PMDD (Premenstrual Dysphoric Disorder)

20 February 2017.

Premenstrual Dysphoric Disorder (PMDD) was first described in 1987, when it was included in the American Psychiatric Association’s DSM (Diagnostic Statistical Manual for mental health disorders)- although it was then called ‘Late Luteal Phase Dysphoric Disorder‘ [1]. It refers to individuals who experience severe (life-affecting) mood swings, anxiety, or low mood (and perhaps some physical symptoms), in the premenstrual phase (two weeks before menstruation), with symptoms disappearing between menstruation and ovulation [1].

PMDD is often described as ‘severe PMS’ (Premenstrual Syndrome) but this is NOT strictly true, since PMS is a term used to describe any symptom experienced in the premenstrual phase i.e. including physical symptoms such as constipation, migraine, painful breasts, or fatigue, and not only, or mainly, mood-related problems (which is the case for PMDD) [1].

PMDD is a highly controversial diagnosis because although it is a hormonal problem by definition, it is classified as a mental health disorder [2]. This is not the case for other hormonal conditions that result in mood swings, anxiety, or depression, e.g. thyroid disorders [2]. So, it is felt by many to be another example of society’s habit of wrongly associating the female reproductive system with supposedly irrational thinking and behaviour [3], or with psychosomatic disorders [4] (a physical problem with a psychological cause- which is definitely not the case for either PMS, or PMDD, since they are obviously triggered by the menstrual cycle).

However, this is not to say that experts do not agree that some people’s moods are significantly affected by their menstrual cycle, the disagreement is only around the way in which the problem is classified (e.g. is it a hormonal, reproductive health, or a psychiatric problem? Is there an underlying mental health disorder that is ‘triggered’ or ‘worsened’ by the menstrual cycle, or is it directly caused by the changing levels of sex hormones, or external social factors?), and treated (e.g. with anti-depressants/ psychological therapy, hormonal medications/ interventions, or lifestyle and dietary options) [1] [3].

Main symptoms: A diagnosis of PMDD requires the presence of at least five ‘PMS’ symptoms with at least one of the main symptoms being; severe tearfulness, irritability, depressed mood, or anxiety/ tension. These symptoms should only occur up to two weeks before menstruation and stop after menstruation begins. In order to meet the criteria for diagnosis, the symptoms should be tracked for at least two consecutive ovulation cycles in order to confirm the cyclical nature of symptoms. The symptoms should also be severe enough to significantly affect normal work, school, or social activities or relationships with others [1].


If your symptoms are severe and debilitating (i.e. they significantly limit your ability to work, socialise, or maintain personal relationships) it is likely that your doctor will prescribe some sort of medication.

Diagnosed PMDD is most commonly treated with SSRIs (Selective Serotonin Reuptake Inhibitors) which are a type of anti-depressant that has been found to be very effective in managing PMDD- but PMDD patients only need to take the medication for a few days before menstruation (up to a maximum of two weeks) [5].

Or, your doctor may prefer to prescribe a hormonal medication or device (usually the contraceptive pill, patch, or implant) to prevent symptoms by stopping ovulation from happening in the first place [5].

Non-medication approaches to managing PMDD:

The good news is that PMDD symptoms respond well to the four steps outlined on our ‘all symptoms‘ page, so it might be worth trying some of these options before turning to medication, or in combination with it:

Try a hormone-balancing diet– As outlined in this blog, a vegetable-based ‘anti-inflammatory’ diet can significantly improve all hormone-related symptoms.

We highlight additional advice for those suffering from PMDD, below;

  1. Eat lots of fresh fruit and vegetables
  2. Eat lots of fibre (and drink water with it)
  3. Eat oily foods (mainly unsaturated fats)
  4. Reduce meat and dairy products
  5. Avoid sugary foods and drinks
  6. Avoid caffeine- Drinking too much caffeine can make you more anxious than normal. This is because caffeine can disrupt your sleep and also speed up your heartbeat. If you’re tired, you’re less likely to be able to control your anxious feelings. Avoiding drinks containing caffeine – such as coffee, tea, fizzy drinks and energy drinks – may help to reduce your anxiety levels [6].
  7. Avoid alcohol (and smoking)- These have been shown to make anxiety worse. Only drinking alcohol in moderation and stopping smoking may help to reduce your symptoms [6]. Read about how stopping smoking can reduce your anxiety.
  8. Take nutritional supplements- Calcium (400- 800 mg daily) [7], and Vitex Agnus Castus (200-500 mg of extract daily) [7] [8] can be beneficial for PMDD (and used in combination with conventional anti-depressants).

NoteVitex Agnus Castus is not suitable for those who are under 18; using hormonal medication (or devices); are pregnant, trying to conceive, or breast-feeding; or have a pituitary problem.


Exercise regularly

Regular exercise, particularly aerobic exercise, may help you combat stress and release tension. It also encourages your brain to release serotonin, which can improve your mood [9].

Research has shown that regular exercise, (more specifically cardio-respiratory fitness), and a healthy BMI (Body Mass Index), significantly reduces the risk of menstrual cycle-related health issues, including low mood [10].


Boost self-esteem- Low self-esteem has been found to increase the risk of developing the symptoms of depression, so it’s worth making sure that your self-esteem is OK, and if not, to do something about it [11].

Cognitive behavioural therapy (CBT) is one of the most effective treatments for low mood, and building self-esteem, and is available on the NHS. Research shows that the benefits of CBT may last longer than those of medication, although no single treatment is best for everyone. CBT helps you to understand how your problems, thoughts, feelings and behaviour affect each other. It can also help you to question your negative and anxious thoughts, to improve the way you see yourself, and reduce damaging internal thought processes. CBT usually involves meeting with a specially trained and accredited therapist for a one-hour session every week for 10-12 weeks.

NoteThe Oxford Cognitive Therapy Centre produces a highly effective (and cheap!) CBT booklet; ‘Building self-esteem‘.


Reduce stress hormones- Research shows that Mindfulness-based Cognitive Behavioural Therapy (MCBT) is highly effective in reducing menstrual cycle-related low mood, anxiety, and other symptoms [12] [13]. Mindfulness works by focusing your awareness on the present moment and by acknowledging and accepting certain feelings. Being mindful can teach you how to overcome negative thoughts – for example, being able to challenge hopeless feelings.

This practice has been found to reduce ‘stress reactivity’, stopping the vicious cycle of low mood and anxiety constantly triggering the ‘fight or flight’ HPA (Hypothalamic Pituitary Adrenal) stress response- leading to further anxiety (and, therefore, worsening hormone-related symptoms) [14]. MCBT usually involves meeting with a therapist for a one-hour session every week for three to four months.

You may find relaxation and breathing exercises helpful, or you may prefer activities such as yoga or pilates to help you unwind.


If you have tried the suggested tips and tricks for at least 3 months, and your symptoms do not improve, please consult your doctor.

If you have any suggestions, or tips, for managing PMDD- please let us know– we can share them with others!


Further information;


Page last reviewed and updated: June 2018


References:

1. American Psychiatric Association. (2013) Diagnostic and Statistical Manual of Mental Disorders (5th Edition). Washington, DC, USA.

2. Bauer M, Goetz T, Glenn T, Whybrow PC. (2008) The thyroid-brain interaction in thyroid disorders and mood disorders. J Neuroendocrinol20:1101–14

3. Ussher, J. (2001) The madness of women: myth and experience, London, Routledge pp 153-184

4. Piko BF, Varga S, Mellor D. (2016) Are adolescents with high self-esteem protected from psychosomatic symptomatology? Eur J Pediatr. Jun;175(6):785-92. doi: 10.1007/s00431-016-2709-7.

5. European Medicines Agency. (2009) Guideline on the treatment of premenstrual dysphoric disorder (PMDD), London, 20 May 2010 [online]. Available from URL: http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2010/05/WC500090882.pdf [Accessed 3 August 2017]

6. NHS. 2017. Anxiety Self Help Information. [ONLINE] Available at: http://www.nhs.uk/Conditions/Anxiety/Pages/self-help.aspx. [Accessed 22 March 2017]

7. Lanza di Scalea T, Pearlstein T. (2017) Premenstrual Dysphoric Disorder. Psychiatr Clin North Am. Jun;40(2):201-216. doi: 10.1016/j.psc.2017.01.002.

8. Atmaca, M., Kumru, S., & Tezcan, E. (2003) ‘Fluoxetine versus Vitex Agnus Castus extract in the treatment of Premenstrual Dysphoric Disorder’ Human Psychopharmacology 18(3): 191-5. PubMed PMID 12672170

9. NHS. (2016) Clinical depression. [ONLINE] Available at: http://www.nhs.uk/Conditions/Depression/Pages/Introduction.aspx. [Accessed 17 April 2017]

10. Haghighi ES, Jahromi MK, Daryano Osh F. (2015) ‘Relationship between cardiorespiratory fitness, habitual physical activity, body mass index and premenstrual symptoms in collegiate students’ J Sports Med Phys Fitness Jun;55(6):663-7. PubMed PMID: 26205766

11. Sowislo JF, Orth U. (2012) ‘Does low self-esteem predict depression and anxiety? A meta-analysis of longitudinal studies’ Psychol Bull. Jan;139(1):213-40. doi: 10.1037/a0028931. Epub 2012 Jun 25. PubMed PMID: 22730921

12. Panahi F, Faramarzi M. (2016) ‘The Effects of Mindfulness-Based Cognitive Therapy on Depression and Anxiety in Women with Premenstrual Syndrome’ Depress Res Treat. 9816481. doi: 10.1155/2016/9816481. Epub 2016 Nov 29. PubMed PMID:
28025621; PubMed Central PMCID: PMC5153465

13. Gotink, R. A., Chu, P., Busschbach, J. J. V., Benson, H., Fricchione, G. L., & Hunink, M. G. M. (2015). Standardised Mindfulness-Based Interventions in Healthcare: An Overview of Systematic Reviews and Meta-Analyses of RCTs. PLoS ONE, 10(4), e0124344. http://doi.org/10.1371/journal.pone.0124344

14. Hoge, E. A., Bui, E., Marques, L., Metcalf, C. A., Morris, L. K., Robinaugh, D. J., … Simon, N. M. (2013). Randomized Controlled Trial of Mindfulness Meditation for Generalized Anxiety Disorder: Effects on Anxiety and Stress Reactivity. The Journal of Clinical Psychiatry, 74(8), 786–792. http://doi.org/10.4088/JCP.12m08083


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