|Year : 2018 | Volume
| Issue : 2 | Page : 83-88
Prevalence and symptoms of premenstrual dysphoric disorder in a sample of psychiatric patients at Zagazig University Hospitals
Mohammed G Sehlo, Usama M Youssef, Rehab S Mahdy, Hayam El-Gohari
Psychiatry Department, Zagazig University Hospital, Egypt
|Date of Submission||28-Sep-2017|
|Date of Acceptance||31-Oct-2017|
|Date of Web Publication||2-May-2018|
Rehab S Mahdy
Lecturer of Psychiatry (MD), Zagazig, Sharkia
Source of Support: None, Conflict of Interest: None
Introduction Premenstrual dysphoric disorder (PMDD) is a severe and disabling form of premenstrual syndrome affecting 3–8% of menstruating women. The relationship between PMDD and psychiatric disorders is still unclear.
Aim The aim of this study was to assess the prevalence and symptoms of PMDD in a sample of psychiatric patients.
Patients and methods A sample of psychiatric outpatients and inpatients who attended for treatment was clinically diagnosed according to Diagnostic and Statistical Manual of Mental Disorders-5 by clinical interview and by applying the premenstrual symptoms screening tool for diagnosis of PMDD.
Results The prevalence of PMDD among cases and controls was 40.5 and 7.6%, respectively. PMDD was most prevalent among depressed patients (96.4%) followed by those with bipolar diseases (38.5%) and was less frequent among anxiety and psychotic patients (4.5 and 1.8%, respectively).
Conclusion PMDD is highly related to psychiatric disorders especially depression and bipolar disorder.
Keywords: premenstrual dysphoric disorder, prevalence, psychiatric patients
|How to cite this article:|
Sehlo MG, Youssef UM, Mahdy RS, El-Gohari H. Prevalence and symptoms of premenstrual dysphoric disorder in a sample of psychiatric patients at Zagazig University Hospitals. Egypt J Psychiatr 2018;39:83-8
|How to cite this URL:|
Sehlo MG, Youssef UM, Mahdy RS, El-Gohari H. Prevalence and symptoms of premenstrual dysphoric disorder in a sample of psychiatric patients at Zagazig University Hospitals. Egypt J Psychiatr [serial online] 2018 [cited 2018 May 22];39:83-8. Available from: http://new.ejpsy.eg.net/text.asp?2018/39/2/83/231701
| Introduction|| |
Many studies point toward a link between female reproductive life events (premenstrual, postpartum, or menopausal) and the exacerbation or worsening of bipolar disorders (Frey and Minuzzi, 2013). Sex hormone fluctuations could influence neurochemical pathways linked to psychiatric illness like mood and psychotic disorder (Schmidt et al., 1998; Bloch et al., 2000). The relationship between the premenstrual dysphoric disorder (PMDD) as a psychiatric disorder and the other psychiatric illness is still unclear. It is not known whether PMDD is highly associated with psychiatric illness or it has a shared etiological factor that is related to the hormonal changes in female menstrual cycle. PMDD is characterized by the occurrence of a range of affective symptoms, including irritability, affective lability, mood swings, depression, and anxiety, and also somatic symptoms that cause severe social or occupational dysfunction (American Psychiatric Association, 2000). These symptoms are confined to the late luteal phase of the menstrual cycle (Pearlstein and Steiner, 2008). The disorder affects 3–8% of premenopausal women (Yonkers, 1997). So, in this study, we aim to assess the prevalence and symptoms of PMDD among psychiatric patients.
| Patients and methods|| |
Study design, settings, and duration
A case–control study was carried out on psychiatric outpatients and inpatients in Zagazig University Hospitals, Sharkia Governorate, during the period from February 2016 to December 2016.
A sample of 345 participants was included (cases N=173 and controls N=172). The cases were female psychiatric outpatients and inpatients between the ages of 18 and 42 years.
A sociodemographic questionnaire was applied on a sample of 345 participants (cases N=173 and controls N=172). The cases were female psychiatric outpatients and inpatients between the ages of 18 and 42 years. The questionnaire answered the information about age, education, marital state, employment, and residence. The cases were diagnosed by clinical interview according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 diagnostic criteria. The patients who were administered the interview were not , not under hormonal contraception, or on psychotropic drugs. The control group included 173 participants with the same inclusion criteria. Both cases and controls were thoroughly screened by the premenstrual symptoms screening tool (Steiner et al., 2003) for diagnosis of PMDD. This instrument includes questions that screen for PMDD based on DSM-IV criteria. The first section of the tool asks, ‘In the past year, have you noticed any of the following symptoms 1–2 weeks before your menstrual period?’ This question is followed by a list of symptoms. Symptom severity is self-graded on a four-point scale: ‘not at all’, ‘mild’, ‘moderate’, or ‘severe’. To evaluate for the degree of impairment required by the DSM-IV criteria, questions about the effect of premenstrual symptoms on work or school; relationships with coworkers, peers, and family members; social activities; and home responsibilities were included. Diagnosis of PMDD was made for those who reported at least 1 of the 4 core mood symptoms (irritability/anger, tearfulness/sensitivity to rejection, anxiety/tension, and depressed mood/hopelessness) as severe and rated 4 or more additional symptoms as moderate to severe. These symptoms were endorsed as interfering severely with at least 1 of the areas of functioning listed as applicable (work efficiency, school, relationships with coworkers/peers/family, social activities, and home responsibilities).
Ethical approval for the study was granted by the Institutional Review Board (IRB) of the Faculty of Medicine, Zagazig University.
All data were collected, tabulated, and statistically analyzed using SPSS 20.0 for windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for windows (MedCalc Software bvba, Ostend, Belgium). Quantitative data were expressed as the mean±SD and median (range), and qualitative data were expressed as absolute frequencies (number) and relative frequencies (percentage). Independent Student’s t-test was used to compare two groups of normally distributed data. All tests were two sided. P value less than 0.05 was considered statistically significant. P value less than 0.001 was considered highly statistically significant, and P value greater than or equal to 0.05 was considered statistically nonsignificant.
| Results|| |
[Table 1] shows that there are no statistically significant differences between cases and controls regarding the demographic characteristics (P>0.05), except for occupation and marital status, in which most of controls were workers and married (P<0.05).
[Table 2] shows that the prevalence of PMDD symptoms among cases and controls was 40.5 and 7.6%, respectively. There was a highly statistically significant difference between cases and controls regarding PMDD, which was statistically more positive among psychiatric patients than normal controls.
|Table 2 Prevalence of premenstrual dysphoric disorder symptoms among studied groups|
Click here to view
[Table 3] shows that there was a highly statistically significant association between PMDD (positive) symptoms of cases and controls with the occupation, in which they were higher among housewives (P<0.001), whereas there was no statistically significant association between PMDD (positive) with residence, education level, or marital status (P>0.05).
|Table 3 Relationship between cases and controls with premenstrual dysphoric disorder (premenstrual dysphoric disorder positive) and their demographic characteristics|
Click here to view
[Table 4] shows that there was a highly statistically significant association between PMDD symptoms and psychiatric patients, in which they were higher among depressed patients (P<0.001).
|Table 4 Relation of premenstrual dysphoric disorder symptoms with the type of psychiatric disease|
Click here to view
[Table 5] shows that there were no statistical significant differences between cases and controls regarding symptoms of premenstrual tension syndrome (P>0.05), except for anxious and hopelessness, which were statistically higher and more severe among cases (P<0.01), and also hypersomnia and physical symptoms, which were statistically higher and more severe among cases (P<0.05).
|Table 5 Comparison between cases and controls regarding symptoms of premenstrual dysphoric disorder|
Click here to view
[Table 6] shows that there was a statistically significant difference between cases and controls regarding effects of symptoms of premenstrual tension syndrome on daily activities, in which negative effect on relations with coworkers was statistically higher among cases (P<0.01). However, there were no statistically significant differences between them regarding effects of PMDD on productivity, relation with family members, social activities, and home responsibilities (P>0.05).
|Table 6 Comparison between cases and controls regarding effects of symptoms of premenstrual dysphoric disorder|
Click here to view
| Discussion|| |
There were no statistically significant differences between cases and controls regarding symptoms of PMDD (P>0.05), except for anxiousness, hopelessness, physical symptoms, and hypersomnia, which were statistically higher and more severe among cases, which may be explained by the presence of psychiatric disorders that affect the mood and increase irritability, also affect sleep rhythm and exaggerate the physical symptoms.
The comorbidity between PMDD and bipolar 1 disorder is reported in different studies: 60% (Price and DiMarzio, 1986), 26 and 25% (Roy-Byrne et al., 1986), 20% (Blehar et al., 1998), 16% (Angst et al., 2001), 5.7% (Wittchen et al., 2002), and 6.7% (Choi et al., 2011). This high discrepancy of the ratio of co-occurrence (16–60%) is partially explained by the different way of looking for PMDD, some studies look for it in patients with bipolar disorder, whereas others look for bipolar disorder in patients with PMMD.
The discrepancy may be explained also by not taking in consideration the pharmacological treatment status. Patients may be more likely to receive treatment, which might suppress the PMDD symptoms. Therefore, the pharmacological treatment status is a potential confounder.
One prospective study that reported on the frequency of bipolar disorder in women with PMDD did not find an association between the two disorders (Fava et al., 1992). Such result is explained by the use of Menstrual Distress Questionnaire, which is only a four-point severity scale; the diagnoses were carried out according the SCID-DSM-III-R (Spitzer et al., 1987); and also clinical sample was with non-PMDD comparison group. In the current study, the frequency of PMDD in patients with bipolar 1 disorder is 38% (n=15 from 39 cases), which is a comparable result with other studies.
The comorbidity of PMDD with anxiety disorders (OCD) in the current study is 4.5%. Wittchen et al. (2002) found the comorbidity of PMDD with OCD at 1.4%. It was a prospective longitudinal study that was done on a large sample based on the Composite International Diagnostic Interview (CIDI) and its 12-month PMDD diagnostic module administered by clinical interviewers. Therefore, there was a different methodology and different sample size used, which may have led to discrepancy in results (Wittchen et al., 2002).
The frequency of PMDD in patients with schizophrenia in the current study was 1.8%. Most of other studies conducted on this matter are case studies (Gerada and Reveley, 1988). Another study (Choi et al., 2001) reported 8% of PMDD prospectively in a small sample of patients with schizophrenia (n=24) who were under antipsychotics with the use of different diagnostic tool called ‘daily rating form’.
The current study reported that 96.4% of depressed patient had the diagnosis of PMDD. As we already mentioned, the study is a retrospective one and the patients were complaining of and already had been diagnosed with major depression disorder, which is completely different from the other previous prospective studies that reported depression in patients with PMDD with the use of different diagnostic tools for PMDD. This may be the cause of high difference in the prevalence of comorbidity between the current results and that of the other studies which reported the comorbidity (10–49%). Wittchen et al. (2002) found 16% of women with PMDD had current major depression (recurrent plus single episode) compared with 7% of women without PMDD (the CIDI assesses diagnoses based on the DSM-IV classification). It was a prospective study on large sample diagnosed with PMDD according to CIDI (Munich-CIDI, World Health Organization, 1990) (Wittchen et al., 2002).
Alpay and Turhan (2001) reported 18% of the women who met the DSM-IV criteria for PMDD had a concurrent DSM-IV diagnosis of major depression, but it is not specified if prospective premenstrual symptom ratings were completed.
In another study, after identifying 49 women with PMDD prospectively over two menstrual cycles, the Structured Clinical Interview (SCID) for the DSM-III-R (Alpay and Turhan, 2001) was administered during the follicular phase and six (12%) were found to have co-morbid MDD (De et al., 2000).
In a sample of 39 women with prospectively diagnosed PMDD, four (10%) women were excluded from further study participation for having a concurrent diagnosis of major depressive disorder, whereas one woman had dysthymia (Kim et al., 2004). The sample of the study was relatively small compared with the current study.
Angst et al. (2001) examined the prevalence,clinical significance and co-morbidity of premenstrual symptoms/syndrome (PERI-MS) in a community sample of women, by making a prospective longitudinal study of a representative community cohort of women (N=299) who were interviewed five times between the ages of 21 and 35 years. They found the prevalence rates were 8.1% for severe and 13.6% for moderate PERI-MS,respectively. They concluded that irritability, nervousness and tension irrespective of the presence of concomitant depressed mood are core elements of the premenstrual syndrome.
Only the study by Soares et al. (2001) did not find an association between PMDD and current depression. This may be explained by the stricter analysis of daily symptom ratings in defining women with PMDD that was used in this study (Soares et al., 2001).
| Conclusion|| |
PMDD can occur co-morbidly with other axis I disorders, particularly mood and anxiety disorders. Psychiatric patients need to be screened for PMDD and vice versa.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alpay FB, Turhan NO (2001). Intermittent versus continuous sertraline therapy in the treatment of premenstrual dysphoric disorders. Int J Fertil Womens Med 46:228–231.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association. 771–774.
Angst J, Sellaro R, Stolar M, Merikangas KR, Endicott J (2001). The epidemiology of perimenstrual psychological symptoms. Acta Psychiatr Scand 104:110–116.
Blehar MC, DePaulo JR Jr, Gershon ES, Reich T (1998). Women with bipolar disorder: findings from the NIMH Genetics Initiative sample. Psychopharmacol Bull 34:239.
Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR (2000). Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry 157:924–930.
Choi SH, Kang SB, Joe SH (2001). Changes in premenstrual symptoms in women with schizophrenia: a prospective study. Psychosom Med 63:822–829.
Choi J, Baek JH, Noh J, Kim JS, Choi JS, Ha K et al.
(2011). Association of seasonality and premenstrual symptoms in bipolar I and bipolar II disorders. J Affect Disord 129:313–316.
De Ronchi D, Muro A, Marziani A, Rucci P (2000). Personality disorders and depressive symptoms in late luteal phase dysphoric disorder. Psychother Psychosom 69:27.
Fava M, Pedrazzi F, Guaraldi GP, Romano G, Genazzani AR, Facchinetti F (1992). Comorbid anxiety and depression among patients with late luteal phase dysphoric disorder. J Anxiety Disord 6:325–335.
Frey BN, Minuzzi L (2013). Comorbid bipolar disorder and premenstrual dysphoric disorder: real patients, unanswered questions. Arch Womens Ment Health 16:79–81.
Gerada C, Reveley A (1988). Schizophreniform psychosis associated with the menstrual cycle. Br J Psychiatry 152:700–702.
Kim DR, Gyulai L, Freeman EW, Morrison MF, Baldassano C, Dube B (2004). Premenstrual dysphoric disorder and psychiatric co-morbidity. Arch Womens Ment Health 7:37–47.
Pearlstein T, Steiner M (2008). Premenstrual dysphoric disorder: burden of illness and treatment update. J Psychiatry Neurosci 33:291.
Price WA, DiMarzio L (1986). Premenstrual tension syndrome in rapid-cycling bipolar affective disorder. J Clin Psychiatry 47:415–417.
Roy-Byrne PP, Rubinow DR, Hoban MC, Parry BL, Rosenthal NE, Nurnberger JI, Byrnes S (1986). Premenstrual changes: a comparison of five populations. Psychiatry Res 17:77–85.
Schmidt PJ, Nieman LK, Danaceau MA, Adams LF, Rubinow DR (1998). Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. N Engl J Med 338:209–216.
Soares CN, Cohen LS, Otto MW, Harlow BL (2001). Characteristics of women with premenstrual dysphoric disorder (PMDD) who did or did not report history of depression: a preliminary report from the Harvard Study of Moods and Cycles. J Womens Health Gend Based Med 10:873–878.
Spitzer RL, Williams JBW, Gibbon M, First MB (1987). Structured clinical interview for DSM-III-R. New York: New York State Psychiatric Institute. Biometrics Research, 11.
Steiner M, Macdougall M, Brown E (2003). The premenstrual symptoms screening tool (PSST) for clinicians. Arch Womens Ment Health 6:203–209.
Wittchen HU, Becker E, Lieb R, Krause P (2002). Prevalence, incidence and stability of premenstrual dysphoric disorder in the community. Psychol Med 32:119–132.
World Health Organization (1990). Composite International Diagnostic Interview (CIDI). World Health Organization, Division of Mental Health, Geneva.
Yonkers KA (1997). The association between premenstrual dysphoric disorder and other mood disorders. J Clin Psychiatry 58:19–25.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]