Case: Premenstrual Dysphoric Disorder

Zephyrr is a 42-year-old married woman, unemployed, with a history of three major depressive episodes.
Over the last two years, she had complained of emotional instability, irritability, anxiety, low self-esteem,
overvalued ideas of guilt, insomnia, sweet craving, poor concentration and difficulties coping with her
work. The symptoms tended to recur in a predictable manner every two weeks and had a negative impact
on her relationship with her husband. One year before, she was cut off from work because of impaired
concentration and poor social interactions. She was diagnosed with rapid-cycling BD and put on lithium
600 mg per day. No improvement was noticed during the six-month treatment period. She was referred to
a clinic and was evaluated every 2 weeks for a period of 2 months. At the second visit, she presented with
identical affective symptoms but with many accompanying somatic complaints, such as breast tenderness
and swelling, abdominal bloating, hot/cold flashes, and swelling of the extremities unnoticed during the
previous 2 years.

Zephyrr was assessed with the Premenstrual Screening Scale and was diagnosed with PMDD. On the
following two visits she was reevaluated during the follicular and luteal phase and the diagnosis was
prospectively confirmed. Since the patient refused any kind of treatment for PMDD, she suffered a major
depressive episode, and treatment with escitalopram 20 mg was initiated. Six weeks later the severity of
depressive symptoms significantly decreased and after another 2 months the patient was free of PMDD
and MDD symptoms. Retrospectively, the patient recognized PMDD symptoms as more distressing and
disabling than the MDD complaints, which she had identified as known and treatable.

DSM 5 criteria [Signs and Symptoms]:

Manifested Symptoms Diagnostic Criteria Based on DSM-V-TR

● Zephyrr has a history of three major ● A. In the majority of menstrual cycles,

depressive episodes. at least five symptoms must be
● For the last two years, Zephyrr had present in the final week before the
complained of emotional instability, onset of menses, start to improve
irritability, anxiety, low self-esteem, within a few days after the onset of
overvalued ideas of guilt, insomnia, sweet menses, and become minimal or
craving, poor concentration and difficulties absent in the week postmenses.
coping with her work. — The symptoms tended to recur in a predictable
● The symptoms tended to recur in a manner every two weeks and had a negative
predictable manner every two weeks and impact on her relationship with her husband.
The patient recognized PMDD symptoms as more
had a negative impact on her relationship
distressing and disabling than the MDD
with Zephyrr’s husband.
complaints, which she had identified as known
● One year before, Zephyrr was cut off from
and treatable.
work because of impaired concentration
and poor social interactions. Zephyrr was
diagnosed with rapid-cycling BD and put
● B. One (or more) of the following
symptoms must be present:
on lithium 600 mg per day.
● Every 2 weeks for a period of 2 months.
3. Marked depressed mood, feelings of
At the second visit, Zephyrr presented
hopelessness, or self-deprecating
 with identical affective symptoms but with thoughts.
many accompanying somatic complaints, 4. Marked anxiety, tension, and/or feelings of
such as breast tenderness and swelling, being keyed up or on edge.
abdominal bloating, hot/cold flashes, and — The symptoms tended to recur in a predictable
swelling of the extremities unnoticed manner every two weeks and had a negative
during the previous 2 years. impact on her relationship with Zephyrr’s husband.
● Zephyrr suffered a major depressive
episode, and treatment with escitalopram
● C. One (or more) of the following
20 mg was initiated. Six weeks later the
symptoms must additionally be
severity of depressive symptoms
present, to reach a
significantly decreased and after another
total of five symptoms when combined with
2 months Zephyrr was free of PMDD and
symptoms from Criterion B above.
MDD symptoms. 2. Subjective difficulty in concentration.
— One year before, Zephyrr was cut off from work
because of impaired concentration and poor social
interactions.

7. Physical symptoms such as breast

tenderness or swelling, joint or muscle
pain, a sensation of “bloating,” or weight gain.
Note: The symptoms in Criteria A–C must
have been met for most menstrual
cycles that occurred in the preceding year.
— Every 2 weeks for a period of 2 months. At the
second visit, Zephyrr presented with identical
affective symptoms but with many accompanying
somatic complaints, such as breast tenderness
and swelling, abdominal bloating, hot/cold flashes,
and swelling of the extremities unnoticed during
the previous 2 years.

● D. The symptoms cause clinically

significant distress or interference with
work,
school, usual social activities, or relationships
with others (e.g., avoidance of
social activities; decreased productivity and
efficiency at work, school, or home).
— For the last two years, Zephyrr had complained
of emotional instability, irritability, anxiety, low self-
esteem, overvalued ideas of guilt, insomnia, sweet
craving, poor concentration and difficulties coping
with her work.

● E. The disturbance is not merely an

exacerbation of the symptoms of
another
 disorder, such as major depressive disorder,
panic disorder, persistent
depressive disorder, or a personality disorder
(although it may co-occur with any
of these disorders).
— Zephyrr has a history of three major
depressive episodes.

● F. Criterion A should be confirmed by

prospective daily ratings during at
least two
symptomatic cycles. (Note: The diagnosis
may be made provisionally prior to
this confirmation.)
— On the following two visits she was reevaluated
during the follicular and luteal phase and the
diagnosis was prospectively confirmed.

● G. The symptoms are not attributable

to the physiological effects of a
substance
(e.g., a drug of abuse, a medication, other
treatment) or another medical
condition (e.g., hyperthyroidism).
— She was diagnosed with rapid-cycling BD and
put on lithium 600 mg per day. No improvement
was noticed during the six-month treatment
period.

FACTORS/CONTRIBUTIONS
BIOLOGICAL- Genetics, stress, and other psychosocial variables, as well as the central
nervous system's (CNS) sensitivity to reproductive hormones, are possible biological
contributors. The timing of PMDD symptom onset and offset points to hormone fluctuation as a
major pathophysiological factor. It might be an aberrant response to the regular fluctuations in
hormones that occur with every menstrual cycle. A serotonin shortage may result from the
hormonal changes. Serotonin is a chemical that occurs naturally in the gut and brain. It narrows
blood vessels, alters mood, and can have physical effects.

PSYCHOLOGICAL- PMS/PMDD is closely correlated with psychological variables such as

neuroticism, coping mechanisms, and perceived stress. It is improbable that this association
results from misclassification bias or confounding. Mood swings are one of the symptoms that a
woman with PMDD may encounter. depressive, dysphoric, or hopeless feelings. intense rage
and interpersonal conflict. One extremely severe form of premenstrual syndrome is called
premenstrual dysphoric disorder (PMDD) (PMS). Every month, it produces a variety of physical
and emotional symptoms in the week or two leading up to your period. 'Severe PMS' is another
term for it.

SOCIAL- Abuse, sexism, and poverty are examples of social factors. PMDD and depression
brought on by a time of poverty are closely related. The effectiveness of PMDD treatment may
be lowered by sexism. The most severe type of early life trauma is emotional abuse. Although
the precise causes of PMDD are still unknown, researchers think that sensitivity to fluctuations
in hormone levels is the primary cause. According to recent research, PMDD may be linked to
heightened sensitivity to the regular hormonal shifts that take place throughout your menstrual
cycle each month.

EMOTIONAL- The following emotional symptoms meet the diagnostic criteria for PMDD: a
pronouncedly depressed mood, a hopeless feeling, or self-deprecating thoughts. An endocrine
disorder, or disorder related to hormones, is the common definition of PMDD. In addition to
physical symptoms, individuals with PMDD may also have a variety of mental health symptoms,
including anxiety, depression, and suicidal thoughts. "Stress, whether emotional, nutritional, or
physical, can cause an increase in endorphins and cortisol secretion which interrupt hormone
production,” explained Jalloul (2022) specialist with UT Physicians. “This can lead to an
abnormal menstrual cycle."

Case formulation [BioPsychSocial]:

Factors Biological Physiological Social

Predisposing ● Zephyrr’a ● Abuse,

● Zephyrr’s mood swings sexism, and
genetics, are one of the poverty are
stress, and symptoms examples of
that a woman social factors.
other
with PMDD PMDD and
psychosocial may depression
variables, as encounter. brought on by
well as the depressive, a time of
central dysphoric, or poverty are
nervous hopeless closely
system's feelings. related. The
intense rage effectiveness
(CNS)
and of PMDD
sensitivity to interpersonal treatment may
reproductive conflict. be lowered by
hormones, are sexism.
possible Zephyrr may
 biological have the most
contributors. severe type of
early life
trauma is
emotional
abuse.

Precipitating ● The timing of ● PMS/PMDD is ● The precise

PMDD closely causes of
symptom correlated PMDD are still
onset and with unknown,
offset points psychological researchers
to hormone variables such think that
fluctuation as as sensitivity to
a major neuroticism, fluctuations in
pathophysiolo coping hormone
gical factor. It mechanisms, levels is the
might be an and perceived primary
aberrant stress. It is cause.
response to improbable According to
Zephyrr’s that this recent
regular association research,
fluctuations in results from PMDD may
hormones that misclassificati be linked to
occur with on bias or heightened
every confounding sensitivity to
menstrual on Zephyrr. the regular
cycle. hormonal
shifts that take
place
throughout
your
menstrual
cycle each
month.

Perpetuating ● Severe ● PMDD ● Perceived

anxiety, symptoms discrimination
depression, start a week can be
and mood before harmful,
swings are menstruation particularly for
also brought and go away women from
on by PMDD. a few days ethnic
Some PMDD after your minorities. .
sufferers period begins.
develop Daily tasks
suicidal are disrupted
thoughts. by these
Symptom symptoms
 relief is ● Women with
possible with PMDD
hormonal birth experience
control and such severe
antidepressan symptoms
ts. that they find
● Bloating, it difficult to
headaches, function in
and breast relationships,
tenderness at work, and
are PMS at home
symptoms during this
that people time.
with Compared to
premenstrual other times
dysphoric during the
disorder month, this is
(PMDD) noticeably
experience in different.
the weeks
leading up to
their period.

Protective ● Your doctor ● PMDD is a The

will assess chronic, effectiveness
your serious illness of PMDD
symptoms that requires treatment may
and obtain a medical be lowered by
medical attention. The sexism. The
history. It severity of most severe
might be PMDD type of early
necessary to symptoms life trauma is
monitor your may be emotional
symptoms for lessened or abuse. There
one or two relieved by is a strong
menstrual using some of correlation
cycles. the following between
● The doctor will treatment PMDD and
look for five or strategies: the four
more PMDD — diet adjustments to factors:
symptoms, reduce sugar, salt, abuse,
including one alcohol, and caffeine sexism,
symptom and increase protein poverty, and
related to and carbs discrimination.
mood, in order — frequent physical ● The article
to diagnose activity urges people
PMDD. The — control of stress to learn about
doctor will — supplements PMDD and to
identify or rule containing vitamins treat women
out additional (like calcium, who have it
 illnesses like magnesium, and fairly, if not
depression, vitamin B6) with greater
anxiety, or —medications that respect.
reproductive reduce inflammation
issues. — serotonin reuptake
inhibitors that are
selective (SSRI)
— birth control tablets

References:

Pre-menstrual
https://intapi.sciendo.com/pdf/10.2478/jbcr-2020-0021