Accepted Manuscript

Prevalence and factors associated with premenstrual dysphoric

disorder: a community sample of young adult women

Adriana Bezerra de Carvalho , Taiane de Azevedo Cardoso ,

Thaı́se Campos Mondin , Ricardo Azevedo da Silva ,
Luciano Dias de Mattos Souza , Pedro Vieira da Silva Magalhães ,
Karen Jansen

PII: S0165-1781(17)32291-6
DOI: 10.1016/j.psychres.2018.06.005
Reference: PSY 11479

To appear in: Psychiatry Research

Received date: 13 December 2017

Revised date: 27 March 2018
Accepted date: 5 June 2018

Please cite this article as: Adriana Bezerra de Carvalho , Taiane de Azevedo Cardoso ,
Thaı́se Campos Mondin , Ricardo Azevedo da Silva , Luciano Dias de Mattos Souza ,
Pedro Vieira da Silva Magalhães , Karen Jansen , Prevalence and factors associated with pre-
menstrual dysphoric disorder: a community sample of young adult women, Psychiatry Research
(2018), doi: 10.1016/j.psychres.2018.06.005

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Highlights

 There is a high prevalence of Premenstrual Dysphoric Disorder in a young adult

sample;
 The high prevalence found should be interpreted considering the retrospective
assessment;
 PMDD is associated with older age, lower economic status, and no current
occupation;

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 PMDD presents comorbidity with mood and anxiety disorder, and with suicide

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risk;
 Clinicians should be alert to PMDD symptoms, specially in young adult women.

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Prevalence and factors associated with premenstrual dysphoric disorder: a community

sample of young adult women

Adriana Bezerra de Carvalho, MsCa, Taiane de Azevedo Cardoso, PhDa*, Thaíse Campos

Mondin, PhDa, Ricardo Azevedo da Silva, PhDa, Luciano Dias de Mattos Souza, PhDa, Pedro

Vieira da Silva Magalhães, PhDb, Karen Jansen, PhDa

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a
Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas,

Pelotas, RS, Brazil

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Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Universidade
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Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Corresponding author:
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Taiane de Azevedo Cardoso

Universidade Católica de Pelotas

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Address: 373, Gonçalves Chaves, Centro, Pelotas – RS – Brazil, Zip Code: 96015560
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Phone: +55 53 2128-8404 / Fax: +55 53 2128-8298

e-mail: taianeacardoso@hotmail.com
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Abstract

Premenstrual Dysphoric Disorder (PMDD) was recently included in DSM-5 as a full

diagnostic category. Few studies have investigated PMDD in a community sample of

young adults, especially in Brazil. Thus, the objective of this study was to evaluate the

prevalence and the factors associated with PMDD in a community sample of 727 young

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adult women between the 18 and 24 years of age in southern Brazil. This was a cross-

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sectional population-based study. The data were collected from 2012 to 2014. PMDD

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was assessed using the Mini International Neuropsychiatry Interview (M.I.N.I. – Plus).

The prevalence of PMDD was 17.6%. PMDD was significantly higher among older

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women, and in women from lower socio-economic status. A trend towards significance
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was found for women without a current occupation (study or work). The comorbidities

significantly associated with PMDD were current major depression disorder,

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agoraphobia, bipolar disorder, current suicide risk, generalized anxiety disorder, social

phobia, and specific phobia. The high prevalence found in the present study should be
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interpreted considering a retrospective report. However, our data showed that

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clinicians should be alert for PMDD symptoms, especially among young adult women.

Keywords: Premenstrual Dysphoric Disorder; community sample; comorbidities; young

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adults.
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1. Introduction

Premenstrual Dysphoric Disorder (PMDD) was recently moved to a full diagnostic

category in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This

disorder is characterized by psychological and physical symptoms, such as depressive

mood, anger, irritability, lack of interest, and internal tension. The symptoms often

occur in the final week before menstruation, reducing during the menstruation, and

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minimum or absent symptoms are observed in the week after the menstruation. It is

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important to highlight that these symptoms have negative effects on work, school, or

social activities (Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth

Edition, 2013).
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Approximately 70-90% women in their reproductive years experience at least
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some degree of premenstrual symptomatology (Mishell 2005). Premenstrual dysphoric

disorder (PMDD) is defined as the most severe form of PMS and its prevalence rate
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ranges from 3 to 8% (Halbreich et al. 2003). In the literature, the factors associated
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with PMDD are white skin color (Pilver et al. 2011), smoking (Cohen et al. 2002;

Wittchen et al. 2002), older age (Adewuya 2008 et al.; Pilver et al. 2011), a history of
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depression (Cohen et al. 2002; Wittchen et al. 2002) and a family history of psychiatric
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disorder (Akyol et al. 2013). PMDD has a significant impact on the daily and working

activities of women. It has also been significantly associated with other mental
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disorders (Wittchen et al. (2002). The impact of premenstrual symptoms and

premenstrual dysphoric disorder has been found to be equivalent to that seen in other

major disorders (Halbreich et al. 2003), which justifies the need for further studies.

Another aspect that should also be investigated is the high rate of comorbidity
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between PMDD and other psychiatric disorders (Adewuya et al. 2008; Wittchen et al.

2002; Kim et al. 2004).

The number of studies conducted on PMDD is increasing, however, more

studies are needed to characterize women with PMDD, by describing the main

comorbidities and estimating the magnitude of the effects of this disorder to be able

to test the effectiveness of treatment and prevention. It is worth noting that the

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majority of previous studies were performed using convenience sampling.

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Nonetheless, few studies on the field have been conducted with samples of individuals

from the community. To the best of our knowledge, only one study has investigated

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the impact of this disorder on young adult women.

Thus, the aim of the study was to investigate the prevalence and the factors
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associated with PMDD in a community sample of young adult women aged 21 to 32

years.
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2. Methods

This was a cross-sectional study nested in a cohort study entitled "Psychosocial

and Biological Factors in Bipolar Disorder: a population-based cohort of young adults",

in the city of Pelotas, RS (Brazil). The sample selection was performed by clusters

considering the population of 39,667 with ages ranging from 18 to 24 years, according

to current census of 448 sectors of the city (IGBE 2008). In order to assure the

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necessary sample size, 89 census-based sectors were randomly selected. The home

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selection in the sectors was performed according to a systematic sampling, the first

one being the house at the corner pre-established by the IBGE as the beginning of the

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sector, the interval of selection was determined by skipping two houses. After

identifying the subjects, 1762 young adults, between the ages of 18 and 24 years, were
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approached. Among these, 202 refused to participate in the study or were not found

after the identification. Therefore, the total sample consisted of 1560 young adults
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(880 women, and 680 men) in the first wave. The full description of the first wave has
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been previously published (Jansen et al. 2011). The second wave of data

collection began five years later. Individuals who took part in the initial assessment
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were invited to participate in a second wave interview. The young adults who met
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diagnostic criteria for a mental disorder were referred to a psychiatry outpatient care.

This study was approved by the Research Ethics Committee of the UCPel, according to
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protocol 2008/118.

The young adult women who accepted to participate in the study answered a

questionnaire to provide socio-demographic information that included age, race,

education level, current occupation (work or study), marital status, and if they had

children. The socio-economic status was assessed using the classification proposed by
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the Brazilian Association of Research Companies (ABEP 2008), which is based on the

total of material goods and the householder's schooling. In this study, “A+B” refers to

the highest economic level, “C” to middle class, and “D+E” to the lowest one.

PMDD was assessed only in the second wave. Information on current PMDD

and other Axis 1 psychiatric disorders was obtained using the Mini International

Neuropsychiatric Interview version Plus (M.I.N.I. – Plus). It is a short structured

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diagnostic interview developed for DSM-IV and ICD-10 psychiatric disorders (Sheehan

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et al. 1998). The MINI was administered to assess the PMDD using a retrospective

report of psychological and physical symptoms one week before menstruation,

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according to DSM-IV criteria. We have used the version translated to Brazilian

Portuguese by Amorin (2000). The validation was performed using a multicenter

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sample. The MINI reliability was overall satisfactory. Compared to various diagnostic

standard criteria (CIDI, SCID-P, and expert opinion) in different settings (psychiatric and
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primary care centers), MINI showed the same psychometric properties seen in more
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complex structured diagnostic interviews (Amorin, 2000). In our study, trained

psychologists administered the interviews.

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Data entry was performed using the Open Data Kit software and then
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submitted to statistical analysis using SPSS 22 for Windows and STATA 13. The

prevalence of PMDD was presented in absolute and relative frequencies. The chi-
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square test was used to assess the factors associated with PMDD and to describe the

prevalence of comorbid disorders in PMDD. Poisson regression was used to obtain

estimates of prevalence ratios (PR) and to adjust the analysis for potential

confounders. We considered potential confounding factors all variables associated

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with PMDD (p<0.20) in the crude analysis. Statistically significant associations were

considered when p<0.05.

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3. Results

A total of 880 young adult women were evaluated in the first wave. In the

second wave, 153 (17.3%) were losses or refusals, totaling 727 women. The majority of

women assessed in the second wave were between the ages of 26 and 30 years

(54.6%), white (70.2%), belonged to middle class (48.5%), were attending university

(41.1%), had a current occupation (73.0%), had a partner (71.9%), and had children

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(51.2%) (Table1).

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The prevalence of PMDD was 17.6%. In the raw analysis, its prevalence was

higher among women that were older (PR=1.48, CI 95%=1.06-2.06, p=0.018), not white

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(PR=1.41, CI 95%=1.02-1.94, p=0.037), belonged to lower economic status (PR=2.64, CI

95%=1.50-4.66, p=0.008), had no current occupation (PR=1.47, CI 95%=1.06-2.03,

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p=0.021) and had children (PR=1.49 CI 95%=1.08-2.06, p=0.015) (Table 1). In the

adjusted analysis, the factors associated with PMDD were older age (PR=1.44, CI
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95%=1.04-2.02, p=0.030), lower economic class (PR=2.16, CI 95%=1.12-4.17, p=0.022),

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and a trend towards significance for women without a current occupation (PR=1.36, CI

95%=0.96-1.93, p=0.081) (Table 2).

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Figure 1 shows the comorbidities associated with PMDD that include current
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major depressive disorder (PR=2.35, CI 95%=1.63-3.39, p<0.001), agoraphobia

(PR=1.86, CI 95%=1.30-2.67, p=0.001), bipolar disorder (PR=2.31, CI=1.60-3.33,

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p<0.001), current suicide risk (PR=1.98, CI 95%=1.33-2.96, p=0.002), generalized

anxiety disorder (PR=1.74, CI 95%=1.15-2.61, p=0.011), social phobia (PR=2.82, CI

95%=1.83-4.34, p<0.001), and specific phobia (PR=1.88, CI 95%=1.07-3.31, p=0.039). In

addition, we found a trend towards significance for panic attacks (PR=1.63, CI

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95%=0.94-2.82, p=0.100), and for abuse/dependence of illicit drugs (PR=1.62, CI

95%=1.01-2.61, p=0.057).

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4. Discussion

This study investigated the prevalence and the factors associated with PMDD

and found a 17.6% prevalence rate of current PMDD in a community sample of young

adult women. PMDD was more prevalent among older, and lower class women.

Additionally, the most prevalent comorbidities were major depressive disorder (MDD)

and bipolar disorder (BD), anxiety disorders (generalized anxiety disorder, social

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phobia, agoraphobia, and specific phobia), and current suicide risk.

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A prevalence rate of 2-8% of PMDD has been reported (Braverman 2007; Qiao

M et al. 2012). Studies assessing PMDD differ in relation to instruments/criteria used

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to evaluate this disorder. A study with university students in Nigeria (mean age of 22

years old) that utilized the same criteria as ours verified a prevalence rate of 6%
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(Adewuya et al. 2008). A study conducted in Brazil with university students (mean age

of 22 years old) found a prevalence rate of 6% (Carvalho et al. 2009). Our study differs
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from these regarding the sample selection and age span. Since the cited studies have
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only included university students with mean age of 22 years, we can hypothesize that

the high prevalence rate found in the present study could be explained by the
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characteristics of our sample (population-based sample) and a wider age span (22-30
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years old), and it is known that the higher prevalence is associated with the older age.

In addition, a possible explanation is that we have used a retrospective report, which

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may have included women with PMS. A systematic review found a prevalence rate

similar to our study but for subthreshold PMDD and it may have also included PMS

(Wittchen et al. 2002).

Studies assessing the factors associated with PMDD found that the variables

older age (Adewuya 2008 et al.; Pilver et al. 2011) and not having an occupation
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(Cohen et al. 2002) were significantly associated with this disorder. Our findings

confirmed this association. The association with these social variables could suggest

that symptoms may be expressions of generally distressing life situations.

Nevertheless, the variability in the prevalence of PMDD from culture to culture and in

its cross-cultural clinical presentation has not been systematically studied at this time.

So far, the available data have suggested that PMDD occurs across cultures at

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approximately comparable rates (Freeman and Sondheimer, 2003). In addition, it is

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important to highlight that the etiology of PMDD is still unknown. The hypothesis is

that the disorder is probably associated with a serotoninergic dysregulation. Studies

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did not find consistent alterations in gonadal steroids in PMDD. Instead, it appears

that normal cyclical changes in sex hormones serve as a trigger for serotonergic
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dysregulation (Freeman and Sondheimer, 2003).

In our study, we found higher rates of major depressive disorder, bipolar

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disorder, agoraphobia, generalized anxiety disorder, social phobia, specific phobia, and
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current suicide risk in women with PMDD compared to population control women. The

high rate of comorbidity between PMDD and MDD is very well described in the
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literature (Padhy et al., 2015). Possibly, this high rate could be justified by the overlap
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of symptoms among these disorders. A recent study showed that

the comorbidity between PMDD and bipolar disorder is associated with worse clinical
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outcomes of bipolar disorder (Slyepchenko et al., 2017). Therefore, early detection of

PMDD is important to better manage the treatment. With regards to other psychiatric

comorbidities, it is also important to highlight that in our sample, women with PMDD

seemed to be two or three times more likely to report suicide risk than women

without PMDD. In a recent case-control study that assessed women admitted to a

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general hospital due to a suicide attempt and found a higher prevalence of PMDD

among women who attempted suicide as compared to controls (Shams-Alizadeh et al.,

2018). These findings suggest that there is a strong association between suicidality and

PMDD. Our data are also in agreement with those reported in the literature that focus

on the comorbidity of PMDD and anxiety (Adewuya et al. 2008). In addition, the

literature also describes high rates of comorbidity between PMDD and bulimia nervosa

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(Nobles et al., 2016). Unfortunately, the eating disorders were not evaluated in the

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present study.

The study has some limitations. First, it did not evaluate the use of

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contraceptive medication. It is known that the contraceptive medication could be

associated with higher severity of depression (Bianco et al., 2004), and in the DSM-
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5, PMDD appears in the depressive disorders section. Second, we did not assess the

age of menarche, teenage pregnancy, abortions, as well as the age of sexual initiation.
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It is also known that teenage pregnancy (Ramirez et al., 2015), abortions (Ramirez et
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al., 2015; Pedersen, 2008), and early sexual initiation are associated with depression in

women (Gonçalves et al., 2017). Third, it was a cross-sectional study, therefore, it was
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impossible to infer causality, once we did not evaluate PMDD in the first wave of the
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study. Finally, our study and the majority of studies have used retrospective reports to

assess PMDD. It should be emphasized that the MINI-Plus provides a probable

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diagnosis of PMDD. Given the poor prospective validity of retrospectively-reported

premenstrual symptoms, this cyclical symptom pattern must be confirmed by

prospective daily symptom ratings. The different prevalence rates of PMDD found

among the studies could be explained by the different measures used to assess this

disorder. It would be helpful to use standard instruments for this purpose. The fact
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that this was a pioneer study carried out in Brazil with a large community-based

sample of young adult women is highly interesting.

In conclusion, our study found a high prevalence rate of PMDD in a Brazilian

community sample of young adult women. The disorder was associated with older age,

lower economic class, and a trend towards significance for those with no current

occupation women. Moreover, PMDD showed significant comorbidity with mood

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disorders (MDD and BD), anxiety disorders (generalized anxiety disorder, social phobia,

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agoraphobia, and specific phobia), and current suicide risk. Considering the high

prevalence rate of PMDD among young adult women and its association with other

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psychiatric disorders, it is of upmost importance to identify and provide the

proper treatment to improve their quality of life.

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Acknowledgements

This study was supported by grant from the following Brazilian governmental

agencies: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq),

Fundação de Amparo a Pesquisa do Estado do Rio Grande do Sul (FAPERGS) and

(CAPES).

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Figure 1: Prevalence of comorbidities associated with Premenstrual Dysphoric Disorder

(PMDD).

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*Statistically significant differences as compared to population control (p<0.05).

Legend: Major Depressive Disorder (MDD), Obsessive Compulsive Disorder (OCD),

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Generalized Anxiety Disorder (GAD).

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Table 1: Association between sociodemographic characteristics and Premenstrual Dysphoric

Disorder (PMDD) in a community sample of young adult women.

Sample
PMDD
Variables distribution PR (95% CI) p value
n (%)
n (%)

Age 0.018
21 to 25 years old 330 (45.4) 46 (13.9) 1.00

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26 to 32 years old 397 (54.6) 82 (20.7) 1.48 (1.06-2.06)

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Race 0.037
White 510 (70.2) 80 (15.7) 1.00

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Not white 217 (29.8) 48 (22.1) 1.41 (1.02-1.94)

Education status 0.161

Primary school
High school
University
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223 (30.7)
205 (28.2)
299 (41.1)
44 (19.7)
41 (20.0)
43 (14.4)
1.37 (0.93-2.01)
1.39 (0.94-2.05)
1.00
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Socioeconomic status (SES) 0.008
High class (A+B) 351 (48.3) 52 (14.8) 1.00
Middle class (C) 352 (48.5) 66 (18.8) 1.26 (0.91-1.76)
M

Low class (D+E) 23 (3.2) 9 (39.1) 2.64 (1.50-4.66)

Current occupation (study or work) 0.021

ED

No 196 (27.0) 45 (23.0) 1.47 (1.06-2.03)

Yes 531 (73.0) 83 (15.6) 1.00
PT

Have a partner 0.504

No 204 (28.1) 39 (19.1) 1.12 (0.80-1.58)
Yes 523 (71.9) 89 (17.0) 1.00
CE

Have children 0.015

No 355 (48.8) 50 (14.1) 1.00
Yes 372 (51.2) 78 (21.0) 1.49 (1.08-2.06)
AC

Total 727 (100) 128 (17.6) --- ---

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 ACCEPTED MANUSCRIPT

Table 2: Adjusted analysis for factors associated with Premenstrual Dysphoric

Disorder in a community sample of young adult women.

Variables** PR (95% CI)* p value

Age
22 to 25 years old 1.00
26 to 30 years old 1.44 (1.04-2.02) 0.030

Race

T
White 1.00

IP
Not white 1.20 (0.84-1.70) 0.316

Education status

CR
Primary school 0.84 (0.50-1.42) 0.520
High school 1.03 (0.67-1.58) 0.891
University 1.00

Economic classification
High class (A+B)
US 1.00
AN
Middle class (C) 1.16 (0.80-1.70) 0.432
Low class (D+E) 2.16 (1.12-4.17) 0.022

Current occupation (study or work)

M

No 1.36 (0.96-1.93) 0.081

Yes 1.00
ED

Have children
No 1.00
Yes 1.29 (0.89-1.87) 0.182
PT

*Analysis performed by Poisson regression.

** All variables were included in the model at the same level, and adjust to
CE

each other
AC

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