PMDD in Women with ADHD: Is It Real or Just Alphabet Soup?

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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