New study on Internet-based Cognitive Behavioral Therapy (iCBT) for PMDD

by Liisa Hantsoo, Ph.D.

By Liisa Hantsoo, Ph.D.

While millions of women worldwide experience premenstrual dysphoric disorder (PMDD) [1], surprisingly there are no manualized psychotherapy treatments specifically for PMDD. Manualized treatments are the gold standard in psychotherapy, and have been developed for disorders ranging from major depressive disorder (MDD) [2,3] to specific phobias [4]. A manualized treatment is an evidence-based psychotherapy protocol that has been established as effective via randomized clinical trials. Often, manualized treatments are based in cognitive behavioral therapy (CBT), a form of therapy that focuses on connections among a person’s cognitions, behaviors, and emotions.

A new study from researchers in Germany and Sweden has looked at a CBT intervention specifically for women with PMDD [5]. The CBT protocol, called Praemensis, included typical cognitive-behavioral techniques such as identifying dysfunctional automatic thoughts, with lifestyle changes such as exercise and nutrition. A novel aspect of this therapy was that it was internet-based. Internet-based CBT (iCBT) is an emerging trend in mental healthcare, and allows patients to access psychotherapy online, regardless of barriers such as geography or perceived stigma. iCBT has been studied for adults with depression [6], anxiety [7], and even women with mental health concerns in the perinatal period [8,9]. This was the first study to look at iCBT for PMDD. The Praemensis program comprised an 8-week protocol of 14 internet modules that included education about PMDD, CBT techniques, and lifestyle modification, along with weekly email check-ins from a psychologist.

The study included nearly 200 women with PMDD, half of whom received the Praemensis intervention and half who were in a control group. After the 8-week treatment, a majority of women experienced improvement in PMDD symptoms, including less intense symptoms, less impact of symptoms on daily functioning, and less functional impairment. This study is an important step toward developing a manualized treatment for PMDD, which has unique symptoms that may not be fully addressed by existing manualized treatments. The study also emphasizes the potential utility of internet-based psychotherapy, particularly for a disorder such as PMDD for which there is a shortage of qualified providers. Finally, CBT or iCBT would provide women with PMDD an alternative to selective serotonin reuptake inhibitors (SSRIs), which are the first-line treatment approach for PMDD [10].

References

1. Hantsoo L, Epperson CN. Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Curr Psychiatry Rep. 2015;17:87.

2. Barlow DH, Farchione TJ, Fairholme CP, Ellard KK, Boisseau CL, Allen LB, et al. Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide [Internet]. Oxford University Press; [cited 2019 Feb 26]. Available from: http://www.oxfordclinicalpsych.com/view/10.1093/med:psych/9780199772667.001.0001/med-9780199772667

3. Gilson M, Freeman A, Yates MJ, Freeman SM. Overcoming Depression: A Cognitive Therapy Approach: Therapist Guide [Internet]. Oxford University Press; [cited 2019 Feb 26]. Available from: http://www.oxfordclinicalpsych.com/view/10.1093/med:psych/9780195300000.001.0001/med-9780195300000

4. Craske MG, Antony MM, Barlow DH. Mastering Your Fears and Phobias: Therapist Guide [Internet]. Oxford University Press; [cited 2019 Feb 26]. Available from: http://www.oxfordclinicalpsych.com/view/10.1093/med:psych/9780195189179.001.0001/med-9780195189179

5. Weise C, Kaiser G, Janda C, Kues JN, Andersson G, Strahler J, et al. Internet-Based Cognitive-Behavioural Intervention for Women with Premenstrual Dysphoric Disorder: A Randomized Controlled Trial. Psychother Psychosom. 2019;1–14.

6. Andrews G, Basu A, Cuijpers P, Craske MG, McEvoy P, English CL, et al. Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. J Anxiety Disord. 2018;55:70–8.

7. Olthuis JV, Watt MC, Bailey K, Hayden JA, Stewart SH. Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database Syst Rev. 2016;3:CD011565.

8. Kim DR, Hantsoo L, Thase ME, Sammel M, Epperson CN. Computer-assisted cognitive behavioral therapy for pregnant women with major depressive disorder. J Womens Health (Larchmt). 2014;23:842–8.

9. Hantsoo L, Podcasy J, Sammel M, Epperson CN, Kim DR. Pregnancy and the Acceptability of Computer-Based Versus Traditional Mental Health Treatments. J Womens Health (Larchmt). 2017;

10. Steiner M, Pearlstein T, Cohen LS, Endicott J, Kornstein SG, Roberts C, et al. Expert guidelines for the treatment of severe PMS, PMDD, and comorbidities: the role of SSRIs. J Womens Health (Larchmt). 2006;15:57–69.

What is Premenstrual Dysphoric Disorder (PMDD), and Why Study It?

By Liisa Hantsoo, Ph.D.

Premenstrual Dysphoric Disorder (PMDD) is a cyclic mood disorder that affects approximately 3-5% of women (1). This translates to millions of women worldwide. While many of PMDD’s symptoms are similar to those of major depression (e.g. irritability, low mood, hopelessness, anxiety), it is unique in that symptoms only occur in the luteal (premenstrual) phase of the menstrual cycle. This can include physical symptoms as well, such as bloating, headaches or breast tenderness. For some women, symptoms may only last two or three days, but for others, symptoms can last for as long as two weeks each month. When not in the luteal phase, women with PMDD report feeling well and functioning normally. PMDD is also different from premenstrual syndrome (PMS); while both occur in the luteal phase, PMS is characterized by fewer symptoms than PMDD, and affects a larger proportion of women, around 20% (2). If we consider only premenstrual symptoms, whether mood or physical, the majority of women , roughly 80%, will experience at least one symptom (3). While PMDD is less common than major depressive disorder, it has roughly the same lifetime prevalence as panic disorder, and a higher prevalence than bipolar disorder and obsessive compulsive disorder (OCD) (4).

PMDD is more prevalent in the U.S. than bipolar disorder or panic disorder. (Data from the US National Comorbidity Survey Replication (4).)

As recently described in The New York Times (5), “the average woman has her period for 2,535 days of her life,” which is nearly 7 years. If we consider this in the context of PMDD, the average woman with PMDD may experience debilitating mood symptoms for the same amount of time. Indeed, if a woman with PMDD has 450 periods over the course of her lifetime, and is symptomatic for 5 days each cycle, she spends over 6 years of her life experiencing PMDD symptoms. This is similar to the cumulative amount of time that someone with major depressive disorder would be symptomatic over the course of their life (6).

The average woman has 450 periods over the course of her life. For women with PMDD, this translates to a cumulative 6 years spent symptomatic. (Assumes menarche at age 12 and menopause at age 50.)

Therefore, the need to study PMDD, and its more common counterpart, PMS, is clear. With PMDD and PMS together affecting around a third of women worldwide, understanding the etiology of these cyclic disorders, and improving treatment options, is critical. When a woman is experiencing PMDD symptoms, it can interfere with her ability to be productive at work or school, affects her ability to take care of herself and family, and can have a major impact on her  relationships with friends, partner, or family (7). An especially serious concern is that some women with PMDD experience suicidal ideation during the luteal phase (8). For this reason alone, it is crucial that we raise awareness of PMDD and work to improve treatment availability. PMDD is also quite unique in comparison to other mood or anxiety disorders, in its cyclicity. While disorders such as bipolar disorder or seasonal affective disorder also exhibit cyclicity, no other disorder has the clear onset and offset that occurs with PMDD across the hormonal fluctuations of the menstrual cycle. This, therefore, can give us important information on how hormones, such as estrogens and progesterone, act in the brain to affect mood and cognition. At a broader scale, this may provide important insights to sex differences in disorders such as major depression, anxiety disorders, or addiction.

References:

1.         Hantsoo L, Epperson CN. Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Curr Psychiatry Rep. 2015;17(11):87. doi:10.1007/s11920-015-0628-3

2.         Dennerstein L, Lehert P, Heinemann K. Epidemiology of premenstrual symptoms and disorders. Menopause Int. 2012;18(2):48-51. doi:10.1258/mi.2012.012013

3.         Budeiri DJ, Li Wan Po A, Dornan JC. Clinical trials of treatments of premenstrual syndrome: entry criteria and scales for measuring treatment outcomes. Br J Obstet Gynaecol. 1994;101(8):689-695.

4.         KESSLER RC, PETUKHOVA M, SAMPSON NA, ZASLAVSKY AM, WITTCHEN H-U. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21(3):169-184. doi:10.1002/mpr.1359

5.         Zraick K. It’s Not Just the Tampon Tax: Why Periods Are Political. The New York Times. https://www.nytimes.com/2018/07/22/health/tampon-tax-periods-menstruation-nyt.html. Published July 26, 2018. Accessed August 6, 2018.

6.         Burcusa SL, Iacono WG. Risk for Recurrence in Depression. Clin Psychol Rev. 2007;27(8):959-985. doi:10.1016/j.cpr.2007.02.005

7.         Halbreich U, Borenstein J, Pearlstein T, Kahn LS. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology. 2003;28 Suppl 3:1-23.

8.         Pilver CE, Libby DJ, Hoff RA. Premenstrual dysphoric disorder as a correlate of suicidal ideation, plans, and attempts among a nationally representative sample. Soc Psychiatry Psychiatr Epidemiol. 2013;48(3):437-446. doi:10.1007/s00127-012-0548-z