Perimenstrual exacerbation of symptoms in borderline personality disorder: evidence from multilevel models and the Carolina Premenstrual Assessment Scoring System

Predicting Acute Changes in Suicidal Ideation and Planning: A Longitudinal Study of Symptom Mediators and the Role of the Menstrual Cycle in Female Psychiatric Outpatients With Suicidality

OBJECTIVE

Cross-sectional and preliminary longitudinal findings suggest that cyclical ovarian hormone fluctuations influence acute suicide risk. The authors provide the first analyses in females with suicidality to investigate which daily symptoms covary with suicidal ideation and planning thoughts, the role of the menstrual cycle in daily symptom variation, how daily fluctuations in symptoms mediate the menstrual cycle-suicidality relationship, and how these associations vary across individuals.

METHODS

Naturally cycling psychiatric outpatients (N=119) with past-month suicidal ideation provided daily ratings of psychiatric symptoms (depression, hopelessness, anxiety, feeling overwhelmed, agitation, anhedonia, worthlessness, rejection sensitivity, anger, perceived burdensomeness, and interpersonal conflict), suicidal ideation, and suicidal planning across at least one menstrual cycle. Symptom ratings were decomposed into trait (person-centered mean) and state (daily person-centered mean deviation) components. Five cycle phases were identified in relation to menses onset and ovulation (surge in urine luteinizing hormone level). Hypotheses were tested in multilevel structural equation models.

RESULTS

Nearly all psychiatric symptoms covaried with fluctuations in daily suicidal ideation, and a limited set of symptoms (depression, hopelessness, rejection sensitivity, and perceived burdensomeness) predicted within-person increases in suicidal planning. Many patients demonstrated perimenstrual worsening of psychiatric symptoms, suicidal ideation, and suicidal planning. Depressive symptoms (depression, hopelessness, perceived burdensomeness, and anhedonia) were the most robust statistical mediators predicting perimenstrual exacerbation of suicidality.

CONCLUSIONS

Research on the menstrual cycle and suicide has been limited historically by small, cross-sectional samples. This study provides the first evidence that measuring day-to-day correlates of suicidality in a large transdiagnostic sample of females with suicidal ideation can contribute to understanding the pathways by which the menstrual cycle influences acute suicide risk.

A case series of premenstrual disorders presenting to the UK's National Female Hormone Clinic

AIMS AND METHOD

We aimed to describe the clinical characteristics of female patients presenting with premenstrual disorders to a tertiary service in the UK. We conducted a retrospective case-note review of referrals to the National Female Hormone Clinic from April 2014 to August 2020. Based on clinical assessment, we determined whether the patient met criteria for premenstrual dysphoric disorder or premenstrual exacerbation of an underlying psychiatric disorder.

RESULTS

Of 146 patients seen in clinic for premenstrual disorders, an ICD-10 psychiatric diagnosis was made in 130 (89.0%); a minority 16 (11.0%) did not have a psychiatric diagnosis. Following assessment, 94 patients (64.4%) met criteria for premenstrual dysphoric disorder and 67 (45.6%) had exacerbation of a psychiatric disorder.

CLINICAL IMPLICATIONS

Patients presenting to this specialist service had complex psychiatric comorbidity; almost half presented with exacerbation of a psychiatric disorder.

Menopause and Mood: The Role of Estrogen in Midlife Depression and Beyond

Depression is a disabling condition that often leads to significant burden. Women are more vulnerable to depression during reproductive-related "windows of vulnerability" such as the menopause transition and early postmenopausal years. This heightened vulnerability can be attributed, at least in part, to the neuromodulatory effects of estrogen on mood and cognition and the exposure to rapid fluctuations of estradiol levels during midlife years. The management of midlife depression can be challenging due to the presence and severity of other complaints such as vasomotor symptoms and sleep disturbances. Psychopharmacologic, behavioral, and hormonal interventions should be part of the treatment armamentarium.

Cyclical exacerbation of suicidal ideation in female outpatients: Prospective evidence from daily ratings in a transdiagnostic sample

Suicide is a leading cause of death among females of reproductive age. The menstrual cycle is a plausible yet understudied trigger for acute suicide risk. Cross-sectional studies have demonstrated a greater frequency of suicide attempts and deaths in the weeks before and after the onset of menses compared to other cycle phases. Here, using prospective daily ratings, we examine the relationship between the cycle and suicidal ideation (SI) and related symptoms known to show a cyclical change in some patients (depression, hopelessness, guilt, rejection sensitivity, interpersonal conflict, anxiety, mood swings, and anger/irritability). Thirty-eight naturally cycling outpatients recruited for past-month SI reported SI severity and other symptoms across an average of 40 days. Participants were excluded for hormone use, pregnancy, irregular cycles, serious medical illness, and body mass index > 29.9 or < 18. Intraclass correlations ranged from .29 to .46, highlighting that most symptom variance lies within-person. Cyclical worsening of symptoms was evaluated using phase contrasts in multilevel models. Most symptoms, including SI, were significantly worse in the perimenstrual phase than in all other phases. Additionally, anger/irritability was higher in the midluteal than in the midfollicular phase, and several symptoms of depression were higher in the midfollicular than in the periovulatory phase. Otherwise, symptoms did not significantly differ between the midluteal, midfollicular, and periovulatory phases. Cycle phase predictors accounted for 25% of the within-person variance in SI. Females with SI may be at risk for perimenstrual worsening of SI and related symptoms. These findings highlight the importance of assessing the cycle phase for improved prediction of suicide risk. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Daily ovarian hormone exposure and loss of control eating in adolescent girls: A registered report

OBJECTIVE

The daily biobehavioral factors that precipitate loss of control eating (LOCE) in adolescent girls are not well known. Ovarian hormone levels are key biological factors associated with the etiology of eating disorders in adolescent girls. Yet, models on how daily ovarian hormone exposure predicts LOCE in adolescent girls are underdeveloped. The goal of this study is to examine the daily patterns and mechanisms of ovarian hormone levels on LOCE across the menstrual cycle in adolescent girls and the mediating roles of food-related reward anticipation and response inhibition. Ecological momentary assessment (EMA) paired with daily hormonal sampling will be used to examine (1) daily associations between within-person hormones and LOCE, and (2) the mediating role of within-person food-related reward anticipation and response inhibition.

METHODS

Normally cycling adolescent girls who have reached menarche will provide daily saliva samples for hormone analysis and complete EMA for 35 days. During EMA, girls will report LOCE and will complete task-based and self-report measures of food-related response inhibition and reward anticipation.

DISCUSSION

This work has implications for the development of new real-world biobehavioral models of LOCE in adolescent girls, which will guide theory improvements and treatment for LOCE. Results will provide preliminary evidence for treatment targets for novel interventions for adolescent girls-for example, a response inhibition intervention.

PUBLIC SIGNIFICANCE

Adolescent eating disorders are severe mental health conditions, often marked by loss of control eating. Estrogen and progesterone play a role in the development and persistence of loss of control eating. The current study will examine how daily exposure to estrogen and progesterone predicts loss of control eating in adolescent girls and identify possible daily mechanisms linking estrogen and progesterone exposure and loss of control eating.

Auditory steady-state responses in the auditory cortex of mice during estrus cycle

Auditory-steady state responses (ASSRs) disclose brain's potency to oscillate and have been suggested to serve as biomarkers in various psychiatric disorders. GABAergic neurotransmission, a critical component for brain oscillations, is heavily influenced by sex hormones. In line, the severity of symptoms in psychiatric disorders is linked to changes in sex hormones during menstrual cycle. However, how these sex hormones affect ASSRs remain largely unknown. This was addressed by performing chronic recordings of ASSRs in mice while monitoring its estrus cycle. Here, the stability of ASSRs during long term recordings were validated and showed good reliability. 40 Hz ASSRs showed changes throughout estrus cycle where it decreased in metestrus phase compared to diestrus phase. In contrast, other frequency ASSRs did not show significant changes throughout estrus cycle. Taken together, our findings illustrate that the estrus cycle can influence the generation of ASSRs and the phase of the estrus cycle should be taken into consideration when ASSRs are recorded in females.

Effects of acute estradiol and progesterone on perimenstrual exacerbation of suicidal ideation and related symptoms: a crossover randomized controlled trial

Female suicide attempts peak peri-menstrually-around the onset of menses-when the ovarian steroids estradiol (E2) and progesterone (P4) fall rapidly. Given preclinical evidence that withdrawal from either E2 or P4 can provoke behaviors consistent with elevated suicide risk, we hypothesized that withdrawal from one or both of these steroids contributes to perimenstrual exacerbation of suicidal ideation (SI) and related symptoms. In a randomized, controlled, double-blind crossover experiment (NCT03720847), a transdiagnostic sample of naturally cycling, medically healthy psychiatric outpatients reporting past-month SI completed two conditions during two different 14-day experimental intervals (days 7-20 where the luteinizing hormone surge = day 0), separated by a monthlong washout cycle. In the E2 and P4 (EP) condition, participants received transdermal E2 (0.1 mg/day) plus oral micronized P4 (200 mg/day as 100 mg twice daily) to buffer perimenstrual steroid withdrawal. A matched placebo (PBO) condition allowed natural perimenstrual steroid withdrawal. Participants reported daily SI and planning (primary outcomes) and indices of depression (low mood, hopelessness), threat sensitivity (anxiety, perceived stress), executive functioning (difficulty concentrating, impulsivity), and social cognitive bias (rejection sensitivity, perceived burdensomeness). In baseline cycles, no participant met prospective criteria for DSM-5 premenstrual dysphoric disorder, but 59% met all criteria except full follicular symptom remission, and 93% showed the highest SI in the perimenstrual phase. Of 29 randomized, 28 were analyzed (14 EP-PBO, 14 PBO-EP). Experimental administration of E2 and P4 (relative to PBO) reduced perimenstrual exacerbation of SI, suicide planning, depression, hopelessness, perceived stress, rejection sensitivity, and perceived burdensomeness, particularly in the perimenstrual (natural E2 and P4 withdrawal) days. Further, delayed withdrawal from experimental E2 and P4 (but not PBO) recapitulated SI, hopelessness, and rejection sensitivity. Acute perimenstrual withdrawal from ovarian steroids may play a causal role in perimenstrual worsening of depression and SI.

Late manifestation of borderline personality disorder: Characterization of an under-recognized phenomenon

Although uncommon, borderline personality disorder (BPD) may manifest for the first time later in life. A retrospective clinical file audit was used to identify the clinical manifestation of BPD for the first time at or above the age of 30, and to examine whether particular clinical and psychosocial factors may be associated with a later-in-life manifestation of BPD. Twenty-three cases of late manifestation BPD were identified. People with late manifestation of BPD had similar risk factors and vulnerabilities, including childhood trauma, to the broader BPD population. They were distinguished by having higher levels of education, employment, and long-term intimate relationships. Interpersonal problems, loss of employment and reminders of past sexual trauma were key precipitating factors. The findings underscore the legitimacy of a late-manifestation diagnosis of BPD by demonstrating that BPD does not present exclusively during adolescence and early adulthood. BPD may present for the first time in later life in response to loss of protective factors or triggering of past trauma. This understanding may reduce misdiagnosis or delayed diagnosis, prescription of inappropriate treatments or delays in receiving BPD-appropriate treatments.

Premenstrual exacerbation of mental health disorders: a systematic review of prospective studies

Mental health disorders can be exacerbated during periods of hormonal fluctuation (e.g. pregnancy, menopause), and the risk factors for sensitivity to these fluctuations are similar to those of mental disorders (e.g. trauma). However, the extent to which hormonal fluctuations during the menstrual cycle impact symptoms of preexisting mental disorders remains unclear. Prospective methodology is considered the gold standard for measuring symptoms across the menstrual cycle. Thus, the aim of the review was to address this knowledge gap by summarising all available studies prospectively measuring symptoms of mental disorders across the menstrual cycle. A systematic review with narrative synthesis was conducted; meta-analysis was precluded due to methodological heterogeneity of included studies. Electronic databases MEDLINE, Embase, PyschINFO and CINAHL were systematically searched from inception. Risk of bias for individual studies was assessed using a modified version of the Newcastle-Ottawa Scale. The search identified 629 studies from which 35 met inclusion criteria. There was clear evidence of symptom exacerbation during the perimenstrual phase for psychotic disorders, panic disorder, eating disorders, depression and borderline personality disorder. Less consistent evidence was found for anxiety, and a different pattern of symptom exacerbation was observed in bipolar disorder. Sample size and methodology varied considerably amongst studies. Overall, there was mixed evidence for perimenstrual exacerbation across mental disorders, which could be partly explained by methodological limitations of the studies. However, hormonal fluctuations during the menstrual cycle may exacerbate psychiatric symptoms in a subgroup of individuals who are hormone sensitive.

Affective Risk Associated With Menstrual Cycle Symptom Change

In the present study we test whether cyclical changes in affective symptoms of the menstrual cycle are associated with higher mean levels of those same symptoms. Using prospective daily reports across two full menstrual cycles, from two samples of female University students (n = 213; n = 163), we applied both quartic polynomial regressions and cosine regressions to model cyclical change in symptoms, and to test for mean-level differences in symptoms across the resulting trajectory patterns. Counter to prior findings, but consistent with theoretical expectations, these results show that females who experience menstrual cycle-related changes in affect (whether a perimenstrual or mid-cycle increase) are at risk for higher average levels of affective symptoms. These results suggest that the mid-cycle group should be recognized as a target for future research that is associated with increased risk for chronic negative affective symptoms.

Menstrual Cycle in Trauma-Related Disorders: A Mini-Review

Fluctuations of sex hormones across the menstrual cycle have been linked to exacerbation of symptoms of psychiatric disorders. Women diagnosed with trauma-related disorders such as post-traumatic stress disorder (PTSD) and borderline personality disorder (BPD) have reported worsening of mood symptoms at various phases of their menstrual cycle. There is also considerable overlap between PTSD, BPD, and complex-PTSD (cPTSD) symptoms, suggesting similar biological underpinnings. This mini-review examines the influence of sex hormones and the menstrual cycle on PTSD, BPD, and cPTSD symptoms, and discusses the involvement of the hypothalamic-pituitary-adrenal (HPA) axis. We review literature showing that PTSD and BPD symptoms fluctuate with the menstrual cycle, though the effect of the menstrual cycle phase appears to be inconsistent, warranting future research. Based on the reported phasic vulnerability in individuals with PTSD and BPD, it is plausible to assume that women diagnosed with the newly introduced cPTSD may experience similar difficulties. However, no study to date has addressed this. This review highlights the importance of considering an individual's trauma history as it may influence symptom severity and diagnosis, and the phase of the menstrual cycle at the time of diagnosis. This review also highlights that additional work is needed to clarify the influence of estradiol and progesterone fluctuations on trauma-related symptoms, especially in cPTSD. Continued research on menstrual cycle vulnerability and trauma will lead to better informed management and treatment of PTSD, BPD, and cPTSD.

Psychiatric Symptoms Across the Menstrual Cycle in Adult Women: A Comprehensive Review

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Discuss and outline the general and overlapping effects of the menstrual cycle on women's mental health.

ABSTRACT

A growing body of research demonstrates menstrual cycle-dependent fluctuations in psychiatric symptoms; these fluctuations can therefore be considered as prevalent phenomena. Possible mechanisms underlying these fluctuations posit behavioral, psychological, and neuroendocrine influences. Recent reviews document cyclic exacerbation of symptoms and explore these mechanisms in the context of specific and often single disorders. The question remains, however, as to whether there are general and overlapping effects of the menstrual cycle on women's mental health. To address this gap, we synthesized the literature examining the exacerbation of a variety of psychiatric symptoms across the menstrual cycle in adult women. Results show that the premenstrual and menstrual phases are most consistently implicated in transdiagnostic symptom exacerbation. Specifically, strong evidence indicates increases in psychosis, mania, depression, suicide/suicide attempts, and alcohol use during these phases. Anxiety, stress, and binge eating appear to be elevated more generally throughout the luteal phase. The subjective effects of smoking and cocaine use are reduced during the luteal phase, but fewer data are available for other substances. Less consistent patterns are demonstrated for panic disorder, symptoms of posttraumatic stress disorder, and borderline personality disorder, and it is difficult to draw conclusions for symptoms of generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and trichotillomania because of the limited data. Future research should focus on developing standardized approaches to identifying menstrual cycle phases and adapting pharmacological and behavioral interventions for managing fluctuations in psychiatric symptoms across the menstrual cycle.

Advances in Research on Adolescent Suicide and a High Priority Agenda for Future Research

Suicide is the second leading cause of death for adolescents in the United States, yet remarkably little is known regarding risk factors for suicidal thoughts and behaviors (STBs), relatively few federal grants and scientific publications focus on STBs, and few evidence-based approaches to prevent or treat STBs are available. This "decade in review" article discusses five domains of recent empirical findings that span biological, environmental, and contextual systems and can guide future research in this high priority area: (1) the role of the central nervous system; (2) physiological risk factors, including the peripheral nervous system; (3) proximal acute stress responses; (4) novel behavioral and psychological risk factors; and (5) broader societal factors impacting diverse populations and several additional nascent areas worthy of further investigation.

Premenstrual Mood Symptoms in the Perimenopause

PURPOSE OF REVIEW

This review considers how reproductive aging may impact the trajectory of menstrually related mood disorders (MRMDs) such as premenstrual dysphoric disorder and considers how the treatment of MRMDs might require adjustment as patients approach midlife.

RECENT FINDINGS

The early menopause transition is accompanied by important hormonal changes that may exacerbate existing MRMDs. Indeed, recent research confirms that an important subset of women experiences depressive mood in response to perimenopausal elevations in ovarian hormones. In addition, a subset of women with an MRMD may exhibit an increased mood sensitivity to the ovarian hormone withdrawal that accompanies the late menopause transition and early postmenopausal phase. Though additional research is needed to clarify the trajectory of premenstrual dysphoria in the menopause transition, there is reason to believe that health care providers should be vigilant for a potential worsening of symptoms in perimenopause for women with past or current premenstrual dysphoric disorder.

Reciprocal effects between daily situational perceptions and borderline personality symptoms in young adulthood: the role of childhood parenting experiences

BACKGROUND

Recent research has emphasized the importance of within-person transactions between situational perceptions and borderline symptomatology. The current study extends current evidence by evaluating a broad range of situational perceptions and their transactions with borderline symptomatology across both private and professional contexts. Additionally, it explores whether early experiences of parental harsh punishment and emotional support during childhood, two well-established etiological factors in developmental theories of borderline symptomatology, influence the effect of daily situation perception in adulthood on borderline symptom presentation.

METHODS

N = 131 young adults (Mage = 20.97, s.d.age = 1.64) completed end-of-day diaries of their borderline symptoms and perceptions of the home and school or work environment for 14 days. During their mid-childhood, reports of maternal strategies of harsh punishment and emotional support were collected.

RESULTS

Findings revealed that on the same day, borderline symptoms were associated with more negative and stressful, and less positive perceptions of both the private and professional context. Additionally, borderline symptoms predicted more negative and stressful perceptions of school/work on subsequent days. Finally, while early harsh punishment predicted overall increases in daily borderline symptoms 10 years later, emotionally supportive parenting in childhood predicted decreases in borderline symptom expression in less positive and more stressful contexts.

CONCLUSIONS

The current study points to the importance of managing BPD symptoms to reduce subsequent negative perceptions of the environment, and also indicates the relevance of exploring adult person-situation processes based on early parenting experiences.

Premenstrual Exacerbations of Mood Disorders: Findings and Knowledge Gaps

PURPOSE OF REVIEW

In contrast to premenstrual dysphoric disorder (PMDD), premenstrual exacerbations (PMEs) of ongoing mood disorders are understudied. The aim of this review is to describe diagnostic issues, epidemiology, underlying mechanisms, and treatment for PME in unipolar depression and bipolar disorder, and to discuss clinical and research implications.

RECENT FINDINGS

Community-based and clinical studies estimate that in women with mood disorders around 60% report PME, while some women with bipolar disorder also show symptom exacerbations around ovulation. In general, PME predicts a more severe illness course and an increased burden. While heightened sensitivity to fluctuations of sex hormone levels across the menstrual cycle appears to contribute to PME and PMDD, the overlap of their underlying biological mechanisms remains unclear. Beneficial treatments for PMDD show less or no efficacy in PME. Pharmacological treatments for PME in mood disorders predominantly seem to profit from adjustable augmentation of treatment dosages during the luteal phase for the underlying disorder. However, the evidence is sparse and mainly based on earlier small studies and case reports. Previous research is mainly limited by the lack of a clear differentiation between PME and PMDD comorbidity with mood disorders. More systematic research with uniformly defined and prospectively assessed subgroups of PME in larger epidemiological and clinical samples is needed to receive reliable prevalence estimates and information on the clinical impact of PME of mood disorders, and to uncover underlying mechanisms. In addition, larger randomized controlled trials are warranted to identify efficacious pharmacological and psychotherapeutic treatments for affected women.

How to study the menstrual cycle: Practical tools and recommendations

Despite decades of research on the physiological and psychological effects of the menstrual cycle, studies have not sufficiently adopted consistent methods for operationalizing the menstrual cycle. This has resulted in substantial confusion in the literature and limited possibilities to conduct systematic reviews and meta-analyses. In order to facilitate more rapid accumulation of knowledge on cycle effects, the present paper offers a set of integrative guidelines and standardized tools for studying the menstrual cycle as an independent variable. We begin with (1) an overview of the menstrual cycle and (2) premenstrual disorders, followed by (3) recommendations and tools regarding data collection in cycle studies. These recommendations address selecting the appropriate study design and sampling strategy, managing demand characteristics, identifying a sample of naturally-cycling individuals, and measuring menstrual bleeding dates, ovarian hormones, and ovulation. We proceed with suggestions for (4) data preparation and coding of cycle day and phases, as well as (5) data visualization, statistical modeling, and interpretation of menstrual cycle associations. We also provide (6) recommendations for using menses start day and ovulation testing to schedule visits in laboratory studies and end with a (7) comprehensive summary and conclusion. Regardless of whether the influence of the menstrual cycle is of central interest in a study or should be controlled to accurately assess the effects of another variable, the use of these recommendations and tools will help make study results more meaningful and replicable.

Progesterone - Friend or foe?

Estradiol is the "prototypic" sex hormone of women. Yet, women have another sex hormone, which is often disregarded: Progesterone. The goal of this article is to provide a comprehensive review on progesterone, and its metabolite allopregnanolone, emphasizing three key areas: biological properties, main functions, and effects on mood in women. Recent years of intensive research on progesterone and allopregnanolone have paved the way for new treatment of postpartum depression. However, treatment for premenstrual syndrome and premenstrual dysphoric disorder as well as contraception that women can use without risking mental health problems are still needed. As far as progesterone is concerned, we might be dealing with a two-edged sword: while its metabolite allopregnanolone has been proven useful for treatment of PPD, it may trigger negative symptoms in women with PMS and PMDD. Overall, our current knowledge on the beneficial and harmful effects of progesterone is limited and further research is imperative.

Understanding When and Why Some Adolescent Girls Attempt Suicide: An Emerging Framework Integrating Menstrual Cycle Fluctuations in Risk

The prevalence of suicidal thoughts and behaviors increases dramatically across the transition to puberty, particularly among adolescent girls. Yet we know little about why adolescent girls are at heightened risk, or when girls may be most likely to consider or engage in suicidal behavior. In this article, we outline evidence supporting a role for the menstrual cycle in the onset of and fluctuations in adolescent girls' suicide risk. This emerging framework outlines developmental (i.e., biological, social, and cognitive) characteristics that might place certain girls at higher risk (e.g., between-subjects factors), as well as potential mechanisms that occur during the perimenstrual phase of the menstrual cycle (i.e., within-subjects factors) that increase adolescent females' increased risk for suicide.

Are there temporal subtypes of premenstrual dysphoric disorder?: using group-based trajectory modeling to identify individual differences in symptom change

BACKGROUND

Premenstrual dysphoric disorder (PMDD) is a new Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 diagnosis characterized by the cyclical emergence of emotional and physical symptoms in the luteal phase of the menstrual cycle, with symptom remission in the follicular phase. Converging evidence highlights the possibility of distinct subtypes of PMDD with unique pathophysiologies, but temporal subgroups have yet to be explored in a systematic way.

METHODS

In the current work, we use group-based trajectory modeling to identify unique trajectory subgroups of core emotional and total PMDD symptoms across the perimenstrual frame (days -14 to +9, where day 0 is menstrual onset) in a sample of 74 individuals prospectively diagnosed with DSM-5 PMDD.

RESULTS

For the total daily symptom score, the best-fitting model was comprised of three groups: a group demonstrating moderate symptoms only in the premenstrual week (65%), a group demonstrating severe symptoms across the full 2 weeks of the luteal phase (17.5%), and a group demonstrating severe symptoms in the premenstrual week that were slow to resolve in the follicular phase (17.5%).

CONCLUSIONS

These trajectory groups are discussed in the context of the latest work on the pathophysiology of PMDD. Experimental work is needed to test for the presence of possible pathophysiologic differences in trajectory groups, and whether unique treatment approaches are needed.

Pathoetiology and pathophysiology of borderline personality: Role of prenatal factors, gut microbiome, mu- and kappa-opioid receptors in amygdala-PFC interactions

The pathoetiology and pathophysiology of borderline personality disorder (BPD) have been relatively under-explored. Consequently, no targetted pharmaceutical treatments or preventative interventions are available. The current article reviews the available data on the biological underpinnings of BPD, highlighting a role for early developmental processes, including prenatal stress and maternal dysbiosis, in BPD pathoetiology. Such factors are proposed to drive alterations in the infant's gut microbiome, in turn modulating amygdala development and the amygdala's two-way interactions with other brain regions. Alterations in opioidergic activity, including variations in the ratio of the mu-and kappa-opioid receptors seem a significant aspect of BPD pathophysiology, contributing to its comorbidities with depression, anxiety, impulsivity and addiction. Stress and dysphoria are commonly experienced in people classed with BPD. A growing body of data, across a host of medical conditions, indicate that stress and mood dysregulation may be intimately associated with gut dysbiosis and increased gut permeability, coupled to heightened levels of oxidative stress and immune-inflammatory activity. It urgently requires investigation as to the relevance of such gut changes in the course of BPD symptomatology. Accumulating data indicates that BPD symptom exacerbations may be linked to cyclical variations in estrogen, in turn decreasing serotonin and local melatonin synthesis, and thereby overlapping with the pathophysiology of migraine and endometriosis, which also have a heightened association with BPD. Future research directions and treatment implications are indicated.

Differential effects of the menstrual cycle on reactive and proactive aggression in borderline personality disorder

Borderline personality disorder (BPD) is characterized by rapidly shifting symptoms, including intense anger and aggressive behavior. Understanding how fluctuations in ovarian hormones across the menstrual cycle may contribute to symptom instability is key for accurate assessment of BPD symptoms and effective interventions. Reactive and proactive aggression, as well as anger-in and anger-out, were assessed daily in 15 physically healthy, unmedicated naturally cycling female individuals meeting criteria for BPD across 35 days. Urine luteinizing hormone surge and salivary progesterone were used to confirm ovulation and verify the cycle phase. Multilevel models evaluated cyclical differences of symptoms between cycle phases. Both forms of aggressive behavior demonstrated marked cycle effects, with reactive aggression highest during the midluteal cycle phase, co-occurring with initial increases in anger and irritability and followed by perimenstrual peaks in anger and anger-in. In contrast, highest levels of proactive aggression were observed during the follicular and ovulatory phases, when emotional symptoms and anger were otherwise at lowest levels. These findings highlight the importance of identifying the function of aggression when considering potential psychological and biological influences. Naturally cycling individuals with BPD may be at elevated risk for luteal worsening of a range of interpersonally reactive symptoms, including reactive aggression, whereas proactive aggression may occur more in phases characterized by less emotional and cognitive vulnerability and greater reward sensitivity. Research on aggression in this population should consider cycle effects. Cycling individuals with BPD attempting to reduce aggressive behavior may benefit from cycle-tracking to increase awareness of these effects and to develop appropriate strategies.

A Systematic Review and Meta-Analysis of Within-Person Changes in Cardiac Vagal Activity across the Menstrual Cycle: Implications for Female Health and Future Studies

Interest in cardiac vagal activity (CVA; e.g., parasympathetically-mediated heart rate variability) as a biomarker of physical and mental health has increased exponentially in recent years. However, the understanding of sources of within-person change (i.e., intra-individual variance) in CVA is lagging behind. This systematic review and meta-analysis summarizes and quantifies current empirical evidence of within-person changes in measures of CVA across the menstrual cycle in naturally-cycling premenopausal females. We conducted an extensive literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement in five databases to identify observational studies with repeated measures of CVA in at least two menstrual cycle phases. A broad meta-analysis (n_studies = 37; n_individuals = 1,004) revealed a significant CVA decrease from the follicular to luteal phase (d = −0.39, 95% CI (−0.67, −0.11)). Furthermore, 21 studies allowed for finer-grained comparisons between each of two cycle phases (menstrual, mid-to-late follicular, ovulatory, early-to-mid luteal, and premenstrual). Significant decreases in CVA were observed from the menstrual to premenstrual (n_studies = 5; n_individuals = 200; d = −1.17, 95% CI (−2.18, −0.17)) and from the mid-to-late follicular to premenstrual phases (n_studies = 8; n_individuals = 280; d = −1.32, 95% CI (−2.35, −0.29)). In conclusion, meta-analyses indicate the presence of CVA fluctuations across the menstrual cycle. Future studies involving CVA should control for cycle phase. Recommendations for covarying or selecting cycle phase are provided.

Ovarian Hormones as a Source of Fluctuating Biological Vulnerability in Borderline Personality Disorder

PURPOSE OF REVIEW

To examine the potential role of ovarian hormones in biological vulnerability to borderline personality disorder (BPD). The review focuses primarily on research examining the menstrual cycle as a source of short-term lability of BPD symptom expression, while discussing the currently understudied possibility of ovarian hormone influence in the developmental course of BPD.

FINDINGS

Several patterns of menstrual cycle effects on BPD symptoms and relevant features in non-clinical samples have been observed in empirical studies. Most symptoms demonstrated patterns consistent with perimenstrual exacerbation; however, timing varied between high and low arousal symptoms, potentially reflecting differing mechanisms. Symptoms are typically lowest around ovulation, with an exception for proactive aggression and some forms of impulsive behaviors. Preliminary evidence suggests ovarian hormones may exert strong effects on BPD symptom expression, and further research is warranted examining mechanisms and developing interventions. Recommendations for researchers and clinicians working with BPD are provided.

Suicide Risk and the Menstrual Cycle: a Review of Candidate RDoC Mechanisms

PURPOSE OF REVIEW

Risk for suicidal behavior may fluctuate across the menstrual cycle. Here, we use the RDoC framework to review potential mechanisms by which the cycle may increase acute suicide risk.

RECENT FINDINGS

The menstrual cycle impacts the majority of RDoC constructs linked to suicide risk, particularly among hormone-sensitive women, such as those with premenstrual dysphoric disorder or premenstrual exacerbation of a psychiatric disorder. Despite this, there are no published studies examining suicidal ideation, planning, or behavior longitudinally across the cycle. More work is needed to understand how hormone sensitivity may relate to both trait and state suicide risk. Intensive multilevel investigations of cyclical hormone effects on suicide risk through specific RDoC mechanisms are suggested. This is a fertile research area and may provide key insights regarding the mechanisms of acute suicide risk.