for the medicalization of the menstrual cycle needs to be addressed. It is clear that the menstrual cycle itself should not be considered a problem, disease, or illness that needs to be solved or treated. However, it is also clear that some women will experience moderateto-severe premenstrual symptoms that may impair their normal functioning. Does receiving a diagnosis of PMS perpetuate a myth that women are emotionally unstable and captives to raging hormones? Does this diagnosis reinforce traditional beliefs about femininity? For these reasons, sociocultural factors are particularly important to consider. There are inconsistent findings regarding the effect of education, employment, and marital status on PMS prevalence. One study found that work-related stress was a significant predictor of premenstrual symptom severity. Another study found that younger age, high levels of stress, and less education were positively associated with emotional symptoms of PMS. As women age, anxiety, mood changes, and back pain associated with PMS decrease. Women with low BMI tend to report less premenstrual symptoms (possibly due to lower levels of estrogen). Relatedly, women who are obese are three times more likely to suffer from PMS. Preliminary research also suggests that Caucasian women, smokers, and younger women are more at risk for PMS. Clearly, more research on age and weight as they relate to PMS experience is needed. Although PMS is thought to be found worldwide, culture plays a role in the reporting of symptoms. In one large survey, women of Asian descent reported fewer premenstrual symptoms than Caucasian, African American, and Hispanic women. Anxiety and mood changes were reported less by African American and Japanese women. There are, however, too few studies to be able to definitively say that race and culture may play a significant role in PMS experience.
Assessment and Treatment of PMS Assessment Assessment of PMS requires daily monitoring of symptoms for two consecutive menstrual cycles. Given that women may vary in the types of symptoms they experience, symptoms from
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the emotional, behavioral, and physical realms should be included. Women should be able to indicate the severity of the symptoms as well as the level of impairment of the daily symptoms in all life domains. In addition, other medical conditions that have similar symptom presentations, such as menopause, hyperthyroidism, hypothryroidism, and polycystic ovary syndrome, should be ruled out. Recent assessment measures have led to more consistencies in how premenstrual symptoms are measured. For example, the premenstrual symptoms screening tool (PSST), a short survey of 14 items, maps onto current diagnostic criteria for PMDD, and can also be used to screen for PMS symptoms. The daily record of severity of problems (DRSP), a prospective monitoring tool, is completed daily for two consecutive menstrual cycles to obtain a diagnosis of PMS or PMDD. The premenstrual symptoms impact survey (PMSIS), a brief survey of six items, can discriminate between women with clinically significant PMS and controls. With the continued use of such measures in larger samples, study results will be more reliable and generalizable to other populations.
Treatment Typically, women who seek treatment for their PMS symptoms are prescribed medication. Although there is no support for the progesterone deficiency model of PMS, progesterone-based therapies are commonly prescribed. SSRIs (e.g., fluoxetine, sertraline, paroxetine) are also frequently used throughout the menstrual cycle or just during the premenstrual phase (e.g., luteal phase dosing) with demonstrated efficacy compared to placebo. SSRIs may help reduce depression, anxiety, irritability, and fatigue associated with PMS. However, the long-term efficacy of using SSRIs has not been demonstrated for PMS and 40% of women with PMS do not have reduction in symptoms. Another treatment involves the suppression of ovulation and/or menstruation (e.g., GnRH analogs, Danazol, transdermal estradiol patches). However, the long-term use of such medications may include bone loss, menopausal symptoms (e.g., hot flashes, irritability), and cardiac difficulties. Oral contraceptives (OCs) may also be used to suppress ovulation. Research has shown that continuous use of OCs may result in reductions of headaches, fatigue, and water retention. Dietary changes are often suggested for women with PMS such as reducing salt intake, chocolate, caffeine, nicotine, and alcohol. Eating frequent meals high in complex carbohydrates may help reduce binges and cravings. Intake of vitamin B6, calcium, magnesium, and vitamin E is also recommended. Moderate aerobic exercise may also help manage PMS symptoms. Stress management techniques may also be helpful in reducing stress associated with work, school, and relationships. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help some women with PMS in reducing muscle tension and headaches. Yoga, acupuncture, relaxation, and social support are also recommended but have no empirical support or controlled trials. Compared to a wait-list control group, women with PMS who received cognitive–behavioral therapy (CBT) reported a reduction in the negative effects of symptoms and these results were maintained over time. However, the majority of CBT for
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PMS studies were not controlled trials and CBT has not demonstrated greater efficacy compared to SSRIs. More research is necessary to determine the mechanisms and which women with PMS might benefit from this type of treatment.
PMDD Diagnosis, Epidemiology, and Quality of Life Impact Diagnosis of PMDD Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual distress characterized by significant increases in physical and affective symptoms during the premenstrual phase of the menstrual cycle. These symptoms are serious enough to cause clinically significant distress and interfere with functioning (e.g., in work, school, home, daily activities, and/or social relationships). Symptoms of PMDD include depressed mood, anxiety, anger/irritability, mood swings, loss of interest, difficulty in concentrating, lack of energy, appetite changes or cravings, sleep disturbance, feeling overwhelmed or out of control, and physical symptoms (e.g., bloating, breast tenderness, weight gain). In women with PMDD, these symptoms are present during the premenstrual phase, improve within the first few days of the onset of menstruation, and remit during the remainder of the menstrual cycle. In other words, PMDD is characterized by dramatic emotional, physical, and behavioral changes that occur cyclically and are restricted to the premenstrual phase. Thus, PMDD is a separate diagnostic entity, rather than a premenstrual exacerbation of another disorder, such as depression.
Epidemiology PMDD is estimated to impact 2–9% of women in the United States. Similar prevalence rates have been found in several European, African, and Asian countries. However, no research has examined potential differences between racial and ethnic groups in the United States in terms of prevalence rates, symptom expression, or correlates. Regarding onset of PMDD, symptoms typically emerge during the mid- to late twenties and follow a chronic course if left untreated. In women with PMDD, symptoms tend to worsen over time but discontinue during interruptions of the ovulatory cycle (i.e., menopause, pregnancy, and ovariectomy). Lifetime comorbidity rates for PMDD are high (30–70%), particularly with other mood disorders. PMDD may put women at risk for later depression, including perimenopausal and postpartum depression. Conversely, mood or anxiety disorders may put women at risk for later development of PMDD.
Quality of Life Impact Women with PMDD experience significant impairment in quality of life. PMDD is associated with decreased social and parental functioning, as well as occupational performance. Some women with PMDD also report cognitive difficulties (e.g., attention, concentration), although research findings in this area are mixed. PMDD is also related to health-related quality of life impairment in both physical and mental health
domains. Women with PMDD report health-related quality of life burden comparable to individuals with other chronic physical (e.g., arthritis) and mental (e.g., depression) disorders. Although individuals with PMDD are most impaired during the premenstrual phase, they are more impaired in several areas of functioning during other menstrual cycle phases compared to women not diagnosed with PMDD. Overall, it is clear that PMDD has a major impact on the lives of women diagnosed with this disorder.
Biopsychosocial Perspective of PMDD Biological Aspects Most research on the etiology of PMDD has focused on biological explanations. However, research on biological models for PMDD has produced mixed findings. The majority of research has investigated the potential role of gonadal hormones. Support comes from evidence that symptoms are not present during interruptions of the ovarian cycle, and research suggesting that oral contraceptives may be an effective treatment. Symptoms may be related to the declining levels of ovarian steroid hormones during the premenstrual phase of the menstrual cycle. Estrogen and progesterone are elevated during the luteal phase, and then drop dramatically in the late luteal (premenstrual) phase. Estrogen is linked to mood through its influence on the serotonin system. Fluctuations in estrogen may also impact the secretion of corticotrophin releasing hormone (CRH), of which decreased levels have been associated with depression. There is some initial research suggesting that women with PMDD may have higher levels of estrogen during the follicular phase, and that PMDD symptoms may vary as levels of estrogen change. However, research has not confirmed relationships between estrogen levels and PMDD, and research does not support a relationship between progesterone levels and PMDD. Hormone imbalance, rather than fluctuations, may be related to PMDD. For example, a hormonal ratio imbalance between estrogen and progesterone has been implicated. In particular, when estrogen levels are high in relation to progesterone, this may be related to PMDD. In addition, it has been suggested that the pattern of secretion of hormones in women with PMDD may be abnormal. However, some studies have found that levels of ovarian hormones are normal in women with PMDD, and studies have not found differences in hormone levels in women with PMDD compared to controls. Thus, evidence regarding the role of hormones in PMDD is mixed at best. Neurotransmitters have also been studied relating to the etiology of PMDD. Decreased levels of GABA have been associated with depression and anxiety; therefore, it has been suggested that women with PMDD may have low levels of GABA during the premenstrual phase. Serotonin has also been studied in relation to PMDD, due to its links with other mood disorders. Endogenous opiate withdrawal during the premenstrual phase may be associated with fatigue, depression, and pain sensitivity. However, research on the role of neurotransmitters in PMDD has produced inconsistent findings, and many studies lack a comparison control group. At present, there is no confirmed relationship between neurotransmitter deficiencies and PMDD.
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In sum, biological explanations for PMDD have produced mixed findings. However, given that symptoms coincide with physiological changes, it is important to continue to research these factors. Research that investigates biological factors in relation to psychological and social factors may be particularly valuable in understanding this complex disorder. It is likely that PMDD is multiply determined by a combination of biological, behavioral, and cognitive factors such that attempts to assign primacy to any one of them could be misguided. In other syndromes such as panic disorder, it is now clear that unfamiliar bodily sensations stemming from normal physiological variations can be misinterpreted in ways that amplify the original concern needlessly. A similar formulation has been applied to some chronic pain syndromes. The development of negative expectations, together with the operation of conditioning processes, can create a feedback pattern that escalates manageable discomfort into seemingly unendurable distress. In the context of panic disorder, that formulation has proven to be extremely helpful in clarifying etiology and focusing effective treatment regimens that have been demonstrated to have substantial empirical support.
Psychological Aspects of PMDD Limited research has investigated psychological factors that may play a role in the development of PMDD. Psychoanalytic explanations have focused on the ‘meaning’ of the symptoms for PMDD. For example, premenstrual symptoms could be interpreted as repressed hostility toward males, who are more favored in society. Another view suggests that premenstrual mood symptoms are caused by a woman’s grief over failure to conceive. These explanations are refuted by the pattern of symptom onset and remittance in PMDD, since symptoms actually decrease at the onset of menstruation. The state of the empirical literature on psychological factors related to the etiology of PMDD is severely lacking at present. However, as research has demonstrated in PMS, the role of beliefs, expectations, and interpretations of symptoms may be influential in PMDD (e.g., menstrual reactivity hypothesis). Research on psychological factors involved in PMS has resulted in two important findings that may shed light on our understanding of PMDD: (1) Women with PMS may respond to emotional changes in a manner that is maladaptive (e.g., rumination, self-blame), and (2) Women with PMS may focus inward on physiological sensations and view these as catastrophic, thus increasing these symptoms (e.g., anxiety sensitivity). Therefore, it is possible that the manner in which women with PMDD respond to their symptoms is related to increased distress during the premenstrual phase. That is, biological changes alone do not account for PMDD per se, but rather women’s responses to physiological and emotional changes that result from the menstrual cycle may be related to the experience of PMDD. Given that research on biological factors involved in the etiology of PMDD has yielded mixed findings, incorporating psychological and social factors is likely to provide a more complete explanation of this disorder. Another line of research has examined potential shared etiologies between PMDD and other psychological disorders. Although PMDD involves symptoms of depression, it also shares similarities with anxiety disorders. Interestingly, irritability and
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anxiety are actually reported more often in women with PMDD than sadness or loss of interest. Research in this area has resulted in criticism of the classification of PMDD as a mood disorder. For example, women with PMDD respond more strongly to panicogenic challenges than women with depression, and women with PMDD and panic disorder seem to share underlying etiological factors, such as anxiety sensitivity. Given these findings, it has been suggested that PMDD is particularly similar to panic disorder. Furthermore, there are high rates of comorbidity between PMDD and other psychological disorders, such as anxiety and depression. It is possible that shared vulnerabilities exist between PMDD and these other diagnoses that may make women more susceptible to developing comorbid disorders.
Sociocultural Factors in PMDD Social constructionist perspectives contend that diagnostic categories emerge out of social processes. As such, psychological disorders are social, not natural, categories. In other words, the etiology of PMDD lies with society rather than individuals. Within this framework, feminist critics have raised concerns over the diagnosis of PMDD. In particular, a diagnosis such as PMDD may serve to subjugate women. Labels such as PMS and PMDD may reinforce women’s lower class standing. Furthermore, this classification system can be seen as medicalizing women’s sexuality. Labeling women’s premenstrual symptoms as a disorder may validate the ideas that there is something ‘wrong’ with women’s bodies, and thus underemphasize social and cultural influences on attitudes and beliefs about menstruation. For example, what girls are taught about menstruation and societal views tend to reinforce is that menstruation is painful, debilitating, and something to be embarrassed about, rather than emphasizing that menstruation is healthy and natural. These views may lead to negative attitudes toward menstruation, which could in turn contribute to premenstrual distress. For example, the menstrual reactivity hypothesis suggests that women may respond to cultural stereotypes regarding the menstrual cycle in addition to actual symptoms. Social constructionist and feminist critics have also pointed out the large financial stake in the PMDD diagnosis, particularly through pharmaceutical sales.
Assessment and Treatment of PMDD Assessment of PMDD PMDD is currently listed in the Diagnostic and Statistical Manual of Mental Disorders (APA [DSM-IV-TR], 2000) in the appendix as a set of criteria provided for further study. PMDD is diagnosed as a Mood Disorder Not Otherwise Specified. There has been debate over the classification of PMDD, including the number of symptoms required for diagnosis, as well as the location of PMDD in the manual. The state of the classification of PMDD for the updated version of the diagnostic manual (DSM-V) is unknown at present. According to current diagnostic criteria, PMDD involves five moderate-to-severe symptoms, of which at least one is primarily affective in nature (i.e., depression, anxiety, irritability, loss of interest). Of the ten symptoms listed, only one
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involves physical symptoms (e.g., bloating, aches). Symptoms must also cause significant interference in work, school, or social activities/relationships. Additionally, symptoms must not be premenstrual exacerbation of another disorder. Diagnosis of PMDD is made using prospective ratings of symptoms for two consecutive menstrual cycles. This is typically done using a daily rating form (e.g., DRSP) on which women report the severity of each symptom. Prospective rating is particularly important considering the presence of a significant recall bias for premenstrual symptoms. Many women who retrospectively report meeting PMDD criteria do not meet criteria after rating symptoms prospectively, and retrospective and prospective ratings often do not correlate with each other. The requirement of prospective ratings for two menstrual cycles has been criticized in terms of its practicality. However, it is often possible to make a provisional diagnosis prior to obtaining prospective ratings of symptoms, for example by using a screening tool (e.g., PSST). It is particularly important to consider differential diagnoses when assessing for PMDD. For example, women with mood or anxiety disorders may experience premenstrual exacerbation of these disorders, which can present similar to PMDD in the absence of prospective ratings. Similarly, mood or anxiety disorder onset could occur during the premenstrual phase but not follow a cyclical pattern, highlighting the importance of rating two consecutive cycles. Additionally, women with menstrual-cycle-related symptoms (e.g., cramps) that occur during the menstrual phase, after the onset of bleeding, could report increased symptoms on premenstrual screening tools, despite the fact that these symptoms do not occur premenstrually.
Treatment of PMDD In general, treatment of PMDD is similar to that of PMS. Pharmacological treatments for PMDD include psychotropic medications, such as SSRIs and anxiolytics, both of which have demonstrated some success in treating PMDD. Interestingly, some studies show that SSRIs may be effective even when taken only during the premenstrual phase. Oral contraceptives (i.e., birth control pills) have also been used in the treatment of PMDD; however, empirical studies on the success of this intervention have produced mixed findings. Research suggests that oral contraceptives may be most beneficial for physical symptoms compared to the affective symptoms of PMDD. Type of oral contraceptive may also be important. Thus, more research on pharmacological treatments for PMDD is warranted. Research on psychological treatment for PMDD has demonstrated some promising results. In particular, CBT interventions for PMDD indicate that this may be a potentially beneficial treatment for PMDD. However, research in this area is lacking and more studies are necessary to establish empirical support for the treatment of PMDD with CBT.
Conclusions Since the 1990s, considerable research has been conducted on women’s premenstrual experience. Stricter diagnostic criteria
have been proposed for PMS and PMDD. However, there is still no agreed-upon etiology for the two conditions. Most researchers agree that any causal model of PMS/PMDD must be multifactorial, considering biological, psychological, and sociological factors from multidisciplinary fields. More is known about treatment options, even though this research is plagued by small samples and uncontrolled trials. It is important that researchers continue to tease apart premenstrual exacerbation of existing conditions from primary PMS/PMDD.
See also: Hormones and Behavior.
Further Reading Chrisler JC (2008) PMS as a culture-bound syndrome. In: Chrisler JC, Golden C, Rozee PD, Chrisler JC, Golden C, and Rozee PD (eds.) Lectures on the Psychology of Women, 4th edn., pp. 155–171. New York, NY: McGraw-Hill. Clayton A (2008) Symptoms related to the menstrual cycle: Diagnosis, prevalence, and treatment. Journal of Psychiatric Practice 14(1): 13–21. Cohen HB (2008) Premenstrual syndrome and premenstrual dysphoric disorder. In: Clouse AL and Sherif K (eds.) Women’s Health in Clinical Practice, pp. 19–28. Totowa, NJ: Humana Press. Davis L and Yonkers KA (1997) Diagnosis and treatment of premenstrual dysphoric disorder. International Journal of Psychiatry in Clinical Practice 1: 149–156. Denmark F and Paludi M (eds.) (2008) Psychology of Women: A Handbook of Issues and Theories, 2nd edn. Westport, CT: Praeger Publishers/Greenwood Publishing Group. Di Guilio G and Reissing ED (2006) Premenstrual dysphoric disorder: Prevalence, diagnosis considerations, and controversies. Journal of Psychosomatic Obstetrics and Gynecology 27(4): 201–210. Dohi A, Dillon GH, and Singh M (2008) The role of progesterone and its metabolites in premenstrual disorders of affect. In: Ritsner MS, Weizman A, Ritsner MS, and Weizman A (eds.) Neuroactive Steroids in Brain Function, Behavior, and Neuropsychiatric Disorders: Novel Strategies for Research and Treatment, pp. 483–491. New York, NY: Springer Science þ Business Media. Doyle C, Ewald HAS, and Ewald PW (2007) Premenstrual syndrome: An evolutionary perspective on its causes and treatment. Perspectives in Biology and Medicine 50: 181–202. Hunter MS (2007) A biopsychosocial approach to premenstrual problems. In: Cockburn J and Pawson ME (eds.) Psychological Challenges in Obstetrics and Gynecology: The Clinical Management, pp. 255–262. New York, NY: Springer Science þ Business Media. Lustyk MKB, Gerrish WG, Shaver S, and Keys SL (2009) Cognitive–behavior therapy for premenstrual syndrome and premenstrual dysphoric disorder: A systematic review. Archives of Women’s Mental Health 12: 85–96. Macdougall M, Born L, Krasnik CE, and Steiner M (2006) Premenstrual syndromes. In: Fisher JE and O’Donohue WT (eds.) Practitioner’s Guide to Evidence-Based Psychotherapy, pp. 550–566. New York, NY: Springer Science þ Business Media. O’Brien PMS, Rapkin A, and Schmidt PJ (eds.) (2007) The Premenstrual Syndromes: PMS and PMDD. Boca Raton, FL: Taylor & Francis. Offman A and Kleinplatz PJ (2004) Does PMDD belong in the DSM? Challenging the medicalization of women’s bodies. The Canadian Journal of Human Sexuality 13(1): 17–27. Sigmon ST, Dorhofer DM, Rohan K, and Boulard NE (2000) The impact of anxiety sensitivity, bodily expectations, and cultural beliefs on menstrual symptom reporting: A test of the menstrual reactivity hypothesis. Journal of Anxiety Disorders 14: 615–633. Sigmon ST and Schartel JG (2008) Anxiety, anxiety disorders, and the menstrual cycle. In: Zvolensky MJ and Smits JAJ (eds.) Anxiety in Health Behaviors and Physical Illness, pp. 181–206. New York: Springer. Steiner M (2000) Premenstrual syndrome and premenstrual dysphoric disorder: Guidelines for management. Journal of Psychiatry & Neuroscience 25: 459–468.
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Steiner M and Born L (2000) Advances in the diagnosis and treatment of premenstrual dysphoria. In: Palmer KJ and Palmer KJ (eds.) Managing Depressive Disorders, pp. 139–157. Kwai Chung, Hong Kong: Adis International Publications. Ussher JM (2002) Premenstrual syndrome: Fact, fantasy, or fiction? In: Von-Hofsten C and Ba¨ckman L (eds.) Social, Developmental, and Clinical Perspectives. Psychology at the Turn of the Millennium, vol. 2, pp. 497–527. Florence, KY: Taylor & Frances-Routledge. Yonkers K, O’Brien P, and Eriksson E (2008) Premenstrual syndrome. Lancet 371: 1200–1210.
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Relevant Websites http://www.pmsandpmdd.eclipse.co.uk/ – Help and Support for Premenstrual Syndrome. http://www.medicinenet.com/premenstrual_syndrome/article.htm – Premenstrual Syndrome (PMS). http://www.nlm.nih.gov/medlineplus/ency/article/007193.htm – Premenstrual Dysphoric Disorder. http://menstruationresearch.org/ – Society for Menstrual Cycle Research. http://www.mayoclinic.com/health/pmdd/AN01372 – Premenstrual Syndrome (PMS).