Case of the month:

“PMDD” which isn’t

This case came from one of our colleagues: 

A 26 year-old female without prior psychiatric history presents for a consultation upon the recommendation of primary care. Both primary care and gynecology have diagnosed pre-menstrual dysphoric disorder (PMDD). In 2014, primary care prescribed Sarafem (fluoxetine) for several months, "but it didn't do anything." Primary care also recommended this consultation for an ADHD evaluation. The patient has taken a friend's ADHD medication (Adderall 5-10mg) and "it brings me up to par. It just really helps with the lows and the attention." The patient describes a long history, since teenage years, of alternating mood cycles. She only became aware of them in 2012 when she experienced several months of continuous depressive symptoms after a family death. She reports that about 14 days before menses she develops significant depressive symptoms, especially very low energy (“it just completely dives”), poor motivation ("don't even want to get out of bed”), no desire to socialize and very low mood.  At the same time, attention and thinking are poor (“I feel like there is this film over my brain, a hard time thinking and articulating things”). In contrast, the other two weeks of the month (at menses and onward), she experiences the opposite: "I'm just motivated, doing a lot better. It's the way I should be feeling all month long." She reports being productive at work, bright and optimistic, "but I think my mood is usually optimistic." The patient reports chronic sleep impairment and racing thoughts since teenage years: "I have always been a night-owl... My brain is incredibly more active at night time. I have a hard time shutting my mind off in the evenings." There are periods where sleep is worse and she averages 6 hours at night, (1am-730am), but she still has good energy. She denies past manic episodes. In reference to the 2 weeks of elevated mood, energy, and thinking, she denies these as above her baseline: “I feel like this is how I should be. I just feel more organized. I have more motivation to do the small things like working out or doing chores."  

She recently had another consultation with a psychiatrist who agreed with the PMDD diagnosis but referred her back to her gynecologist. "He said there is nothing behaviorally he could do for me. He said what was happening was a chemical process and I should go back to gynecology."  Past medical history is notable for past ovarian cysts s/p excision x 2 (emergency surgery after a rupture). She has taken several oral contraceptives but each caused various psychiatric side effects: "a few months where I felt depressed 24/7." 

Family history is as follows: Maternal aunt: was "treated for some depression throughout her life." Father "is like me in a lot of ways, hyper focused sometimes and stays up late;" also a "procrastinator like me." Brother is diagnosed with ADHD and uses stimulants, "but I think he just uses it for a high stress job." 

She had no behavioral or academic problems throughout schooling, with a high school GPA of 3.5. She was active with many hobbies including tennis, soccer, and softball. Mother has told patient that she has suspected patient was periodically depressed in high school. 

She denies any physical symptoms associated with menses - no bowel changes, cramping, bloating, heavy bleeding, or headaches. Extensive laboratory testing for TSH, FSH, prolactin, and cortisol are all within normal limits.

During the consultation, her mental status examination was notable for: Hyperactivity (restless, fact and quick movements); pressured speech but interruptible; mood "pretty great!"; mildly euphoric affect - very animated, gregarious; and mild tangentiality requiring some redirection.

The colleague who sent this case had the following overall clinical impression:  

The case reflects a long history of mood cycles, which likely have less to do with her menses than with bipolar illness. Pre-menstrual dysphoric disorder is unlikely here because of (1) severity of symptoms between pre- and post menses cycles (2) lack of any physiologic symptoms associated with menses (no bloating or cramping) (3) chronic symptoms of insomnia and racing thoughts (which have nothing to do with PMDD but are a frequent feature of untreated bipolar) (4) family history being suspicious for mood cycling, likely in father (5) lack of response to Prozac, and (6) oral contraceptives induced depression. Timing of cycles may not be as clear-cut around menses as the patient believes, but hormonal exacerbations are likely happening. There is no indication that ADHD is present.

Questions for PL:

(1) Is PMDD a valid scientific construct? What about PMS?

(2) If this patient actually has underlying bipolar (type 2, rapid cycling?), what does the literature say about hormonal influences of mood cycles?

(3) What is the approach for medication management in this patient who disagrees that anything other than PMDD could be occurring?

(4) Is ADHD present?

To read the PL clinical impression for this case, please click here or subscribe!

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