Research report
Pretreatment pattern of symptom expression in premenstrual dysphoric disorder

https://doi.org/10.1016/j.jad.2004.10.004Get rights and content

Abstract

Background

Use of intermittent dosing strategies for the treatment of premenstrual dysphoric disorder (PMDD) highlights the need for detailed empirical data on the onset, duration and pattern of symptom expression in women suffering from PMDD.

Method

Data were analyzed from 276 women who met DSM-IV criteria for PMDD and prospectively charted two menstrual cycles prior to commencing sertraline treatment. The presence and severity of PMDD symptoms were measured using the Daily Record of Severity of Problems (DRSP).

Results

The most frequent PMDD symptoms (moderate-to-severe for ≥3 days) included anger/irritability (76%), anxiety/tension (71%), tired/lethargic (58%), and mood swings (58%). Mean DRSP scores peaked at day −2 (2 days prior to the onset of menses), but the within-patient day of onset of PMDD-level symptoms was highly variable, differing from cycle-to-cycle by ≥4 days in 45% of women. Similarly, the within-patient duration of PMDD symptoms varied from cycle-to-cycle by 3 or more days in ≥50% of women. Depending on the criteria used, 1 day after the onset of menstruation, 34–46% of women continued to report moderate to severe symptoms.

Limitation

Women in this sample were recruited for participation in a treatment study, and the results may not generalize to women with PMDD in the community.

Conclusion

The results of this analysis found significant within-patient variability in the time-to-onset and offset of PMDD symptoms, as well as their duration. The temporal pattern and high degree of within-patient variability across menstrual cycles of PMDD symptoms may have treatment implications.

Introduction

Women with premenstrual dysphoric disorder (PMDD) constitute the most severely afflicted end of the spectrum of women suffering with premenstrual symptoms. The requirement that symptoms be associated with functional impairment ensures that the disorder is clinically significant. It is estimated that approximately 3–9% of women suffer from the disabling form of this disorder (Halbreich et al., 2003).

The codification of diagnostic criteria in DSM-IV, and the availability of reliable methods to prospectively chart symptoms, provides the means to test the benefit of new treatments for PMDD. As demonstrated by a recent meta-analysis (Dimmock et al., 2000), the efficacy of serotonin reuptake inhibitors is now well established. Treatment studies have confirmed that daily dosing throughout the menstrual cycle is highly effective ( Steiner et al., 1995, Yonkers et al., 1997). However, the episodic nature of PMDD makes intermittent, premenstrual medication administration an appealing alternative for patients who wish to minimize medication exposure (Cohen et al., 2002, Halbreich et al., 2002, Yonkers et al., 2005). Despite the success of intermittent treatment and the recommendation in the literature over the past two decades to document the on–off symptom pattern with prospective ratings (Rubinow and Roy-Byrne, 1984), few studies are available that provide details regarding the onset–offset pattern of symptoms experienced by women with PMDD. Such information would be useful for optimizing the efficacy of the intermittent treatment approach. The goal of the present study was to map the onset, duration, peak severity and offset of PMDD symptoms. We used the two screening menstrual cycles before a controlled clinical trial to explore patterns of symptom onset and offset.

Section snippets

Methods

Study methods for the clinical trial under analysis here have been previously reported (Halbreich et al., 2002). Briefly, women who met DSM-IV criteria for PMDD, and who completed two prospective screening cycles and one single-blind placebo cycle, were randomized to three cycles of double-blind, luteal phase treatment with either placebo or sertraline in a flexible daily dose of 50–100 mg. To qualify for entry, women were required to be 24–45 years old, with regular menstrual cycles lasting

Results

The baseline demographic and clinical characteristics of the patients in the original treatment sample are summarized in Table 1. The proportion of women reporting an individual PMDD symptom as being moderate-or-greater in severity for 3 or more premenstrual days is shown in Fig. 1. As can be seen, psychological symptoms, notably anger/irritability, anxiety/tension, and mood symptoms, predominate over physical symptoms (e.g., breast tenderness, bloating, increased headache or other pain) or

Discussion

This is one of the few studies we are aware of that has analyzed symptom severity patterns based on prospectively charted menstrual cycles in women meeting DSM-IV criteria for PMDD. In the current sample, mood symptoms predominated over both physical symptoms and food craving/vegetative symptoms (Fig. 1). These results are consistent with some, but not all, data from other treatment samples in which mood symptoms appear to have a higher incidence than what is observed in patients with PMDD in

Acknowledgments

Funding for this study was provided by Pfizer. Editorial assistance in the preparation of this manuscript was provided by Edward Schweizer, MD.

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