Late
Luteal
Phase
Dysphoric
Disorder
Ana D. Rivera-Tovar,
Ph.D.,
The authors determined the prevalence oflate luteal phase dysphoric disorder in 21 7 university women aged 1 7-29 years. Unaware of the focus on premenstrual syndrome (PMS), the participants rated DSMIII-R symptoms oflate luteal phase dysphoric disorder over 90 days. Using a 30% or greater premenstrual change as an index of luteal variation, the authors found that 1 0 women (4.6%) met the symptom criteria during two menstrual cycles. Compared to 25 young women seeking treatment for PMS who met the same diagnostic criteria, the 1 0 women from the university
sample reported significantly concentration and somewhat and overall symptoms. (AmJ
less fatigue and impaired less severe depression
Psychiatry 1990; 147:1634-1636)
E
stablishing the prevalence of premenstrual syndrome (PMS) on the basis of existing data is difficult because of the 1) lack of agreement on the syndrome’s definition, 2) failure to differentiate premenstrual symptoms from a syndromal condition, and 3) past reliance on retrospective diagnoses in estimating prevalence rates. While depression and irritability are among the most common emotional manifestations of the condition (1, 2), researchers have not always focused on a similar subset of symptoms, and the lack of a common definition of PMS has led to disparate estimates of its occurrence, ranging from 20% (3) to 50% (4) of women. The recent inclusion of diagnostic criteria in the appendix to DSM-III-R, under the heading of Late Luteal Phase Dysphoric Disorder, has established guidelines for clinicians and researchers that can further systematic research in this area. Prevalence rates based on retrospective data are highly questionable, since approximately 50% of women who report histories of premenstrual changes fail to confirm these reports when they complete prospective daily ratings over several months (5). Only
Received March 9, 1990; accepted June 4, partment of Psychiatry, University of Pittsburgh and Western Psychiatric Institute and Clinic. quests to Dr. Rivera-Tovar, Western Psychiatric Rm. 820, Bellefield Towers, 38 1 1 O’Hara 15213-2593. Supported by Mental Health Clinical Research 30915 to Dr. Rivera-Tovar from NIMH. Copyright
1634
© 1990
American
Psychiatric
1990. From the DcSchool of Medicine, Address reprint reInstitute and Clinic, St., Pittsburgh, PA Center
Association.
grant
MH-
and
Ellen
in Young
Frank,
Women
Ph.D.
Haskett has used prospective ratings and a rigorous application of the DSM-III-R criteria in a community survey (R.F. Haskett, unpublished data, 1987). He found that late luteal phase dysphoric disorder occurred in only 3.4% of women of reproductive age. This estimate is quite different from earlier figures based on retrospective self-reports and needs to be substantiated by additional prospective epidemiological data. The average age at onset of the syndrome has also been subject to speculation, as PMS was once thought to be an affliction of women oven 30. Older women did in fact predominate in many study settings, such as gynecological outpatient clinics, which led to the belief that PMS was more common in mature women (6), despite studies that found no relationship between prevalence and age (7, Haskett). As yet, however, no prospective study has specifically examined the extent or nature of late luteal phase dysphonic disorder in younger women. In our investigation we evaluated this research question in a nonclinical sample, using a design intended to overcome several of the limitations of previous studies.
METHOD The subjects were 217 female university students fulfilling a research participation requirement for an introductory psychology course in which they were enrolled. Pregnant women, women taking oral contraceptives or any medication on a daily basis, and those with chronic health problems were excluded. The women ranged in age from 17 to 29 years (mean ±SD = 1 8.5 ± 1 .8), were predominantly Caucasian (94%, N=20S), and were regularly menstruating (cycles=21-3S days). Although an initial sample of 335 participated in symptom monitoring, the 84 women who supplied data on only one menstrual cycle and the 34 whose cycles were irregular (35 days) were not included in the final sample. Those women did not differ from the final sample on any demographic variable. The subjects were informed that the study was investigating the occurrence of emotional and physical changes in relation to life events in young women. Our interest in premenstrual symptoms was not disclosed at recruitment in order to 1) prevent biasing the sample toward women who believed they suffered menstrually
Am J Psychiatry
147:12,
December
1990
RIVERA-TOVAR
related problems and 2) reduce the possible tendency to respond according to stereotypic beliefs about the deleterious effects of menstruation on mood and performance (8). Eligible participants were asked to rate the occurrence of 33 physical and emotional symptoms (including DSM-III-R symptoms of late luteal phase dysphoric disorder) daily over 90 days using a 6-point rating scale, ranging from 1 (no symptom or change) to 6 (extreme change). The 90-day rating period was used to ensure the collection of data on at least two menstrual cycles. The self-report instrument (Daily Assessment Form) also asked the participants to indicate any significant life events, the use of alcohol or medication, and whether or not they were menstruating. The diagnosis of late luteal phase dysphoric disorder was determined by applying a rigorous percent-change criterion. Scores on the items on the Daily Assessment Form that corresponded to each of the 10 symptoms of the DSM-III-R criteria were summed and averaged over the 7 days before menses (premenstrual week) and the 7 days after the cessation of menses (postmenstrual week). For each symptom, the difference between the premenstrual average and the postmenstrual average (premenstrual minus postmenstrual) was divided by the postmenstrual average and expressed as percent change. A subject met the diagnostic criteria for a given cycle if the averages for at least five of the 10 symptom areas showed a 30% or greaten premenstrual increase in severity and if all postmenstrual averages were less than 3. In an attempt to exclude cases of chronic symptoms that were heightened premenstrually (premenstrual magnification), symptoms with a postmenstrual average score higher than or equal to 3 (signifying “mild” distress) were excluded. A positive diagnosis also required that at least one of the five symptoms be one of the first four symptoms listed in the DSM-III-R criteria (mood lability, irritability, anxiety, or depressed mood) and that the subject meet the criteria during at least two menstrual cycles. To determine the differences between women who do and do not seek treatment for PMS, we compared the symptoms of the undergraduates who met our syndrome criteria with those of a clinic sample of 25 women under age 30 with prospectively confirmed late luteal phase dysphonic disorder. Although similar in age range, the clinic women were significantly older than the undergraduate sample (mean ±SD = 25.4 ± 3.2 versus 18.5± 1.8; z=2.74, p=O.OO6, Mann-Whitney U test). The diagnoses for the clinic sample were derived with the same rating instrument and symptom criteria as those just outlined. Mann-Whitney U tests were used to compare the distributions and evaluate whether the treatment seekers’ symptoms were more severe than those of the undergraduate sample.
RESULTS In our sample of 217 female women (4.6%) met all the criteria
Am]
Psychiatry
147:12, December
undergraduates, for the diagnosis
1990
10 of
AND
FRANK
TABLE 1. Symptom Severity in Young Women With Late Luteal Phase Dysphoric Disorder Who Did or Did Not Seek Treatment Score
Assessment Treatment
University
Seekers Symptom
Mann-
Sample
(N=2S)
Premenstrual
on Daily Forma Whitney
(N=10)
U Test
Mean
SD
Mean
SD
z
p
Physical discomfort Depression Social withdrawal
2.52 2.76 2.00
0.9 1.1 1.0
2.17 2.15 1.98
0.7 0.7 0.8
-
-
-1.55
0.06
-
-
Irritability Fatigue Mood swings
3.13 3.10 3.15
1.2 1.2 1.3
2.65 2.35 2.82
1.0 0.7 1.0
-
-
Anxiety Concentration
2.89
1.2
2.62
0.9
-
-
3.00
1.2
2.15
0.7
-1.83
0.03
2.78 2.07 2.50 2.58
1.4 1.3 1.2 0.7
2.33 2.33 1.94 2.22
0.9 1.2 1.0 0.6
-
-
difficulties Increased Decreased Increased Total a1 =no
appetite sleep sleep symptom
or change,
6=extreme
-
-1.75
-
-1.28 -1.38
-
0.04
-
0.10 0.08
change.
late luteal phase dysphonic disorder. The mean age of these 10 women was 20.3±4.5 years. Nine reported mild premenstrual symptoms, and only one woman’s symptoms fell in the moderate-to-severe category (average premenstrual total of 4 on a 6-point scale). The premenstrual symptom severity ratings for the undergraduates and clinic sample are displayed in table 1. The young college women reported significantly less fatigue and concentration difficulties than the clinic women. In addition, there were nearly significant differences in depression, increased sleep, and overall premenstrual symptoms.
DISCUSSION
Our results indicate that late luteal phase dysphoric disorder, when strictly and carefully defined, is relatively rare; it was found in only 4.6% of the young college women we studied. This modest estimate is consistent with the 3.4% found by Haskett in a prospective epidemiological study of premenstrual changes among women of reproductive age in a cornmunity sample. This finding underscores the importance of using specific criteria to differentiate between premenstrual symptoms and the less common premenstrual syndrome. While isolated or minor premenstrual changes are reported by at least 75% of women (912), such cases do not signal the presence of a syndromal condition that may disrupt daily activities. Although college women may not be completely representative of the population of late adolescent and young adult women, our large sample, prospective ratings, rigorous diagnostic criteria, and blinding of subjects to our focus on the menstrual cycle reduced the bias inherent in earlier studies. The present findings, therefore, contradict previous indications that late
1635
LATE
LUTEAL
PHASE
DYSPHORIC
luteal phase dysphoric tion of women over criteria are used, the
DISORDER
disorder is primarily 30 and suggest that rate of PMS is quite
The finding that women
seeking
an when low.
afflicstrict
help for late luteal
phase dysphoric disorder had more severe depression, fatigue, impaired concentration, and overall symptoms than undergraduates who met the symptom criteria may be a direct result of selection factors, since help seekers would tend to be more debilitated by symptoms. An alternative hypothesis, however, is that the severity of symptoms increases over time, thus accounting for more severe symptoms in the somewhat older clinic sample. Longitudinal studies may be able to answer questions about the natural course of this cyclical disorder and examine whether women with a milder syndrome in late adolescence and early adulthood are at risk for increased distress in the future. If this pattern were demonstrated, early identification of
the syndrome ventive
and prompt
strategies
would
RF, Steiner delineation
2.
RF,
Haskett
1636
Abplanalp
M, Osmun JN, of the syndrome. JM:
4. S.
6.
7. 8.
syndrome:
Gynecology
Wetzel
Kessel N, symptoms. AuBuchon teristics.
9.
Wood
and
RD:
Fertility.
LG, Taylor
subjects.
Psychiatry
Premenstrual
Edited
PJ. Chicago,
affective
syn-
by LeventhalJM,
Year Book
Coppen A: The prevalence Lancet 1963; 2:61-64 P, Calhoun KS: Menstrual
the role of social
12.
tension
T, McClureJN,
of research
and psychiatric disorder. Dis Nerv Syst 1976; 37:116-119 Hargrove JT, Abraham GE: The incidence of premenstrual tension in a gynaecological clinic. J Reprod Med 1982; 27:721-724 Rubinow DR, Roy-Byrne P: Premenstrual syndromes: overview from a methodologic perspective. Am J Psychiatry 1984; 141: 163-172 Reid RL: Premenstrual syndrome, in Current Problems in Obman JJ, Keith lishers, 1985
et al: Severe premenstrual Biol Psychiatry 1980; 15:
Premenstrual
Kashiwagi
stetrics,
10.
of effective
criteria and selection 9:125-138
drome
pre-
initiation
be warranted.
REFERENCES
1. Haskett tension: 121-139
3.
diagnostic Res 1983;
Psychosom
C, Larsen
expectancy Med
of
common
cycle
L, Williams
Pub-
menstrual
symptomatology:
and experimental 1985;
Hoff-
Medical
demand
charac-
47:35-45
R: Menstrual
characteristics
2,343 women attending the Shepard Foundation. ObstetGynaecol 1979; 19:107-110 Lamb WM, Ulett GA, Masters WH, et al: Premenstrual
Aust
of
J
NZ tension:
EEG, hormonal, and psychiatric evaluation. Am J Psychiatry 1953; 109:840-848 1 1. Friedman D, Jaffe A: Influence of life-style on the premenstrual syndrome: analysis of a questionnaire survey. J Reprod Med 1985; 30:715-719 Johnson
SR,
strual symptoms history and 340-346
McChesney C, Bean in a non-clinical help-seeking behavior.
Am J Psychiatry
JA: Epidemiology of premensample, I: prevalence, natural
J Reprod
147:12,
Med
December
1988;
33:
1990
Luteal
Phase
Dysphoric
Disorder
Ana D. Rivera-Tovar,
Ph.D.,
The authors determined the prevalence oflate luteal phase dysphoric disorder in 21 7 university women aged 1 7-29 years. Unaware of the focus on premenstrual syndrome (PMS), the participants rated DSMIII-R symptoms oflate luteal phase dysphoric disorder over 90 days. Using a 30% or greater premenstrual change as an index of luteal variation, the authors found that 1 0 women (4.6%) met the symptom criteria during two menstrual cycles. Compared to 25 young women seeking treatment for PMS who met the same diagnostic criteria, the 1 0 women from the university
sample reported significantly concentration and somewhat and overall symptoms. (AmJ
less fatigue and impaired less severe depression
Psychiatry 1990; 147:1634-1636)
E
stablishing the prevalence of premenstrual syndrome (PMS) on the basis of existing data is difficult because of the 1) lack of agreement on the syndrome’s definition, 2) failure to differentiate premenstrual symptoms from a syndromal condition, and 3) past reliance on retrospective diagnoses in estimating prevalence rates. While depression and irritability are among the most common emotional manifestations of the condition (1, 2), researchers have not always focused on a similar subset of symptoms, and the lack of a common definition of PMS has led to disparate estimates of its occurrence, ranging from 20% (3) to 50% (4) of women. The recent inclusion of diagnostic criteria in the appendix to DSM-III-R, under the heading of Late Luteal Phase Dysphoric Disorder, has established guidelines for clinicians and researchers that can further systematic research in this area. Prevalence rates based on retrospective data are highly questionable, since approximately 50% of women who report histories of premenstrual changes fail to confirm these reports when they complete prospective daily ratings over several months (5). Only
Received March 9, 1990; accepted June 4, partment of Psychiatry, University of Pittsburgh and Western Psychiatric Institute and Clinic. quests to Dr. Rivera-Tovar, Western Psychiatric Rm. 820, Bellefield Towers, 38 1 1 O’Hara 15213-2593. Supported by Mental Health Clinical Research 30915 to Dr. Rivera-Tovar from NIMH. Copyright
1634
© 1990
American
Psychiatric
1990. From the DcSchool of Medicine, Address reprint reInstitute and Clinic, St., Pittsburgh, PA Center
Association.
grant
MH-
and
Ellen
in Young
Frank,
Women
Ph.D.
Haskett has used prospective ratings and a rigorous application of the DSM-III-R criteria in a community survey (R.F. Haskett, unpublished data, 1987). He found that late luteal phase dysphoric disorder occurred in only 3.4% of women of reproductive age. This estimate is quite different from earlier figures based on retrospective self-reports and needs to be substantiated by additional prospective epidemiological data. The average age at onset of the syndrome has also been subject to speculation, as PMS was once thought to be an affliction of women oven 30. Older women did in fact predominate in many study settings, such as gynecological outpatient clinics, which led to the belief that PMS was more common in mature women (6), despite studies that found no relationship between prevalence and age (7, Haskett). As yet, however, no prospective study has specifically examined the extent or nature of late luteal phase dysphonic disorder in younger women. In our investigation we evaluated this research question in a nonclinical sample, using a design intended to overcome several of the limitations of previous studies.
METHOD The subjects were 217 female university students fulfilling a research participation requirement for an introductory psychology course in which they were enrolled. Pregnant women, women taking oral contraceptives or any medication on a daily basis, and those with chronic health problems were excluded. The women ranged in age from 17 to 29 years (mean ±SD = 1 8.5 ± 1 .8), were predominantly Caucasian (94%, N=20S), and were regularly menstruating (cycles=21-3S days). Although an initial sample of 335 participated in symptom monitoring, the 84 women who supplied data on only one menstrual cycle and the 34 whose cycles were irregular (35 days) were not included in the final sample. Those women did not differ from the final sample on any demographic variable. The subjects were informed that the study was investigating the occurrence of emotional and physical changes in relation to life events in young women. Our interest in premenstrual symptoms was not disclosed at recruitment in order to 1) prevent biasing the sample toward women who believed they suffered menstrually
Am J Psychiatry
147:12,
December
1990
RIVERA-TOVAR
related problems and 2) reduce the possible tendency to respond according to stereotypic beliefs about the deleterious effects of menstruation on mood and performance (8). Eligible participants were asked to rate the occurrence of 33 physical and emotional symptoms (including DSM-III-R symptoms of late luteal phase dysphoric disorder) daily over 90 days using a 6-point rating scale, ranging from 1 (no symptom or change) to 6 (extreme change). The 90-day rating period was used to ensure the collection of data on at least two menstrual cycles. The self-report instrument (Daily Assessment Form) also asked the participants to indicate any significant life events, the use of alcohol or medication, and whether or not they were menstruating. The diagnosis of late luteal phase dysphoric disorder was determined by applying a rigorous percent-change criterion. Scores on the items on the Daily Assessment Form that corresponded to each of the 10 symptoms of the DSM-III-R criteria were summed and averaged over the 7 days before menses (premenstrual week) and the 7 days after the cessation of menses (postmenstrual week). For each symptom, the difference between the premenstrual average and the postmenstrual average (premenstrual minus postmenstrual) was divided by the postmenstrual average and expressed as percent change. A subject met the diagnostic criteria for a given cycle if the averages for at least five of the 10 symptom areas showed a 30% or greaten premenstrual increase in severity and if all postmenstrual averages were less than 3. In an attempt to exclude cases of chronic symptoms that were heightened premenstrually (premenstrual magnification), symptoms with a postmenstrual average score higher than or equal to 3 (signifying “mild” distress) were excluded. A positive diagnosis also required that at least one of the five symptoms be one of the first four symptoms listed in the DSM-III-R criteria (mood lability, irritability, anxiety, or depressed mood) and that the subject meet the criteria during at least two menstrual cycles. To determine the differences between women who do and do not seek treatment for PMS, we compared the symptoms of the undergraduates who met our syndrome criteria with those of a clinic sample of 25 women under age 30 with prospectively confirmed late luteal phase dysphonic disorder. Although similar in age range, the clinic women were significantly older than the undergraduate sample (mean ±SD = 25.4 ± 3.2 versus 18.5± 1.8; z=2.74, p=O.OO6, Mann-Whitney U test). The diagnoses for the clinic sample were derived with the same rating instrument and symptom criteria as those just outlined. Mann-Whitney U tests were used to compare the distributions and evaluate whether the treatment seekers’ symptoms were more severe than those of the undergraduate sample.
RESULTS In our sample of 217 female women (4.6%) met all the criteria
Am]
Psychiatry
147:12, December
undergraduates, for the diagnosis
1990
10 of
AND
FRANK
TABLE 1. Symptom Severity in Young Women With Late Luteal Phase Dysphoric Disorder Who Did or Did Not Seek Treatment Score
Assessment Treatment
University
Seekers Symptom
Mann-
Sample
(N=2S)
Premenstrual
on Daily Forma Whitney
(N=10)
U Test
Mean
SD
Mean
SD
z
p
Physical discomfort Depression Social withdrawal
2.52 2.76 2.00
0.9 1.1 1.0
2.17 2.15 1.98
0.7 0.7 0.8
-
-
-1.55
0.06
-
-
Irritability Fatigue Mood swings
3.13 3.10 3.15
1.2 1.2 1.3
2.65 2.35 2.82
1.0 0.7 1.0
-
-
Anxiety Concentration
2.89
1.2
2.62
0.9
-
-
3.00
1.2
2.15
0.7
-1.83
0.03
2.78 2.07 2.50 2.58
1.4 1.3 1.2 0.7
2.33 2.33 1.94 2.22
0.9 1.2 1.0 0.6
-
-
difficulties Increased Decreased Increased Total a1 =no
appetite sleep sleep symptom
or change,
6=extreme
-
-1.75
-
-1.28 -1.38
-
0.04
-
0.10 0.08
change.
late luteal phase dysphonic disorder. The mean age of these 10 women was 20.3±4.5 years. Nine reported mild premenstrual symptoms, and only one woman’s symptoms fell in the moderate-to-severe category (average premenstrual total of 4 on a 6-point scale). The premenstrual symptom severity ratings for the undergraduates and clinic sample are displayed in table 1. The young college women reported significantly less fatigue and concentration difficulties than the clinic women. In addition, there were nearly significant differences in depression, increased sleep, and overall premenstrual symptoms.
DISCUSSION
Our results indicate that late luteal phase dysphoric disorder, when strictly and carefully defined, is relatively rare; it was found in only 4.6% of the young college women we studied. This modest estimate is consistent with the 3.4% found by Haskett in a prospective epidemiological study of premenstrual changes among women of reproductive age in a cornmunity sample. This finding underscores the importance of using specific criteria to differentiate between premenstrual symptoms and the less common premenstrual syndrome. While isolated or minor premenstrual changes are reported by at least 75% of women (912), such cases do not signal the presence of a syndromal condition that may disrupt daily activities. Although college women may not be completely representative of the population of late adolescent and young adult women, our large sample, prospective ratings, rigorous diagnostic criteria, and blinding of subjects to our focus on the menstrual cycle reduced the bias inherent in earlier studies. The present findings, therefore, contradict previous indications that late
1635
LATE
LUTEAL
PHASE
DYSPHORIC
luteal phase dysphoric tion of women over criteria are used, the
DISORDER
disorder is primarily 30 and suggest that rate of PMS is quite
The finding that women
seeking
an when low.
afflicstrict
help for late luteal
phase dysphoric disorder had more severe depression, fatigue, impaired concentration, and overall symptoms than undergraduates who met the symptom criteria may be a direct result of selection factors, since help seekers would tend to be more debilitated by symptoms. An alternative hypothesis, however, is that the severity of symptoms increases over time, thus accounting for more severe symptoms in the somewhat older clinic sample. Longitudinal studies may be able to answer questions about the natural course of this cyclical disorder and examine whether women with a milder syndrome in late adolescence and early adulthood are at risk for increased distress in the future. If this pattern were demonstrated, early identification of
the syndrome ventive
and prompt
strategies
would
RF, Steiner delineation
2.
RF,
Haskett
1636
Abplanalp
M, Osmun JN, of the syndrome. JM:
4. S.
6.
7. 8.
syndrome:
Gynecology
Wetzel
Kessel N, symptoms. AuBuchon teristics.
9.
Wood
and
RD:
Fertility.
LG, Taylor
subjects.
Psychiatry
Premenstrual
Edited
PJ. Chicago,
affective
syn-
by LeventhalJM,
Year Book
Coppen A: The prevalence Lancet 1963; 2:61-64 P, Calhoun KS: Menstrual
the role of social
12.
tension
T, McClureJN,
of research
and psychiatric disorder. Dis Nerv Syst 1976; 37:116-119 Hargrove JT, Abraham GE: The incidence of premenstrual tension in a gynaecological clinic. J Reprod Med 1982; 27:721-724 Rubinow DR, Roy-Byrne P: Premenstrual syndromes: overview from a methodologic perspective. Am J Psychiatry 1984; 141: 163-172 Reid RL: Premenstrual syndrome, in Current Problems in Obman JJ, Keith lishers, 1985
et al: Severe premenstrual Biol Psychiatry 1980; 15:
Premenstrual
Kashiwagi
stetrics,
10.
of effective
criteria and selection 9:125-138
drome
pre-
initiation
be warranted.
REFERENCES
1. Haskett tension: 121-139
3.
diagnostic Res 1983;
Psychosom
C, Larsen
expectancy Med
of
common
cycle
L, Williams
Pub-
menstrual
symptomatology:
and experimental 1985;
Hoff-
Medical
demand
charac-
47:35-45
R: Menstrual
characteristics
2,343 women attending the Shepard Foundation. ObstetGynaecol 1979; 19:107-110 Lamb WM, Ulett GA, Masters WH, et al: Premenstrual
Aust
of
J
NZ tension:
EEG, hormonal, and psychiatric evaluation. Am J Psychiatry 1953; 109:840-848 1 1. Friedman D, Jaffe A: Influence of life-style on the premenstrual syndrome: analysis of a questionnaire survey. J Reprod Med 1985; 30:715-719 Johnson
SR,
strual symptoms history and 340-346
McChesney C, Bean in a non-clinical help-seeking behavior.
Am J Psychiatry
JA: Epidemiology of premensample, I: prevalence, natural
J Reprod
147:12,
Med
December
1988;
33:
1990
