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by Dr. Daniel J. Heller
As discussed in part one of our PMDD article, premenstrual dysphoric disorder is a severe form of premenstrual syndrome (PMS.) Because PMDD has such severe emotional and cognitive symptoms, it is classified in the DSM-IV, the medical manual of psychological disorders. In contrast, the very similar syndrome of PMS is usually defined using criteria determined by the American College of Obstetricians and Gynecologists. Despite their symptoms being nearly indistinguishable, PMDD is considered a psychiatric diagnosis because it has so much overlap with clinical depression (though, unlike PMDD, depression does not wax and wane with the menstrual cycle).
It is easy enough to understand the terms "premenstrual" and "syndrome" and "disorder," but the word dysphoric may need a little more explanation. Perhaps the simplest explanation of the term dysphoria is that it is a medical or psychological name for a really bad, depressed mood. Just as euphoria is an extremely happy mood, dysphoria is an excessively "down" mood. However, a single premenstrual depressed mood would never be called an instance of dysphoria. What distinguishes PMDD, and dysphoria, is their persistence. Part one of our PMDD article explains that for a formal diagnosis of premenstrual dysphoric disorder to be made, the symptoms must have been present for most of the cycles of the previous 12 months, meaning the dysphoria of PMDD is highly persistent.
So, persistence and severity are the defining qualities of PMDD. In the real world, however, practitioners generally rely to some degree on their own judgment, and on expediency, to determine if symptoms qualify as PMDD. So in practice, the distinction between PMS and PMDD can be rather blurry. Since there are approved drug treatments for PMDD, premenstrual symptoms are often mislabeled as PMDD, when in fact premenstrual syndrome—which in many cases differs in only a small degree of severity, and which can have just as many emotional and psychological symptoms—can cause just as much suffering.
The short answer to this question, according to medical and biological research, is that no one knows with 100% certainty what causes PMDD. Because of its cyclical nature, however, most investigations have looked into a connection with the sex steroids estrogen, progesterone, and their upstream hormones FSH and LH. A second theory has examined serotonin pathways in the brain. Other hormonal causes have been proposed, including effects of testosterone, cortisol, and prolactin. There is also some evidence that the tendency to PMDD is genetically inherited.
With regard to serotonin and sex hormones, these theories derive from the success of pharmacological treatments. Oral contraceptives, which shut down a woman's intricate natural hormonal balance, are nevertheless often successful in removing (some would say "covering up") the symptoms of PMDD (and PMS.)
Of course, birth control pills have a notorious reputation for side effects, and many women prefer not to subject their bodies to this type of treatment. The serotonin theory derives from the success of SSRIs and other serotonergic compounds in treating PMDD and luteal-phase depression and accounts for why PMDD is considered a psychiatric more than a gynecological condition. Of course, SSRIs also have a range of problematic side effects, making them an unsuitable treatment for many concerned women.
Other factors impact the development of PMDD: sociocultural influences, life stress, cigarette smoking, and even a history of sexual abuse. This is why we believe a complete, whole-woman approach to health and to the problems of PMDD and PMS is ideal. Natural treatments, both nutritional and herbal supplements, and lifestyle changes, have long been used in the treatment of PMDD and PMS, either as measures supplementing conventional therapy or on their own. You can learn more about our natural program that can help relieve your PMS and PMDD symptoms.