PMDD: A Guide to Diagnosis and Coping

It’s strange, hearing a complete stranger excavate the dirtiest cavities of your mind with 100% accuracy. It was the first meeting I’d had with the new therapist, and as she read aloud from the four-inch-thick book balanced on her thighs, I imagined her scanning the pages of my journal, pulling out each and every one of my issues I’d meticulously documented only for myself over the past two years.

Cross-stiched illustration by Demi Lahr.

Cross-stiched illustration by Demi Lahr.


The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) establishes four criteria for the diagnosis of premenstrual dysphoric disorder (PMDD). The first criterion provides a list of eleven symptoms, out of which a person has to have experienced at least five in the past year, including at least one of the first four. The symptoms are as follows:

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

Yes, yes, yes, yes, and yes. That book had me to a T. All this time I thought I was just moody with an uncommonly brutal period, but that was putting it lightly. In actuality, I was dealing with a severe, disabling, mental-physical depressive disorder far removed from the familiar premenstrual syndrome (PMS). Both PMS and PMDD are menstrual cycle-related mood disorders and share descriptors, but the difference lies in impact. It’s like pitting sadness against depression; it’s normal to be sad and go through mood and hormone fluctuations, and usually sadness doesn’t stop you from enjoying life—but depression very much does. Likewise, PMS can be annoying and cause minor mood shifts and increased irritability, but PMDD noticeably interferes with your life and can disrupt work and damage relationships.

That’s criterion #2. As the DSM-5 puts it, “the symptoms must be severe enough to interfere significantly with social, occupational, sexual, or scholastic functioning.” This can manifest in several different ways, from decreased sex drive to self-imposed isolation to decreased productivity.

Imagine waking up warmed by a ray of sunshine, the birds are chirping, your sheets smell clean under your face—and your heart is about to burst through your chest. Why? Who knows. Your night’s sleep was fulfilling, but your eyes and stomach hurt. You get up, try to adhere to your usual routine, but food doesn’t taste the same and you skip the shower because it doesn’t matter anyway. You yawn throughout the day and your body takes on an all-over ache, as if you’re getting a cold. There’s not much to say at work or school. You keep to yourself at lunch, maybe mindlessly scroll through the internet instead of engaging with your co-workers, your friends. You go home after getting almost nothing done, but home doesn’t offer much reprieve either. One nightcap turns into six, and you fall asleep before 9 p.m.

Now imagine these episodes of apathy mixed with anxiety and heavy, depressive feelings recurring day after day after day until one of those days, you wake up with the sun on your bed and—it’s over. You take a deep breath and your lungs fill from top to bottom for the first time in a week, you’re hungry and you eat, you get all that work done you’d been putting off, and you decide to go out after your long day instead of curling up on the couch. You think back to the previous week’s events and try to pinpoint exactly what happened, but nothing comes to mind.

Except the river of blood between your legs that started only yesterday, and suddenly everything makes sense.

Your symptoms and effects have to be directly related to the menstrual cycle and not another disorder in order for you to be diagnosed with PMDD (although PMDD is more common in women who’ve faced depression3). The DSM-5’s third criterion specifies that “symptoms must have been present for most of the time during the last week of the luteal phase [the week between ovulation and bleeding], must have begun to remit within a few days of the onset of menstrual flow, and must be absent in the week after menses.”

For us plebeians, this means you have to feel like death for the week before your period, a little better the first few days of bleeding, and fine and dandy after it’s all over.

Now, if you’re reading this and keep saying "yes" "also yes" "that's a yes," you probably have PMDD, but you’re only provisionally diagnosed. In order to get be official, your symptoms have to be tracked and recorded for two consecutive periods—criterion #4. But let’s face it, if you’re “yesing” all over the place, you’ve probably spent enough time with your body to know when there’s something significantly off with it.

Since we’ve skipped the doctor for an official diagnosis, who’s going to tell you how to deal with this newly-defined-but-terribly-familiar pit of despair you’ve landed yourself in? Me of course! And Leia Raphaelidis, a nurse practitioner of 14 years working at Planned Parenthood of the Southern Finger Lakes in Ithaca, NY. She recommends several different modes of treatment for women suffering with PMDD. Both western and more holistic remedies can be used either independently or in conjunction, depending on the severity of symptoms and the woman’s preferences. Acupuncture, vitamins, herbs, and prescribed exercise regimens can help ease symptoms, but if they’re too stubborn, pharmaceuticals can work wonders. “We've seen some pretty dramatic improvements with drugs such as Zoloft, given in low doses,” she says. “Contraceptives such as the birth control pill can help too.” (Personal voucher—BC pills worked wonders for my intense mood swings and moderately helped with body pains. After I went off the pill and got an IUD, my physical symptoms completely disappeared, although I find myself moodier than I was when I was on the pill.)

Unfortunately, there’s really no such thing as a “cure” for PMDD. Pills and herbs and exercise are all symptom management techniques, but there’s no fool-proof off switch. Some women may be lucky enough to outgrow PMDD, though. Raphaelidis says, “As women go through their reproductive years, menstrual patterns and associated symptoms can change.” The Lord giveth, and the Lord taketh away. Hopefully.

The best thing you can do for yourself is share any concerns you may have with your provider, and don’t freak out if it turns out you do have the disorder. When I received my diagnosis, I did just that. “Diagnosis.” “Disorder.” The words scared me, and as I was crying on the phone to a dear friend, she told me, “Don’t think of a diagnosis as a definition. Your disorder—any disorder—is just a made-up word people use to come up with ways to help you be happier and healthier. It has nothing to do with you.”

So yeah, your body can be terrible to you sometimes for no reason. But there are plenty of online resources you can turn to for more information (follow the hyperlinks in this article to get to my sources), and WebMD 4 has a decent overview of the disorder and coping methods as well. But every body is different, so do talk to your doctor! There is no one-size-fits-all when it comes to treatment.

Good luck, and you're not alone.