Complex post-traumatic stress disorder and pre-menstrual dysphoric disorder

To the editor

Pre-menstrual dysphoric disorder (PMDD) is characterised by behavioural, cognitive and physical symptoms that cause clinically significant distress or psychosocial impairment. These symptoms typically commence in the pre-menstrual week and last into early menses (American Psychiatric Association, 2013).

Louise (pseudonym) is a woman in her early 20s who presented with symptoms of PMDD such as mood swings, irritability, profound fatigue and difficulties concentrating. Delving further into her past, Louise revealed a history of traumatic events leading to profound emotional neglect during her childhood. Consistent with complex post-traumatic stress disorder (cPTSD – International Classification of Diseases 11th Revision [ICD 11]), Louise also reported feelings of low self-esteem, difficulties in maintaining friendships/relationships and episodes of dissociation/depersonalisation.

Numerous studies have found that women who experience trauma are more likely to present with PMDD in later life, as was seen in Louise’s case. In particular, one study found that of the women with PMDD, 18% had a history of early trauma, whereas only 3.2% of women without PMDD had the same history (Beddig et al., 2019).

During times of stress, the body releases cortisol which is known to cause disruption to neuroendocrine systems (via the hypothalamus–pituitary–adrenal [HPA] axis) and the autonomic nervous system (Heim et al., 2010). In particular, the HPA axis is modulated by ovarian hormones, and dysregulation of these systems, especially in early life, can result in abnormal changes to the pathways that control ovarian function. This may explain why women like Louise are prone to developing abnormal mood reactions to normal cyclical changes in ovarian hormones (Eisenlohr-Moul et al., 2016).

In terms of treating PMDD, it seems that the newer oral contraceptive pill (normegestrol acetate + oestradiol) is effective (Kulkarni, 2020). Biopsychosocial management including hormone intervention, psychotherapy for trauma work and reviewing social issues is a useful way forward.