Cognitive therapy for premenstrual syndrome: A controlled trial

doi:10.1016/S0022-3999(98)00042-7

Journal of Psychosomatic Research

Volume 45, Issue 4, October 1998, Pages 307-318

https://doi.org/10.1016/S0022-3999(98)00042-7 Get rights and content

Abstract

The aim of this study was to evaluate the effectiveness of cognitive therapy (CT) as a psychological treatment for premenstrual syndrome (PMS), by comparison with a waitlist control group. Women meeting selection criteria for PMS were randomly allocated to one of two treatment groups: (i) an immediate treatment group, who received 12 weekly sessions of individual CT; or (ii) a waiting list group who recorded symptoms of PMS for a length of time equivalent to the duration of an individual treatment in the immediate treatment group. General practitioners and gynecologists referred women who were complaining of distressing and disabling emotional and physical symptoms in the second half of the menstrual cycle, as verified by 2 months of prospective diary recording. Assessments of the women’s psychological and social functioning were made on entry to the study, 2 months later, and at the end of the treatment period. This design allows evaluation of the efficacy of CT relative to any spontaneous remission that may have occurred as a consequence of the passage of time, the keeping of menstrual diaries, interview, and self-rated assessments. Results indicated that CT was significantly more effective than assignment to the waitlist group. Diary measures and self-report questionnaires indicated an almost complete remission of psychological and somatic symptoms and of impairment of functioning. It is concluded that CT for PMS is associated with substantial improvements that cannot be attributed to the passage of time or the completion of the diary and other assessments.

Section snippets

Overview

Women complaining of premenstrual symptoms were referred by general practitioners and gynecologists in Oxford. During an initial period of 2 months, these women completed daily diaries of premenstrual symptoms. These diaries were used to select women with PMS as defined by specific criteria explained in what follows.

Women meeting the selection criteria were randomly allocated to one of two groups: (i) an immediate treatment group, who began cognitive therapy within 2 weeks of allocation; or

Results

The main findings are shown in Table I. For all women, before treatment, levels of general psychopathology, marital distress, and social adjustment were in the range usually considered mild. This reflects the study referral criteria, in which the referring physician was asked not to refer women they regarded as suffering from diagnosable psychiatric disorders. The two groups did not differ in their initial ratings; except for one instance (p>0.25). The scores for global rating of impairment

Discussion

In the present study, cognitive therapy for premenstrual syndrome (PMS) was found to be associated with significant improvements on a range of measures, which included measures of PMS symptoms, associated impairments, and depression. The limited follow-up data available suggest that the gains made at the end of cognitive-behavioral treatment were maintained for at least 4 months, and there was no sign of any tendency to lose the gains made. General ratings of social adjustment and of quality of

Acknowledgements

Acknowledgments—The study was supported by the Medical Research Council and the Oxford Regional Health Authority. Paul Salkovskis is a Wellcome Trust Senior Research Fellow. The authors are grateful to the gynecologists and general practitioners for their cooperation.

References (33)

D.M. Clark
A cognitive approach to panic
Behav Res Ther
(1986)
J.M. Watson
Relevant and irrelevant fear in floodinga crossover study of phobic patients
Behav Ther
(1971)
F. Blake et al.
Psychological aspects of premenstrual syndromedeveloping a cognitive approach
M. Anderson et al.
Premenstrual syndrome researchusing the NIMH guidelines
J Clin Psychiatry
(1988)
R.L. Spitzer et al.
Late luteal phase dysphoric disorder and DSM-III-R [see comments]
Am J Psychiatry
(1989)
American Psychiatric Association
Diagnostic and statistical manual of mental disorders
(1987)
American Psychiatric Association
Diagnostic and statistical manual of mental disorders
(1994)
B. Parry
Biological correlates of premenstrual complaints
A.L. Magos et al.
Treatment of the premenstrual syndrome by subcutaneous estradiol implants and cyclical oral norethisteroneplacebo controlled study
BMJ Clin Res Ed
(1986)
Watson NR, Studd JW, Savvas M, Garnett T, Baber RJ. Treatment of severe premenstrual syndrome with oestradiol patches...

S. Hammarback et al.

Induced anovulation as treatment of premenstrual tension syndrome. A double-blind cross-over study with GnRH-agonist versus placebo

Acta Obstet Gynecol Scand

(1988)

A.L. Magos et al.

The effects of norethisterone in postmenopausal women on oestrogen replacement therapya model for the premenstrual syndrome

Br J Obstet Gynaecol

(1986)

A.J. Rapkin

The role of serotonin in premenstrual syndrome

Clin Obstet Gynecol

(1992)

J. Bancroft et al.

Premenstrual syndrome

Clin Endocrinol Oxf

(1985)

J. Ussher

Research and theory related to female reproductionimplications for clinical psychology

Br J Clin Psychol

(1992)

A.E. Reading

Cognitive model of premenstrual syndrome

Clin Obstet Gynecol

(1992)

Cited by (129)

Premenstrual dysphoric disorder (PMDD): Drug and psychotherapeutique management, a literature review
2024, Encephale
Le trouble dysphorique prémenstruel (TDPM) est reconnu pour la première fois en juillet 2013 dans le DSM-5 après un long parcours pour identifier son existence. Ce n’est qu’en 1983 que l’institut national de la santé mentale américaine détermine des critères de recherche pour l’étude sur le syndrome prémenstruel. En 1994, Le terme « trouble dysphorique prémenstruel » (TDPM) remplace ce terme dans la quatrième édition du Diagnostic System Manuel (DSM), il est inscrit dans la section « Trouble de l’humeur non spécifié » et restera à l’étude jusqu’au DSM-5, dans lequel il apparaîtra dans la section des troubles dépressifs. La légitimation du diagnostic psychiatrique ainsi que la détermination de critères de symptomatologie clairs en 2013 ouvrent sur des possibilités de prises en charge, de développement des études cliniques, physiopathologiques, thérapeutiques et psychothérapeutiques. Ce trouble invalidant peut retentir sur la vie personnelle, sociale, familiale et professionnelle. En 2019, la CIM-11 fait apparaître à son tour le diagnostic de trouble dysphorique prémenstruel, ce qui solidifie la reconnaissance du trouble.
(I) faire le point sur les traitements existants, médicamenteux et psychothérapeutiques, ainsi que (II) faire le point sur leur efficacité. À l’issue de ce travail nous formulerons des recommandations pour les prises en charge de ces patientes.
Une recherche bibliographique a été effectuée du 7 juin 2021 au 7 juillet 2021 sur les bases de données Psychinfo APA, Scopus, PubMed, ainsi que les bases de données de l’organisation Cochrane et les documents de recommandations de la Haute Autorité de la santé. Après une première sélection à partir de mots-clés, une lecture du texte intégral de l’ensemble a été effectuée pour arriver à la sélection finale de 32 articles.
Les antidépresseurs et les thérapies cognitivo-comportementales (TCC) apparaissent comme les traitements majoritairement recommandés dans la prise en charge du TDPM. D’autres recherches montrent l’efficacité des contraceptifs oraux comprenant de la drospirénone. On identifie les inhibiteurs sélectifs de la recapture de sérotonine (ISRS) comme étant un traitement efficace du TDPM. Ces données vont dans le sens de l’hypothèse étiologique actuelle du TDPM qui est un impact négatif des fluctuations hormonales naturelles sur certains neurotransmetteurs. Les TCC montrent des résultats positifs pour réduire l’impact fonctionnel du TDPM.
Les antidépresseurs de type inhibiteur sélectif de la recapture de la sérotonine (ISRS) seraient les traitements de première intention du TDPM (sertraline 50–150 mg/j, la fluoxétine 10–20 mg/j, l’escitalopram 10–20 mg/j, la paroxétine 12,5–25 mg par jour/j). La drospirénone (EE 3 mg et EE 20 mg/j 24 jours de pilules hormonales, 4 jours inactifs) apparaît comme un traitement de première intention ou de deuxième intention en fonction des articles. Les résultats actuels vont clairement dans le sens d’une efficacité de la TCC pour contribuer à réduire : l’atteinte fonctionnelle, l’humeur dépressive, le sentiment de désespoir, l’anxiété, les sauts d’humeur, la sensibilité, l’irritabilité, l’insomnie, les conflits avec les autres, l’impact des symptômes prémenstruels sur la vie quotidienne, l’intensité des symptômes ressentis et le handicap des symptômes. Les TCC pourraient également apparaître dans les traitements de première intention si les preuves de leur efficacité étaient plus nombreuses. Dans l’avenir, il semble utile de proposer une prise en charge psychothérapique qui puisse être reproductible et de multiplier les recherches d’un haut niveau de comparabilité scientifique afin de clarifier la place des TCC dans la prise en charge du TDPM. Les recherches sur l’étiopathologie du trouble et le schéma thérapeutique médicamenteux optimal sont encore en cours. Il est nécessaire de développer des techniques psychothérapeutiques adaptées afin de soutenir et d’accompagner ces patientes.
Pour permettre une meilleure évaluation des traitements du TDPM, l’homogénéisation des études sur le sujet est nécessaire à plusieurs niveaux : design, doses de traitements, techniques psychothérapeutiques, et mesures d’évaluation. À l’heure actuelle, certaines études portent à la fois sur des patientes qui souffrent de syndrome prémenstruel (SPM) et sur des patientes qui souffrent de TDPM. Le SPM et le TDPM n’incluent pas les mêmes symptômes, ni la même sévérité et potentiellement pas la même étiologie chez les patientes étudiées. Afin de proposer des recherches rigoureuses qui évaluent l’efficacité des traitements sur le TDPM et d’accompagner correctement les personnes atteintes de ces troubles, il semble essentiel de bien distinguer les deux pathologies. Le rôle du praticien de santé est de savoir identifier le TDPM en le différenciant d’autres troubles cliniquement proches. La patiente doit ensuite être accompagnée pour faire un choix de traitement adapté en fonction des symptômes, de leur sévérité, des antécédents, de ses projets de procréation, des contre-indications et de ses préférences. En 2021, la Haute Autorité de la Santé ne propose aucun guide ou recommandation pour la gestion du trouble dysphorique prémenstruel. Il est nécessaire de développer les recherches en France.
Premenstrual Dysphoric Disorder (PMDD) was first recognised in July 2013 in the DSM-5 after a long journey to identify its existence. It was not until 1983 that the US National Institute of Mental Health determined research criteria for the study of PMS. In 1994, the term “premenstrual dysphoric disorder” (PMDD) replaced this term in the 4th edition of the Diagnostic System Manual (DSM). It was listed in the section “Mood Disorder Not Otherwise Specified” and remained under consideration until the DSM-5, in which it appeared in the depressive disorders section. The legitimisation of the psychiatric diagnosis as well as the determination of clear symptomatology criteria in 2013 opened up possibilities for management, development of clinical, pathophysiological, therapeutic and psychotherapeutic studies. This disabling disorder can affect personal, social, family and professional life. In 2019, the ICD-11 in turn introduced the diagnosis of premenstrual dysphoric disorder, which solidifies the recognition of the disorder.
(I) to review the existing treatments, both medicinal and psychotherapeutic, and (II) to review their effectiveness. At the end of this work we will formulate recommendations for the management of these patients.
A bibliographic search was carried out from 7 June 2021 to 7 July2021 on the databases (bases de données) Psychinfo APA, Scopus, PubMed, as well as the bases de données of the Cochrane organisation and the recommendation documents of the Haute Autorité de la santé. After an initial selection based on keywords, the full text of all articles were read to arrive at the final selection of 32 articles.
Antidepressants and Cognitive Behavioural Therapies (CBT) appear to be the most commonly recommended treatments for PMDD. Other research shows the effectiveness of oral contraceptives including drospirenone. Selective serotonin reuptake inhibitors (SSRIs) were identified as an effective treatment for PMDD. These data are consistent with the current etiological hypothesis of PMDD which has a negative impact of natural hormonal fluctuations on certain neurotransmitters. CBT showed positive results in reducing the functional impact of PMDD.
Selective serotonin reuptake inhibitor (SSRI) antidepressants were reported to be first-line treatments for PMDD (sertraline 50–150 mg/d, fluoxetine 10–20 mg/d, escitalopram 10–20 mg/d, paroxetine 12.5–25 mg/d). Drospirenone (EE 3 mg and EE 20 mg/d 24 days of hormonal pills, 4 days inactive) appears to have been a first or second line treatment depending on the articles. Current results clearly point to the effectiveness of CBT in helping to reduce: functional impairment, depressed mood, feelings of hopelessness, anxiety, mood swings, sensitivity, irritability, insomnia, conflict with others, impact of premenstrual symptoms on daily life, intensity of symptoms experienced, and symptom handicap. CBTs could also become a first-line treatment if there were to be more evidence of their effectiveness. In the future, it would seem useful to offer a psychotherapeutic treatment that can be reproduced and to multiply research with a high level of scientific comparability in order to clarify the place of CBT in the management of PMDD. Research on the etiopathology of the disorder and the optimal drug regimen is still ongoing. There is a need to develop appropriate psychotherapeutic techniques to support and accompany these patients.
In order to better evaluate treatments for PMDD, there is a need to homogenise studies on the subject at several levels: design, treatment doses, psychotherapeutic techniques, and evaluation measures. At present, some studies include both premenstrual syndrome (PMS) and PMDD patients. PMS and PMDD do not include the same symptoms, nor the same severity and potentially the same aetiology in the patients studied. In order to propose rigorous research that evaluates the effectiveness of treatments for PMDD and to properly support people with both these disorders, it seems essential to distinguish the two conditions. The role of the health practitioner is to be able to identify PMDD by differentiating it from other clinically related disorders. The patient must then be accompanied to make a choice of treatment adapted to her symptoms, their severity, her history, her plans for procreation, contraindications and her preferences. In 2021, the French National Authority for Health did not offer any guidelines or recommendations for the management of premenstrual dysphoric disorder. There is a need to develop research in France.
Emotional interference and attentional processing in premenstrual syndrome
2017, Journal of Behavior Therapy and Experimental Psychiatry
Citation Excerpt :
Blake, Gath, and Salkovskis (1995) for example, proposed a cognitive model of PMS. According to this model, the interaction of premenstrual physical changes and cognitive-emotional processes determine the development of subjective distress, which is crucial for the diagnosis of PMS (Blake, 1995; Blake, Salkovskis, Gath, Day, & Garrod, 1998; Blake et al., 1995). The authors assume that in women suffering from PMS, distress cannot be induced solely by the physical changes that occur during the luteal phase.
Premenstrual syndrome (PMS) is characterized by menstrual cycle-related affective, behavioral, and/or somatic symptoms. By applying the emotional Stroop task (EST) the current study examined if changes in processing emotional information, which have been demonstrated in affective disorders, are also present in PMS.
Via online screening, telephone interviews, and daily records over two months 55 women for the PMS group (on the basis of the specific inclusion criteria and a prospectively confirmed PMS) and 55 ‘non-PMS’ controls were recruited. All participants completed three emotional Stroop tasks (EST) with neutral and negative word, picture, and facial stimuli, during the follicular and luteal phase of the menstrual cycle.
Mixed 2 × 2 univariate analyses of variance and post-hoc comparisons showed primarily a greater emotional Stroop effect with respect to picture and facial stimuli in the luteal menstrual cycle phase in women with PMS, compared to the control group. No significant group differences were observed for word stimuli. With respect to the facial stimuli, a kind of paradox effect was revealed (Stroop facilitation) in the PMS group.
This study provides important information regarding cognitive processes in women suffering from PMS that have to be interpreted in the light of the following limitations: a limited representativeness of the sample, the determination of menstrual cycle phases based on symptom diaries but not hormone levels, and a limited interpretability of our results as causal relationships.
Our findings are in line with the assumption that alterations in cognitive-emotional processes are associated with PMS. Further research on the etiology of PMS should focus more on cognitive-emotional processing and its interaction with biological changes relating to the menstrual cycle.
Environmental enrichment prevents anxiety-like behavior induced by progesterone withdrawal in two strains of rats
2016, Neuroscience
Citation Excerpt :
Albeit controversial, it was reported that this approach could be useful to treat mild to moderate symptoms (Jarvis et al., 2008; Kleinstaüber et al., 2012). Cognitive Behavior Therapy (CBT) has been proposed as the first alternative for the treatment of mental disorders (Blake et al.,1998; Christensen and Oei, 1995; APA, 2001); however, in a meta-analysis study, it was reported that both CBT and serotonergic antidepressants were not enough for PMS treatments (Kleinstaüber et al., 2012). Therefore, results regarding the management of PMS/PMDD symptoms are still inconclusive.
Stress vulnerability could influence the treatment response to anxiety associated with abrupt hormonal suppression. The present study explored the effects of different treatments on experimental anxiety induced by progesterone withdrawal (PW) in a stress-sensitive rat strain, Wistar Kyoto (WKY), in the burying behavior test (BBT). The following experimental series was conducted using independent groups of Wistar (control strain) and WKY ovariectomized rats: Experiment 1: Rats were treated for 5 days with oil, a constant dose of progesterone (0.5 mg/rat, s.c) or a combination of progesterone (0.5 mg/rat, s.c) plus fluoxetine (10 mg/kg, i.p); on day 6, all rats were subjected to BBT. Experiment 2: Rats received corn oil or decreasing doses of progesterone (0.84, 0.67, 0.5, 0.33 and 0.17 mg/rat; one dose daily); on day 6, the rats were subjected to BBT. Experiment 3: Rats were divided into two groups that were subjected to 30 days of standard conditions or environmental enrichment (EE); from days 25 to 30, all rats received a fixed dose of progesterone (0.5 mg/rat, s.c.) or vehicle. On day 31, the rats were tested with BBT. Results showed that PW increased anxiety in both strains, and fluoxetine prevented anxiety in WKY rats. In contrast, a gradual reduction of progesterone prevents the anxiety in Wistar but not in WKY. EE was preventive against the anxiety induced by PW in both strains of rats. Thus, the results suggest that anxiety induced by PW is prevented by EE while the anxiolytic effect of pharmacological treatments depends on stress vulnerability.
Oral contraceptives containing drospirenone for premenstrual syndrome
2023, Cochrane Database of Systematic Reviews
Mindfulness-based cognitive therapy for coping with premenstrual syndrome distress: An overview
2023, Perspectives on Coping Strategies for Menstrual and Premenstrual Distress
Unfolding the mystery of premenstrual syndrome (PMS): An overview
2023, International Journal of Adolescent Medicine and Health

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Original ArticleCognitive therapy for premenstrual syndrome: A controlled trial

Abstract

Section snippets

Overview

Results

Discussion

Acknowledgements

Behav Res Ther

Behav Ther

Psychological aspects of premenstrual syndromedeveloping a cognitive approach

Premenstrual syndrome researchusing the NIMH guidelines

J Clin Psychiatry

Late luteal phase dysphoric disorder and DSM-III-R [see comments]

Am J Psychiatry

Diagnostic and statistical manual of mental disorders

Diagnostic and statistical manual of mental disorders

Biological correlates of premenstrual complaints

Treatment of the premenstrual syndrome by subcutaneous estradiol implants and cyclical oral norethisteroneplacebo controlled study

BMJ Clin Res Ed

Induced anovulation as treatment of premenstrual tension syndrome. A double-blind cross-over study with GnRH-agonist versus placebo

Acta Obstet Gynecol Scand

The effects of norethisterone in postmenopausal women on oestrogen replacement therapya model for the premenstrual syndrome

Br J Obstet Gynaecol

The role of serotonin in premenstrual syndrome

Clin Obstet Gynecol

Premenstrual syndrome

Clin Endocrinol Oxf

Research and theory related to female reproductionimplications for clinical psychology

Br J Clin Psychol

Cognitive model of premenstrual syndrome

Clin Obstet Gynecol

Original Article
Cognitive therapy for premenstrual syndrome: A controlled trial