ADHD and PMDD

As a women who was diagnosed with ADHD in my 40's I lived most of my 'reproductive' life unaware that I had ADHD and that I had PMDD. It was not until my hormones started to change in my early 40's that I started to track my cycles and realise my mood was really low and I was unusually tearful and anxious for one specific week of the month. For a while I brushed it off, however around the same time of the month I noticed other changes in my behaviour and thoughts that I would later understand were ADHD symptoms that were exacerbated with the sudden spikes or drops in hormones.

ADHD in women is massively under-researched, and therefore not well understood. The research into womens health in general doesn't fare much better with a tiny percentage of the health budget going to womens health.

What is now unsurprising to me, and perhaps will be to you if you have found this article because you have ADHD and PMDD, is that 40% of women who have been diagnosed with ADHD also have PMDD. This is very likely to be a huge underestimate because, well as we know both are under-researched and therefore not always identified. Many women get to their 40s without a formal diagnosis of ADHD, because ADHD tends to present differently in women than men, because we are different. Then when hormones change and symptoms increase alongside other perimenopausal symptoms (some of which overlap) ADHD is harder to manage and this is when many women are correctly (and finally) diagnosed.

What are the symptoms of PMDD?

'Premenstrual syndrome (PMS) is characterised by repetitive, cyclical, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle. Symptoms may extend into the first few days of menses. The symptoms cannot be an exacerbation of another disorder, and they must interfere with some aspects of the woman's life' - BMJ Best Practice

The symptoms can be both physical, emotional and psychological. But there will always be a change in mood that is around the same time of the month and is often intense and feels automatic but not triggered by anything specific, this then changes shortly after the menses.

PMDD is classified as a mental illness, the criteria must meet 5 out of 11 cognitive, behavioural and physical symptoms during the final week of the luteal phase, and must then resolve with or near the onset of menses.

Symptoms - Must include at least one from each category:

Category A:

• Unstable and easily influenced mood

• Irritability

• Depressive or hopeless mood

• Anxiety or tension

Category B:

• Decreased interest in usual activities

• Difficulty concentrating

• Fatigue

• Appetite changes

• Sleep difficulties, either insomnia or hypersomnia

• Feeling of overwhelm

• Physical symptoms: breast tenderness, joint or muscle pain, a sensation of bloating, or weight gain

The interplay between ADHD and PMDD - How do they make each other worse?

Research by Queen Mary Hospital London led by Dr Thomas Broughton and Dr Jessica Agnew-Blais, concluded that women with a clinical ADHD diagnosis were over three times more likely to meet criteria for PMDD than those without. Women who had high levels of ADHD symptoms and impairment (even if they did not have a diagnosis from a clinician) were also over four times more likely to have PMDD. The risk for PMDD was highest among women with ADHD who also had a depression or anxiety diagnosis. 

Although the symptoms of PMDD are not linked directly with ADHD and can be present in those without ADHD, it is clear that there are similarities in the presentation and that having both ADHD and PMDD will make those symptoms that do cross over more extreme, and likely impact other symptoms that exist in each condition.

Emotional Symptoms

PMDD will always have a marked change in the intensity of one or several emotions, this may be sadness, anger, anxiety. With PMDD this is an increase on what would usually be experienced or unrelated to a specific event or existing problem.

ADHD has now been shown to have an emotional difference in the way emotions are experienced, something often referred to as emotional dysregulation. Put simply it is where emotions can change rapidly, going from fine to very dysregulated in a short space of time. This can be due to an external trigger, or a thought or belief that triggers that emotional response. It can lead to having unpredictable emotional reactions and ones that seem disproportionate. ADHD can make this hard to manage as if the emotions are not anticipated or recognised before they become intense, being swept up in or taken over by the intense feeling can make it very hard to try and regulate or feel safe until the feeling has dissipated again.

When PMDD is making emotions more intense and less manageable and less predictable, then ADHD emotional dysregulation will become more of a problem and can then feel very much out of control and sometimes helpless. This in itself can create anticipatory anxiety and fear, knowing that for one week emotions can become very unpredictable. When you have to continue to work, parent, and just get through the week having emotions that are big, unpredictable and hard to get back under control can be extremely disruptive and have a huge impact on day to day life.

Difficulty Concentrating & Memory Issues

PMDD can interfere with concentration and working memory in the luteal phase, this is thought to be linked to the change in hormones during this time. It can create brain fog and feeling of being unable to focus on work, forgetting information and difficulties in planning and organisation.

ADHD diagnostic criteria is all about differences in executive functioning, which is responsible for our working memory and external led actions such as focusing on what you are doing without being distracted or losing concentration.

So again although the two are not the same, one is a change in hormones the other is a structural, chemical and functional difference in the way that the brain processes information and directs our attention, they will no doubt impact each other.

For many women, systems and processes can help to manage ADHD attention and planning issues, however with PMDD these can become less helpful and things that can sometimes work do not have that benefit.

Sleep

It is well documented that circadian rhythms are different in ADHD with many people finding sleep challenging.

PMDD can also disrupt sleep, so even those who do manage to get a decent night perhaps due to lifestyle changes or melatonin or magnesium, can find that week is not the same.

Lack of sleep can effect everything, mood, concentration, energy and motivation. So this is going to impact all of the the other symptoms of both ADHD and PMDD in a negative way.

Physical Pain

PMDD often involves physical pain, whether that is cramping and stomach pain, headaches, body aches, digestive issues and bloating, nausea and breast tenderness.

There is emerging research into ADHD and pain, but the pathway in the brain that processes pain is the same pathway that is effected with ADHD, which could make those with ADHD more aware or and sensitive to physical pain signals in the body. Science has already identified that emotional pain is processed in the same location as physical pain, which is why some emotional pain physically hurts, but now we are starting to see the connections with physical pain and emotional pain.

Appetite

PMDD can involve a change in appetite, with reduced hunger or increased cravings and appetite.

ADHD is also linked to differences in appetite, often due to poor introspection or awareness of hunger signals, or an emotional or boredom response to eating. ADHDers can also be drawn to sugar for the dopamine reward, craving it when dopamine is not being optimised by challenges or interest. There is also the impulsive differences of not thinking before acting which can lead to more food being consumed that intended. This can lead to periods of not eating and then binging on food, not necessarily intentionally or for body image related reasons.

When you have an inconsistent relationship with food and lack of structure around eating PMDD can make this worse, this can lead to feelings of guilt or shame if eating more than usual due to negative self beliefs.

Why are hormones effecting ADHD symptoms?

ADHD is associated with differences in dopamine production and functioning in the brain. Dopamine is a chemical that is involved in many functions including mood, attention, sleep, motivation and satisfaction.

This difference in dopamine can leave some women more vulnerable to hormonal changes, meaning that they have a bigger effect on mood and other dopamine related pathways than in a woman without ADHD.

This might explain why some women with ADHD are particularly effected by PMDD, meanwhile, hormones also effect dopamine itself, so it might have a double impact when certain hormones such as estrogen and progesterone drop and increase. it is still not fully understood how these hormones interact and what impact they have on each other, but anecdotal evidence and understanding shows that there is a connection that needs more research to understand.

Because of the link with hormones and dopamine, serotonin and other neurtransmitter such as GABBA and the link with these hormones and severity of ADHD symptoms, it is thought that hormonal changes do change the severity of ADHD symptoms, meaning if like me you track symptoms and notice that your ADHD related symptoms change throughout the month you are not imagining things.

What are the treatments for PMDD and ADHD?

PMDD is often misdiagnosed, but keeping a daily symptom tracker for at least 4 months can be very helpful in obtaining the correct diagnosis.

If you can see a clear pattern of changes in mood, emotions, physical symptoms and cognitive behaviours that come and go at the same time each month, and it has a significant impact on your life then you should speak to your GP or a womens health specialist to get the right support.

PMDD can be treated with anti-depressants such as SSRIs, which can be taken at specific times in the cycle.

Contraceptive medication is sometimes offered and can be effective, however this is not always the case and some hormonal contraceptives can cause low mood and other issues for women with ADHD.

Lifestyle changes can help women, although you cannot 'cure' PMDD with lifestyle changes, and it is not caused by lifestyle, symptoms can get worse with some factors, but also improve with others.

Prioritising rest is important, not all rest involves laying in bed, rest can be gentle movement, play, cuddling etc.

Nutrition although will not prevent the symptoms can stop symptoms from getting worse. Although appetite may change and with that cravings, making sure to include some foods that can support mood and wellbeing as well as getting the right nutrients.

Exercise can be helpful, for many reasons, but is shown to improve mood and energy levels. Listening to your body, not over-doing it or pushing through pain or low energy is equally as important as doing nothing, finding exercise that feels the right level and good is really beneficial.

Mindfulness, as mentioned above being able to identify what you are feeling and what you might need is very helpful with PMDD, noticing when you have negative thoughts about yourself of your body and when you are feeling low and tired so that you can adapt and adjust what needs to be done.

Compassion is essential, if this could be made into a pill it would be the best treatment for PMDD, being kind to yourself and caring about your health and wellbeing has a positive impact of every part of your life. It will allow you to ask for what you need and to receive it with gratitude, it will give you the kindness to slow down and take care of your body, it will improve your mood and allow you to be more forgiving and accepting when you do react or feel a certain way. It will allow you to be more understanding of your mind and body, and to feel better about yourself. It will allow you to have better relationships with others as a result.

ADHD treatment is complex and very much individual. It can involve taking stimulant medication which has to be prescribed by a professional.

Lifestyle changes such as those mentioned and Mindfulness and compassion are all very important, but need to be adapted and work with ADHD, if you do not take ADHD into consideration when trying to implement this it can lead to the wrong approach and feelings of disappointment and shame if things don't work.

Therapy and Coaching can be very beneficial for ADHD, focusing on small and achievable changes that you can make, accountability, encouragement and support, help with planning and creating systems that work, but also looking at self beliefs and awareness of behaviours with a compassionate and non-judgemental view, finding acceptance and understanding and education around the differences in the ADHD mind.

If you are looking for support with either PMDD or ADHD and you would like to work with someone who understands the symptoms and the challenges and can adapt therapy and coaching to work for you, then get in touch for a consultation where we can look at everything together and work out what the best way to approach things are.

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