Premenstrual dysphoric disorder makes some women a bit crazy every month

By Anne Miller
Special to The Washington Post
Tuesday, June 22, 2010

Every month I battle a monster. I gird myself with a healthful diet and a couple of pills, but the personality switch comes, like a lamp switched on, three weeks into my menstrual cycle. If most women get a little bloated, a little cranky, maybe a little confused, I swell an entire dress size and try to ban my husband from any room I'm in. Deciding what to eat for dinner so overwhelms me that I've broken down crying in the frozen food aisle.

Two years ago I was given a diagnosis of premenstrual dysphoric disorder, or PMDD. It is, as it might sound, like premenstrual syndrome, or PMS, on steroids. To diagnose PMDD, doctors look for signs that mental and physical changes tied to a woman's monthly cycle affect her ability to lead a normal life. Those of us who have it liken it to an out-of-body experience: We go kind of crazy, even while part of us knows that the behavior isn't right.

No one knows exactly what causes PMDD or why it strikes some women and not others. Medical experts estimate that between 3 and 6 percent of women in their child-bearing years suffer from it.

JoAnn V. Pinkerton, a professor of obstetrics and gynecology at the University of Virginia, said some women's bodies and brain chemicals react harshly to normal hormone cycles. "Most women feel like it's something they should be able to control or handle, even though it is truly a medical illness," Pinkerton said.

PMDD is a new name for a condition women have complained about for years. My mother suffered symptoms similar to mine. Sometimes such complaints were dismissed as belittling to women. After two British women -- one who killed her lover and another who wielded a knife in a police station -- used severe PMS as a defense in separate trials in 1981, the prosecution decried it as a setback to the women's movement. When a New York woman used the same defense in 1982 after being accused of beating her child, a Columbia University professor curtly commented: "Do we now say that the full moon causes crime and that the actor is not criminally responsible?"

PMDD became an accepted diagnosis in the early 1990s, when the Diagnostic and Statistical Manual of Mental Disorders, a widely used reference work published by the American Psychiatric Association, included it as a "depressive disorder not otherwise specified." Today, most doctors have heard of it, though many PMDD sufferers say they have been misdiagnosed at some point.

It's not always easy to catch. Even experienced doctors may not realize that a patient's depression or anxiety comes at a certain time every month, partly because she may not have noticed it, either. "If they don't say, 'This is affecting my family or my ability to work,' then the doctor isn't going to know this is a problem," said Pinkerton.

Doctors make their diagnosis of PMDD by asking patients to chart how they feel each day for at least two months. If it's PMDD, the chart will show several symptoms in the 10 days to two weeks before menstruation, and those symptoms will be severe enough to affect the patient's ability to work, socialize or care for her family. That means that some women struggle to function nearly half of the time through their childbearing years.

I started feeling symptoms in my mid-20s -- I'm 33 now -- and they have steadily worsened. Although I had talked about my symptoms with doctors, they had brushed them off or suggested that I get more sleep or exercise, without considering the bigger picture. It was only after I did the research myself, made my own two-month chart and presented it to my doctor that I got a PMDD diagnosis. I'm usually outgoing, but PMDD makes me drastically antisocial with a side of severe cravings. I'll avoid walking the dog in the evening so that I don't run into neighbors, and some days I feel as if I need (not just could -- need) to eat every chocolate muffin in every Au Bon Pain on the Eastern Seaboard.

Stephanie Auteri, a writer and editor in New Jersey, doesn't think of herself as a violent person, and she's pretty happily married. Most of the time. "I would get into these huge, huge arguments with my husband over nothing, and it would get completely out of control," she said. "I'd know as it was happening that I was acting like a crazy person." Sometimes she would demand a divorce and threaten to leave. She also hurt herself once by smacking her face against a door.

Auteri, who is 29, eventually found some help for her symptoms by taking the oral contraceptive Yaz, which can help regulate hormones and has been approved by the Food and Drug Administration as a PMDD treatment for some women.

When Auteri went off the pill recently in an effort to become pregnant, she found some of her crazy feelings returning, but she's hoping to be able to keep them in check.

Treatment options

Because body chemistry is such a variable balance, there's no cure for PMDD, only an inexact science of trying to lessen symptoms. Once it is diagnosed, doctors often suggest as a first step that women watch their diet, especially sugar, salt, alcohol and caffeine, which can affect bloating and weight gain and possibly mood. Increasing their intake of calcium and Vitamin B12 and engaging in yoga or regular aerobic exercise might also help, although much of the reported benefits of food, vitamins and exercise are more anecdotal than scientifically proven.

"Some people can find that their symptoms are better [with such steps], and that's better enough," said Nancy Gaba, an associate professor of obstetrics and gynecology at the George Washington University School of Medicine and Health Sciences. Others respond well to acupuncture or birth control pills, or small doses of the antidepressant fluoxetine, commonly known as Prozac but marketed for PMDD as Sarafem. Dosages are daily for some women; others use it only during the 10 premenstrual days, when they take it every day or every other day.

"It may not go away completely," Gaba said. "It may not go from 100 percent bad to 100 percent good. If you have a more realistic expectation, you're much more likely to say you succeeded."

Seeing a Sarafem commercial helped Stefanie Prose, 36, realize that what she had suffered with every month since her teen years actually had a name -- and possibly a treatment. Today, the stay-at-home mother of four blogs about PMDD and runs an online forum for PMDD sufferers.

As an adult, Prose asked her doctor for Sarafem, and it clearly helped her. Yet, she said, her doctor didn't note a formal PMDD diagnosis on her file for some reason. Prose, who lives in Texas, began doing her own research into PMDD; eventually that led to her blog. She says women who post to her blog often worry about the impact of their PMDD moods on their children.

"I hear [from] a lot of women [about] throwing stuff and screaming bloody murder. It's sad, and it just breaks your heart," she said. She recognizes the situation: Prose herself screamed at her husband and kids. She cried and would forget simple things -- she was "foggy-headed," she said. She also suffered from heavy menstrual bleeding. She controlled her diet, exercised and took medication, "but in the end, that wasn't enough -- to have half my life, two weeks every month, when I couldn't go to [her kids'] soccer games." Her solution was extreme, and not one doctors usually recommend: Earlier this year, she had a hysterectomy.

"I would agree with any doctor who said it's definitely a last resort," she said. But Prose was done having children, and that made her drastic option easier to choose. Because of the heavy bleeding and her lengthy struggles with PMDD, her doctor agreed with the decision to do surgery and her health insurance covered it.

While some women with PMDD work from home for a few days during the worst part of the month or call in sick, most of the women I spoke with manage, like me, to function fine at work. It's our personal lives that suffer.

I've learned to conserve my resources. For the majority of the month, I typically get up around 7 a.m., make coffee, walk the dog for an hour, work, make dinner, run or do yoga, and sometimes meet friends for a drink. On my worst PMDD days, I sleep as late as possible. My husband has dog and dinner duties. I force myself to walk around the block, which feels like a marathon but wakes me up and helps me concentrate. I don't go out. Through diet, exercise and a week's worth of fluoxetine, I've shrunk my bad 10 days to about two. It's not perfect, but it feels pretty close to victory to me.

Miller is a freelance writer and news producer in New York.

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