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

38 THE PREMENSTRUAL SYNDROMES
prospectively for 90 days. 17 Ten women (4.6%) met
criteria for late luteal phase dysphoric disorder, now
called PMDD. Cohen and colleagues reported on the
prevalence of PMDD in 513 women (aged 36–44 years
old) participating in the Boston area community
Harvard Study of Moods and Cycles who rated their
symptoms prospectively using the DRSP for one menstrual
cycle. 18 The diagnosis of PMDD was confirmed
in 33 (6.4%) of 513 women and was associated with
previous major depressive disorder (MDD), lower education,
and current cigarette smoking. Sternfeld and
colleagues reported on the prevalence of premenstrual
symptoms in 1194 women (aged 21–45 years old)
enrolled in a California health maintenance organization
who prospectively rated their symptoms for two
cycles using the DRSP. 4 Fifty-six (4.7%) met criteria for
PMDD and 151 (12.6%) women met criteria for severe
PMS (defined as meeting PMDD criteria for one cycle
with at least one symptom rated a 5 or 6 in the other
cycle). The prevalence rates in this study may have been
low due to the exclusion of women with known PMDD
or psychotropic medication use. The number and severity
of emotional premenstrual symptoms were inversely
related to age and oral contraceptive use, and directly
related to having a medical comorbidity and being
Hispanic relative to being white.
Prevalence studies using PMDD criteria
without prospective confirmation
Wittchen and colleagues published a study that has made
a significant contribution to knowledge about prevalence
and comorbidity data in an adolescent community
sample. 19 These authors reported the 12-month prevalence
and 4-year incidence rates of provisional PMDD
in 1488 women aged 14–24 years old in a community
cohort from Munich, Germany. Although women did
not complete prospective ratings, subjects completed
questions corresponding to the DSM-IV PMDD criteria
relating to the past 12 months, with additional questions
about impairment, psychosocial interference, and
the absence of symptoms in the postmenses week. In
addition, comorbid axis I disorders over the previous
year were systematically assessed. At baseline, women
aged 14–24 years old were enrolled, with 14–15 year olds
sampled at twice the probability of 16–21 year olds,
and 22–24 year olds sampled at half this probability.
Follow-up assessments were conducted at approximately
2 and 4 years following enrollment; the age range of the
sample at final follow-up was 18–29 years old.
At least one premenstrual symptom was endorsed by
79.8% of the total sample, with the five most common
premenstrual symptoms being physical symptoms, affect
lability, fatigability, depressed mood, and appetite/
craving. The estimated 12-month prevalence of PMDD
at baseline was 5.8% and the total overall cumulative
incidence up to age 29 years old was 7.4%. When
comorbid MDD and dysthymia were excluded, the
baseline rate dropped to 5.3% and the cumulative
incidence rate to 6.7%. PMDD was stable across the
4 years, with remission occurring in only 4.9%. The
five most common PMDD symptoms were depressed
mood (90.5%), affect lability (89.7%), irritability/
anger (81.5%), fatigability (78.6%), and physical complaints
(78.1%). Subthreshold PMDD was found in
18.6% of the total sample at baseline, defined as
meeting most, but not all, of the PMDD criteria. The
most frequent reason for not meeting full PMDD criteria
was failure to meet the persistent impairment criterion.
The rank order of premenstrual symptoms was
similar for women with subthreshold PMDD but at
lower frequencies compared to women with PMDD.
Both PMDD and subthreshold PMDD groups were
significantly more likely to have a 12-month comorbidity
of affective disorder, anxiety disorder, and nicotine
dependence. Unusual findings from this study included
the finding of suicide attempts having occurred in
15.8% of women with threshold PMDD, and significantly
elevated 12-month rates of bipolar I, bipolar II
post-traumatic stress disorder (PTSD), social phobia,
and somatoform disorder compared with women without
PMDD. Further analyses of this data have suggested
that previous trauma or an anxiety disorder is associated
with the development of PMDD, while having PMDD
is associated with future episodes of depression. 19–21
Steiner and colleagues developed a Premenstrual
Symptoms Screening Tool (PSST) that assesses each of
the PMDD criteria and five questions related to functioning
and relationships rated as ‘not at all’, ‘mild’,
‘moderate’, or ‘severe’. 22 The PSST was administered to
508 women attending a primary care clinic in Ontario,
Canada. Although prospective ratings and evaluation
of comorbid disorders were not obtained, the PSST
directly inquired about symptoms that started before
the period and stopped soon after menses. Results indicated
that 26 (5.1%) women met criteria for PMDD
and 105 (20.7%) women met criteria for moderate–
severe PMS, similar to the results of the Wittchen study
suggesting that approximately 1 in 5 women meet criteria
for subthreshold PMDD.
In a cross-sectional telephone survey of 1045 women
in the USA, UK, and France, Hylan and colleagues evaluated
premenstrual symptoms based on the DSM-IV
criteria by retrospective report, the extent to which the
symptoms interfered with their home, school, work, or
social life, and treatment-seeking behavior. 23 Between
23% and 31% of women were classified as having