Cramps, Bloating and...Suicidal Thoughts? Premenstrual Dysphoric Disorder and Ways to Combat PMDD

Monday, February 23, 2015 by Meg   •   Filed under General

PMS doesn’t have an official definition, so anyone can attribute anything to it. Cramping. Bloating. Irritability. Tearfulness over cat videos or commercials. The incessant craving for ice cream. The incessant eating of ice cream. (More here in 5 Ways Your Hormones are Affecting Your Brain).

But Premenstrual Dysphoric Disorder (PMDD) is a completely different beast. And it is a beast. It disrupts the daily lives of women, decreases their ability to function and at worst can tear families apart. I know. It happened to mine. But we’ll get into that in a minute. 

Despite the seriousness of the issue, the drug companies kinda fucked us up and made everyone and their mother pretty sure they have it through clever drug marketing. This has led to a great deal of potentially dangerous misconceptions. 

So let’s clear this up shall we?

What is Premenstrual Dysphoric Disorder (PMDD)?

PMDD was only recently added as a clinical diagnosis in the Diagnostic and Statistical Manual-V (before that it was classified as Depressive Disorder Not Otherwise Specified). The symptoms of PMDD, like PMS, start about a week to ten days before your period. To be diagnosed with PMDD, the symptoms must decrease a few days after you start bleeding and become minimal or go away completely once your cycle is over1

In PMDD, the symptoms can’t be from any other medical or psychological issue (though many with PMDD have other diagnoses, such as personality disorders, or anxiety issues). The symptoms of PMDD and must interfere with your life, for instance reducing your ability to work, causing you to avoid school or social activities or fucking up your relationships with others. I’m pretty sure that last part is a clinical term. I’ll get back to you on that. 

You need five symptoms total from the following lists to meet criteria. These symptoms must be present during most cycles in the last year. 

One or more of the following: 

  • Labile mood, e.g., mood swings, feeling suddenly sad or tearful, more sensitive to guilt or rejection
  • More conflicts with others, irritably or anger 
  • Depressed mood e.g. helplessness, hopelessness, negative or self deprecating thoughts (more on depressive symptoms here)
  • Anxiety, feeling on edge or “stressed”

One or more of these: 

  • Physical symptoms such as weight gain (non-cookie related), breast tenderness, headaches, bloating, joint pain, swelling or muscle pain
  • Anhedonia (loss of pleasure in things you usually enjoy) or lack of interest in usual activities
  • Fatigue
  • Trouble concentrating
  • Changes in appetite
  • Changes in sleep (such as wanting to do it all the time, or insomnia)
  • Feeling out of control or overwhelmed

Who Gets Premenstrual Dysphoric Disorder (PMDD)? 

In random samples o the population, the rates of PMDD are around  5.8%1. However some estimates put it as low as 3% of women, some as high as 18%2. I am more likely to trust the randomized samples and believe that the rates are probably closer to the standard 3-8% of all women, but this is an area that needs more concentrated study so I will be looking forward to following the research as it develops. 

At this point the exact cause is unknown though most think it has to do with trouble regulating the  hormones during the latter part of the menstrual cycle and issues with regulating neurotransmitters, most notably serotonin. In this way it is similar to other depressive disorders, and probably shows similar brain alterations over time (read more about this here in Depression and Brain Changes). And like in depression, it is more common in those with family members who also have it, and in those who have a history of other depressive disorders or bipolar conditions. 

Premenstrual Dysphoric Disorder, Pharmaceutical Companies and Misinformation

But not everyone who thinks that they have it does, because of clever marketing. When the patent on Prozac was about to expire, Eli Lilly relabeled it as “Sarafem”, made it pink and ran ads on PreMenstrual Dysphoric Disorder (PMDD)3.

Watch the advertisement here (seriously, watch it). 

While this ad was eventually pulled, it is a good example of the way the market works. The goal in advertising is to frame a disorder like an all-purpose horoscope so you can convince a lot of people that they have it. Whether or not they do, the more who go in to seek help, the higher the likelihood that someone will be prescribed your medication, even if they don’t meet full criteria for the illness.  And I can’t tell you how many times I saw women convinced that they had it when they didn’t because they had been misinformed about the issue. 

Shit, most of us have a few of those symptoms above. Irritability? Checkity-check, mother fuckers. Fatigue? DUH. I have kids for god’s sakes. But that doesn’t mean I have a disorder.  

What misinformation does is lead to rampant issues for those who are really suffering. While it seems as if it might lead to more diagnoses and more awareness, this is not the case because the people being targeted are the ones who have fewer symptoms, not the ones who actually meet criteria. If you actually had PMDD and saw that commercial, you still might not think you have it. After all, you’re too depressed to even get to the grocery store before your period, let alone be irritated at shopping carts.

Plus, most who see ads and seek physical treatment for PMDD seek it from a general practitioner and not a qualified psychiatrist. And the drug companies employ armies of drug reps to go visit all those physicians and OBGYNs touting their new “miracle drug.” So if you went to your general practitioner saying, “I have PMDD” you’d get a script and a diagnosis whether you actually had it or not. This is dangerous on a number of levels not the least of which is that it makes the issue seem less severe. And those who actually have it might be less likely to seek help if they think they are truly abnormal. (I have a series on the pharmaceutical industry coming up, guys, so stay tuned.)

Either way, if you don’t get the help you need, you end up in a perilous situation indeed. 

PMDD and Suicide

Women with PMDD tend to have higher rates of suicidal thoughts and suicidal behaviors4. And over time, like in depression, symptoms may worsen leading to more suicidal thoughts and more serious attempts. And women who are misdiagnosed are more likely to end up succeeding in these attempts.

Let me tell you a story. 

My aunt Renee was one of my favorite people when I was little. She was good at flagging down waitresses in restaurants so I didn’t have to go without ketchup. Some days she was my hero. 

But I never saw her the week before her period. Because she didn’t see anyone.  

She was diagnosed Bipolar. She wasn’t. 

To be fair it was before PMDD was a “thing” and there were many who fell through the cracks twenty years ago. When symptoms don’t fit a known diagnosis, there are those who write them off as opposed to truly looking at the whole person and forming new ideas based on their symptoms. I tend to think that most people are too complex to fit into boxes even if they have a concrete diagnosis, but this is a personal philosophy I suppose. It doesn’t mean I don’t use the statistics on whatever diagnosis someone has for insight. It just means I think we need to work harder to really see the things that don’t fit so we can do right by people. 

Renee shot herself when she was 29. She left me her dog and her piano which I still play. Because she can’t. Her boyfriend came home and found her body. He called his daughter to say goodbye, put a gun in his mouth and pulled the trigger. Very Romeo and Juliet if instead of, “Don’t be a dick to your neighbors,” the moral is, “Don’t give people bullshit misdiagnoses and ignore everything else.” 

This may also help to explain my careful attention to detail in sessions and my drive to research tirelessly the issues at hand. If my extra time in asking questions outside of, “How do you feel,” bothered any of my clients they never told me. Not that it would stop me; I’d rather be annoying as fuck than wrong. That shit’s dangerous. At least I now have a place to put my tireless researching. (Thanks for reading, people.)

Alright, so what can we do about PMDD?

Treatments For Premenstrual Dysphoric Disorder (PMDD)

  • You can’t treat PMDD with ice cream and chick flicks despite the mockery that we have made of it. The first step is accurate diagnosis, so if you meet the above criteria, get yourself to a psychiatrist (not a general practitioner) ASAP. And if you’re feeling suicidal, get yourself to an emergency room or call an ambulance. NOW. 
  • Overall Health: Adequate vitamin intake are a must because of the way those vitamins and minerals interact with your brain, specifically vitamin D (more here in SAD). Exercise is also critical because of the way it works to regulate your nervous system (more in The Benefit of Green Exercise).
  • Support (Professional or Otherwise): Therapy can help you to deal with the symptoms when they arise, so find a professional nearby to help you today. Peter Kramer notes that therapy is just as effective as medications in his book Against Depression5, but medications may also be necessary. 
  • It is also common knowledge that social support is critical for mental health, so IN ADDITION TO A PROFESSIONAL surround yourself with people you like even if you don’t feel like hanging out. Invite a friend over the week your symptoms are the worst to watch a movie and order pizza. Talk about what you’re feeling to family and friends. Get it out, hug it out and distract yourself with friends and family when the going gets tough.
  • Chart Your Cycles: If you can predict when you will be suffering, it might be easier to deal with the symptoms. Reduce your stress as much as possible during the days you expect to have your worst symptoms, and plan to do more yoga or more meditation. Try to schedule big meetings or in law visits the week after your period. The in laws are hard enough to handle on your best days. 
  • Medications: SSRIs (serotonin reuptake inhibitors) like Prozac are seen as a first line of defense, particularly in severe cases, as these drugs are effective in combatting the symptoms. (More about Prozac here in When Does Personality Become Mental Illness? You might also like the book Listening to Prozac.) Your psychiatrist can prescribe these if necessary, and if you have a therapist they can refer you to a psychiatrist for medications. But please see a specialist, not your general practitioner. 
  • Hormone Therapy: For disorders that rely on hormones to show up, altering that balance might be necessary. Birth control pills are the most common. I would look at this as a last resort as hormonal supplementation can have drawbacks in the long term. However, if the symptoms are severe enough and you don’t want more kids, it might be a viable option. 
  • Evening Primrose Oil has been shown to reduce symptoms of PMS, likely due to the vitamins and antioxidants, namely Vitamin E and Vitamin B-6 7(read more about B-6 and depression here). You can get Evening Primrose Oil here, but it is not a stand alone treatment for PMDD

Other Natural Remedies for PMDD

Because I get asked all the time, I will mention some other natural remedies. However, these should not be used as stand alone testaments for PMDD or depression. Click on the links for more about these treatments: 

Premenstrual Dysphoric Disorder can be a scary diagnosis. But there are options available to assist you. Don’t give up and don’t go it alone. 


Topic-Relevant Resources

The PMDD Phenomenon : Breakthrough Treatments for Premenstrual Dysphoric Disorder (PMDD) and Extreme Premenstrual Syndrome
Great overview on PMDD, the causes, the symptoms, the treatments and stories from real women.

The Mindfulness Solution
Meditative and cognitive techniques for everyday use

Against Depression
Detailed explanations of the systems involved in depression along with personal stories of success from psychiatrist Peter Kramer.

Listening to Prozac: The Landmark Book About Antidepressants and the Remaking of the Self, Revised Edition
Psychiatrist Peter Kramer discusses the implications of preferred personality on mental health along with the evolution of Prozac as a preferred treatment for undesired traits.