What is PMDD and Why is it Important?
Let's start with the basics. Here’s the clinical discussion.
Premenstrual dysphoric disorder (PMDD) is a severe form of a premenstrual syndrome that includes physical and behavioral symptoms that usually resolve with the onset of menstruation.
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PMDD causes extreme mood shifts can disrupt work and damage relationships. Symptoms include extreme sadness, hopelessness, irritability, or anger, plus common premenstrual syndrome symptoms such as breast tenderness and bloating.
In 2013, they added PMDD to the DSM (Diagnostic and Statistical Manual of Mental Disorders). At, least five of the 11 specified symptoms must be present for a diagnosis of PMDD. The symptoms should only be limited to the luteal phase and should not amplify preexisting depression, anxiety, or personality disorder. In addition, daily rating must confirm prospectively them for at least two consecutive menstrual cycles. A symptom-free period during the follicular phase of the menstrual cycle is essential in differentiating PMDD from preexisting anxiety and mood disorders.
The conversation around PMDD is one that has been only shoved into the corners of those who were born biologically female for decades–even longer than that, honestly.
In doing my research, Reddit user, @robotpolarbear wrote, “I'm a student studying for my Masters in counseling psychology and while I don't doubt that women's experiences and pain are real, I don't believe that PMDD should be a diagnosis."
Before we get bent out of shape about this claim, let's listen to why this matters...
A few things you may not know about PMDD:
They proposed PMDD for addition to the DSM-IV back in 1994, but when many female psychologists argued against its inclusion in was added to the back of the book under the section for disorders needing further research. It was NOT officially added as a valid diagnostic category.
Pharmaceutical companies fund much of the research with a vested interest in PMDD being recognized as a valid mental illness. When a drug's patent runs out, the drug makers can apply for an extension if they can prove that the drug treats another disorder. Creating PMDD as a diagnostic category would allow companies that make antidepressants to extend and vastly increase their profits.
Pharmaceutical companies have considerable influence over APA decisions and much of the push to include PMDD in the DSM comes from these lobby groups.
The drug company that makes prozac actually dyed the pill pink and re-marketed it as a drug to treat PMDD. There was no other change to the drug, but it allowed them to extend their patent.
The Reddit user continues, “I believe that while many women experience these symptoms, creating a diagnostic category of PMDD pathologize women unnecessarily. I thinks it's dangerous to label women's cycles with a mental illness. I think this whole diagnosis is stigmatizing and sexist, driven by money and greed rather than a desire to actually give women the best mental health care available.”
So again, why does it matter to talk about PMDD?
Because right now, pharmaceutical companies own the conversation and there aren't enough women discussing the disorder in a larger space. Not to mention, labeling women's cycles as mental illness is dangerous... BUT when you are physically incapable of getting out of bed, have long-lasting crying spells, depression and panic attacks that leave you in a daze, it's a mental illness.
How do we know which mental disorders are spectrum disorders or discrete disorders? How do we tell the difference between different depression?
Every case of every mental illness has so many compounding factors and grey areas because we can never place the brain into black and white categories with 100% diagnosing accuracy. There are also important points on how PMDD affects politics, womanhood, and neurodivergent people.
To further understand, PMDD and its gender, political and mental health affects. Let's go over the symptoms of PMDD. This is what the people with PMDD state:
"After seeing two therapists, three psychiatrists, and two gynecologists, I have been misdiagnosed with many mental illnesses: depression, anxiety, bipolar disorder, you name it. I would experience:"
extreme mood swings
panic attacks that got me hospitalized on two occasions
depression so severe I often went into a daze and started cutting my wrists
suicide ideation
weight gain of about 7 pounds every month
crying/laughing spells (very confusing, mind you.)
extreme sensitivity to light and sound
difficulty concentrating
extreme anger swings where I would be impulsive and unable to control myself
From a clinical/diagnostic perspective, PMDD has three different Criterias; A, B, and C. Let's go over A, first.
Criteria A: During most menstrual cycles throughout the past year, at least 5 of the following 11 symptoms (especially including at least 1 of the first 4 listed) must be present in the final week before the onset of menses, must start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses:
•Marked lability (e.g., mood swings)
•Marked irritability or anger
•Markedly depressed mood
•Marked anxiety and tension
•Decreased interest in usual activities
•Difficulty in concentration
•Lethargy and marked lack of energy
•Marked change in appetite (e.g., overeating or specific food cravings)
•Hypersomnia or insomnia
•Feeling overwhelmed or out of control
•Physical symptoms (e.g., breast tenderness or swelling, joint or muscle pain, a sensation of bloating and weight gain
One (or more) of the following symptoms must be present, in addition to Criteria A symptoms being met:
•Marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
•Marked irritability or anger or increased interpersonal conflicts
•Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
•Marked anxiety, tension, and/or feelings of being keyed up or on edge
One (or more) of the following symptoms must be present additionally, to reach a total of 5 symptoms when combined with present symptoms from Criterion B on previous page:
•Decreased interest in usual activities (e.g., work, school, friends, hobbies).
•Subjective difficulty in concentration.
•Lethargy, easy fatigability, or marked lack of energy.
•Marked change in appetite; overeating; or specific food cravings.
•Hypersomnia or insomnia.
•A sense of being overwhelmed or out of control.
•Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," or weight gain.
Sadly, because the symptoms are primarily being used as psychological diagnosis evidence, PMDD is more often misdiagnosed as Bipolar Disorder, BPD, Generalized PMS, Generalized Anxiety Disorder, Major Depressive Disorder, Premenstrual Exacerbation, and ADHD.
This leaves Enormous gaps in care for people with periods and continues to exacerbate the stigmas around periods, people with a uterus, and people with periods actively living with mental illness. Which brings up another point–the information that is lacking surrounding how PMDD affects other mental health diagnosis.
INSERT PHOTOS OF WHO IS AFFECTED FROM RAINBOW POST
PMDD can look a lot like depression. But the major difference between PMDD and Depression is the simple fact that it directly tied PMDD depression to the person's cycle and how the hormonal changes affect the serotonin in the brain.
PMDD symptoms only occur during the days or weeks before your period. Once the period starts, the symptoms should drastically improve. Depression symptoms are pretty persistent (although they may vary in severity from day to day).
Up to 5% of folks who get periods develop depression or anxiety that’s linked to the weeks leading up to their period, and a few days into it.
Symptoms could include any combination of at least five of:
despair
mental and physical fatigue
hopeless feelings
eating too much or too little
sleeping too much or too little
issues with concentration, decision making, or focus
sudden aimlessness or disinterest in favorites
guilt and worthless feelings
thoughts of suicide or dying
If you’re experiencing depression symptoms that come and go, have fewer than five symptoms from the list above, or your symptoms are only present for a few days and not 2 full weeks, you might be experiencing depression-like PMS symptoms but not PMDD or PME.
This chart from Psych Central is a great resource.
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"Diagnosis of PMDD is defined by experiencing a combination of five or more depression symptoms and PMS symptoms in the week before your period, instead of the full 2 weeks for clinical depression.”
“In most cases, symptoms will go away or lessen around the start of your period.”
“For a doctor to diagnose PMDD, they must rule out depression symptoms resulting from an underlying clinical depression or anxiety disorder.”
So, here's the thing. Like with most mental health diagnosis, psychiatrists and doctors have to compare and contrast symptoms with many other disorders along the way to ensure they rule things out. Which means misdiagnosis is VERY HIGH, and it can take a lot of time to get a PMDD diagnosis.
BUT, you can help fast-track your diagnosis by doing:
Track your cycle–use apps like Stardust to make it more fun and help you improve your awareness around cycle start times.
Utilize a mood journal. Track when your mood changes, what symptoms of PMDD you're experiencing, and enhance your self-awareness.
Employ a roommate or partner to help track any shifts in mood or physical symptoms.
How do we know which mental disorders are spectrum disorders or discrete disorders?
This is a question that applies to MORE than just PMDD, but for the sake of this post. We're going to focus on the application of PMDD to this question.
According to the National Library of Medicine, "At present, there is no international standard for the use of psychological tests that takes the definition of a specific symptom as listed in DSM-5 as its starting point, and reliably and validly measures this symptom." So there is absolutely a fatal flaw incorporated in the diagnosis of PMDD (and other disorders and conditions).
This has been problematic for centuries, and I, as well as thousands of psychiatric professionals believe it is time for change.
According to the American Psychiatric Association, “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (American Psychiatric Association, 2013, p. 20).
The problem with this statement is that there are so many symptoms that overlap within categories of psychiatric disorders, leaving millions of patients with co-morbid disorders and furthering the confusion in diagnosis and effective treatment.
Spectrum Disorders
Okay, so here's a big problem with the DSM-5 classification, the DSM-5 states: “(…) scientific evidence places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors (…).” And “(…) we recognize that the boundaries between disorders are more porous than originally perceived” (American Psychiatric Association, 2013, p. 6). So what does this mean in basic language?
It means, that with PMDD, you only need to meet 5 diagnostic criteria within Category A, most in Category B and all in C. The problem? Category A, B, and C, literally cross over into six or more different psychiatric disorders. As mentioned earlier, this taxonomic discription leads to misdiagnosis and undertreatment.
Someone with PMDD could be cross-diagnosed with ADHD and PMDD, or Bipolar and PMDD–or just Bipolar II, for example. This equates to incorrect medication prescribing and so much more. And because women's psychiatric symptoms are often dismissed or treated with less care than men comparatively, women and trans men go misdiagnosed for far longer than they should.
Discrete Disorders
Discrete disorders refer to how the APA and DSM-5 define psychiatric disorders and mental illness. Discrete meaning "you have it or you don't" based diagnosis and language.
Basically, this means you meet the diagnostic criteria = you have the disorder VS you only have some of the symptoms, therefore you don't have the disorder.
Discrete diagnosis is flawed because it does not speak to the true nuance of psychiatric diagnosis and spectrum of PMDD that is experienced within people with periods.
In recent analysis of the DSM-5 and those who focus on discrete diagnosis as the fundamental way in which they define a patient, it has been said that spectral diagnosis is more percise and addresses the main issue patients face regarding their mental health.
So for period having people and PMDD, you may want to directly ask your provider what their diagnostic perspective is when it comes to the DSM-5, and may even want to hardline advocate for a PMDD psychiatric treatment FIRST before being pushed into a Bipolar diagnosis.
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SOURCES
https://psychcentral.com/depression/depression-during-period#period-depression-explained
https://www.webmd.com/women/pms/pms-vs-pmdd
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523712/
https://psychology.stackexchange.com/questions/13300/why-are-disorders-discrete
https://www.reddit.com/r/IAmA/comments/xhiza/iama_woman_diagnosed_with_pmdd_a_severe_rare_and/
https://www.goodrx.com/conditions/pmdd/vs-depressionhttps://teentalk.ca/learn-about/gender-identity/