Imagine you experienced severe symptoms of mental illness. You were extremely anxious or even suicidal. If you went to a doctor, they might send you to a psychiatrist who could prescribe medication to treat your condition. You might encounter some societal stigma, but on the whole this stigma is falling in many countries, and there are robust treatments in place that are likely to help you.
However, suppose those symptoms only appeared every so often—say, for a few days every month. Your risk of suicide would still be far higher than average, not to mention the overall decrease in your quality of life due to those few days of distress (which add up to eight straight years of symptoms throughout your life). But taking medication throughout the whole month wouldn’t make much sense—especially if your condition was due to a hormonal state only relevant for a few days. So how could this condition be addressed?
Commonly considered a more severe form of premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD) is a sometimes-disabling condition affecting 3-8% of menstruating people. This is a subset of the 90% of menstruating people who experience PMS. People with PMDD can be extremely distressed for approximately a week per month. This may disrupt their relationships and even their work productivity, as their dependability may lessen during this time.
A person with severe depression might experience relationship and workplace disruptions as they cannot keep pace with their obligations or even get out of bed, but with treatment many people with depression are able to reach stability in these areas of their lives. For people with PMDD, these symptoms will strike for a week and then vanish, making them appear unpredictable and even unbelievable. If you are fine three-quarters of the time, your distress the remaining quarter of the time can appear faked.
Symptoms of PMDD are not restricted to emotional health; they include physical symptoms ranging across the gastrointestinal, neurological, and cardiovascular systems. PMDD can cause migraines, acne, numbness, insomnia, or dozens of other disruptive symptoms almost anywhere else in the body.
Nevertheless, the stigma surrounding the condition makes it incredibly hard to speak up about it or ask for help. People with uteruses are regularly, and mercilessly, mocked for “moodiness” attributed to their period; they are regularly discredited and dismissed, their opinions, objections, and feelings attributed to their periods instead of their minds. When facing this stigma, how could someone go to their doctor and say “I feel very depressed before my period”? They may have been ridiculed for years for their emotions (and for menstruating in general), so they would not necessarily know that it is an actual medical issue. While stigma around physical symptoms of menstruation is falling (albeit slowly), the mental health aspects of menstruation are hardly ever taken seriously.
It is very difficult to diagnose PMDD. The diagnostic criteria are vague, requiring an arbitrary five out of eleven indefinite symptoms (like “edginess”) present for over a year. Treatments are also arbitrary and vague. Other than suppressing the menstrual cycle altogether, frontline therapies include “education about the disorder,” dietary modifications, and meditation.
While these are often helpful, it is crucial to note that they are often helpful in addressing nearly every medical condition known to humankind; they are not targeted therapies, and are not the result of targeted research. If these treatments fail, further courses of action include prescription pharmacologics, such as SSRIs or BZDs.
Why has PMDD not received as much attention as other mood disorders affecting similar numbers of people to similar degrees? Until 2013, PMDD only appeared in the DSM (the American Diagnostic Manual of Mental Disorders) as an entry in the appendix labeled “needs further study.” This impeded American patients’ ability to use federal rights such as medical leave or accessibility accommodations, as many of these rights depend on legal classification of disorders.
For example, if a person with PMDD asked to work from home for a few days each month, or leave the workplace early, to accommodate their symptoms, an employer would have been easily able to refuse as this would not necessarily have been seen as a reasonable accommodation for an established medical condition.
Legitimizing PMDD it almost seems to give credence to the misogynistic ideas about period moodiness, or older ideas about female “hysteria.” This makes it difficult for researchers to justify their study of the disorder. These misogynistic ideas also suggest that PMDD is not a real disorder, but simply sensitive women who complain too much—making it hard to receive funding for research. However, without taking PMDD seriously, we are neglecting a significant area of women’s health. Mental health symptoms can be disruptive and life-threatening. When we leave them out of research into menstrual symptoms, we abandon millions of people worldwide.