Bipolar disorder is characterized by mood swings, with depression being the most common. Premenstrual dysphoric disorder (PMDD) is also characterized by mood swings, with depression being most prominent. One has a discernable pattern and the other is largely unpredictable. Sometimes they occur together. Having more than one mental illness is extremely common, but distinguishing whether bipolar disorder and PMDD coexist can be difficult. They also have conflicting treatment guidelines.
Premenstrual dysphoric disorder is different than PMS (premenstrual syndrome). PMS is very common, with up to 80% of people who menstruate experiencing mild to moderate symptoms like cramping, bloating, fatigue, irritability and depression. This happens from 1-2 weeks before menstruation and usually subsides in the first few days of menses. It’s unpleasant for certain, but doesn’t have a major impact on your daily life.
PMDD, on the other hand, is severe, affecting 3-8% of people of who menstruate. They experience the same types of physical symptoms, but the psychological symptoms mimic major depressive disorder. Symptoms are severe enough that they interfere with social and occupational functioning. These symptoms must be documented for at least two months by a medical professional. According to the DSM-V, a person must have five of the following 11 symptoms in most cycles of the previous year:
- Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
- Marked anxiety, tension, feelings of being “keyed up” or “on edge”
- Marked affective lability (eg, feeling suddenly sad or tearful or experiencing increased sensitivity to rejection)
- Persistent and marked anger or irritability or increased interpersonal conflicts
- Decreased interest in usual activities (eg, work, school, friends, and hobbies)
- Subjective sense of difficulty in concentrating
- Lethargy, easy fatigability, or marked lack of energy
- Marked change in appetite, overeating, or specific food cravings
- Hypersomnia or insomnia
- A subjective sense of being overwhelmed or out of control
- Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain
Another qualification for PMDD is that symptoms must exist on their own and not just as exacerbated symptoms of another psychological illness. About 40% of people seeking treatment for PMDD actually have an underlying mood disorder.
In the case of bipolar disorder there is evidence that hormone levels influence moods. Some 60-70% of people who menstruate report worsening bipolar disorder symptoms, mostly depression, around their periods. So, it’s up to physicians and psychologists to determine whether the symptoms are related to bipolar disorder or if the patient needs a separate diagnosis.
If a comorbid diagnosis is reached, the course of treatment has to be considered. There are several non-medical treatments recommended for both disorders including therapy, mood tracking and lifestyle changes. However, most people will require pharmacological treatments. The problem is that the treatments for these two disorders can conflict with one another.
One treatment for PMDD is oral contraceptives, especially those containing the hormone drospirenone. Some birth control users reported reduced symptoms of PMDD, especially when taken continuously, without the typical week of placebo pills each month. The problem with this treatment method is that mood stabilizers used to treat bipolar disorder do not mix well with birth control pills. On the one hand, mood stabilizers are thought to reduce the efficacy of birth control pills. On the other, birth control pills can decrease the effectiveness of mood stabilizers.
Other medications used to treat PMDD are anti-depressants. This makes sense since the dominant symptoms of PMDD are also symptoms of depression. Again, there is a contraindication for this treatment when PMDD is accompanied by bipolar disorder. The use of antidepressants in bipolar disorder patients can actually trigger a manic episode, especially when not taken alongside a mood stabilizer. There is also evidence that they can worsen depression in those with rapid cycling bipolar disorder.
Finding the right treatments for premenstrual dysphoric disorder and bipolar disorder can be difficult, especially when both disorders are present. It’s essential for patients to work with their physicians and psychiatrists to find an individualized combination of treatments. This provides the best possible outcome all around.