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PREMENSTRUAL DYSPHORIC DISORDER AND THE CONTROVERSY OVER DIAGNOSIS AND TREATMENT By KATIE SOREY A dissertation/thesis submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING WASHINGTON STATE UNIVERSITY - SPOKANE, WA College of Nursing AUGUST 2011 Washington State University Spokane Riverpoint Campus Library Academic Center, Suite 211 PO Box 1495 Spokane, WA 99210-1495 To the Faculty of Washington State University: The members of the Committee appointed to examine the master's project of KATIE SOREY find it satisfactory and recommend that it be ac.cepted. ii PREMENSTRUAL DYSPHORIC DISORDER AND THE CONTROVERSY OVER DIAGNOSIS AND TREATMENT Abstract by Katie Sorey, BSN Washington State University August 2011 Chair: Lorna Schumann Premenstrual dysphoric. disorder has received great attention and c.ontroversy since it was first adapted into the DSM IV in 1994. Since that time, treatment options have stolen the spotlight, and limited focus has occurred on the actual disorder. The diagnosis of premenstrual dysphoric disorder (PMDD), risks and benefits of the diagnosis, and alternative treatment modalities used in a clinical setting will be reviewed in this manuscript. The most alarming risk of the diagnosis includes a misdiagnosis and the possibility of covering up an underlying condition. The major benefit of correct diagnosis is likely improvement of health related quality of life through symptom control and management. A major problem is that accurate diagnostic screening tools are not being utilized properly and effectively in the clinical setting. The treatment ofPMDD is diverse and complicated. If the appropriate diagnostic measures are not taken an underlying medical condition, including a psychiatric diagnosis may be missed. In the clinical setting this is important, because approximately 5-8% of the female population is affected by premenstrual dysphoric disorder, which is proven to have a significant effect on lifestyle, work function, relationships, and social interaction. By appropriately diagnosing this iii disorder, and using evidence based practice to treat, the symptoms can be controlled and burdens on activities of daily living can be lifted. Keywords: Premenstrual dysphoric disorder, underlying psychiatric conditions, misdiagnosis, premenstrual syndrome iv TABLE OF CONTENTS Page iii ABSTRACT INTRODUCTION 1 Search Strategies 2 Theoretical Framework 3 LITERATURE REVIEW Pathophysiology 3 Diagnostic Criteria 4 Assessment ofPMDD 5 Non-pharmacological Treatments 7 Pharmacological Treatments 9 SIGNIFICANCE OR IMPLICATIONS FOR PRACTICE Summary 12 13 REFERENCES 14 APPENDIX A. DAILY SYMPTOM REPORT 16 B. DAILY RECORD OF SEVERITY OF PROBLEMS 17 v Running Head: PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 1 Premenstrual Dysphoric Disorder and the Controversy over Diagnosis and Treatment Introduction Premenstrual dysphoric disorder was formalized into the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV in 1994. PMDD is stated to affect 5-8% of tIle female population (Pearlstein & Steiner, 2008). Premenstrual dysphoric disorder is defined as a psychiatric disorder with biological, psychological, and sociocultural components (Dipiro et aI., 2008). PMDD is costly to society and the diagnosis and treatment have been controversial. Premenstrual dysphoric disorder places a high burden on quality of life as well as cost to society. A cross-sectional study was conducted to compare women at risk for PMDD with other chronic conditions such as hypertension, type 2 diabetes, depression, and back pain. The study population consisted of 971 multiethnic women. The results show that women at risk for PMDD report a lower functioning and well-being in all physical and mental health domains (Yang et aI., 2008). The burden ofPMDD was reported highest in general pain and social functioning. The conclusion of this study suggests that PMDD places a substantial burden on both physical and mental health aspects that can affect health related quality of life more than type 2 diabetes, hypertension, osteoarthritis, rheumatoid arthritis, and are somewhat comparable to depression (Yang et aI., 2008). The study's limitation is the retrospective nature of data collection. Also, the validity of online data collection is also questionable. Another burden present is the high ec·onomic· indirect cost. In 2005, a quantifiable self- study collected data from 374 women that correlated indirect costs, such as missed work or decreased productivity, to premenstrual symptoms that totaled approximately PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 2 $4,300 annually (Borenstein, Chiou, Dean, Wong, & Wade, 2005). Other burdens can include decrease in effectiveness at work or school, a disturbed marital relationship, difficulty parenting without distraction, and increased doctor visits for symptom control (Pearlstein & Steiner, 2008). Due to the fact that the quantifiable data was reported by the participants the accuracy is questionable. In 1994, controversy sparked on the diagnosis of premenstrual dysphoric disorder, when it was added into the Diagnostic and Statistical Manual of Mental Disorders, or DSM IV (Che~ 2008). "Women's health activists argued that the diagnosis pathologized the menstrual cycle and would stigmatize many women by wrongly labeling them mentally ill, and put them in jeopardy of discrimination at the workplace or in child custody battles" (Chen, 2008). Today, controversy surrounds the diagnosis ofPMDD, because experts argue that PMDD may cover up an existing psychiatric condition. PMDD should generally not be diagnosed when an underlying psychiatric disorder is present because many of these conditions can be exacerbated by premenstrual symptoms (Pearlstein & Steiner, 2008). There is thought that with dietary and lifestyle changes medication may not be needed to treat symptoms ofPMDD. The question that presents and should be asked is: Is the diagnosis ofPMDD over used, and could it be managed efficiently with dietary, lifestyle, and non-pharmacological agents? The purpose of this literature review is to identify the appropriate methods of assessment and diagnosis of premenstrual dysphoric disorder and identify alternative methods of symptom management. Search Strategies Search strategies used to obtain research literature correlating to PMDD included PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 3 the use of CINAHL, Medscape, and PubMed search engines. The keywords searched included PMDD, controversy, diagnosis, and treatment. With these keywords approximately four pages of articles resulted in each search engine. Of these articles the most applicable, scholarly, and peer reviewed journals were utilized. Integrated in this literature review are seventeen articles that summarize the most recent and clinical applicable data. Theoretical Framework Symptoms ofPMDD including depression can directly and indirectly impact a patient's appraisal and outlook of their situation. In tum, the patient's appraisal is impacted by personality factors, social support, and coping skills. These variables determine the health outcome for the patient. Health outcomes would include medical treatment, inability to function to carry out employment or other activities of daily living, health related quality of life, and overall mood. Therefore, the structural framework will incorporate symptoms of PMDD, as well symptom management, and their impact on health outcomes. Literature Review Pathophysiology The pathophysiology of PMDD is closely linked to an active hypothalamic. pituitary- gonadal axis (HPG). Somatic and physical symptoms are thought to be brought on by changes in the ovarian cycle (Steiner et aI., 2006). The etiology ofPMDD is still being investigated. An allelic variation on the estrogen receptor alpha gene in women with PMDD may be the source of abnormal estrogen signaling during the luteal phase PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 4 that leads to premenstrual affective, cognitive, and somatic symptoms (Pearlstein & Steiner, 2008). In a 2008 cross-sectional and prospective experimental study, that included a two month self assessment and one month hormonal evaluation, it was identified that serum concentration of free estradiol (E2), percent free E2, and sex hormone-binding globulin (SHBG) are markedly different in women with PMDD, as opposed to women without PMDD (Thys-Jacobs, McMahon, & Bilezikian, 2008). During the luteal phase, free E2 was significantly lower in the PMDD group when compared with controls. "Acute changes in ovarian function or even relatively lower estrogen concentrations during the luteal phase of the menstrual cycle may influence serotonergic metabolism and neurotransmitter reuptake, both thought to mediate mood and emotion" (Thys-Jacobs, McMahon, & Bilezikian, 2008, p. 99). In both follicular and luteal phases, SHBG was higher in women with PMDD. '''Higher SHBG concentrations as noted in the PMDD group may limit the bioavailability ofE2 to the brain, liver, and other tissues, and ultimately affect mood" (Thys-Jacobs, McMahon, & Bilezikian, 2008, p. 100). Conversely, levels ofLH, progesterone, E2, peak E2, and free E2 were not different between the two groups. Therefore, appropriate labs to monitor in patients with PMDD would include luteal phase estradiol, percent free E2, and SHBG. Limitations in this study include a limited eight day monitoring of hormone levels, which may indicate that certain trends may have been missed. Diagnostic Criteria According to the American Psychiatric Association, confirmation of the diagnosis must be obtained by daily ratings for two consecutive menstrual cycles. Of the daily PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 5 information that is gathered, five or more symptoms must have occurred in the majority of the cycles in the past year. These symptoms are broken up into core symptoms and other symptoms (Wysocki, 2008). Core symptoms include a markedly depressed mood, anxiety, affective lability, persistent anger or irritability, decrease in interest in usual activities including work, school, friends, or hobbies, difficulty concentrating, insomnia, change in appetite, and the sense of being overwhelmed. Other symptoms include physical symptoms such as breast tenderness, swelling, weight gain, and joint or muscle pain (Wysocki, 2008). For the diagnosis ofPMDD there needs to be at least one symptom that is a core symptom. Symptoms must present in the last week of the luteal phase, ease after a few days of menses, and resolve in the week post-menses. Also, symptoms must be interfering with daily life. This can include relationships, work, school, or other activities (Wysocki, 2008). Assessment of PMDD Assessment information for PMDD that can be useful in practice includes either the Daily Record of Severity of Problems or the Penn Daily Symptom Report (APPENDIX A & B). These are scoring methods that can be used to record daily ratings of symptoms (Pearlstein & Steiner, 2008). These reports compare a patient's premenstrual symptoms with post menses symptoms, and are used over a consecutive two-month time frame to aid in the diagnosis ofPMDD. These tools also help rule out differential diagnoses in the process. PMDD symptoms should increase from 30-50% from the follicular phase to the luteal phase (Wysocki, 2008). The follicular phase is the first half of the menstrual cycle that ranges from 10-14 days. It begins on the first day of the menstrual bleed (Wysocki, 2008). During this phase there should be a resolution or PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 6 reduction in symptoms after the onset of menses."Ratings that demonstrate follicular symptoms with increase symptom severity in the premenstrual phase suggest the premenstrual exacerbation of an underlying disorder rather than PMDD" (First & Tasman, 2010, p. 304). Common Axis 1 disorders that may be premenstrually exacerbated include depression, anxiety, bipolar I, posttraumatic stress disorder, eating disorders, and substance abuse disorders (First & Tasman, 2010). In 2004, a self reported study was conducted to analyze 433 women to determine if their depressive states were exacerbated premenses. The results indicated that women who reported premenstrual exacerbation of symptoms had a prolonged duration of their current depressive episode (Komstein et aI., 2005). The women who experienced premenstrual exacerbation of symptoms also noted more somatic disturbance and psychomotor dysfunction (Komstein et aI., 2005). If recorded symptoms are largely confined to the premenstrual phase with relative absence during the follicular phase, then the clinician should assess premenstrual function impairment (First & Tasman, 2010). The limitation to this study is that retrospective rating was used, and it is argued that, in the participants, the actual rates of premenstrual exacerbation (PME) may be somewhat lower than those found in this study. "On the other hand, it is also possible that the lower rate of PME· reported by women at the very times it was oc.c.urring is a function of altered cognition or perception associated with premenstrual mood changes" (Komstein et aI., 2005, p. 8). Another important factor in the assessment ofPMDD is to order laboratory tests to exclude differential diagnoses. These would include thyroid and glucose testing to rule PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 7 out conditions that may exhibit similar symptoms. A provider may also incorporate the testing of luteal phase estradiol, percent free E2, and SHBG. Non-pharmacological Treatments Treatment for PMDD is comprised of collaboration between psychosocial interventions, lifestyle change and modification, and pharmacological therapies. Experts recommend that during the first two cycles, while the patient is gathering symptom information, lifestyle changes be put into practice (Steiner et aI., 2006). An example of a lifestyle change is alteration of diet, which includes the limitation of caffeine. Reducing caffeine intake can decrease irritability. A 2007 cross-sectional analysis by Gold et aI., reported that increasing caffeine intake in a population of 3302 multiethnic, midlife women was associated with reporting of premenstrual anxiety and mood changes, but the association was not monotonic (Gold et aI., 2007). This study also indicated that greater fat intake was associated with less premenstrual craving and bloating, possibly reflecting ingestion of comfort food to self treat PMS symptoms (Gold et aI., 2007). Limitations of the study included the use of statistical comparisons, therefore, some of the observed associations may have occurred by chance or represent markers for other uncontrolled factors. Also, the symptoms re-called by participants may lac·k accuracy (Gold et aI., 2007). Increasing carbohydrate intake premenstrually has been shown to improve mood, carbohydrate craving, and short term memory by elevating the serotonin level in the brain (Steiner et aI., 2006). A randomized trial conducted in 2001, shows that a carbohydrate rich beverage, PMS Escape, reduced PMS mood symptoms in one third of the 53 participants (Freeman, Stout, Endic.ott, & Spiers, 2002). The limitation to the study is that PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 8 there is no significant group difference in demographic, physical characteristics, or baseline daily symptom rating (DSR). Vitamin intake is beneficial in treating premenstrual symptoms. Studies have shown that Calcium 600 mg twice daily reduces emotional and physical symptoms of PMDD. A double blind, randomized, placebo-controlled study conducted in 1998, reveals that 1200 mg! day of calcium carbonate decreases all core PMS symptoms during the luteal phase (Thys-Jacobs, Starkey, Berstein, & Tian, 1998). Of the 466 women analyzed, 48% reported reduction in symptoms by the third treatment cycle. This occurs most likely by the reduction of neuromuscular irritability and vascular reactivity (Thys Jacobs, Starkey, Berstein, & Tian, 1998). The limitation to the study is that it investigated women with PMS and not specifically premenstrual dysphoric disorder. Natural remedies and supplements have also been evaluated in the treatment of PMDD. In a 2006 biopharmaceutical scientific study, c-haste berry was proven as effective in treating PMS symptoms. In this study two different vitex agnus-castus extracts were analyzed for receptor binding and functional assays. Chaste berry or vitex agnus-castus (VAC) has been proven to be clinically effective by acting on the opiate pathway that plays a role in pain perception, mood, appetite, and other functions (Webster, Lu, Chen, Farsworth, & Wang, 2006). "VAC may improve symptoms ofPMS by activating opiate receptors to reverse the loss of opiate tonic inhibition or directly activating analgesic and mood regulatory pathways" (Webster, Lu, Chen, Farsworth, & Wang, 2006, p. 219). The limitation to this study is that it was evaluated for the treatment ofPMS not specifically PMDD. PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 9 Education and psychosocial support information should also be given to the patient in the beginning stages. Peer support, cognitive behavioral modifications, relaxation exercises, stress reducing activities, and counseling may all be appropriate interventions for the patient. A randomized trial, funded by the National Institute of Health, studied 134 women in 1999 (Taylor, 1999). This study analyzed the use of nonpharmacological approaches including self-monitoring, personal choice, self regulation, and self/environmental modification with women diagnosed with severe premenstrual symptoms. The results indicated that with these methods PMS severity was reduced by 75% and premenstrual depression was reduced by 30-540/0. The most improvement was found after 3 months but continued to show effectiveness long-term (Taylor, 1999). The limitation to this study is the limited number of participants and that it focuses on PMS instead ofPMDD. Pharmacological Treatments Pharmacological interventions may be considered, if the above methods have not improved symptoms and if the appropriate assessment criteria is met in order to confirm the diagnosis ofPMDD. The United States Food and Drug Administration (FDA) has approved treatment ofPMDD with three selective serotonin reuptake inhibitors (SSRIs) including Fluoxetine (Prozac), Sertraline (Zoloft), and controlled released Paroxetine (Paxil CR). Also, one combined oral contraceptive, Ethinyl Estradiol/Drospirenone (YAZ) has been approved by the FDA for treatment ofPMDD. Agents used off label include gonadotropin-releasing honnone agonists, anxiolytics, and hormonal interventions (Wysocki, 2008). PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 11 SSRIs interact with only one receptor so they have the advantage of fewer associated side effects. However, side effects do include reduced libido, dysorgasmia, nausea, weight gain, sweating, and headache. When using SSRIs in young adults and adolescents, it is extremely important to monitor the risk of suicidal thinking and behavior. Education is crucial with this matter. When treating an adolescent, consulting with a child psychologist would he critical prior to treating them with SSRIs (Claman & Miller, 2006). Also, following up with any abnormal lab values would be imperative to rule out an underlying medical condition, such as anemia, autoimmune disorders, endocrine and thyroid disorders (hyperprolactinemia, hypothyroidism, diabetes mellitus), chronic fatigue syndrome, endometriosis, and psychiatric disorders (Claman & Miller, 2006). Further research acknowledging long term effects with the use of SSRls for the treatment ofPMDD is necessary. Research regarding the use ofSSRls in the adolescent population, diagnosed with PMDD, would be informative and applicable in the clinical realm. The combined oral contraceptive approved by the FDA for the treatment of PMDD is YAZ. "It contains 3mg of progestin drospirenone and 20 mcg of ethinyl estradiol (DRSP/EE)" (Wysocki, 2008, p. 28). Studies have shown that YAZ is effective in reducing mood, behavioral, and physical symptoms associated with PMDD. A double blind, random clinical trial conducted in 2005, resulted in a 37.4 symptom decrease as recorded on the Daily Record of Severity of Problems after a 24/4 regimen of drospirenone 3 mg and ethinyl estradiol 20 mcg was given for three treatment cycles (Yonkers et aI., 2005). The study population consisted of 450 women diagnosed with PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 12 premenstrual dysphoric disorder. Oral contraceptive agents can potentially change the characteristics of a menstrual cycle, and therefore, can limit the accuracy of the study. Taking oral contraceptives can cause adverse effects including breakthrough bleeding, nausea, and breast pain (Wysocki, 2008). "The creation of a reliable and well tolerated coe with an additional benefit of treating premenstrual disorders may be a welcomed alternative for women suffering from PMDD, who are dissatisfied with the side-effect profile of SSRIs or fail to respond to SSRIs" (Rapkin, McDonald, & Wilner, 2007, p. 408). Significance or Implications for Practice The diagnosis of premenstrual dysphoric disorder has significant implication for practice, because it has been proven that PMDD can dramatically influence health related quality of life and be a burden financially, emotionally, and physically if not diagnosed and treated. The appropriate methods of assessment include either the Daily Record of Severity of Problems or the Penn Daily Symptom Report (APPENDIX A & B). During the two full cycles in which that information is being gathered, the first and primary method of treatment should be lifestyle and diet modification, while ruling out any differentials. Once the follow-up interview has been completed, previous methods have not improved symptoms, and the patient meets diagnostic. criteria they should be considered for pharmacological treatment options. These options should begin with an SSRI or the combined oral contraceptive, YAZ, depending on their symptoms and treatment desires. Each patient should be treated individually and assessed thoroughly, because treatment should not be the same for everyone. PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 13 Summary Five to eight percent of the female population struggle with premenstrual dysphoric disorder and exhibit physical, social, and emotional burdens from this condition. With correct assessment by health care providers including the use of daily symptom reports over two consecutive months' menstrual cycles, this diagnosis can be correctly identified. The first line pharmacological treatment for the disorder is an SSRI. The second line of treatment is either YAZ or an additional SSRI. Changes in lifestyle and diet can also be made to achieve relief in symptoms and should be a primary intervention. The biggest concern for health care providers is to rule out differential diagnoses that may be covered up or exacerbated by premenstrual symptoms. PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 14 References Borenstein, J., Chiou, C., Dean, B., Wong, l., & Wade, S. Estimating direct and indirect costs of premenstrual syndrome. Journal ofOccupational & Environmental Medicine. 2005, 47(1), 26-33. Chen, I. (2008). A class of science and politics over PMS. The New }Tork Times. Retrieved March 25, 2011 at http://www.nytimes.com/ref/health/healthguide/esn pms-ess.html Claman, F., & Miller, T. Premenstrual syndrome and premenstrual dysphoric disorder in adolescence. Journal ofPediatric Health Care. 2006, 20(5), 329-333. Dipiro, l., et ala (2008) Pharmacotherapy: a pathophysiologic approach. McGraw-Hill Companies, Inc. New York. First, M., & Tasman, A. (2010). Clinical guide to the diagnosis and treatment ofmental disorders. West Sussex, UK: John Wiley & Sons. Freeman, E., DeRubeis, R., & Rickels, K. Reliability and validity of a daily diary for premenstrual syndrome. Psychiatry Research. 1996,65,97-106. Freeman, E., Stout, A., Endicott, J., & Spiers, P. Treatment of premenstrual syndrome with a carbohydrate-rich beverage. International Journal ofGynecology & Obstetrics. 2002, 77, 253-254. Gold, E., et al. Diet and lifestyle factors associated with premenstrual symptoms in a racially diverse community sample: Study of women's health across the nation (SWAN). Journal of Women's Health. 2007, 16(5),641-655. Komstein, S., et aI. Self reported premenstrual exacerbation of depressive symptoms in patients seeking treatment for major depression. Psychological Medicine. 2005, 35, 1-10. Pearlstein, T., & Steiner, M. Premenstrual dysphoric disorder: Burden of illness and treatment update. Journal ofPsychiatry & Neuroscience. 2008, 33(4), 291-301. Rapkin, A., McDonald, M., & Wilner, S. Ethinyl estradiol/ drospirenone for the treatment of the emotional and physical symptoms of premenstrual dysphoric disorder. Women's Health. 2007, 3(4), 395-408. Steiner, M., et ala Expert guidelines for the treatme·nt of severe PMSS, PMDD, and comorbidities: the role ofSSRI's. Journal a/Women's Health. 2006,15(1), 57-68. PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 15 Steiner, M., et ale Luteal phase administration of paroxetine for the treatment of premenstrual dysphoric disorder. Journal ofClinical Psychiatry. 2008, 69(6), 991 -998. Taylor, D. Effectiveness of professional-peer group treatment: Symptom management for women with PMS. Research in Nursing and Health. 1999, 22(6), 496-511. Thys-Jacobs, S., McMahon, D., & Bilezikian, J. Differences in free estradiol and sex honnone-binding globulin in women with and without premenstrual dysphoric disorder. Journal of(~linical Endocrinology and Metabolism. 2008, 93(1), 96 102. Thys-Jacobs, S., Starkey, P., Bernstein, D., & Tian, J. Calcium carbonate and the premenstrual syndrome: Effects on premenstrual and menstrual symptoms. American Journal ofObstetrics and Gynecology. 1998, 179, 444-452. Webster, D., Lu, J., Chen, S., Farsworth, N., Wang, J. Activation of the opiate receptor by Vitex agnus-castus methanol extracts: Implication for its use in PMS. Journal ofEthnopharmacology. 2006, 106, 216-221. Wysocki, S. (2008). Clinical challenges in women's health in the 21 st century: A practice handbookfor nurse practitioners. Cranbury, NJ: NP Communications. Yang, M., et ale Burden of premenstrual dysphoric disorder on health-related quality of life. Journal of Women's Health. 2008, 17(1), 113-121. Yonkers, K., et ale Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstetrics & Gynecology. 2005, 106(3), 492 501. PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY 16 APPENDIX A Daily Symptom Report 2.1--" ~- _ ..._ ... _.. j. ~- f-----. ... _..... . .....~ -- ··-l·~ ~ . __.~_. -l-.. I 4 I 1 5 i I I Severity scoring for each symptom: 0= No symptom 1= Minimal or slightly apparent to you 2 = Moderate, awareness of symptom but does not affect your daily routine 3 = A lot, continuously bothered by the symptom and/or symptoms interferes with your daily routine 4 = Severe, symptom is overwhelming and/or unable to carry out your daily routine Freeman, E., DeRubeis, R., & Rickels, K. Reliability and validity of a daily diary for premenstrual syndrome. Psychiatry Research. 1996, 65, 97. 17 PREMENSTRUAL DYSPHORIC DISORDER CONTROVERSY Appendix B l\1ed'icClj)(~ wwwmedscapc com OAllY RECORO OF SEVERITY OF PROBlEMS Please print and use as many sheets as you need for at least two FUll months of ratings. Nome or ""'rob MOOlh/Y'.XJr r<xh '",eOl"g nore ,h'! cl.<>g'ee 10 whichyo'J e~j>(l.ie"ced each 01 'he prQiJ.!lm" lis.ed below P,,' on "x" in the box which cOHespo1\OS '0 the ~,,·,e·';ly: I . not 0' 011, 2· ",iM;moL 3 . mild, A . nlodemre. 5 ·se,·ere, 6 . ex'.eme. ~~'n ra', 01 12 • 011 ·;'IYIr:·:! (t:1I~_L-.... 'j.-..rJ . ... , . _... f~~t tit'~re,~. wd, "dO"H1't ~o'!"!t '~0fH"}.,'.' {}oj '.,:)f -~hJC'~ f4!:.s WQ"hle':o$ rJ! eJi'!'r '2 ~t:J {ltll"Ov'. ,~.,~-=- "~"f'le..d IJ$}- t~ "(tfr od~tJ~ Hod mood 1W>09' I' n 'c'drlcnly foo! ,ng lod or 'CGr~!) cr ....'(1~ ..~n';.:rl·.1} t() ,(rr-e-(t.~ 0'" i~,~ wl!.ff) I~I~)' ~;Jn <. .s Hoa lo~" IltltJ~ot:-~t t..... IJfi., l{'~liX.I. \I~UQ,) G(k"t~q.. In to(fl.d ... 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' At J~'H' l")(,v d shit f",-,bl(!;'1\.fo ""'~N ~i'O«"""1] . i"'t<r -~(l'..J .....'ri'l rmoltOrnh1t:h ',., ,I~I .).J~;('f)- ~ - . , - Source J Pe-d at, Heall" Care @ 2000 Mosby, 1m; Claman, F, & Miller, T., Premenstrual syndrome and premenstrual dysphoric disorder in adolescence. Journal ofPediatric Health Care, 2006; 20(5): 329-333.