Premenstrual Dysphoric Disorder (PMDD)

Kiran is 29 years old. She has two children - a four-year-old boy and a two-year-old girl. Kiran feels extremely cranky and irritable when she is on her period. She's not able to concentrate on her work; she gets very anxious and tense about her deadlines, which she manages with ease during the rest of the month. She also feels very low and ends up crying about trivial matters. She feels guilty for getting angry at her children for no reason, but feels helpless. Kiran's mood swings affect her social, personal, and professional life. When she considers seeing a psychologist, her husband says she’s ‘just PMSing'. When Kiran does meet a doctor, she finds that she has PMDD, and begins consulting a psychologist.

Pre-menstrual syndrome (PMS) describes the physiological and hormonal changes a woman experiences during each menstrual cycle. The changes typically occur in the second half of the cycle, and the symptoms may fade at the onset of menstruation. However, some women experience the symptoms of PMS so severely that it interferes with their quality of life. This is a condition called premenstrual dysphoric disorder (PMDD).

What is the difference between the two?

While about 75% of women have mild PMS symptoms, PMDD affects around 3-8% of women1. At first glance, both PMS and PMDD seem to have similar symptoms like bloating, tender breasts, muscle or joint pain, fatigue, sleep problems, food cravings, and sudden changes in mood. But they both vary in terms of the severity of the issue. For eg.,

• Depression: PMS depression causes one to feel (momentarily) sad but someone with PMDD may experience intense feelings of sadness, hopelessness, and guilt, and may also have suicidal thoughts.

• Anxiety: Anxiety may be very mild or non-existent in the case of PMS. In the case of PMDD, it is severe, accompanied by feeling tense and 'on the edge' all the time.

• Mood swings: Mood swings are common in women with PMS; with PMDD, the swings are severe. Women tend to feel out of control of their lives, and sometimes may pick fights over petty issues.

• Outlook towards life: During PMS, women tend to feel depressed and detached from their lives. Women with PMDD entirely stop caring about their family or job, and may want to stay in all the time.

For a diagnosis of PMDD, a woman needs to have 5 out of the following 10 symptoms, including at least one of the first 4, cyclically preceding menstruation.

1. Markedly low mood, feelings of hopelessness, or self-deprecating thoughts

2. Significant anxiety or tension

3. Marked changes in emotion

4. Persistent and pronounced irritability

5. Decreased interest in regular activities

6. Inability to concentrate

7. Fatigue, lack of energy

8. Changes in appetite, food cravings, overeating

9. Excessive sleeping or insomnia

10. Physical symptoms such as breast pain, bloating and headaches.

Women with PMS may not need professional help to cope with the symptoms, but women with PMDD will require professional help.

What causes PMDD?

The exact causes of PMDD are unknown, but fluctuations in hormone levels during the cycle are thought to play a part. Depression and other mood disorders are thought to be linked to both PMS and PMDD, but the causal relationship is unknown: that is, it’s unclear if depression is a cause or an effect of PMS and PMDD.

How is PMDD diagnosed?

There are no formal tests to detect either PMS or PMDD, but the doctor can tell depending upon the intensity, severity and duration of the symptoms. Often, a doctor gives out a diary or a chart to be filled over two menstrual cycles. The chart usually contains details of  the person's emotional state, physical symptoms, and eating and sleeping patterns. The doctor then examines the symptoms and their severity to diagnose the symptoms as either PMS or PMDD.

For a complete diagnosis, women are tested for thyroid abnormalities (overactive thyroid) and other psychological problems like depression which might be causing these symptoms. Once the other possible diagnoses are ruled out, they are treated for PMDD.

How is PMDD treated?

Treatment is focused on improving the quality of life for the woman. PMS can be managed by lifestyle changes such as diet and exercise. Treatment approaches for PMDD include:

• Medication: Antidepressants are often used, and are effective in fighting the symptoms. Birth control pills are also prescribed as they stop ovulation, thereby reducing symptoms of PMDD. It is important to note that these medications are only approved for treatment of PMDD and not for PMS.

• Behavioral techniques: Techniques such as stress and anger management are also used along with medication.

• Lifestyle changes: Regular exercise, good diet, quality sleep and stress reduction are also helpful in managing the symptoms.

References

1. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (2000).