Premenstrual Dysphoric Disorder (PMDD) is a psychiatric disorder characterized by depressed mood, anxiety, irritability, and mood swings occurring in a cyclical pattern in the week prior to the onset of menses (Association, 2000
). PMDD affects approximately 3–8% of American women of reproductive age (Halbreich et al., 2003
). Knowledge of the correlates and causes of PMDD is limited and inconclusive, particularly among ethnic minority immigrants and US-born ethnic minority women. According to US Census estimates, ethnic minorities comprise one third of the US population today, and are projected to become the majority in 2042 (Bernstein and Edwards, 2008
). Furthermore, 82% of the increase in the US population expected between 2005 and 2050 will be due to immigrants and their descendants (Passel and Cohn, 2008
), and a greater percentage of immigrants are of reproductive age (and thus at risk for PMDD), compared to US-born women (Larsen, 2004
). Given these trends, the majority of American women suffering from PMDD will be non-white, and immigrants or the children of immigrants in the near future. Consequently, the Office for Women’s Health Research has listed the examination of PMDD among ethnic minority women as a research priority (U.S. Department of Health and Human Services, 1999
We applied an acculturation model to examine patterns in the prevalence of PMDD among ethnic minority women. Acculturation is the process by which individuals acquire the norms and values that are dominant in a society (Lara et al., 2005
). This model has been proposed to explain patterns observed in the psychopathology of foreign and US-born ethnic minority populations. The acculturation model highlights the role of culturally-specific protective factors, socialization experiences, and the adoption of American cultural values in development of psychiatric illness.
Ethnic minority immigrants are far less likely than their US-born counterparts to develop mood, anxiety, and substance use disorders over their lifetimes (Escobar et al., 2000
; Takeuchi et al., 2007
; Vega et al., 1998
; Vega et al., 2004
; Williams et al., 2007
). Some researchers have argued that immigrants’ health advantage is due to a selection bias known as the “healthy immigrant hypothesis.” According to this theory, immigrants are younger, better educated, and healthier compared to persons who stay behind; these factors favor immigrants’ adjustment to their host country. Consequently, immigrants represent a non-random sample of healthier than average individuals, and thus have lower rates of medical and physical illness in comparison to ethnic minorities born in the US. This phenomenon may partially explain the physical and mental health advantage observed among immigrants (Escobar et al., 2000
; Vega et al., 1998
; Vega et al., 2004
), although evidence in support of this theory is mixed.
Researchers have also suggested that foreign-born ethnic minorities have a mental health advantage over US-born ethnic minorities that is attributable to certain protective factors engendered by immigrants’ attachment to their country and culture of origin. Research links these culturally-specific protective factors, namely strong social support networks, family cohesion, and religiosity, to positive mental health outcomes among minority populations (Levin et al., 1995
; Mulvaney-Day et al., 2007
; Zhang and Ta, 2009
). However, the culturally-specific protective factors that contribute to immigrants’ mental health advantage are degraded over time, and rates of psychopathology converge to those of the US-born (Breslau et al., 2007
). For example, intergenerational conflict and family discord is commonly observed as immigrants and their native-born children gain greater exposure to American cultural norms that are in opposition to the values of their country of origin. Furthermore, immigrants may face greater racial and ethnic discrimination through their attempts to assimilate into majority culture and growing contact with non-immigrants. Other aspects of acculturative stress, such as the challenge of maintaining a bicultural identity, language difficulties, and coping with the dissolution of ties to family remaining in one’s country of origin, may also elevate immigrants’ susceptibility to mental illness.
In support of these explanations, several studies have shown that that risk for psychopathology is positively associated with immigrants’ length of residence in the United States (Alegria et al., 2006
; Alegria et al., 2007b
; Breslau et al., 2007
). In a study of Latinos, Alegria et al. (Alegría et al., 2007
) found the likelihood of any lifetime psychiatric disorder (depressive, anxiety, and substance abuse) increased in a dose-response fashion as duration of residence in the United States increased, with US-born Latinos having the greatest likelihood for psychopathology. In separate studies this dose-response pattern was observed in relation to lifetime risk for anxiety disorders among Asian American (Takeuchi et al., 2007
) and Black (Williams et al., 2007
Evidence from the acculturation model indicates that the developmental timing of exposure (the degree of contact with American culture) may contribute to immigrants’ risk for psychopathology. The developmental timing of exposure is operationalized as the age at which immigrants first arrived in the US. A number of studies have shown that immigrants that spend their childhood in Asia, Central or South America, and Africa or the Caribbean, are at much lower risk for psychiatric disorders, including depression, anxiety, and substance abuse, compared to US-born Asians, Latino/as, and Blacks, respectively (Breslau et al., 2007
; Breslau et al., 2009
; Breslau and Chang, 2006
; Takeuchi et al., 2007
). In contrast, immigrants that spend their childhood in the US demonstrate elevated risk for psychopathology that is comparable to US-born ethnic minorities (Alegria et al., 2007a
; Breslau et al., 2007
; Vega et al., 2004
In considering the developmental phenomena that determine children’s exposure experience and may explain these patterns, Suarez-Orozco and Suarez-Orozco (Suarez-Orozco and Suarez-Orzoco, 2001
) identify age six as a critical year. At age six, children in the United States begin formal schooling. Although exposure to native culture and traditional values is predominant in the years preceding entry into the school system, US-born children and children who immigrate before age six are inundated with acculturating forces through schooling and interaction with peers after age six (Suarez-Orozco and Suarez-Orzoco, 2001
). In contrast, later arriving immigrants encounter these acculturating influences at later ages, following socialization experiences in their country of origin that anchor them to native cultural values and practices. Recognizing that US-born children and immigrants who arrive in early childhood (before age 6) have essentially the same exposure experiences, Alegria and colleagues (Alegria et al., 2007a
) argue that these groups can be combined into a single category of exposure, “in-US-as-child”. Persons arriving after age 6 have a different exposure experience, and are characterized as “later-arrival-immigrants.” Using these definitions of exposure, Alegria and colleagues (Alegria et al., 2007a
) found that later-arrival-immigrant Mexicans were significantly less likely to have a depressive disorder in their lifetimes compared to in-US-as-child Mexicans.
In the context of research on PMDD, the acculturation model suggests two broad pathways that may contribute to the development of the disorder. The first pathway is through stress. Several studies have shown that women reporting premenstrual symptoms or PMDD also report greater life stresses (Fontana and Palfai, 1994
; Warner and Bancroft, 1990
; Woods et al., 1985
) and poorer methods of coping with stress (Ornitz and Brown, 1993
). In the absence of culturally specific factors such as family cohesion and extended social support networks, individuals may experience their lives as more stressful and thus be more vulnerable to PMDD. Discrimination, which is a chronic stressor particularly salient for immigrants, is also positively associated with PMDD among ethnic minorities (Pilver et al., in preparation). Other aspects of acculturative stress, such as language difficulties, may also contribute to immigrants’ unique vulnerability to PMDD.
The second pathway is through cultural variations in attitudes toward menstruation. In America menstruation is viewed rather negatively and is highly medicalized. American women are bombarded with messages about premenstrual symptoms and PMDD, from an industry of “products, pills, and prescriptions” geared to alleviate these symptoms (Figert, 2005
). Exposure to the medicalization of premenstrual symptoms, the pervasiveness of pharmaceutical products for the alleviation of premenstrual symptoms and PMDD, and the belief that premenstrual symptoms are unusual and intolerable, may negatively influence the perception of premenstrual experiences among immigrants and US-born ethnic minority women. In line with this argument, a study demonstrated that women exposed to negative beliefs about premenstrual symptoms reported more severe symptoms at follow up, compared to women exposed to a neutral condition (Marván and Escobedo). Thus, greater acculturation and adoption of American attitudes, exposure to these attitudes from an early age, and the loss of (more positive) traditional beliefs related to menstruation may contribute to elevated rates of PMDD among immigrants who are long-term residents of the US and immigrants who arrived in early childhood, in contrast to US-born ethnic minorities.
In this analysis, we applied the acculturation model to the study of PMDD among immigrant and US-born ethnic minority women for the first time. On the basis of prior evidence from research on other psychiatric disorders, we hypothesized the following:
- Compared to US-born ethnic minorities, foreign-born ethnic minorities would be significantly less likely to have PMDD.
- Duration of residence would be positively associated with PMDD, with US-born ethnic minorities demonstrating the greatest likelihood for PMDD.
- Late-arrival immigrants (women who immigrate to the US after age six) would be significantly less likely than in-US-as-child women (US born or immigrated before age 6) to have PMDD.