Case Study: Severe Cyclical Mood Disturbance in a Young Adult Female
Case at a Glance
A 22-year-old female presents with a history of severe, debilitating mood and behavioral symptoms that follow a distinct cyclical pattern corresponding to her menstrual cycle. Her symptoms, which include depression, anxiety, paranoia, and suicidal ideation, are absent during the follicular phase but emerge around ovulation and persist through the luteal phase, significantly impairing her functioning.
Patient's Story
The patient reports a long-standing pattern of severe emotional and physical distress that she has been tracking in relation to her menstrual cycle. She describes a distinct period of wellness, lasting from the end of her menses until ovulation, where she feels euthymic, productive, and stable. However, she notes a dramatic shift in her state beginning around the time of ovulation.
Initial Assessment
Upon presentation, the patient described a predictable onset of severe symptoms post-ovulation. These include profound sadness, feelings of loneliness, crying spells, fatigue, and generalized body aches (myalgia). She reported experiencing an increased libido and intrusive, distressing thoughts about romantic relationships and childbearing, which are incongruent with her current life goals and circumstances. These thoughts contribute to feelings of failure and suicidal ideation. As her period approaches, the symptom profile shifts to severe anxiety, paranoia, dissociative episodes, and panic attacks, particularly upon waking. These symptoms resolve completely with the onset of her period, after which the cycle repeats. Previous consultations with physicians had not yielded a diagnosis or effective management plan.
The Diagnostic Journey
The patient's detailed self-tracking and the clear delineation between a symptom-free follicular phase and a symptomatic luteal phase strongly suggested a hormone-sensitive mood disorder. The primary differential diagnosis considered was Premenstrual Dysphoric Disorder (PMDD), given the severity and nature of the affective symptoms (mood lability, depression, anxiety, anger) and their functional impairment. Other potential diagnoses were ruled out due to the lack of symptoms during the follicular phase. During the discussion of potential treatments, the possibility of using an oral contraceptive containing drospirenone or an SSRI antidepressant like sertraline was raised. The patient expressed significant hesitation and concern regarding hormonal therapies, stating a fear of potential long-term adverse effects.
Final Diagnosis
Provisional Diagnosis: Premenstrual Dysphoric Disorder (PMDD). A definitive diagnosis is pending confirmation via prospective symptom charting over two consecutive menstrual cycles.
Treatment Plan
The initial management plan focused on two key areas: 1. Diagnostic Confirmation: The patient was asked to complete a formal daily symptom diary for two months to prospectively validate the diagnosis. 2. Therapeutic Options: Given the patient's apprehension about hormonal treatments, a first-line approach with a selective serotonin reuptake inhibitor (SSRI) was proposed. Options for dosing (continuous vs. luteal phase only) were discussed. Referral for psychotherapy, such as Cognitive Behavioral Therapy (CBT), was also recommended to develop coping strategies for the severe psychological symptoms.
Outcome and Follow-up
The patient agreed to begin prospective symptom charting to confirm the diagnosis. A follow-up appointment was scheduled to review the charts and make a final decision on initiating pharmacological treatment, with a preference for starting with an SSRI. The importance of a multimodal approach, including lifestyle adjustments and psychotherapy, was emphasized to provide comprehensive support.