This is what premenstrual dysphoric disorder (PMDD) symptoms look like in real life, how they're different from premenstrual syndrome (PMS), and how to get help if you need it.

By Heather M. Jones
February 07, 2020
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Illustration by Laura Liedo

Before becoming a mom of two, I never had premenstrual syndrome (PMS). Not even cramps. I may even have been a little bit smug about it. Then one month, about a year after the birth of my second child, I found myself in the depths of despair.

Having lived with depression for most of my life, I thought it was just related that. But this felt different. It was more severe. It was scary. I felt completely hopeless, even suicidal. I couldn't stop crying. I felt rage at minor triggers. This deep emotional spell lasted only a few days and then I felt back to myself. I didn't notice at first that it had lifted when my period started.

For several more months, I felt myself fall into the highly emotional state for a few days, then get my period, and feel fine again. Each time it happened, I would become completely irrational, make major and ill-advised life decisions, and feel like an entirely different person. One month, I almost divorced my husband. Other months, I abruptly ended important friendships, including a woman with whom I had been friends for nearly thirty years. Frequently during these episodes, I questioned if I even wanted to be alive. I was terrified. Despite having had depression for decades, these episodes were the first time I had ever felt out of control of my actions.

Then I made the connection with my period. Noticing that the onset and then relief of these episodes seemed to coincide with the arrival of my period, I turned to Google for some answers. When I came across the description of premenstrual dysphoric disorder (PMDD), it was like reading an account of my own life. I finally had a reason for my monthly breakdowns.

What is PMDD?

PMDD is a condition that is similar to PMS, affecting about 5 percent of women of childbearing age. Symptoms begin in the week or two before menstruation, and resolve in the week after the period starts. The condition can come and go, but generally occurs in most menstrual cycles.

What Is the Difference Between PMDD and PMS?

"PMDD is very similar to PMS, but more severe," says Mary T. Jacobson, M.D., chief medical director at Alpha Medical. "Approximately 20 percent of us experience mood swings, cramps, food cravings, no interest in activities, and anxiety in advance of our cycle, whereas only around 3-8 percent of women experience PMDD."

While both PMS and PMDD can have physical and mental/emotional symptoms, PMDD tends to present with more severe psychological symptoms. PMDD is classified as a mental illness, but PMS is not. PMDD can be very serious. About 15 percent of women with PMDD attempt suicide.

What Are the Symptoms of PMDD?

According to Harvard Medical School, a diagnosis of PMDD should include five or more of the following symptoms (at least one related to mood) for most menstrual cycles in the past year:

  • Depression
  • Anxiety or tension
  • Sudden mood changes
  • Irritability
  • Loss of interest in daily activities
  • Difficulty concentrating
  • Decreased energy
  • Food cravings and appetite changes
  • Insomnia or sleepiness
  • Physical symptoms, such as breast tenderness or bloating

Questions a doctor may ask when it comes to diagnosing PMDD:

  • Do symptoms interfere with other activities, work, school, or relationships?
  • Are symptoms due to a cyclical exacerbation of another disorder?
  • Have you tracked your daily symptoms for at least two menstrual cycles?

Who Is at Risk for PMDD?

"Any reproductive-age woman is at risk for PMDD," says Camille A. Clare, M.D., MPH, associate professor of obstetrics and gynecology at New York Medical College. Dr. Jacobson points out that women who have a history of anxiety and depression are susceptible to PMDD. She also mentions a National Institutes of Health (NIH) study that suggests PMDD may be genetic.

While it can begin at any age after the onset of menstruation, many women report a worsening of symptoms as they approach menopause. I was in my mid-30s when I first noticed symptoms.

Environmental factors such as stress, a history of trauma, and even seasonal changes can increase the risk of developing PMDD.

How Is PMDD Treated?

"Treatments for PMDD may be similar to treatments for depression," says Dr. Clare. "For PMS, treatment can include supportive therapy, such as a complex carbohydrate diet, aerobic exercise, [and] nutrition supplements such as calcium. Oral contraceptives may improve the physical symptoms of PMS, but they may not work as well to relieve mood symptoms."

For women with the severe symptoms that come with PMDD, selective serotonin reuptake inhibitors (SSRIs, a class of antidepressants) such as fluoxetine, sertraline, paroxetine, or citalopram may be prescribed. Other antidepressants may also be considered.

When my doctor put me on a combination of citalopram and Wellbutrin to treat my "regular" depression, I noticed a decrease in my PMDD symptoms as well. Which treatment course it right for you should be discussed between you and your health care provider.

Dr. Jacobson also suggests relaxation and stress management, as well as over-the-counter pain relievers to help with physical symptoms.

PMDD is difficult and can be scary. It can also be confusing—many women downplay what is happening to them and don't seek the help they need. Dr. Jacobson urges women, health care providers, and society at large to take PMDD seriously. "We often assign harmful and limiting words to conditions like PMDD and PMS, such as emotional, dramatic, moody, hysterical, acting crazy—when women and girls experiencing these conditions are enduring truly severe symptoms that affect them in extreme ways, all from hormone shifts that cause a central nervous system response that they cannot control. From both medical and cultural standpoints, we need to better validate this condition and educate women about how to recognize it, and get the support they need."

Even just knowing why you are feeling this way—and that it will pass—can help. Medication has reduced the number of PMDD episodes I experience, but when I do feel myself spiraling into these intense emotions and thinking irrationally, I am able to remind myself that this is the PMDD talking, not me, and avoid taking any actions I can't take back. Being able to let my husband know that I am experiencing PMDD symptoms has reduced conflict in our relationship. I know that I need to be aware of how I am feeling and how I express it, and he knows I will need some space, support, and patience. He will also take on more than his typical share of parenting responsibilities for a few days.

If you are experiencing these symptoms, or my story sounds familiar, book an appointment with your health care provider. They can rule out other possible causes, help you track your symptoms and cycles, and find a treatment plan that works for you.

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