
Understanding loneliness; testing a headache remedy; a serious premenstrual disorder: Upstate Medical University's HealthLink on Air for Sunday, Sept. 15, 2024
Researcher Roger Wong, PhD, and student Miguel Pica explain what the pandemic revealed about loneliness and isolation. Neuroscientist Yi-Ling Kuo, PhD, tells of her research using magnets to treat headaches after mild traumatic brain injury. Psychiatrists Luba Leontieva, MD, PhD, and Nevena Radonjic, MD, PhD, discuss premenstrual dysphoric disorder.
Transcript
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air" researchers share the impact the pandemic had on loneliness and isolation.
Roger Wong, PhD: ... this really affected older adults moreso, because they're more vulnerable to infectious diseases ...
Host Amber Smith: A neurophysiologist invites people with headaches after mild traumatic brain injury to try an experimental treatment.
Yi-Ling Kuo, PhD: ... the magnetic field penetrates the air, the hair, and the skull to reach the surface of the brain ...
Host Amber Smith: And a pair of psychiatrists discuss premenstrual dysphoric disorder, an extreme type of PMS.
Nevena Radonjic, MD, PhD: ... emotional lability, such as sudden sadness, tearfulness, or sensitivity to rejection. Then irritability, anger or increased interpersonal conflicts, depressed mood, hopelessness or self-deprecating thoughts, or just being more anxious ... or keyed up or being on edge ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, we'll hear about an experimental treatment for headaches that develop after a head injury. Then we'll learn about an extreme type of premenstrual syndrome. But first, what did the pandemic teach us about loneliness and isolation?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
More than one-third of adults 65 and older in the United States reported loneliness during the COVID-19 pandemic. But was that because they were socially isolated? I'm talking with some public health researchers who've looked at this issue.
Dr. Roger Wong is an assistant professor of public health and preventive medicine at Upstate, and Mr. Miguel Pica was a student in his advanced biostatistics course.
Welcome, both of you, to "HealthLink on Air."
Roger Wong, PhD: Thank you, Amber.
Miguel Pica: Thank you, Amber.
Host Amber Smith: So Dr. Wong, the surgeon general declared loneliness and social isolation to be a national epidemic in May 2023. Do you think the rates of both have stayed high because of the aftereffects of the pandemic?
Roger Wong, PhD: Before I answer your question, I first want to congratulate Miguel for leading this study. It's, as you mentioned, his final project from my advanced biostatistics course. It was a wonderful paper. He is the first author on it.
So Amber, your question was about the trends in loneliness and social isolation.
Before the pandemic, before 2020, it was pretty stable every year for social isolation and loneliness. It spiked in 2020 during the pandemic, and then it has remained elevated after that. It hasn't really gone down to pre-pandemic levels yet, but I think what I'm seeing from the data is that the further away we're moving from 2020, it's gradually going down to pre-pandemic levels, so I expect once we see the new data released that it'll probably be closer to pre-pandemic levels either this year or next year.
Host Amber Smith: Well, that's encouraging, but it has taken a lot longer than you would think, I guess.
Roger Wong, PhD: Yeah, and as many people would imagine, the pandemic really disrupted everyone's social networks, but this really affected older adults moreso, because they're more vulnerable to infectious diseases.
So that's why their social networks were really interrupted during the pandemic.
Host Amber Smith: So, Mr. Pica, the database you used was from the 2020 National Health and Aging Trends Study. What can you tell us about it?
Miguel Pica: The National Health and Aging Trends Study, has been utilized as a survey since 2011, collecting annual data through interviews with older adults, ages 65 and older. They've been followed every year, collecting details on a national level on disability trends and trajectories.
Roger Wong, PhD: And to add to Miguel, I think most of the responses were submitted in, I think, August 2020, so that was, like, the height of the, biggest wave of the COVID pandemic. So I think a lot of the data that we're looking at today for social isolation, loneliness, it's like right during the peak.
Host Amber Smith: How were you able to compare those that were the reports of loneliness before the pandemic and after, or during, the pandemic?
Roger Wong, PhD: Before the pandemic, as I mentioned, both loneliness and social isolation, they were both around 20% to 25% for older adults 65 years and older. And then, I think in the paper we wrote that both of them spiked to around 35% of older adults felt lonely or socially isolated during the pandemic.
We don't have any data for this specifically, for loneliness before, starting from 2011, but we do have the data at least for 2020.
Host Amber Smith: So do you know how many people were reported social isolation before, and then compared with during, the pandemic? Or is that something entirely different?
Roger Wong, PhD: Yes. So that's actually in the separate paper that a student and I are about to publish.
So before the pandemic, social isolation was pretty stable, around 20% every year, from, like, the data we have is from like 2011 through 2019. It spiked to about 35% in 2020, and then it's been elevated after that.
Host Amber Smith: Were those who were lonely the same people who were isolated?
Roger Wong, PhD: For this paper, Miguel and I looked at loneliness and social isolation individually because we were basically interested in seeing how a group of 25 sociodemographic, health, social support and community variables were associated with loneliness and social isolation. It was already a really complicated paper, so we decided to just look at those, loneliness and social isolation, individually.
And I agree with you, Amber. I think it would be really interesting to see the different combinations of loneliness and social isolation, but we didn't want to do that for this paper because it was just already really complicated.
Host Amber Smith: Well, let me ask Mr. Pica to define these terms. What is loneliness and what is social isolation?
Miguel Pica: When we look at loneliness, we took it off the National Academies of Sciences, Engineering and Medicine, and we defined loneliness in our paper as "the distressing subjective experience that rises from perceived isolation or lack of building meaningful connections."
Host Amber Smith: So what is a social connection? Is that a friendship?
Miguel Pica: When it comes to social connections, especially when we look at our paper, we actually look more for social disconnection, referring to loneliness and social isolation in combination, for brevity. For example, for social isolation, we use that more as an objective measure for the lack of, or restriction of, interpersonal relationships, group memberships and social roles and the interactions.
Roger Wong, PhD: Yeah. And to summarize -- thank you, Miguel -- what Miguel just mentioned, I think the key word here is that when we're thinking about loneliness, it's a subjective experience, whereas social isolation, it's more of an objective measure for social networks.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with public health and preventive medicine assistant professor Roger Wong and one of his students, Miguel Pica.
Dr. Wong, were you able to describe what type of people had an increased risk for loneliness during the pandemic?
Roger Wong, PhD: Yes. So as I mentioned earlier, we were looking at a group of around, like, 25 different factors to see how they were either protective or a risk factor for loneliness. So I think I'll talk about that first, and then maybe Miguel will talk about the social isolation, protective and risk factors for the loneliness, for those that felt lonely.
If we're looking at sociodemographics, we found that Black older adults were less likely to be lonely. We found that female and those that had higher education were significantly more likely to feel lonely during the pandemic. And I think, the higher-education aspect may be a little bit counterintuitive, but if you think about it, those that have higher education, they were more likely to be moved to telework suddenly during the pandemic.
This was exactly what happened to me. I was teaching graduate students, not in Syracuse yet, I wasn't at Upstate yet, but the grad students that I was teaching, suddenly I had to shift to telework. I was told that we could only do prerecorded lectures, so it felt really lonely for me when I was doing my job. I think that those results sort of make sense. That's kind of the sociodemographic results we found.
If we look at health in general, we found that people with poor physical health and mental health disorders, they were significantly more likely to feel lonely during the pandemic. We also found that good sleep was a protective factor for loneliness as well.
And then finally, if we're looking at more social support aspects, we found people that were married, and they also had children in the household, they were less likely to feel lonely during the pandemic.
Host Amber Smith: Mr. Pica, who was most likely to be socially isolated during the pandemic?
Miguel Pica: When we look at social isolation, starting in a similar format with Roger, when we look at the social demographics, older adults, the older they become, the more likely they are to become socially isolated. Specifically, Black older adults and Hispanic older adults were more at risk for isolation.
With income, more income was found to be protective from isolation. When it comes to health, those who were more physically active were less likely to be isolated.
When it comes to social supports, we looked at different methods of communication. Those with more modes of communication, such as cellphones, Zoom, contact with family, friends, they were less likely to be isolated. But when there was more children, unlike loneliness, we found that while it was protective for loneliness, social isolation was increased for those with multiple children in the household.
Host Amber Smith: What did you find that helped reduce social isolation? You mentioned having access to a phone and social media and things like that. Were those the only things that were found to help reduce the social isolation?
Miguel Pica: So to lessen the risk was access to technology as well as having access to transportation. This was something that was found. And being more physically active. This really reduced the social isolation aspect.
Host Amber Smith: So, Dr. Wong, before we wrap up, I'd like to ask you more about the people who were socially isolated but not lonely during the pandemic.
How did they manage that, and what can we learn from them?
Roger Wong, PhD: I feel like your underlying question is the resilience factors.
OK, these people are socially isolated, but what are they doing to protect themselves from feeling lonely? And I think that's a wonderful question. I don't think I have a direct answer for that since we didn't look at the different combinations for social isolation and loneliness. But I think some of the protective factors that I talked about earlier for loneliness are ones that I would say are probably going to be productive for those that are socially isolated objectively, but feel lonely.
So I think the ones that are a little bit more modifiable that I would recommend are making sure that your physical health is addressed and also mental health as well, because that's definitely the No. 1 risk factor that we saw in our paper for loneliness. I think for those that were depressed and also had anxiety, they had about a three times increased risk for feeling lonely during the pandemic, so that's the largest amount of degree that we could find in the study.
So I think making sure that physical health and mental health are addressed is really important. I think another modifiable risk factor is also good sleep because we're finding that to be a protective factor for loneliness as well.
And this is a little bit off topic, but I think one of the calls to action that we talk about in the paper is that we looked at a group of 25 different variables. They all range from, like, individual to community to society to policy. And the call to action that we really talked about in the paper is that it's not just one thing that we could do to protect older adults from loneliness and social isolation. There are so many things that I think each of us has a really important part in making sure that our parents and our grandparents are not feeling lonely and not socially isolated. So I think it's really important to reach out to them and see and check in with them because this is quite common among older adults.
Host Amber Smith: You mentioned taking care of physical and mental health. Does loneliness and isolation cause, or lead to, mental health issues?
Roger Wong, PhD: Starting with the physical health, I think the physical health aspect is that those with more chronic diseases, they're more likely to be homebound and not be able to be mobile enough. So I think that mechanism really makes sense for feeling lonely and socially isolated.
I think for the mental health aspects, it's interesting because I think for those that are depressed and have anxiety, it doesn't look like they're really socially isolated, but they feel lonely, though, so I think, again, the loneliness aspect is more aligned with the subjective feelings. So I think it's more related to their mental health disorder, that they're subjectively feeling lonely, even though, objectively, they're not really socially isolated. I think that's a great question, and I think that's one of the things that we're seeing for this research.
Host Amber Smith: Well, it's very interesting, and it's encouraging to know that people are looking into what can we learn from this experience that everyone in the world experienced at the same time in different ways. But we went through something, and it's good that we're going to be learning from it.
Roger Wong, PhD: Yes. And I'm really excited to see how Miguel's research, how this paper, takes off, because as you mentioned, this is a huge problem the surgeon general had mentioned in May 2023. This is a national epidemic, so I am really looking to forward to see more research in this area because I think it's definitely understudied.
Host Amber Smith: I appreciate both of you making time for this interview. Thank you.
Roger Wong, PhD: Yeah. Thank you so much for having us, Amber.
Miguel Pica: Of course. Thank you so much.
Host Amber Smith: My guests have been Dr. Roger Wong, an assistant professor of public health and preventive medicine at Upstate, and Mr. Miguel Pica, who was a student in his advanced biostatistics course.
I'm Amber Smith for Upstate's " HealthLink on Air."
Treating headaches after head injury with magnets -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."
A physical therapist and researcher is seeking volunteers for a study that uses a non-invasive brain stimulation technique as a novel treatment for chronic headaches and other post-concussion symptoms in people with mild traumatic brain injury.
Here to talk about this study and how you can get involved is physical therapist Yi-Ling Kuo, who is an assistant professor in the department of physical therapy education in Upstate's College of Health Professions.
Welcome to "The Informed Patient," Dr. Kuo.
Yi-Ling Kuo, PhD: Thank you for having me.
Host Amber Smith: What is this non-invasive brain stimulation technique?
Yi-Ling Kuo, PhD: The technique that we're going to be using is called transcranial magnetic stimulation, or TMS. It is a type of non-invasive stimulation technique that stimulates your brain, but without opening up your skull. And we reach some findings with some signals so that we get to know what's going on inside your brain indirectly.
There are different forms of TMS. Some forms are used for assessment, which means that we monitor your brain status. And other forms are called repetitive transcranial magnetic stimulation, or RTMS, which is the form that's going to be used in this study. And it has the capability to modulate the brain status so that it's used for treatment.
Host Amber Smith: So there's no incision. The magnets do their work through the skin, through the bone, through the muscle?
Yi-Ling Kuo, PhD: Exactly. Yep.
Host Amber Smith: Interesting. Can you tell me how magnets affect the brain? .
Yi-Ling Kuo, PhD: So the stimulation coil will generate magnetic field to simulate the brain. The magnetic field will make current generated in the brain, and that electric current will stimulate the neurons in the brain. And this mechanism is called electromagnetic induction. And that was discovered by Michael Faraday in the 19th century. So the stimulated neuron, by the current, will then activate and fire and generate potential to move your body. So we capture the response in the movement to tell what's going on inside the brain in an indirect way.
Host Amber Smith: Is this already being used to treat regular headaches?
Yi-Ling Kuo, PhD: So currently the use of RTMS in headaches is in an investigational stage, which means that's used in only research. It's not been FDA (Food and Drug Administration) approved for headaches for clinical use yet. But RTMS has been FDA approved for other mental illnesses, including depression, which is the most well known one.
So we're using RTMS in headaches in this study as an off-label application.
Host Amber Smith: I understand you've been involved in brain stimulation research for more than a decade.
Have you always focused on magnets?
Yi-Ling Kuo, PhD: Myself, yes. My research is primarily in TMS, but there are actually many other forms of non-invasive brain stimulation, including, for example, transcranial direct current stimulation that uses electrical current to stimulate the brain, or ultrasound stimulation, or infrared lights for stimulation, et cetera.
But for myself, yes, TMS is my primary focus.
Host Amber Smith: Please walk us through how this transcranial magnetic stimulation works. Is this done in a medical office or a hospital?
Yi-Ling Kuo, PhD: For clinical use, it is used in a clinic, so it can be a clinic or in a hospital. But for research use, so like us, we use that in a research laboratory.
Host Amber Smith: And are patients sitting up or laying down? How is this applied to them?
Yi-Ling Kuo, PhD: So they will be reclined, sitting in your chair. That chair will be similar to a dental chair, so that we'll recline the chair, and the patient can be semi-lying on that chair.
Host Amber Smith: And they don't need to shave their hair or anything? This works right through their hair, right?
Yi-Ling Kuo, PhD: Exactly, yes. So the magnetic field penetrates the air, the hair and the skull to reach the surface of the brain. We don't require any preparation of the hair to be shaved or in any other way. The patient can just receive TMS as they are, after they walk into the clinic or the laboratory.
Host Amber Smith: So is this like a hat that goes over their head?
Yi-Ling Kuo, PhD: Well, we use a coil that's connected to the stimulator. So the coil, it can be in different shapes, but the most commonly used and the one being used in our study is in a figure-eight shape. So that coil will be placed upon the head, and to generate magnetic field to stimulate the surface of the brain.
Host Amber Smith: What do the patients feel during the treatment session? Or, I guess I should call them subjects because it's a research project. What do they feel during the treatment session?
Yi-Ling Kuo, PhD: So there will be a tapping kind of feeling on their scalp. It is painless, and the strength of the tapping will depend on the stimulation intensity. So if I turn up the intensity a little bit more, they may feel the tapping to be stronger, but it is always painless.
Some people may feel the stimulation being spread out to their facial muscles, so they may experience some twitches in their facial muscles. And also, depending on where we target in the brain area, for example, if we target the motor area, let's say the hand, when we stimulate the hand area in the brain, the subject may feel muscle twitches in their hand as well.
Host Amber Smith: Interesting. So I know you're monitoring during these sessions. What is the goal of these sessions?
Yi-Ling Kuo, PhD: We monitor the participants using some signals. For example, electromyography, or EMG, is the one that we use to monitor muscle activity because in this study we target the motor area in the brain.
So, those signals will be analyzed to help us interpret what's going on inside the brain. But other than the muscle activities, we will also monitor the participants in their facial expression or relying on their reports to us to see how they respond to the treatment during the experiment.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with physical therapist Yi-Ling Kuo from Upstate's College of Health Professions.
Now, Dr. Kuo, for the study, what people are you looking for?
Yi-Ling Kuo, PhD: We are looking for people with mild traumatic brain injury, with chronic, unresolved post-concussion headaches. So if people have chronic headaches for more than three months, and that's not resolved after standard care, then those will be the target for our study.
Host Amber Smith: What is traumatic brain injury, and how would a person know if theirs was mild or more severe?
Yi-Ling Kuo, PhD: A mild traumatic brain injury typically means that after the person is hit in the head -- for example, due to motor vehicle accidents, sports injury or full accident -- those symptoms will not be life threatening. And typically there's no pathology detectable with new imaging like CT (computerized tomography) or MRI (magnetic resonance imaging)? So that's why they're considered mild.
And typically symptoms go away within a month with proper management. But some people, their symptoms might last outside of the normal recovery window. And for those who have headaches, for example, that will be the target in this study.
Host Amber Smith: How long ago could the people have had a traumatic brain injury in order to be included? Do these have to be relatively current?
Yi-Ling Kuo, PhD: Well, we do not limit the onset time of the headaches or the concussion to be enrolled in this study. It's that we said the inclusion criteria should be the timing or the length of the headache that's going on out there. So, chronic headaches for more than three months, and if the patient went through standard care and that's not resolved, then those will be the target for our study.
Host Amber Smith: Are there any other symptoms besides headache that you're also including?
Yi-Ling Kuo, PhD: Well, so, we will also monitor the changes in other post-concussion symptoms such as dizziness, difficulty concentrating, anxiety, memorizing issues or trouble sleeping. Those are secondary symptoms being monitored.
But for the main thing being studied in the study, will be headaches, the chronic ones.
Host Amber Smith: And are you looking for men, women? What ages? Races?
Yi-Ling Kuo, PhD: We will be recruiting both men and women. There's no limitation in race, and we will be targeting adults. So they need to be older than 18 years old.
Host Amber Smith: Is there anything that would exclude someone from participating, medically?
Yi-Ling Kuo, PhD: If someone's headaches happened prior to the concussion or the diagnosis of mild traumatic brain injury, that means their headaches came from something else. Then those people won't be studied in our experiment.
And for people who have metal implants inside their body that has electromagnetic steel -- for example, a pacemaker that's helping their heart rhythm -- those patients will be excluded as well. And also someone who has a history of seizure or epilepsy, those people will be excluded as well. And we do use safety screening questionnaires just to make sure that the patients are eligible to receive TMS.
Host Amber Smith: Will all the volunteers receive the TMS therapy?
Yi-Ling Kuo, PhD: So in the experimental stage, they will be randomly assigned to either receive active or sham stimulation. So sham means that there's no active or real stimulating applied to their brain, and this is for scientific methodology purposes to minimize the effect of placebo.
But after they complete the experimental stage, they will be unblinded to know which group they were assigned to. And for those who are in the sham group can opt to receive active RTMS after we're done with the entire procedure. And we offer that at no cost.
Host Amber Smith: I see. Now, if the volunteers are signing up for this, what's expected of them? How long are the sessions that they go to, and how long does this last?
Yi-Ling Kuo, PhD: We would ask the volunteers to keep a total of 12 sessions of appointments to the laboratory. And also throughout the treatment course, within four weeks, we will ask them to complete a daily diary to track their headache, intensity, frequency, things like that, and also sleep and their physical activity levels.
And we would also ask the participants to not start a new treatment for their headaches while they are in this study.
Host Amber Smith: So 12 sessions, would that be spread out over a year, or less, or more?
Yi-Ling Kuo, PhD: Twelve sessions will be spread out in four weeks, typically. So we do three times a week for a total of four weeks to complete those 12 sessions of RTMS.
Host Amber Smith: So what's the best way for someone who's interested in participating to learn more?
Yi-Ling Kuo, PhD: If they are interested in participating, they can contact us through my email address, [email protected].
Host Amber Smith: What do you plan to do with your results?
Yi-Ling Kuo, PhD: We will eventually publish the findings in scientific conferences and journals. So that's the first thing. Secondly, we will use the data to obtain future funding so that we can refine RTMS protocols and to better individualize, to maximize patient responsiveness.
So we do expect the preliminary results to be out in a few months, probably in a conference. and the completion of the entire study will be probably one to two years from now. And also we are happy to send the results to the participants if they're willing to know what's happening.
Host Amber Smith: Very good to know. Dr. Kuo, thank you so much for making time for this interview.
Yi-Ling Kuo, PhD: Thank you so much. And I look forward to any participation that we can welcome.
Host Amber Smith: My guest has been physical therapist, Dr. Yi-Ling Kuo, an assistant professor of the department of physical therapy education in Upstate's College of Health Professions.
I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- what is premenstrual dysphoric disorder?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Premenstrual dysphoric disorder is a disabling form of premenstrual syndrome that affects women of reproductive age, and it can range from severe mood swings to suicide attempts. Today I am talking about how this is diagnosed and the challenge of treatment with Dr. Luba Leontieva and Dr. Nevena Radonjic. Both are from Upstate's department of psychiatry and behavioral sciences.
Welcome to "HealthLink on Air," both of you.
Nevena Radonjic, MD, PhD: Thank you.
Luba Leontieva, MD, PhD: Thank you.
Host Amber Smith: Now, what percentage of women have PMS, and what portion of that number have PMDD?
Nevena Radonjic, MD, PhD: Amber, it's a great question to start this conversation. A majority of women do have premenstrual syndrome, and this can really vary in presentation from one woman to another. And we think that it's usually around 80 to 95% of women that are going to have PMS.
From that number, only 1.3 to 7.7 percentage of women are diagnosed with PMDD. PMDD, premenstrual dysphoric disorder, is a fairly novel psychiatric diagnosis that has been included in DSM-5 (Diagnostic & Statistical Manual of Mental Illnesses, from the American Psychiatric Association) only in 2014. And for these reasons we have, we are still learning how to identify the past, how to treat and how to help other providers recognize the disease.
Host Amber Smith: Does it primarily affect younger women?
Luba Leontieva, MD, PhD: Not necessarily. It affects women in reproductive age.
Host Amber Smith: I see. Is it equally spread among races and geographic locations?
Luba Leontieva, MD, PhD: So, research in this area is still developing. It's seen less in black women, 2.9% prevalence, and more in white women, 4.4% prevalence. The lifetime prevalence is also lowest in black women, 3.37%. And in white women, 5.29%. That's what research shows. But it could be that Black women are underreporting the changes that occur in premenstrual dysphoric disorder. Interestingly enough, Asian women is the lowest lifetime prevalence, 3.23%.
Host Amber Smith: Can we go over the symptoms? What are the typical symptoms that you see?
Nevena Radonjic, MD, PhD: This diagnosis is really unique in many different ways. First is when it actually occurs, so there is temporal correlation or time relation to your period. So, just to remind our listeners, period we consider to start on first day of menstruation. And around the 14 days of period is usually the ovulation.
And then after that we have the part of the period we call the luteal phase. And in this phase, which is usually 10 days before the next period, is when women are going to start experiencing different symptoms that can be either affective or cognitive behavioral symptoms.
In order for the diagnosis of PMDD to be made, one person has to have at least five symptoms, and it has to be in both of these categories -- mood and cognitive behavioral symptoms. What are the most usual mood symptoms? Emotional lability, such as sudden sadness, tearfulness or sensitivity to rejection. Then irritability, anger or increased interpersonal conflicts. Depressed mood, hopelessness or self-deprecating thoughts. Or just being more anxious or keyed up or being on edge. edge These are the moods and anxiety symptoms or what we call affective symptoms. In other category, we have cognitive behavioral symptoms such as decreased interest in usual activities, difficulty focusing, lethargy, low energy, change in appetite, overeating or food cravings, hypersomnia or insomnia, so we see changes in sleep, feeling overwhelmed or out of control, and having various physical symptoms that can present as a reaction to period, such as breast tenderness, swelling, headache, joint or muscle pain, bloating and weight gain.
So just to sum up, we need to have five symptoms, five or more, and it has to be present in both affective and cognitive behavioral categories.
Host Amber Smith: So Dr. Radonjic, is this medical or psychiatric?
Nevena Radonjic, MD, PhD: That's another great question, Amber.
I think we are, in our field, stepping away from diagnosis being either/or, and we are now seeing, or we at least on our end, conceptualize the diagnosis that are psychiatric to be medical as well, or we don't see any more behavioral health to be removed from medical diagnosis. So it is, though, most commonly diagnosed by psychiatrists, then family providers and OB-GYNs (obstetrician-gynecologists), our colleagues who are seeing patients or women for different reasons, can also diagnose the patient with PMDD.
Host Amber Smith: So if the majority of women have some symptoms of PMS, what determines which of those women might go on to develop the premenstrual dysphoric disorder?
Nevena Radonjic, MD, PhD: It's really the impact on functioning. In the field of psychiatry, it's always the impact on functioning and how much it affects person's well-being. But I think the key here is this temporal correlation, what we see that is in specific period of the month. The resolution once when period starts. And, I think that these are going to be the key factors.
Dr. Leontieva, what do you think?
Luba Leontieva, MD, PhD: Yes, and to add to this, there is a certain conditions in women that predispose to PMDD, such as a family history of this condition, anxiety and depression, trauma that increase stress, of course. And for the premenstrual syndrome, again, depression, stress and proneness to stress, peculiar eating habits, such as craving for certain food.
Host Amber Smith: So, do we know what causes PMDD or why one woman gets it and the others do not? I know you just listed some of the risk factors, but what's happening biologically that determines how that's going to play out in a woman?
Nevena Radonjic, MD, PhD: It's a combination of things. We think there is genetic predisposition. But the key question here is, we see the hormonal fluctuations. So why one woman is going to have PMDD, versus one only having PMS?
What we think the key or the answer lies is in the sensitivity of the brain to hormonal fluctuations. So, it's not really the absolute levels of the hormones. Those studies have been done and measured. So there is no difference in absolute level of hormones, estrogen or progesterone that are levels are that are being measured during the period. However, in some women, there is going to be increased vulnerability, how the brain tolerates the changes in ratios that happens normal during the month. And these women are often also more at risk for postpartum depression or for other affective disorders that can be seen in normal reproductive life cycle.
Host Amber Smith: Does PMDD go away as a woman ages?
Luba Leontieva, MD, PhD: This disappears when the periods stop, basically in menopause. But it can get worse before in premenopausal women.
Host Amber Smith: What about during pregnancy?
Nevena Radonjic, MD, PhD: So the hormone levels in pregnancy are rising, and they're just going to continuously rise until the delivery. So the next, the pregnancy itself, it's not characterized by cyclical changes. So in a way, there is a steady state that is just increasing of the hormones. However, after the delivery, this can be a period of vulnerability for onset of symptoms.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Luba Leontieva and Dr. Nevena Radonjic. Both are from Upstate's department of psychiatry and behavioral sciences, and we're talking about PMDD.
Would you please tell us about the case you wrote about for the journal Cureus that involved a 19-year-old?
Luba Leontieva, MD, PhD: Yes, sure. So we have the 19-year-old female who came with severe anger problems, mood swings and a suicide attempt that was very ego-dystonic for her, which means that she was shocked by the fact that she overdosed on pills. It was very impulsive. She was very remorseful. And she recognized that this is not who she is and not what she wanted to do.
So as we treated the young woman, we discovered that she has the intense anger and intense mood swings around periods. And that's qualified for, with a lot of other symptoms that were listed before, it qualified her for this diagnosis.
Host Amber Smith: It sounds like this can be, for someone who's afflicted, this can make you feel like you're out of your mind, it sounds like.
Luba Leontieva, MD, PhD: That's exactly how this young woman thought she is, and her family also noticed that her mood swings became so intense that she basically couldn't control herself. She was throwing things, she had intense anger outbursts. She was very sensitive to what others are telling her, which culminated in her impulsively overdosing.
Host Amber Smith: Now, what role, if any, did her use of birth control pills have?
Nevena Radonjic, MD, PhD: So birth controls can actually be very helpful for the treatment of PMDD. I think for this patient justcoincided that there was a use of one and another. However, what we know from clinical studies is that some birth controls are more favorable, and they are decreasing the fluctuations in the level of hormones that are happening, which for which patient usually has vulnerability. So as such, it can actually help as a second line treatment for PMDD.
Host Amber Smith: Well, I'd like to talk to you about treatment. What did you recommend for this particular person, and what do you recommend in general for people who are newly diagnosed? How is this treated?
Nevena Radonjic, MD, PhD: We usually recommend as a first-line treatment selective serotonin re-uptake inhibitors, or what would be in general population known as antidepressant. So this medication can be given in very unique way if patient only has this disorder, PMDD, which is only to be taken 10 days before getting the period.
We often see in clinical practice that women who have history of anxiety or depressive disorders, they have what we call a premenstrual worsening of already existing mood and anxiety disorder. And that is going to be what we see probably the most often in clinical practice. The women come, and they say, "Well, I'm doing worse," but even after the period starts, they don't have complete resolution of symptoms. So we know that we are actually seeing premenstrual worsening versus pure PMDD. And for those patients, they are continuously on antidepressants, and we try to titrate the dose, which means adjust the dose until the symptoms are well controlled. That's No. 1.
No. 2 is going to be use of hormonal contraceptives. The one that contains drospirenone with a combination of synthetic estrogen have been FDA-approved for treatment of PMDD. And of course, we always recommend behavioral modifications and alternative lifestyle. Dr. Leontieva can tell us more about that.
Host Amber Smith: So, Dr. Leontieva, are there things that women can do to help reduce the symptoms?
Luba Leontieva, MD, PhD: Yes, there is some things that women can do. So, first we're going to talk about diet modifications. So, complex carbohydrates or proteins that are slow burning in nature, it's a slow-burning fuel, another name of it, is believed to be increasing the substance in our body called tryptophan. And tryptophan is a precursor to serotonin, which helps with PMDD. And serotonin reuptake inhibitors, the medication that Dr. Radonjic talked about just recently, increase the serotonin. So what are those complex carbohydrates? It's whole grains, oats, lentils, peas, quinoa, brown rice and fruits and vegetables, such as carrots, for example.
The second one is, there is some studies show that vitamin B6 -- 50 to 100 milligrams a day -- can help ease the PMDD symptoms. Another supplement is called chasteberry. Another name of it, scientific name, is vitex agnus castus. So this supplement helps to stimulate progesterone and has some dopaminergic effect, and dopamine helps with the mood swings and depression.
And of course, stress management such as relaxation, meditation, deep breathing and yoga can help to ease the anxiety.
Host Amber Smith: In terms of avoiding certain activities or food, we can recommend avoiding stimulating caffeinated beverages before bed, so, like, after 3 o'clock. TV screens, other devices, phones before bed as well, so the sleep is more full and better, not taking long naps during the day and try to stop smoking or go into smoking cessation. Before we wrap up, I wanted to ask your advice for women who may believe they have some degree of PMDD. The young woman that you wrote about, she kept a symptom diary. Was that helpful?
Nevena Radonjic, MD, PhD: Diaries are very helpful when it comes to PMDD. When we initially see the patient, we administer the diary that is retrospective, which basically we are asking for recollection. We are asking you, can you remember how you have been doing? What we learned is that although here sensitivity is high, specificity, which means is it really going to stand for what it shows is kind of lower. So the standard in the field is actually to administer prospectively from the moment patient sees us to give them the diary where they can follow affective and cognitive behavioral symptoms for two months. And they follow, daily, the symptoms, and they're also going to chart when they got their period, when they're ovulating and when there are fluctuations.
If now we see a patient after two months, they bring the diary, we review and we can see that there is a clear correlation between increase in the symptom severity and menstrual cycle, then we can proceed further to diagnose either with PMDD or premenstrual exacerbation of anxiety or mood disorders. So that's huge. I always encourage all of our patients, as I'm seeing mostly women, to keep the period diary. It's going to give us not only important information about mood symptoms in earlier stages of life, but also in later when women are going to be closer to their perimenopausal period and can also have mood symptoms.
Host Amber Smith: Are there additional strategies that you think work better for teens?
Nevena Radonjic, MD, PhD: I'm always going to go with psychoeducation. I think understanding and explaining clearly what they're experiencing is going to provide any patient the sense of agency and ability to be in better control of their symptoms and disease management. So I think there is a lot of learning or teaching the patient about what they're experiencing, helping them utilize all of the behavioral modifications Dr. Leontieva very nicely suggested and outlined, keeping in mind, for some patients only understanding that they're in that period of month is already going to give them huge relief because they understand why they're feeling this certain way, although they're still not feeling great, but the fact that you know that this is happening for a certain reason versus out of the blue is so important in how patients are perceiving their well-being and how they're going to act on that.
Host Amber Smith: So I know, I think I understand, this goes away or gets tremendously better at menopause, but are there lingering issues for women that have had this for years and then reach menopause? Or do we know yet?
Luba Leontieva, MD, PhD: I think it's hard to predict, but of course there is lingering issue, if somebody has been struggling with intense mood swings throughout their life, it damage the relationship. It breaks certain relationship with a family members and friends, spouses, it has this connotation of somebody's very moody. So, yes, it is, it's similar to untreated ADHD, attention-deficit/hyperactivity disorder. There is things that linger with individuals who have ADHD.
Host Amber Smith: This has been a lot of important information. I appreciate both of you making time to share it.
Nevena Radonjic, MD, PhD: Thank you for this opportunity.
Luba Leontieva, MD, PhD: Thank you very much.
Host Amber Smith: My guests have been Dr. Luba Leontieva and Dr. Nevena Radonjic. Both are from Upstate's department of psychiatry and behavioral sciences.
I'm Amber Smith for Upstate's "HealthLink on Air."
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
KB Ballentine's sixth poetry collection, "The Light Tears Loose," can be found at Blue Light Press. The poem she gave us, "After Surgery," is a meditation on all we see and feel as we recover. Here is "After Surgery":
A pair of swans preen, slide
swiftly across the blue cool
of lake -- soon they will taste
the frost before it comes and rise
together finding a thermal draft
that guides them to warmer climes.
The lamps on each bedside table beckon,
downy softness sandwiched
between them where letters turn to words
that take dreams to flight:
promise of light before the final dark.
Following the trail as sure as scent,
the wolf of smoky fur and tender heart
nuzzles his mate. She licks his ear
while they pause beneath an evergreen
leaning with the weight of snow.
Branches bristle, spear the feathery mounds.
Toes seek solace in fuzzy comfort ,
left and right slippers waiting by the door.
Twelve hours constricted in stiff leather
pressing concrete pleads a soothing escape
to stretch and wiggle.
Seahorses couple, anchor themselves
in the reeds, the grass. Undulating
they wrap around each other
and daily dance invisible currents --
nodding to blennies and gobies, to kelp
clinging across the rock and sand.
I didn't know I was grateful,
with my eyes and ears and lungs,
to watch the moon twin the sun: two flawed
globes that balance night and day --
lead the seasons, reel against the dizziness
that unbalances my new walk, my new life.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.
Next week on "HealthLink on Air," an update on Alzheimer's disease. If you missed any of today's show, or for more information on a variety of health, science, and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.