PMDD or Bipolar Disorder: Understanding the Differences

Premenstrual Dysphoric Disorder (PMDD) and Bipolar Disorder (BD) are two distinct conditions, yet they have some similarities and may coexist in certain individuals. PMDD is a severe form of Premenstrual Syndrome (PMS) where significant mood disturbances occur during the luteal phase. In contrast, BD is a mood disorder characterized by extreme mood swings, ranging from mania to depression, which are not connected to the menstrual cycle and do not follow a predictable pattern.

1- What is PMDD?

PMDD (Premenstrual Dysphoric Disorder) is a mood disorder that affects around 5.5% of women and AFAB individuals during their reproductive years. Recognized in the DSM-5 Mood Disorder Section, PMDD manifests through severe psychological symptoms like mood swings, irritability, depression, and a sense of unease.

These symptoms are not caused by a hormonal imbalance. Instead, they are a severe negative response to the usual hormonal changes that occur during the menstrual cycle. Symptoms usually begin during the luteal phase and end after menstruation. PMDD can disrupt daily life and overall well-being, and it often remains undiagnosed for many years following its onset.

PMDD differs from PMS in the severity and impact of symptoms. While PMS is a more common and moderate syndrome with physical and emotional symptoms, PMDD is a severe condition characterized by significant mood shifts and mental distress.

In contrast, PME (Premenstrual Execerbation) refers to the exacerbation of other mental or physical disorders during the premenstrual phase.

To gain a deeper understanding of the journey toward a proper Premenstrual Disorder diagnosis, please explore our article.

2- Official Criteria for PMDD according to the DSM-5

Criterion	Description
A	In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses. These symptoms usually start to improve within a few days after the onset and become minimal or absent in the week following the menses.
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	To reach a total of five symptoms, one or more of the following symptoms must also be present, in combination 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).

3- Understanding Bipolar Disorder

Bipolar Disorder (BD) is a serious mental health condition. It manifests as repeated periods of depression and high energy (mania), which alternate with symptom-free periods. It’s estimated to affect 3-7% of people at some point in their lives.

The exact cause of bipolar disorder is unknown, but it’s likely due to a combination of factors. Genetics, neurochemical imbalances, and stress can contribute to its onset. Conditions like thyroid disorders and substance abuse can exacerbate it. However, having risk factors doesn’t ensure one will develop bipolar disorder.

There are two main types of bipolar disorder:

• Bipolar I Disorder: This type is characterized by at least one full manic episode, which may be preceded or followed by hypomanic or major depressive episodes. However, a major depressive episode is not required for diagnosis. The manic episodes in Bipolar I are severe and may need hospitalization due to potentially dangerous behavior.
• Bipolar II Disorder: This type involves a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes seen in Bipolar I. Hypomanic episodes are similar to manic episodes, but they are less severe and shorter in duration.

Symptoms of Bipolar Disorder

People with bipolar disorder (BD) experience alternating low and high moods:

• Low Mood Phase (Depression): This phase lasts at least two weeks and involves feelings of sadness, a lack of interest in activities, hopelessness or indifference.
  • Low mood all day, every day: Pervasive sense of sadness that lasts throughout the day
  • Feeling worthless daily: Persistent negative self-perception leading to a sense of worthlessness
  • Loss of enthusiasm: A marked decrease in interest towards activities previously enjoyed
  • Alterations in sleep patterns: Experiencing insomnia or excessive sleep
  • Fatigue: A persistent sensation of fatigue, lack of energy, and lethargy
  • Physical issues: Experiencing physical ailments such as backache, headaches, and other forms of pain
  • Weight fluctuations: Unintended weight loss or gain
  • Difficulty focusing: Struggling with concentration and decision-making
  • Social isolation: Withdrawing from social interactions with friends and family
  • Suicidal thoughts: Thoughts of death, suicide ideation, or attempted suicide
• High Mood Phase – emotional “highs” (Mania): During this phase, people feel unusually high or irritated mood and energy for at least a week. These manic episodes can result in abnormal behaviors that cause concern of weird and atypical behavior. Symptoms involving euphoric, energized, or irritable behavior cause impaired functioning and may be severe enough to require hospitalizations.
  • High Mood: An extended period of mood that is elevated beyond the usual state
  • Little need for sleep: Elevated energy level that reduces the need for sleep
  • Acelerated thoughts: Rapid thoughts that are hard to manage
  • Boosted energy: An observable increase in energy that often leads to restlessness
  • Impulsive behavior: Engaging in high-risk activities without considering potential long-term impacts
  • Distracted: Easily distracted by environmental factors, resulting in difficulty completing tasks

4- Getting Diagnosed with Bipolar

	Criteria for Manic Episode	Criteria for Major Depressive Episode
Timeframe	A sustained and abnormally elevated, expansive, or irritable mood for at least one week	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
Impact	May cause hallucinations, delusions, or extremely strange or dangerous behavior that leads to hospitalization	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
Symptoms	Grandiosity or an inflated sense of self	Depressed mood most of the day, nearly every day
	Little need for sleep	Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
	Feeling pressured to speak, talking loudly and rapidly	Significant weight loss when not dieting or weight gain, or decrease or increase in appetite, nearly every day
	Easily distracted	A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down)
	Significantly increased activities or agitated movement	Fatigue or loss of energy, nearly every day
	Engaging in risky behavior (like gambling or unprotected sex)	Feelings of worthlessness or excessive or inappropriate guilt, nearly every day
	Racing thoughts	Diminished ability to think or concentrate, or indecisiveness, nearly every day
	Symptoms should be clearly abnormal and impair a person’s ability to function at home, school, and/or work	Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

5- Bipolar Symptoms in Women: A Closer Look

Bipolar Disorder exhibits different symptoms in men and women. Current research indicates that the prevalence and incidence of Bipolar Disorder type I are approximately equal between the sexes. However, there is some debates about the differences in prevalence and incidence of Bipolar Disorder type II.

Studies state certain distinctive patterns in the way women experience Bipolar Disorder compared to men. Although data is still limited, two studies reveal some key differences:

• A greater proportion of women (54.5%) than men (46.6%) with bipolar disorder experience rapid cycling, characterized by four or more mood episodes annually.
• Mood episodes tend to occur in quicker succession in women (30.3%) as compared to men (20.3%).
• Bipolar disorder episodes tend to worsen over time for a higher percentage of women (50.1%) than men (39.2%).
• Women are more likely to experience mixed episodes, where symptoms of mania and depression occur at the same time.
• Antidepressant-induced mania, a condition in which the use of antidepressants triggers a manic or hypomanic episode, is over three times more common in women than in men.

These findings highlight the unique challenges women and AFAB individuals face when dealing with bipolar disorder. They also underscore the need for a sex-specific approach to treatment and management of the disease.

6- Prevalence of Bipolar Disorder and PMDD

The prevalence of Bipolar Disorder in women with PMDD was around 10%, an 8-fold increase in risk in a large community sample of 1488 women. This is seven times higher compared to women without PMDD.

A systematic review from 2014 indicated that:

• 44% to 68% of women with bipolar disorder experienced changes in mood premenstrually (premenstrual worsening of depressive or manic symptoms, called PME).
• 25% to 77% met the criteria for premenstrual dysphoria.
• 15% to 27% met the criteria for Premenstrual Dysphoric Disorder (PMDD).

This could state that a significant proportion of women with Bipolar Disorder also experience PMDD or premenstrual mood changes. This indicates a possible link between these conditions and the role of hormonal sensitivity in Bipolar Disorder.

Interpreting the data linking bipolar disorder prevalence in women diagnosed with PMDD requires caution. These figures were obtained retrospectively, a method that is susceptible to inaccuracies. For a more accurate understanding of PMDD, it’s recommended the prospective tracking of symptoms on a daily basis.

7- PMDD vs Bipolar Disorder: Differences and Similarities

Bipolar disorder and PMDD can be confused because both involve mood changes. However, PMDD symptoms are linked to the menstrual cycle, appearing after ovulation and disappearing with menstruation.

On the other hand, mood swings in bipolar disorder, which include mania and depression, can occur at any time and are not tied to a specific biological rhythm.

The conditions can be confused because they both can involve depression. It’s also important to note that some women and AFAB individuals with bipolar disorder may have more severe symptoms during specific menstrual phases, similar to PMDD. This is known as Premenstrual Exacerbation (PME), highlighting the complex relationship between these conditions.

So… Do I have Bipolar Disorder or PMDD?

It is possible to have both PMDD and bipolar disorder, although the exact prevalence is not well-documented. The connection between these two conditions is complex and likely due to shared biological mechanisms.

Careful tracking of symptoms is essential to distinguish cyclical symptoms, observe if they resolve during the follicular phase, and determine their response to various treatments.

8- Diagnosing PMDD, Bipolar Disorder, or Both

Tracking Symptoms:

Tracking symptoms over at least two menstrual cycles is crucial for diagnosis. Take note if symptoms are cyclical and resolve during the follicular phase. With the Belle App you can accurately track PMDD and also other symptoms. (the app is available for iPhone and Android)

Condition	Pattern
PMDD but not Bipolar and not PME	Symptoms arise only during the luteal phase (after ovulation and before menstruation) and disappear during the follicular phase (from the start of menstruation until ovulation).
Bipolar and not PMDD	Symptoms occur independently of the menstrual cycle. Mood swings, depression, and mania can happen at any time and do not resolve during any specific phase of the menstrual cycle.
PMDD and Bipolar with PME	Symptoms consistent with both conditions, but they worsen premenstrually.
PMDD and Bipolar without PME	Symptoms of both conditions are present, but bipolar symptoms do not intensify during the luteal phase.
PME of Bipolar Symptoms but not PMDD	Bipolar symptoms worsen during the luteal phase without the specific symptoms of PMDD.

Differentiating PMDD and Bipolar based on treatment response

Some very preliminary research suggestions:

• PMDD: It often responds well to SSRIs (antidepressants) and hormonal therapies that target menstrual cycle symptoms.
• Bipolar Disorder: Typically requires mood stabilizers and antipsychotics.

If symptoms improve with SSRIs or hormonal therapies, it might indicate PMDD. If symptoms respond to mood stabilizers or antipsychotics, it could suggest Bipolar Disorder. If symptoms increase during the luteal phase but respond to either treatment, PME could be the cause.

However, this is not evidence-based enough to provide a solid recommendation. More research is necessary to gain this insight.

9- Getting the right diagnosis

Given the complexity and overlap of these conditions, seeking a professional diagnosis is essential. Accurate diagnosis and effective treatment need the expertise of a qualified clinician.

Steps to Take:

1. Track Symptoms: Use the Belle app to document your symptoms.
   1. Prospective daily tracking is actually really important for getting an accurate diagnosis. The app includes the DRSP, a common used clinical tool for tracking premenstrual symptom severity, but you can also tailor with any other symptoms.
2. Consult a Professional: Provide detailed symptom records to a healthcare provider. The informations can help them make an informed diagnosis and create a treatment plan tailored for your needs.

*The information in this article is for education and informational purposes only and should never be substituted for medical advice, diagnoses, or treatment. If you or someone you know may be in danger, call 911 or the National Suicide and Crisis Lifeline at 988 right away.