Premenstrual Dysphoric Disorder in Adults

To be diagnosed with PMDD, a person must experience at least five diagnostic symptoms.  These five symptoms must include at least one symptom from the following list:

• Affective lability,which can include mood swings, feeling suddenly sad or tearful, or being very sensitive to rejection
• Irritability or anger, or increased interpersonal conflicts
• Depressed mood, hopelessness, or self-deprecating thoughts,or
• Anxiety, tension, or restlessness

The five symptoms must also include at least one symptom from the following list:

• Anhedonia, or decreased interest in one's usual activities

• Difficulty concentrating
• Lethargy or fatigue
• Appetite disturbance, including marked change in appetite, overeating, or specific food cravings
• Sleep disturbance, including insomnia or hypersomnia
• Overwhelmed or out of control feelings
• Physical symptoms, such as breast swelling or tenderness, joint or muscle pain, a sensation of bloating, or weight gain

PMDD should not be diagnosed if the symptoms are solely an exacerbation of another disorder, such as major depressive disorder.

PMDD symptoms may be subject to memory biases.  For example, a person may misremember when symptoms occur, attributing them to the menstrual cycle when in fact there is no association.  Therefore, PMDD diagnoses should be confirmed through the use of prospective daily symptom ratings for at least two menstrual cycles.  Prior to confirmation, the diagnosis should be listed as provisional.  

Currently, little is known about the precise biological factors that contribute to PMDD.  However, increased sensitivity or other abnormalities in neuroendocrine-modulated neurotransmitters such as serotonin and the hypothalamic-pituitary-gonadal axis have been proposed as candidate mechanisms.  Neurobiological abnormalities include abnormal activation in the amygdala, which is involved in emotion generation, and the orbitofrontal cortex, which is involved in emotion regulation. The disorder appears to be heritable, although having a genetic predisposition to PMDD does not necessarily mean that someone will develop PMDD.

Currently, clinical research suggests that antidepressant medications, which work by altering the amount of serotonin in the brain, are effective for treating PMDD.  Specific medications that have shown efficacy for the treatment of PMDD include:

• Selective serotonin reuptake inhibitors (SSRIs), including citalopram, escitalopram, fluoxetine, and sertraline.  SSRIs are generally considered a first-line pharmacological treatment for PMDD.  SSRIs can be administered continuously throughout the month or intermittently, corresponding to the menstrual cycle.
• Other serotonergic antidepressant medications, including velafaxine and clomipramine

Additionally, the following treatments have shown some promise in treating PMDD:

• Vitamin supplementation with calcium or vitamin B6
• Hormone therapies, including the oral contraceptive drosperinone, 3mg/ethinyl estradiol, 20mcg (Yasmin), estrogen, and gonadotropin-releasing hormone agonists such as buserelin and goserelin
• Herbal supplementation with chasteberry
• Cognitive-behavioral therapy consists of a variety of interventions designed to help the patient think and behave in more adaptive ways.  Some specific components of cognitive-behavioral therapy include behavioral activation, which involves increasing the individual’s engagement in potentially rewarding activities, and cognitive therapy, which involves helping the person to challenge inaccurate beliefs that they may hold (such as “I’ll never feel better” or “I’m not a worthwhile person”).

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered.

• Aerobic exercise
• Consuming more high-protein foods or complex carbohydrates, which increase tryptophan, a building block of serotonin