A 33-year-old woman comes to the office due to weight gain and low self-confidence. She says, "I've always had trouble with my weight and mood swings. I've gained 11 pounds [5 kg] in the last 2 years and feel horrible about myself. I go through this cycle in which I feel good, stick to a diet, and exercise for a couple of weeks, but then my mood gets really down. I start eating junk food and feel bloated until I get my period." The patient is also upset about a recent fight with her best friend, saying "I blame myself because I am much more irritable before my period, and I lashed out at her for no reason. The following week I felt much better, but the damage was done." The patient has struggled with moodiness and being overweight for most of her adult life. She says, "I hate when I feel this way because, generally, I'm a pretty upbeat person." Physical examination and laboratory evaluation are unremarkable. BMI is 29 kg/m². Which of the following is the most likely diagnosis?

Question

Quizplus · Accepted Answer

This patient's cyclical pattern of overeating, mood swings, and irritability, which worsen prior to menstruation and resolve for a few weeks at a time, is suggestive of premenstrual dysphoric disorder (PMDD). PMDD, a severe variant of premenstrual syndrome (PMS), is characterized by prominent mood symptoms, including sadness, mood swings, anger, anxiety, irritability, and decreased interest, as well as fatigue, changes in appetite, and physical discomfort (eg, bloating, breast tenderness). These mood symptoms decrease in intensity or resolve completely after menstruation. Mood changes in the premenstrual phase are common, requiring differentiation of PMS and PMDD from premenstrual worsening of another medical or psychiatric condition. For example, patients with persistent depressive disorder (dysthymia), a chronic form of depression, may describe premenstrual exacerbation of depressive symptoms. However, careful history-taking in such a patient shows that depressive symptoms are present at other times during the menstrual cycle (Choice E), unlike in this patient, who has 2 weeks of feeling good before the mood changes occur. The accurate diagnosis of PMDD requires prospective daily ratings for ≥2 cycles demonstrating a symptom-free period in the follicular phase. (Choices A and C) Both binge-eating disorder and bulimia nervosa are characterized by episodes of excessive, uncontrollable eating within a specified period (eg, 1-2 hr) that occur at least once a week for 3 months. In bulimia nervosa, this is accompanied by compensatory behaviors such as fasting, laxative abuse, or excessive exercising. Compared with patients with these eating disorders, this patient describes a more cyclical pattern of overeating, together with mood lability and irritability, findings consistent with PMDD. (Choices B and D) Although irritability can be a symptom of hypomania, as seen in bipolar II and cyclothymic disorder, this patient does not have a history of other hypomanic symptoms (eg, increased energy, decreased need for sleep, pressured speech, grandiosity), which is required to diagnose these disorders. Educational objective: Premenstrual dysphoric disorder is characterized by cyclical mood swings, irritability, appetite changes, and physical discomfort that resolve after menses. It is not diagnosed when premenstrual mood symptoms represent an exacerbation of an underlying disorder in which the symptoms are not limited to the premenstrual phase. References: Premenstrual dysphoric disorder: epidemiology and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/26377947) Premenstrual disorders. (http://www.ncbi.nlm.nih.gov/pubmed/28571724)

A 33-Year-Old Woman Comes to the Office Due to Weight