Premenstrual Dysphoric Disorder
Kristina Conner, ND
I’ve reached an interesting point in my career, becoming no longer enamored of diagnosing. Perhaps I have done it enough to realize the shortcomings of our diagnosis system. As I mature in my practice and revisit information to teach classical naturopathic medicine to students, I rediscover the importance of a naturopathic orientation.
I share this to explain my point of reference on the topic for this article. This is a process I find myself doing often now – analyzing a conventional diagnosis to find the value in it that can be applied to naturopathic patient management. My intent is to revise, rather than oppose, the process of diagnosis.
Premenstrual dysphoric disorder (PMDD) was first recognized as a separate diagnosis in 1987, and was included in the 1994 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) appendix (DiGiulio and Reissing, 2006). Before this, symptoms of PMDD were considered a subset of premenstrual syndrome (PMS) – in fact, the most severe expression of PMS. Prevalence of PMS is reported from 53% in some studies to as high as 95% in others (Tabassum et al., 2005; Takeda et al., 2006), while PMDD prevalence is reported at 5.8% to 8% (Wittchen et al., 2002; Angst et al., 2001).
What advantage does creating a separate diagnosis for PMDD have for conventional practitioners? It allows a diagnosis code. It justifies the usage of medications that NDs would consider suppressive. In contrast to the non-steroidal anti-inflammatory drugs (NSAIDS) and oral contraceptives used to treat PMS, first- and second-line medications such as selective serotonin reuptake inhibitors (SSRIs) and anxiolytics are the standard for treatment of PMDD. SSRI dosing can be continuous (throughout the cycle) or intermittent (luteal phase only), based on symptoms, compliance, tolerability and patient choice (Steiner and Born, 2000; Steiner et al., 2006). Last-resort therapies include pharmaceutical suppression of ovarian function with a gonadotropin-releasing hormone agonist and surgical ovariectomy. Yet, treatment efficacy with conventional medical treatment is less than 60% (Halbreich et al., 2006).
For NDs, what advantage does the diagnosis of PMDD have? We are less concerned with finding the correct International Classification of Disease (ICD) coding for a disorder. Since we consider an individual before a diagnosis, does it matter whether we give the correct name to the patient’s dysfunction? I would put forth that there is value in looking at this disorder another way. By considering PMDD as a separate entity from PMS, we use the somewhat artificial separation of diagnosis to maintain a true naturopathic focus. I believe we can uncover more about treating this condition using a naturopathic approach, resulting in higher treatment efficacy than an allopathic approach.
What is Different About PMDD?
First, we need to scrutinize the criteria for diagnosis (see the accompanying list). The locus of dysfunction is in the psychiatric, rather than the physical, realm. Gamma-aminobutyric acid (GABA) levels are decreased in women with PMDD, accounting for food cravings and mood disorders at a higher rate than with PMS. Women with PMDD have more fluctuations in their serotonergic function; it is higher during the follicular phase and lower during the luteal phase than women with or without PMS (Inoue et al., 2007). But there is no recognized abnormal ovarian function (Steiner et al., 2006); this is more of a disorder in processing the information that is received.
In contrast, if we were to consider PMDD as simply the most severe expression of PMS, it becomes easy to warrant the usage of natural (yet still suppressive) therapies. The stronger the disorder, the stronger the therapy used. A naturopathic approach might be to prescribe natural hormones and Hypericum instead of oral contraceptive pills (OCPs) and fluoxetine; but this need not be the case. By taking a fresh look at the patient’s condition, we can treat her according to the naturopathic hierarchy.
Restoration of the determinants of health (exercise, hydration, sleep, air, light, nutrition, etc.) would be primary in guiding the patient to health. In fact, there already is some evidence that this is an effective strategy. Light therapy was effective in reducing PMDD symptoms: In one study, 10,000lux cool-white fluorescent light for 30 minutes each evening was the protocol (Lam et al., 1999). There may be an increased incidence of PMDD among women with Seasonal Affective Disorder (Praschak-Rieder et al., 2001). Relaxation treatment has also been shown to be effective for physical and emotional symptoms of PMS (Goodale et al., 1990). One study concludes that qi therapy may be an effective complementary therapy for PMS (Jang and Lee, 2004).
From a naturopathic perspective, we consider this a deeper pathology than PMS, involving primarily the emotional, mental and sometimes spiritual levels. Therefore, we should consider a primary treatment strategy of stimulating the Vis Medicatrix Naturae, because that will reach the deeper level of pathology. Non-specific stimulation with hydrotherapy, followed by specific stimulation with homeopathy or acupuncture, could be the foundation of naturopathic treatment. These therapies alone will accomplish some fundamental tasks: soothe and restore the nervous system, relieve tension, stimulate the Vis, regulate internal organ function and decrease edema.
Weakened systems in PMDD include psychological and neurological. There are numerous options to strengthen these areas, several of which already have been investigated. Cognitive behavioral therapy (CBT) is effective in decreasing the distress of PMDD (Christensen and Oei, 1995). In fact, CBT was just as effective as fluoxetine, with better maintenance rates (Hunter et al., 2002). Increased carbohydrate consumption pre-menstrually increases tryptophan and, therefore, serotonin. Tryptophan at a dosage of 6g daily during the luteal phase was found to be effective for PMDD. It reduced symptoms of dysphoria, mood swings, tension and irritability by 34% (Steinberg et al., 1999). B vitamins, particularly B6, are another possible therapeutic that may be effective in PMDD, since we have evidence that they are beneficial for mood disorders. However, inositol, effective for disorders such as depression and bulimia, was not shown to be effective for PMDD at a dosage of 12g daily (Nemets et al., 2002). In addition, chiropractic manipulation with soft tissue therapy may be effective, allowing the correction of structural integrity (Walsh and Polus, 1999).
Using specific natural therapeutics is the final step we might employ in the naturopathic realm. Vitex agnus-castus was shown to be as effective as fluoxetine for PMDD, although more women reported relief of physical symptoms with Vitex and relief of emotional symptoms with fluoxetine (Atmaca et al., 2003). Vitex has been shown in other studies to be effective for treatment of PMS (Schellenberg, 2001; Berger et al., 2000). Given its comparability in effectiveness to fluoxetine and other SSRIs for mood disorders (Behnke et al., 2002; Woelk, 2000), Hypericum perforatum would be another reasonable therapeutic, despite the lack of any specific evidence that it is effective for PMDD. With any natural therapeutic, special attention should be made to the timing of administration. Unlike pharmaceutical management for depression and related mood disorders, PMDD tends to show rapid improvement, efficacy with intermittent dosing and sufficient response with low dosage of an SSRI (Steiner et al., 2006). If we draw the same parallel for using herbs to restore function, it seems likely that a lower dosage with administration only during the luteal phase is preferred.
Improving a woman’s PMDD symptoms may benefit her in the future. It is possible that a subset of women are susceptible to increased dysfunction during times of hormonal change, such as pre-menstrually, postpartum and peri-menopausally (Endicott et al., 1999). Looking at this in a general sense, it is likely that a common cause, once corrected, will result in improved balance in other related stages of reproductive life.
Rather than throwing out the baby with the bathwater, I think there is a way that we can make the often haphazard convention of assigning a diagnosis work for us, while still retaining a naturopathic orientation. Through analyzing PMDD, I hope that I have elucidated how this process can occur.
Kristina Conner, ND graduated from Bastyr University. She completed her residency at the University of Bridgeport College of Naturopathic Medicine, where she also served as clinical faculty and clinic coordinator. Following that, she had a private practice in Indiana. Dr. Conner is currently an instructor at the National University of Health Sciences in Lombard, Ill. She can be reached at firstname.lastname@example.org.
Marie was a 28-year-old, married Caucasian woman who had a primary concern of PMS. Her secondary concern was fatigue that overlapped with the PMS symptoms of depression, irritability, emotional lability, hyperinsomnia, difficulty concentrating, breast tenderness and bloating. These symptoms were present the week before her menses, with fatigue present through her cycle. The symptoms caused significant strain on her daily functioning and her relationship with her husband. Otherwise, their relationship was very good. These symptoms had been present since adolescence, worsening over time.
At the time, I considered a primary diagnosis of PMS and adrenal fatigue. Treatment included diet with less sugar and more protein and organic foods; sleep hygiene (seven to eight hours of sleep each night in a comfortable and dark room free of distractions, and consistent sleep/awake hours); regular, moderate exercise; B complex with 50mg B6 QD; adrenal support formula; and regular massage therapy. At the second visit, I also prescribed a Bach flower remedy – a combination of Aspen, Cerato, Hornbeam, Impatiens and Olive to be taken 5 drops 2-3 times a day or as needed.
In reviewing Marie’s case, I would certainly change my emphasis in approach. Keeping in mind the diagnosis for PMDD, I would still suggest sleep hygiene and massage for stress management. Continuing to address the determinants, I would be sure to include a prescription for mild daily outdoor exercise, such as Qigong. With nutrition, I would also include discussion about increasing complex carbohydrates pre-menstrually. Instead of prescribing the B complex initially, I would emphasize food sources instead. I would suggest a series of constitutional hydrotherapy treatments and a homeopathic remedy (or acupuncture) from the beginning. And I might consider Vitex orHypericum at a later date.
Diagnostic Criteria for PMDD
Five or more of the following (one of the first four must be present) present in most menstrual cycles during the past year, for most of the last week of the luteal cycle:
- Depressed mood or dysphoria
- Anxiety or tension
- Affective lability
- Persistent anger or irritability
- Decreased interest in usual activities
- Lethargy or marked lack of energy
- Marked change in appetite, overeating or food cravings
- Hyperinsomnia or insomnia
- Feeling overwhelmed
- Difficulty with concentration
- Other symptoms, such as abdominal bloating, breast tenderness, headaches or joint pain.
- Symptoms occur one week before menses and resolve in the first few days after menses begins
- Symptoms are severe enough to interfere with work, school, usual activities or interpersonal relationships
- Symptoms may be superimposed on an underlying psychiatric disorder, but may not be an exacerbation of another condition.
- These criteria must be confirmed by prospective daily charting for a minimum of two consecutive symptomatic menstrual cycles.
Source: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
Kristina Conner, ND graduated from Bastyr University. She completed her residency at the University of Bridgeport College of Naturopathic Medicine, where she also served as clinical faculty and clinic coordinator. Following that, she had a private practice in Indiana. Dr. Conner is currently an instructor at the National University of Health Sciences in Lombard, Ill.
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