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The Imposters | PMDD vs PMDD

If you’re here, you probably already know you have PMDD, but just in case, here are the symptoms:
The Diagnostic Criteria for PMDD

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), established 4 research criteria (A through D) for the diagnosis of PMDD.

Criterion A is that in most menstrual cycles during the past year, at least 5 of the following 11 symptoms (including at least 1 of the first 4 listed) were present:

  • Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
  • Marked anxiety, tension, feelings of being “keyed up” or “on edge”
  • Marked affective lability (eg, feeling suddenly sad or tearful or experiencing increased sensitivity to rejection)
  • Persistent and marked anger or irritability or increased interpersonal conflicts
  • Decreased interest in usual activities (eg, work, school, friends, and hobbies)
  • Subjective sense of difficulty in concentrating
  • Lethargy, easy fatigability, or marked lack of energy
  • Marked change in appetite, overeating, or specific food cravings
  • Hypersomnia or insomnia
  • A subjective sense of being overwhelmed or out of control
  • Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain

The symptoms must have been present for most of the time during the last week of the luteal phase, must have begun to remit within a few days of the onset of menstrual flow, and must be absent in the week after menses.

Criterion B is that the symptoms must be severe enough to interfere significantly with social, occupational, sexual, or scholastic functioning. For example, the patient may avoid social activities or exhibit decreased productivity and efficiency at work or school.

Criterion C is that the symptoms must be discretely related to the menstrual cycle and must not merely represent an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although the symptoms may be superimposed on those of any of these disorders).

Criterion D is that criteria A, B, and C must be confirmed by prospective daily ratings during at least 2 consecutive symptomatic menstrual cycles. The diagnosis may be made provisionally before this confirmation.

Of the 11 symptoms listed in DSM-V, 10 are emotional and behavioral in nature; only 1 includes multiple common physical symptoms. Thus, PMDD defines a narrow group of women with the most severe premenstrual emotional symptoms, with functional impairment, and without a concurrent Axis I or Axis II disorder that is exacerbated pre-menstrually.

So What Does That Mean In Language I Can Understand?

The following section breaks the symptoms down into everyday language.

Markedly Depressed Mood, Feelings of Hopelessness, or Self-Deprecating Thoughts

Major episodes of depression, plain and simple.  The hallmark of PMDD.  PMDD is so much more than a bad case of the blues.  During the latter half of a woman’s menstrual cycle, the depression that comes is clinical in nature, and can include thoughts of hurting yourself or others, and suicide.  

Marked Anxiety, Tension, Feelings of Being Keyed-Up or On Edge

This goes beyond simple edginess, nervousness, or jitters.  You're so hyper-sensitive (to sights, sounds, smells, touch) that feel like you want to jump out of your skin, slap somebody—anybody—or feel like something really bad is about to happen and you don’t know what it is or how to stop it.  Panic attacks fall under this heading.  

Marked Affective Lability

One minute you’re laughing, the next you’re crying – What’s up with that?  Split-second shifts in emotions come without warning and are as uncontrollable as an allergic reaction.  Know that you’re not at fault for this!  Do you apologize for an allergic reaction?  If you do, you might want to check into some classes to boost your self-esteem because there’s more going on here than PMDD.  You are not your PMDD.  Never let your PMDD make you feel badly about yourself as a person.  If you hurt a loved one's feelings, then yes, please do apologize, but do not beat yourself up over it.  Accept that the PMDD won this round and move on.

Persistent and Marked Anger or Irritability or Increased Interpersonal Conflicts

You’re angry all the time and can’t stop snapping at or arguing with people.  You fear the loss of friends and family relationships—or may have already lost them.  There’s suddenly a mean streak in you a mile wide and you lash out at your partner, children, friends, and co-workers, and don’t know how to stop.  You hate yourself afterward, and spend excessive amounts of time either apologizing or doing damage control.  See the paragraph above.  Own what is yours and move on.  Don't let the PMDD keep you down.  

Decreased Interest in Usual Activities  (work, school, friends, and hobbies) 

Some days nothing seems like a good idea.  You can’t even muster the energy to get out of bed, shower, dress, or see to your simplest needs, much less the needs of your loved ones.  This takes a devastating toll on family life, especially for those with children.  You call in sick to work, cancel out on friends and family, let everything around the house slide.

Subjective Sense of Difficulty in Concentrating

How about some multi-tasking ADD-style, forgetfulness a là Alzheimer’s, with a side order of clumsiness and foggy thinking?  How can you get through the day when you can’t stay focused, can’t remember anything, keep dropping or bumping into things, and can’t seem to string two coherent thoughts together—much less make a decision?  This includes women who appear to be extremely flighty, maybe forget to pay bills, pick up or feed the kids, comb their hair or put shoes on before they go out, as well as lose the ability to control their balance.

Lethargy, Easy Fatigability, Marked Lack of Energy

You can’t stop yawning, and you feel like you’re moving uphill through molasses.  Every step forward drains you.  It’s almost like narcolepsy, at times preventing women from being able to drive or use heavy equipment, including the stove.  PMDD also lowers immunities, making women more susceptible to colds and flus for at least one to two weeks of every month.  This can lead to chronic illness and debilitating fatigue from simply being run down physically.

Marked Change in Appetite, Overeating, or Specific Food Cravings

When you want to eat everything in sight, especially everything you shouldn’t.  The good news is it’s not all in your head, it’s not a matter of willpower, and there are reasons why you crave the things you do.  But until you understand that, you’ll keep binge eating and having cravings that don’t occur during any other time of the month.

Hypersomnia or Insomnia

You’re exhausted, but you still can’t sleep at night, or you just can’t wake up no matter what.  You toss and turn all night, or wake up feeling like a wet, heavy blanket of fog has rolled into your brain—or both.    

A Subjective Sense of Feeling Overwhelmed or Out of Control

You think you’re going crazy (but the good news is you’re not).  You feel like you’re losing your mind.  One day everything can be running smoothly and life is good, and the next day nothing has changed, but suddenly everything seems out of control and too overwhelming.   You find you can't make the simplest decisions.  The choices simply confound you.  The train of negative thoughts runs through your mind in loops and loops and just won’t stop, especially those guilty thoughts about what your behavior is doing to your loved ones.  

At this point some beg God to just get it over with, and “Take me now.”  Others attempt suicide.  Fifteen percent of women with PMDD who attempt suicide succeed.  Don't be one of them.  We need you here.  If you're in crisis, call 1-800-273-TALK (8255)

Physical Symptoms

Just like depression, PMDD hurts.  Joint pain, muscle pain, back pain, pelvic pain, headaches, and cramping.  Bloating, swelling, inflammation, upset stomach, and allergies are intensified.  Excessive bleeding and anemia can come into play here.  You can lose the ability to control normal body temperature, making you feel extremely cold, or very hot, no matter the weather.  

Other Symptoms Include (But Are Not Limited To)

Lack of Impulse Control  (eg, excessive shopping, gambling, substance abuse, addictions, or inappropriate behaviors)
Sexual Aggression

Rare Symptoms of PMDD

Delusions and Hallucinations
Psychotic Episodes
Sensory Disturbances

PMDD in the News: A Word About Homicide

Yes, a woman can and does feel angry enough to kill.  In the 1980s in England, the currently-called “PMS defense” freed Christine English after she confessed to killing her married boyfriend by ramming him into a utility pole with her car.  After killing a co-worker, Sandie Smith was put on probation with one condition: she had to report monthly for injections of progesterone to control symptoms of PMS.  By the 1990s, the PMS defense had paved the way for other hormonal defenses.

Charting Your Symptoms is a Must

The best way to find out if your symptoms are PMDD or part of an ongoing condition not related to your menstrual cycle is to chart the symptoms.  A chart for you to print out is provided here, or you can use any number of period trackers on your cellphone.  You’ll need to do this for at least two months (Criterion D in the DSM-V list above), to get a proper diagnosis of PMDD.  Three months would be ideal, but who wants to wait that long for relief?

The main thing you need to watch for is whether your symptoms are present at all times, or whether they come and go.  It can also be confusing if you have an underlying condition that worsens in concert with your menstrual cycle, both around the times of ovulation (approximately Day 14) and when your period is due.  More on this in the sections labeled Confusion City and The Imposters (coming soon).