What Is Premenstrual Dysphoric Disorder?

Premenstrual dysphoric disorder (PDD) is a severe premenstrual disorder that is defined by psychiatric or somatic symptoms that develop during the late luteal phase (after ovulation) of the menstrual cycle (or 7 to 10 days before menstruation) and end after menstruation begins.1 While it may share some symptoms with Premenstrual Syndrome (PMS), it causes significantly more distress that negatively affects a woman’s mental health and is officially classified as a mental health disorder, whereas PMS is not. Some symptoms common to PDD and PMS might include:2Woman in pain holding stomach

  • Headaches.
  • Irritability.
  • Sleep disruptions.
  • Tiredness.
  • Water retention or bloating.
  • Breast tenderness.
  • Digestive concerns.
  • Abdominal pain.
  • General discomfort.
  • Serious mood fluctuations or impairment (e.g., depression, anxiety).

If these symptoms impair a woman’s daily activities and ability to function normally, then a diagnosis of PDD may be considered. Because it’s a relatively new diagnosable disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), some people may be skeptical if the disorder is real.3 So, in this article, we’ll explore in greater detail:

  • What PDD is.
  • Who is most susceptible to it.
  • How to treat it.

What Are the Symptoms?

Premenstrual disorders affect as many as 40% of women, however only 3–8% experience symptoms that negatively affect their everyday routines or rise to the level of a PDD diagnosis.

The criteria for symptoms to meet a diagnosis of PDD are:5

Criteria A:

The DSM-5 specifies that a person must have at least 5 of the symptoms listed in Criteria B and C—with at least 1 from each category—in the week preceding menstruation, with improvement seen a few days after the first day of the woman’s period and nearly completely ending about a week later.

Criteria B:

  • Significant mood swings: increased sensitivity to rejection, sudden onset of feeling sad or tearful.
  • Excessive irritability or anger.
  • More interpersonal conflicts than normal.
  • Significant depressed mood or hopeless feelings.
  • Marked anxiety or tension.
  • Constantly feeling on edge.

Criteria C:

  • Hypersomnia.
  • Insomnia.
  • Lethargy.
  • Lack of energy.
  • Increased fatigability.
  • Difficulty concentrating.
  • Decreased interest in daily activities (work, social outings, school, etc.).
  • Change in appetite (overeating or craving something specific).
  • Feeling overwhelmed or out of control.
  • Physical symptoms: feeling bloated, breast tenderness or swelling, joint or muscle pain, weight gain.

Unhappy isolated woman at homeThese symptoms must also be present in the majority of your menstrual cycles over the past year and significantly impair or interfere with daily activities and social relationships.5 Also, the symptoms cannot be attributed to substance use, other medications or medical illness, or be an exacerbation of another disorder (e.g., panic disorder, major depressive disorder, persistent depressive disorder, or a personality disorder).1

Who Is Most Susceptible?

It is not completely certain what the exact cause of PDD is, but a few studies have named 5 contributing factors:6

  • Genetics: There is a 30%–80% heritability rate based on several family, twin, and genetic studies.
  • Progesterone and allopregnanolone (ALLO): Ongoing exposure to progesterone and ALLO (a progesterone metabolite that has sedative and anxiolytic effects), along with a rapid withdrawal from ovarian hormones, may contribute to PDD. ALLO is generally released during times of stress to relieve those feelings naturally. However, people with PDD seem to have less ALLO, which may be a factor in their symptoms.
  • Brain structure and functioning: Studies have found that women with PDD have greater gray matter in the posterior cerebellum and the hippocampal cortex. Those same women also have less gray matter in the parahippocampal cortex.
  • Estrogen and serotonin: Although the relationship is not fully understood yet, it is believed that the estrogen-serotonin interaction may be involved with the etiology of PDD.
  • Trauma: Some studies have found correlations between trauma and PDD, but further research needs to be conducted.

In addition, the following risk factors increased the likelihood of people developing PDD in a separate 2010 study:7

  • Those living in a large city were more than 4 times as likely to develop PDD than those living in rural areas.
  • Unemployed women were 2.29 times more likely than employed women to develop the disorder.
  • Alcohol drinkers and cigarette smokers were, respectively, 2.66 and 2.33 times more likely to suffer from PMDD compared to non-drinkers and non-smokers.

If you or a loved one have PDD, there are several options for treating it.

Getting the Necessary TreatmentMeeting with a doctor

Treatment of PDD focuses on relieving both the physical and psychiatric symptoms associated with the disorder through options like hormonal treatment, psychiatric medication, or alternative approaches. Research is constantly being conducted for new treatment options, and several types of medications have so far been deemed appropriate to treat PDD, including:1

  • Selective Serotonin Reuptake Inhibitors (SSRIs): Prescribed to treat the psychological symptoms of PDD, these include Paxil, Lexapro, Zoloft, Celexa, and Prozac. SSRIs may also relieve some of the associated physical symptoms.
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): These medications have also been used to help treat the psychological effects of PDD. One example is venlafaxine (Effexor).
  • Oral contraceptives: Prescribed to reduce and treat both the physical and psychological symptoms of PDD, contraceptives have shown in multiple trials to improve depressive and physical symptoms (mean percent of improvement ranged from 30% to 59% in controlled clinical trials). Oral contraceptives have also helped relieve abdominal bloating, headache, extremities swelling, and weight gain. However, further analysis is still needed to prove consistent efficacy.
  • Calcium: Calcium levels tend to fluctuate through cyclic changes in women with PDD. Two randomized studies reported a 50% reduction in symptoms of fatigue, depression, and appetite in women who received 1,000–1,200mg of calcium every day for 3 months.

Other, non-pharmacologic treatments have proven effective in some women, though further research needs to be conducted to support some of them.1,4

  • Chinese medicine (herbs and acupuncture) to reduce symptoms.
  • Cognitive Behavioral Therapy (CBT) for psychological issues.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for menstrual cramps.
  • Diuretics or water pills for water retention or bloating.
  • Relaxation and mindfulness techniques.
  • Exercise.
  • Decreasing caffeine consumption.
  • Decreasing alcohol consumption.
  • Decreasing salt intake.
  • Supplements such as St. John’s wort, vitamin B6, chase tree extracts (vite agnus castus), and vitamin D.

Sources

  1. Hofmeister, S. & Bodden, S. (2016). Premenstrual Syndrome and Premenstrual Dysphoric Disorder. American Family Physician, 94(3), 236–240.
  2. U.S. National Library of Medicine. (2017). Premenstrual Dysphoric Disorder (PMDD).
  3. Daw, J., American Psychological Association. (2002). Is PMDD Real?
  4. U.S. National Library of Medicine. (2017). Premenstrual Syndrome: Overview.
  5. The American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association.
  6. MGH Center for Women’s Mental Health. (2017). The Etiology of Premenstrual Dysphoric Disorder: 5 Interwoven Pieces.
  7. Skrzypulec-Plinta, V., Drosdzol, A., Nowosielski, K., & Plinta, R. (2010). The Complexity of Premenstrual Dysphoric Disorder—Risk Factors in the Population of Polish Women. Reproductive Biology and Endocrinology, 8, 141.
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