What is the recommended approach to assess a patient for Premenstrual Dysphoric Disorder (PMDD)?

Assessment of Premenstrual Dysphoric Disorder (PMDD)

The recommended approach for assessing PMDD requires prospective daily symptom tracking over at least two menstrual cycles using validated instruments like the Daily Record of Severity of Problems (DRSP) to confirm the timing of symptoms and rule out other conditions.

Diagnostic Criteria and Assessment Tools

• PMDD diagnosis requires symptoms that occur exclusively during the luteal phase (two weeks before menses) with a symptom-free interval after menstruation and before ovulation 1
• The Daily Record of Severity of Problems (DRSP) is the recommended assessment tool as it mirrors the diagnostic criteria for PMDD in DSM-IV and includes assessments for mood, physical symptoms, and other symptoms 2
• Prospective symptom charting over at least 2 menstrual cycles is essential to confirm the timing of symptoms and rule out other diagnoses 3
• Other validated assessment tools include the Hamilton Depression Rating Scale (HAMD-17) and the Clinical Global Impression Severity of Illness (CGI-S) and Improvement (CGI-I) scores 2

Key Symptoms to Assess

• Core symptoms include depressed mood, anxiety, affective lability, and irritability 3
• Physical symptoms may include breast tenderness, bloating, headache, and joint/muscle pain 4
• Symptoms must cause significant distress or functional impairment in work, school, social activities, or relationships 3
• Symptoms must be absent or minimal during the follicular phase (after menstruation and before ovulation) 1, 4

Differential Diagnosis

• Rule out other medical conditions that may cause similar symptoms, such as thyroid disorders and diabetes 1
• Distinguish from psychiatric conditions like major depressive disorder, dysthymia, and anxiety disorders 1, 3
• Consider that PMDD symptoms worsen premenstrually but are absent during the follicular phase, whereas other psychiatric disorders typically persist throughout the menstrual cycle 4

Assessment Process

1. Initial Screening: Use standardized questionnaires to identify potential PMDD 5
2. Prospective Symptom Tracking: Have patient complete daily symptom diaries for at least two menstrual cycles 3, 4
3. Symptom Pattern Analysis: Confirm cyclical pattern with symptoms appearing during luteal phase and resolving shortly after menstruation begins 6
4. Severity Assessment: Determine if symptoms cause clinically significant distress or functional impairment 4
5. Differential Diagnosis: Rule out other medical and psychiatric conditions 1, 3

Common Pitfalls to Avoid

• Relying solely on retrospective reporting, which is often inaccurate and may lead to misdiagnosis 5, 4
• Failing to use validated assessment tools specifically designed for PMDD 2
• Not collecting sufficient data across multiple menstrual cycles to establish the cyclical pattern 3
• Confusing normal premenstrual symptoms with clinically significant PMDD 4
• Not distinguishing between PMDD and exacerbation of underlying psychiatric disorders during the premenstrual phase 1, 3

Treatment Considerations After Diagnosis

• Sertraline has been shown to be effective for PMDD in placebo-controlled trials, administered either daily throughout the menstrual cycle or only during the luteal phase 2
• SSRIs are generally considered first-line pharmacological treatment for PMDD 7
• Continuous SSRI administration appears more effective than luteal phase dosing for symptom reduction 7
• Non-pharmacological approaches including dietary modifications and exercise may be beneficial for some patients 1

By following this systematic assessment approach, clinicians can accurately diagnose PMDD and distinguish it from other conditions with similar presentations, leading to appropriate treatment selection and improved outcomes for patients.