Association between Premenstrual Symptoms and Posttraumatic Stress Symptoms by COVID-19: A Cross-Sectional Study with Japanese High School Students.

COVID-19 has caused an unprecedented global pandemic. Premenstrual symptoms include mood-related, behavioral, and physical symptoms that are limited to the luteal phase of the menstrual cycle. Psychosocial stress is a risk factor for premenstrual symptoms. The aim of this study was to examine the association between premenstrual symptoms and stress caused by COVID-19. We analyzed data from 871 students with regular menstrual cycles who completed the Premenstrual Symptoms Questionnaire (PSQ), Fear of COVID-19 Scale, and Impact of Event Scale-Revised version (IES-R). The total PSQ score was significantly higher in women with COVID-19-induced posttraumatic stress symptoms (PTSS) than in non-PTSS groups. Compared with pre-pandemic data (2019), the total PSQ score did not change in non-PTSS, but increased in PTSS groups. All symptoms were more severe in PTSS groups than in non-PTSS groups. Compared with 2019, PTSS groups had more severe symptoms for all symptoms except 'physical symptoms' and 'decreased social activity', and non-PTSS groups only exhibited improvements in the 'decreased social activity'. Multiple regression analysis revealed that the IES-R score was a significant exacerbation factor of the total PSQ score, along with age and menstrual pain. This study revealed the association between pandemic-associated PTSS and the severity of premenstrual symptoms.

The relationship between short stature and menstrual pattern in a large cohort of Iranian girls.

The aim of this study was to investigate the relationship between stature and menstrual pattern. Nine hundred and seventy six girls were selected from regions within two cities in north-eastern Iran in 2015. They were assessed with respect to: their stature and menstrual pattern, age of menstruation, severity of dysmenorrhoea, duration of their menstrual cycle and flow. 841 girls had experienced menarche. 10.5% had a short stature. There were significant differences in age, height, weight and body mass index between those who had experienced their first menstrual cycle and others (p < .001). There were weak and negative correlation between age of menarche and height percentiles (r = -0.12, p < .001). Premenstrual syndrome, duration of menstruation cycle and bleeding period did not differ between these two groups (p > .05). We found that dysmenorrhoea was significantly influenced by height. Although the mean age at menarche was statistically significant among different statures, the range was narrow (12.2-12.7). Further studies considering environmental factors, including socioeconomic status and nutrition concurrently, are also required.Impact statementWhat is already known on this subject? Various menstrual characteristics, including age of menarche, severity of dysmenorrhoea and duration of menstrual period may be associated with height. But, there have been few studies on the relationship between short stature and its impact on health status and menstrual patterns in adolescents.What do the results of this study add? There were significant differences in age, height, weight and body mass index between adolescent girls who had experienced their first menstrual cycle, and others. There were weak, negative, significant correlations between age of menarche and height percentiles. Dysmenorrhoea was significantly influenced by height.What are the implications of these findings for clinical practice and/or further research? Life style modification and nutritional interventions that optimise the height of girls may resolve their menstrual problems and dysmenorrhoea.

Protein intake and the risk of premenstrual syndrome.

OBJECTIVE: To examine the relationship between protein intake and the risk of incident premenstrual syndrome (PMS). DESIGN: Nested case-control study. FFQ were completed every 4 years during follow-up. Our main analysis assessed protein intake 2-4 years before PMS diagnosis (for cases) or reference year (for controls). Baseline (1991) protein intake was also assessed. SETTING: Nurses' Health Study II (NHS2), a large prospective cohort study of registered female nurses in the USA.ParticipantsParticipants were premenopausal women between the ages of 27 and 44 years (mean: 34 years), without diagnosis of PMS at baseline, without a history of cancer, endometriosis, infertility, irregular menstrual cycles or hysterectomy. Incident cases of PMS (n 1234) were identified by self-reported diagnosis during 14 years of follow-up and validated by questionnaire. Controls (n 2426) were women who did not report a diagnosis of PMS during follow-up and confirmed experiencing minimal premenstrual symptoms. RESULTS: In logistic regression models adjusting for smoking, BMI, B-vitamins and other factors, total protein intake was not associated with PMS development. For example, the OR for women with the highest intake of total protein 2-4 years before their reference year (median: 103·6 g/d) v. those with the lowest (median: 66·6 g/d) was 0·94 (95 % CI 0·70, 1·27). Additionally, intakes of specific protein sources and amino acids were not associated with PMS. Furthermore, results substituting carbohydrates and fats for protein were also null. CONCLUSIONS: Overall, protein consumption was not associated with risk of developing PMS.

Posttraumatic stress disorder and development of premenstrual syndrome in a longitudinal cohort of women.

We examined the association between posttraumatic stress disorder (+PTSD) symptoms and incident premenstrual syndrome (PMS) in a longitudinal study with 14 years follow-up of 2924 women aged 27-44. Compared to women with no trauma exposure, women with trauma/PTSD were at significantly increased risk of PMS (p-trend < .001): 1) trauma/no PTSD odds ratio (OR) = 1.31 [95% confidence interval (CI) 1.05-1.63], 2) 1-3 PTSD symptoms OR = 1.71 [95% CI = 1.33-2.20], 3) 4-5 PTSD symptoms OR = 2.90 [95% CI = 2.07-4.05], and 4) 6-7 PTSD symptoms OR = 3.42 [95% CI = 2.18-5.36].

Intake of dietary fat and fat subtypes and risk of premenstrual syndrome in the Nurses' Health Study II.

Approximately 8-20 % of reproductive-aged women experience premenstrual syndrome (PMS), substantially impacting quality of life. Women with PMS are encouraged to reduce fat intake to alleviate symptoms; however, its role in PMS development is unclear. We evaluated the association between dietary fat intake and PMS development among a subset of the prospective Nurses' Health Study II cohort. We compared 1257 women reporting clinician-diagnosed PMS, confirmed by premenstrual symptom questionnaire and 2463 matched controls with no or minimal premenstrual symptoms. Intakes of total fat, subtypes and fatty acids were assessed via FFQ. After adjustment for age, BMI, smoking, Ca and other factors, intakes of total fat, MUFA, PUFA and trans-fat measured 2-4 years before were not associated with PMS. High SFA intake was associated with lower PMS risk (relative risk (RR) quintile 5 (median=28·1 g/d) v. quintile 1 (median=15·1 g/d)=0·75; 95 % CI 0·58, 0·98; P trend=0·07). This association was largely attributable to stearic acid intake, with women in the highest quintile (median=7·4 g/d) having a RR of 0·75 v. those with the lowest intake (median=3·7 g/d) (95 % CI 0·57, 0·97; P trend=0·03). Individual PUFA and MUFA, including n-3 fatty acids, were not associated with risk. Overall, fat intake was not associated with higher PMS risk. High intake of stearic acid may be associated with a lower risk of developing PMS. Additional prospective research is needed to confirm this finding.

The cytokine-hormone axis - the link between premenstrual syndrome and postpartum depression.

Premenstrual syndrome (PMS) and related disorders, and postpartum depression (PPD) can affect women to the extent that their quality of life and that of their near ones can be severely impaired. This review focuses on the different theories regarding the etiologies of PMS and PPD, and attempts to draw a link between the two. Theories focus mainly on hormonal and cytokine factors throughout different phases in the female reproductive cycle. Changes in this symptomatology during pregnancy are also reviewed, as are changes in hormones and cytokine levels. Hypotheses are thus developed as to why the symptoms experienced in PMS often subside during pregnancy yet may recur and be exacerbated after birth, giving rise to the symptoms experienced in PPD.

Stress and Premenstrual Symptoms in Reproductive-Aged Women.

Premenstrual symptoms are often reported from reproductive-aged women worldwide. The etiologies of the symptoms are complex (e.g., biological and sociocultural factors), and require an international and multidisciplinary approach. A total of 48 studies were reviewed on how stress and premenstrual symptoms have been defined and measured, and major findings on relational patterns and other associated factors were examined. Subsequently, we discuss several trends and limitations identified from the review. Prospective studies, which use valid assessment measures and consider women's subjective and objective symptoms for several menstrual cycles, are necessary for a valid conclusion. More intervention studies and studies on various populations are needed.

Premenstrual syndrome in Turkish medical students and their quality of life.

This study aimed to analyse the frequency and symptoms of premenstrual syndrome (PMS) and its effect on quality of life in medical students. Sociodemographic data, a symptom calendar for the following consecutive two menstrual periods and SF-36 quality of life questionnaire were collected. A total of 228 students joined the survey. The average age of the students was 20.77 ± 1.90. The frequency of PMS was 91.8%. The most frequent symptoms were abdominal bloating (89.5%), irritability (88.3%) and breast tenderness (82.6%). Quality of life scores ranged from 17.00 to 97.00 and were lowest in the severe PMS group. Alcohol consumption, stress events and fat rich diets increased the severity of PMS. Family history significantly affected the severity of PMS and quality of life scores. Premenstrual syndrome was found to be a frequent entity among medical students and seemed to affect quality of life in a moderate way.

Premenstrual syndrome: management and pathophysiology.

Premenstrual syndrome (PMS) is triggered by hormonal events ensuing after ovulation. The symptoms can begin in the early, mid, or late luteal phase and are not associated with defined concentrations of any specific gonadal or non-gonadal hormone. Women with PMS experience affective or somatic symptoms that cause severe dysfunction in social or occupational realms. Although evidence for a hormonal abnormality has not been established, the symptoms of the premenopausal disorders are related to the production of progesterone by the ovary. The progesterone metabolites may bind to a neurosteroid-binding site on the membrane of the neurotransmitters. Thus, ovulation suppression is an area of focus for diagnostic and treatment options. Many treatment studies have focused on suppression of ovulation with gonadotropin-releasing hormone analogs (GnRHa), high doses of transdermal estrogen, and bilateral oophorectomy all have positive evidence as treatment options for prevention of PMS. However, because of these limitations and their substantial intensive care, these do not appear to be appropriate methods for conventional treatment of PMS. Serotonergic antidepressants, selective serotonin reuptake inhibitors, are well-established, highly effective, and first-line pharmacologic therapy.

The effect of uterine artery embolization on premenstrual symptoms in patients with symptomatic fibroids or adenomyosis.

PURPOSE: To evaluate whether uterine artery embolization (UAE) can reduce the premenstrual symptoms in women undergoing UAE for fibroid tumors or adenomyosis. MATERIALS AND METHODS: Among 141 women who underwent UAE for symptomatic fibroid tumors or adenomyosis at a single institution between March 2011 and February 2013, 54 premenstrual symptoms in 39 patients were prospectively analyzed. Premenstrual symptoms were rated by the patient on a scale of 0 to 10, with 0 representing no symptom and 10 representing the baseline severity. The change in premenstrual symptom score was calculated by subtracting the baseline score from the post-UAE score. At 3-6 months after UAE, each woman also completed a symptom severity questionnaire to assess the severity of menstrual bleeding to compare the changes in premenstrual symptoms scores between women with and without menorrhagia. RESULTS: Back pain, headache, and gastrointestinal symptoms (eg, constipation, indigestion, lower abdominal pain) were significantly improved after UAE (P < .05). Muscle pain, fatigue, nervousness, breast tenderness, and systemic edema were also improved, but not significantly so. The mean premenstrual symptom score change in patients with menorrhagia was significantly greater than in those without menorrhagia (-6.4 vs -3.7; P = .044).There was no correlation between the degree of menorrhagia score change and the degree of premenstrual symptom score change (P = .186). CONCLUSIONS: UAE could be a method to alleviate some premenstrual symptoms in patients with uterine fibroid tumors or adenomyosis.

Effects of physical exercise on the female reproductive system.

The excess in physical activity could be closely linked to considerable negative consequences on the whole body. These dysfunctions called as "female athlete triad"' by the American College of Sports Medicine (ACSM) include amenorrhea, osteoporosis and disorder eating. The female athlete triad poses serious health risks, both on the short and on the long term, to the overall well-being of affected individuals. Sustained low energy availability can impair health, causing many medical complications within skeletal, endocrine, cardiovascular, reproductive and central nervous system. On the contrary, several studies have shown, that physical activity improves cardiovascular risk factors, hormonal profile and reproductive function. These improvements include a decrease in abdominal fat, blood glucose, blood lipids and insulin resistance, as well as improvements in menstrual cyclicity, ovulation and fertility, decreases in testosterone levels and Free Androgen Index (FAI) and increases in sex hormone binding globulin (SHBG). Other studies reported that physical activity improved self-esteem, depression and anxiety. Thus, the aim of this review is to elucidate the effect of physical exercise on female reproductive system and viceversa the impact of hormonal status on physical activity and metabolism. In addition this review supports the idea that physical exercise is a helpful tool for the management of obesity, prevention of cardiovascular, metabolic diseases and female reproductive organs related diseases (e.g. breast cancer). When the excess in physical activity leads up to the female athlete triad, it is imperative to treat each component of the triad by employing both pharmacological and non pharmacological treatments.

Premenstrual symptoms and posttraumatic stress disorder in Japanese high school students 9 months after the great East-Japan earthquake.

On March 11, 2011, the Great East-Japan Earthquake occurred and a massive tsunami hit the northeastern coast of Japan. Catastrophic disasters such as earthquakes and war cause tremendous damage, not only physically but also mentally. Posttraumatic stress disorder (PTSD) is an anxiety disorder that occurs in the aftermath of a traumatic event. Premenstrual syndrome (PMS) is a cluster of psychological and somatic symptoms that are limited to the late luteal phase of the menstrual cycle. Premenstrual dysphoric disorder (PMDD) is considered a severe form of PMS. To determine the relationship between premenstrual symptoms and natural disaster-induced PTSD among Japanese adolescent girls, we conducted a cross-sectional study. Overall, 1489 high school students who belong to two high schools in Sendai, the largest city in northeastern Japan, were assessed 9 months after the earthquake. These schools are located inland, far from the seashore, and were not damaged by the tsunami. Premenstrual symptoms were assessed using the Premenstrual Symptoms Questionnaire, and PTSD symptoms were assessed using the Japanese-language version of Impact of Event Scale-Revised, which is a widely used self-assessment questionnaire about PTSD symptoms. We analyzed the data of 1,180 girls who completed the questionnaires and 118 girls (10.0%) were classified as having PTSD. The prevalence rates of PMDD and moderate to severe PMS increased according to the comorbidity of PTSD (p < 0.001), showing a correlation between the severity of PMS/PMDD and natural disaster-induced PTSD. The comorbidity of PMS/PMDD and PTSD may complicate the follow-up of both conditions.

Development and validation of risk prediction model for premenstrual syndrome in nurses: results from the nurses-based the TARGET cohort study.

Objective: Premenstrual syndrome (PMS) stands as a significant concern within the realm gynecological disorders, profoundly impacting women of childbearing age in China. However, the elusive nature of its risk factors necessitates investigation. This study, therefore, is dedicated to unraveling the intricacies of PMS by focusing on nurses, a cohort with unique occupational stressors, to develop and validate a predictive model for assessing the risk of PMS. Methods: This investigation employed a multi-center cross-sectional analysis drawing upon data from the TARGET Nurses' health cohort. Utilizing online survey versions of the Premenstrual Syndrome Scale (PMSS), a comprehensive dataset encompassing physiological, social, psychological, occupational, and behavioral variables was collected from 18,645 participants. A stepwise multivariate logistic regression analysis was conducted to identify independent risk factors for PMS. Furthermore, a refined variable selection process was executed, combining the Least Absolute Shrinkage and Selection Operator (LASSO) method with 10-fold cross-validation. The visualization of the risk prediction model was achieved through a nomogram, and its performance was evaluated using the C index, receiver operating characteristic (ROC) curves, and the calibration curves. Results: Among the diverse variables explored, this study identified several noteworthy predictors of PMS in nurses, including tea or coffee consumption, sleep quality, menstrual cycle regularity, intermenstrual bleeding episodes, dysmenorrhea severity, experiences of workplace bullying, trait coping style, anxiety, depression and perceived stress levels. The prediction model exhibited robust discriminatory power, with an area under the curve of 0.765 for the training set and 0.769 for the test set. Furthermore, the calibration curve underscored the model's high degree of alignment with observed outcomes. Conclusion: The developed model showcases exceptional accuracy in identifying nurses at risk of PMS. This early alert system holds potential to significantly enhance nurses' well-being and underscore the importance of professional support.

The multifactorial aetiology and management of premenstrual dysphoric disorder with leuprorelin acetate.

Up to 18% of women of reproductive age may experience symptoms during the luteal phase of the menstrual cycle known as premenstrual syndrome (PMS) or its more severe form, premenstrual dysphoric disorder (PMDD). A plethora of symptoms have been described, but both are commonly associated with other mood-related disorders such as major depression causing significant life impairment. Originally known as late luteal phase dysphoric disorder in the DSM-III-R (American Psychiatric Association 1987), the syndrome was renamed PMDD in the DSM-IV (American Psychiatric Association 1994). Between 3% and 8% of women meet the diagnostic criteria for PMDD. Currently, there is no consensus on its aetiology although it is thought to be multifactorial. Biological, genetic, psychological, environmental and social factors have all been suggested. However, an altered sensitivity to the normal hormonal fluctuations that influence functioning of the central nervous system is thought most likely. PMDD is identified in the DSM-5 by the presence of at least five symptoms accompanied by significant psychosocial or functional impairment. During evaluation, it is recommended that clinicians confirm symptoms by prospective patient mood charting for at least two menstrual cycles. Management options include psychotropic agents, ovulation suppression and dietary modification. Selective serotonin reuptake inhibitors (SSRIs) are considered primary therapy for psychological symptoms. Ovulation suppression is another option with the combined oral contraceptive pill (COCP) or GnRH (gonadotropin-releasing hormone) agonists. Rarely symptoms warrant a bilateral oophorectomy and a 6-month trial of GnRH agonists prior to surgery may be prudent to determine its potential efficacy. The authors present the case of a multiparous woman in her mid-30s experiencing severe symptoms during the luteal phase of her menstrual cycle. A trial of the contraceptive pill and SSRIs were unsuccessful. Treatment with leuprorelin acetate (Prostap) improved her symptoms. She therefore elected to undergo a bilateral oophorectomy with resolution of her symptoms. She started hormone replacement therapy (HRT). This case demonstrates the multifactorial aetiology of PMDD and the challenges in its management. Women with PMDD suffer functional impairments comparable with other depressive disorders and yet PMDD and its impact remain under-recognised. As the psychological nature and consequences of PMDD often seem indistinguishable from symptoms of other mental health difficulties, this condition presents distinct diagnostic challenges for healthcare professionals. It is crucial to establish the correct diagnosis using clearly defined criteria because if it is left untreated, it can cause considerable impairment to the woman's quality of life.

[Premenstrual Dysphoric Disorder (PMDD) as an independent disease]. / Die prämenstruelle dysphorische Störung (PMDS) als eigenständiges Krankheitsbild.

This paper provides an overview of premenstrual dysphoric disorder (PMDD) and its clinical relevance in differentiation to premenstrual syndrome (PMS). Regarding recent research on epidemiology, aetiology, symptoms and therapy, PMDD is a discrete disorder and has a good prognosis in cases of appropriate diagnosis and therapy. The information provided in this review will help to better integrate PMDD into the psychiatric diagnostic process; options for diagnosis and treatment are also presented.

[Analysis on content of serum monoamine neurotransmitters in macaques with anger-in-induced premenstrual syndrome and liver-qi depression syndrome].

OBJECTIVE: To observe the changes in content of monoamine neurotransmitters in the serum of rhesus macaques, and explore the role of serum monoamine neurotransmitters in premenstrual syndrome (PMS) and liver-qi depression induced by anger-in emotion. METHODS: Social level pressure was applied on 24 female macaques to induce the angry emotional reaction, and then nine of the low-status macaques with anger-in emotional reaction were screened out and were divided into anger-in emotion group, PMS and liver-qi depression group (model group) and Jingqianshu Granule group. Macaques in the last two groups were suffered extruding in a pack cage for inducing PMS liver-qi depression. After 5 d of extruding, experimental animals were evaluated according to the emotional evaluation scale, meanwhile, macaque serum of follicular phase and middle-late luteal phase was collected to analyze the content of serum norepinephrine, dopamine, and 5-hydroxytryptamine. RESULTS: Compared with the normal control group, the scores of depression of the model group and the anger-in emotion group evaluated with emotional evaluation scale were significantly increased (P<0.01, P<0.05); while the score of the model group was significantly higher than that of the anger-in emotion group (P<0.05), and it returned to normal after Jingqianshu Granule treatment. As compared to the normal control group, serum monoamine neurotransmitter levels of the model group and the anger-in emotion group were increased (P<0.05, P<0.01), and the serum monoamine neurotransmitter levels of the model group were significantly higher than those of the anger-in emotion group (P<0.05), while there was no significant difference when compared with the normal control group after the treatment. CONCLUSION: Anger-in emotion can induce liver-qi depression syndrome which is related to the changes in monoamine neurotransmitters.

Association among Premenstrual Syndrome, Dietary Patterns, and Adherence to Mediterranean Diet.

Premenstrual syndrome (PMS) adversely affects the physiological and psychological health and quality of life of women. Mediterranean diet (MD) could be helpful for managing and preventing PMS, but evidence on the association between dietary patterns and PMS in Asian women is limited. This study aimed to investigate the association of dietary patterns and adherence to MD with PMS in Korean women. This cross-sectional study recruited 262 women aged 20-49 years via an online survey. PMS was diagnosed using the American College of Obstetricians and Gynecologists diagnostic criteria. MD adherence was assessed using the Korean version of the Mediterranean Diet Adherence Screener. Mediterranean Diet Score (MDS) was classified into tertiles (T) (T1: 0-3, T2: 4-5, and T3: ≥6). Dietary pattern was assessed with the Food Frequency Questionnaire. Multiple logistic regression analyses were conducted to evaluate the association between dietary pattern scores and PMS prevalence. The proportion of PMS was significantly lower in MDS tertile (T) 3 than in T1 (55.4% in T3 vs. 74.4% in T1, p = 0.045). After adjusting for confounders, participants in the highest tertile of the bread/snack pattern had a higher risk of PMS (odds ratio [95% CI]: 2.59 [1.32-5.06]), while traditional dietary pattern and meat/alcohol pattern were not associated with PMS. In conclusion, we found that low adherence to MD and higher bread/snack dietary pattern were associated with increased risk of PMS, respectively.

Premenstrual syndrome and premenstrual dysphoric disorder / Premenstruális szindróma és premenstruális dysphoriás zavar

Premenstrual syndrome (PMS) is one of the most common problems for women of reproductive age worldwide, along with painful menstruation and genital inflammation. The physical, mental and behavioural symptoms recur during the luteal phase of the cycle and cause a deterioration in the quality of life, affecting the patient's social, work and family relationships. Symptoms typically disappear spontaneously within a few days after the onset of menstruation. A severe form of PMS is premenstrual dysphoric disorder (PMDD), which requires psychiatric management. The onset and severity of PMS with multifactorial pathogenesis is triggered by psychoneuroendocrine mechanisms that are influenced by the cyclical functioning of the hypothalamic-pituitary-ovarian axis, altering the neurotransmitter or neuropathway functions of the brain, e.g., the serotoninergic system. The psychoneuroendocrine mechanisms contribute to the development of physical, psychological and behavioural symptoms, which are also influenced by the combined presence of other physiological (genetical background, metabolic and chronic inflammatory processes, chronobiological and circadian disorders) and psychological stressors and their interaction.

Prevalence of violence exposure in women with premenstrual dysphoric disorder in comparison with other gynecological patients and asymptomatic controls.

OBJECTIVE: The aim of the present study was to estimate prevalence rates of physical, emotional and sexual abuse in women with premenstrual dysphoric disorder (PMDD) in comparison with gynecological outpatients and asymptomatic healthy control subjects. DESIGN: Cross-sectional study. SETTINGS: Departments of obstetrics and gynecology in three different Swedish hospitals. POPULATION: Fifty-eight women meeting strict criteria for PMDD, a control group of 102 women seeking care at the gynecological outpatient clinic (ObGyn controls) and 47 asymptomatic healthy control subjects were included in this study. METHODS: The Swedish version of the Abuse Assessment Screen was used to collect information on physical and sexual abuse, and the screening instrument was administered as a face-to-face interview. MAIN OUTCOME MEASURES: Previous and ongoing physical and sexual abuse. RESULTS: Any lifetime abuse (physical, emotional or sexual) was reported by 31.0% of PMDD patients, by 39.2% of ObGyn controls and by 21.3% of healthy controls. The ObGyn controls reported physical and/or emotional abuse significantly more often than PMDD patients as well as healthy controls (p<0.05). Lifetime sexual abuse was reported significantly more often by ObGyn controls than by healthy controls (p<0.05). CONCLUSIONS: Patients with PMDD appear not to have suffered physical, emotional or sexual abuse to a greater extent than other gynecological patients or healthy control subjects. However, exposure to violence was common in all groups of interviewed women, and for the individual patient these experiences may contribute to their experience of symptoms.