Premenstrual Dysphoric Disorder: A Case Report

Premenstrual Dysphoric Disorder: A Case Report

Aardra Menon^*'Aardram', Pullazhy PO Olari Thrissur, Kerala, India

Received Date: January 01, 2023; Accepted Date: January 17, 2023; Published Date: January 23, 2023;
^*Corresponding author: Aardra Menon. 'Aardram', Pullazhy PO Olari Thrissur, Kerala, India. Email: aardra19@gmail.com

Citation: Menon A (2023) Premenstrual Dysphoric Disorder: A Case Report. Adv Pub Health Com Trop Med: APCTM-175.

DOI: 10.37722/APHCTM.2023103

Abstract
Background and Objective

Premenstrual Dysphoric Disorder (PMDD) affects up to 8% of menstruating women and is recognised as a separate entity in DSM - 5. It is often misdiagnosed as symptoms of PMDD overlaps with mood disorders like major depressive disorder or bipolar affective disorder.

PMMD is a severe form of pre-menstrual symptoms which include both mental symptoms and physical symptoms. These symptoms begin 1-2 weeks before the onset of menstruation and terminate a day or two after the onset of menstruation.

Method: This case report deals with a 29-year-old female patient, who is a stay-at-home mother of 2. She presented to the psychiatry department with low mood, feeling of worthlessness, insomnia and irritability. She reports that she lashes out at her husband and kids because she feels 'high strung' and anxious “on-and-off” for over a year. This has led to severe guilt and a feeling of wanting to escape. Her symptoms have put a strain on her married life as she is increasingly irritable with her husband and kids when symptomatic. She has complaints of lack of sleep. She also mentions she experiences severe abdominal pain and bloating as part of her menstrual cycle. On further evaluation, she described her symptoms usually starts in the weeks following up to her menstruation. She admits that she feels markedly better once she starts menstruating.

She had previously undergone cognitive behavioural therapy following advice from a general practitioner for her symptoms but hasn't felt any improvement.

Due to the association of her symptoms with her menstrual cycle, the patient was assessed using the Premenstrual Screening Scale and was diagnosed with PMDD.

Results: She was put on Combined Oral Contraceptive Pills containing ethinylestradiol 30 mcg and drospirenone 3mg. for the duration of her luteal phase and was reviewed after 4 weeks for 3 months. She showed a significant improvement in her symptoms following treatment.

Conclusion: Diagnosis of PMMD is important as the treatment is limited to a course of SSRI for the duration of the luteal phase (first line), OCP or GnRH agonists. This is different from the treatments used in BPAD or major depression and is associated with less adverse effects. Awareness of PMMD among clinicians will help diagnose it earlier and safeguard patients from misdiagnosis.

Keywords: Depression; Premenstrual Dysphoric Disorder; Premenstrual Symptoms; SSRI

Introduction
Premenstrual dysphoric disorder affects upto 8% of menstruating women and is recognised as a separate entity in DSM-5. PMDD is a severe form of pre-menstrual syndrome with both mental symptoms and physical symptoms. It is often misdiagnosed as symptoms of PMDD overlaps with mood disorders like major depressive disorder or bipolar affective disorder.

Aim

To discuss an often misdiagnosed but extremely debilitating and quite common condition that is Premenstrual Dysphoric Disorder with the help of a case report.

History

29-year-old female patient, who is a stay-at-home mother of two presented to the psychiatry department with low mood, insomnia and irritability “on-and-off” for over a year. She reports that she lashed out at her husband and kids because she feels ‘high strung’ and severely anxious about her life. This has led to feelings of guilt and a feeling of ‘wanting to escape’. She also reports a lack of interest in house work and embroidery which she earlier used to enjoy. She admits to crying more often. Her symptoms have put a strain on her married life and her relationship with her kids. She complains of severe abdominal pain and bloating with her menstruation. On further evaluation, she described her symptoms usually starts in the week following up to her menstruation. She admits that she feels markedly better once she starts menstruating. She had undergone cognitive behavioural therapy following advice from her general practitioner for her symptoms but has not felt any improvement.

Examination
General Examination

Pulse rate: 72bpm
BP: 130/80
SpO2: 99% on room air
Temp: 98.6*F

Systemic Examination

GIT: Abdomen soft, non – tender with no hepatosplenomegaly and no palpable masses
RESP: Normal
CVS: Normal
CNS: Normal

Psychiatric Evaluation

Appearance: Normal
Speech: Normal

Emotional expression: Subjectively she reports feeling irritable and depressed as she is not able to handle her family well. Objectively she appears angry and sad at different times. Her emotional expression is labile, of full range and appropriate to content.
Thinking and perception: Normal
Sensorium: Patient is alert, oriented to time, person and place, demonstrates reasonable, concentration, memory, ability to calculate and abstract reasoning.

Premenstrual Screening Score:

Do you experience some or any of the following pre-menstrual symptoms which start before your period and stop within a few days of bleeding?

SYMPTOM	NOT AT ALL	MILD	MODERATE	SEVERE
1. Anger/irritability				X
2. Anxiety/ tension		X
3. Tearful/ increased sensitivity to rejection			X
4. Depressed mood/ hopelessness			X
5. Decreased interest in work activities	X
6. Decreased interest in home activities				X
7. Decreased interest in social activities				X
8. Difficulty concentrating			X
9. Fatigue/ lack of energy		X
10. Overeating/ food cravings	X
11. Insomnia				X
12. Hypersomnia	X
13. Feeling overwhelmed/ feeling out of control			X
14. Physical symptoms (breast tenderness, headache, joint/muscle pain, bloating and weight gain			X

Have your symptoms as listed above, interfered with:

	NOT AT ALL	MILD	MODERATE	SEVERE
A. Your school/work efficiency or productivity	X
B. Your relationships with friends/ co workers		X
C. Your relationship with your family				X
D. Your social life activities	X
E. Your home responsibilities			X

Criteria for a diagnosis of Pre-menstrual Dysphoric Disorder:

At least one of #1, #2, #3, #4 is severe
In addition, at least four of #1 - #14 are moderate to severe
At least one of A, B, C, D, E is severe

The patient reported to have severe anger/irritability which satisfies criteria one of the above three criteria. She also reported as having experienced moderate – severe symptoms of decreased interest in home activities, decreased interest in social activities, insomnia, depressed mood/hopelessness, feeling overwhelmed and physical symptoms which satisfy the second criteria of the three criteria. Her symptoms have been severe enough to interfere with her relationship with her family, which satisfies the last criteria required for a diagnosis of PMDD. Her symptoms satisfactorily correlates with her menstrual cycle, for more than two consecutive cycles.

Her symptoms do not satisfy the criteria for any other similar psychiatric disorders.

Treatment

Since the patient had already undergone Cognitive Behavioural Therapy for her symptoms without significant relief, the patient was treated with Combined Oral Contraceptive Pills containing ethinylestradiol 30 mcg and drospirenone 3mg. The patient was reviewed after 3 months and reported a significant improvement in her symptoms following treatment.

Discussion
Premenstrual symptoms include a variety of mood, behavioural, and physical symptoms that occur in a cyclic pattern prior to menstruation and then wane off after the onset of menstruation in women of reproductive age.

Most women have only mild symptoms but 3% to 8% of them have moderate-to-severe symptoms that can cause significant distress and functional impairment.

Premenstrual Dysphoric Disorder is a new and separate entity that is defined in DSM-V to denote a severe form of pre-menstrual syndrome.

Obesity, Cigarette smoking and a history of past traumatic events are all proven risk factors for PMDD.

The pathophysiology of PMDD is not yet fully understood, but studies show that it could be related to the changes in levels of gamma-aminobutyric acid (GABA) in relation to progesterone levels.

The diagnosis of PMDD can be made by comparing the patients’ symptoms with a pre-defined set of symptoms in the Pre-menstrual Scoring Scale, over a period of at least two cycles. To diagnose PMDD, it has to be established that these symptoms provide significant distress to the patient, particularly in her luteal phase.

The treatment of PMDD begins with a trial of Cognitive Behavioural Therapy along with lifestyle modifications including exercise, which has proven to be effective in many patients.

The first line treatment for PMDD is Combined Oral Contraceptive Pills containing ethinylestradiol 30 mcg and drospirenone 3mg, used continuously than cyclically for over 3 months.

Second line drugs include SSRI (Selective Serotonin Re-Uptake Inhibitors) like fluoxetine and GnRH analogues.

Conclusion
Diagnosis of Premenstrual Dysphoric Disorder is essential due to the stark difference in the treatment duration of PMDD in comparison to its differentials like Major Depressive Disorder or Bipolar Affective Disorder. Treatment of Premenstrual Dysphoric Disorder is limited to a course of Oral Contraceptive Pills, Selective Serotonin Re-Uptake Inhibitor like fluoxetine or GnRH agonists for the duration of their luteal phase. This form of treatment with a much shorter duration safeguards the patient from the many adverse effects associated with long term medications. Awareness about Premenstrual Dysphoric Disorder among clinicians is imperative to prevent its misdiagnosis and provide the best possible treatment option to the patient.

References