premenstrual dysphoric disorder

If you suffer from the debilitating symptoms of PMDD, also known as premenstrual dysphoric disorder, it may surprise you to learn that up until now, it has been at the margins—or, more accurately, in the appendix—of mainstream psychological thinking in the U.S. That’s because the formal guide to the diagnosis of mental illness, the DSM-IV, listed PMDD at the back of the book, in its appendix, where conditions that the psychiatric profession wasn’t sure about were listed. Now, PMDD appears to be poised to join other recognized illnesses and conditions in the main section of the upcoming new DSM-V.

If you’ve been diagnosed with PMDD, or wondered if you have PMDD, you might be a little disconcerted to learn that it is considered a mental illness – but for any condition to be treated by medical doctors with psychiatric medications like Prozac® or Sarafem® (Fluoxetine®) and other SSRIs, it has to be listed in the DSM and is then called a mental illness.

The downside of this, of course, is that there is a social stigma associated with the word “mental illness.” Many people don’t realize that by itself, it is just a label that doesn’t really mean anything, and that millions of people have depression and other “mental” illnesses that we now understand are physical ailments like any other – they just happen to affect the brain, instead of joints or kidneys or other structures.

One potential upside to PMDD’s promotion to the main section of the DSM-V, up from the appendix, is an increased recognition of premenstrual dysphoric disorder, with more attention to research and investigation on possible causes and cures likely to follow.

An interesting side note: with an increasing recognition of PMDD, there will be a tendency for general practitioners to make this diagnosis, even though gynecologists and psychiatrists are probably more familiar with the condition, its diagnostic criteria, and how to manage it. PMDD can’t be diagnosed in your typical 5-15 minute doctor’s visit.

Another evolving factor to keep an eye on: it is now recognized at the highest levels of research and medicine that SSRIs—selective serotonin reuptake inhibitors, like Prozac®, Sarafem® and Zoloft®—don’t work for depression through helping with serotonin levels in the brain. In fact, they don’t work any differently than placebo, a fact that is causing tremendous reverberations in the world of mental health.

This may not be true for PMDD: since it hasn’t been studied, we don’t know if SSRIs work differently in PMDD than they do in depression. But this is unlikely, since the use of Fluoxetine® for PMDD grew out of the similarities between depression and what used to be called late luteal phase disorder. So as the whole paradigm of serotonin deficiency begins to crumble, the treatment of PMDD may change too—perhaps just in time for the DSM-VI.

Antidepressants like Sarafem®, Prozac®, and Zoloft® are the most commonly prescribed medications for PMDD and PMS. In fact, if you’ve talked to a doctor or done a little internet research about PMDD and PMS, there’s a good chance you’re already familiar with the use of the selective serotonin reuptake inhibitor (SSRI) class of drugs for the treatment of PMDD and severe PMS.

We discussed previously how Sarafem® was brought to market for PMS only after the patent on Prozac was about to expire, and that before Sarafem®, PMDD was not a household word. And, of course, like all medications, antidepressant side effects are a real concern.

Recently an even more important question has come to the forefront, accentuated by the recent New York Times Magazine article by Siddhartha Mukherjee which discussed, among other things, the research of the Ph.D. psychologist Irving Kirsch, who conducted groundbreaking research showing that SSRI antidepressants do not work much better than placebo (sugar pill.) Kirsch also found that the drug companies and the FDA suppressed negative studies of SSRI antidepressants, and this resulted in a skewed and overly optimistic estimate of their effects. At this point, the the research on SSRIs adds up to one unavoidable conclusion: most of the prescriptions for Prozac®, Zoloft®, and similar drugs are of questionable utility, because these drugs don’t work significantly better than placebo for mild and moderate depression. SSRIs do work well for serious, major depression.

This brings us to the important question of whether SSRI antidepressants for PMDD and PMS are a good idea. Do they work? Are they better than placebo? How can we tell which woman really needs antidepressants for PMDD, and who doesn’t? Is the risk of side effects worth the risk of trying a medication that may be no better than sugar pill?

The answer to the first question is yes – antidepressants work for PMDD. The tricky part is that it is now a clear scientific fact that for mild and moderate depression, antidepressants aren’t superior to placebo, so it is unlikely that they are better than placebo for severe PMS and PMDD.  But the real crux of the issue is the third question: how does anyone know if antidepressants are the right choice?

There is no way to determine this answer based on blood tests or a doctor’s exam. This important decision must be based on the severity of the symptoms, as determined by both the prescribing health care practitioner, and the patient. Do the symptoms resemble those of major depressive disorder? Are they truly debilitating and oppressive so that they are major impediment to functioning in the world, living life, and fulfilling one’s role and responsibilities?

There are certainly cases of major depression that meet these criteria, and they often respond to the SSRI antidepressants. Similarly, we can expect that when PMDD symptoms are so severe that they might as well be major depressive disorder for days to weeks out of the month, SSRIs are appropriate.

However, as we referenced earlier, SSRI antidepressants have side effects, and many women prefer to avoid them. When PMS and even PMDD symptoms fall short of the kind of interference with living that major depression causes, there are a wealth of excellent alternatives that have few side effects; are effective, and more effective than placebo; and that in some cases have been shown to be as effective as antidepressants.

Women and doctors should consider diet and stress management, as well as other lifestyle factors, as effective PMS & PMDD therapies. Proven remedies like Vitex agnus-castus, or Chasteberry; calcium; magnesium; and vitamin B6 as first line natural PMDD treatments that can be used before, or even instead of, antidepressants. Other supplements and herbs such as B-complex vitamins; the herbs Dong Quai and Black Cohosh; and the problems of food allergy and hypoglycemia are all worth adding to the list of natural PMDD alternatives.

We keep talking about how PMS and PMDD are real, physical, genetic, biochemical, hormonal conditions, and not, as some would have you believe, simply “in your imagination” or a “neurosis.” We’re happy to report that the evidence—scientific evidence—keeps rolling in that the supports our position.

We have to keep revisiting this, and hammering the topic home, because sometimes it seems as if the only people who understand PMS (and this goes for PMDD too) are the women who suffer from it, and occasionally an understanding husband or partner who is truly supportive. All too often doctors, health care practitioners, family and friends seem to think PMS is an imaginary affliction that women dream up because…well, apparently, just because. But let's get real for a second: no woman would actually wish for a bloated, achey feeling several days out of the month; for difficulty concentrating and brain fog; for fatigue and mood swings; and all the other PMS symptoms that are no walk in the park, despite what the PMS doubters think.

Now, the good news: the “PMS is imaginary” school of thought took a major hit last year when research was published showing that among identical twins, there is a strong genetic component to premenstrual syndrome. When a strong genetic component is proven it suggests a biochemical or physical basis for a condition, rather than a purely psychological or emotional one. As always in the world of science, more studies are needed to confirm the findings, but this study of 176 sets of girl twins clearly showed that the tendency to PMS is an inherited trait.

The results of this study made us curious: has any other researcher looked into this question? Twin studies are among the most reliable studies for a wide variety of medical conditions and personality characteristics because they make it clear what is being affected by genetics, and what is a result of environment and psychology.

As it turns out, a 1993 study looked at this same question of PMS in twins and found that, lo and behold, there is a strong genetic influence on PMS. This study came from Australia; the one mentioned above came from Canada. We weren’t surprised by this: it seems the United States has a prejudice against PMS—many people don’t take it seriously, and assume that only PMDD, the most severe type of PMS, is “real.” There are studies showing this genetic component for PMDD as well: a 2007 study showed that a variation in an estrogen receptor gene is associated with PMDD.

Of course, these studies don’t mean that genetics is the one and only cause of PMS and PMDD: the genes involved could cause a woman to have higher than usual requirements for vitamin B6, calcium, or magnesium, or some other nutrient, or to be more susceptible to the effects of caffeine or stress.

If you’re a scientific type, here’s how to look up the two PMS studies themselves (you can go directly to pubmed or try google scholar):

 

October 2011, The heritability of premenstrual syndrome. Lead author: Jahanfar S, in the Journal Twin Research and Human Genetics

April 1993, The premenstrual syndrome: a twin study. Lead Author: Condon JT, in the British Journal of Psychiatry.

A study that was published about a year ago in the journal, Psychological Medicine, caught our eye recently. It compared black women, both African-American women and Afro-Caribbean women, to white women, including Hispanics, to determine if they experienced the same rates of PMDD (premenstrual dysphoric disorder.)

What the study found was somewhat surprising: black women were less than half as likely as white women to have PMDD, which is the most severe form of PMS. They were also 36% less likely to have any premenstrual symptoms at all, meaning they had over one-third less risk of PMS-type symptoms compared to Caucasians and Latinas. This health advantage for black African-American women had never before been shown in any research.

African-Americans Have Less Mental Illness

What is even more surprising, at least to those not familiar with the subject, is that this research is consistent with previous research showing that there is less depression in black African-Americans and less mental illness in black women than in Caucasians. Because the U.S.’s black population overall is subjected to economic hardship and discrimination to a greater degree than most whites, this result seems surprising. But the psychology of black women shows that there must be some factor—perhaps genetic—that is protective for African-American women against depression.

All of this is especially surprising in light of our recent post showing that minority women who perceive discrimination are more susceptible to PMDD. In some ways this is counterintuitive, but it may show the power of discrimination: minority women who appeared less susceptible to PMDD seem to become more susceptible when they perceived discrimination. This result also suggests that not all black African-American women feel they are subject to discrimination.

In my practice, I’ve found that women of color, whether African-American or Latina, are often less comfortable talking about depression-like symptoms such as PMDD because it is less acceptable in their culture, whereas physical symptoms of PMS and PMDD such as cramps and pain, and physical symptoms of depression such as fatigue, are easier to acknowledge and discuss.

Whether symptoms are physical, emotional, or both, the kind of holistic support program we use in our practice and at PMS Comfort addresses health at all levels: body, mind, and spirit.

There’s a very good chance that you’ve never met anyone who was diagnosed with PMDD—premenstrual dysphoric disorder—before 2001. That’s because PMDD was almost unheard of before August 2001, when Prozac (Fluoxetine) went off patent. The Eli Lilly drug company responded by rebranding (a fancy drug company word for renaming) their bestselling antidepressant as Sarafem. They then began promoting Sarafem, and the very concept of PMDD, to consumers, gynecologists, psychiatrists, and general practitioners. This is a common strategy in the pharmaceutical industry: when a drug is about to go off patent, it is repackaged into a different color and shape of pill, usually, and promoted for a related but previously underutilized purpose.

Some have accused Eli Lilly of “inventing” PMDD, which is certainly untrue: there are research papers on PMDD going back as far as 1987. Although this is the year the FDA approved the marketing and sales of Prozac, there’s no reason to think that that research was related to the release of the drug. Shortly after it hit the market, doctors from many disciplines were thrilled with the effectiveness of Fluoxetine, and were exploring its use for many conditions. It’s quite logical that it was tested for severe PMS, because previous generations of anxiolytics and antidepressants had been prescribed for PMS before that.

Still, if not for Eli Lilly’s interest in extending their Fluoxetine franchise, there can be little doubt that PMDD would not be anywhere as recognizable as it is today.

At PMS Comfort, we are all for greater recognition of PMS, especially severe PMS, and PMDD. However, a mistaken belief has taken hold across the medical universe, among researchers, doctors, and patients that PMDD and PMS are completely separate conditions. They’re not. The main difference between them is that PMDD received a very clear medical definition in the 4th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), while PMS received a weak definition in 2000 that has never been updated. Since medical doctors understandably embrace clear diagnostic criteria, and because there are now drugs approved for the treatment of PMDD, it has an imprint of legitimacy that PMS does not seem to have.

But you only need to just scratch the surface to see that there is major overlap between their possible symptoms, and to realize that both PMDD and moderate to severe PMS, by definition, interfere with life and living. This is a source of confusion: while mild PMS is a mere annoyance, moderate to severe PMS interferes with women’s lives to a similar degree as PMDD. In fact, they're really not separate conditions. We wish more medical professionals were aware of this fact, because it might help women understand it also.

We are at the forefront of those trying to get PMS and PMDD the recognition, understanding, and compassion they deserve: unfortunately, too much of the wrong kind of attention gets focused on them. And we are pleased that more and more women are realizing that drugs aren’t the only answer for premenstrual symptoms. Natural and holistic treatments are safe, effective, and were never patented in the first place.

Bayer Pharmaceuticals is famous for many reasons: they’re one of the leading chemical and drug companies in the world; they have been leaders in bringing aspirin to the world not just for aches and pains but for heart attacks and even colon cancer; and lately, and less favorably, they’re under fire for some problems that allegedly resulted in young women who took one of their popular birth control brands, Yaz and Yasmin.

So our ears pricked up when we saw a research article on PMDD, also known as premenstrual dysphoric disorder, was written by Bayer scientists in Brazil. The paper is an attempt to estimate the number of women who suffer from severe PMS and PMDD in Latin America. While it’s a worthwhile subject, when a drug company goes about creating increased awareness of a medical condition for which their medication is very likely to be prescribed, we can’t help but think that such research contains some profit motive.

You see, drospirenone-containing birth control has been studied quite a bit for use in PMDD and severe PMS, with many of these studies indicating these drugs should be a first-line treatment. In fact, such medications are considered part of the standard of care for these conditions. Recently, though, the British Medical Journal has published studies showing that drospirenone is associated with roughly four times the risk of blood clots compared to an older drug that drospirenone is meant to replace.

It’s not unusual for drug companies to publish research from which they’ll benefit, though we might wish they would publish their negative results just as readily. It’s also not unusual for doctors to have to balance risks and benefits when making the decision to prescribe medication. Unfortunately, many doctors are unaware of the significant risks allegedly associated with Yaz and Yasmin.

We look forward to the day when there is money available to adequately research natural therapies for PMS and PMDD such as a natural diet, supportive lifestyle, and hormone-balancing herbs and nutrients.

Life is stressful, and PMS and PMDD make life more stressful. And as I wrote in my first blog post here, life stresses cause PMS. Well, PMDD, or Premenstrual Dysphoric Disorder—the most severe form of PMS—is just as tied into stress, and researchers have proven it. Increase your stress, and you increase your chances of having PMDD, which is a lot like having PMS depression: you sleep too much or too little, you’re tense and on edge, you feel sad and lose interest in things you usually like, plus women with PMDD can get all the same symptoms like bloating and cramps that are usually associated with PMS.

Not everyone is equally likely to develop PMS, though, and there are many factors that determine who will get it. We know there’s an inherited genetic tendency to PMDD, plus there’s also the stress component, and there’s definitely a hormonal and a brain chemistry aspect (we know this because PMDD has been treated with birth control hormones and antidepressants.) To that list, we can now officially add another likely culprit: discrimination.

That’s right—when minority women feel discrimination on the basis of gender, race, weight, or other factors, they’re more likely to have PMDD. Just to be clear, this doesn’t mean that these women felt discriminated against and then went home and felt bad about it. It means that when they felt this kind of prejudice directed towards them, weeks later it threw off their hormones, their brain chemistry, and their whole lives!

These findings were published in a paper in the Journal of Women’s Health from June of this year. Over 2700 Latina, Black, and Asian women reported their experiences and 83% reported experiencing discrimination during their lifetime. Interestingly, PMDD was connected more to subtle prejudice than to overt bias, which makes some sense: overt discrimination is mostly frowned upon in the culture, plus you know when it’s there. It’s the sneaky underhanded stuff that creates more stress. It's akin to the difference between an out-and-out argument with a friend that blows over rapidly like a violent thunderstorm, versus a simmering feud that boils below the surface and goes on and on.

Corey J. Pilver, the lead author on this scientific paper, is a researcher with the Connecticut Veteran’s Administration, and wrote the paper as part of her doctoral dissertation at Yale University.

One final note: minority women aren’t the only ones subject to gender discrimination: all women experience it. We’d love to see a study that looks at women of all ethnicities who feel gender discrimination to see if they experience more PMS/PMDD. There’s every reason to think that this form of bias causes stress for all women—and we know what stress can do.

PMS, PMDD, & Your Emotions
by Dr. Daniel J. Heller August 24, 2011
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Your sister calls to ask if she can borrow that sweater that looks so good on her: you know, the one you save for special occasions? The one you had to take to the cleaners after the last time she borrowed it?  Well, it’s hard to say “no” to your older sister, and besides, hasn’t she fed your cat when you went away for the weekend, taken you to the doctor for that test, not to mention had your back on numerous occasions?

So, you let her borrow the sweater, but then all those old resentments get stirred up, that have nothing to do with the sweater, and by the time she brings it back, this time in perfectly good condition, you feel bent out of shape, and she doesn’t understand why, and neither do you—it doesn’t seem rational.

Here’s a possible explanation, and it’s not some Dr. Phil recommendation to be more assertive or to communicate your feelings. It’s simpler than that. Maybe all really need to do is actually feel your feelings.

This might seem like a strange recommendation: you might think, don’t I already feel my feelings? And, perhaps you'd rather not feel them, when they are feel confused and overwhelming.

Here’s why: when those resentments for events from last year, or ten years ago, start to pop up, it’s painful. It hurts to feel that you were treated unfairly, or that you didn’t get the recognition you deserve, or simply to remember a time when your feelings were hurt. And so, if you’re like most of us, when those feelings and memories get stirred up, you avoid feeling them (which makes sense—they’re painful!)

Instead, you might end up thinking about who is to blame for causing those feelings; about how you can orchestrate events differently in the future so that those painful feelings don’t recur; or about an explanation for why you feel that way, which is often a story that leads into blame and resentment anyway.

You might be asking, what does this have to do with PMS and PMDD? How is this going to help cramps or bloating or mood swings or irritability?  What do emotions have to do with hormones?  Those are all very good questions. The connection between hormones and emotions, and between PMS and your feelings, can be summed up in once word: Stress. When you bottle up your feelings, or try to suppress them, they end up coming out in some other way anyway, plus they increase your stress level. And, as the blog post above makes clear, stress makes PMS worse.

Most of the time, the anticipation of painful feelings is much worse than the feelings themselves. But when you directly feel what is really going on in your own heart: sadness, anger, joy, or fear—sometimes referred to as “mad, sad, glad, or scared”—you may then find it easier to assert yourself, or to express your feelings if you need to do so, or to hold them back if you don’t. It can even make it easier to apportion blame if that is necessary, or to avoid unfairly blaming someone who didn’t know any better.

Once you really feel your own feelings—the mad, sad, glad, or scared ones—you may also find yourself feeling more compassion and sympathy for others and their feelings, plus you’ll be a lot more clear about what is happening inside of you. For your overall emotional health, and to release the stress valve that builds up with PMS, feeling your feelings is a good place to start.