East Asian Arch Psychiatry 2014;24:174-177

ORIGINAL ARTICLE

N Mehta, S Mehta

Dr Nidhi Mehta, DGO, Department of Obstetrics and Gynaecology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka 560002, India. Dr Shubham Mehta, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan 302004, India.

Address for correspondence: Dr Shubham Mehta, Room No. 9, N. M. H. P. Trainees Hostel, Psychiatric Centre Campus, Sethi Colony, Jaipur, Rajasthan 302004, India. Tel: (91) 9799723735; email:drshubhammehta@gmail.com

Submitted: 20 November 2013; Accepted: 27 January 2014

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Introduction

Among all the changes and new inclusions made in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5),¹ one significant change has been moving the premenstrual dysphoric disorder (PMDD) from the DSM-IV Appendix-B, “Criteria Sets and Axes Provided for Further Study”² to the main body of DSM-5. This entity now has its own 7 diagnostic criteria as described below¹:

(A) In the majority of menstrual cycles, at least 5 symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses.

(B) One (or more) of the following symptoms must be present:

• Marked affective lability (eg mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection).
• Marked irritability or anger or increased interpersonal conflicts.
• Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts.
• Marked anxiety, tension, and / or feelings of being keyed up or on the edge.

(C) One (or more) of the following symptoms must be additionally present, to reach a total of 5 symptoms when combined with symptoms from criterion B above:

• Decreased interest in usual activities (eg work, school, friends, and hobbies). 174
• Subjective difficulty in concentration.
• Lethargy, easy fatigability, or marked lack of energy.
• Marked change in appetite, overeating, or specific food cravings.
• Hypersomnia or insomnia.
• A sense of being overwhelmed or out of control.
• Physical symptoms such as breast tenderness or swelling, joint or muscle pain, sensation of “bloating,” or weight gain (the symptoms in Criteria A to C must have been met for most menstrual cycles that occurred in the preceding year).

(D) The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (eg avoidance of social activities; decreased productivity and efficiency at work, school, or home).

(E) The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).

(F) Criterion A should be confirmed by prospective daily ratings during at least 2 symptomatic cycles.

(G) The symptoms are not attributable to the physiological effects of a substance (eg a drug of abuse, a medication, other treatment) or another medical condition (eg hyperthyroidism).

This move is significant as it reflects international concerns about betterment of women’s mental health.

The special panel of experts on women’s mental health created by the Mood Disorders Work Group for DSM-5 found robust evidence regarding the distinctiveness of PMDD. The reproductive mood disorder specialists have thoroughly analysed the diagnostic validators of PMDD from the literature and recommended PMDD to reside as a diagnosis in a newly created chapter of ‘Depressive Disorders’ in DSM-5.

We view this move with interest and try to generate a gestalt of research findings regarding PMDD from the Asian continent. To consider any disorder as a valid diagnostic entity, it must have separate antecedent, concurrent / biological, and predictive diagnostic validators.³ While we scrolled through the literature, we found that there have been quite a few contributions from Asia when analysed in terms of diagnostic validators of PMDD. With the help of this article, we intend to provide a gist of these contributions as this would help in identifying the strengths and lacunas in the Asian literature on PMDD, thus, providing a probable direction for further research in this area.

Antecedent Validators

These include demographic factors, pre-morbid personality traits, family studies, and environmental risk factors or precipitating factors. The prevalence of PMDD in Asian studies ranged from 1.2%⁴ to 6.4%,⁵ keeping in mind the different measures used by various researchers to assess its symptomatology. In a study of 136 patients attending a specialised mental health clinic in gynaecology settings in Taiwan, the incidence of DSM-IV PMDD criteria was noted to be as high as 16.3%.⁶

The same study⁶ also examined the individual characteristics of women with PMDD. It was found that 86% of the women had another concurrent psychiatric disorder. In another study that examined the personality of 142 patients, the investigators found a significant overlap in overall personality profiles of women with PMDD and major depressive disorder (MDD).⁷ Impulsiveness subscore was significantly higher in women with PMDD versus those with MDD.

The possible relationship between environmental factors such as stress and seasonal changes and the onset or expression of PMDD symptoms, as well as the role of interpersonal trauma has been investigated in the West⁸ but not in the Asian continent. Also, there is a lack of family studies from Asia highlighting the role of genetics in the aetiogenesis of PMDD as against a longitudinal population- based twin study from the West⁹ which reported the heritability of premenstrual symptoms.

Concurrent Validators

Concurrent or biological validators include neuropsychological, neurophysiological, and neuroimaging factors. The Asian literature has examined the physiological differences present in PMDD relative to controls. One study examined serotonergic functioning in 24 Japanese women who had PMDD, premenstrual symptoms (PMS) or were healthy (controls), and found significant differences across these 3 groups as measured by adrenocorticotropic hormone and cortisol responses to paroxetine challenge.¹⁰ Subjects with PMDD showed higher serotonergic function in the follicular phase but lower serotonergic function in the luteal phase compared with women in the other 2 groups. Matsumoto et al¹¹ examined autonomic function, as measured by heart-rate variability (HRV) in Japanese women diagnosed with PMDD or PMS or who were healthy (controls). They found that women in the PMDD group had the greatest decrease in HRV among the 3 groups.

Studies from the West^12-14 have suggested that symptom severity in PMDD is correlated with levels of oestradiol, progesterone, or neurosteroids such as allopregnanolone and pregnenolone sulfate. However, we could not find any neuroimaging studies pertaining to PMDD, or studies assessing the neuropsychological correlates of PMDD in the Asian population. However, even in the West, such studies remain in a stage of infancy and only a few studies have reported specific central nervous system differences in neural network activation, glucose metabolism, and neurotransmitter concentration between women with PMDD and healthy comparison subjects, based on findings of functional magnetic resonance imaging,¹⁵ positron emission tomography,¹⁶ and proton magnetic resonance spectroscopy,¹⁷ respectively.

Predictive Validators

These include course and outcome of disorder and the response to treatment. Assessment of stability of symptom pattern prospectively, from cycle to cycle, would serve as a guide to establish diagnostic stability and also the course of PMDD. Furthermore, longitudinal studies are imperative to determine the outcome of PMDD and its response to treatment.

There have been some follow-up studies assessing treatment response in PMDD. Hsiao and Liu¹⁸ conducted an open-label study to examine the response of 30 patients with PMDD to venlafaxine and found significant reduction in mood and behaviour subscales of Prospective Record of the Impact and Severity of Menstrual symptomatology calendar, the Zung Self-Rating Depression Scale (Zung- SDS), Hamilton Anxiety Rating Scale, and Hamilton Depression Rating Scale (HDRS). Wu et al¹⁹ examined the effect of paroxetine when administered intermittently versus continuously in 36 women seeking treatment for PMDD. They followed the patients for 6 menstrual cycles and found that rate of response on HDRS, Zung-SDS, and Clinical Global Impression scale ranged from 50% to 78.6% with continuous dosing and from 37.5% to 93.8% with intermittent dosing, with no significant differences between the 2 treatment protocols.

Similarly, the western literature mentions a preferential response of PMDD patients to serotonin reuptake inhibitors as compared with other mood disorders.²⁰ Likewise, PMDD has been shown to be responsive to treatment with oral contraceptives containing progestin drospirenone^21,22 as well as to ovarian suppression with gonadotropin-releasing hormone analogue agonists.^23,24

Roles of non-pharmacological treatments like herbal medications,²⁵ St. John’s wort,²⁶ and acupuncture²⁷ have been examined to a larger extent in Asian studies than in western studies. These treatment modalities have been proven beneficial in improving both emotional and physical symptoms associated with PMDD.

However, the treatment-seeking females are quite few as they are unaware of the terminology of PMS / PMDD, as reported recently.²⁸ This highlights the underlying need of educating women about PMDD, and also creating awareness about the available treatment options.

Conclusion

It appears that the Asian literature has contributed primarily in the form of prevalence studies on PMDD. There are some studies regarding the physiological correlates of PMDD and some have prospectively assessed treatment responses in such patients. Environmental and genetic risk factors and neuropsychological and neuroanatomical correlates of PMDD are domains which remain largely untouched in Asia. On a positive note, this offers enormous scope for Asian investigators to widely explore these areas and, thus, contribute to improvement in women’s mental health.

Declaration

The authors declared no conflict of interest in this study.

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