Abstract
Bipolar disorder (BD) differs in its clinical presentation in females compared to males. A number of clinical characteristics have been associated with BD in females: more rapid cycling and mixed features; higher number of depressive episodes; and a higher prevalence of BD type II. There is a strong link between BD and risk for postpartum mood episodes, and a substantial percentage of females with BD experience premenstrual mood worsening of varying degrees of severity. Females with premenstrual dysphoric disorder (PMDD)—the most severe form of premenstrual disturbances—comorbid with BD appear to have a more complex course of illness, including increased psychiatric comorbidities, earlier onset of BD, and greater number of mood episodes. Importantly, there may be a link between puberty and the onset of BD in females with comorbid PMDD and BD, marked by a shortened gap between the onset of BD and menarche. In terms of neurobiology, comorbid BD and PMDD may have unique structural and functional neural correlates. Treatment of BD comorbid with PMDD poses challenges, as the first line treatment of PMDD in the general population is selective serotonin reuptake inhibitors, which produce risk of treatment-emergent manic symptoms. Here, we review current literature concerning the clinical presentation, illness burden, and unique neurobiology of BD comorbid with PMDD. We additionally discuss obstacles faced in symptom tracking, and management of these comorbid disorders.
Highlights
There is a notable impact of hormonal fluctuations on the presentation of bipolar disorder (BD), during periods of reproductive life events such as pregnancy, the postpartum period, during menarche, and menopause
Females with premenstrual dysphoric disorder (PMDD) are much more likely to have a diagnosis of BD compared to the general population, with an 8-fold increase in risk reported by one study [20], and 2.3 times higher prevalence of BD reported by a study among young females [21]
In a study from our group where all participants completed at least 2 months of prospective daily symptom charting, we found that individuals diagnosed with both BD and PMDD had worse depressive symptom severity during the follicular phase compared to females with BD, females with PMDD, a female control group, and individuals with both BD and PMDD
Summary
There is a notable impact of hormonal fluctuations on the presentation of bipolar disorder (BD), during periods of reproductive life events such as pregnancy, the postpartum period, during menarche, and menopause. One or more of the symptoms must fall into the somatic or cognitive domain, including [1] a reduction in interest in activities or hobbies; [2] trouble concentrating; [3] feelings of lethargy, fatigue, or reduced energy; [4] changes in appetite; [5] sleep difficulties (i.e., insomnia or hypersomnia); [6] reports of feeling out of control, or feeling overwhelmed; [7] physical symptoms, like swelling or tenderness of breasts, reports of pain, bloating, or increased weight These symptoms must be tracked through prospective ratings every day for at least 2 symptomatic cycles, though a provisional diagnosis may be provided if these ratings are not available [1]. We will discuss tracking these comorbid conditions, and potential treatment options for females with these disorders
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