premenstrual dysphoric disorder premenstrual dysphoric disorder premenstrual dysphoric disorder (pmdd) is a mood disorder characterized by emotional, cognitive, and physical symptoms. pmdd causes significant distress or impairment in menstruating women during the luteal phase of the menstrual cycle. the symptoms occur in the luteal phase (between ovulation and menses), improve within a few days after the onset of menses, and are minimal or absent in the week after menses. pmdd has a profound impact on a person's quality of life and dramatically increases the risk of suicidal ideation and even suicide attempts. many women of reproductive age experience discomfort or mild mood changes prior to menstruation. however, 5-8% experience severe premenstrual syndrome causing significant distress or functional impairment. within this population of reproductive age, some will meet the criteria for pmdd. premenstrual dysphoric disorderother nameslate luteal phase dysphoric disorderspecialtypsychiatrysymptomssevere mood swings, depression, irritability, agitation, uneasiness, change in appetite, severe fatigue, anxiety, anger, swelling, bruising, insomnia/hypersomnia, breast tenderness, decreased interest in usual social activities, reduced interest in sexual activity, heart palpitations, tachycardia, difficulty in concentrationusual onsetcan occur anytime during reproductive yearsduration6 days – 3 weeks of cyclecauseslikely neuro-sensitivity to reproductive hormonesrisk factorsfamily history, history of violence/trauma, smoking, presence of other mental health disordersdiagnostic methodbased on symptoms & criteriadifferential diagnosispremenstrual syndrome, depression, anxiety disordertreatmentmedication, counselling, lifestyle change, surgerymedicationssris, drospirenone-containing oral contraceptives, gnrh analogs, cognitive behavioral therapy (cbt)prognosisexcellentfrequencyup to about 8% of menstruating women the exact cause of pmdd is currently unknown. however, because the symptoms are only present during ovulatory cycles and resolve after menses, it is believed to be caused by fluctuations in gonadal sex hormones or variations in sensitivity to sex hormones. in 2017, researchers at the national institutes of health discovered that women with pmdd have genetic changes that make their emotional regulatory pathways more sensitive to estrogen and progesterone, as well as their chemical derivatives. the researchers believe that this increased sensitivity may be responsible for pmdd symptoms. some studies have suggested that those with pmdd are more at risk of developing postpartum depression after pregnancy, but other evidence has been found to suggest against that notion. pmdd was added to the list of depressive disorders in the diagnostic and statistical manual of mental disorders in 2013. it has 11 main symptoms, and a woman has to exhibit at least five to be diagnosed with pmdd. roughly 20% of females have some symptoms of pmdd, but either have less than five or do not have functional impairment. first line treatment for pmdd is with selective serotonin reuptake inhibitors (ssris). hormonal therapy with oral contraceptives that contain drospirenone have demonstrated efficiency in reducing pmdd symptoms as well. cognitive behavioral therapy, whether in combination with ssris or alone, has shown to be effective in reducing impairment. dietary modifications and exercise may also be helpful, but studies investigating these treatments have not demonstrated efficacy in reducing pmdd symptoms. signs and symptoms clinicians consider mood symptoms, physical symptoms and impact on the patient's life in making the diagnosis of pmdd. mood symptoms include emotional lability (rapidly changing emotions, sensitivity to rejection, etc.), irritability and anger that may lead to conflict, anxiety, feeling on edge, hopelessness, difficulty concentrating, appetite changes, sleeping more or less than usual, or feeling out of control. the physical symptoms are similar to the symptoms of premenstrual syndrome (pms). these include breast tenderness or swelling, joint pain, muscle pain, gaining weight, or feeling bloated. because of the broad variety in clinical presentation, the onset of symptoms only during or around the luteal phase is key for diagnosing someone with pmdd rather than any other mood disorders. pmdd follows a predictable, cyclic pattern. symptoms begin in the late luteal phase of the menstrual cycle (after ovulation) and end or are markedly reduced shortly after menstruation begins. on average, the symptoms last six days but can start up to two weeks before menses, meaning symptoms can be felt for up to three weeks out of a cycle. severe symptoms can begin and worsen until the onset of menstruation, with many not feeling relief until a few days after menstruation ends. the most intense symptoms occurring in the week and days leading up to the first day of menstrual blood flow. the symptoms usually cease shortly after the start of the menstrual period or a few days after it ends. various symptom and severity tracking questionnaires exist to document presence and severity of symptoms throughout consecutive menstrual cycles. the international society for the study of premenstrual disorders (ispmd) defines two categories of premenstrual disorders: core pmd and variant pmd. core pmd has six characteristics, all mainly focusing on the cyclical nature of pmdd and its typical onset pre-menses tracked over the course of more than two menstrual cycles. the four classified variant pmds involve more unexpected variables that cause the onset of premenstrual distress; such as, pmd with absent menstruation or premenstrual exacerbation, wherein the symptoms of another preexisting psychological disorder may be heightened as a result of pmdd onset. epidemiology about 5-8% of women who are of reproductive age experience severe premenstrual syndrome; most of these people also meet criteria for pmdd. pathophysiology pmdd mood symptoms are only present in menstruating women. thus, symptoms do not occur during pregnancy, after menopause, or in women who have anovulatory cycles. other mood disorders typically persist across all reproductive life events and are independent of a woman's menstrual cycle. the current consensus on the cause of pmdd is a combination of heightened sensitivity to fluctuating levels of certain hormones (i.e. the reproductive hormones), environmental stress, and genetic predisposition. the sex steroids—estrogen and progesterone—are neuroactive; they have been noted in rat models to be involved in serotonin pathways. serotonin is involved in mood regulation alongside estrogen, whose receptors are found in the prefrontal cortex and hippocampus—the regions most known for their involvement in regulating one's mood and cognition overall. while the timing of symptoms suggests hormonal fluctuations as the cause of pmdd, a demonstrable hormonal imbalance in women with pmdd has not been identified. in fact, levels of reproductive hormones and their metabolites in women with and without pmdd are indistinguishable. it is instead hypothesized that women with pmdd are more sensitive to normal levels of hormone fluctuations, predominantly estrogen and progesterone, which produces biochemical events in the nervous system that cause the premenstrual symptoms. these symptoms are more predominant in women who have a predisposition to the disorder. it is apparent that the premenstrual disorders are biologically driven and are not only psychological or cultural phenomena. pmdd has been reported by menstruating women worldwide, indicating a biological basis that is not geographically selective. most psychologists infer that this disorder is caused by both a reaction to hormone flux and also genetic components. there is evidence of heritability of (retrospectively-reported) premenstrual symptoms from several twin and family studies done in the 1990s, with the heritability of pmdd proving to be about 56%. genetic factors whether or not this disorder has a specific genetic basis is still being discussed in the academic community. the possible genetic factors contributing to pmdd also have yet to be thoroughly researched. however, multiple genetic factors that contribute to the moodiness, depression, irritability, increased appetite, trouble sleeping, acne, fluid retention, headaches, nausea, and other symptoms associated with this disorder have recently been identified. many studies have noted that a polymorphism of the brain-derived neurotrophic factor gene (bdnf), a gene that helps support neurons in their function and survival in the brain by creating a protein that helps in the growth, maturation, and maintenance of these cells, may play a role in causing pmdd symptoms. this is because the result of this polymorphism mimics the hallmarks of pmdd: volatile moods, depression and irritability centered around the menstrual cycle. this gene has been studied extensively in its association with depression and, promisingly for pmdd research, mice homozygous for the bdnf polymorphism exhibited anxiety-like traits that fluctuated and changed around the mice's estrus, analogous to the human's menstruation, therefore mimicking some of the symptoms of pmdd. risk factors environmental stressors have also been found to prospectively increase risk for pmdd symptoms. environmental components such as stress, hormonal fluctuation, and epigenetics play a key role in the pathology and onset of the disorder. some studies have noted evidence of interpersonal trauma (domestic violence, physical or emotional trauma, or substance abuse) or seasonal changes (making pmdd potentially comorbid with seasonal affective disorder) having an impact on pmdd risk. but the most common pre-existing disorder found in those diagnosed with pmdd is major depression, wherein they either actually had it or were misdiagnosed when they should have only been diagnosed with pmdd. finally, an easily modifiable risk factor for pmdd is cigarette smoking. one meta-analysis found dramatically increased risk of developing pmdd in menstruating women who smoke. relationship to pregnancy and menopause women with pmdd usually see their symptoms disappear while they are pregnant. premenstrual dysphoric disorder is primarily a mood disorder that is associated with onset of menstruation; pregnancy, menopause, and hysterectomies all cause menstruation to cease, thereby stopping the proposed sex steroid-/serotonin-caused symptoms from occurring. although one might expect a higher rate of postpartum depression among those with pmdd, a large study of women with prospectively-confirmed pmdd did not find a higher prevalence of postpartum depression than in controls. if a woman had experienced ppd beforehand, there was found to be a less-than 12% chance of pmdd pathology emerging—hardly any differentiation from the regular population of those who have never experienced postpartum depression. however, pmdd symptoms can get worse following pregnancy, or other associated events such as birth and miscarriage. mental health comorbidities in pmdd the lifetime incidence of other psychiatric disorders is high among women with pmdd. an older review article (2002) utilizing the previous edition of the diagnostic and statistical manual of mental disorders (dsm-iv) used studies from 1966 to 2002 on pms and mental health disorders and selected for patients who retrospectively met the diagnostic criteria for pmdd and found that major depressive disorder, seasonal affective disorder, and generalized anxiety disorder often co-occur in pmdd. another systematic review study suggests that patients with bipolar disorder, type i or ii, have a higher incidence of pmdd. while the diagnosis of pmdd requires a mental health provider to determine that the symptoms a woman is facing is not due to an underlying mental or physical health condition, it is important to note that other conditions often co-occur and impact the quality of life and treatment plan for people with pmdd. suicidality in premenstrual dysphoric disorder previous links to suicidality and pms have been made, but women with pmdd are more likely still to consider and attempt suicide even when controlling for mental health comorbidities. despite the increase in suicidal ideation and attempts in this population, the data currently suggests that suicidal ideation or action is not more likely to occur during the late luteal phase when pmdd symptoms would occur. it is difficult to study whether treatment reduces suicidality because of the multifaceted reasons provided for suicidal ideation. however, treatment has been well documented to reduce physical and emotional symptoms of pmdd. diagnosis diagnostic criteria for pmdd are provided by a number of expert medical guides. diagnosis can be supported by having women who are seeking treatment for pmdd use a daily charting method to record their symptoms. daily charting helps to distinguish when mood disturbances are experienced and allows pmdd to be more easily distinguished from other mood disorders. with pmdd, mood symptoms are present only during the luteal phase, or last two weeks, of the menstrual cycle. while pmdd mood symptoms are of a cyclical nature, other mood disorders are variable or constant over time. although there is a lack of consensus on the most efficient instrument by which to confirm a pmdd diagnosis, several validated scales for recording premenstrual symptoms include the calendar of premenstrual experiences (cope), daily record of severity of problems (drsp), and prospective record of the severity of menstruation (prism). in the context of research, standardized numerical cutoffs are often applied to verify the diagnosis. the difficulty of diagnosing pmdd is one reason that it can be challenging for lawyers to cite the disorder as a defense of crime, in the very rare cases where pmdd is allegedly associated with criminal violence. dsm-5 the dsm-5 which