Eating Disorders in Premenstrual Dysphoric Disorder: A Neuroendocrinological Pathway to the Pathogenesis and Treatment of Binge Eating

By Dahlgren, Camilla Lindvall; Qvigstad, Erik | Journal of Eating Disorders, October 25, 2018 | Go to article overview

Eating Disorders in Premenstrual Dysphoric Disorder: A Neuroendocrinological Pathway to the Pathogenesis and Treatment of Binge Eating


Dahlgren, Camilla Lindvall, Qvigstad, Erik, Journal of Eating Disorders


Author(s): Camilla Lindvall Dahlgren[sup.1] and Erik Qvigstad[sup.2,3]

Background

Premenstrual dysphoric disorder (PMDD) is a DSM-5 [1] depressive disorder (for diagnostic criteria, see Table 1), and the most severe form for premenstrual distress [2] affecting 3-5% of pre-menopausal, menstruating females [3]. The disorder comprises a cluster of cyclically occurring affective, behavioral and somatic symptoms, with some the most essential features being marked depressed mood, anxiety, anger/irritability, decreased interest in daily activities, social withdrawal and appetite changes [4, 5]. The pathogenesis of PMDD is not fully understood, but it is likely to have multiple biological, psychological and sociocultural determinants [4]. In recent years, research has focused largely on the role of serotonin in the pathophysiology of PMDD, and the effect of neuromodulation on PMDD symptoms, in particular antidepressants in the selective serotonin reuptake inhibitor (SSRI) class [6]. Findings showing rapid symptom relief using SSRIs support the role of serotonin in the etiology of PMDD, and is currently the recommended first line treatment for the disorder [7]. However, not all patients respond to SSRI treatments [8], and for some, side effects may preclude ongoing therapy [9]. For a selected group of patients where SSRIs are not acceptable, suppression of cyclical ovarian activity using a gonadotropin-releasing hormone (GnRH) agonist is often the next step. In combination with a low-dose estrogen replacement, this approach is highly effective in reducing, often completely alleviating PMDD symptoms [6]. A small number of patients do, however, tolerate GnRH agonist treatment poorly, preventing long-term use. For these patients, bilateral salpingo-oophorectomy (BSO) (i.e. the removal of both ovaries and both fallopian tubes) to induce surgical menopause may be considered as a last resort measure [6]. The vast majority of studies documenting post-surgery outcome, including treatment satisfaction, support the use of BSO in the treatment of PMDD [10-12].

Premenstrual Dysphoric Disorder (PMDD) diagnostic criteria according to the DSM-5

The severity of symptoms is the key component of PMDD in that they cause clinically significant, often severely disabling, distress or interference in daily functioning. The most severe PMDD symptoms reported are often those related to mood (e.g. depression, anxiety, anger/irritability), but a number of somatic symptoms also contribute to luteal phase impairments. One of these is the marked change in appetite, overeating and/or specific food cravings (see Table 1, Criterion C4). Cyclic variations in food intake has been documented in several studies, with binge eating (i.e. eating large amounts of food within a limited period of time while experiencing feelings of loss of control) being more pronounced during the luteal phase [13, 14]. The link between excessive energy intake or hunger, i.e. hyperphagia [15], and binge eating in PMDD, however, remains elusive. It is not unlikely, though, that a proportion of those with PMDD who experience hyperphagia engage in binge eating behaviors, and that an additional few fulfill criteria for binge eating disorder (BED) and/or bulimia nervosa (BN). If binge eating can be fully explained by the presence of PMDD, i.e. that is state-dependent and only manifests when the disorder is active, one would expect individuals to "lose" their binge eating behavior when they no longer have PMDD. The current case report details the pre- and post-operative outcome of an adult female with co-occurring binge eating and PMDD who did, in fact, "lose" her eating disorder parallel to recovering from PMDD. To our knowledge, this is the first study to illustrate the immediate recovery (following DSM-5 criteria) from a long-term eating disorder following this surgical procedure.

Case presentation

The patient was a 39-year old female, self-presenting for treatment for severe PMDD. …

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