Transcript Depression in Chronic Illness

Lecture 6: Premenstrual
Syndrome
Dr. Antoinette Lee
The University of Hong Kong
Outline
Definitions and Related Conditions
Assessment and Diagnosis
Etiologies
Nature of the Problem among Chinese
Females
Treatment
What is Premenstrual Syndrome?
(I) History of PMS:
Frank (1931): Premenstrual Tension (PMT)
Dalton (1953): Premenstrual Syndrome (PMS)
Court cases
NIMH (1983): research standard for PMS
American Psychiatric Association (1987): Late
Luteal Phase Dysphoric Disorder (LLPDD) as a
provisional research category
What is Premenstrual Syndrome?
American Psychiatric Association (1994):
Premenstrual Dysphoric Disorder (PDD) as
a “mood disorder not otherwise classified”
Lay arena
What is Premenstrual Syndrome?
(II) Definition of PMS
“the cyclic recurrence in the luteal phase of
the menstrual cycle of a combination of
distressing physical, psychological, and/or
behavioral changes of a sufficient severity
to result in deterioration of interpersonal
relationships and/or interference with
normal activities”
Reid and Yen (1981)
What is Premenstrual Syndrome?
Distinguish from:
Other physical (e.g. mastalgia) or
psychological (e.g. depression bulimia)
problems
Premenstrual exacerbation of pre-existing
conditions
Diagnosis of PMS (Ling, 2000)
A. Does not meet DSM-IV criteria for PMDD but
does meet ICD-10 criteria for PMS
B. Symptoms occur only in the luteal phase, peak
shortly before menses, and cease with
menstrual flow or soon after
C. Presence of 1 or more of the following
symptoms:
Mild psychological discomfort
Bloating and weight gain
Breast tenderness
Swelling of hands and feet
Aches and pains
Poor concentration
Sleep disturbance
Change in appetite
(III) Related Conditions
1.) Premenstrual Dysphoric Disorder (PMDD)
In Diagnostic and Statistical Manual of Mental
Disorders, 4th edition (DSM-IV) (APA, 1994)
Under “mood disorders not otherwise classified
Mood symptoms as the primary complaint
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder
A. In most menstrual cycles during the past
year, five (or more) of the following symptoms
were present most of the time during the last
week of the luteal phase, began to remit within a
few days after the onset of the follicular phase,
and were absent in the week postmenses, with
at least one of the symptoms being either (1),
(2), (3), or (4).
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder
1.
2.
3.
4.
5.
6.
markedly depressed mood, feelings of hopelessness,
or self-deprecating thoughts affective
marked anxiety, tension, or feeling of being “keyed
up,” or “on edge”
marked affective lability (e.g. feeling suddenly sad
or tearful or increased sensitivity to rejection)
persistent and marked anger or irritability or
increased interpersonal conflicts
decreased interest in usual activities (e.g. work,
school, friends, hobbies)
subjective sense of difficulty in concentrating
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder
7. lethargy, easy fatigability, or marked lack of
energy
8. marked change in appetite, overeating, or
specific food cravings
9. hypersomnia or insomnia.
10. a subjective sense of being overwhelmed or out
of control
11. other physical symptoms, such as breast
tenderness or swelling, headaches, joint or
muscle pain, a sensation of “bloating”, weight
gain
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder
B. The disturbance markedly interferes with
work or school or with usual social activities or
relationships with others (e.g., avoidance of
social activities, decreased productivity and
efficiency at work or school).
C. The disturbance is not merely the
exacerbation of the symptoms of another
disorder, such as major depressive disorder, panic
disorder, dysthymic disorder, or a personality
disorder (although it may be superimposed on
any of these disorders).
DSM-IV Research Criteria for
Premenstrual Dysphoric Disorder
D. Criteria A, B, and C must be confirmed by
prospective daily ratings during at least two
consecutive symptomatic cycles. (The
diagnosis may be made provisionally prior to
this confirmation.)
(APA, 1994)
Content Validity of Premenstrual
Dysphoric Disorder
Hartlage & Arduino (2002) investigated the
mood-related symptoms reported by 26
women seeking treatment for premenstrual
disorders and found that premenstrual
irritability or anger were more frequent than
depressed mood.
Irritability and affect lability as the most
characteristics features of PMDD rather than
depressed mood or anxiety (Landen, M. &
Eriksson, E. 2003)
(III) Related Conditions
2.) Premenstrual Tension Syndrome
In the International Classification of Diseases,
10th edition (ICD-10) (WHO, 1992)
Coded under “Diseases of the Genitourinary
System” (N94.3)
The Menstrual Cycle
Symptoms of PMS
More than 150 symptoms associated
with PMS
No “hallmark symptom”
Variable constellation of symptoms
Across individuals and over time
Symptoms of PMS
Moos (1968): 7 clusters of symptoms
Pain
Concentration
Behavioral change
Autonomic reactions
Water retention
Negative affect
Arousal
Symptoms of PMS
Abraham (1983): 4 subgroups of PMS:
PMT-A
Anxiety, irritability, mood swings
Estrogen-progesterone imbalance, serotonin,
psychological factors
PMT-H
Water retention, bloating, breast tenderness
PMT-D
Depressed mood, cognitive impairment, insomnia
PMT-C
Carbohydrate cravings, fatigue
Insulin sensitivity, stress, depressed mood
Diagnosis and Assessment of
PMS
1.) Self-report measures
Prospective daily rating
At least 2 menstrual cycles
Moos Menstrual Distress Questionnaire (MDQ):
Moos (1968)
47 items
8 subscales
Premenstrual Assessment Form (PAF):
Endicott and Halbreich (1982)
Diagnosis and Assessment of
PMS
Calendar of Premenstrual Experiences
(COPE)
Prospective Record of Impact and
Severity of Menstrual Symptoms (PRISM)
Calendar of Premenstrual Experiences
Begin our calendar on the first day of your menstrual cycle. Enter the calendar date below
the cycle day.
Day 1 is your first day of bleeding. Shade the box above the cycle day if you have bleeding
(). Put an X for spotting ().
If more than one symptom is listed in a category, i.e., nausea, diarrhea, constipation, you do
not need to experience all of these.
Rate the most disturbing of the symptoms on the 1-3 scale.
Weight: Weigh yourself before breakfast. Record weight in the box below date.
Symptoms: Indicate the severity of your symptoms by using the scale below.
Rate each symptom at about the same time each evening.
0 = None (symptom not present)
2 = Moderate (interferes with normal activities)
1 = Mild (noticeable but not troublesome) 3 = Severe (intolerable, unable to perform normal
activities)
Other Symptoms: If there are other symptoms you experience, list and indicate severity.
Medications: List any medications taken. Put an X on the corresponding day(s).
Calendar of Premenstrual Experiences
B leed in g
C yc le d ay
D ate
W eight
SYMPTO MS
Acne
B loated n es s
B r es t tend ern es s
D iz z in es s
F atig u e
H ead ac h e
H ot flas h es
N aus ea,
diarr h ea,
c ons tip ation
P alpitations
S w ellings
( h an ds , ank les ,
br eas t)
A n gr y outburs t,
arg u m ents ,
violen t ten d enc ies
A n xiety,
tens ion,
n er v ous n es s
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Calendar of Premenstrual Experiences
B leed in g
C yc le d ay
D ate
W eight
S Y M P TO M S
C onfus ion ,
D iffic ulty c onc entratin g
C ryin g eas ily
D ep res s ion
F ood c ravin gs (s w eets ,
s alts )
F org etfuln es s
Irritability
Inc reas ed ap p etite
M ood s wings
O verly s ens itiv e
W is h to b e alon e
O th er s ym ptom s
1._ __ __ _ __ __
2._ __ __ _ __ __
M edic ations
1._ __ __ _ __ __
2._ __ __ _ __ __
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Calendar of Premenstrual Experiences
The COPE Calendar is scored by adding the total number of
points from days 3-9 of the menstrual cycle (The follicular phase
score) and the total number of points from the last 7 days of the
cycle (luteal phase score).
PMS: follicular phase score < 40 and luteal phase score > 42
Follicular phase scores > 40(regardless of luteal phase scores)
suggest the possibility of underlying psychiatric disorder
Although not strictly required for the diagnosis, almost all
patients with PMS will have at least a 30% increase in scores
from follicular to luteal phase. If this is not observed, the
diagnosis should be reconsidered.
Typical PRISM Calendar Record Indicating Depression
B le e d in ggХ Х Х Х Х
Х Х Х Х Х
M e n s tru a l C yc le 1 2 3 4 5 6 7 8 9 1 0 11 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 3 2 3 3 3 4 3 5
D ate :
SYMPTOMS
Irrita b le
2 3
F atig u e 2 2
In w ar d A n g er 2
1
1
1
2 2 2 2
2 2
1
2 2 2
2 2
1
1
1
2 2
1
L a b ile M o o d (c r yin g ) 3
3
1
1
2 2
2
1
2 2
1
D ep r es s e d 3
1
1
2
1
1
2 2
R es tles s
1
1
1
1
2 3
3
3
A n xio u s 3
1
1
1
2 3
3
1
In s o m n ia
L ac k of C o n tr o l
3
1
2
3
1
3 2 2
1
2
1
2 2
1
3 2
1
1
2
1
2
2
1
2 2
1
2 2
2 2
1
2 2
2
1
1
1
2 2
1
2 2
1
2 2
2 2
2 2 2
2 2
1
1
2
3
2
1
1
2
1
1
2
1
1
2
1
2
1
2 2 3
2 2
3
1
1
1
1
2 2 2 2 2
2
2 2
2
1
1
2
2 2 3
2
D rive : u p  d o w n 
1
2 2
A b d o m in al B lo a tin g
C
A p p e tite : u p  d o w n   
C
 


2
1
2
1
B r es t Te n d er n es s
B o w e ls : c o n s t. (c ) lo o s e (l)
1
1
2
2 2
1
1
1
3
3
2 2
1
1
E d e m a or R in g s T ig h t
2 2 2
2 2 2 2 3
3 2 2 2 2 2
2
1
C C C

C
   
 
 
     
2 2 3
1
2
1
2
1
1
1
1
1
2
C C

 


 
C h ills (C ) / S w e a ts (S )
H e a d ac h e s
2 2
1
2 2 2
2 2 2
3 2 2
2 2 2 2
C r a ve : s w e e ts , s a lt
F e e l U n attr ac tive 2 2 2 2 2 3
1
2 2
1
1
G u ilty 2 2 2 2 2 2 2 2 2 2 2
U n r e as o n a b le b e h a vio r
1
L o w S e lf= Im a g e 2 2
1
2 2 2 2 2
2 2 2 2 2 2 2 2
2
2 2
N au s e a 1
M e n s tru a l C r a m p s 2 2 2
2 2
1
2 2
1
2 2 2
2
2 2 2
1
2 2
2 2
2 2 2
1
2 2 2 2
2 2 2
3
3 2 2
2 2 2
1
1
2
1
2
Typical PRISM Calendar Record Indicating PMS
B le e d in ggХ Х Х Х Х
Х Х Х Х Х
M e n s tru a l C yc le 1 2 3 4 5 6 7 8 9 1 0 11 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 3 2 3 3 3 4 3 5
D ate :
SYMPTOMS
Irrita b le 3 2
F atig u e 2 2 2 2
1
1
1
2
1
1
1
1
2 2 2 3 2 2 2
In w ar d A n g er 1
1
L a b ile M o o d (c r yin g ) 2 2
D ep r es s e d 2
1
R es tles s 3
1
A n xio u s 2
1
In s o m n ia 2
1
2
1
1
2
2
2
3 2
2
1
A b d o m in al B lo a tin g 3 2
1
2
A p p e tite : u p  d o w n 
1 2 2 2 2
1
1
3 2 3
1
2
3 3
2 2 2
C C C
L L
  
3
3 3
2 2 2 2
C C
 
 
2
3 3
1
3 3
1
D rive : u p  d o w n  
1
2 2 2
1
1
L C
3
2
1 2 2
2
B r es t Te n d er n es s 2 2
B o w e ls : c o n s t. (c ) lo o s e (l) L
1
1
2 3 2 2 2
L ac k of C o n tr o l 1
E d e m a or R in g s T ig h t
2 3 2 3 3
2
2 2 3
2
1
1

 
  
C h ills (C ) / S w e a ts (S )
H e a d ac h e s 3 2 2
1
1 2 2 3
1
2 2
2 2 3
3 2
C r a ve : s w e e ts , s a lt
F e e l U n attr ac tive 2
2 3 2
G u ilty 1
1
U n r e as o n a b le b e h a vio r 2 2
L o w S e lf= Im a g e 2
N au s e a 1
M e n s tru a l C r a m p s 1
1
2
2
2 2
1
3
2 2
2
3 2 2
1
2 2
1
2 2 2
1
1
2 2
Diagnosis and Assessment of
PMS
2.) Clinical Diagnosis
APA and ICD criteria
Differential diagnoses
Lack of a biological marker
3.) Role of laboratory tests
Limited to screening for medical conditions
in screening for differential diagnoses
Diagnosis and Assessment of
PMS
4.) Differential Diagnoses
E.g. hypothyroidism, hyperthyroidism, ,
breast disorders, pelvic diseases, major
depression, bipolar disorder, anxiety
disorders, personality disorders, anorexia
nervosa, bulimia nervosa
Prevalence of PMS
Cross-study and cross-cultural comparisons heavily limited
by inconsistent definition and assessment criteria + other
methodological issues
PMS: 2-5%
PMDD: 3-5% (APA, 1994), 2-10% (Yonkers and Davis, 2000)
20-40%: some kind of premenstrual symptoms (American
College of Obstetricians and Gynecologists, 1989)
24% of women from psychiatric population meet diagnostic
criteria for PMDD (Casper, 1998)
Etiologies
No definitive etiology for PMS or PMDD
Possible etiologies include biological, psychological, and social
factors
(1) Biology
(i) Hormonal imbalance
Estrogen, progesterone
Absolute level and ratio
(ii) Neurotransmitter
Serotonin, norepinephrine, GABA
Efficacy of SSRIs
Psychosocial Context of PMS
(2) Psychological and Social Factors
(i) Relationship with Psychiatric Disorders
59% of LLPDD patients had a current diagnosis of one or
more anxiety disorders, 56% had a lifetime occurrence
(Veeninga et al., 1994)
Level of anxiety and depression higher than controls
63% of PMS patients had at least one episode of depression
or anxiety disorder (Anderson, 1986)
PMS contribute to suicidal attempts among female
psychiatric patients (Zhou and Fan, 1998)
Psychosocial Context of PMS
(ii) Stress
PMS and life events
Stressful life events predisposes individuals to PMS
or PMS influences perception of stressors?
(iii) Personality
Neuroticism and trait anxiety
(iv) Attitudes and Expectations
Psychosocial Context of PMS
(v) Role Quality
The impact of multiple roles: scarcity
hypothesis vs enhancement hypothesis
Role occupancy & role quality vs number of
roles
PMS related to role conflict and
dissatisfaction
Psychosocial Context of PMS
(6) Feminist Theories
PMS as a male-created illness to depict women as
the weaker gender
Medicalization of normal fluctuations
(7) Social Constructionism
PMS socially constructed to serve certain social
purposes
PMS in Chinese Societies
Johnson (1987): a culture-bound Sx
92% of women in Hong Kong reported
some premenstrual symptoms (Chang
et al., 1995)
60% of urban women in China
experience negative menstrual changes
(Yu et al., 1996)
PMS in Chinese Societies
Abdominal pain (33%), backache
(30%), and bloating (23%) common in
the menstrual phase
validity of instruments questionable
local forms of perimenstrual distress?
PMS in Chinese Societies
Reduced number of pregnancies
Traditional conservative attitudes towards
menstruation and sexuality
Status of women
Modernization
Lack of a locally valid research and clinical
instrument
A Local Study of Perimenstrual Distress
Sample: 538 young females in HK
Mean age: 20.18 (SD=7.17)
5 premenstrual symptoms with highest
endorsement:
Irritability (22%)
Hypersomnia (21%)
Fatigue (20%)
Body dissatisfaction (20%)
Easy to lose temper (20%)
5 menstrual symptoms with highest
endorsement:
Abdominal cramps (46%)
Fatigue (43%)
Abdominal pain (41%)
Hypersomina (32%)
Take naps (32%)
Perimenstrual Distress and
Female Roles
339 females in HK (Mean age = 37.3, SD
= 9.39)
SYMPTOM ENDORSEMENT:
Premenstrual Menstrual
5 or more symptoms: 19.6%
27.5%
10 or more symptoms: 9.8%
11.6%
20 or more symptoms: 2.8%
4.3%
Single women without children had the
highest level of menstrual distress
Level of menstrual distress:
wife + worker > wife + mother
worker > wife + mother
worker > wife + mother + worker
wife and mother roles appeared to
exert a protective function against
menstrual distress
A study of the relationship between the
menstrual cycle and suicide attempts
N = 52 women admitted to the ER in Turkey
because of a suicide attempt and 50 healthy
female controls
Inclusion criteria:
Fertility
Regular menstrual cycles of 28  3 days
Lack of intake of oral contraceptive or other
gonadal hormones and psychotropic drugs
Mean age of patients = 26.51 (SD=7.82)
A study of the relationship between the
menstrual cycle and suicide attempts
Subjects were divided into four groups
according to menstrual cycle phase:
Menstrual follicular phase (MPF, days 1-7)
Non-menstrual follicular phase (NMPF, days 8-11)
Mid cyclic phase (MCP, days 12-16)
Luteal phase (LP, days 17-28  3)
Subjects were given the Stat-Trait Anxiety
Inventory (STAI) and Hamilton Depression
Rating Scale (HDRS)
Socio-demographic and clinical characteristics
were also obtained
Precent of suicide attempts according to the
menstrual cycle phases
45
40
35
30
% 25
20
15
10
5
0
MFP
NMFP
MCP
LP
Note: The frequency of suicide attempts among the four phases of the menstrual cycle
was sig. different (p<.001)
Caykoylu A et al., Psychiatry Clin Neurosci 2004; 58:460-464
HDRS and STAI scores of patients according to the
menstrual cycle phases
50
45
Score
40
HDRS score
35
STAI (Trait) score
30
STAI (State) score
25
20
15
10
5
0
MFP
NMFP
MCP
LP
Note: No statistical difference in HDRS and STAI scores was found between
MPF and other phases
Caykoylu A et al., Psychiatry Clin Neurosci 2004; 58:460-464
The hormone levels of patients and controls at
different menstrual phases
Estrogen (pg/mL)
Patients
Controls
Progesterone (ng/mL)
8
80
7
70
6
60
5
50
4
40
3
30
2
20
1
10
0
0
MFP
NMFP
MCP
LP
MFP
NMFP MCP
LP
Note: No statistical difference of hormone levels in the different phases was found
between patients and controls
Caykoylu A et al., Psychiatry Clin Neurosci 2004; 58:460-464
A study of the relationship between the
menstrual cycle and suicide attempts
No significant difference of socio -demographic
and clinical characteristics was observed between
MFP and the other phases
 the frequency of suicide attempts in MFP may
originate from other factors independent of
clinical and socio-demographic ones
A study of the relationship between the
menstrual cycle and suicide attempts
Possible explanations:
The low levels of gonadal hormones in MFP
may induce a suicide attempt in predisposed
women
Suicide attempts may occur as a consequence
of increased impulsivity brought about by the
low serotonergic function due to gonadal
hormone levels are low
PMS and Menopause
Premenstrual syndrome was the main
predictor of climacteric symptoms,
followed by perimenopausal state and
negative life events (Binfa et al., 2004)
Influence of psycho-social factors and women's reproductive on the
risk of suffering climacteric symptoms
4
*
3.5
**
Odds ratio
3
*
2.5
2
1.5
1
0.5
0
Life events
n = 300
Family
dysfunction
*p<.05 level of significance
** p<.001 level of significance
Premenstrual
syndrome
Perimenopause
Binfa et al., Maturitas 2004; 48: 425-431
Treatment of PMS
1.) Drug treatment
(a) Hormonal therapy
Estrogen, oral contraceptives, ovulation suppressant
(b) Other medications
Analgesic, diuretics, antidepressant, anxiolytics
SSRIs emerging as the most effective treatment option (Steiner,
2000)
SSRIs: intermittent administration of fluoxetine (Prozac) (Steiner
et al., 1997) and sertraline (Zoloft) (Yonkers et al. , 1997) for tx of
PMDD
Calcium was presented as an inexpensive and healthy option in a
recent study (Pearlstein & Steiner, 2000)
Treatment of PMS
2.) Psychotherapy
Cognitive-behavioral therapy, stress management,
relaxation training
3.) Lifestyle changes
(a) Exercise
Moderate aerobic and stretching exercises
Improvement of blood circulation, muscle
relaxation, and mood
Treatment of PMS
(b) Nutritional/dietary changes
Avoid:
Caffeinated Drinks & Stimulants
Alcohol
Treatment of PMS
Avoid:
High Sodium Foods
Treatment of PMS
Avoid:
Refined Sugar
Treatment of PMS
Avoid:
Dairy Products
Treatment of PMS
Avoid:
High Fat Foods
Treatment of PMS
Consume more of:
Complex Carbohydrates
Treatment of PMS
Consume more of:
Soy and Beans
Treatment of PMS
Consume more of:
Leafy Green Vegetables and Root
Vegetables