For some time, women with AD/HD have been reported
to have an increase in coexisting anxiety and mood disorders. Clinically,
many of these women report severe mood disturbance during the latter
half of their menstrual cycle suggestive of PMDD (Premenstrual Dysphoric
Disorder). If this is indeed the case, the questions then become
– Is PMDD real and what can be done about it?
Over the last decade, there has been considerable
controversy about disorders of mood surrounding a woman’s menstrual
cycle. It has taken years for the medical community to recognize
that women suffer physical symptoms and mood disturbances around
their period and that they aren’t “crazy.” Bloating,
irritability, mood swings, and mild depression commonly make up
symptoms of Premenstrual Syndrome (PMS). Many women experience these
bothersome PMS symptoms on a monthly basis, while another 3-9% of
women suffer from a much more serious condition, PMDD or Premenstrual
Dysphoric Disorder. Premenstrual Dysphoric Disorder includes symptoms
of clinical depression, anxiety, and irritability with a severity
that impairs a woman’s ability to function during the second
half of her menstrual cycle in her activities of daily living and
in her relationships with others.
PMDD was first included in the American Psychiatric
Association’s Diagnostic and Statistical Manual (DSM-IV) in
1994, but the controversy surrounding it continues. Many mental
help professionals still insist that PMDD does not exist and that
labeling a woman as “mentally ill” in order to provide
treatment and support for PMDD symptoms is absurd. Recent studies
are, however, proving that PMDD does exist and that it has a biologic
basis.
In 1999, a panel of experts was convened to examine
this issue. After reviewing the published literature on the disorder,
they concluded that those women with PMDD exhibited biologic characteristics
related to the serotonin system in the brain with a genetic component
unrelated to major depression. Although PMDD is a separate
disorder, an NIMH study found that women with PMDD have a greater
risk for developing a major depressive disorder.
Several studies have addressed treatment approaches
for PMDD. One study found that 60% of patients with PMDD responded
to treatment with an SSRI antidepressant. Another study done in
1998 (American Journal of Obstetrics & Gynecology, Vol 179,
No 2) demonstrated that calcium carbonate could improve PMDD symptoms.
In this study of 500 women, 55% reported relief of some of their
symptoms within three months of initiating therapy.
A more recent study published in September in the
Archives of General Psychiatry (2002) has linked PMDD with a chemical
shift in the brain. In this study, researchers investigated the
association between changing hormone levels during the menstrual
cycle and cortical levels of the neurotransmitter gamma–aminobutyric
acid (GABA). Brain scans measuring GABA levels in the occipital
cortex were performed at three distinct times during the menstrual
cycle to coincide with changing levels of hormones. A significant
difference was found in GABA levels when women with PMDD were compared
to healthy volunteers. In the healthy women, GABA levels were found
to decrease from the follicular phase to the mid- and late-luteal
phases. In PMDD patients, GABA levels were lower during the follicular
phase and found to rise significantly with increasing estrogen and
progesterone levels and to stay at these increased levels. These
investigators further postulated that the SSRI antidepressants have
an effect on PMDD symptoms by enhancing GABA-A receptor sensitivity.
Treatment for PMDD includes support, counseling, and
medication. Two medications are currently approved by the FDA for
treating PMDD - Prozac (fluoxetine) and Zoloft (sertraline). Research
has demonstrated that both of these drugs are more effective than
placebo in treating PMDD symptoms (Journal of Women’s Health
and Gender-based Medicine, Vol 10, No 8).
Women with AD/HD who experience severe mood changes
in relation to their menstrual cycle may need to seek a diagnosis
of PMDD and treatment with an SSRI medication in addition to treatment
with stimulant medication for AD/HD symptoms. Documenting symptoms
prospectively for two months is critical to accurate diagnosis of
PMDD. Without such documentation, women with ADHD and PMDD run the
risk of having their severe mood fluctuations, emotional reactivity
and hyperactive/impulsive behaviors mistaken for symptoms of Bipolar
Disorder.
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