Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS). Like PMS, premenstrual dysphoric disorder follows a predictable, cyclic pattern. Symptoms begin in the late luteal phase of the menstrual cycle (after ovulation) and end shortly after menstruation begins. On average, the symptoms last six days, with the most intense symptoms happening in the two days before through the day of the start of menstrual blood flow.
Emotional symptoms are generally present, and in PMDD, mood symptoms are dominant. Substantial disruption to personal relationships is typical for women with PMDD. Anxiety, anger, and depression may also occur. The main symptoms, which can be disabling, include
Feelings of sadness or despair, or even thoughts of suicide
Feelings of tension or anxiety
Mood swings or frequent crying
Lasting irritability or anger that affects other people
Lack of interest in daily activities and relationships
Trouble thinking or focusing
Tiredness or low energy
Food cravings or binge eating
Feeling out of control
Physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain
The symptoms occur during the week before menstruation, and go away once it starts. A diagnosis of PMDD requires the presence of at least five of these symptoms.
In 2007, the first significant genetic finding in premenstrual dysphoric disorder was reported. Variants in the estrogen receptor alpha gene are associated with PMDD. Women with these genetic variants were more likely to suffer from PMDD. They also discovered that this association is seen only in women with a variant form of another gene, Catechol-O-methyl transferase also known as COMT, which is involved in regulating the function of the prefrontal cortex, a critical regulator of mood.
Previously, research showed that women with PMDD have an abnormal response to normal hormone levels, and, thus, are differentially sensitive to their own natural hormone changes.
There is objective correlational evidence of a neurological connection for PMDD distress. The self-rated cardinal mood symptoms of women suffering premenstrual dysphoria was found to be significantly correlated with the concomitant worsening of their brain serotonin precursors, measured by positron emission tomography (PET).
Supporting the hypothesized important role of serotonin, a number of selective serotonin reuptake inhibitors (SSRIs) have been shown in clinical trials to effectively treat the mood component of PMDD when taken during the dysphoric phase, as detailed in the treatment section below.
Women with PMDD who have never experienced major depressive disorder (MDD) have lower sensitivity and response to stress and pain than people with a MDD. This suggests that PMDD is a separate disease from MDD.
General life stress is also associated with the prevalence of PMDD and the severity of symptoms. Research shows that perceived discrimination is a stressor associated with the lifetime prevalence of PMDD. The experience of subtle forms of gender and race discrimination is correlated with PMDD among ethnic minority women.
Originally called late luteal phase dysphoric disorder (LLPDD), the disorder was renamed PMDD by the American Psychiatric Association in its May 1993 revision of the DSM-IV. In 1993, PMDD was not yet recognized as a disorder in the DSM-IV, but was noted in appendix B, "Criteria Sets and Axes Provided for Further Study." In the DSM-5 (publication May 2013,) premenstrual dysphoric disorder has been moved from Appendix B to the main body of DSM-5.
In 2003, the manufacturer of Prozac (fluoxetine) was required by the Committee for Proprietary Medicinal Products to remove PMDD from the list of indications for fluoxetine sold in Europe. Reflecting the approach of the ICD-10, the committee found that
...PMDD is not a well-established disease entity across Europe... There was considerable concern that women with less severe pre-menstrual symptoms might erroneously receive a diagnosis of PMDD resulting in widespread inappropriate short and long-term use of fluoxetine.
Lifestyle changes such as regular exercise and a well balanced diet may ameliorate some of the effects of PMDD. L-tryptophan, a serotonin precursor, was found to provide significant relief (p = 0.004) when supplemented daily in a large dose of 6 grams per day. There is some evidence that vitamin B6 can alleviate symptoms.
^Halbreich U (December 2004). "The diagnosis of premenstrual syndromes and premenstrual dysphoric disorder--clinical procedures and research perspectives". Gynecol. Endocrinol.19 (6): 320–34. doi:10.1080/0951590400018215. PMID15724807.
^Endicott J, McLaughlin TP, Grudzinski AN (December 2003). "Comparison of managed care charges among patients treated with selective serotonin reuptake inhibitors for premenstrual dysphoric disorder". J Clin Psychiatry64 (12): 1511–6. doi:10.4088/JCP.v64n1216. PMID14728114.
^PMDD affects "... 3-8% of women of reproductive age. Assessment of published reports demonstrate that the prevalence of clinically relevant dysphoric premenstrual disorder is probably higher. 13-18% of women of reproductive age may have premenstrual dysphoric symptoms severe enough to induce impairment and distress, though the number of symptoms may not meet the arbitrary count of 5 symptoms on the PMDD list." PMID 12892987
^Yonkers KA, Pearlstein T, Fayyad R, Gillespie JA. Luteal phase treatment of premenstrual dysphoric disorder improves symptoms that continue into the postmenstrual phase. J Affect Disord. 2005 Apr;85(3):317-21. doi:10.1016/j.jad.2004.10.006PMID 15780701
^ abEriksson O, Wall A, Marteinsdottir I, et al. (March 2006). "Mood changes correlate to changes in brain serotonin precursor trapping in women with premenstrual dysphoria". Psychiatry Res146 (2): 107–16. doi:10.1016/j.pscychresns.2005.02.012. PMID16515859.
Severe form of premenstrual syndrome considered as a distinct clinical entity, characterized by prominent symptoms of irritability, anger, internal tension, dysphoria and mood lability. Diagnosis requires a prospective symptom diary documenting specific cyclic symptoms associated with the luteal and menstrual phases of the cycle, and evidence of socioeconomic dysfunction.
^Steiner M, Pearlstein T, Cohen LS, et al. (2006). "Expert guidelines for the treatment of severe PMS, PMDD, and comorbidities: the role of SSRIs". J Womens Health (Larchmt)15 (1): 57–69. doi:10.1089/jwh.2006.15.57. PMID16417420.
^Steiner M, Pearlstein T (2000). "Premenstrual dysphoria and the serotonin system: pathophysiology and treatment". J Clin Psychiatry. 61 Suppl 12: 17–21. PMID11041380.