Content Warning: This article contains references to suicide. 

Food cravings, bouts of sadness and irritability, mood swings… about 90% of women experience premenstrual syndrome, or PMS, leading up to their period, but for a smaller subset of women, the symptoms during this time are much more severe.

Known as premenstrual dysphoric disorder (PMDD), this mood disorder is known to affect 8% of people during the luteal phase (the stage right before the start of menstruation). While its symptoms on paper closely mirror those of PMS, PMDD symptoms tend to be more extreme, causing major life disturbances and even suicidality. 

In 2023, TikTok influencer Dixie D'Amelio shared with the world that she suffers from PMDD: “People are going to be like, ‘Oh my God everybody gets that,’ Like no. I didn’t know that you weren’t supposed to want to die every month before you got your period. It’s not supposed to affect every single aspect in your life from sleep to anxiety.” 

D’Amelio’s right: A period should not be taking an extreme mental and emotional toll like that.

First, it’s important to even recognize that you may be experiencing PMDD, versus regular PMS.  Are there specific risk factors for this unique mood disorder? How can you be evaluated for PMDD? And how can you manage the symptoms? 

What is PMDD?

Because both PMS and PMDD typically occur the week before menstruation, those who suffer from PMDD are usually dismissed as having PMS. But PMDD’s symptoms are much more debilitating and fall on the severe end of the spectrum.

PMDD symptoms may include:

• Mood swings, depression, anxiety, and/or irritability

• Decreased interest in activities you usually enjoy – also known as anhedonia

• Difficulty concentrating

• Changes in appetite and/or sleep

• Fatigue

• Feeling out of control or overwhelmed

• Physical symptoms, such as bloating, joint pain, or tenderness in breasts

• Suicidality (though not considered part of the diagnostic criteria, many patients with diagnosed PMDD report suicidal ideation) 

When menstruation begins, symptoms of PMDD typically resolve. The whiplash after experiencing such intense symptoms for one week, followed by three weeks of relative normality, tends to be a very disruptive and exhausting experience. 

While PMDD may cause physical symptoms such as bloating or breast pain, it does not impact pain related to menstrual bleeding, which may include severe cramping, clotting, or heavy flow. These symptoms may be indicative of a physical health issue and should be addressed with a gynecologist or primary care provider immediately.

There is no singular reason people experience PMDD, though research has found that risk factors include:

• Trauma: Traumatic events like childhood abuse and life-threatening experiences have an increased risk for PMDD though the underlying reason as to why is unknown.

• Cigarette smoking: A 2008 study showed that cigarette smokers were 2.1 times as likely as non-smokers to develop PMS. Smoking, especially in adolescence and young adulthood, may increase risk of PMDD.

• Genetic mutations: Mutations on certain genes responsible for serotonin receptors have been shown to double the risk for developing PMDD.

How to Get a Diagnosis for PMDD

There is no official test or evaluation to diagnose PMDD, which is why it’s important to work with a gynecologist and a therapist who are familiar with PMDD. A proper diagnosis requires several months of observation with a detailed record of symptoms and when they occur. 

Misdiagnosis is common because of the overlap of symptoms that occur in other mental health disorders. Because of the similarities in symptoms, looking at the frequency and onset of symptoms is crucial for proper diagnosis. 

For example, a client may experience severe depression, but only when they are leading up to their period. If this is the only time these symptoms occur and they cause significant dysfunction, that may be an indication of PMDD. 

Detailing the frequency, timing, and duration of symptoms can also help rule out other conditions like bipolar disorder which is also a cyclical disorder and is a common misdiagnosis for people with PMDD. 

Research shows that it takes an average of 20 years for someone with PMDD to receive an accurate diagnosis and appropriate treatment. This is especially alarming because people with PMDD are 4x more likely to experience thoughts of suicide. Getting an accurate diagnosis is critical with a condition like PMDD.

Barriers to Care with PMDD 

PMDD has been a historically under diagnosed condition — partly because researchers, physicians, and psychologists have disagreed on its categorization as a mental illness.

In the last decade, there’s been more recognition of PMDD though it wasn’t even added as a medical health classification until 2022. Because of this, providers may not be familiar with or even acknowledge the existence of PMDD. This creates major barriers in receiving proper treatment, especially when providers dismiss or medically gaslight patients. 

Regardless of whether PMDD is classified as a mental health disorder or a physical condition, the impact it has on the people who experience it is real. 

In addition to being underdiagnosed, PMDD has been studied mostly among white women and only few studies have examined its presence in women of color. 

How to Manage PMDD Symptoms

Symptoms of PMDD usually last until menopause, which means treatment will likely continue until then as well. There can be relief in lifestyle changes like increasing physical activity and finding activities to distract yourself. However, most people with PMDD require specific expertise to manage their symptoms:

Establish Menstrual-Affirming Medical Care 

Working with a gynecologist and primary care provider who are well-versed and affirm menstrual health disorders is a crucial part of treatment, as they may be able to prescribe antidepressants, birth control, hormone therapy, or other medications to help manage symptoms. Nutritionists can provide further support by providing guidance about food and movement that may also reduce the severity of symptoms. 

Find a Therapist who Specializes in Women’s Issues 

A therapist is another valuable member to add to your medical team, especially one who specializes in mood disorders and/or women’s health. When searching for a provider, check their bios or ask questions about whether or not they work with clients with PMDD. 

A therapist may assist clients in practicing acceptance of their diagnosis and symptoms, can help create a monthly care plan that is easily accessible, and can help identify and modulate changes in thoughts, moods, and behaviors that occur when PMDD occurs. Therapy modalities such as Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Solutions Focused Therapy have been found to be effective in helping clients manage symptoms.

If you believe you or a loved one suffers from PMDD, Octave has hundreds of therapists trained to support you and your unique needs.

Build a Support System

In addition to medical support, increasing your personal support system may help reduce the interpersonal and professional issues that may occur due to PMDD. In a 2022 study of women with PMDD:

• 98% of women with PMDD felt it put a significant strain on their intimate partner relationship;

• 56% reported having lost an intimate partner relationship due to PMDD; and

• 16% reported having lost a job due to PMDD.

By having friends and family understand what’s going on, they’ll be able to support you while also coping with how the PMDD symptoms affect them. Telling a supervisor, or human resource representative, can also open up opportunities for accommodations, such as utilizing Family and Medical Leave Act benefits or other resources and support. Engaging in a support group, online or in person, can also help build a validating and supportive community.

Resources for PMDD

The International Association for Premenstrual Disorders

The International Association for Premenstrual Disorders is a lifeline of support, information, and resources for women and (assigned female at birth) AFAB individuals with Premenstrual Dysphoric Disorder (PMDD) and Premenstrual Exacerbation (PME).

Suicide & Crisis Lifeline

The Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals. 

Call 988

Crisis Text Line

Text from anywhere in the USA to text with a trained Crisis Counselor.  Every texter is connected with a Crisis Counselor, a real-life human being trained to bring texters from a hot moment to a cool calm through active listening and collaborative problem solving. 

Text TALK to 741741 to text with a trained crisis counselor.

Full List of Suicide Prevention Resources provided by American Foundation for Suicide Prevention