Motivation and emotion/Book/2022/Menstrual cycle mood disorders

Overview
A mood disorder affects a persons general emotional state. They can distort an individuals mood and can make a persons mood inconsistent with their circumstances. This can interfere with their ability to function (Mayo Clinic, 2021.) Menstrual cycle mood disorders are mood disorders found in women, associated with or caused by their menstrual cycle. Menstrual cycles are associated with intense hormonal fluctuation that can cause vulnerabilities to depression and other symptoms commonly associated with mood disorders (Menstrually related mood disorders 2019).



There is no test to diagnose either Premenstrual Syndrome (PMS) or Premenstrual Dysphoric Disorder (PMDD). To be diagnosed with either disorder, a woman must have physical symptoms and mood changes prior to the onset of her menstrual period. Symptoms of PMDD can often be misdiagnosed as Bipolar in women due to similar symptoms being displayed. PMDD affects emotions and the fluctuation of hormones. Many women who experience PMDD may experience clinical levels of depression or anxiety. The severity of emotional symptoms that may be experienced in sufferers of PMDD can damage or interfere with the normal functioning of relationships. This mood disorder has clinical, biological and treatment characteristics that differ from other mood disorders (The Journal of Clinical Psychiatry 2000.)

It is important that these disorders are recognised, diagnosed and treated because the symptoms and side effects associated with menstrual cycle mood disorders can be crippling and cause everyday life disturbances that can grossly affect a woman in her everyday life. The symptoms of PMDD are both physical and mental in women can include depression, anxiety, loss of interest in activities, bloating, fatigue, overwhelming mood swings etc.

In this chapter, there is information regarding PMDD, what it is and how it is diagnosed, how PMDD differs from other mood disorders and how it impacts a woman's emotions. There is also be a case study about a woman with PMDD and how the diagnosis and treatment affected her life, and how it changed it. There is also sections to spread awareness and how important the future research surrounding PMDD will be for women. This chapter will focus on the main focus questions found below;

Focus questions:
 * What Menstrual Cycle Mood Disorders are there?
 * How are they diagnosed? How can they be treated?
 * How does PMDD differ from other mood disorders?
 * How does PMDD impact ones emotions?
 * What does future research look like for PMDD?

What are Menstrual Cycle Mood Disorders?
A mood disorder affects a persons general emotional state. They can distort an individuals mood and can make a persons mood inconsistent with their circumstances. This can interfere with their ability to function (Mayo Clinic, 2021.) Premenstrual Dysphoric Disorder is a mood disorder that causes mood changes and irritability that occurs during the premenstrual phase of a woman's menstrual cycle and go away with the onset of menses (Mayo Clinic, 2021.)

Menstrual Cycle Mood Disorders are mood disorders in women, associated with or caused by the menstrual cycle. Menstrual cycles are a period with intense hormonal fluctuation that can cause vulnerabilities to depression and other symptoms commonly associated with mood. The two most common mood disorders/syndromes associated with the Menstrual cycle are Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) which is a more 'severe' version of PMS. To find out more about the difference between PMS and PMDD you can visit this link https://youtu.be/OEF3CEky6WU. PMDD generally affects 5-10% of women in their reproductive years (Menstrually related mood disorders 2019.) Despite this number, many women still go undiagnosed, or worse misdiagnosed, generally with other mood disorders such as bipolar disorder.

Both of these disorders occur during one specific phase of the menstrual cycle; the 'luteal' phase. The luteal phase occurs after ovulation (when the ovaries release an egg), and before the period starts. The diagnostic criteria and symptoms associated with a diagnosis of PMDD can be found in the section below (Robert L Reid, 2017.)

Researchers at the National Institute of Health (NIH) have discovered that women with PMDD have an altered gene complex that processes the body's response to hormones and stress, these findings are important as they have structured a biological basis for the mood disturbances associated with PMDD (Harvard Health Publishing, 2017.)

With the current literature and future research, hopefully more awareness is spread of this disorder and will allow women who are diagnosed in the future to be treated and feel relief from the straining emotional and physical symptoms of PMDD. While there is some information with recent literature coming up, there is still more research that is underway for the future.

History of PMDD
First described in 1931 by a man called Robert Frank, this disorder was first named 'Premenstrual Tension Syndrome. Robert was the first person to produce and publish studies about this disorder. The name eventually changed to Premenstrual Syndrome, and then again to Late Luteal Phase Dysphoric Disorder (LLPDD). As it is currently known now as PMDD, It was first listed in the DSM-III as a Psychiatric Disorder and was then moved to the section requiring further study into the disorder. PMDD returned to the DSM-5 listed as a depressive disorder as a diagnosis approved for clinical use (Zachar & Kendler, 2015.) Today, PMDD research is still not well known about and there is a long way to go until people know more about the disorder and how it effects women, or even, what causes it. Future research and literature is up and coming and seems to be a hot topic for research at this point in time.

Treatment & Diagnosis
There are no current tests to diagnose PMDD. However, there is certain criteria according to the DSM V. The timing of the symptoms is vital to the diagnosis, PMDD can often be misdiagnosed as Bipolar Disorder due to the similarity of emotional symptoms presented. Table 1 shows some of the similarities of symptoms that can cause misdiagnosis, the symptoms are essentially identical and are often mistakenly confused with each other.

According to the diagnostic criteria in the DSM V; In the majority of menstrual cycles, at least 5 symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses. Symptoms can include;


 * Depressed, feelings of hopelessness, self depreciating thoughts.
 * Anxiety, tension, feeling on edge.


 * Decreased interest in usual activities.


 * Difficulty in concentration.
 * Lethargy, fatigue, lack of energy.
 * Change in appetite, overeating or specific food cravings.
 * Hypersomnia, Insomnia.
 * Feeling overwhelmed or out of control.
 * Physical Symptoms.

There are several treatment options available for PMDD. These treatment options help to relieve or decrease the severity of symptoms. Symptoms tend to be mainly psychological or emotional including depression, suicidal ideation, intense mood swings, lethargy, extreme sensitivity. Options for treatment that can help relieve these symptoms include:


 * SSRI Medications (fluoxetine, sertraline, citalopram, paroxetine) - These are the most common.
 * Anti Inflammatory Medication
 * Birth Control Medications
 * Stress Management
 * Regular Exercise

The severity of symptoms can differ between women, this condition is generally long lasting up until menopause. While there is no 'cure' for this disorder, medication will often suppress the physical and mental symptoms of the disorder to help, SSRI Medications (Anti Depressants) are the most common form of medication used for this disorder and are known to be the most useful in helping with symptoms. PMDD can also be treated with hormone treatments and in very rare cases, if recommended by a doctor, the removal of the ovaries. Talking therapy, such as Cognitive Behavioural Therapy is often used as the most popular form of talking therapy to help with emotional regulation and managing symptoms of PMDD. While PMDD can overlap with other mood disorders such as Major Depressive Disorder, it can differ from other mood disorders by being marked by a symptom-free period after menses begins and before ovulation (Pinkerton et al., 2010.)

Causes
Figure 1 shows some common causes of PMDD among women. These common causes include genetic predisposition, smoking, history of mood disorders, stress etc. There is also research to suggest that there is a genetic predisposition to this disorder however women with a history of a mood disorder are also more susceptible to having PMDD.

Is it PMS or PMDD, How can you tell?
While PMS symptoms include a combination of mood, behavioural and physical alterations prior to menstruation, most women do not report any major discomfort with PMS. The 5-8% of women who have PMDD experience debilitating symptoms that cause significant psychological stress and functional impairment. While they may have some similar symptoms, PMDD symptoms seem to be more debilitating on women than PMS. Most symptoms that women get with PMS compared to PMDD are more severe or extreme (WebMD, 2020.)

"My Periods make me Suicidal"
A YouTube video was posted by the BBC where they had interviewed 4,000 women with PMDD and showed their experiences living with PMDD and how it has affected their lives. The video stated it takes on average 12 years to be diagnosed with PMDD. Click on the link below to view this short video that allows people to hear these women's experiences with PMDD.

https://youtu.be/qNSiiRpy0pM

Facts & Figures

 * Women wait on average 12 years for an accurate diagnosis of PMDD.
 * On average women saw 6.15 providers before receiving a diagnosis of PMDD.
 * 90% of women with PMDD are thought to be undiagnosed.
 * 85% of Women with PMDD have thoughts of suicide.
 * 30% with PMDD have attempted suicide, compared to the 10% of women who have depression without PMDD.
 * About half of the women with PMDD report to losing an intimate partner due to PMDD.
 * 98% feel PMDD puts a strain on their intimate relationship.

Case Study
Elena Venturelli provided a case study based upon her own experience of being diagnosed with PMDD. In this case study she explains the up's and down's that come with a PMDD diagnosis. Find below a glimpse of her story and her experience with PMDD after being diagnosed and receiving proper treatment for her condition.

Elena was diagnosed in 2017 after years of feeling misunderstood. 50% more women than men are diagnosed with Bipolar Disorder. The explanation for this is that women with PMDD are often misdiagnosed due to the almost identical symptoms.

Elena stated that according to statistics from 'The Recovery Village' website, 30% of women with PMDD attempt suicide and you are 70% more likely to experience suicidal ideation if you are a woman with PMDD, compared to a woman without.

Elena tells of her experience admitting herself to the emergency department as she was considering suicidal. She mentioned that she thought her PMDD was the cause of this suicidal ideation. After a sleepless night she was seen by a doctor. The doctor told her she did not show sufficient sign of neither bipolar disorder nor borderline personality disorder, so she was sent home with some leaflets and crisis team numbers. Later that day Elena tried to jump out of a window due to her emotional distress and suicidal ideation.

Elena stated that according to statistics from 'The Recovery Village' website, 30% of women with PMDD attempt suicide and you are 70% more likely to experience suicidal ideation if you are a woman with PMDD, compared to a woman without.

After gaining a diagnosis and being able to get proper treatment, Elena saw a staggering improvement in her mental and physical health. (Venturelli, 2019.)

While there are few case studies available around this topic, the ones that are, are about spreading awareness around PMDD and how there is lack of information surrounding treatment and the misdiagnosis of this disorder, {{gr} Elena's case study is a great example of spreading awareness of such an important mood disorder that receives little attention.

PMDD and Emotion
PMDD is well known to cause problems with emotional regulation in women. Emotional regulation is very important as it gives people the ability to identify and influence which emotions a person feels and how these emotions are expressed and experienced. A study on emotional regulation in women with PMDD showed that there is a significant increase in behavioural impulsivity and greater difficulty in regulating emotions in socioemotional functioning (Petersen et al., 2016.) The study showed that women with PMDD struggled with emotional regulation. The women also exhibited evidence of behavioural impulsivity, impaired social connectedness and elevated stress. The results from the study were that Emotion Regulation Therapy has previously been proposed as an effective form of therapy that is adaptive to treating symptoms of PMDD (Petersen et al., 2016.)

How is PMDD treated in relation to Psychological Symptoms?
There are a few therapy treatment options when it comes to treating the psychological symptoms of PMDD and emotional regulation. Talking therapy seems to be the best option for supporting these women with their emotions and management of symptoms associated with PMDD. Cognitive Behavioural Therapy (CBT) is the most popular option for talking therapy. This has been shown to be the most effective form of therapy for managing symptoms of PMDD, specifically to do with regulating and managing emotions and finding ways that work for the person to deal with them to help in the future.

PMDD Awareness
Every year in April, PMDD awareness months is celebrated. There is fundraising and donating that occurs to help spread awareness of this disorder and to also fund for future research and treatment of this disorder. PMDD awareness month was started in the UK in 2013 by Cat Hawkins. Every year the event grows larger and more awareness is spread. People can get involved by taking the pledge to smash stigma around PMDD, Donate or fundraise to keep awareness and research going, or you can even post on Instagram or Facebook to spread awareness. The more information that we can share surrounding PMDD, the more aware people are going to be of this debilitating disorder. More people will be able to be diagnosed and access the help and treatment they need to live a long and non-debilitating life suffering from the symptoms of PMDD.

If you would like to read more information around PMDD awareness months, Please find the link below;

https://iapmd.org/pam-2021

Quiz
Test your knowledge on PMDD after reading the information in the chapter. Choose the correct answers and click "Submit": {Women with PMDD are 7 times at higher risk of suicide attempts than those without: + True - False
 * type=""}

{PMDD is common in every woman: - True + False
 * type=""}

{PMDD is commonly misdiagnosed as major depressive disorder: - True + False
 * type=""}

{PMDD symptoms occur during menses: - True + False
 * type=""}

{PMDD is commonly misdiagnosed as Bipolar Disorder: + True - False
 * type=""}

Conclusion
As menstrual mood disorders are only prevalent in 5-10% of women during their reproductive years, there is still a lot that is unknown about these mood disorders. As they are still being misdiagnosed, there is a lot of research still to be done to understand PMDD and the importance of the symptoms and the importance of it being diagnosed properly to receive proper treatment and awareness of this disorder.

This mood disorder has a large impact on a women's emotions which can cause severe emotional symptoms that play as a factor in being able to maintain functional relationships, this affects a woman's everyday life and creates severe emotional strain. With medication, specifically SSRI medications (Anti Depressants), talking therapy for emotional regulation, as well as physical activity to help regulate physical symptoms, symptoms both mental and physical can be suppressed which can provide temporary relief for people suffering from the debilitating effects of PMDD.

The importance of future research will enable women to find reason like Elena did in the case study presented in this chapter. Diagnosis enabled her to understand what was happening to her emotionally and then enabled her to find the treatment and the help to treat the severe symptoms of PMDD. Hopefully this chapter as well as explaining what PMDD is and how it can be managed, can help spread awareness and the importance of this disorder, as well as figuring out future treatment options expanding from what is current.

This area of mood disorders are still current in research, a frontiers article identified 2,833 publications from 1945 - 2018 (Gao et al., 2021.) With the literature and research in this area growing, PMDD is becoming more known and prevalent within young women of today and helping others spread awareness and gain an insight into the reality of this crippling mood disorder and the opportunities it brings for proper diagnosis and helpful treatment options. This disorder can no longer be dismissed as PMS, dismissing and ignoring this puts women at a disadvantage to accessing proper treatment and care. Research into this mood disorder also opens doors for more research into hormones and the way that menstrual cycles can affect a woman, especially with a disorder that perpetuates such intense emotions.