Premenstrual moods or depression? Use logs to track monthly cycles
Differentiating premenstrual dysphoric disorder (PMDD) from depression or premenstrual syndrome (PMS) is crucial to restoring the patient’s well-being. PMS is relatively mild; its symptoms range from bloating to breast tenderness to irritability. PMDD is more severe and is characterized by marked and persistent irritability, depressed mood, anxiety, or affective lability.
Symptoms of clinical depression are present throughout the month, but PMDD symptoms emerge only during the luteal phase of most menstrual cycles. Having the patient keep a menstruation log can provide valuable clues to diagnosis.
Choosing the right tool
PMDD diagnosis requires confirmation of symptoms by prospective daily ratings over at least two menstrual cycles.
Available monitoring tools include:
- Daily Record of Severity of Problems (DRSP), the only scale keyed to DSM-IV criteria for PMDD. The patient rates symptoms daily from 1 (not present) to 6 (extreme).
- Premenstrual Symptom Diary (PSD), which uses a 4-point scale. It includes common psychological and physical symptoms and allows the patient to add others.
- Calendar of Premenstrual Experiences (COPE). One of the best-validated scales, COPE contains many more symptoms (10 physical and 12 psychological) than the others, making it both more thorough and more difficult to use.
How to use the log
Although many symptoms point to PMDD, a woman with this disorder tends to have the same symptoms across cycles. Common symptoms include irritability, anxiety, mood swings, sadness, crying spells, fatigue, lethargy, insomnia or hypersomnia, bloating, headaches, breast tenderness, poor concentration, and food cravings. The patient can rate each symptom or choose three or four that bother her most, then rate them daily from absent to severe.
Have the patient begin charting on the first day of her period. Few or no symptoms during the follicular phase (days 7-14) and an increase in symptoms during the luteal phase (days 14-28) may indicate PMDD.
Compare postmenstrual follicular phase and luteal phase scores. A luteal phase symptom increase of 30% to 50% (depending on which scale is used) confirms the PMDD diagnosis. The log can also help distinguish PMDD from pre-menstrual worsening of major depression or other disorders.
By keeping a menstruation log, a patient can predict and manage days when she will be most symptomatic. For example, the patient can adjust her diet, maximize sleep and exercise, and—where possible—avoid stressful events the week before her period. In severe cases, the log can help determine when antidepressants are warranted.
Dr. Rasminsky is assistant professor of clinical psychiatry, Women’s Mental Health Program, University of Illinois at Chicago.