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Premenstrual dysphoric disorders & peripartum psychiatric disorders DONE B Y : SA I F IMSEEH E D I T ED B Y : Introduction Premenstrual dysphoric disorder (PMDD) is: • a diagnosis used to indicate serious premenstrual distress with associated deterioration in functioning • a severely distressing and disabling condition that requires treatment. • characterized by depressed or labile mood, anxiety, irritability, anger, and other symptoms occurring exclusively during the 2 weeks preceding menses. • The symptoms must be severe enough to interfere with occupational and social functioning Epidemiology • Epidemiologic studies indicate that as many as 80% of women in the United States experience emotional, behavioral, or physical premenstrual symptoms.[Between 3% and 8% of women meet the diagnostic criteria for PMDD. • women in the late third to middle fourth decades of life are most vulnerable to experience PMDD Pathophysiology • Ovarian hormone hypothesis • Serotonin hypothesis • Psychosocial hypothesis • Cognitive and social learning theory • Sociocultural theory Signs and symptoms Signs and symptoms • The most common primary symptom of premenstrual dysphoric disorder (PMDD) is irritability • by depressed or labile mood • Anxiety • Anger • Decreased interest in usual activities • difficulty in concentrating • Lethargy, easy fatigability • change in appetite • pain Signs and symptoms • The symptoms must have been present for most of the time during the last week of the luteal phase. • must have begun to remit within a few days of the onset of menstrual flow. • must be absent in the week after menses. Risk factors • Personal history of a major mood disorder • A family history of mood disorder • Premenstrual depression • Premenstrual mood changes Diagnosis DSM V : • (A) ; that in most menstrual cycles during the past year, at least 5 of the following 11 symptoms (including at least 1 of the first 4 listed) were present: 1. Markedly depressed mood, feelings of hopelessness 2. Marked anxiety, tension 3. Marked affective lability 4. marked anger or irritability 5. Decreased interest in usual activities 6. difficulty in concentrating Diagnosis DSM V : 7- Lethargy, easy fatigability 8- Marked change in appetite 9- Hypersomnia or insomnia 10- A subjective sense of being overwhelmed or out of control 11- Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain Diagnosis DSM V : • (B) : that the symptoms must be severe enough to interfere significantly with social, occupational, sexual, or scholastic functioning. • (C) : the symptoms must be discretely related to the menstrual cycle and must not merely represent an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder • (D) : that criteria A, B, and C must be confirmed by prospective daily ratings during at least 2 consecutive symptomatic menstrual cycles. http://www.uptodate.com/contents/image?imageKey=ENDO%2F86743&to picKey=ENDO%2F7382&rank=1~150&source=see_link&search=premenstru al+dysphoric+disorder&utdPopup=true Management • Treatment of PMDD includes both nonpharmacological and pharmacologic therapies. Prognosis • PMDD is a multifactorial syndrome that occurs with varying degrees of severity and thus may have a range of potential adverse effects on work, social activities, and interpersonal relationships. • Upon treatment, symptoms tend to improve rapidly. After cessation of treatment, symptoms recur rapidly • Problems tend to recur each cycle • Problems may become more severe over time • Problems may not go away if ignored • Problems can be readily diagnosed and effectively treated Postpartum things.. • There are large changes in the levels of several psychologically active hormones over the peripartum period • Their evolutionary role is probably to help coordinate both parturition and the new maternal role of the mother • These large hormonal changes may also contribute to changes in mood in vulnerable women • caused by changes in biology, psychology, environment and hormones • Maternal anxiety and depression are the most common complications of childbirth. Postpartum things.. • Three types of postpartum disturbances: 1. Postpartum blues (“baby blues”) 2. Postpartum depression 3. Postpartum psychosis Baby blues • The postpartum blues, maternity blues, or baby blues is a transient condition that 75-80% of mothers could experience shortly after childbirth with a wide variety of symptoms which generally involve mood lability, tearfulness, and some mild anxiety and depressive symptoms. • Baby blues is not postpartum depression, Causes • After the placenta is delivered, the placental "hormone factory" shuts down causing radical changes in hormone levels, and the woman can suffer symptoms due to withdrawal from the high pregnancy levels of oestrogen, progesterone and endorphins. Combined with this shift in hormone levels is the physical, mental and emotional exhaustion - as well as sleep deprivation typical of parenting a newborn. All of these factors contribute to the condition. Symptoms • Weepiness and bursting into tears. • Sudden mood swings. • Anxiousness and hypersensitivity to criticism. • Low spirits and irritability. • Poor concentration and indecisiveness. • Feeling 'unbonded' with baby. • Restless insomnia. Postpartum depression • 6.8% to 16.5% of women experience postpartum depression (PPD) also known as postpartum major depression (PMD) • Onset can be as early as 24 hours or as late as several months following delivery Post-Partum Depression Emotional Symptoms • Increased Crying • Irritability • Hopelessness • Loneliness • Sadness • Uncontrollable mood swings • Feeling overwhelmed • Guilt • Fear of hurting self or baby Post-Partum Depression Behavioral Symptoms • Lack of, or too much, interest in the baby • Poor self-care • Loss of interest in otherwise normally stimulating activities • Social withdrawal and isolation • Poor concentration, confusion Post-Partum Depression Physical Symptoms • Exhaustion, fatigue • Sluggishness • Sleeping problems (not related to screaming baby) • Appetite changes • Headaches • Chest pain • Heart Palpitations • Hyperventilation Post-Partum Depression Risk Factors • Self or family history of mental illness or substance abuse • Marital or financial stresses • Birth complications • Lack of self-confidence as a parent • Problem’s with baby’s health • Major life changes around time of delivery • Lack of support or help with baby • The mother being of young age • Severe premenstrual syndrome Post-Partum Depression Treatment • Treatments can include: • • • • Counseling/psychotherapy Medication Support groups Self-help • For mild to moderate symptoms, focus less on pharmacological treatment and more on counseling and group therapy. • All antidepressants pass through breast milk. Post-Partum Depression Treatment • Medications: • First-line choices are SSRIs such as fluoxetine (Prozac) 10-60 mg/d, sertraline (Zoloft) 50-200 mg/d, paroxetine (Paxil) 20-60 mg/d, citalopram (Celexa) 20-60 mg/d, or escitalopram (Lexapro) 10-20 mg/d • SNRIs such as venlafaxine (Effexor) 75-300 mg/d or duloxetine (Cymbalta) 40-60 mg/d, are also highly effective for depression and anxiety. • ECT is effective for those with severe depression/psychosis “Baby Blues” vs. Post-Partum Depression Onset Baby Blues Onset at 3rd or 4th day postdelivery and can last from a few days to a few weeks Postpartum Depression Onset can be anytime one year after delivery “Baby Blues” vs. Post-Partum Depression Onset Baby Blues 70-80% of women will experience depressive symptoms that disappear within a few weeks. Postpartum Depression 10% experience some degree of postpartum depression which can last a year. Postpartum Psychosis • A very small number of women (less than .5%) • 0.1-0.2% incidence rate • Postpartum Psychosis is considered a medical emergency due to the potential for a mom to harm herself or her baby. Symptoms • Extreme confusion • Distrusting other people • Seeing things or hearing voices that are not there, which may seem like greater forces, like God or the devil • Thoughts of hurting herself, the baby, or others • Hopelessness • Inability to Sleep (even when exhausted) • Refusing to eat Postpartum Psychosis • Usually last days to 4-6 weeks • Tt: antidepressants , antipsychotics , possible inpatient hospitalization , assessment of child safety Pregnancy and Postpartum Anxiety Disorders • Up to fifteen percent (15%) of women will develop postpartum anxiety disorders • •Generalized anxiety disorder (GAD) - excessive worry or anxiety which the mother finds difficult to control and associated with restlessness, fatigue, irritability, muscle tension or insomnia. • •Obsessive-compulsive disorder (OCD)- including obsessions or thoughts that are persistent, frequently about hurting the baby and/or compulsions that are repetitive, ritualistic behaviors that the mother finds difficult to control • •Panic disorder - extreme anxiety with chest pains, dizziness, sweating, shaking, etc. often associated with a certain place or event. 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