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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 118-122

Disability associated with premenstrual dysphoric disorder: A prospective study


1 Associate Professor, Department of Psychiatry, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Visakhapatnam, Andhra Pradesh, India
2 Assistant Professor, Department of Psychiatry, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Visakhapatnam, Andhra Pradesh, India
3 Professor and H.O.D., Department of Psychiatry, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Visakhapatnam, Andhra Pradesh, India

Date of Submission13-Jul-2022
Date of Acceptance04-Aug-2022
Date of Web Publication27-Sep-2022

Correspondence Address:
Dr. S. V. R. Naga Pavan Kumar Kampalli
Flat. No. 402, 39-22-11/2, Sri Durga Residency, Kalinganagar, Madhavadhara, Vi-sakhapatnam - 5300 007, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amh.amh_110_22

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  Abstract 


Introduction: Premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome (PMS), is a of emotional, behavioral, and physical symptoms that cause severe functional impairment. This prospective, observational study was performed on students to assess the prevalence, the factors associated with PMS and PMDD, and the functional impairment caused by PMDD in various aspects of life.
Methodology: The present study was conducted on 224 consenting college students who attained menarche using standardized instruments such as the Daily Record of Severity of Problems, the Carolina Premenstrual Assessment Scoring System, and the Sheehan Disability Scale.
Results: The prevalence of PMS and PMDD was 19.64% and 4.46%, respectively. disability scores and functional impairment in the study were comparable to other major mental illnesses.
Conclusion: This study therefore emphasizes the need for identification and prompt management of PMS and PMDD so as to improve the quality of life.

Keywords: Disability, functional impairment, premenstrual dysphoric disorder


How to cite this article:
Nemani A, Kampalli SV, Nadukuru NR. Disability associated with premenstrual dysphoric disorder: A prospective study. Arch Ment Health 2022;23:118-22

How to cite this URL:
Nemani A, Kampalli SV, Nadukuru NR. Disability associated with premenstrual dysphoric disorder: A prospective study. Arch Ment Health [serial online] 2022 [cited 2023 Jan 29];23:118-22. Available from: https://www.amhonline.org/text.asp?2022/23/2/118/357202




  Introduction Top


Background/rationale

Premenstrual syndrome (PMS) is a constellation of emotional, behavioral, and physical symptoms that occur in the luteal phase of the menstrual cycle waning off with menstruation. A common health problem in women of reproductive age, at least 1 mild premenstrual symptom, is reported by 80% of women.[1] 20%–40% of women report moderate-to-severe and 5% report severe symptoms, and these patients meet diagnostic criteria for premenstrual dysphoric disorder (PMDD), a severe form of PMS. The morbidity associated with PMS is because of severity of symptoms, chronicity, the resulting emotional distress or impairment in work, relationships, and activities.[1]

The functional impairment in PMDD has been shown to be similar in severity to the impairment reported in major depression and dysthymic disorder. Women with severe PMS also have reported disruption in social relationships, parenting roles, and work productivity. Although PMS is a common condition causing impairment at family, social, and work functions, there has not been much data on the epidemiology of PMS and PMDD in Indian women. The tedious daily prospective two-cycle assessment and unfamiliarity with English language to rate on a rating scale hamper the assessment. Although most of the women experience premenstrual symptoms, they are under-reported and unattended to, leading to impairments in all aspects of their lives.

An idea of prevalence of PMS and PMDD and their variables, associated symptoms, and impairments caused by it will lead to greater understanding of this silent epidemic. Appropriate management options improve the quality of life and mental health of women in India. With this background, this study was performed on students to assess the prevalence, the factors associated with PMS and PMDD, and the functional impairment caused by PMDD in various aspects of life.

Objectives

  • To estimate the prevalence of PMS and PMDD
  • To determine the variables associated with PMS and PMDD
  • To assess the functional impairment caused by PMS and PMDD.



  Methods Top


Study design

The present study was a prospective observational study.

Setting

The present study was conducted on students studying in various colleges of Gayatri Vidya Parishad society. Data were collected over a period of 3 months from February 2022 to April 2022.

Participants

Inclusion criteria

  1. Students who attained menarche
  2. Students who consented to participate in this study.


Exclusion criteria

Students who did not consent to participate in this study.

The data were collected online. A pro forma was created on Google Forms and was shared with all the participants of the study in a group created on social media networks.

Variables

  1. Prevalence of PMDD and PMS
  2. Severity of symptoms
  3. Disability associated with PMS and PMDD.


Data measurement

  1. Semi-structured questionnaire including sociodemographic data and menstrual history
  2. The Daily Record of Severity of Problems (DRSP) is a symptom chart consisting of 24 items to assess the symptoms and their severity. Women rate daily symptoms prospectively for two cycles on a six-point scale from 1 – not at all to 6 – extreme. The DRSP measures all 11 DSM-5 PMDD symptoms. It provides sensitive, reliable, and valid measures of the symptoms and impairment criteria for PMDD[2]
  3. The C-PASS (available as a worksheet, Excel macro, and SAS macro) is a standardized scoring system companion protocol to DRSP for making DSM-5 PMDD diagnosis. The scores obtained on DRSP are transferred to CPASS and analyzed to lead to a cycle-level diagnosis of PMS and PMDD. Comparison of CPASS decisions (MRMD vs. no MRMD) to expert diagnosis revealed 98% agreement[3]
  4. The Sheehan Disability Scale (SDS) is a ten-point visual analog scale used to assess the extent to which the symptoms impair the responsibilities in three domains – work/school, family, and social life. High scores are associated with significant functional impairment.[4]


Bias

To avoid potential measurement bias, standardized measurement instruments were used to measure the data.

Study size

A total of 224 students participated in the study. The minimum sample size was 164, calculated using the formula n = z2 × p^ (1 − p^)/ɛ2.

Statistical methods

Data were entered in Microsoft Excel and analyzed in IBM Statistical Package for Social Sciences,Version 25. Descriptive statistics were represented with percentages, mean with standard deviation, or median with interquartile range depending on the nature of the data. Shapiro–Wilk test was applied to find normality. Chi-square test and analysis of variance tests were applied. P < 0.05 was considered statistically significant.


  Results Top


Participants

A total of 350 students were approached for the study, of which 224 completed the study. The remaining students were either unwilling to participate or did not record the responses for two consecutive cycles.

Descriptive data

[Table 1] provides a summary of the sociodemographic data of the study sample.
Table 1: Sociodemographic data of the sample

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Outcome data

Prevalence of premenstrual syndrome and premenstrual dysphoric disorder

Based on the scoring of DRSP values on CPASS for two prospective consecutive cycles, 10 (4.46%) students qualified for a diagnosis of PMDD, 44 (19.64%) subjects had PMS, and 170 (75.89%) subjects had no menstrual-related mood disorder. [Table 2] provides the prevalence data of the study sample.
Table 2: Prevalence of premenstrual syndrome and premenstrual dysphoric disorder

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Sociodemographic variables were compared across the three diagnostic groups, and there was no significant difference among the groups in relation to the variables.

Main results

Sheehan Disability Scale

The total scores on SDS for the three groups are compared and the data are presented in [Table 3].
Table 3: Total scores on Sheehan Disability Scale for no diagnosis, premenstrual syndrome, and premenstrual dysphoric disorder

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Further individual domains are scored on SDS and the values for the three groups are presented in [Table 4].
Table 4: Individual subscores on Sheehan Disability Scale - no cycle diagnosis

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In [Table 4], the individual subscores on SDS in the domains work, social, family, days lost, and days unproductive in cycle 1 and cycle 2 for no diagnosis of any menstrual-related mood disorders are depicted.

In [Table 5], the individual subscores on SDS in the domains work, social, family, days lost, and days unproductive in cycle 1 and cycle 2 for PMS are depicted.
Table 5: Premenstrual syndrome - Sheehan Disability Scale subscores

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In [Table 6], the individual subscores on SDS in the domains work, social, family, days lost, and days unproductive in cycle 1 and cycle 2 for PMDD are depicted.
Table 6: Premenstrual dysphoric disorder - Sheehan Disability Scale subscores

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  Discussion Top


Key results

This is one of the few Indian studies that used CPASS as a scoring instrument to measure the extent of functional impairment caused by PMS and PMDD. Assessment of PMS and PMDD is a complicated process requiring familiarity of English and daily subjective rating on DRSP. Hence, college students were chosen as the study population for easy and continuous access to sample for the duration of the study. The prevalence of PMS and PMDD was 19.64% and 4.46%, respectively. These values are comparable with other similar studies.[5],[6],[7],[8]

In the current study, there was no significant difference among the diagnostic groups with respect to the sociodemographic variables such as age, residence, early menarche, and body mass index (BMI). Even though there are certain anecdotal evidences that BMI has an effect on PMDD, it is advisable to maintain a healthy lifestyle and normal weight as part of treating PMDD. Certain studies have shown that being a hosteller tends to have more stress on life and contributes to increased severity of PMDD. However, our study was in contrast to this. This could be due to a more accommodative environment and a higher level of peer support among the hostellers.

In the current study, the mean total scores on SDS for PMDD were 22.5 + 3.14 for cycle 1 and 22 + 2.62 for cycle 2. In a recent Indian study by Thakrar et al.,[9] on medical and paramedical students, the mean score on SDS in subjects with PMDD is 15.9 and SD is 4.0. The mean scores in our study were greater than the study by Thakrar et al.[9]

The values in our study were comparable to scores on SDS in major depressive disorder in the studies by Lara Muñoz et al.,[10] Soares et al.,[11] and Sheehan et al.[12] This indicates that the disability caused by PMS and PMDD is similar to the disability caused by major depressive disorder as evident from previous studies.[10] This insists on the need for early identification and prompt treatment of PMDD and PMS so as to reduce the impact of these disorders daily.

In the current study, the individual scores on the work/school work domain of SDS for the group with PMS are 6.39 in cycle 1 and 6.65 in cycle 2. The mean scores for the group with PMDD in cycle 1 and cycle 2 are 7.3 and 7.0, respectively. The results of the current study are comparable to the study by Thakrar et al.,[9] in which the mean score on work domain is 6.8 for subjects with PMDD.

In a study by Lara Muñoz et al.,[10] the mean scores in the work/school domain for the disorders are as follows: depression – 4.88, mania – 2.69, generalized anxiety disorder – 2.95, panic disorder – 2.9, posttraumatic stress disorder – 5.2, and chronic conditions – 2.2. Accordingly, the mean scores for PMS and PMDD in the work/school work domain in this study are greater than that for all major psychiatric diseases and chronic medical conditions indicating higher functional impairment in the work domain.

In the current study, the individual scores on the social life/leisure activity domain of SDS for the group with PMS are 6.46 in cycle 1 and 6.58 in cycle 2. The mean scores for the group with PMDD in cycle 1 and cycle 2 are 7.4 and 6.8, respectively.

The results of the current study are higher than the scores in a study by Thakrar et al.,[9] in which the mean score on social life domain is 4.7 for subjects with PMDD.

In a study by Lara Muñoz et al.,[10] the mean scores on social/leisure activity domain for the disorders are as follows: depression – 4.8, mania – 3.6, generalized anxiety disorder – 3.0, panic disorder – 3.3, posttraumatic stress disorder – 5.3, and chronic conditions – 1.23. Accordingly, the mean scores for PMS and PMDD in social life/leisure activity domain in this study are greater than that for all major psychiatric diseases and chronic medical conditions indicating higher functional impairment in social domain.

In the current study, the individual scores on the family life/home responsibility domain of SDS for the group with PMS are 6.65 in cycle 1 and 6.46 in cycle 2. The mean scores for the group with PMDD in cycle 1 and cycle 2 are 7.1 and 7.0, respectively.

The results of the current study are higher than the scores in the study by Thakrar et al.,[9] in which the mean score on family life domain is 4.3 for subjects with PMDD.

In a study by Lara Muñoz et al.,[10] the mean scores in the family/home responsibility domain for other disorders are as follows: depression – 4.6, mania – 3.7, generalized anxiety disorder – 2.45, panic disorder – 2.9, posttraumatic stress disorder – 5.1, and chronic conditions – 2.25. Accordingly, the mean scores for PMS and PMDD in the family life/home responsibility domain in this study are greater than that for all major psychiatric diseases and chronic medical conditions indicating higher functional impairment in the family domain.

The mean of days lost in the group with PMDD in 1 month is 4.3 resulting in a total loss of 51.6 days in a year. In a study done by Lara Muñoz et al.,[10] the mean days lost in a year for patients with depression was 25.51 and panic disorder was 20.0. This indicates that the loss of days due to PMDD is very high compared to all the other mental disorders. Mental disorders are usually episodic, and most of them will attain remission in the natural course of the disease even if untreated. However, in untreated females with PMDD, the monthly recurrence results in higher loss of days in a year.

Limitations

  • The present study was carried out in the narrow range of age group 17–23 years. Hence, as there is no diverse age group, it is a limitation of this study
  • The study was done on college students, so the results cannot be generalized to the general population.


Interpretation

In the lifetime of a female, menses start from the age of 13 lasting till 45–50 years of age and occur in monthly intervals. Hence, if the female has PMDD and is unattended to, she will be disabled every month in all the major domains of life and also loses on an average of 4 days a month, thus adding burden to the patient and family.

The disability due to PMDD is comparable to any other chronic or mental illness. This study therefore emphasizes the need for identification and prompt management of PMS and PMDD so as to improve the quality of life.

Strengths

  • The present study is a prospective observational study
  • The assessment method used is a standardized scale – DRSP
  • Scores from DRSP are assessed using “CPASS” which is a standardized scoring system companion protocol to DRSP for making DSM-5 PMDD diagnosis
  • The functional disability due to PMDD is calculated using “SDS” which has good reliability and validity
  • This is one of the few studies to use CPASS for the assessment of PMDD in India
  • This is one of the few studies to assess the disability caused by PMS and PMDD in India.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Shenuka S, Vijayalakshmi R, Sambath Kumar R. Prevalence, severity and coping behaviour of premenstrual syndrome and premenstrual dysphoric disorder among female students in a private institution in India. Int Res J Pharm 2018;9:193-7.  Back to cited text no. 3
    
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Sheehan DV. The Anxiety Disease. New York, NY: Bantam Books; 198.  Back to cited text no. 4
    
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Raval CM, Panchal BN, Tiwari DS, Vala AU, Bhatt RB. Prevalence of premenstrual syndrome and premenstrual dysphoric disorder among college students of Bhavnagar, Gujarat. Indian J Psychiatry 2016;58:164-70.  Back to cited text no. 5
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Kamat SV, Nimbalkar A, Phatak AG, Nimbalkar SM. Premenstrual syndrome in Anand District, Gujarat: A cross-sectional survey. J Family Med Prim Care 2019;8:640-7.  Back to cited text no. 6
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Durairaj A, Ramamurthi R. Prevalence, pattern and predictors of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) among college girls. New Indian J OBGYN 2019;5:93-8.  Back to cited text no. 7
    
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Srikanth S, Nandini S. Menstrual hygienic practices and prevalence of premenstrual syndrome in medical students. Indian J Appl Res 2019;9:55-7.  Back to cited text no. 8
    
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Thakrar P, Bhukar K, Oswal R. Premenstrual dysphoric disorder: Prevalence, quality of life and disability due to illness among medical and paramedical students. J Affect Disord Rep 2021;4:100112.  Back to cited text no. 9
    
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Lara Muñoz MD, Medina-Mora M, Borges G, Zambrano J. Social cost of mental disorders: Disability and work days lost. Results from the Mexican survey of psychiatric epidemiology. Salud Ment 2007;30:4-11.  Back to cited text no. 10
    
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Soares CN, Zhang M, Boucher M. Categorical improvement in functional impairment in depressed patients treated with desvenlafaxine. CNS Spectr 2019;24:322-32.  Back to cited text no. 11
    
12.
Sheehan DV, Mancini M, Wang J, Berggren L, Cao H, Dueñas HJ, et al. Assessment of functional outcomes by Sheehan Disability Scale in patients with major depressive disorder treated with duloxetine versus selective serotonin reuptake inhibitors. Hum Psychopharmacol 2016;31:53-63.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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