Premenstrual Dysphoric Disorder: Differential Diagnosis

Differential Diagnosis

Depression and anxiety disorders are the most common Axis I psychiatric disorders that may be concurrent and exacerbated premenstrually, with less clear evidence for bipolar disorder, eating disorders and substance abuse. Since most PMDD symptoms are affective or anxiety-related, “pure PMS” or PMDD is generally not diagnosed when an underlying depression or anxiety disorder is present; these women would be considered to have premenstrual exacerbation of their underlying depression or anxiety disorder. Personality disorders are not elevated in prevalence in women with PMDD, but women with PMDD and a personality disorder may demonstrate premenstrual phase amplification of personality dysfunction. Schizophrenia may be an example of a disorder that does not have premenstrual exacerbation of psychotic symptoms but may have the superimposition of affective and anxiety symptoms of PMDD. The prevalence of premenstrually exacerbated disorders is unknown, but women with these conditions present frequently to their primary care clinician or gynecologist. Since most recent treatment studies have been conducted on women with PMS and PMDD without follicular symptomatology, this literature is not particularly informative on how to treat women with premenstrually exacerbated disorders. The general guideline is to treat the underlying disorder first and see if subsequent daily ratings suggest persistence of premenstrual symptoms that might meet criteria for PMDD.

Several medical conditions should also be considered when evaluating a woman with premenstrual complaints. Symp-toms of endometriosis, polycystic ovary disease, thyroid disor-ders, disorders of the adrenal system, hyperprolactinemia and panhypopituitarism may mimic symptoms of PMS. Several medical disorders may demonstrate a premenstrual increase in symptoms without accompanying emotional symptoms, such as migraines, asthma, epilepsy, irritable bowel syndrome, diabetes, allergies and autoimmune disorders. It is presumed that the men-strual cycle fluctuations of gonadal hormones influence some of the symptoms of these medical conditions.