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The Search For Premenstrual Dysphoric Disorder (PMDD): Scientific Evidence is Lacking
Premenstrual Dysphoric Disorder (PMDD) is a term that was created in recent years by the American Psychiatric Association (APA). Like all psychiatric diagnoses, it is debated and voted on. It is not based primarily on physical criteria. And like many psychiatric illnesses, such as homosexuality, addiction, sexual dysfunction, the outcome is largely influenced by psychiatrists' personal values and views about how society should be.
While the APA devotes itself to mental and emotional problems, it does not hold any special authority over the medical profession. In fact, it is known as being the least scientific of all the branches of medicine. Thus, leading most doctors to disregard psychiatry's mandates in favor of the clinical evidence.
The vast majority of women have some symptoms in the pre-menstrual phase, physical, emotional, or both. There are many different types of menstrually associated symptoms. But, it is the mood symptoms that most often lead women to consult their doctor for help. Correct identification of symptoms as menstrually related, or menstrually caused is crucial, but difficult. Optimal treatment of the women depends on it.
Definitions and Diagnoses
PMDD is an attempt, by psychiatrists to zero in on the mood aspects of PMS. To be considered PMDD, the mood aspects of PMS must be present in severe form, but only during the last two weeks of the cycle. Here's the APA's criteria (link to pop-up of criteria, put banner ads on pop-up thanks).
Women's Health have criteria for a range of categories for menstrually related changes, which apply to physical as well as mood changes. (link the underline to the article on menstrual changes, not always PMS). Each type has its own treatment strategy. Should a woman's mood symptoms be present during PMS time only, but not severe, she is a case of plain old PMS. Should her symptoms be severe, but not completely resolve in the first half of the cycle, she is Pre-menstrual Exacerbation. That means her underlying problem -- depression or anxiety or mood swings -- is the main problem to be treated. In the area of mood related PMS changes, the evidence of women having severe mood symptoms only in the PMS phase, and not the rest of the cycle, is virtually non-existent.
Physical Differences Are Not Found in Women Diagnosed With PMDD
Obviously, hormonal changes are implicated in the theories surrounding the causes of PMDD. So far, there have been no clear physical differences found between those diagnosed with PMDD per the APA's definition and those with plain old PMS.
Specifically, the following have been investigated extensively but NOT found to be different.
All variations of hormonal levels, ratios, or changes (estrogen and progesterone)
B6
Prolactin
Renin-angiotensin-aldosterone
Prostaglandins
Insulin receptors
Glucose tolerance
Vitamin A
Allergies
Serotonin levels are decreased in PMS women (not PMDD specifically). But this specific phenomenon has not been clearly linked to clinical depression or mood problems in women. In other words, serotonin levels don't automatically lead to mood states.
Remaining theories are that women with PMDD have a greater sensitivity to hormone levels, ratios, or changes. Another idea is that we do not yet have the technology that is sensitive enough to see the differences.
Problems With Documenting Symptoms
The symptoms of PMS and PMDD are always a judgement call on the part of the woman and her doctor. The need to have more specific, concrete definitions is currently a recognized, but unsolved problem in psychiatry.
Expectation that PMS is a factor in one's symptoms tends to be a self-fulfilling prophesy. A majority of women who believe they have PMS, find they do not when they keep a diary of their symptoms. Women tend to believe they are premenstrual when they experience the symptoms they associate with that. It is difficult to keep a woman ignorant of where she is in her cycle, so the role of belief is difficult to separate.
With mood disorders, the desire to be diagnosed as having "PMS" rather than depression or anxiety may be a strong motivator among women to emphasize the premenstrual phase difficulties with mood and ignore the rest.
Prevalence of PMS, Mood Disorder, and the Overlap Between the Two
Cyclic symptomology of some sort is almost universal among women. Women have disproportionate as well as high rates of mood disorders in general. Put these two together, and any woman with a mood disorder also has some cyclic changes and is thus in the running for the PMDD diagnosis. Many more women will believe they have PMDD, than will meet criteria after keeping a diary.
Strengthening this argument are several studies that find there are higher rates of PMS complaints among women with mood disorders. Most notably, women will report being pre-menstrual when they have symptoms, even if, in reality, they are not premenstrual.
A major criticism of the concept of PMDD is that its evidence for its existence is identical to the evidence that it is really a misdiagnosis of a standard psychiatric problem.
With the lack of physical differences, researchers will often point to similar responses to treatment (most recently Prozac and Zoloft) or challenges (panic producing stimuli) of women with PMDD and those with a mood disorder and constrast them with women with plain PMS or normals. While this interpretation is consistent with the data, it is not the exclusive conclusion one can draw. If women with PMDD acts just like a mood disorder but different than other women, and the correlation with the cycle is always suspect, then there is nothing to argue for this as a separate diagnosis.
Alternatives For the Diagnosis of PMDD
If you are reading this, you probably think you have or know someone who has PMDD. So, if there is really no PMDD, what is going on and how do you get relief?
First thing to do is the infamous PMS diary. Chart out everything -- mood especially, what happened, food and cravings, physical symptoms, and of course menses. Your ability to be diagnosed correctly will depend mostly on you. If you feel comfortable, try to get others who see you frequently to rate you. It can guard a bit against the self fulfilling prophesy aspects, but it won't work if in your mind PMS gives you a reason to change your reactions to situations.
Other Explanations to consider:
1) PMS exacerbation of a Mood Disorder -- few mood problems disappear and reappear like clockwork. If severe or disruptive symptoms abound, consider the mood diagnosis to be primary and the PMS to be an amplifier. Attack each individually.
2) Mood Disorders -- Anxiety, depression, and irritability. Careful checking may reveal that the variations are not tied to menses at all. It is best to recognize this and seek treatments that address it specifically. If you are drawn to the diagnosis of PMDD, because most women have PMS, then don't be afraid of a diagnosis of Anxiety or Depression -- many, many women have these too.
3) Cyclic physical symptoms -- Feeling uncomfortable or not up par can make anyone irritable or depressed. Dread of dysmenorrhea (cramps) is also a factor. Attacking your physical manifestations as a group (hormonally) or individually can get at the root of your problems.
3) Anger, Justifiable -- If you're not pissed off you are not paying attention? From discrimination and sexual harrassment to pay differentials and single motherhood, women have many reasons to be stressed and angry. You cannot change these problems overnight, and some you can't change at all. Begin formulating a plan today to improve some of what makes you angry. Start taking steps within a week. Fill out the census and pretend like the rest of your problems will get solved like they say on the commercials : )
4) Anger, Otherwise -- women still feel inhibited about being angry, get more negative reactions from others. And yes, some women genuinely have too much. The Anger Management classes are ubiquitous in most communities. Maybe you will even meet a celeb doing their terms of probation. : )
5) Life -- you will not be happy all the time. There is nothing wrong with this.
Treatments For Menstrually Related Mood Changes
Keep in mind that this section is limited to discussing the improvement of mood problems in the pre-menstrual phase only. Strategies and treatments that don't work on this, often work just fine on treating various PMS physical symptoms or the syndrome as a whole. Those that are drugs that do work, also work on people with psychological distress that is not cyclic. So there is nothing specific.
No particular diet or food supplement as been shown to work. This includes standard and alternative, particularly B vitamins, calcium, and primrose oil.
Hormonal treatments of various stripes have not been shown to make a difference in controlled studies. This includes the progesterones, progestins, and birth control pills, and all standard types of ovulation suppression. Some believe that benefits of these are masked by methodology flaws. Inhibiting ovulation through major hormonal manipulation such as androgens, gonadotropins, estrogen implants has shown some limited empirical improvement. However, there are many side effects and safety issues with these.
Support groups nor psychotherapy have not been shown to work.
Clonidine and naltrexone have shown some limited effect. Prozac and Zoloft have been shown to provide relief for psychological distress at PMS time. These are the anti-depressants in the serotonin increasing category. But, of course, they all do this regardless of cycle. Serafem is simply Prozac marketed under a different name. Lithium has been shown to be ineffective.
Clonidine is anti-anxiety drug. The dose is 17 micrograms per day. Naltrexone is a narcotic agonist. The dosage is 25mg twice a day on days 9- 18 of the cycle.
Prozac is closest to getting an official FDA approval for use as a PMS mood drug. Studies have shown effectiveness at 20 mg every day of the cycle -- in other words like any other person taking it. It is a long-acting drug, so taking it just before menses is unlikely to work.
Other sedatives and anti-depressants that have improved women's mood in the PMS phase are: alprozolam, buspirione, nortripytline, and nefazadone. Again, these are all used for the same things and have the same results in non-cyclic cases. They can be prescribed for PMS/PMDD even though the FDA has not approved it. There is nothing wrong with doing this. Alprozalam has a pre-menstrual regimen -- .25 - 1 mg four times a day one week before, tapering to day two of menstruation. It is addicting. Zoloft is a shorter acting anti-depressant and shows promise of developing 7-10 day regimens also.
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