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Premenstrual Dysphoric Disorder (PMDD)

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Sophie Stein, MSN
Sophie Stein, MSN
Sophie Stein, MSN, received her master's of science in nursing from Vanderbilt University and has previously worked as an advanced practice registered nurse at an outpatient psychiatric practice.
Premenstrual dysphoric disorder (PMDD) is a serious condition characterized by a severe change in mood in the one or two weeks leading up to a woman’s period.1 PMDD should not be confused with premenstrual syndrome (PMS), a common condition that also involves symptoms that occur in the week or two before menstruation, possibly resulting from falling levels of certain hormones after ovulation.2

Woman with depersonalization disorder putting head in hand

PMDD is similar to PMS but involves more severe symptoms, such as severe depression, tension, and irritability. One of the requirements to be diagnosed with PMDD is that the symptoms must interfere with the woman’s functioning or cause significant distress.3 PMDD may necessitate the use of medication.1

People also sometimes struggle to differentiate premenstrual dysphoric disorder from depressive disorders. Some of the symptoms are similar; however, PMDD is linked to a woman’s menstrual cycle. The symptoms start in the week or two before the woman’s period and will usually resolve within a few days after the start of the woman’s menstrual cycle.1,4

The condition affects up to 5% of women of childbearing age. There are different approaches to treatment, including stress management techniques, specific birth control pills, and some antidepressant medications.1 Multiple treatments may be used together.

What Causes PMDD?

It’s not clear what causes PMDD. The disorder might be an abnormally severe reaction to hormonal changes associated with a woman’s menstrual cycle.1,5

It’s also been suggested that serotonin levels might play a role. A woman’s serotonin levels fluctuate throughout her menstrual cycle, and some women may be more sensitive to these fluctuations.1,5

Certain risk factors make it more likely that a woman will develop premenstrual dysphoric disorder. These include:5

  • Family history of PMDD or PMS.
  • Personal or family history of depression or other mood disorders.

Other possible risk factors include:5,6

  • Significant stress.
  • Lower education level.
  • Smoking cigarettes.

Symptoms

Symptoms vary between women but may include:1,3

  • Anxiety.
  • Mood swings.
  • Crying suddenly or often.
  • Feeling overwhelmed or out of control.
  • Problems focusing.
  • Loss of interest in normal day-to-day activities.
  • Persistent irritability or feelings of anger.
  • Sadness or feelings of despair.
  • Panic attacks.
  • Suicidal thoughts.
  • Fatigue.
  • Insomnia.
  • Changes in appetite and eating patterns.
  • Bloating.
  • Tender breasts.
  • Headaches.

Diagnosis

In order for a woman to be diagnosed with premenstrual dysphoric disorder, she will need to experience 5 or more PMDD symptoms (at least one of which must be mood-related).1

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) states that a subset of symptoms must be present in the week before her menstrual cycle begins, improve within a few days after her period starts, and resolve or become minimal in the week after menstruation in order for a woman to be diagnosed with PMDD. This pattern must have occurred in most menstrual cycles in the previous year.

The symptoms need to be severe enough to cause a significant disruption to her daily life (interfering with work, school, social activities, or relationships) or to cause significant distress. The symptoms cannot be caused by another mental illness or other medical condition, a drug, or a medical intervention.3

Treatment for PMDD

The recommended treatment plan for PMDD varies according to each woman’s individual needs. Options include:1,7,8

  • Medication:
    • Antidepressants: Fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are selective serotonin reuptake inhibitors, or SSRIs, approved to treat PMDD.
    • Birth control pills: A birth control pill containing drospirenone and ethinyl estradiol has been approved to help alleviate symptoms.
    • Over-the-counter medication: OTC pain medications, such as ibuprofen, may help relieve breast tenderness, cramps, headaches, backaches, and joint pain.
  • Therapy: Cognitive behavioral therapy (CBT), in particular, may be an effective treatment.
  • Lifestyle changes: Stress management techniques may help treat PMDD. Cutting back on sugary and salty foods and drinks, eating a healthy mix of foods, and getting exercise may also help to relieve some of the symptoms of PMDD. However, if a woman is experiencing serious symptoms or if these lifestyle changes are not effective, she should schedule an appointment with a health care provider. Anyone considering harming herself or others should call 911 immediately. 

Controversy

Browse through articles discussing PMDD and you may find sources questioning its reality. The disorder has not been accepted by all in the health care community for various reasons.

Some health care professionals believe that PMDD can be explained by depression or other mental health disorders. Some say that women shouldn’t need to be diagnosed with a mental health disorder for others to recognized their suffering or to get assistance.9 However, a 2010 study found that PMDD and major depression are linked to different biological stress responses, supporting the claim that they are biologically distinct disorders.

Controversy is common when studies reveals different pieces of information, which can be due to variation in what exactly is being investigated, the methods used in the research, and more. This is why it is important that research into PMDD, its causes, and the most effective treatment approaches for the disorder continue.

Is There a Link Between Premenstrual Difficulties and Substance Use?

In 2018, a review article was published that found that alcohol intake was linked to a higher risk of PMS. Their study didn’t investigate cause and effect, but it also found that heavy alcohol intake was associated with an even higher risk of PMS.10

A 2015 study found that past-year illicit drug use was linked to a higher risk of PMS.11

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Co-Occurring Disorders

Evidence suggests that women with PMDD may be at an increased risk of experiencing mood disorders and anxiety disorders. An analysis published by the Psychiatric Times reports that anxiety disorders and mood disorders occur more frequently in women with PMDD than in the general population. Panic disorder co-occurs in approximately a quarter of women with PMDD, social phobia in about 1 in 5, and obsessive-compulsive disorder in about 12%. Studies have found that 18% to 69% of women with retrospectively diagnosed PMDD had a depressive disorder.12

Anxiety disorders and mood disorders occur more frequently in women with PMDD than in the general population.

According to the Anxiety and Depression Association of America, approximately 20% of Americans who struggle with an anxiety or mood disorder also have a substance use disorder.13 A woman who suffers from PMDD along with anxiety and/or depression may turn to substances for relief. Although this might work temporarily, symptoms are often worse, longer-lasting, and more difficult to treat in individuals with both a substance use disorder and another mental illness.14

For individuals with both mental illness(es) and substance use disorder(s), integrated treatment that addresses all psychiatric disorders provides better results.15

PMDD Today

Research into PMDD is ongoing. Women are dealing with the consequences of the disorder every day.

In addition to sharing some symptoms, major depressive disorder and premenstrual dysphoric disorder also share some treatment approaches. Medication, therapy, and lifestyle changes can be helpful for both conditions. With treatment, most women suffering from PMDD have their symptoms decrease to tolerable levels or go away completely.16

References:

  1. U.S. Department of Health and Human Services. (n.d.). Premenstrual dysphoric disorder (PMDD).
  2. U.S. Department of Health and Human Services. (n.d.). Premenstrual Syndrome (PMS).
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  4. Kennedy S. H. (2008). Core symptoms of major depressive disorder: relevance to diagnosis and treatment. Dialogues in clinical neuroscience10(3), 271-7.
  5. Johns Hopkins Medicine. (n.d.). Premenstrual Dysphoric Disorder (PMDD).
  6. Skrzypulec-Plinta, V., Drosdzol, A., Nowosielski, K., & Plinta, R. (2010). The complexity of premenstrual dysphoric disorder–risk factors in the population of Polish womenReproductive biology and endocrinology : RB&E8, 141.
  7. Ricciotti, Hope. (2015). Premenstrual dysphoric disorder: When it’s more than just PMS.
  8. Management of premenstrual syndrome. BJOG 2016; DOI: 10.1111/1471-0528.14260.
  9. Daw, Jennifer. (2002). Is PMDD Real? Monitor on Psychology, 33(9), 58.
  10. Fernández MDM, Saulyte J, Inskip HM, et al. Premenstrual syndrome and alcohol consumption: a systematic review and meta-analysis. BMJ Open 2018;8:e019490.
  11. Ju, H., Jones, M., & Mishra, G. D. (2015). Illicit drug use, early age at first use and risk of premenstrual syndrome: A longitudinal studyDrug and alcohol dependence152, 209-217.
  12. Kim, D. & Freeman, E. (2010). Premenstrual Dysphoric Disorder and Psychiatric Comorbidity. Psychiatric Times, 27(4).
  13. Anxiety and Depression Association of America. (n.d.). Substance Use Disorders.
  14. National Institute on Drug Abuse. (2018). Common Comorbidities with Substance Use Disorders: What are some approaches to diagnosis?
  15. Kelly, T. M., & Daley, D. C. (2013). Integrated treatment of substance use and psychiatric disorders. Social work in public health28(3-4), 388-406.
  16. U.S. National Library of Medicine, Medline Plus. (2019). Premenstrual dysphoric disorder.
Last Updated on February 4, 2020
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Sophie Stein, MSN
Sophie Stein, MSN
Sophie Stein, MSN, received her master's of science in nursing from Vanderbilt University and has previously worked as an advanced practice registered nurse at an outpatient psychiatric practice.
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