If you’re someone who menstruates or know others who do, you’re probably no stranger to what is popularly known as PMS or Premenstrual Syndrome. But, are you familiar with its bigger, badder cousin, known as Premenstrual dysphoric disorder or PMDD? Estimates suggest that anywhere between 3–8% of women of reproductive age suffer from PMDD and yet awareness remains very low.  In this blog, we focus on breaking down PMDD, symptoms and potential lines of treatment.
Premenstrual dysphoric disorder (PMDD) is a significant health issue that involves a “set of negative physiological and emotional changes of sufficient severity to cause functional impairment in the late luteal phase of the menstrual cycle (approximately Day 21- Day 28)”  It is considered to be a more serious form of Premenstrual syndrome.
With PMS, it is common to feel bloated, have headaches and experience breast tenderness a week or two prior to your period starting.  With PMDD, you could experience all the PMS symptoms, and also have to face significant mental health consequences including anxiety, depression, extreme irritability, anger issues, appetite changes and sleep problems. While PMDD symptoms may subside a few days into your period, they can be debilitating enough to interfere with the normal functioning of your life. PMDD poses a significant disruption to work, school, social life, and relationships, which PMS mostly doesn’t. Unfortunately, most women don’t seek medical assistance for PMDD until much later in their life.
The diagnosis of PMDD can be complicated and more often than not, is done incorrectly. Per DSM IV (a diagnostic standard for PMDD), a person must meet four criteria in order to qualify for a successful diagnosis. These include
Additionally, while diagnosing PMDD, it is important to rule out any other chronic medical conditions that could be responsible for the symptoms. Your doctor will likely conduct a few emotional and physical tests and also take your detailed medical history into account. You may also need to keep a journal or use an app to track your symptoms for a few cycles before diagnosis is made. A detailed breakdown of DSM IV criterion can be found in the image below. It must however be noted that DSM-IV diagnostic criteria comes with its own share of controversies with many people disregarding its relevance.
PREMENSTRUAL SYNDROME AND PREMENSTRUAL DYSPHORIC DISORDER Wilhelm H. Cronje, MBChB, and John W. W. Studd, MD, DSc, FRCOG
This is a great question but the exact pathology of PMDD is not yet known. Several biological theories have been put forth so far, including those about reproductive hormones and serotonin. Lowered levels of estrogen and progesterone hormones post ovulation and pre-menstruation could play a role. Alternatively, serotonin, the brain chemical responsible for mood, sleep and hunger could also be to blame. The involvement of genetics is another theory that has been suggested. Recently, Dr. Schmidt, a NIH researcher, published data that support the possibility that it is the changes in hormone levels (the ratio), not just the hormones, that set the symptoms of PMDD in motion. 
Per Harvard Health, if you believe that you have PMDD, there are a few things you can do to get started. First things first, you should begin tracking your symptoms for at least 3 cycles to ensure that it is a persistent occurrence. Second, try to educate yourself to become your own health advocate as this condition isn’t that well understood even among the medical community. Find support groups and peer networks who are going through the same thing or at the very least, understand your feelings. It is also important to get in touch with a doctor to evaluate your diagnosis and treatment options. Do not brush your symptoms under the carpet, thinking that this is a “normal” part of the menstrual cycle and you just have to live with it.
Similar to that for PMS, Lifestyle changes (spanning dietary modifications, physical fitness, supplementation, and stress management)—are usually the first line treatment options for PMDD as well. Since PMDD can have a particularly debilitating impact on your mental health, it is crucial that you spend time meditating, de-stressing and building better mental health environments. Spending time in nature, getting adequate sunlight and fixing sleep patterns can be good victories in this situation.
We also have to stress the importance of exercising for managing both PMS and PMDD as movement not only has a positive impact on physical health but has also been shown to improve mood and relieve anxiety or depression. The intensity of exercise is secondary to frequency. In other words, don’t worry about spending 3 hours in the gym each day. Gradually build up the duration, while letting consistency improve symptoms. 
Lastly, when dealing with nutrition, it is best to switch up processed and refined carbs in favour of complex, whole grains, proteins and healthy fats. This can help curb cravings and mood swings. Additionally, being mindful of your sodium intake (especially through packaged food) can help reduce bloating and tenderness. It is also prudent to discuss supplementation with vitamin B6, calcium, vitamin E and magnesium with your doctor. Vitamin B6, for instance, is believed to increase the synthesis of neurotransmitters such as serotonin and dopamine. Women who decide to take vitamin B6 have been recommended to limit their daily dosage to 100 mg. 
With respect to pharmacological treatment for PMDD, a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Sarafem) and sertraline (Zoloft) might be recommended. Please consult your doctor before starting any medications as they may have related side-effects.