Bipolar Disorder & PMDD

What is Bipolar Disorder and what are the symptoms?

Bipolar disorder is a brain disorder that affects your moods, causing distinct periods of time where moods are at extremes. It used to be known as “manic depression”. The exact cause of bipolar disorder is unknown. Experts believe there are a number of physical, environmental and social factors that work together to make a person more likely to develop it. Bipolar disorder is characterized by episodes of depression and mania, and like PMDD, is a disorder that tends to “cycle” between mood states. During depressive episodes, there are distressing or impairing symptoms of either low mood or loss of interest in activities, and these symptoms last at least two weeks.  During manic episodes, there is an abnormally and persistently elevated, expansive, or irritable mood and energy, lasting at least one week. This manic episode must result in abnormal behaviors that would lead other people  to be concerned, or say that you are not acting like your normal self. 

Unsure if you might have PMDD or PME? Take the self-screen here:

 

Criteria for Manic Episode: 

During a manic episode, a person has a sustained and abnormally elevated, expansive, or irritable mood for at least one week, and at least three of the following symptoms:

  1. Grandiosity or an inflated sense of self

  2. Little need for sleep

  3. Feeling pressured to speak, talking loudly and rapidly

  4. Easily distracted

  5. Significantly increased activities or agitated movement

  6. Engaging in risky behavior (like gambling or unprotected sex)

  7. Racing thoughts

These symptoms should be clearly abnormal (not simply “feeling happier than usual”) and should be noticed by family members and loved ones. They impair a person's ability to function at home, school, and/or work, and may cause hallucinations, delusions, or extremely strange or dangerous behavior that leads to hospitalization. 




Criteria for Major Depressive Episode: 

The individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.

  1. Depressed mood most of the day, nearly every day.

  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

  3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.

  4. A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).

  5. Fatigue or loss of energy nearly every day.

  6. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

  7. Diminished ability to think or concentrate, or indecisiveness, nearly every day.

  8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

To receive a diagnosis, symptoms must cause significant distress or interference in social, occupational, or other important areas. The symptoms must also not be due to substance abuse or another medical condition.

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What is PMDD and what are the symptoms?

Premenstrual Dysphoric Disorder (PMDD) is a cyclical, hormone-based mood disorder with symptoms arising during the luteal phase of the menstrual cycle and subsiding by the week after menstruation. It affects an estimated 5.5% of women and AFAB individuals of reproductive age. While PMDD is directly connected to the menstrual cycle, it is not a hormone imbalance. PMDD is a severe negative reaction to the natural rise and fall of estrogen and progesterone. It is a disorder in the brain’s ability to adapt to hormone changes. Symptoms can worsen over time and or around reproductive events such as menarche (the first menstrual cycle), pregnancy, birth, miscarriage, and perimenopause.

Official Criteria for Premenstrual Dysphoric Disorder

A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.

B. One (or more) of the following symptoms must be present:

1. Mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection

2. Intense irritability or anger or increased interpersonal conflicts.

3. Depressed mood, feelings of hopelessness, or self-deprecating thoughts.

4. Anxiety, tension, and/or feelings of being keyed up or on edge.

C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.

1. Decreased interest in usual activities (e.g., work, school, friends, hobbies).

2. Subjective difficulty in concentration.

3. Lethargy, easy fatigability, or marked lack of energy.

4. Marked change in appetite; overeating; or specific food cravings.

5. Hypersomnia or insomnia.

6. A sense of being overwhelmed or out of control.

7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.

D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).

E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).

F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (note: The diagnosis may be made provisionally before this confirmation.)

G. The symptoms are not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).

Read more about PMDD and read a full etiology:

Can you have PMDD and Bipolar Disorder?

Yes. It is possible to have any of the following: 

  • PMDD (and not bipolar disorder) 

  • Bipolar disorder (and not PMDD)

  • PMDD and Bipolar disorder at the same time, with PME of the bipolar symptoms

  • PMDD and Bipolar disorder at the same time, without PME of the bipolar symptoms

  • or PME of bipolar disorder symptoms, but not PMDD. 

We would always encourage careful tracking to distinguish which symptoms are cyclical, whether those symptoms resolve fully in the follicular phase, and whether each symptom responds to various forms of treatment. 

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Can Bipolar Disorder worsen across the menstrual cycle?

Some (though not all) women and AFAB individuals who have Bipolar Disorder can find that their depression or mania symptoms worsen at different points of the menstrual cycle; this has been documented in numerous studies. While this worsening of depressive or manic symptoms often happens premenstrually (called PME - Premenstrual Exacerbation), some with bipolar also experience worsened symptoms around ovulation. There are only a few research studies on this topic, and most of them simply describe the fact that these symptoms do change for some females with the disorder. So far, we still don’t know the underlying causes of PME in bipolar symptoms, and we don’t have enough evidence to make strong evidence-based recommendations about treatment of the PME aspect specifically. However, some expert clinicians have recommended the combined use of bipolar medications (such as mood stabilizers or atypical antipsychotics) and hormone stabilization treatments in people who experience both bipolar and hormone sensitivity. 

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Similarities and differences

It is clear there are many similarities between Bipolar Disorder and PMDD. They have similar symptoms, and are both disorders characterized by cycling between different emotional states. It is often critical to distinguish between the two, so that accurate treatment, therapy and support can be given. 

While PMDD and bipolar disorder are both associated with mood lability and extreme mood states, the two disorders can often be differentiated by when the symptoms occur. In PMDD, symptoms only appear within a certain window of the menstrual cycle, triggered by ovulation.  In contrast, the mood swings associated with bipolar disorder are not necessarily linked to any regular body cycle. However it is important to note that some women and AFAB individuals with Bipolar Disorder can find that their symptoms worsen in the luteal phase - this is known as PME - Premenstrual Exacerbation. 

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Getting an accurate diagnosis

The first step to an accurate diagnosis is to track your symptoms carefully inline with your menstrual cycle for a minimum for 2 months. To do this you can download this free printable symptom tracker form or a free tracking app such as Me v PMDD for iPhone or Android. 

  • With PMDD, symptoms are very on:off and only occur in the luteal phase of the menstrual cycle - so there is a symptom free window after your period each month.

  • With bipolar disorder, in contrast, the mood swings associated with bipolar disorder are not tightly linked to any regular body cycle so will not appear in such a set, on:off predictable, cycle like PMDD. 

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Citations

  1. Bipolar Disorder in Adults. (2012). Retrieved October 19, 2015, from http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-adults/index.shtml.

  2. Pearlstein, T., & Steiner, M. (2008, July 1). Premenstrual dysphoric disorder: Burden of illness and treatment update. Retrieved November 15, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440788/.

  3. Nimh.nih.gov,. 2015. 'NIMH » Mental Health Medications'. Retrieved November 15, 2015. http://www.nimh.nih.gov/health/topics/mental-health-medications/mental-health-medications.shtml.

  4. J, Studd. 2015. 'Severe Premenstrual Syndrome And Bipolar Disorder: A Tragic Confusion. - Pubmed - NCBI '. Ncbi.Nlm.Nih.Gov. Accessed November 15, 2015. http://www.ncbi.nlm.nih.gov/pubmed/22611228.

  5. Amhc.org,. 2015. 'Bipolar Disorder Versus Major Depression And Premenstrual Dysphoric Disorder - Bipolar Disorder'. Accessed November, 15 2015. http://www.amhc.org/4-bipolar-disorder/article/11199-bipolar-disorder-versus-major-depression-and-premenstrual-dysphoric-disorder.

Updated 4th November 2020 by Dr. Tory Eisenlohr-Moul.