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

28 THE PREMENSTRUAL SYNDROMES
METHODS OF MEASUREMENT
REPORTED TO DATE
Early research projects attempted to use rating scales
that were essentially established and designed to quantify
other psychiatric and psychological conditions.
Examples of this are the use of the Hamilton Rating
Scale for Depression 1 and the Beck Depression
Inventory. 2 The lack of specificity of these techniques
to quantify PMS led to the development of new
‘bespoke’ techniques.
The earliest published measure specific to premenstrual
symptoms was the Moos’ Menstrual Distress
Questionnaire (MDQ), 3 which used a 47-item 0–6 rating
scale. The first use of visual analog scales (VAS) was published
as the Premenstrual Mood Index, which was used
for the first time within the context of a randomized clinical
trial of spironolactone at the University of
Nottingham, UK. 4 We will look at the use of VAS first.
Visual analog scales
VAS techniques demonstrate admirably the character
and cyclicity of symptoms. It is likely that visual analog
scales (VAS) are the most sensitive measure of PMS/
PMDD, as they allow a continuous rating. When first
used back in 1976, each score had to be measured by
hand, and this was tedious and onerous. The VAS can
be used to look at individual scores and their response
to therapy or a global score. Visual analog scales have
been found to be an effective tool in measuring the
change in premenstrual symptoms over time, and their
validity and reliability have since been well documented.
4–6 Bipolar visual analog scales, which record
mood changes, differ in one important respect from the
more usual unipolar ratings; the 100 mm line has both
positive and negative mood adjectives, with the midline
being ‘a normal day’; they are thus rated either side of
50 mm scores. Bipolar visual analog scales are more
difficult to handle in a statistical sense.
Unipolar VAS consists again of a 100 mm horizontal
line with vertical line anchors at each end. The anchors
are 0 � ‘not at all’ (i.e. the way you normally feel when
you don’t have premenstrual symptoms) and 100 �
‘extreme symptoms’ (i.e. the way you feel when your
premenstrual symptoms are at their worst). Data collected
from more recent trials of women with severe
premenstrual symptoms indicate that the use of the
revised VAS, which better reflects the current DSM-IV
(Diagnosis and Statistical Manual of Mental Disorders,
fourth edition) definition of PMDD, provides a reliable
measure of premenstrual symptoms when evaluated
against the well-validated Premenstrual Tension
Syndrome – Observer (PMTS-O). It is more user
friendly and also improves compliance. However, the
relentless measuring of the 100 mm lines of the scales
was at the time a disincentive to further development of
the method. 7 Later on, the ability to optically read the
scores and to provide a measuring technique on touchsensitive
PDA screens showed the promise of greater
simplicity and utility (Figure 4.1). This is discussed in
detail later.
OTHER RATING SCALES
The original Moos MDQ had significant limitations,
mainly related to the specificity of the symptoms. Even
so, this is the model on which most other PMS rating
techniques were based. It used a 46-item 0–6 rating
scale; the various newer techniques rate from 0 to 3, 4,
5, 6, or 7, using categorical rating scales. The cynic
might observe that there are about the same number of
scales as there are research groups. Early scales
included the Clinical Global Impression Scale (CGIS),
the Global Assessment Scale (GAS), 8 the Steiner Self-
Rating Scale, 9 while later the more widely used scales
included Premenstrual Assessment Form (PAF), 10
Prospective Record of the Impact and Severity of
Menstrual Symptoms (PRISM), 11 and the Calendar of
Premenstrual Experiences (COPE). 12 These and many
other tools used over the past 30 years are summarized
in Table 4.1.
The Daily Record of Severity of Problems
During the evolution of these various methods, the
DSM-III and DSM-IV criteria 23 were developed for late
luteal phase dysphoric disorder (LLPDD), and then
PMDD. In line with that, in 1990, Endicott and
Harrison 20 published the somewhat simple tool named
Daily Record of Severity of Problems (DRSP). DRSP
was developed to help individual women and their
therapist assess the nature, severity, and timing of onset
and offset of problems which may develop during specific
phases of the menstrual cycle. The feelings and
behaviors which are to be rated each day are those
which make up the diagnostic criteria for PMDD.
Completion of such rating is essential to determine the
nature of the problem being experienced. 20
Daily ratings made for several menstrual cycles help
to establish when specific symptoms first appear or
become more severe, how severe they become, how
much impairment in functioning they cause, and when
they go away or become less severe. The pattern of change
in the symptoms helps the woman and her therapist
to determine which of the following conditions are