Establishing the Existence and Prevalence of Premenstrual Dysphoric Disorder

Background and Purpose: The idea has existed since the 1970s of a subtype of premenstrual syndrome (PMS) primarily distinguished by a debilitating mood disturbance. Termed Premenstrual Dysphoric Disorder (PMDD), it was included as a provisional diagnostic category in the appendices of DSM-III-R and remained there in DSM-IV. Other prevalence studies of PMDD failed to take into account all four research criteria. Because of the potential repercussions of a new mental disorder for vulnerable persons, the present study aimed to determine the prevalence of PMDD using all four DSM-IV research diagnostic criteria in a community-based sample of women of reproductive age.

Method: Data were collected in the homes of women between the ages of 13 and 55 in two urban and two rural sites using a random sampling procedure developed by the National Opinion Research Center (NORC), to ensure inclusion of women from all racial/ethnic and socioeconomic backgrounds. Recruiters visited 12,800 homes to locate eligible women. Interviewers followed women who agreed to participate in their homes for two menstrual cycles. To maintain participation, interviewers: (1) lived in the same area; (2) were assigned to the same women; and, (3) visited every two weeks. Women completed daily symptom questionnaires and provided urine specimens each day for two menstrual cycles to establish cycle phase and were screened for psychiatric disorders using the SCID I/NP, IPDE, and K-SADS-E. Symptoms were counted toward a diagnosis of PMDD if they worsened significantly during the late luteal week during two consecutive menstrual cycles, occurred on days in which women reported marked interference with functioning, and weren't due to another mental disorder.

Results: Of the 12,800 addresses selected by NORC, 9,867 were determined to be valid. Women meeting eligibility for the study were found in 2,696 housing units, and 66.17% agreed to participate. During the study, 21.2% of participants dropped out, 6.5% became ineligible (e.g., moved from the area), and 2.5% of subjects' data were unusable due to significantly missing responses in daily ratings. As a result, 1,246 cases were used in the final analysis, yielding a completion rate of 69.8%, which is comparable to the completion rates of other studies in which women completed daily symptom diaries. The prevalence rate was 5.5% when symptom change alone was considered. It dropped to 1.8% when interference was considered simultaneously. The rate dropped slightly, to 1.3%, when symptoms shared with other disorders were excluded from consideration and did not change when the fourth criterion (i.e., must occur during both cycles) was added.

Conclusions and Implications: The prevalence of PMDD is considerably lower than DSM-IV estimates of 5% to 10% when all diagnostic criteria are considered. We suggest a compromise for clinical diagnosis in which: (1) women complete a daily diary of symptoms and interference with functioning between provider visits and (2) psychiatric diagnostic testing is done on those women whose prospective symptom profiles suggest that they have PMDD. This approach is feasible, yet based on empirical evidence. Using a standard approach will minimize the diagnosis' misuse.