Journal of Affective Elsevier
129
Disorders, 20 (1990) 129-134
JAD 00750
Prevalence of axis I and axis II disorders in women with late luteal phase dysphoric disorder Teri B. Pearlstein, Ellen Frank, Ana Rivera-Tovar, Judith S. Thoft, Elizabeth Jacobs and T.A. Mieczkowski Healthsource
Premenstrual
Syndrome Program, Magee- Women’s Hospital and the University of Pittsburgh Pittsburgh, PA, U S.A.
Department
of Psychiatry,
(Received 9 January 1990) (Accepted 11 June 1990)
Summary The authors interviewed 78 female patients with late luteal phase dysphoric disorder and found a 78% lifetime prevalence of axis I disorders but only a 10% prevalence of axis II disorders. A prior depression was the predominant axis I disorder found, and 29% of parous patients had a prior postpartum depression. A comparison of Global Assessment Scale scores obtained at both the follicular and luteal phases of the menstrual cycle confirmed luteal increases in symptoms and role impairment.
Key words:
Late luteal phase dysphoric
disorder;
Introduction Understanding the existing literature about premenstrual syndrome has been confounded by the lack of established diagnostic criteria. Numerous studies have included samples of women with ‘ premenstrual syndrome’ whose diagnosis has not been confirmed by prospective, daily symptom charting over two menstrual cycles. Clinical studies suggest that as many as 40% of women claiming to suffer from premenstrual syndrome are not
Address for correspondence: Teri Pearlstein, M.D., Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, U.S.A. 0165-0327/90/$03.50
Premenstrual
syndrome;
Affective
disorder
prospectively confirmed (Endicott and Halbreich, 1982; Rubinow et al., 1984). For this reason, the criteria for late luteal phase dysphoric disorder (LLPDD) in Appendix A of DSM-III-R, which represents an attempt to standardize diagnostic criteria for premenstrual syndrome, require the prospective confirmation of the diagnosis by daily symptom charting over two menstrual cycles. Interpreting studies of premenstrual syndrome is further limited by the fact that there is as yet no widely used daily assessment measure of premenstrual symptoms or a widely used method of determining the presence of premenstrual syndrome from daily assessment measures. Commonly used daily self-report instruments include graphic visual analogue scales and daily symptom
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
130
checklists, in which the woman rates the severity of her symptoms. Some researchers compare a variable number of premenstrual days to a variable number of postmenstrual days. Premenstrual increases in symptom severity have been examined using a 30% change criterion (Rubinow et al., 1984; McMillan and Pihl, 1987). Other researchers compare a number of premenstrual days to the full menstrual cycle by effect size (Schurr, 1988) or spectral density analysis (Severino et al., 1989). Each statistical method attempts to detect premenstrual symptoms that are not merely exacerbations of symptoms present throughout the menstrual cycle. Little is known, however, about how women who meet such criteria compare to population norms in terms of the absolute severity of symptoms in either the luteal or the follicular phase. In spite of serious methodologic flaws in many clinical studies, a relationship between premenstrual syndrome and affective disorder has been suggested. Several investigators have found an increased prevalence of premenstrual symptoms by retrospective report in populations with affective disorder (Diamond et al., 1976; Kashiwagi et al., 1976; Endicott et al., 1981; Hurt et al., 1982). Lifetime prevalence of major depression was found to be 70% in 86 women with prospectively confirmed LLPDD (Harrison et al., 1989b), 76% in 52 women with prospectively confirmed premenstrual syndrome (Harrison et al., 1987) and 30% in 33 women with prospectively confirmed premenstrual mood disorder (DeJong et al., 1985). Some studies have examined treatment for depression and possible peripheral markers of depression in women with premenstrual syndrome. There have been reports of successful treatment of LLPDD patients with fluoxetine in a double-blind controlled trial (Stone et al., 1990) with nortriptyline in an open trial (Harrison et al., 1989a), and with evening bright light in a cross-over trial (Parry et al., 1989). There have also been reports of successful treatment of prospectively confirmed premenstrual syndrome patients with clomipramine in an open trial (Eriksson et al., 1990) and with sleep deprivation (Parry and Wehr, 1987). Three studies have examined peripheral markers of central neurotransmitter function in controlled studies of women with prospectively confirmed premenstrual
syndrome. Women with premenstrual syndrome were reported to have decreased luteal platelet serotonin (Ashby et al., 1988) and decreased luteal whole-blood serotonin (Rapkin et al., 1987). The former study reported increased luteal platelet monoamine oxidase activity, while another study found no phase difference in monoamine oxidase B activity (Rapkin et al., 1988). Axis I disorders other than depression may also be overrepresented in the premenstrual syndrome population. Lifetime axis I diagnoses were found in 81% of 123 women with premenstrual syndrome (Stout et al., 1986) and in 66% of 29 women with ‘moderate-severe peri-menstrual difficulties’ (MacKenzie et al., 1986). The high lifetime prevalence figures in these two studies are difficult to interpret because women without prospectively confirmed premenstrual syndrome were included. Subjects ‘diagnosed’ with premenstrual syndrome without prospective confirmation have been reported to have lifetime axis I prevalence figures as high as 88% (DeJong et al., 1985). The findings in these studies, therefore, may be due to psychopathology in the improperly ‘diagnosed’ group alone. No published study has examined the prevalence of specific axis II disorders in populations with premenstrual syndrome or LLPDD. Clearly, the relationship between LLPDD and other psychiatric disorders needs to be further elucidated by studying women selected using the LLPDD criteria and assessment requirements. We explored the prevalence of axis I and axis II psychiatric disorders in a consecutive series of women with prospectively confirmed LLPDD. We also assessed the severity of premenstrual symptomatology and role dysfunction in our sample by comparing Global Assessment Scale scores that were obtained at both follicular and luteal phases of the menstrual cycle. Methods Diagnosis
The diagnosis of LLPDD was determined by applying the 30% Change Criteria to the Daily Assessment Forms completed by each subject. The Daily Assessment Form was a 33-item symptom checklist developed by the authors to include items similar to the 10 symptoms found in the DSM-III-
131
R criteria for LLPDD. Eighteen of the 33 items were identical to items found on the Daily Rating Form (Endicott and Halbreich, 1982). Each item was rated using a scale from 1 for ‘no change’ or ‘no distress’ to 6 for ‘extreme change’ or ‘extreme discomfort’. The items or groups of items of the Daily Assessment Form that corresponded to each of the 10 symptoms of the DSM-III-R LLPDD criteria were summed and averaged over the 7 days before menses and the 7 days after the menses. Differences between premenstrual averages and postmenstrual averages were computed. The subject met criteria for LLPDD by 30% Change Criteria on a given cycle if the 7 day averages for at least five of 10 symptoms showed a 30% or greater premenstrual increase in severity and all postmenstrual average scores were less than 3. In an attempt to exclude ‘chronic symptomatology, symptoms with a postmenstrual average score greater than or equal to 3 (signifying at least ‘mild’ distress) were excluded. At least one of the five symptoms was required to be one of the first four symptoms listed in the DSM-III-R LLPDD criteria, i.e., affective lability, irritability, anxiety or depressed mood. Subjects Subjects were women who contacted the Healthsource Premenstrual Syndrome Clinic in Pittsburgh, PA, following physician referral or in response to media announcement. The Healthsource Premenstrual Syndrome Clinic offered careful diagnostic work-up, detailed assessment of other psychiatric parameters and both pharmacologic and non-pharmacologic treatment of premenstrual syndrome. Interested women were sent assessment packets that contained 90 Daily Assessment Forms and a medical clearance form to be completed by the woman’s gynecologist. The Daily Assessment Forms were returned by mail, and women who met LLPDD criteria for two cycles were offered entrance into the clinic. Follicular and luteal assessment interviews were then arranged. Women not meeting criteria for LLPDD were given appropriate referrals. The 97 women included in this report were aged 18-45, had regular menstrual cycles and were not regularly taking diuretics, psychoactive medications, hormones or oral contraceptives.
Measures The follicular interview was conducted during the subject’s postmenstrual week, and the luteal interview was scheduled to occur in the week preceding the next expected first day of menses. The actual date of menses was obtained to confirm that the luteal interview occurred in the premenstrual phase. The follicular interview involved collection of demographic data and a detailed gynecologic and general medical history. Two semi-structured interviews were conducted to identify psychiatric disorders. The Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer, 1978) elicited the presence of current and prior RDC psychiatric disorders. Because of the possible misdiagnosis of a long and severe episode of LLPDD as an episode of major or minor depression, a duration of greater than 1 month was required in order to make these diagnoses. A Global Assessment Scale score was obtained. The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) (Spitzer et al., 1987), administered as a combined self-report instrument and clinician interview, elicited the presence of DSM-III-R personality disorders. The luteal assessment involved a clinical interview and completion of the Global Assessment Scale. The luteal visit allowed the clinician to document clinically significant social or occupational impairment. Since there is no currently available means for distinguishing premenstrual exacerbation of existing disorders from LLPDD, women who met any axis I diagnosis within the prior 6 months were evaluated separately and excluded from subsequent data analyses. Results Ninety-seven women who met criteria for LLPDD on two cycles completed initial follicular and luteal assessment interviews. Despite our attempts to exclude women with current psychiatric diagnoses, both through telephone interview and through the application of the ‘no postmenstrual average greater than or equal to 3’ criterion on the Daily Assessment Forms, 19 (20%) of these 97 women were found to have current psychiatric disorders by SADS interview and were not in-
132
eluded in the subsequent analyses. The current RDC diagnoses found were intermittent depressive disorder (n = 9) generalized anxiety disorder (n = 4) major depression (n = 2) minor depression (n = l), phobic disorder (n = 2), schizophrenia (n = l), schizo-affective, depressed (n = l), alcoholism (n = 1) and drug abuse (n = 1). The 78 women without current axis I diagnoses were predominantly white (99%), in their early thirties (mean 33.5, SD 5.7), educated beyond high school (70%), married (70%) with children (63%) and employed in either full-time or part-time jobs (69%). Of the 78 subjects, 61 (78%) had at least one prior RDC-defined psychiatric disorder. A prior major depression was found in 36 (46%) subjects, while a prior major or minor depression was found in 54 (69%) subjects. Fewer subjects had a prior generalized anxiety disorder (n = 5), panic disorder (n = 3) phobic disorder (n = 3) alcoholism (n = 4) and drug abuse (n = 5). Fifteen (29%) of the 51 subjects with children had experienced a postpartum major or minor depression of greater than 1 month’s duration. Only one-tenth of subjects (n = 8) had a DSM-III-R personality disorder. These included avoidant personality disorder (n = 5), paranoid personality disorder (n = 2) and compulsive personality disorder (n = 1). Global Assessment Scale (GAS) mean scores were examined for the follicular versus luteal phases. Luteal GAS scores (X = 69.7) were significantly lower than follicular GAS scores (X = 84.9) (1 = 11.05, df = 70, P < O.OOOl), indicating increased symptomatology and functional impairment in the luteal phase. Discussion
This report examined the lifetime prevalence of axis I and axis II disorders in a relatively large sample size of women with LLPDD. The diagnosis of LLPDD was confirmed by prospective daily symptom recordings for two menstrual cycles and by clinical interviews at the follicular and luteal phases of the cycle. This is the first published report of the prevalence of specific axis II disorders in women with LLPDD. A prior major depression of at least 1 month’s duration was found in 46% of our 78 subjects with LLPDD. This result is consistent with earlier re-
ports of increased prevalence of prior affective disorder in women with premenstrual syndrome. The 46% lifetime prevalence of major depression in our sample is much higher than the 8% reported in the ECA community survey (Robins et al., 1984). Almost one-third of the mothers in our sample had a history of postpartum affective disorder. This figure is twice the prevalence of postpartum RDC-defined major or minor depression reported in a prospective study by O’Hara et al. (1984). As recently reviewed by Harding (1989) a prior affective disorder is consistently related to the incidence of postpartum depression. It is possible that the increased lifetime prevalence of postpartum depression in our mothers is primarily related to the increased prevalence of prior affective disorders in women with LLPDD. It is also possible that there is a specific relationship between postpartum depression and LLPDD. The lifetime prevalence figures of other axis I disorders (anxiety disorders, substance abuse disorders) in this sample of LLPDD patients are very similar to lifetime prevalence figures in community samples in the ECA studies (Robins et al., 1984). One-tenth of subjects had an axis II diagnosis, with avoidant personality disorder being the most common diagnosis. While the prevalence of axis II disorders in the general population is not known, a recent study found a prevalence of lo-20% of axis II disorders in a population of family members of patients and controls (Zimmerman and Coryell, 1989). Few studies exist that assess personality profiles in women with prospectively confirmed premenstrual syndrome. A recent review stresses the importance of evaluating personality characteristics in the follicular (asymptomatic) phase of the menstrual cycle (Severino and Moline, 1989). One study that administered the Eysenck Personality Inventory to women with prospectively confirmed premenstrual syndrome found neuroticism scores lower than those of women seeking treatment for premenstrual syndrome whose diagnosis was not confirmed by prospective ratings (Hammarback et al., 1989). A global diagnosis of personality disorder, as determined by the Personality Diagnostic Questionnaire - Revised, was not associated with a prospectively confirmed diagnosis of premenstrual syndrome or LLPDD (Eckerd et al., 1989).
133
These findings suggest that the prevalence of axis II disorders and of prior axis I disorders, other than affective disorder, is not elevated in women with LLPDD when compared to community samples. Future studies using a comparison group of menstruating women not seeking treatment for premenstrual syndrome could better explore the relationship between lifetime axis I and axis II disorders and LLPDD. Harrison et al. (1989b) recently demonstrated how difficult it is to obtain an appropriate comparison group. Their control subjects were women who responded to posted notices seeking subjects for studies of mood, behavior and physical condition during the menstrual cycle, but who did not have premenstrual syndrome after prospective assessment. Their finding of a 41% lifetime prevalence of major depression by SADS-L interview in this group supports the previous findings of DeJong et al. (1985) that women seeking treatment for premenstrual syndrome, but who are not prospectively confirmed, also have an elevated prevalence of major depression. Women coming for routine medical care might provide a better comparison group. The luteal Global Assessment Scale mean scores were significantly lower than follicular scores, reflecting clinician-observed increases in premenstrual symptomatology and role dysfunction in these women. The diagnosis of LLPDD must be confirmed by prospective daily symptom charting; however, the Global Assessment Scale can be used as an adjunct to assessing the degree of severity of LLPDD. The luteal Global Assessment Scale scores could also serve as an efficient way to monitor improvement after treatment. A limitation of the present report is that neither the clinicians nor the patients were blind to the menstrual cycle phase when Global Assessment Scale scores were determined. Ideally, a clinician blind to the woman’s cycle phase should determine the Global Assessment Scale score at follicular and luteal visits. In our experience, however, clinicians who interview women with LLPDD cannot be effectively blinded to cycle phase due to the marked difference in clinical presentation (including affect, motor behavior and physical appearance) between the follicular and lutea phases. Populations of women with LLPDD provide a
unique opportunity to explore the relationship between menstrually related affective changes and affective disorders. Questions which remain to be elucidated include (1) the temporal relationship among onset of LLPDD, onset of major depression and onset of postpartum depression in this population, and (2) whether there is one general predisposition to affective illness which makes women vulnerable to all three of these conditions or whether one condition might predispose a woman to either of the other two. References Ashby, C.R., Carr, L.A., Cook, C.L., Steptoe, M.M. and Franks, D.D. (1988) Alteration of platelet serotonergic mechanisms and monoamine oxidase activity in premenstrual syndrome. Biol. Psychiatry 24, 225-233. DeJong, R., Rubinow, D.R., Roy-Byrne, P., Hoban, M.C., Grover, G.N. and Post, R.M. (1985) Premenstrual mood disorder and psychiatric illness. Am. J. Psychiatry 142, 135991361. Diamond, S.B., Rubinstein, A.A., Dunner, D.L. and Fieve, R.R. (1976) Menstrual problems in women with primary affective illness. Compr. Psychiatry 17, 541-548. Eckerd, M.B., Hurt, S.W. and Severino, S.K. (1989) Late luteal phase dysphoric disorder: relationship to personality disorders. J. Pers. Disord. 3, 338-344. Endicott, J. and Spitzer, R.L. (1978) A diagnostic interview: the Schedule for Affective Disorders and Schizophrenia. Arch. Gen. Psychiatry 35, 837-844. Endicott, J. and Halbreich, U. (1982) Retrospective report of premenstrual depressive changes: factors affecting confirmation by daily ratings. Psychopharmacol. Bull. 18, 109112. Endicott, J., Halbreich, U., Schacht, S. and Nee, J. (1981) Premenstrual changes and affective disorders. Psychosom. Med. 43, 519-529. Eriksson, E., Lisjo, P., Sundblad, C., Andersson, K., Andersch, B. and Modigh, K. (1990) Effect of clomipramine on premenstrual syndrome. Acta Psychiatr. Stand. 81, 87-88. Hammarback, S., Backstrom, T. and MacGibbon-Taylor, B. (1989) Diagnosis of premenstrual tension syndrome: description and evaluation of a procedure for diagnosis and differential diagnosis. J. Psychosom. Obstet. Gynecol. 10, 25-42. Harding, J.J. (1989) Postpartum psychiatric disorders: a review. Compr. Psychiatry 30, 109-112. Harrison, W.M., Endicott, J., Rabkin, J.G., Nee, J.C. and Sandberg, D. (1987) Treatment of premenstrual dysphoria with alprazolam and placebo. Psychopharmacol. Bull. 23, 150-153. Harrison, W.M., Endicott, J. and Nee, J. (1989a) Treatment of premenstrual depression with nortriptyline: a pilot study. J. Chn. Psychiatry 50, 136-139. Harrison, W.M., Endicott, J., Nee, J., Glick, H. and Rabkin,
134 J.G. (1989b) Characteristics of women seeking treatment for premenstrual syndrome. Psychosomatics 30, 405-411. Hurt, S.W., Friedman, R.C., Clarkin, J., Corn, R. and Aronoff, MS. (1982) Psychopathology in the menstrual cycle. In: R.C. Friedman (Ed), Behavior and the Menstrual Cycle. Marcel Dekker, New York, NY, pp. 299-316. Kashiwagi, T., McClure, J.N. and Wetzel, R.D. (1976) Premenstrual affective syndrome and psychiatric disorder. Dis. Nerv. System 37, 116-119. MacKenzie, T.B., Wilcox, K. and Baron, H. (1986) Lifetime prevalence of psychiatric disorders in women with perimenstrual difficulties. J. Affect. Disord. 10, 15-19. McMillan, M.J. and Pihl, R.O. (1987) Premenstrual depression: a distinct entity. J. Abnorm. Psychol. 96, 149-154. G’Hara, M.W., Neunaber, D.J. and Zekoski, E.M. (1984) A prospective study of postpartum depression: prevalence, course and predictive factors. J. Abnorm. Psychol. 93, 158-171. Parry, B.L. and Wehr, T.A. (1987) Therapeutic effect of sleep deprivation in patients with premenstrual syndrome. Am. J. Psychiatry 144, 808-810. Parry, B.L., Berga, S.L., Mostofi, N., Sependa, P.A., Kripke, D.F. and Gillin, J.C. (1989) Morning versus evening bright light treatment of late luteal phase dysphoric disorder. Am. J. Psychiatry 146, 1215-1217. Rapkin, A.J., Edelmuth, E., Chang, L.C., Reading, A.E., McGuire, M.T. and Su, T. (1987) Whole-blood serotonin in premenstrual syndrome. Obstet. Gynecol. 70, 533-537. Rapkin, A.J., Buckman, T.D., Sutphin, M.S., Chang, L.C. and Reading, A.E. (1988) Platelet monoamine oxidase B activity in women with premenstrual syndrome. Am. J. Obstet. Gynecol. 159, 1536-1540.
Robins, L.N., Helzer, J.E., Weissman, M.M., Orvaschel, H., Gruenberg, E., Burke, J.D. and Regier, D.A. (1984) Lifetime prevalence of specific psychiatric disorders in three sites. Arch. Gen. Psychiatry 41, 949-958. Rubinow, D.R., Roy-Byrne, P., Hoban, M.C., Gold, P.W. and Post, R.M. (1984) Prospective assessment of menstrually related mood disorders. Am. J. Psychiatry 141, 684-686. Schurr, P.P. (1988) Some correlates of prospectively defined premenstrual syndrome. Am. J. Psychiatry 145, 491-494. Severino, S.K. and Moline, M.L. (1989) Psychological factors and the menstrual cycle. In: Premenstrual Syndrome: A Clinician’s Guide. Guilford Press, New York, NY, pp.7093. Severino, S.K., Hurt, SW. and Shindledecker, R.D. (1989) Spectral analysis of cyclic symptoms in late luteal phase dysphoric disorder. Am. J. Psychiatry 146, 1155-1160. Spitzer, R.L., Williams, J.B. and Gibbon, M. (1987) Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II, 3-l-87). Biometrics Research Department, New York State Psychiatric Institute, New York, NY. Stone, A., Pearlstein, T. and Brown, W. (1990) Fluoxetine in the treatment of premenstrual syndrome. Psychopharmacol. Bull. (in press). Stout, A.L., Steege, J.F., Blazer, D.G. and George, L.K. (1986) Comparison of lifetime psychiatric diagnoses in premenstrual syndrome clinic and community samples. J. Nerv. Ment. Dis. 174, 517-522. Zimmerman, M. and Coryell, W. (1989) DSM-III personality disorder diagnoses in a nonpatient sample: demographic correlates and comorbidity. Arch. Gen. Psychiatry 46, 682689.
129
Disorders, 20 (1990) 129-134
JAD 00750
Prevalence of axis I and axis II disorders in women with late luteal phase dysphoric disorder Teri B. Pearlstein, Ellen Frank, Ana Rivera-Tovar, Judith S. Thoft, Elizabeth Jacobs and T.A. Mieczkowski Healthsource
Premenstrual
Syndrome Program, Magee- Women’s Hospital and the University of Pittsburgh Pittsburgh, PA, U S.A.
Department
of Psychiatry,
(Received 9 January 1990) (Accepted 11 June 1990)
Summary The authors interviewed 78 female patients with late luteal phase dysphoric disorder and found a 78% lifetime prevalence of axis I disorders but only a 10% prevalence of axis II disorders. A prior depression was the predominant axis I disorder found, and 29% of parous patients had a prior postpartum depression. A comparison of Global Assessment Scale scores obtained at both the follicular and luteal phases of the menstrual cycle confirmed luteal increases in symptoms and role impairment.
Key words:
Late luteal phase dysphoric
disorder;
Introduction Understanding the existing literature about premenstrual syndrome has been confounded by the lack of established diagnostic criteria. Numerous studies have included samples of women with ‘ premenstrual syndrome’ whose diagnosis has not been confirmed by prospective, daily symptom charting over two menstrual cycles. Clinical studies suggest that as many as 40% of women claiming to suffer from premenstrual syndrome are not
Address for correspondence: Teri Pearlstein, M.D., Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, U.S.A. 0165-0327/90/$03.50
Premenstrual
syndrome;
Affective
disorder
prospectively confirmed (Endicott and Halbreich, 1982; Rubinow et al., 1984). For this reason, the criteria for late luteal phase dysphoric disorder (LLPDD) in Appendix A of DSM-III-R, which represents an attempt to standardize diagnostic criteria for premenstrual syndrome, require the prospective confirmation of the diagnosis by daily symptom charting over two menstrual cycles. Interpreting studies of premenstrual syndrome is further limited by the fact that there is as yet no widely used daily assessment measure of premenstrual symptoms or a widely used method of determining the presence of premenstrual syndrome from daily assessment measures. Commonly used daily self-report instruments include graphic visual analogue scales and daily symptom
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
130
checklists, in which the woman rates the severity of her symptoms. Some researchers compare a variable number of premenstrual days to a variable number of postmenstrual days. Premenstrual increases in symptom severity have been examined using a 30% change criterion (Rubinow et al., 1984; McMillan and Pihl, 1987). Other researchers compare a number of premenstrual days to the full menstrual cycle by effect size (Schurr, 1988) or spectral density analysis (Severino et al., 1989). Each statistical method attempts to detect premenstrual symptoms that are not merely exacerbations of symptoms present throughout the menstrual cycle. Little is known, however, about how women who meet such criteria compare to population norms in terms of the absolute severity of symptoms in either the luteal or the follicular phase. In spite of serious methodologic flaws in many clinical studies, a relationship between premenstrual syndrome and affective disorder has been suggested. Several investigators have found an increased prevalence of premenstrual symptoms by retrospective report in populations with affective disorder (Diamond et al., 1976; Kashiwagi et al., 1976; Endicott et al., 1981; Hurt et al., 1982). Lifetime prevalence of major depression was found to be 70% in 86 women with prospectively confirmed LLPDD (Harrison et al., 1989b), 76% in 52 women with prospectively confirmed premenstrual syndrome (Harrison et al., 1987) and 30% in 33 women with prospectively confirmed premenstrual mood disorder (DeJong et al., 1985). Some studies have examined treatment for depression and possible peripheral markers of depression in women with premenstrual syndrome. There have been reports of successful treatment of LLPDD patients with fluoxetine in a double-blind controlled trial (Stone et al., 1990) with nortriptyline in an open trial (Harrison et al., 1989a), and with evening bright light in a cross-over trial (Parry et al., 1989). There have also been reports of successful treatment of prospectively confirmed premenstrual syndrome patients with clomipramine in an open trial (Eriksson et al., 1990) and with sleep deprivation (Parry and Wehr, 1987). Three studies have examined peripheral markers of central neurotransmitter function in controlled studies of women with prospectively confirmed premenstrual
syndrome. Women with premenstrual syndrome were reported to have decreased luteal platelet serotonin (Ashby et al., 1988) and decreased luteal whole-blood serotonin (Rapkin et al., 1987). The former study reported increased luteal platelet monoamine oxidase activity, while another study found no phase difference in monoamine oxidase B activity (Rapkin et al., 1988). Axis I disorders other than depression may also be overrepresented in the premenstrual syndrome population. Lifetime axis I diagnoses were found in 81% of 123 women with premenstrual syndrome (Stout et al., 1986) and in 66% of 29 women with ‘moderate-severe peri-menstrual difficulties’ (MacKenzie et al., 1986). The high lifetime prevalence figures in these two studies are difficult to interpret because women without prospectively confirmed premenstrual syndrome were included. Subjects ‘diagnosed’ with premenstrual syndrome without prospective confirmation have been reported to have lifetime axis I prevalence figures as high as 88% (DeJong et al., 1985). The findings in these studies, therefore, may be due to psychopathology in the improperly ‘diagnosed’ group alone. No published study has examined the prevalence of specific axis II disorders in populations with premenstrual syndrome or LLPDD. Clearly, the relationship between LLPDD and other psychiatric disorders needs to be further elucidated by studying women selected using the LLPDD criteria and assessment requirements. We explored the prevalence of axis I and axis II psychiatric disorders in a consecutive series of women with prospectively confirmed LLPDD. We also assessed the severity of premenstrual symptomatology and role dysfunction in our sample by comparing Global Assessment Scale scores that were obtained at both follicular and luteal phases of the menstrual cycle. Methods Diagnosis
The diagnosis of LLPDD was determined by applying the 30% Change Criteria to the Daily Assessment Forms completed by each subject. The Daily Assessment Form was a 33-item symptom checklist developed by the authors to include items similar to the 10 symptoms found in the DSM-III-
131
R criteria for LLPDD. Eighteen of the 33 items were identical to items found on the Daily Rating Form (Endicott and Halbreich, 1982). Each item was rated using a scale from 1 for ‘no change’ or ‘no distress’ to 6 for ‘extreme change’ or ‘extreme discomfort’. The items or groups of items of the Daily Assessment Form that corresponded to each of the 10 symptoms of the DSM-III-R LLPDD criteria were summed and averaged over the 7 days before menses and the 7 days after the menses. Differences between premenstrual averages and postmenstrual averages were computed. The subject met criteria for LLPDD by 30% Change Criteria on a given cycle if the 7 day averages for at least five of 10 symptoms showed a 30% or greater premenstrual increase in severity and all postmenstrual average scores were less than 3. In an attempt to exclude ‘chronic symptomatology, symptoms with a postmenstrual average score greater than or equal to 3 (signifying at least ‘mild’ distress) were excluded. At least one of the five symptoms was required to be one of the first four symptoms listed in the DSM-III-R LLPDD criteria, i.e., affective lability, irritability, anxiety or depressed mood. Subjects Subjects were women who contacted the Healthsource Premenstrual Syndrome Clinic in Pittsburgh, PA, following physician referral or in response to media announcement. The Healthsource Premenstrual Syndrome Clinic offered careful diagnostic work-up, detailed assessment of other psychiatric parameters and both pharmacologic and non-pharmacologic treatment of premenstrual syndrome. Interested women were sent assessment packets that contained 90 Daily Assessment Forms and a medical clearance form to be completed by the woman’s gynecologist. The Daily Assessment Forms were returned by mail, and women who met LLPDD criteria for two cycles were offered entrance into the clinic. Follicular and luteal assessment interviews were then arranged. Women not meeting criteria for LLPDD were given appropriate referrals. The 97 women included in this report were aged 18-45, had regular menstrual cycles and were not regularly taking diuretics, psychoactive medications, hormones or oral contraceptives.
Measures The follicular interview was conducted during the subject’s postmenstrual week, and the luteal interview was scheduled to occur in the week preceding the next expected first day of menses. The actual date of menses was obtained to confirm that the luteal interview occurred in the premenstrual phase. The follicular interview involved collection of demographic data and a detailed gynecologic and general medical history. Two semi-structured interviews were conducted to identify psychiatric disorders. The Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer, 1978) elicited the presence of current and prior RDC psychiatric disorders. Because of the possible misdiagnosis of a long and severe episode of LLPDD as an episode of major or minor depression, a duration of greater than 1 month was required in order to make these diagnoses. A Global Assessment Scale score was obtained. The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) (Spitzer et al., 1987), administered as a combined self-report instrument and clinician interview, elicited the presence of DSM-III-R personality disorders. The luteal assessment involved a clinical interview and completion of the Global Assessment Scale. The luteal visit allowed the clinician to document clinically significant social or occupational impairment. Since there is no currently available means for distinguishing premenstrual exacerbation of existing disorders from LLPDD, women who met any axis I diagnosis within the prior 6 months were evaluated separately and excluded from subsequent data analyses. Results Ninety-seven women who met criteria for LLPDD on two cycles completed initial follicular and luteal assessment interviews. Despite our attempts to exclude women with current psychiatric diagnoses, both through telephone interview and through the application of the ‘no postmenstrual average greater than or equal to 3’ criterion on the Daily Assessment Forms, 19 (20%) of these 97 women were found to have current psychiatric disorders by SADS interview and were not in-
132
eluded in the subsequent analyses. The current RDC diagnoses found were intermittent depressive disorder (n = 9) generalized anxiety disorder (n = 4) major depression (n = 2) minor depression (n = l), phobic disorder (n = 2), schizophrenia (n = l), schizo-affective, depressed (n = l), alcoholism (n = 1) and drug abuse (n = 1). The 78 women without current axis I diagnoses were predominantly white (99%), in their early thirties (mean 33.5, SD 5.7), educated beyond high school (70%), married (70%) with children (63%) and employed in either full-time or part-time jobs (69%). Of the 78 subjects, 61 (78%) had at least one prior RDC-defined psychiatric disorder. A prior major depression was found in 36 (46%) subjects, while a prior major or minor depression was found in 54 (69%) subjects. Fewer subjects had a prior generalized anxiety disorder (n = 5), panic disorder (n = 3) phobic disorder (n = 3) alcoholism (n = 4) and drug abuse (n = 5). Fifteen (29%) of the 51 subjects with children had experienced a postpartum major or minor depression of greater than 1 month’s duration. Only one-tenth of subjects (n = 8) had a DSM-III-R personality disorder. These included avoidant personality disorder (n = 5), paranoid personality disorder (n = 2) and compulsive personality disorder (n = 1). Global Assessment Scale (GAS) mean scores were examined for the follicular versus luteal phases. Luteal GAS scores (X = 69.7) were significantly lower than follicular GAS scores (X = 84.9) (1 = 11.05, df = 70, P < O.OOOl), indicating increased symptomatology and functional impairment in the luteal phase. Discussion
This report examined the lifetime prevalence of axis I and axis II disorders in a relatively large sample size of women with LLPDD. The diagnosis of LLPDD was confirmed by prospective daily symptom recordings for two menstrual cycles and by clinical interviews at the follicular and luteal phases of the cycle. This is the first published report of the prevalence of specific axis II disorders in women with LLPDD. A prior major depression of at least 1 month’s duration was found in 46% of our 78 subjects with LLPDD. This result is consistent with earlier re-
ports of increased prevalence of prior affective disorder in women with premenstrual syndrome. The 46% lifetime prevalence of major depression in our sample is much higher than the 8% reported in the ECA community survey (Robins et al., 1984). Almost one-third of the mothers in our sample had a history of postpartum affective disorder. This figure is twice the prevalence of postpartum RDC-defined major or minor depression reported in a prospective study by O’Hara et al. (1984). As recently reviewed by Harding (1989) a prior affective disorder is consistently related to the incidence of postpartum depression. It is possible that the increased lifetime prevalence of postpartum depression in our mothers is primarily related to the increased prevalence of prior affective disorders in women with LLPDD. It is also possible that there is a specific relationship between postpartum depression and LLPDD. The lifetime prevalence figures of other axis I disorders (anxiety disorders, substance abuse disorders) in this sample of LLPDD patients are very similar to lifetime prevalence figures in community samples in the ECA studies (Robins et al., 1984). One-tenth of subjects had an axis II diagnosis, with avoidant personality disorder being the most common diagnosis. While the prevalence of axis II disorders in the general population is not known, a recent study found a prevalence of lo-20% of axis II disorders in a population of family members of patients and controls (Zimmerman and Coryell, 1989). Few studies exist that assess personality profiles in women with prospectively confirmed premenstrual syndrome. A recent review stresses the importance of evaluating personality characteristics in the follicular (asymptomatic) phase of the menstrual cycle (Severino and Moline, 1989). One study that administered the Eysenck Personality Inventory to women with prospectively confirmed premenstrual syndrome found neuroticism scores lower than those of women seeking treatment for premenstrual syndrome whose diagnosis was not confirmed by prospective ratings (Hammarback et al., 1989). A global diagnosis of personality disorder, as determined by the Personality Diagnostic Questionnaire - Revised, was not associated with a prospectively confirmed diagnosis of premenstrual syndrome or LLPDD (Eckerd et al., 1989).
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These findings suggest that the prevalence of axis II disorders and of prior axis I disorders, other than affective disorder, is not elevated in women with LLPDD when compared to community samples. Future studies using a comparison group of menstruating women not seeking treatment for premenstrual syndrome could better explore the relationship between lifetime axis I and axis II disorders and LLPDD. Harrison et al. (1989b) recently demonstrated how difficult it is to obtain an appropriate comparison group. Their control subjects were women who responded to posted notices seeking subjects for studies of mood, behavior and physical condition during the menstrual cycle, but who did not have premenstrual syndrome after prospective assessment. Their finding of a 41% lifetime prevalence of major depression by SADS-L interview in this group supports the previous findings of DeJong et al. (1985) that women seeking treatment for premenstrual syndrome, but who are not prospectively confirmed, also have an elevated prevalence of major depression. Women coming for routine medical care might provide a better comparison group. The luteal Global Assessment Scale mean scores were significantly lower than follicular scores, reflecting clinician-observed increases in premenstrual symptomatology and role dysfunction in these women. The diagnosis of LLPDD must be confirmed by prospective daily symptom charting; however, the Global Assessment Scale can be used as an adjunct to assessing the degree of severity of LLPDD. The luteal Global Assessment Scale scores could also serve as an efficient way to monitor improvement after treatment. A limitation of the present report is that neither the clinicians nor the patients were blind to the menstrual cycle phase when Global Assessment Scale scores were determined. Ideally, a clinician blind to the woman’s cycle phase should determine the Global Assessment Scale score at follicular and luteal visits. In our experience, however, clinicians who interview women with LLPDD cannot be effectively blinded to cycle phase due to the marked difference in clinical presentation (including affect, motor behavior and physical appearance) between the follicular and lutea phases. Populations of women with LLPDD provide a
unique opportunity to explore the relationship between menstrually related affective changes and affective disorders. Questions which remain to be elucidated include (1) the temporal relationship among onset of LLPDD, onset of major depression and onset of postpartum depression in this population, and (2) whether there is one general predisposition to affective illness which makes women vulnerable to all three of these conditions or whether one condition might predispose a woman to either of the other two. References Ashby, C.R., Carr, L.A., Cook, C.L., Steptoe, M.M. and Franks, D.D. (1988) Alteration of platelet serotonergic mechanisms and monoamine oxidase activity in premenstrual syndrome. Biol. Psychiatry 24, 225-233. DeJong, R., Rubinow, D.R., Roy-Byrne, P., Hoban, M.C., Grover, G.N. and Post, R.M. (1985) Premenstrual mood disorder and psychiatric illness. Am. J. Psychiatry 142, 135991361. Diamond, S.B., Rubinstein, A.A., Dunner, D.L. and Fieve, R.R. (1976) Menstrual problems in women with primary affective illness. Compr. Psychiatry 17, 541-548. Eckerd, M.B., Hurt, S.W. and Severino, S.K. (1989) Late luteal phase dysphoric disorder: relationship to personality disorders. J. Pers. Disord. 3, 338-344. Endicott, J. and Spitzer, R.L. (1978) A diagnostic interview: the Schedule for Affective Disorders and Schizophrenia. Arch. Gen. Psychiatry 35, 837-844. Endicott, J. and Halbreich, U. (1982) Retrospective report of premenstrual depressive changes: factors affecting confirmation by daily ratings. Psychopharmacol. Bull. 18, 109112. Endicott, J., Halbreich, U., Schacht, S. and Nee, J. (1981) Premenstrual changes and affective disorders. Psychosom. Med. 43, 519-529. Eriksson, E., Lisjo, P., Sundblad, C., Andersson, K., Andersch, B. and Modigh, K. (1990) Effect of clomipramine on premenstrual syndrome. Acta Psychiatr. Stand. 81, 87-88. Hammarback, S., Backstrom, T. and MacGibbon-Taylor, B. (1989) Diagnosis of premenstrual tension syndrome: description and evaluation of a procedure for diagnosis and differential diagnosis. J. Psychosom. Obstet. Gynecol. 10, 25-42. Harding, J.J. (1989) Postpartum psychiatric disorders: a review. Compr. Psychiatry 30, 109-112. Harrison, W.M., Endicott, J., Rabkin, J.G., Nee, J.C. and Sandberg, D. (1987) Treatment of premenstrual dysphoria with alprazolam and placebo. Psychopharmacol. Bull. 23, 150-153. Harrison, W.M., Endicott, J. and Nee, J. (1989a) Treatment of premenstrual depression with nortriptyline: a pilot study. J. Chn. Psychiatry 50, 136-139. Harrison, W.M., Endicott, J., Nee, J., Glick, H. and Rabkin,
134 J.G. (1989b) Characteristics of women seeking treatment for premenstrual syndrome. Psychosomatics 30, 405-411. Hurt, S.W., Friedman, R.C., Clarkin, J., Corn, R. and Aronoff, MS. (1982) Psychopathology in the menstrual cycle. In: R.C. Friedman (Ed), Behavior and the Menstrual Cycle. Marcel Dekker, New York, NY, pp. 299-316. Kashiwagi, T., McClure, J.N. and Wetzel, R.D. (1976) Premenstrual affective syndrome and psychiatric disorder. Dis. Nerv. System 37, 116-119. MacKenzie, T.B., Wilcox, K. and Baron, H. (1986) Lifetime prevalence of psychiatric disorders in women with perimenstrual difficulties. J. Affect. Disord. 10, 15-19. McMillan, M.J. and Pihl, R.O. (1987) Premenstrual depression: a distinct entity. J. Abnorm. Psychol. 96, 149-154. G’Hara, M.W., Neunaber, D.J. and Zekoski, E.M. (1984) A prospective study of postpartum depression: prevalence, course and predictive factors. J. Abnorm. Psychol. 93, 158-171. Parry, B.L. and Wehr, T.A. (1987) Therapeutic effect of sleep deprivation in patients with premenstrual syndrome. Am. J. Psychiatry 144, 808-810. Parry, B.L., Berga, S.L., Mostofi, N., Sependa, P.A., Kripke, D.F. and Gillin, J.C. (1989) Morning versus evening bright light treatment of late luteal phase dysphoric disorder. Am. J. Psychiatry 146, 1215-1217. Rapkin, A.J., Edelmuth, E., Chang, L.C., Reading, A.E., McGuire, M.T. and Su, T. (1987) Whole-blood serotonin in premenstrual syndrome. Obstet. Gynecol. 70, 533-537. Rapkin, A.J., Buckman, T.D., Sutphin, M.S., Chang, L.C. and Reading, A.E. (1988) Platelet monoamine oxidase B activity in women with premenstrual syndrome. Am. J. Obstet. Gynecol. 159, 1536-1540.
Robins, L.N., Helzer, J.E., Weissman, M.M., Orvaschel, H., Gruenberg, E., Burke, J.D. and Regier, D.A. (1984) Lifetime prevalence of specific psychiatric disorders in three sites. Arch. Gen. Psychiatry 41, 949-958. Rubinow, D.R., Roy-Byrne, P., Hoban, M.C., Gold, P.W. and Post, R.M. (1984) Prospective assessment of menstrually related mood disorders. Am. J. Psychiatry 141, 684-686. Schurr, P.P. (1988) Some correlates of prospectively defined premenstrual syndrome. Am. J. Psychiatry 145, 491-494. Severino, S.K. and Moline, M.L. (1989) Psychological factors and the menstrual cycle. In: Premenstrual Syndrome: A Clinician’s Guide. Guilford Press, New York, NY, pp.7093. Severino, S.K., Hurt, SW. and Shindledecker, R.D. (1989) Spectral analysis of cyclic symptoms in late luteal phase dysphoric disorder. Am. J. Psychiatry 146, 1155-1160. Spitzer, R.L., Williams, J.B. and Gibbon, M. (1987) Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II, 3-l-87). Biometrics Research Department, New York State Psychiatric Institute, New York, NY. Stone, A., Pearlstein, T. and Brown, W. (1990) Fluoxetine in the treatment of premenstrual syndrome. Psychopharmacol. Bull. (in press). Stout, A.L., Steege, J.F., Blazer, D.G. and George, L.K. (1986) Comparison of lifetime psychiatric diagnoses in premenstrual syndrome clinic and community samples. J. Nerv. Ment. Dis. 174, 517-522. Zimmerman, M. and Coryell, W. (1989) DSM-III personality disorder diagnoses in a nonpatient sample: demographic correlates and comorbidity. Arch. Gen. Psychiatry 46, 682689.
