Association of a trait-like bias towards the perception of negative subjective life events with risk of developing premenstrual symptoms

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Abstract

Objective

Premenstrual symptoms affect the majority of healthy women. Premenstrual symptomatology has earlier been linked to stress and a state-like alteration in the perception of life events in the late-luteal phase of the menstrual cycle. We hypothesised that there is also a trait-like negative bias in the perception of life events evident throughout the whole cycle which is associated with the likelihood to manifest more marked symptoms in the late-luteal phase of the cycle.

Methods

88 healthy women completed the PRISM calendar for three consecutive cycles and the Objective and Subjective Event Checklist during the follicular phase of the first cycle. Association between PRISM score change from the follicular through the late-luteal phase and life event variables was investigated by Generalized Linear Model Analysis (GENMOD).

Results

The PRISM score change showed a significant negative association with the ratio of positive subjective life events and a significant positive association with the ratio of negative subjective life events. There were no significant results in case of the objective life events.

Conclusion

Our results indicate that women manifesting a more marked increase of symptoms from the late follicular through the late-luteal phase of the menstrual cycle are more likely to notice negative subjective life events and less likely to notice positive subjective life events. This suggest a trait-like negative bias in the perception of life events present throughout the whole reproductive cycle which may play an important role in the emergence of premenstrual symptoms.

Introduction

Premenstrual syndrome is the monthly recurrence of several physiological and mood symptoms in the luteal phase of the menstrual cycle, which are serious enough to interfere with everyday interpersonal, social and work functions. Although in some cases premenstrual syndrome can be a seriously disabling condition, this variant affects only a smaller portion of reproductive-age women (Weisz and Knaapen, 2009, Potter et al., 2009). However, the majority of women experience some or more marked fluctuations of mood and physical symptoms associated with the reproductive cycle although these symptoms do not reach level for diagnostic criteria. Yet they may influence quality of life (Rapkin and Winer, 2009). These subthreshold symptoms, however, rarely attract scientific attention, although their overall impact on the wellbeing of healthy average women is significant.

Several studies have been carried out in order to gain a better understanding of the factors underlying the emergence of late-luteal phase-associated symptomatology (Yonkers et al., 2008, Cunningham et al., 2009). The results of these studies contradict for several reasons, however, it can be concluded for the evidence accumulating so far that premenstrual syndromes can be understood only with a multidisciplinary, bio-psycho-social approach, since so far neither biological, nor psychological factors could fully account for this phenomenon (Ross and Steiner, 2003, Di Giulio and Reissing, 2006). Comparison of study results is also confounded by the fact that different research teams study different populations using different criteria systems and diagnostic categories such as PMS, LLPDD or PMDD. Therefore studying premenstrually occurring reproductive cycle-related phenomena in healthy women not meeting diagnostic criteria for any of the above disorders should be a valuable new approach in gaining a deeper and wider understanding concerning the background of premenstrual syndromes. Adopting such a dimensional approach allows for a better insight into the nature of late-luteal symptoms since it views these phenomena as part of a continuum.

In the beginning, studies mainly focused on the biological and endocrinological factors in the background of premenstrual syndromes, suggesting that abnormal oestrogen and progesteron levels (Halbreich et al., 1986, Redei and Freeman, 1995), or the abnormal secretional pattern of these hormones (Facchinetti et al., 1990) may be responsible. Later it was suggested that an abnormal reaction to normal hormonal levels is a major contributing factor (Rubinow and Schmidt, 1995, Halbreich et al., 2003, Yonkers et al., 2008), and several studies have reported that oestrogen influences central nervous system functions and neurotransmitter systems regulating mood, behaviour and cognition (Holsboer, 2003, McEwen et al., 1997, Chakravorty and Halbreich, 1997, Halbreich et al., 2003, Posener et al., 2003, Rubinow and Schmidt, 2006), while progesterone was reported to induce depression and anxiety and reduce neuronal excitability and its neurosteroid metabolites were also implicated in the etiogenesis of premenstrual syndromes (Halbreich et al., 2003, Wang et al., 1996). However, it was obvious that biochemical and neuroendocrine factors by themselves cannot fully account for the emergence of premenstrual symptoms, therefore psychological factors must also be taken into consideration. Several studies found a positive association between premenstrual syndromes and attributional style (Trunnell et al., 1988, Ussher, 1992), beliefs, cognitions and prior knowledge concerning premenstrual symptomatology (Marvan et al., 1998, Marvan and Escobedo, 1999), as well as attitudes and expectations concerning the reproductive cycle (Bancroft, 1995, Choi and McKeown, 1997, Reilly and Kremer, 1999, Marvan and Cortes-Iniestra, 2001, Woods et al., 1998) and towards the female role (Berry and McGuire, 1972, Reid and Yen, 1981).

The role of stress has also been implicated in the background of premenstrual disorders (Deuster et al., 1999). A retrospective study of life events indicated that lifetime stressors exert a cumulative influence on premenstrual symptomatology (Beck et al., 1990) while other studies emphasise the role of daily stress. It has also been suggested that how stressful a life event is perceived is also related to cycle phase, since both self-reported stress, and neuroendocrine markers for stress increased in the premenstrual period although the events were equally stressful in all phases of the cycle (Woods et al., 1998, Woods et al., 1982, Woods et al., 1985, Beck et al., 1990, Matteo, 1987, Collins et al., 1985, Kirsh and Greer, 1988). According to another study, during the luteal phase of the cycle the number of life events perceived negative is significantly higher in premenstrual syndrome compared to controls, and within the cycle, in premenstrual syndrome patients there was significantly more negatively perceived and less positively perceived life events in the luteal phase compared to the follicular phase (Schmidt et al., 1990). These suggest a state-dependent fluctuation of perception of life events influenced by reproductive cycle phase. In another study it was concluded that women suffering from premenstrual syndromes are especially sensitive towards the negative effects of stressful life events (Barnhart et al., 1995). Therefore it seems likely that premenstrual syndromes are associated with the effects of life events and inner and outer stressors, however, it seems to play a greater role how a given potentially stressful event is perceived. It has also been described that life events can modify how the symptoms are experienced (Schmidt et al., 1990).

From the evidence above it appears that there is a strong relationship between life events and premenstrual symptoms. Studies so far concentrated on the state-dependent perception of life events associated with menstrual cycle phase. However, it is also possible that there is a trait-like bias in the perception of life events in women suffering from premenstrual symptoms, which makes them more prone to interpreting the detected neutral physiological changes accompanying their reproductive cycle as negative. In this case, this trait-like bias is observable throughout the whole menstrual cycle, that is, in the symptom-free follicular phase as well.

We hypothesise that women reporting more severe premenstrual symptoms exhibit a marked negative bias in the perception of events, therefore they perceive the neutral changes accompanying the menstrual cycle as negative leading to more distress. The aim of our study was to investigate the association between the follicular-phase perception of life events and late-luteal phase mood and physical symptoms in a sample of healthy women not meeting diagnostic criteria for any premenstrual disorders.

Section snippets

Methods

88 healthy women were included in our sample. The participants were aged between 18 and 45 years, with a mean age of 27.1 (SD = 5.5) years. Participants were university students or university graduates. The sample was recruited from universities and from workers of the National Institute for Psychiatry and Neurology, Budapest. All participants went through thorough physical and psychiatric examination, and only healthy subjects were included in the sample. None of our participants met DSM-IV

Results

The total PRISM score change showed a significant negative association with the number of positive subjective life events (PS, p = 0.04, n = 88) and the ratio of positive subjective life events (RELPS, p = 0.02, n = 88). The total change of the PRISM score showed a significant positive association with the ratio of negative subjective life events (RELNS, p = 0.05, n = 88). A standard deviation unit increase in RELNS was associated with the increase of PRISM total score (RC = 1.23 [95% CI: 1.00–1.51]). The

Discussion

We found a significant negative association between the ratio of positive subjective life events (relative to all reported life events) and magnitude of symptom change from the late-follicular to the late-luteal phase of the female reproductive cycle. This indicates that the higher the increase in symptoms from the late-follicular to the late-luteal phase, the less likely the person is to perceive subjective positive life events. Parallel to this, we also found a significant positive

Conclusions

According to our results there appears to be trait-like bias towards the perception of negative subjective life events in psychiatrically healthy, non-PMDD women who report more physiological and psychological changes towards the late-luteal phase of the female reproductive cycle. This perceptional bias may play an important role in the development of menstrual cycle-associated psychiatric conditions such as premenstrual syndrome or premenstrual dysphoric disorder. This trait-like tendency

Declaration of interests

Dr. Rihmer is a member of the speakers bureaus or advisory boards of AstraZeneca, BMS, Egis, GSK, Lundbeck, Lilly, Organon, Pfizer, Richter, Schering-plough, Sanofi-Aventis and Servier. Dr. Gonda has received travel grants from Richter, GSK, Lilly, Krka, Organon and Schering-Plough. Dr. Telek is an employee of MSD. Dr. Fountoulakis is a member of the International Consultation Board of Wyeth for desvenlafaxine and Servier for agomelatine and has received honoraria for lectures from AstraZeneca,

Acknowledgement

These studies were supported by the Sixth Framework Programme of the EU, LSHM-CT-2004-503474.

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