Prevalence, phenomenology and personality characteristics of premenstrual dysphoric disorder among female students at Zagazig University, Egypt

Background Premenstrual dysphoric disorder (PMDD) is a female psychiatric disorder affecting the behaviour, cognitive abilities, mental health status and academic performance of female students. It includes: mood symptoms, behaviour symptoms and physical symptoms. Aim To assess phenomenology, measure the prevalence of PMDD among university students and assess the relationship between PMDD and socio-demographic and personality characteristics. Setting This study was conducted at Zagazig University, Sharqia Governorate, Egypt. Methods A cross-sectional study was conducted from September 2020 to December 2020. It included 755 university students. They filled several questionnaires covering Diagnostic and Statistical Manual of Disorders (DSM-5) criteria to diagnose PMDD, socio-demographic, menstrual factors, physical activity and personality traits. Results Premenstrual dysphoric disorder was found in 159 out of 755 students (21.1%). Overall, the most frequently reported premenstrual symptoms were overeating/food cravings (84.2%), fatigue/lack of energy (83.6%), depressed mood/hopelessness (82.0%) and hypersomnia (78.9%). Binary logistic regression model revealed that significantly related PMDD risk factors include: being a medical student, having a duration of menstrual bleeding ≥ 7 days, the average length of one cycle ˂ 28 days, high menstrual blood loss, presence of dysmenorrhea and positive family history of premenstrual syndrome (sister/mother). Regarding personality traits, low extroversion and agreeableness, and high neuroticism were also significant PMDD risk factors. Conclusion Prevalence of PMDD was high among university students, especially medical students, and it can have a detrimental effect on both academic life and educational accomplishments, quality of life and daily living activities.


Introduction
Premenstrual dysphoric disorder (PMDD) is also referred to as late luteal phase dysphoric disorder. Mood symptoms, behaviour symptoms and physical symptoms are involved in the syndrome. This pattern of symptoms is seen during the menstrual cycle at a particular moment, and for a while, between menstrual cycles, the symptoms resolve. In female students in higher education institutions, it is one of the most common problems that has negatively affected academic performance and professional and interpersonal relationships. 1 Mental health problems that result from or are associated with menstruation are critical genderrelated mental health disorders in women. Especially in the luteal phase, menstrual changes are linked to various cognitive, behavioural and psychological symptoms called premenstrual symptoms. 2 While premenstrual syndrome (PMS) generally refers to any somatic or psychological symptoms that affect functioning, PMDD is a newly recognised psychiatric disorder that affects 1%-8% of women, often conceptually placed at the extreme end of premenstrual symptom severity. 3 Premenstrual dysphoric disorder has strict diagnostic criteria implemented in the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association in 2013. 4 While the etiology remains unknown, some studies have suggested that premenstrual problems are bio-psycho-social. 5 There is general agreement that premenstrual symptoms may occur because of increased sensitivity of the central nervous system to menstrual cycle related hormonal fluctuations. 6 Concerning psychological factors, some studies have suggested that PMDD is associated with personality characteristics. Elevations of specific personality dimensions, such as harm-avoidance and novelty-seeking, neuroticism and perfectionism, have been reported to harm existing severe premenstrual changes. 7 University students are at an age when there is a lack of psychological and social capacity to manage their daily stressors. They strive for higher academic achievement to secure better jobs and satisfy their own needs for realisation. At the same time, they lack resources and are burdened by psychological and social demands for example self-esteem and social support (friends and family). 8 However, university students do not seek psychological or social assistance for fear of stigma. Perception of consequences of a mental health problem affects the confession of its presence. The consequences include general beliefs about the impact of the illness on the patient's personal life, family, social relationships and finances, and how disabling the disease is likely to be. 9 Therefore, defining and resolving their concerns is very relevant. Around half of Egyptian university students are female, and their educational performance and other aspects of their lives may be affected by premenstrual issues. The prevalence of premenstrual syndrome in Egypt ranges from 80.0% to 92.3% of girls aged 12-25 years. 10 Despite the high prevalence of PMS and PMDD in Egypt, examining the relationship between personality characteristics and PMS and PMDD has received little attention. Therefore, this study aimed to study phenomenology, measure the prevalence of PMDD among university students and assess the relationship between PMDD and socio-demographic and personality characteristics.

Study design and setting
This research utilised a cross-sectional design and was conducted at Zagazig University, a public university located in Zagazig, Egypt. The study includes 25 faculties and institutes (13 practical and 12 theoretical). According to Webometrics, Universities rank (2020), Zagazig University is at the 24th position in Africa and at the 7th position at the national level.

Study population
Female undergraduate students at Zagazig University, in all grades, during the study period, who agreed to participate in the study were included. However, pregnant, lactating females have irregular periods (duration of the cycle is either less than 24 days or more than 35 days), and those taking hormonal contraceptives, substance abuse, having a history of any psychiatric disorders other than PMDD, somatic diseases, gynaecological or hormonal disorders were excluded.

Sample size and sampling
Provided that the total number of female students in Zagazig university during the academic year 2019-2020 was 82 538, the prevalence of PMDD is 7.7%, 11 confidence limit is 3.8% and design effect is 4. At the confidence level, 95% of the total sample size was 755 students. The values were calculated using Epi Info 7 version 7.2.0. 1. 12 Zagazig University has 25 faculties and institutes (13 practical and 12 theoretical). First, by random selection, we choose two faculties. Then, a cluster sample of a section was randomly selected from each grade. Finally, proportional allocation was considered when determining the number of students from each faculty included in our study.

Tools and data collection
The participants completed questionnaires directly on Google Forms; each questionnaire was sent to the final database and downloaded as a Microsoft Excel sheet. The Google Form was distributed to the selected sections through the official e-learning panels. The participants' answers were anonymous and confidential, according to Google's privacy policy. 13 The participants were able to withdraw their participation in the survey at any stage before the submission; non-completed responses were not saved. The survey includes an introductory page describing the background, aims and information on the survey's ethics.
Five tools were used to collect the necessary data about the study subjects as the following: First tool: Socio-economic characteristics of study participants: The socio-economic status was measured by scale for measuring family socio-economic status (SES) for health research in Egypt. 14 This scale includes seven domains: education of both father and mother, occupation of both father and mother, family domain, family possessions domain, home sanitation domain, economic domain and healthcare domain. The total score was 84. The socioeconomic status was classified as low, if total score was less than 43; middle, if total score was between 43 and 62 and high, if total score was above 62.

Second tool: Menstrual blood loss (MBL):
Menstrual blood loss (MBL) is a previously validated, structured scale 15 estimating MBL. The MBL-score is based on three items of the woman's menstrual period obtained from a questionnaire filled out during menstruation and not from memory. Menstrual blood loss is estimated by counting the number of pads then multiplying them with absorbance numbers according to the manufacturer's reported absorbance level. The absorbance numbers for pads were: mini 1, normal 1.5, super 2, night/superplus 3. Tampons are not popular among girls in Egypt, and none of the study participants reported using tampons. Menstrual blood loss-score was calculated as follows: This is an instrument designed by Özdel et al. (2015) 17 to identify the women who suffer from PMDD based on modified DSM-5 criteria. It consists of two sections: • The first section is a checklist that consists of 14 items (from 1 to 14) that inquire about the experience of the premenstrual symptoms. Students were asked, 'Do you experience some or any of the following premenstrual symptoms which start before your period and stop within a few days of bleeding?' The symptoms listed are anger/irritability, anxiety/tension, tearful/ increased sensitivity to rejection, depressed mood/ hopelessness, decreased interest in studying activities, decreased interest in home activities, decreased interest in social activities, difficulty concentrating, fatigue/lack of energy, overeating/food cravings, insomnia, hypersomnia, feeling overwhelmed or out of control and physical symptoms. • The second section consists of five items (A, B, C, D and E). The students were asked if these symptoms interfere with study efficiency or productivity, relationships with co-workers, relationships with their families, social life activities and home responsibilities. The two sections are rated on a five-point scale (from 1 = not at all to 4 = severe). For a diagnosis of PMDD, the following must be present: ■ At least one of the items of 1, 2, 3 and 4 is severe.
■ Besides, at least four of 1 to14 are moderate to severe ■ At least one of A, B, C, D, E is severe

Fifth tool: Big five personality traits inventory (BFI):
This scale was planned by John & Srivastava 18 and measures big five personality traits and comprises 44 items that evaluate five basic personality traits: extroversion, conscientiousness, agreeableness, neuroticism and openness to experience. Extroversion is assessed using eight adjectives, including: 'timid, withdrawn, shy, talkative, lethargic, enterprising, cold and passive'; conscientiousness is assessed using eight adjectives, including: 'self-disciplined, tidy, hardworking, prudent, fussy, determined, irresponsible and lazy'; agreeableness is assessed using eight adjectives including: 'sincere, compassionate, genial, well-intentioned, philanthropic, tolerant, sharer and sensitive'; neuroticism is assessed using nine adjectives including: 'nervous, aggressive, angry, temperamental, impatient, capricious, impetuous, touchy and worried'; openness to experience is assessed using six adjectives including: 'self-confident, self-assured, brave, creative, easy going and capable'. The BFI is rated on a 5-points Likert scale from 1 (disagree a lot) to 5 (agree a lot).

Content validity and reliability
The tools were tested for content validity by the panel comprising five experts of the Psychiatry Department. These experts assessed the tools for clarity, relevance, comprehensiveness, applicability and understanding. All tools were translated into Arabic language using the translate-back-translate technique to ensure their original validity. A pilot study was conducted 1 month before data collection to detect any difficulties and test the questionnaire's reliability after translation. The sample included in the pilot study was excluded from the main sample because of the changes in the final version of the questionnaire.

Statistical analysis
Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS) software version 27 (IBM, 2020). 19 Kolmogorov-Smirnov and Levene tests were used to determine the distribution characteristics of variables and variance homogeneity. Descriptive statistics were generated for all variables. Comparison between students with PMDD and without PMDD was done using the appropriate tests of significance. Student's t test was used to analyse continuous variables. Pearson's chi squared test, and chi square for linear trend were used to analyse qualitative variables as appropriate. All the factors that were significantly associated with PMDD were run in a binary logistic regression model to determine the independent predictors of PMDD. The level of statistical significance was set at p < 0.05.

Results
A total of 755 participants were included in the study. Sociodemographic, menstrual and personality characteristics of the study participants are presented in Table 1.
Premenstrual dysphoric disorder was found in 159 out of 755 students (21.1%) ( Figure 1). Generally, mild premenstrual symptoms were the most frequently reported, followed by moderate symptoms. Severe symptoms were the least frequently reported. Almost two-thirds of the study participants had at least one premenstrual symptom with varying degree of severity (Table 2).
The least frequent symptoms (frequently reported as 'not at all') are insomnia, tearful/increased sensitivity to rejection, feeling overwhelmed or out of control and decreased interest in studying activities.
The premenstrual symptoms interfered mainly with family relationships followed by relationships with colleagues, social life activities, then studying efficiency or productivity (severe in 18.7%, 17.1%, 17.1% & 16.0%, respectively). Home responsibilities were the least to be affected (severe in 3.0% of the study participants).
There were statistically significant relations between PMDD and the study participants' socio-demographic, menstrual and personality characteristics. Students with PMDD had higher age than students without PMDD (21.7 ± 3.4 vs 20.6 ± 3.8). Medical students had a higher prevalence of PMDD than commerce students (32.1% vs. 17.4%). Urban residents had a higher prevalence than rural residents (26.4% vs. 18.2%).
Almost two-thirds of low socio-economic class students had PMDD. Obese students had a higher prevalence of PMDD compared to non-obese students (30.4% vs. 18.1%) ( Table 3).
Regarding the menstrual history of the studied students, PMDD was associated with the early age of menarche (p-value < 0.001). In addition, PMDD was associated with an average length of one cycle less than 28 days (p-value < 0.001),    Premenstrual dysphoric disorder was significantly associated with BFI personality traits as PMDD was related to low extroversion and agreeableness scores. On the other hand, PMDD was associated with a high neuroticism score.
Binary logistic regression model revealed that significantly related PMDD risk factors include being a medical student, having a duration of menstrual bleeding ≥ 7 days, the average length of one cycle ˂ 28 days, high MBL, presence of dysmenorrhea and positive family history of PMS (sister/mother). Regarding personality traits, low extroversion and agreeableness, and high neuroticism were also significant PMDD risk factors (Table 4).

Discussion
This study found that the prevalence of PMDD among female university students was 21.1%. The results infer that the prevalence rate of PMDD in this study is high compared with 13.4% observed in another previous Egyptian study, 11 and higher than that in other studies sharing almost the same cultural backgrounds, such as in Kuwait (5.6%), 20 Jordon (7.7%) 12 and UAE (16.4%). 21 Other available results from Pakistan had analogous PMDD prevalence (18.2% -27.3%). 22,23 In India, the prevalence of PMDD ranged from 8.0% to 11.1%. 24,25,26,27,28 The American Psychological Association (APA) reported prevalence of PMDD between 1.8% and 5.8%. 29 Other studies conducted in the United States and Europe have also reported a much lower prevalence of PMDD. 30 The PMDD rates' inconsistency is probably related to the sample size and characteristics in this study compared with the targeted samples from other studies'. Another possible explanation for this difference could be because of limitations and differences in the definition of PMDD and the usage of different data-collection tools. The American College of Obstetricians and Gynaecologists acknowledges that one of the physical symptoms and mood/behavioral symptoms must be present to diagnose PMDD. 44 But according to DSM-5, diagnosis can be made even in the absence of physical symptoms if the other symptoms are present in significant severity. 29 In this study, the most frequently reported premenstrual symptoms were overeating/food cravings (84.2%), fatigue/lack of energy (83.6%), depressed mood/ hopelessness (82.0%) and hypersomnia (78.9%). These findings are also approximately concordant with previous findings. Tenkir et al., 39 Tschudin et al., 32 Kamat et al. 28 and Seedhom et al., 11 reported that more than 80% of university girls had at least one symptom with any degree of severity. Seedhom et al. 11 stated that severe premenstrual symptoms were fatigue and psychological symptoms (mood swings, anxiety and irritability), while appetite change was not common. According to Hashim et al., 45 the most frequently reported premenstrual symptoms were depressed mood, lethargy/fatigue/decreased energy, muscle, joint, abdominal, and back pain, feelings of anger and craving for certain foods.
In the current study, physical symptoms are not the most frequent, but they are severe in 19.6% of the study participants. These findings were consistent with the works of Amiri et al. 37 and Mchichi et al. 43 Moreover, Qiao et al. 35 reported that the most common symptoms were irritability, breast tenderness, depression, abdominal bloating and angry outbursts (59.62%). According to Pearlstein et al. 46 and Nisar et al., 47 the order of frequency of symptoms was anger, irritability, anxiety, tiredness, difficulty in concentration, mood swings and physical symptoms. Some studies reported that physical symptoms are more frequent than psychological symptoms. Pal et al. 23 and Bansal et al. 26 found that physical symptoms predominate, and the two most prevalent clinical symptoms noted were muscle pain and lack of energy. Breast pain/ tenderness was not common. Ikeako et al. 42 reported that pelvic discomfort and breast fullness were the most common physical symptoms, while mood changes did not come first.   In this study, the premenstrual symptoms interfered mainly with family relationships followed by relationships with colleagues, social life activities and studying efficiency or productivity (severe in 18.7%, 17.1%, 17.1% and 16.0%, respectively). Home responsibilities were the least to be affected (severe in 3.0% of the study participants). These findings were consistent with Sadler et al., 48 Kamat et al., 28 Ikeako et al., 42 and Bansal et al., 26 as they reported that PMDD adversely affects the relationship with family members, social functions, and educational performance. The findings confirm previous findings that negative mood states (dysphoria) have a significant adverse association among university students with academic performance. The academic performance of students is also more likely to deteriorate if they suffer from PMDD. Oral et al., 49 Tenkir et al., 39 Neumann et al., 50 Lyubomirsky et al., 51 Omu et al., 20 Tolossa et al. 40 and Shehadeh et al.,12 found that PMDD interferes with academic achievement, studying efficiency or productivity.
The regression model revealed that significantly related PMDD risk factors include being a medical student, having a duration of menstrual bleeding ≥ 7 days, the average length of one cycle ˂ 28 days, high MBL, presence of dysmenorrhea and a positive family history of PMS (sister/mother).
Dysmenorrhea and a family history of PMS were significantly associated factors in most related studies as in the studies by Rizk et al., 21 Sadler et al., 48 and Tsegaye & Getachew. 38 Other menstrual factors, for example lower age at menarche, the regularity of menstruation, the average length of one cycle of menstruation, and menorrhagia are also reported in previous studies like Balaha et al., 52 Kamat et al. 28 Tolossa et al., 40 and Shiferaw & Mamo. 41 Medical students had significantly more PMDD than commerce college students. This finding is consistent with those of Shehadeh et al. 12 The reason could be the stressful life of the medical students. Types and levels of stressors, the cultural perspective of girls' roles and obligations at college age and sociocultural factors that play a crucial role in the production of PMDD are expected to lead to differences in PMDD rates. According to Cohen et al., 53 university students lack awareness of PMDD and PMS because their familiarity with menstrual problems is considered immature; being young often leads to mixed psychobiological signs and symptoms of this question. Besides, because female university students are continuously aiming for higher academic achievements, they view academic life as a stressful situation that causes more psychological disturbances. Therefore, the academic-related stressors among university students are another potential correlate for high PMDD and PMS rates.
Some studies reported that obesity, physical inactivity, and nutritional habits were significant risk factors like Kamat et al., 28 Hong et al., 34 and Seedhom et al. 11 The current study showed that PMDD was associated with a low extroversion score in terms of personality traits. This result is in line with the findings of the studies conducted by Hallman et al. 54 In our results, PMDD was associated with high neuroticism score. Neuroticism is the trait-like tendency to experience frequent negative emotions and a perceived inability to cope in response to stress. 55 High neuroticism in PMDD was reported by Hallman et al., 55 Hunter, 56 Eissa, 57 Siahbazi et al., 58 Singh et al., 24 Arslantaş et al., 59 Izadi & Amiri. 8 We also found that students suffering from PMDD were associated with lower scores in agreeableness. Agreeableness reflects the individual differences in cooperation and social harmony. The association between agreeableness and PMDD may be influenced by social support; more significant social support enjoyed by women with a higher degree of agreeableness may be associated with less risk of developing PMDD or decreased incidence of premenstrual problems over time. 54 Low agreeableness in PMDD was reported by Hunter 56 and Izadi & Amiri. 8 There was no association between conscientiousness and PMDD in the current study, while in the work of Arslantaş et al., 59 PMDD was associated with a low conscientiousness score. Our results also did not show a significant association between the openness dimension and PMDD. By contrast, Freeman et al. 60 reported higher scores on the noveltyseeking dimension (which has analogy with openness) in women with severe PMS compared to a normative female sample.

Strengths and limitations
This cross-sectional study permitted relationship, but not causality, to be studied.

Conclusion
Based on the results of the current study, PMDD was highly prevalent among university students. Medical students, prolonged menstrual bleeding, the average length of one s.e., standard error; Sig., significant; CI, confidence interval. *, Statistically significant.
cycle ˂28 days, menorrhagia, dysmenorrhea, and positive family history of the PMS were factors that were significantly correlated with PMDD. Regarding personality traits, low extroversion and agreeableness and high neuroticism were also significant PMDD risk factors.
Implementing a reproductive health programme into the school and college health education programme was recommended to help provide students with reliable and up-to-date information, education and support on reproduction in general and menstrual problems in particular.
Girls must receive care. Many girls may feel shy and may be unable to disclose that they suffer from PMS and, as a result, do not seek medical advice and this can have a detrimental effect on both academic life and educational accomplishments, quality of life and daily living activities. Asking regarding PMS and screening for PMS to provide treatment if appropriate is one of the functions of healthcare providers in the related institutions.