Premenstrual Syndromes : PMS and PMDD - Rutuja :: The site ...

18 THE PREMENSTRUAL SYNDROMES
late-luteal phase may be too strict for some women and
very permissive for others (who may have many mild
symptoms which do not exist at mid-follicular phase).
The same considerations apply also to the impairment
items. However, there are women who do not have actual
premenstrual impairment of their performance but maintain
their function with a high level of distress. This
should be considered as a measure of severity no lesser
than impairment in function.
For research purposes, regular menstrual cycles are
obligatory: usually 21–35 days are considered to be
‘regular’. However, currently there is no requirement for
the limit of individual cycle-to-cycle duration stability
within this wide range.
FUTURE DIRECTIONS FOR RESEARCH
ON THE DIAGNOSIS OF PMS/PMDD
The main diagnostic issues that, to my opinion, are still
unsolved are:
1. Are there multiple diversified premenstrual syndromes
that also include diversified premenstrual
dysphoric phenotypes? This issue is also of crucial
importance for the understanding of the pathophysiology
of PMS and effective treatment (beyond
the current efficacy ceiling of 60%).
2. If there are diversified phenotypes, can we move
beyond the DSM-IV-style descriptive arbitrary
cut-off points towards a diagnosis based on the
pattern(s) of symptoms, past history and time course,
biological changes (etiology and pathobiology),
and treatment outcome? Once phenotypes are established,
are they specifically associated with specific
genotypes?
3. If our present understanding of PMS involves the
concept of vulnerability and menstrually related
trigger(s) of symptoms, then is it justified to distinguish
between premenstrual syndromes and PMEs
or catamenial disorders? The difference may be the
degree of the threshold and the magnitude of the
trigger needed to cause expression of symptoms, but
not necessarily a fundamental difference between
premenstrual syndromes and PMEs. If the vulnerability
level changes over time, and may increase or
decrease according to life events and their perception,
as well as repeated assaults (kindling and
dynamically evolving vulnerability), then there may
be a continuum between at least some premenstrual
syndromes, PMEs, and more chronic major
disorders – this notion deserves investigation.
4. What is a clinically relevant PMS (or PMDD)? When
do women warrant and benefit from treatment?
5. Can we develop clinically relevant diagnostic procedures
that would not require prospective monitoring
of symptoms for two consecutive menstrual
cycles (which are too much of a burden for many
women and their primary care physicians)?
There are many more unsolved diagnostic issues of
PMS/PMDD, even before we tackle issues of underlying
mechanisms that may vary from phenotype to phenotype.
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, 4th edn. Washington, DC: American Psychiatric
Press; 1994.
2. American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, 4th edn, text revision (DSM-IV-TR).
Washington, DC: American Psychiatric Press; 2000: 771–4.
3. Angst J, Sellaro R, Merikangas KR et al. The epidemiology of perimenstrual
psychological symptoms. Acta Psychiatr Scand 2001;
104(2):110–16.
4. Johnson SR. The epidemiology and social impact of premenstrual
symptoms. Clin Obstet Gynecol 1987; 30(2):367–76.
5. Merikangas KR, Foeldenyl M, Angst J. The Zurich Study. XIX.
Patterns of menstrual disturbances in the community: results of the
Zurich Cohort Study. Eur Arch Psychiatry Clin Neurosci 1993;
243:23–32.
6. Ramcharan S, Love EJ, Fick GH et al. The epidemiology of premenstrual
symptoms in a population-based sample of 2650 urban
women: attributable risk and risk factors. J Clin Epidemiol 1992;
45(4):377–92.
7. Rivera-Tovar AD, Frank E. Late luteal phase dysphoric disorder
in young women. Am J Psychiatry 1990; 147(12):1634–6.
8. Sveindottir H, Backstrom T. Prevalence of menstrual cycle symptom
cyclicity and premenstrual dysphoric disorder in a random sample
of women using and not using oral contraceptives. Acta Obstet
Gynecol Scand 2000; 79(5):405–13.
9. Wittchen HU, Hoyer J. Generalized anxiety disorder: nature and
course. J Clin Psychiatr 2001; 62(Suppl 11):15–19; discussion
20–1.
10. Woods NF, Most A, Dery GK. Prevalence of perimenstrual symptoms.
Am J Public Health 1982; 72(11):1257–64.
11. Robinson RL, Swindle RW. Premenstrual symptom severity:
impact on social functioning and treatment-seeking behaviors.
J Womens Health Gend Based Med 2000; 9(7):757–68.
12. Steiner M, Brown E, McDougall M. The burden of illness of premenstrual
symptoms. J Womens Health Gend Based Med 2002;
11:324.
13. Cohen LS, Soares CN, Otto MW et al. Prevalence and predictors
of premenstrual dysphoric disorder (PMDD) in older premenopausal
women. The Harvard Study of Moods and Cycles. J Affect Disord
2002; 70(2):125–32.
14. Chawla A, Swindle R, Long S, Kennedy S, Sternfeld B. Premenstrual
dysphoric disorder: is there an economic burden of illness? Med
Care 2002; 40(11):1101–12.
15. Wittchen HU, Becker E, Lieb R, Krause P. Prevalence, incidence
and stability of premenstrual dysphoric disorder in the community.
Psychol Med 2002; 32(1):119–32.
16. Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence
estimates of mental disorders in the United States: using a clinical
significance criterion to reconcile 2 surveys’ estimates. Arch Gen
Psychiatry 2002; 59(2):115–23.