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Abstract

In this dissertation, I investigated the role of cognitive emotion regulation strategies on affective, cognitive, and cortisol trajectories across the menstrual cycle in women with and without Premenstrual Dysphoric Disorder (PMDD). PMDD has been included as a unique diagnostic entity in the ICD-11 and DSM-5 diagnostic systems and is charac-terised by at least one affective core symptom with additional cognitive or somatic symptoms that are restricted to the (late) luteal phase and resolve within a few days after the onset of menstruation in the follicular phase. Given the cyclical-dynamic course of symptoms in PMDD, longitudinal designs (e.g. using diary or ambulatory assessment data) over the menstrual cycle are of particular relevance. The overarch-ing aim of this dissertation was to use such longitudinal methods to identify cycle-phase-specific risk and protective factors for premenstrual mood deterioration and en-docrinological markers for PMDD. Study 1 of my dissertation (Chapter II) examines the role of habitual (trait) tendencies of cognitive emotion regulation strategies for momentary mood across the menstrual cycle in women with PMDD. Compared to healthy controls, women with PMDD showed stronger tendencies towards unfavourable emotion regulation strategies (higher rumi-nation and lower reappraisal and mindfulness tendencies). Multilevel analyses re-vealed that favourable manifestations of these habitual cognitive emotion regulation strategies in women with PMDD were associated with improved mood during the men-strual, follicular and ovulatory phases, but did not protect affected women against mood deterioration during the late luteal phase. This suggests possible cycle-phase-specific difficulties in the implementation of adaptive emotion regulation strategies and possible limitations of conventional psychotherapy methods that address emotion reg-ulation across phases in the treatment of PMDD. The results of this study were repli-cated in Study 2 (Chapter III) in an independent sample. In contrast, favourable mo-mentary cognitive states during the luteal phase predicted better premenstrual mood. Thus, this study points to the potential of cycle-phase-specific microinterventions in which luteal-phase-specific cognitive processes could act as therapeutic mechanisms. Furthermore, in Study 2, women with PMDD did not show cyclical fluctuations in corti-sol activity, whereas healthy women had lower cortisol levels during the late luteal phase compared to the follicular phase, with additional cortisol reductions following moments of favourable cognitive states. Lack of cortisol cyclicity and reactivity to pre-menstrual cognitive processes may therefore represent a possible endocrinological marker for PMDD. In Study 3 (Chapter IV), I investigated affective and cognitive responses to induced ruminative and mindful self-focus across the menstrual cycle using experimental am-bulatory inductions in the daily lives of women with and without PMDD. Women with PMDD responded to induced mindfulness with greater increases in positive affect than healthy controls, especially during the late luteal phase. Regardless of cycle phase and clinical status, induced rumination predicted greater momentary negative affect and momentary rumination and decreased momentary mindfulness, whereas induced mindfulness predicted greater momentary self-acceptance. In Study 4 (Chapter V), I examined a sample with subthreshold PMDD. Here, adaptive habitual emotion regulation (mindfulness and acceptance) was associated with weaker increases in premenstrual symptoms and functional impairment. Stronger increases in premenstrual symptoms and functional impairment in turn predicted increases in rumi-nation and perceived daily stress during the luteal phase. These findings point to the potential of dimensional approaches to investigate possible risk and protective factors for the transition from subclinical to clinical manifestations of premenstrual symptoms, as well as the potential of habitual mindfulness and acceptance as preventive measures for PMDD. In Study 5 (Chapter VI), I showed that in women with PMDD, adverse childhood expe-riences were associated with stronger premenstrual mood deterioration and an addi-tional cortisol decrease during the luteal phase. This suggests the clinical importance of childhood adversity for the cyclical course of symptoms and cortisol in PMDD. Taken together, these studies point to the relevance of a multilevel approach that ex-amines macro-processes (e.g. habitual emotion regulation, adverse childhood experi-ences) as well as meso- and micro-processes (cycle-phase-specific cognitive and en-docrinological risk factors) of psychobiological factors in PMDD in order to identify their potential inter- and intra-individual variations. Evidence from this research approach may inform the development and advancement of personalised treatment approaches for PMDD.