A diagnostic and statistical manual of mental disorders history of premenstrual dysphoric disorder.

The proposals to include a menstruation-related mood disorder in the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R), and DSM-IV led to intense public and behind-the-scenes controversy. Although the controversies surrounding the DSM-5 revision were greater in number than the controversies of the earlier revisions, the DSM-5 proposal to include a menstruation-related mood disorder was not among them. Premenstrual dysphoric disorder was made an official disorder in the DSM-5 with no significant protest. To understand the factors that led to this change, we interviewed those psychiatrists and psychologists who were most involved in the DSM-IV revision. On the basis of these interviews, we offer a list of empirical and nonempirical considerations that led to the DSM-IV compromise and explore how key alterations in these considerations led to a different outcome for the DSM-5.

ISPMD consensus on the management of premenstrual disorders.

The second consensus meeting of the International Society for Premenstrual Disorders (ISPMD) took place in London during March 2011. The primary goal was to evaluate the published evidence and consider the expert opinions of the ISPMD members to reach a consensus on advice for the management of premenstrual disorders. Gynaecologists, psychiatrists, psychologists and pharmacologists each formally presented the evidence within their area of expertise; this was followed by an in-depth discussion leading to consensus recommendations. This article provides a comprehensive review of the outcomes from the meeting. The group discussed and agreed that careful diagnosis based on the recommendations and classification derived from the first ISPMD consensus conference is essential and should underlie the appropriate management strategy. Options for the management of premenstrual disorders fall under two broad categories, (a) those influencing central nervous activity, particularly the modulation of the neurotransmitter serotonin and (b) those that suppress ovulation. Psychotropic medication, such as selective serotonin reuptake inhibitors, probably acts by dampening the influence of sex steroids on the brain. Oral contraceptives, gonadotropin-releasing hormone agonists, danazol and estradiol all most likely function by ovulation suppression. The role of oophorectomy was also considered in this respect. Alternative therapies are also addressed, with, e.g. cognitive behavioural therapy, calcium supplements and Vitex agnus castus warranting further exploration.

Clinical subtypes of core premenstrual disorders: a Delphi survey.

The purpose of this study was to classify the clinical subtypes of core premenstrual disorders during the International Society for Premenstrual Disorders' second consensus meeting. Multiple iterations were used to achieve consensus between a group of experts; these iterations included a two-generational Delphi technique that was preceded and followed by open group discussions. The first round was to generate a list of all potential clinical subtypes, which were subsequently prioritized using a Delphi methodology and then finalised in a final round of open discussion. On a six-point scale, 4 of the 12 potential clinical subtypes had a mean score of ≥5.0 following the second iteration and only 3 of the 4 still had a mean score of ≥5.0 after the third iteration. The final list consisted of these three subtypes and an additional subtype, which was introduced and agreed upon, in the final iteration. There is consensus amongst experts that core premenstrual disorder is divided into three symptom-based subtypes: predominantly physical, predominantly psychological and mixed. A proportion of psychological and mixed subtypes may meet the DSM-IV diagnostic criteria for premenstrual dysphoric disorder.

Classification of perimenstrual headache: clinical relevance.

Although more than 50% of women with migraine report an association between migraine and menstruation, menstruation has generally considered to be no more than one of a variety of different migraine triggers. In 2004, the second edition of the International Classification of Headache Disorders introduced specific diagnostic criteria for menstrual migraine. Results from research undertaken subsequently lend support to the clinical impression that menstrual migraine should be seen as a distinct clinical entity. This paper reviews the recent research and provides specific recommendations for consideration in future editions of the classification.

The Premenstrual Symptoms Screening Tool revised for adolescents (PSST-A): prevalence of severe PMS and premenstrual dysphoric disorder in adolescents.

The Premenstrual Symptoms Screening Tool was modified for use in adolescents and piloted in 578 girls at three international sites. Nearly one third (29.6%) reported experiencing severe PMS or PMDD, with irritability being the most commonly reported symptom. Rates of menstrual-related pain were high, particularly in those with severe PMS or PMDD. Severe PMS and PMDD present with similar rates and symptoms in adolescents as in adults, and the Premenstrual Symptoms Screening Tool modified for adolescents is a fast, reliable tool to screen for these syndromes in adolescents.

Differentiation of women with premenstrual dysphoric disorder, recurrent brief depression, and healthy controls by daily mood rating dynamics.

Enhanced statistical characterization of mood-rating data holds the potential to more precisely classify and sub-classify recurrent mood disorders like premenstrual dysphoric disorder (PMDD) and recurrent brief depressive disorder (RBD). We applied several complementary statistical methods to differentiate mood rating dynamics among women with PMDD, RBD, and normal controls (NC). We compared three subgroups of women: NC (n=8); PMDD (n=15); and RBD (n=9) on the basis of daily self-ratings of sadness, study lengths between 50 and 120 days. We analyzed mean levels; overall variability, SD; sequential irregularity, approximate entropy (ApEn); and a quantification of the extent of brief and staccato dynamics, denoted 'Spikiness'. For each of SD, irregularity (ApEn), and Spikiness, we showed highly significant subgroup differences, ANOVA0.001 for each statistic; additionally, many paired subgroup comparisons showed highly significant differences. In contrast, mean levels were indistinct among the subgroups. For SD, normal controls had much smaller levels than the other subgroups, with RBD intermediate. ApEn showed PMDD to be significantly more regular than the other subgroups. Spikiness showed NC and RBD data sets to be much more staccato than their PMDD counterparts, and appears to suitably characterize the defining feature of RBD dynamics. Compound criteria based on these statistical measures discriminated diagnostic subgroups with high sensitivity and specificity. Taken together, the statistical suite provides well-defined specifications of each subgroup. This can facilitate accurate diagnosis, and augment the prediction and evaluation of response to treatment. The statistical methodologies have broad and direct applicability to behavioral studies for many psychiatric disorders, and indeed to similar analyses of associated biological signals across multiple axes.

Perimenstrual migraines: are they different from migraines in general?

Differences between menstrually related migraine (MRM) and non-MRM are subtle. Preconception that population-based trials do not show differences, but that clinic-based trials showed severe, longer, and clinically refractory menstrual migraines, turns out to be simplistic. This review examines studies comparing and contrasting MRM and non-MRM. All of the pertinent studies show increase of migraine around menses. A judicious reading of the studies suggests that MRM is probably more severe in pain intensity than non-MRM. MRM is more disabling than non-MRM. MRM in clinics is more likely to have both worse prodrome and nausea. A significant subset of MRM patients has poorer response to acute medication. Overall, it appears that MRM is more severe than non-MRM when considering population- and clinic-based studies, with slightly but clinically meaningfully worse intensity, duration, disability, prodrome, nausea, and response to acute medications. Clinicians must have compassion and skill to manage patients with MRM.

Are there differential symptom profiles that improve in response to different pharmacological treatments of premenstrual syndrome/premenstrual dysphoric disorder?

Current evidence suggests that the accepted treatments for premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) have similar overall efficacy. While these treatments are more effective than placebo, response rates associated with them are far from satisfactory (<60%), such that, irrespective of treatment modality, there remain a significant number of women who are unresponsive to current conventional pharmacological therapy. The available data on response rates of specific types of premenstrual symptoms to, or symptom profiles that are most amenable to, each treatment modality are limited and not well defined because most studies were not designed to assess specific symptom profiles. Those studies that have attempted to evaluate which symptom profiles respond to specific therapies have revealed variations within the individual modalities, as well as between the different modalities. It appears that suppression of ovulation ameliorates a broad range of behavioural as well as physical premenstrual symptoms. SSRIs are most effective for irritability and anxiety symptoms, with lesser efficacy for 'atypical' premenstrual symptoms. GABAergic compounds are most efficacious for anxiety and anxious/depressive symptoms, while dopamine agonists, particularly bromocriptine, are perhaps most efficacious for mastalgia. Overall treatment response rates may improve if treatments are targeted at well-defined subgroups of patients. Re-analysis of available datasets from randomised clinical trials may shed more light on the notion that targeting women with specific premenstrual symptom profiles for specific treatment modalities would improve response rates beyond the current ceiling of approximately 60%. Such information would also improve understanding of the putative pathophysiological mechanisms underlying PMS and PMDD, and may point to a more specific diagnosis of these conditions.

Premenstrual syndrome (PMS) in adolescents: severity and impairment.

OBJECTIVES: Identify the presence of patients with premenstrual syndrome (PMS) in an adolescent gynecology practice, and evaluate the reported severity, impairment and timing of the symptoms in the menstrual cycle. METHODS: Adolescents ages 13-18 years completed a symptom questionnaire, functional impairment ratings, and a brief medical history questionnaire during an office visit. Teens who responded that they had PMS and reported a premenstrual symptom score at least 50% greater than the postmenstrual score and rated moderate to severe impairment in one or more domains comprised the "PMS" group. Teens who responded that they had PMS but did not meet the symptom and impairment criteria were termed "PMS not supported." Teens who responded that they did not have PMS and did not meet the PMS symptom and impairment criteria were termed "No PMS." RESULTS: Study participants (n = 94) had a mean age of 16.5 years (+/-1.3 SD); 31% met the criteria for the PMS group, 54% said they had PMS but did not meet criteria, and 15% clearly had no PMS. In the PMS group, the most severe symptoms were mood swings, anxiety, and irritability, with the greatest impairment in the home/family domain. Dysmenorrhea and the duration of PMS were significantly associated (P < 0.01) with PMS in univariate and multivariate analyses. CONCLUSIONS: The reports of premenstrual symptoms, their severity, timing and impairment suggest that PMS is common in adolescents. Further study is warranted to confirm these results with prospective assessment of PMS and to evaluate treatments for adolescents who have clinically significant PMS.

Premenstrual depressive changes. Value of differentiation.

Premenstrual depressive changes and differential correlates of specific subtypes of premenstrual dysphoria vary. Our data support two basic assumptions: (1) Premenstrual changes should be studied as diversified subtypes rather than as a single premenstrual tension syndrome; such an approach might lead to a better understanding of the pathophysiology of specific types of premenstrual changes. (2) Some specific subtypes of premenstrual changes of a depressive nature resemble some subtypes of affective disorder and, hence, may serve as a model for the study of these disorders.

Depressive symptoms and depressive diagnoses in a community population. Use of a new procedure for analysis of psychiatric classification.

A multivariate classification technique was used to examine whether depressive symptoms and symptoms frequently associated with depressive disorders would cluster into recognizable syndromes that parallel traditional DSM-III psychiatric diagnoses. An analysis was made of all respondents in the Epidemiologic Catchment Area (ECA) project of the Piedmont region of North Carolina who reported suffering from depressive symptoms (n = 406) at the second wave of the ECA study. The analysis identified five profiles of symptoms that adequately described the interrelationships of the symptoms as reported in the population. One profile included a set of symptoms nearly identical to the symptoms associated with the DSM-III classification of major depression. Other depressive syndromes emerged and included a premenstrual syndrome among younger women and a mixed anxiety/depression syndrome. The existence of these other depressive syndromes may explain the present discrepancy in the epidemiologic literature between a high prevalence of depressive symptoms and a low prevalence of traditional depressive diagnoses in community populations.

[Premenstrual syndrome--current approach]. / Zespól napiecia przedmiesiaczkowego w swietle wspólczesnych pogladów.

Premenstrual syndrome (PMS) affects 3-5% of women. It still remains controversial in diagnosis and treatment. Dynamic progress in neuroendocrinology in recent years led to PMS etiology explanation. It also influenced therapeutic approach. According to Wang et al. neuroactive steroids and their imbalance evoke PMS symptoms. That theory introduced other therapeutic interventions restoring neuroendorine balance. The newer antidepresants demonstrated excellent efficacy in treatment of somatic and emotional PMS symptoms. PMS is a typical object of contemporary studies on therapeutic efficacy according to evidence based medicine.

Late luteal phase dysphoric disorder and DSM-III-R.

Text and diagnostic criteria for a new category, late luteal phase dysphoric disorder, appear in appendix A of DSM-III-R: "Proposed Diagnostic Categories Needing Further Study." The inclusion of this category in the manual was perhaps the most controversial aspect of the revision of DSM-III. In this paper the authors describe the work of the advisory committee that first proposed the category, the rationale for the category's inclusion in the manual, and the many issues that were the focus of heated debates.

Late luteal phase dysphoric disorder in 670 women evaluated for premenstrual complaints.

OBJECTIVE: The American Psychiatric Association's DSM-IV Work Group on Late Luteal Phase Dysphoric Disorder (LLPDD) reanalyzed existing data from prospective, daily symptom ratings to evaluate the DSM-III-R criteria for LLPDD. The objectives were to 1) evaluate the individual symptoms presently required for the diagnosis and other symptoms, 2) determine the proportion of treatment-seeking women who meet the LLPDD criteria, and 3) explore the association between LLPDD and other mental disorders. METHOD: Data from over 1,000 women seeking evaluation for premenstrual complaints at five U.S. sites were examined. The data from 670 of these women were sufficiently complete to warrant evaluation by four different methods of assessing symptom change. RESULTS: Depending on the assessment method used, 14% to 45% of the women met the criteria for LLPDD. The current DSM-III-R symptoms were classified as positive for 7% to 54% of the women. Each of these symptoms was significantly more common among women with LLPDD regardless of the assessment method used. Five symptoms not presently included were also significantly more common. Women who had had mental disorders in the past, but not present, showed a significantly greater, but very small, relative risk of LLPDD. CONCLUSIONS: The variability in the frequency of LLPDD diagnosis according to method of assessing symptom change underscores the need for a uniform assessment method. The five additional symptoms with frequencies comparable to those of the DSM-III-R symptoms should be studied further for possible inclusion in the criteria.

Premenstrual dysphoria and the serotonin system: pathophysiology and treatment.

The inclusion of research diagnostic criteria for premenstrual dysphoric disorder (PMDD) in the DSM-IV recognizes the fact that some women have extremely distressing emotional and behavioral symptoms premenstrually. PMDD can be differentiated from premenstrual syndrome (PMS), which presents with milder physical symptoms, headache, and more minor mood changes. In addition, PMDD can be differentiated from premenstrual magnification of physical and/or psychological symptoms of a concurrent psychiatric and/or medical disorder. As many as 75% of women with regular menstrual cycles experience some symptoms of PMS, according to epidemiologic surveys. PMDD is much less common; it affects only 3% to 8% of women in this group. The etiology of PMDD is largely unknown, but the current consensus is that normal ovarian function (rather than hormone imbalance) is the cyclical trigger for PMDD-related biochemical events within the central nervous system and other target organs. The serotonergic system is in close reciprocal relationship with the gonadal hormones and has been identified as the most plausible target for interventions. Thus, beyond the conservative treatment options such as lifestyle and stress management, other nonantidepressant treatments, or the more extreme interventions that eliminate ovulation altogether, the serotonin reuptake inhibitors (SRIs) are emerging as the most effective treatment option for this population. Results from several randomized, placebo-controlled trials in women with PMDD have clearly demonstrated that the SRIs have excellent efficacy and minimal side effects. More recently, several preliminary studies indicate that intermittent (premenstrual only) treatment with selective SRIs is equally effective in these women and, thus, may offer an attractive treatment option for a disorder that is itself intermittent.

Alprazolam in the treatment of two subsamples of patients with late luteal phase dysphoric disorder: a double-blind, placebo-controlled crossover study.

OBJECTIVE: To assess the efficacy of alprazolam in the treatment of two groups of patients diagnosed with late luteal phase dysphoric disorder (LLPDD). The first group met only the diagnostic criteria for LLPDD. The second group experienced LLPDD and mild symptoms of anxiety and depression during the follicular phase. METHODS: A double-blind, placebo-controlled crossover design was used. Patients were treated with alprazolam and placebo for 3 months each and completed daily measures of anxiety, tension, depression, irritability, and feelings of being out of control. RESULTS: The response to alprazolam differed significantly by group. For the first group, alprazolam (0.25 mg three times a day) relieved the severity of tension (P = .001), irritability (P = .005), anxiety (P = .008), and feelings of being out of control (P = .012) more than placebo. Few side effects were reported; the incidence (P = .001) and severity (P = .001) of side effects were dose-related. Alprazolam and placebo did not differ for the second group, and the incidence and severity of side effects were unrelated to dose. CONCLUSIONS: Alprazolam benefits women diagnosed solely with LLPDD. It is not recommended for patients who experience LLPDD as well as symptoms of mild anxiety or depression during the follicular phase.

Evaluating premenstrual symptoms in medical practice.

Essential diagnostic criteria for evaluating premenstrual syndrome (PMS) symptoms are marked change in intensity of symptoms measured on postmenstrual and premenstrual days and documentation of changes for at least two cycles. Four symptom evaluation methods in a PMS treatment program are compared and discussed: physician interview, menstrual symptom questionnaire, daily symptom ratings, and the Hopkins symptom checklist. Data from 241 patients who met the criteria for marked change in symptoms show that premenstrual symptom levels are severe, a subgroup has moderate symptoms continuing in the follicular phase, and that emotional symptoms are predominant. Diagnostic evaluation needs to distinguish menstrually related disorder from undiagnosed physical or psychiatric illness. Further research is needed to identify a classification system of multiple subtypes of menstrual disorders.

Operationalizing DSM-IV criteria for PMDD: selecting symptomatic and asymptomatic cycles for research.

While diagnostic criteria for premenstrual syndromes (PMS) exist, studies rarely state how these criteria are operationally applied. We examined the consequences of application of different operational methods for DSM-IV criteria for premenstrual dysphoric disorder (PMDD) to individual cycles in women with PMS and controls. PMDD criteria require the presence of both certain types or numbers of symptoms (5/11 symptoms present premenstrually, at least one being one of four mood symptoms) and certain phenomenal characteristics (present premenstrually, absent postmenstrually, causing interference premenstrually). We identified individual cycles as symptomatic or asymptomatic by applying criteria that operationalized the required phenomenal elements of PMDD according to four severity thresholds: literal (i.e. present or absent), 30%, 50%, 70%. Data examined were Daily Rating Form symptom scores from two symptomatic menstrual cycles both in 25 women with PMS and 25 controls. Literal thresholds correctly identified 28% of symptomatic and 4% of asymptomatic cycles, compared with 86 and 70% identification with a 30% threshold, 60 and 86% with a 50% threshold, and 0 and 100% with a 70% threshold. An "optimal" combination of 30% thresholds for premenstrual symptomatology and premenstrual interference and a 50% threshold for postmenstrual symptomatology correctly identified 92% of symptomatic cycles in women with PMS and 72% of asymptomatic cycles in controls. Different criteria for cycle inclusion yield markedly different sample compositions. No single operational threshold of the phenomenal features maximizes selection of both symptomatic and asymptomatic cycles, largely consequent to the ubiquity of postmenstrual symptoms and premenstrual "interference" even in women without PMS. At the very least, the method for operationalizing DSM-IV criteria should be described in studies of PMDD.

Premenstrual dysphoric disorder. An update.

The recent inclusion of research criteria for premenstrual dysphoric disorder (PMDD) in the DSM-IV should help physicians recognize women with symptoms of irritability, tension, dysphoria, and lability of mood which seriously interfere with their lifestyle. PMDD can be differentiated from premenstrual syndrome (PMS) which is primarily reserved for milder physical symptoms and minor mood changes. The use of DSM-IV criteria in conjunction with prospective daily charting for at least two cycles is now accepted as common practice in confirming the diagnosis. Treatment options range from conservative lifestyle and stress management to treatment with psychotropic medications and hormonal or surgical interventions to eliminate ovulation for the more extreme cases. Results from several randomized placebo-controlled trials have clearly demonstrated that selective serotonin reuptake inhibitors as well as medical or surgical oophorectomy are very effective in treating PMDD. Taken together, these data indicate that treatment may be accomplished by either eliminating the hormonal trigger or by reversing the sensitivity of the serotonergic system.

Diagnosis and treatment of premenstrual dysphoric disorder: an update.

Premenstrual dysphoric disorder (PMDD) appears in the appendix of the DSM-IV under the heading 'depressive disorder not otherwise specified'. Yet, recently, a group of experts reached a consensus that PMDD is a distinct clinical entity with characteristic symptoms of irritability, anger, internal tension, dysphoria, and mood lability. PMDD is the more severe form of premenstrual symptomatology, whereas premenstrual syndrome (PMS) is milder and more prevalent and both must be differentiated from premenstrual magnification/exacerbation of an underlying major psychiatric disorder or a medical condition. Accurate assessment and diagnosis of significant premenstrual symptomatology is paramount and can be influenced by subjective perception, retrospective versus prospective reporting, and cultural context. The serotonergic system, which is in a close reciprocal relationship with the gonadal hormones, has been identified as the most plausible target for intervention. Results from randomized placebo-controlled trials in women with PMDD have clearly demonstrated that serotonin reuptake inhibitors (SSRIs), with daily or intermittent dosing, have excellent efficacy and minimal adverse effects and should be considered first-line treatment. Luteal phase only SSRI administration may offer an attractive treatment option for a disorder that is itself intermittent. Hormonal interventions, in particular the suppression of ovulation will eliminate premenstrual symptomatology; however, the benefits-risk ratio of these approaches should be carefully evaluated with the patient.