Teri Pearlstein

The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation

The overall purpose of the present study was to further our understanding of the mechanisms of self-mutilative behavior in a sample of female inpatients. The study found that self-mutilators (n = 103) displayed a greater degree of dissociative symptoms and alexithymia and a greater number of self-injurious behaviors, as well as higher rates of childhood sexual abuse, than nonmutilators (n = 45). In addition, the study found that among these variables, the number of self-injurious behaviors had the strongest relationship to self-mutilation. However, both dissociative symptoms and alexithymia were independently associated with self-mutilative behavior. Implications of our findings for clinicians and researchers are discussed.

Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder

Objective: To compare the efficacy of a new low-dose oral contraceptive pill (OCP) formulation with placebo in reducing symptoms of premenstrual dysphoric disorder. Methods: This multicenter, double-blind, randomized clinical trial consisted of 2 run-in and 3 treatment cycles with daily symptom charting; 450 women with symptoms of premenstrual dysphoric disorder were randomized to either placebo or an OCP formulation containing drospirenone 3 mg and ethinyl estradiol 20 &mgr;g. Hormones were administered for 24 days, followed by 4 days of inactive pills (24/4). Results: Scores on the total Daily Record of Severity of Problems decreased by –37.49 in the drospirenone/ethinyl estradiol group and by –29.99 in the placebo group (adjusted mean difference –7.5, 95% confidence interval [CI] –11.2 to –3.8; P < .001 by rank analysis of covariance). Mood symptom scores were reduced by –19.2 and –15.3 in active-treatment and placebo groups, respectively (adjusted mean difference –3.9, 95% CI –5.84 to –2.01; P = .003); physical symptom scores were reduced by –10.7 and –8.6 in active-treatment and placebo groups, respectively (adjusted mean difference –2.1, 95% CI –3.3 to –0.95; P < .001); and behavioral symptom scores were reduced by –7.7 and –6.2 in active-treatment and placebo groups, respectively (adjusted mean difference –1.5, 95% CI –2.251 to –0.727; P < .001). Response, defined as a 50% decrease in daily symptom scores, occurred in 48% of the active-treatment group and 36% of the placebo group (relative risk 1.7, 95% CI 1.1 to 2.6; P = .015) and corresponds to a number-needed-to-treat of 8 patients. Conclusion: A 24/4 regimen of drospirenone 3 mg and ethinyl estradiol 20 &mgr;g improves symptoms associated with premenstrual dysphoric disorder. Level of Evidence: I

The long-term sequelae of sexual abuse: support for a complex posttraumatic stress disorder

This study examined the relationship between childhood sexual abuse and symptoms of a newly proposed complex posttraumatic stress disorder or disorder of extreme stress not otherwise specified (DESNOS). Compared to 34 women without histories of sexual abuse, 74 survivors of sexual abuse showed increased severity on DESNOS symptoms of somatization, dissociation, hostility, anxiety, alexithymia, social dysfunction, maladaptive schemas, self-destruction and adult victimization. In addition, a logistic regression found that a complex of symptoms representing DESNOS was significantly related to a history of sexual abuse. Consistent with other studies, the results of this study provide support for the idea that symptoms of DESNOS characterize survivors of sexual abuse.

Affect Regulation and Suicide Attempts in Adolescent Inpatients

OBJECTIVE To examine the relationship between affect dysregulation and self-destructive behaviors in adolescent suicide attempters. METHOD Measures of affect dysregulation, number of risk-taking behaviors in past year, presence of self-mutilative behaviors in past year, and number of different types of self-mutilative behaviors in past year were individually administered to adolescents admitted to an inpatient unit who were either suicide ideators (n = 25) or suicide attempters (n = 35). RESULTS Suicide attempters reported significantly higher levels of affect dysregulation and a greater number of different types of self-mutilative behaviors in the past year than suicide ideators. In addition, the number of different types of self-mutilative behaviors in the past year had the strongest relationship to suicide attempts. CONCLUSION Suicidal behavior among adolescent psychiatric patients is related to poor affect regulation. A risk factor for suicidal behavior in adolescents is a broad range of self-mutilative acts in the year preceding the suicide attempt.

Comparison of fluoxetine, bupropion, and placebo in the treatment of premenstrual dysphoric disorder.

Serotonergic antidepressants have been shown to be effective treatments for premenstrual dysphoric disorder (PMDD). The efficacy of nonserotonergic antidepressants is less well studied. This study was a two-center, parallel design, placebo-controlled, randomized trial of fluoxetine, bupropion, and placebo in women with PMDD. Thirty-four women with PMDD completed 1 month of single-blind placebo and 2 months of fluoxetine 20 mg/day (N = 10), bupropion 100 mg three times daily (N = 12), or placebo (N = 12). Clinical Global Impressions (CGI) Scale, an expanded form of the Hamilton Rating Scale for Depression (HAM-D), and Global Assessment Scale (GAS) ratings were obtained premenstrually in each of the three treatment cycles. The three treatment groups differed significantly in efficacy by CGI ratings. Fluoxetine was superior to both bupropion and placebo. Comparison of posttreatment to pretreatment HAM and GAS scores demonstrated significant superior efficacy of fluoxetine compared with placebo. Posttreatment HAM and GAS scores for bupropion were intermediate between but not significantly different from fluoxetine or placebo. In summary, fluoxetine was significantly superior to bupropion and placebo as an effective treatment for PMDD. Although some improvement with bupropion was noted, and both medications were well tolerated, patient satisfaction was far greater with fluoxetine.

Evaluation of a unique oral contraceptive in the treatment of premenstrual dysphoric disorder.

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS). This is the first trial of a unique oral contraceptive containing a combination of drospirenone (DRSP, 3 mg) and ethinyl estradiol (EE, 30 microg) for the treatment of PMDD. DRSP is a spironolactone-like progestin with antiandrogenic and antimineralocorticoid activity. Spironolactone has been shown to be beneficial in PMS, whereas oral contraceptives have shown conflicting results. In this double-blind, placebo-controlled trial, 82 women with PMDD (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM IV]) were randomized to receive DRSP/EE or placebo for three treatment cycles. The primary end point was change from baseline in luteal phase symptom scores as assessed on the Calendar of Premenstrual Experiences (COPE) scale. Patients treated with DRSP/EE showed a numerically greater change from baseline compared with those treated with placebo on each of the 22 COPE items and each of the 4 symptom factors. Between-group differences in symptom improvement reached statistical significance in factor 3 only (appetite, acne, and food cravings, p = 0.027). The secondary end points, Beck Depression Inventory (BDI) and Profile of Mood States (PMS), were consistent with the primary end point in that patients treated with the oral contraceptive showed a numerically greater improvement from baseline compared with those treated with placebo. The results of this study show a consistent trend in the reduction of symptoms that suggested a beneficial effect of DRSP/EE for the treatment of PMDD, despite limitations of the study design.

MOOD DISORDERS AND MENOPAUSE

Studies of depressive symptoms in menopausal women indicate that menopause is not associated with increased rates of depression, although mild mood and anxiety symptoms may occur in the few years prior to menopause. Women with previous affective disorders that are cyclic or that are associated with reproductive events may be at increased risk for depression at menopause. Because women presenting to menopause clinics are more likely to have affective disorders, the efficacy of estrogen for enhancing mood is an important question. Although some researchers suggest that estrogens have proven mood-elevating and antidepressant properties, others caution that the psychologic benefits of HRT deserve more systematic study before conclusions can be made. It has been suggested that minor psychologic symptoms at menopause or psychologic symptoms accompanied by vasomotor symptoms warrant a trial of HRT before considering psychotropic medication. If the psychologic symptoms do not respond to HRT, are not accompanied by vasomotor symptoms, or are clinically severe, antidepressant medication should be considered first or in addition to HRT. The psychologic effects of progesterone and androgens are less extensively studied than those of estrogen, and further research is needed.

Prevalence of axis I and axis II disorders in women with late luteal phase dysphoric disorder

The authors interviewed 78 female patients with late luteal phase dysphoric disorder and found a 78% lifetime prevalence of axis I disorders but only a 10% prevalence of axis II disorders. A prior depression was the predominant axis I disorder found, and 29% of parous patients had a prior postpartum depression. A comparison of Global Assessment Scale scores obtained at both the follicular and luteal phases of the menstrual cycle confirmed luteal increases in symptoms and role impairment.

Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders : the ISPMD Montreal consensus

Premenstrual disorders (PMD) are characterised by a cluster of somatic and psychological symptoms of varying severity that occur during the luteal phase of the menstrual cycle and resolve during menses (Freeman and Sondheimer, Prim Care Companion J Clin Psychiatry 5:30–39, 2003; Halbreich, Gynecol Endocrinol 19:320–334, 2004). Although PMD have been widely recognised for many decades, their precise cause is still unknown and there are no definitive, universally accepted diagnostic criteria. To consider this issue, an international multidisciplinary group of experts met at a face-to-face consensus meeting to review current definitions and diagnostic criteria for PMD. This was followed by extensive correspondence. The consensus group formally became established as the International Society for Premenstrual Disorders (ISPMD). The inaugural meeting of the ISPMD was held in Montreal in September 2008. The primary aim was to provide a unified approach for the diagnostic criteria of PMD, their quantification and guidelines on clinical trial design. This report summarises their recommendations. It is hoped that the criteria proposed here will inform discussions of the next edition of the World Health Organisation’s International Classification of Diseases (ICD-11), and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) criteria that are currently under consideration. It is also hoped that the proposed definitions and guidelines could be used by all clinicians and investigators to provide a consistent approach to the diagnosis and treatment of PMD and to aid scientific and clinical research in this field.

Hormones and depression: What are the facts about premenstrual syndrome, menopause, and hormone replacement therapy?

The diagnosis, epidemiology, etiology, and treatment of premenstrual syndrome are reviewed. A relationship between depression and premenstrual syndrome is suggested by the increased prevalence of prior depressive episodes in women with premenstrual syndrome, common neurotransmitter and chronobiologic abnormalities, and the successful treatment of premenstrual syndrome with regimens used for depression. The relationship between menopause and depression is not clearly defined, but the perimenopausal years may be a time of increased depression for women who are at risk for depressive recurrences. The role of hormone replacement treatments in either ameliorating or promoting depression in menopausal women is a subject for future studies.