NCP Premenstrual Dysphoric Disorder Premenstrual Syndrome

DSM-IV

Premenstrual dysphoric disorder (provided for further study)

Recommended for further systematic clinical study and research, Premenstrual Dysphoric Disorder (popularly called PMS) is characterized by multiple symptom clusters occurring during the menstrual cycle, becoming progressively disabling. Some research suggests these symptoms may be a delayed effect of hormonal changes earlier in the menstrual cycle, or the result of an independent cyclical mood disorder that is synchronized with the menstrual cycle. Although the physical symptoms produce discomfort, the mood change or premenstrual negative affect symptoms are often more distressing, interfering with familial, social, and work-related activities. The condition usually improves after the onset of menses; however, for some women, symptoms persist through and after menses. The symptoms cannot result solely from cyclic or environmental stress but may be enhanced by these stressors. This diagnosis is not used when the person is experiencing a late luteal phase exacerbation of another disorder, such as major depression, panic disorder, or dysthymia.

ETIOLOGICAL THEORIES

Psychodynamics

Although etiology is not understood, symptoms are believed to be related to the interaction of psychological, social, and biological factors. Underlying personality and psychiatric conditions contribute to how any particular individual deals with these physical problems. An individual’s past and present negative attitudes toward menstruation are likely to influence the symptomatology of Premenstrual Dysphoric Disorder. Emotion is the result of complex interactions between hormonal changes and cognitive variables. Hormonal changes during the menstrual cycle are likely to increase the female’s susceptibility to negative psychological experiences rather than to cause such experiences.

Biological

Although not completely understood, it may be related to the alterations (fluctuations) in estrogen and progesterone and the fluid-retaining action of estrogen during the menstrual cycle. Estrogen excess/deficiency, progresterone deficiency, vitamin deficiency, hypoglycemia, and fluid retention have all been proposed to contribute to Premenstrual Dysphoric Disorder. In addition, levels of androgen, adrenal hormones, and prolactin have been hypothesized to be important in the etiology of this syndrome. Finally, an increase in prostaglandins secreted by the uterine musculature has been implicated in accounting for the pain associated with this disorder.

Family Dynamics

The behaviors associated with this disorder may be learned through modeling during the socialization process. Children may observe and identify with this behavior in significant adults and incorporate it into their own responses as they grow up. Positive reinforcement in the form of primary or secondary gains for these behaviors may perpetuate the learned patterns of disability.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Decreased interest in usual activities; lack of regular exercise

Sleep disorders (hypersomnia, insomnia)

Fatigue, lethargy; restlessness

Circulation

Heart pounding/palpitations

Increased sweating/diaphoresis

Ego Integrity

Changes in body image (e.g., feeling fat, ugly)

Anxiety, feelings of being unable to cope, sense of loss of control/powerlessness

Mood swings; irritability, frustration, crying spells

Elimination

Urinary frequency or retention, oliguria; recurrent cystitis

Constipation; diarrhea

Food/Fluid

Increased appetite/food craving (e.g., sugar)

Nausea, vomiting

Poor nutritional habits; overeating

Difficulty maintaining a stable weight/transient weight gain

Abdominal bloating

Swelling of extremities, generalized edema

Neurosensory

Headaches (classic migraine)

Dizziness or fainting, vertigo, syncope

Paresthesias of extremities; trembling

Visual disturbances; ringing in ears

Aggravation of seizure activity

Mental Status

Decreased concentration, forgetfulness, confusion

Sense of depersonalization

Nervous tension, impatience, anger, hostility, aggressiveness

Personality changes (mood swings) not unlike Jekyll and Hyde (e.g., feeling happy or serene during the follicular phase of the menstrual cycle and tense, irritable, and depressed beginning any time in the luteal phase but primarily during the last week), occurring during most menstrual cycles and ceasing at the onset of the menstrual period

Irrational thought processes involving guilt or suicide

Pain/Discomfort

Abdominal cramping

Breast tenderness, joint and muscle stiffness/pain, backache

Respiration

Nasal congestion

Hoarseness

Aggravation of asthmatic episodes

Safety

Skin changes: acne, neurodermatitis; easy bruising

Conjunctivitis

Suicidal ideation/attempts

Sexuality

Intolerance or multiple side effects to birth control pills (however, a small percentage of women report improvement in condition)

Breast swelling

Changes in sexual drive

History of pregnancy-induced hypertension

Social Interactions

Interference with the quality of life (home, social, and work)

Difficulty with relationships

Nagging behavior/interactions

Teaching/Learning

Age of onset may be any time after menarche but may not be noticeable until the 20s (may not seek treatment until 30s or 40s, when the symptoms worsen)

May have close female relative(s) with similar problems

Alcohol/other drug intolerance or addictions

DIAGNOSTIC STUDIES

As indicated by individual situation, dependent on age, medication, therapy, family history, and symptomatology and may include testing to rule out general medical conditions that may present with dysphoria and fatigue exacerbated during the premenstrual period (e.g., seizure disorders, thyroid/other endocrine disorders, cancer, systemic lupus erythematosus, anemias, endometriosis, and various infectious processes).

Measurement of Circulating Reproductive Hormones and/or Daily Self-Rating: Determines the timing of luteal and follicular phases in women who have had a subtotal hysterectomy.

Serum Progesterone and Estradiol 17 (Midluteal Phase): Assesses inadequate luteal phase.

Serum Prolactin and TSH: Rules out pituitary/thyroid abnormalities in client with galactorrhea.

Adrenal Suppression Test: Locates source of androgen excess and serves as a guide for therapy for clients with hirsutism.

Abraham Menstrual System Questionnaire (MSQ), the Dalton Diagnostic Checklist (or Similar Premenstrual Symptoms Worksheet), and Calendar of Premenstrual Symptoms (Minimum 2 Months): Self-reporting tools to determine cycles of symptoms and degree of impairment.

Psychological Assessment: Minnesota Multiphasic Personality Inventory (MMPI) administered twice—once during the follicular phase of the menstrual cycle and again during the luteal phase (preferably the client’s most critical day) of the menstrual cycle to identify psychological components and degree of impairment.

NURSING PRIORITIES

1. Provide emotional support and relief of symptoms.

2. Present information about condition/healthcare needs and resources.

3. Encourage adoption of a lifestyle promoting health and diminishing premenstrual symptoms.

DISCHARGE GOALS

1. Assertive behavior/stress-management techniques used to manage problems.

2. PMS condition understood and sources for assistance are identified.

3. Lifestyle changes to promote health/diminish symptoms implemented.

4. Family/SO participating in treatment process.

5. Plan in place to meet needs after discharge.