What Is Premenstrual Dysphoric Disorder (PMDD)?

Several years ago, when a 35-year-old patient named Michelle first visited Amen Clinics, she and her partner were baffled by her irritability, anger, and irrational behavior. This mood instability fluctuated throughout the month. Four days before her period, she might engage in extreme actions, like physically attacking her husband. By the third day after her period started, the temper flares usually ended. When she reached Amen Clinics, she appeared to be a gentle, soft-spoken woman. What could be causing these dramatic ups and downs? Was it bipolar disorder, depression, or premenstrual dysphoric disorder (PMDD)? Functional brain-imaging studies using SPECT scans at Amen Clinics showed vast differences in her brain activity at various points of her menstrual cycle. At the time, she was diagnosed with premenstrual syndrome (PMS). However, if she were evaluated today, she likely would have been diagnosed with PMDD. Back then, PMDD hadn’t yet been recognized as an official diagnosis. PMDD was finally added to the International Classification of Diseases 11th Revision (ICD-11) on January 1, 2022. PMDD comprises a group of moderate to severe symptoms—impacting mood, behavior, and the physical body—that occur cyclically, starting before menstruation and subsiding after the start of menstruation.

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WHAT IS PREMENSTRUAL DYSPHORIC DISORDER?

PMDD is a severe form of premenstrual syndrome. PMDD comprises a group of moderate to severe symptoms that impact mood, behavior, and the physical body. They typically occur cyclically, starting before menstruation and subsiding after the start of menstruation. Experts estimate that 6% of reproductive-age women have premenstrual dysphoric disorder. Let’s look at some causes and risk factors for PMDD, its associated brain changes, and some common premenstrual dysphoric disorder symptoms. The National Library of Medicine notes that, while genetic links are possible, other factors are proven risks, including past traumatic events, cigarette smoking, and obesity.

PMDD SYMPTOMS

What are the symptoms of premenstrual dysphoric disorder? According to the Office on Women’s Health (a division of the U.S. Department of Health & Human Services), symptoms of PMDD include:

Prolonged irritability or anger
Feelings of sadness or despair, or suicidal thoughts
Tension or anxiety
Panic attacks
Mood swings or crying often
Lack of interest in activities and/or relationships
Difficulty thinking or concentrating
Feeling tired or low-energy
Food cravings or binge eating
Difficulty sleeping
Feeling “out of control”
Physical symptoms, such as cramps, bloating, breast tenderness, headaches, and joint or muscle pain

Premenstrual dysphoric disorder symptoms typically appear in about a week or so before a woman’s period begins and dissipate a few days after it starts.

PMDD AND THE BRAIN

Not surprisingly, the changes seen in PMDD are reflected in the brain. When Amen Clinics compared Michelle’s SPECT scans from the most difficult time in her cycle to those from 11 days later (the best time of her cycle), clear differences emerged. The first scan showed increased activity in the limbic system, the brain’s emotional center, and in the anterior cingulate gyrus, which acts as the brain’s “gear shifter.” This combination explains the tendency to get stuck in negative thoughts. In addition, Michelle’s brain showed low activity in the temporal lobes (associated with unstable mood) and reduced activity in the prefrontal cortex (associated with impulse problems). Just 11 days later, her brain activity looked much more typical of a healthy woman her age. Michelle’s PMDD-Affected Brain:

During worst time of cycle: Increased limbic and cingulate activity

Michelle’s Brain:

During best time of cycle: Calmer overall activity

In other words, PMDD is not an “imaginary” condition. A hijacking of the brain’s chemistry creates difficult-to-manage reactions. It’s also worth noting that the limbic system contains a higher density of estrogen receptors than other parts of the brain. This means it can be more vulnerable to estrogen fluctuations, such as those that occur at puberty, after birthing a child, or during menopause. Clearly, for Michelle and many other women, these brain changes can lead to dramatic—even dangerous—shifts in behavior.

PMDD, PMS, and Mental Health Conditions

How is PMDD different from premenstrual syndrome (PMS)? According to the ICD-11, certain qualifications must be met for a diagnosis of PMDD. First, symptoms must happen during the luteal phase of the menstrual cycle and occur in most cycles within the past year. PMDD also requires a combination of two types of symptoms:

Affective symptoms, such as irritability or a depressed mood
Somatic or cognitive symptoms, such as lethargy, joint pain, or trouble concentrating

Finally, the condition must cause “significant distress.” PMS may present various physical and emotional disturbances before a period, but PMDD creates a much more intense set of symptoms, disrupting a woman’s life and the lives of those around her. Medical professionals admit that there is enough overlap between symptoms of PMDD and mental health disorders—such as bipolar disorder and clinical depression—to create the possibility of misdiagnosis. To complicate matters further, the American Psychological Association (APA) notes that women who have other mental health conditions, such as depression or anxiety, may experience a worsening of symptoms before the start of their periods. But this does not necessarily point to PMDD.

PREMENSTRUAL DYSPHORIC DISORDER TREATMENTS

Because PMDD can be both tricky to diagnose and potentially debilitating in its effects, it’s important to incorporate as many interventions as possible to help reduce symptoms. Here are some natural solutions to try:

Track your cycle.

The International Association for Premenstrual Disorders notes that because PMDD can’t be determined through a blood, hormone, or saliva test, tracking symptoms is a must for diagnosis. The organization recommends tracking over a span of at least two menstrual cycles. You can do this on pen and paper, noting various symptoms and their severity, or through an app. Information is power, for both you and your healthcare providers.

Increase serotonin.

This step is especially important during the last half of your cycle. Selective serotonin reuptake inhibitors (SSRIs), a category of antidepressants, are often used for this, but you can also reach for natural supplements to boost serotonin. Saffron has been shown in studies to help increase and maintain serotonin levels in the brain, making it a natural antidepressant—try a dosage of 30mg. Finally, 5-hydroxytryptophan (5-HTP), a natural building block for serotonin, has been studied in the medical community as an effective alternative to SSRIs.

Exercise.

Getting regularly scheduled activity has been shown to have numerous positive effects on mood, making it an effective natural treatment for mental health issues. Exercise helps reduce feelings of anxiety and depression, improves sleep, and combats the effects of stress. It also stimulates feel-good endorphins. Aim for a mix of high-intensity exercise, like tennis or running, and more relaxing movements, like yoga. Find activities you love so they’ll be easier to stick with.

Optimize vitamin D levels.

Vitamin D is believed to help regulate mood, and it also promotes bone health—crucial for women to help prevent osteoporosis later in life. Spending 15 to 20 minutes in the sun a few times a week can increase vitamin D levels. You can also obtain vitamin D through your diet, including fatty fish (such as salmon, tuna, and mackerel), eggs, and some mushrooms. If your levels are low, take vitamin D supplements to ensure you’re getting enough.

Make dietary changes.

Women with PMDD might benefit from a diet that is higher in protein and eliminates sugar, caffeine, and alcohol. For example, some studies show that the ketogenic diet may help with stabilizing mood. One Amen Clinics patient, who was coping with severe PMDD, reported that her moods significantly improved on this kind of diet. With its focus on obtaining calories from protein and fat, plus reduced carbohydrates (less than 50 grams daily), this diet can considerably lessen pre-menstruation brain overactivity.

Stress management.

Managing stress is important for everyone, but especially for those who have PMDD. Though the possibilities are numerous, here are a few suggestions. Add journaling or gratitude lists to your daily regimen. Confront your automatic negative thoughts and mental dragons. Seek therapy for talking through stresses and traumas. Join a support group to foster community. Practice meditation, prayer, and/or diaphragmatic breathing. Mix and match these and other approaches throughout your day, week, and monthly cycle.

A HOPEFUL FUTURE FOR PMDD

Despite the recent official medical acknowledgment of PMDD, it remains a controversial diagnosis. There may remain a long road ahead for acceptance and understanding among doctors and patients alike. More research is needed to learn more about this premenstrual disorder. Ideally, its establishment as a recognized disorder will help fuel those efforts. In the meantime, certain lifestyle choices combined with medical help can work wonders on reducing symptoms and their impact on daily life. Premenstrual dysphoric disorder (PMDD) and other mental health issues can’t wait. At Amen Clinics, we’re here for you. We offer in-clinic brain scanning and appointments, as well as mental telehealth, clinical evaluations, and therapy for adults, teens, children, and couples. Find out more by speaking to a specialist today at 888-288-9834 or visit our contact page here.