[Expert Guide] Premenstrual Dysphoric Disorder - PMDD: Symptoms, Causes & Treatment

PMDD: A Historical Perspective 

Historically, women’s bodies have been misunderstood, or not understood enough. One thing that has been and, to some extent, continues to remain shrouded in mystery is menstruation. 

Many myths abound related to women’s monthly cycles. In some places in India, women are excluded from activities in the house, are not allowed to enter the kitchen or places of worship, and are treated as if they are ill while menstruating. 

While the term PMS has become popular, it is often used as an excuse to blame or dismiss women. Even in this day and age, it may seem that we know very little about menstruation. But, we have come a long way… 

From Ancient Observations to Modern Diagnosis

The emotional and physical discomfort women experience before the onset of menstruation has been a matter of intrigue for healthcare professionals since the time of Hippocrates. 

Hippocrates is believed to have noted and spoken about the emotional distress women sometimes experience prior to their monthly cycle. Having said that, it wasn’t until the 1930s that the concept was consolidated and given the name of ‘premenstrual tension syndrome’ by physician R.T. Frank. 

In a study with 15 women, Frank shed light not only on the physical discomfort associated with menstruation but also on the emotional and behavioral changes women sometimes experience. The term ‘premenstrual tension syndrome’ was then shortened to ‘premenstrual syndrome’ in 1953 by two doctors, Raymond Greene, and Katherina Dalton, in an article describing the cluster of physical and emotional discomforts women experience before menstruation. In this cluster, they bloating, tender breasts, fatigue, migraine, anxiety, depression, and irritability. 

The Evolution of PMDD: Inclusion in the DSM

In the last few decades, we have come to understand a lot more about premenstrual syndrome and its implications for the physical and emotional well-being of women. Katherina Dalton, one of the doctors who rechristened premenstrual tension syndrome to the simpler, ‘premenstrual syndrome’ spent decades of her professional life researching and creating awareness about the distress that menstruation causes among some women. 

In 1987, her work was rewarded with a milestone moment when ‘premenstrual dysphoric disorder’ was included in the DSM (Diagnostic and Statistical Manual of Mental Health Disorders), enabling proper care for women in need.  

Premenstrual dysphoric disorder or PMDD is a much more severe condition than what was understood as PMS before this milestone. Its inclusion in the DSM paved the way for the care that women with PMDD deserve.  

What is PMDD(Premenstrual Dysphoric Disorder)?

During the luteal phase each month, women’s bodies go through changes that can cause bloating and cramps, breast tenderness, migraines, fatigue, irritability, anxiety, and depression. If you talk to women, you’ll find that almost all women experience these symptoms but for some, these symptoms are so severe that they find it difficult to function. While the symptoms of mild discomfort associated with PMS and PMDD are the same, the severity is vastly different.

PMDD is a severe condition that causes extreme discomfort during the luteal phase. This is the phase between ovulation and menstruation where the body is preparing to expel the unfertilized eggs. Some women may experience extreme physical distress. Others may experience extreme fluctuations in mood. Some may experience a combination of both. PMDD becomes concerning when it interferes with one’s ability to engage in daily tasks. 

While its symptoms disappear during other phases of menstruation, PMDD still requires attention and care. This is not only because women have a monthly menstrual cycle, but also because healthy periods or menstruation should not be severely uncomfortable. 

What are the 11 symptoms of PMDD: When Premenstrual Becomes Debilitating

Since its inclusion in the DSM, clear symptoms and signs of PMDD have been defined. 

According to the DSM-V, physical and emotional symptoms of PMDD include: 

1. Mood swings and hypersensitivity 
2. Increased irritability 
3. Anxiety, tension, or feeling “on edge”
4. Decreased interest in daily activities 
5. Difficult concentrating 
6. Lethargy, fatigue, and lack of energy 
7. Changes in appetite 
8. Changes in sleep 
9. Feeling overwhelmed or out of control 
10. Physical symptoms such as cramping, bloating, breast tenderness, migraines, joint or body aches
11. In severe cases, one may also experience suicidal thoughts or ideation 

In addition to the symptoms listed above, a PMDD diagnosis is considered based on the severity. If the severity of the symptoms interferes with one’s daily function, there is a likelihood of PMDD. In order to make an official diagnosis, the symptoms should be present for at least 2 menstrual cycles. 

How is PMDD Different from PMS?

As discussed above, the symptoms of PMS and PMDD may be the same, but because of the vast difference in severity, PMDD warrants separate treatment and diagnosis. 

At what age does PMDD start?

While PMDD can start anytime after puberty, it is more likely to begin in one’s 20s or later. It’s also important to note that as we age, the symptoms of PMS become more severe or uncomfortable, further delaying the onset or diagnosis of PMDD. 

What are the Impacts of PMDD[Premenstrual Dysphoric Disorder] on Daily Life?

Because of the severity of the symptoms, PMDD can be quite disruptive to one’s daily life. The impact of PMDD can include: 

• Difficulty showing up at or concentrating on work 
• Higher absenteeism and lower productivity at work may create feelings of guilt and a need to overcompensate 
• Lower quality of life
• Mood changes which can impact one’s relationships as well 
• Disruptions in one’s routine across domains such as work, personal life, exercise and nutrition 
• Absentmindedness, which can lead to increased proneness to making mistakes and forgetting important tasks 
• Emotional distress caused by the symptoms 

Is your severe PMS actually a premenstrual dysphoric disorder?

Since the demarcation between PMS and PMDD lies in the severity of symptoms, it is expected that severe PMS symptoms may be indicative of PMDD. However, only a qualified mental health professional or gynecologist can make the diagnosis for you. If you feel your PMS symptoms are too severe and impacting your daily life, it is advisable to consult with a professional. 

Does PMDD Follow a Cyclical Pattern?

Since PMDD is related to a woman’s menstrual cycle, yes, it follows a cyclical pattern. In fact, this cyclical nature is one of the criteria considered in the diagnosis of PMDD. The symptoms appear during the luteal phase and disappear for the rest of the month. The other aspect of the cyclical nature of PMDD is that the symptoms appear month after month. 

Is PMDD a Form of Bipolar Disorder?

Since PMDD is cyclical, it’s easy to confuse it with bipolar disorder. However, the two are vastly different and have no connection with each other. Bipolar disorder is a mood disorder while PMDD is related to the menstrual cycle. Bipolar disorder can happen to anyone, regardless of gender or age while PMDD can happen only to individuals who menstruate during their menstruating years. 

4 Causes of Premenstrual Dysphoric Disorder[PMDD]: Unveiling the Mystery 

While the exact cause of PMDD is unclear, there are several factors that contribute to the development of the disorder. These include: 

1. Hormonal changes: Fluctuations in hormones, particularly estrogen and progesterone, contribute to the development of PMDD. Our hormones fluctuate throughout the month. But for some women, if the level of progesterone is chronically high, and has a sudden and rapid drop, the withdrawal can lead to physical and emotional symptoms of PMDD. 
2. Psychosocial factors such as high stress and a history of trauma can also contribute to the development of PMDD: Stress and trauma impact our body and mind at multiple levels. A few cross-sectional and longitudinal studies have found that a history of trauma leaves women more susceptible to developing PMDD. However, more research is needed in this area to determine how this happens. 
3. A family history of PMDD makes it more likely for a woman to develop PMDD in her lifetime, pointing to the contribution of genetic factors. 
4. Considering PMDD symptoms are eased to some extent by making lifestyle changes including regular exercise and a nutritious and balanced diet, it is likely that lifestyle habits also contribute to the development of PMDD. 

Who is More Likely to Get PMDD?

While PMDD can happen to anyone, those with a family history of PMDD and a personal history of mental health conditions such as depression or anxiety are at a higher risk of developing PMDD. 

Diagnosing PMDD: Getting the Right Support

If you or someone you know suffers from severe PMS, it is important to get the right support and treatment. A diagnosis of PMDD can be made by a psychiatrist, gynecologist, or endocrinologist. 

In order to facilitate proper diagnosis, you can track your symptoms for a couple of months or menstrual cycles. This will help you report your symptoms accurately. 

How Can I Track My Symptoms for a PMDD Diagnosis?

The first step to tracking your symptoms for a possible diagnosis of PMDD is to track your menstrual cycle. There are several apps that can help you do this (listed in the next section). As you add the dates and length of your period, the app will alert you of your luteal phase. 

During the luteal phase, make a note of any and all physical and emotional discomforts you feel. Since the absence of symptoms during other phases of the menstrual cycle is an important diagnostic criterion, try to pay attention to and note down how you’re feeling outside of the luteal phase as well. 

Do this for at least two months so that when you visit a doctor, you have the information and data they need to make an informed diagnosis.  

What are the Criteria for a PMDD Diagnosis?

Since some of the symptoms of PMDD may be similar to other physical and mental health conditions, it is important to keep in mind two key criteria for a PMDD diagnosis. These are: 

1. The symptoms disappear outside of the luteal phase 
2. The symptoms are present for at least 2 consecutive menstrual cycles 

What Tools Can Help Diagnose PMDD?

There are several apps that can help you track your periods and physical and emotional symptoms of PMDD. Some of the best apps are My Calendar, Flo, Me Vs PMDD, and Clue. These apps allow you to log the end and start dates of your period along with any symptoms you may be feeling. Some apps also allow you to rate the intensity of your symptoms, which is useful insight for the diagnosis of PMDD. 

Effective PMDD Treatment: Finding Relief 

PMDD can be managed with a variety of interventions including medications such as anti-depressants and birth control pills, supplements to ward off any deficiencies, therapy, and lifestyle changes.

Are Antidepressants the First-Line Treatment for PMDD?

Anti-depressants are often the first line of treatment for PMDD. Studies show that anti-depressants work differently for PMDD than they do for depression. While in depression, it is recommended that one continues taking the medication every day for some time, in cases of PMDD, taking it just during the luteal phase has been shown to help. 

Can Birth Control Help Manage PMDD Symptoms?

Combination birth control pills are often prescribed for the treatment of PMDD by gynecologists.

Is Therapy Helpful for PMDD?

Several psychotherapeutic modalities including CBT can be useful in the treatment of PMDD. CBT can help manage some of the psychological distress caused by CBT. Solution and goals-focused therapy can help set and attain lifestyle-related changes that may be necessary for the management of PMDD. Therapy for PMDD is usually given in tandem with pharmaceutical treatment. We’ve covered Therapy for everyone's benefit.

Are There Other Ways to Manage PMDD Symptoms?

Lifestyle changes that help take care of the pillars of well-being can help ease some of the distress caused by PMDD. Regular exercise, a nutritious and balanced diet, adequate and good quality sleep, and healthy relationships are good for overall well-being and can help alleviate some of the unease caused by PMDD as well. 

PMDD and Other Related Conditions: Understanding the Connections

PMDD is a cluster of physical and psychological symptoms and is associated with other conditions such as anxiety, and depression.

Does PMDD Increase the Risk of Depression?

Yes, PMDD has been shown to increase the risk of depression, including postpartum depression. Underlying or pre-existing depression also increases the chances of PMDD symptoms, thus becoming a cycle wherein both contribute to each other. 

How Does PMDD Affect Women During Pregnancy and Menopause?

Since PMDD is specifically related to the luteal phase, the symptoms dissipate during pregnancy and once full menopause has been achieved. During perimenopause, the physical and emotional symptoms of PMDD may exacerbate given the age and increased fluctuation of hormones.  

What are the Potential Complications of PMDD?

The most pressing complication of PMDD is the risk of suicide. When PMDD is left untreated, it can increase one’s risk of depression and suicidal ideation.

Living with PMDD: 5 Strategies and Support 

Since the symptoms of PMDD are time-limited and predictable, you can put certain strategies in place that can come in handy during the luteal phase. These may include: 

1. Letting people around you know you’ll be going through a period of low energy and discomfort so that they can be more understanding and accommodating
2. Informing your workplace and taking period leaves if they are offered by your employer 
3. Relaxation practices like progressive muscle relaxation have been seen to be helpful in easing the physical and emotional symptoms of PMDD 
4. Getting light movement during the luteal phase is also recommended. It’s also a good idea to adjust your workout routine to suit your energy level and practice lighter workouts during the luteal phase. 
5. Making dietary changes as necessary

It is important to remember that while these strategies can help ease the symptoms, proper treatment and management with a healthcare professional is necessary

When Should I See a Healthcare Professional About PMDD?

If you experience severe symptoms of PMS for two or more consecutive cycles, you should see a healthcare professional about PMDD

How Can I Care for Someone with PMDD?

Care for someone with PMDD would include:

• Being compassionate and accommodative of their needs 
• Avoid shaming them for their experience, and understand that every woman experiences menstruation differently 
• Ensuring they get proper and adequate medical care
• Enjoying some relaxed and relaxing activities together 
• Not pressurising them to be super active or energized if they are experiencing discomfort 

PMDD: Questions and Answers 

What Does a PMDD Episode Look Like?

A PMDD episode occurs during the luteal phase and can involve a range of physical and emotional symptoms. The physical symptoms of PMDD include bloating, cramps, swollen and tender breasts, body and joint pain, and migraines. The emotional symptoms of PMDD include irritability, anxiety, feelings of sadness, and anger outbursts. 

Is PMDD Considered a Mental Illness?

PMDD is considered a mental illness and has been included in the DSM. 

Can PMDD Cause Physical Discomfort?

Yes, PMDD can cause physical discomfort. This includes severe bloating, cramps, swollen and tender breasts, body and joint pain, and migraines. An individual may experience one or more of these symptoms. In many cases, the physical symptoms are accompanied by emotional distress. 

Resources and Support Groups for PMDD[Premenstrual Dysphoric Disorder]

There are various support groups and organizations that provide resources for women experiencing PMDD. A few are listed below: 

• International Association for Premenstrual Disorders (IAPMD) - They run a peer support group and have a glossary of useful information and resources 
• See Her Thrive is a women’s networking organization that has developed a chatbot named Dottie who can provide information and support for PMDD
• Me Vs PMDD offers a symptom tracker as well as an online peer support community 

If you would like to find a local support group, but there doesn’t seem to be one, you can always start a community. Certainly, other women will appreciate having a space to share their experiences and get support.

How Can I Manage PMDD and Improve My Quality of Life?

There is a pervasive idea that it’s normal for a woman to be in discomfort before or during their period. Many of us suffer in silence. Some are vocal about their suffering but surrender to it because of the myth that “this is how periods are”. But, menstruation is a natural and normal part of the female body and life cycle, and should not be uncomfortable to the point of being debilitating. 

PMDD can lower one’s quality of life, and no woman deserves this, especially when there are treatments available! So, the most important thing to do if you suffer from PMDD is to get the right help. With the right treatment and management, you can maintain a decent quality of life. 

Conclusion

PMDD is a severe form of premenstrual syndrome that impacts women during the luteal phase of menstruation. It can begin at any age, though the symptoms tend to become more intense as one grows older. PMDD can be a debilitating illness. But, it’s possible to manage it with a combination of medication, therapy, and lifestyle changes, and maintain a decent quality of life. 

Citations/references:

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