Sh*t You Wish You Learned in Grad School with Jennifer Agee, LCPC

Episode 20: Misdiagnosed: Understanding Premenstrual Dysphoric Disorder featuring Jaime Duke

August 31, 2022 Jennifer Agee, LCPC Season 1 Episode 20
Sh*t You Wish You Learned in Grad School with Jennifer Agee, LCPC
Episode 20: Misdiagnosed: Understanding Premenstrual Dysphoric Disorder featuring Jaime Duke
Show Notes Transcript

During this episode, I talk with Jaime Duke, LCPC, MAC, NCC (she/her) about the importance of therapists understanding Premenstrual Dysphoric Disorder (PMDD). Jaime is a private practice owner in Prairie Village, Kansas and specializes in working with women who are experiencing Perinatal or Postpartum Mood & Anxiety Disorders, PMS or PMDD, menopausal symptoms, PCOS, Endometriosis, or other hormonal health problems.


  • Distinguish PMDD from other mental health conditions such as Postpartum Depression and Anxiety
  • Understand the importance of proper diagnosis and treatment of PMDD
  • Understand risk factors and comorbidity for PMDD
  • Learn how to support women with PMDD and their partners/family members


Jennifer: Hello Hello and welcome to Sh*t You Wish You Learned in Grad School. I’m your host Jennifer Agee, licensed clinical professional counselor, and with me today is Jaime Duke. She is the owner of Open Invite Therapy Group in the greater Kansas city area, she specializes in working with women's hormonal health and in particular PMDD. So Jaime, welcome to the show.

Jaime: Thank you. Thanks, Jennifer, thank you for having me.

Jennifer: Absolutely. So tell me what is something that you wish you learned in grad school?

Yeah, I wish I learned more about women's hormonal health and how it impacts their mental health and treatment and particularly PMDD. I don't think it's talked about much, and so I think it's an important topic because women are cyclical, and so it impacts our mental health and overall health, and so it would've been nice to know a little bit more about that.

Jennifer: Absolutely. And for those listening who might not know, PMDD stands for premenstrual dysphoric disorder. So premenstrual dysphoric disorder, and it's important because I was really interested to learn when I did a training with you, how many women are actually misdiagnosed with having bipolar disorder or other things, when in fact the culprit was PMDD

Jaime: Yep. It gets misdiagnosed a lot because the symptoms usually are worse the week before women's menstrual cycle. So the 10 to seven days before it's called the luteal phase of your cycle, and so people don't realize that the symptoms are in conjunction with their menstrual cycle. So they think, oh I'm fine on my period, but the week before I feel terrible. And so it gets misdiagnosed, ‘cause a lot of this, there's a lot of similar symptoms and then it's happening every month. So it's kind of like, they think, oh you're having these big mood swings every month, It must be bipolar.

Jennifer: Ah, so tell me a little bit about what are some of the symptoms of PMDD?

Jaime: Yeah. So it's definitely much more like a PMS, but I always say on steroids it's much more extreme. So there's the typical, you know, maybe food cravings or feeling bloated or cramps, things like that. But then there's also the emotional component, which is where the big difference is. Usually they're gonna have a lot of irritability and anger. There's gonna be maybe even panic attacks or anxiety, depression, a lot of trouble controlling kind of thought distortions, and then usually there's more interpersonal conflict because of all that. A lot of times people report, I feel like two different people each month, it's like Jekyll and Hyde. One part of the month I feel great and feel normal, and the next half I don't even recognize me and how I respond to things and how I react. So that's where you can usually tell like, okay something's going on.

Jennifer: Okay, so I don't wanna take over the conversation. You tell us what we need to know, and I'll engage you in conversation and ask questions, but you're the expert here. So just share with us what you think that would be helpful for us to know as clinicians with our butts in the seats, with the clients, what would be helpful for us to know?

Jaime: Yeah, absolutely. Just knowing, you know, assessing a woman, she's having maybe extreme mood shifts, and you're noticing a pattern, just double checking, like, hey is this happening the week before your period? Or in conjunction with your cycle at all? And having them start tracking that, ‘cause PMDD is not a hormonal imbalance so I always like to rule that out as well. ‘Cause sometimes women do have a hormonal imbalance and let's say their estrogen or progesterone is out of balance or their testosterone, it is so finite like the tiniest shift can cause things or maybe even their thyroid. So just knowing that, double checking, like let's make sure it's not a hormonal imbalance. If they have any blood work, that's what I usually start with, and then if there's no hormonal imbalance, then tracking their cycle for at least two months to see, is there a big shift and are these symptoms coming up that they are just not feeling like themselves and these mood swings. Then knowing that since it's not hormonal imbalance what's happening is they think that your brain with PMDD is just more sensitive to the rise and fall of hormones throughout your cycle. It's really relatively new. It was like 2013 when it was added to the DSM, and so they started researching and they think that what happens is there's a metabolite, the short name is called ALLO, but it's in conjunction with progesterone and that metabolite, and most people makes you feel really calm and really good. But with women with PMDD, for some reason, it has the opposite effect. And so they don't know if women have built up a tolerance to it or what it is, but for some reason it's causing irritability, anger, feeling out of control, anxious, depressed, that kind of thing.

Jennifer: So when you have a client start tracking, are there any specific mood tracker apps, and then also, how can we differentiate PMs versus PMDD? Because some of what you're describing is very common PMS symptoms, you know.

Jaime: Yeah. So there's a lot of great apps now they can track their cycle on. And then also I always refer to the International Association for Premenstrual Dysphoric Disorders. Their website is, and it's just one D instead of two. They actually have a symptom tracker on there you can print off, and it's really great, and they can just check which symptoms they're having each month. And so I usually recommend they do that or just use an app, which, you know, there's a lot of great apps. I know like OVIA is one, In the Flow is another one.

Jennifer: Okay, so there’s a couple places to look at. So you were talking about the luteal phase and how, I mean I feel like as a woman I should know this, but I don't. So if I'm asking, other people are asking, how do I know the difference? Is there a time factor of like, when it's more likely PMS versus PMDD?

Jaime: Yeah, usually what happens with PMDD is the day you start your period or the next day you feel great, like you notice a big shift, you're like, I feel so much better, and so that's usually the difference. With PMS Typically it's not the week before that you might feel a little weird, you know, like emotional or something a couple days before your cycle, but usually the symptoms are in conjunction, like, okay, I'm bleeding and I'm feeling I'm craving chocolate. And I feel really tired and I might feel a little weepy or irritable, but it's actually during your cycle. So it's much easier to connect like, okay, this is PMS, but PMDD, you usually actually feel the symptoms go away. You feel much better.

Jennifer: Okay, and I will tell you, I've heard the same thing from women that I've worked with that have PMDD that have said it's like, I'm two different people. And some families even give that part of themselves, the PMDD, when the PMDD is coming out, give it a different name. I've had a client about that, but it's a very clear differentiation of this isn't the way I normally react, behave, or feel.

Jaime: Yes, absolutely. So yeah, a lot of times working with externalizing it, like this isn't my normal self. And a lot of times I'll say it kind of is clueing you into maybe something you're upset about or angry about, and there's validity to that, but it's just magnified times a thousand. So then, working maybe the times throughout the month, when you feel good like, okay, I know I'm upset about this. I'm gonna communicate now when I'm feeling good, and reign in my emotions, more that kind of thing.

Jennifer: So if you suspect, or you start tracking with a client and you suspect that it is PMDD, what do you recommend that the client do? What's treatment look like?

Jaime: Yeah. Obviously the biggest thing is lifestyle factors of really having to get good sleep, eating healthy, blood sugar balance, a lot has to do with it. I usually will look at making sure they're drinking plenty of water, They're getting exercise. And like maybe they're doing exercise where they can get some of that anger out, like kickboxing, something like that. And then the other thing, usually once we go from there with the lifestyle factors and just doing like cognitive behavioral therapy, it's the most studied, but it's shown to be the most effective for treating it. Then the other lines of treatment, like 70% of women have a positive experience with an SSRI. So with PMDD, that's kind of the next line of treatment. Some do well with hormonal birth control, not everyone, some people it makes them feel worse ‘cause you know, with hormonal birth control, it's kind of making a very low dose, they're not having that big swing usually of the hormones. So it's kind of nice ‘cause it's kind of leveling them out, so sometimes it works well, but some women report it doesn’t. It kind of goes on the down from there of like how extreme, like some people get to the point where they need a hysterectomy or an oophorectomy, like even taking the ovaries out to stop the cycling, almost enacting menopause because it's that extreme, but that's like the very last line of treatment. I know they're doing research right now on new medications to treat it, but there's nothing really close. Right now, SSRIs, lifestyle factors, CBT, those are kind of the main things.

Jennifer: And then do you have them, or do you coordinate care with the primary care physician? It sounds like this would be more something that you want their gynecologist to take a look at.

Jaime: Yeah, absolutely. I usually like to try to coordinate care with their OBGYN if possible. I will say some OBGYNs still don't really know what it is, or don't know how to treat it, or maybe think, oh it's not as bad, we'll just give you birth control and you'll feel better. So it's important to try to find a provider that really knows it and understands. So people can search for providers on the website and find someone hopefully in their area that treats it and understands what it's like.

Jennifer: Okay, well that's good to know. It's still shocking to me how much we don't understand particularly about the female body.

Jaime: Yeah, it's just crazy to me. I think that's why it's so important, ‘cause they're starting to do research on, they say biohacking your hormones, but that women actually, you know, men have a 24 hour hormonal cycle and so they can eat the same thing every day and exercise the same way every day and they feel great. Well women, we have weekly, we have four different distinct weeks each month and our hormones change each week. So if you're wanting to biohack your hormones, that's also something I'll recommend for clients like, you need to eat certain foods, and exercise a certain way, and even work and sleep a certain way each week differently to feel best for a woman to optimize your hormones. So the main people that have kind of, realized that or come up with it, or done the research, her name's Alisa Bitti, um, A L I S A and then B I T T I, and she has a great book called Woman Code and she has another one called In the Flow and she has a lot of great resources on her website and things like that, but I would definitely suggest people start there, especially with clients, I'll have them start. She calls it cycle syncing, so that's been nice.

Jennifer: It's amazing. The more we understand, the more research is being done, And the more we understand about the human body, just the interconnectedness of mind and body of mood and mental health, and what's happening physiologically in someone's body, how close those connections really are. I think we're just starting to understand how intensely all these things are connected.

Jaime: Yeah, absolutely. It's fascinating. And you know, ‘cause she talks about the luteal phase, typically when women aren't feeling good, you actually need 200 to 300 extra calories a day and usually more complex carbohydrates. So people are like, well I'm craving all this stuff, and it's like, it's actually okay to eat that, your body's needing those nutrients right then. So things like that and she talks about, if you're more emotional, you might need to journal more, or do some progressive muscle relaxation, or mindfulness or self care.

Jennifer: Yeah, I mean that makes sense. I remember when I was pregnant, the doctor said often when whatever you're craving, there's something in what you're craving that your body needs. So, eating ice cream sundaes every day, like probably ain't gonna do it, but what is it in that, that your body is craving and can you give it what it needs in a way that's healthy for your body.

Jaime: Yeah. Like if it's chocolate, maybe you're low on magnesium, so I'm gonna get some, eat magnesium or have some dark chocolate. ‘Cause it has magnesium in it, so that's right.

Jennifer: Yeah. So when you are working with hormonal health and you're looking at things like PMDD, another big component of this is the people in the lives of someone with PMDD. So when you work with them, do you bring partners in? Like how do you really help support the client more?

Jaime: I'm so glad you brought that up, yeah. That's a big part of the treatment planning process is bringing in a spouse or partner or family members or, working with even how they relate to their children, things like that, because it can cause a lot of disruption in their life, especially usually their partner is the person that gets the brunt of it, or maybe parents or family members or their own kids. There's usually a lot of shame around it too, of just feeling like I yelled at my kids and I normally never yell at them, but this time of the month, I just can't take it. And so yeah, a lot of times I'll bring the partner in and have, you know, half of the month, she's not gonna feel great, So what can we do to help support her? Maybe we have some freezer meals ready to go and you know that she can't hang with the kids as much in the evenings, you have to take over that kind of thing. Also just talking about how to even tell or communicate with kids. Like, hey mom doesn't feel as good right now tonight, it's one of those nights she doesn't feel as good. We're gonna leave her alone tonight or we're gonna watch a movie and she's gonna go to bed. Things like that.

Jennifer: I could see how that could be very destigmatizing for a woman to be able to have words for the fact that her body is taking her on a ride she did not agree to. And that, it's not just because I am a mean mother, or I am a yell-y mom, or I am an insert whatever shameful thing you wanna say about yourself here. My body is going through this process and I don't have to shame myself, I can offer it what I need.

Jaime: Yeah. I always say there's usually some truth to it, or it's telling you it needs some rest or something, so that's okay. Like honor that and then have things in place so you can do that. So you're not feeling guilty or bad or, I'm such a mean mom, like, no it's my PMDD it's not me. It's this special, you know, my body's on this different wavelength right now because of my hormones.

Jennifer: Are there any strong connections between PMDD and other, other diagnoses that women may have like PCOS or different things like that, or there's not necessarily any known strong links?

Jaime: I mean, they've found more women with PMDD have trauma in their background, and they're not really sure why. So that's always something to keep in mind, and I have noticed with clients, if we work on a lot of their trauma, sometimes those symptoms and how intense they are start to be a little bit better. So I don't know what the conjunction is with that, but yeah, it's super interesting. And a lot of times there could be PCOS, endometriosis, those things could also affect it I think too. It's hard to say because those are a little different. They have more to do with the ovaries, but also that they found that the ovaries are what's causing the big shift in your hormone levels. And so they found that it is kind of controlling the PMDD, so it's super fascinating.

Jennifer: Yeah, it is. And I know just mood-wise even though I know the ovaries are what controls that when I had a partial hysterectomy, I noticed a huge difference. Like I would always know when I was gonna have my period before because of my mood and all, how I felt and just a little more irritable or whatever, and I don't at all, I don't at all. So yeah, I don't know, we'll find out more later I'm sure. But all of this stuff is for sure connected. I love talking about the connection with trauma and PMDD because it makes sense, ‘cause you're saying that there's usually a negative truth. There's something under there, so that something under there could strongly link probably to trauma or unmet need that someone experienced during trauma, which is making the connections in the brain wanna fire off and say, last time we felt this way, it didn't go well.

Jaime: Absolutely. Even like, you know, something happens because of the PMDD, then there's trauma from that, like I blew up at my person and now I lost my job or something and I'm spiraling, so yeah, absolutely.

Jennifer: I'm really glad people like you exist that specialize in this, because we can't know everything about everything, which is why we send clients to see a psychiatrist versus their GP a lot of times, because the psychiatrist is reading all the latest research and things that pertain to the brain and mental health. And the same thing is true a lot for women's health, even being a woman, some of the things that you're saying to me are new information. You know it's not something that I've ever researched or studied, I don't remember it in biology class, It's new information. So I'm glad that therapists like you exist that do have a great working understanding of the way hormones affect mood.

Jaime: Thank you, yeah. I think I remember doing a project in grad school, we had to make a big poster and present it to other therapists. And I had, you know, really big on there, CBT for PMDD, and every single person that came up was like, what's that, what's PMDD. And so it's kind of just became a passion of mine like, there needs to be more awareness because there's, I think the statistic is that women go nine to 10 years without being diagnosed, or being misdiagnosed before they get like, oh this might be PMDD. So if we can raise more awareness, that'll help so many people and just be so much better.

Jennifer: One of the things I noticed because you and I did a training together, about PMDD, you did the training, I hosted the training, let's be real. But it was very surprising to me there wasn't a single man that signed up for the training, and even though I have a lot of male therapists on my list that received the same information, I did not have a single male therapist sign up. And the fact is, if you're going to work with female clients, this is something that you need to be aware of. Statistically, about how many women deal with this? Do you know?

Jaime: I think it's about 5%, yeah. And so that's a fair number, and then I know that one of the main reasons that's important to look at it is that the suicide rate is a lot higher in women with PMDD, and so that's something to keep in mind as well. Thinking about it, even if you're a male therapist and you see mostly male clients, like what if he's talking about his wife and how every month she explodes on him, like maybe there's something there we need to explore that would help them so much. I thought that was interesting too. I think maybe, I don't know of a stigma or like kind of this, a little bit of embarrassment or something when we talk about PMS or that kind thing or periods, or I don't know, people are uncomfortable with.

Jennifer: Well I definitely think men are uncomfortable with periods. But it also strikes me like, if around 5% of women live with PMDD, it also makes me think that the percentage might be a little bit higher of who is seen in therapy, right? Because you're coming in because I've got relational issues because I'm going off and I don't know why I'm having trouble at work,
there's certain times of the month where I'm really struggling with motivation. All are reasons that someone might actually reach out for counseling services.
Jaime: Yep. And so yeah, I think the number probably actually could be higher. We just, it's not diagnosed enough when people don't know about it.

Jennifer: Yeah, that's kind of where I'm going. I'd be very curious to know, as people become more educated about it, if in five or 10 years, that statistics started to change, because we actually know what to look for right now, instead of going immediately to the old go-tos of borderline bipolar disorder, you know, things like that.

Jaime: Yeah, absolutely. Yep, and most, I would say almost all of my clients with PMDD have come to me self-diagnosed, they're like, I figured this out on my own because I put the connection together finally, but I went to doctor after doctor and no one knew what I was struggling with or understood or even other therapists. So yeah, it's really important I think that we start getting more awareness out there.

Jennifer: Yeah, good old doctor Google. The other thing you just said is women may go from doctor to doctor and not be diagnosed, and that's another one of these areas that oftentimes we can stand in the gap with our clients and help them learn to advocate for themselves. We can connect them with the flow tracker so that they track their mood in relation to where they are on their cycle and take evidence then into the doctor to say, my therapist brought this information to me, I've been tracking, we suspect I have PMDD, can you take a look at this? Because I think the ambiguity sometimes of how we talk about our periods, because we're not all consistent and all that stuff, it is kind of confusing to doctors as well, like trying to give them the benefit of the doubt. But if we can help them learn how to advocate for themselves and come in, then with evidence and of what they're experiencing, I can imagine that could be very powerful.

Jaime: Absolutely. That's like you said, it does vary cycle to cycle, no cycle's the same. So yeah, there might be one cycle you do feel a little better. Like maybe I don't have it or you know, or like the doctor's like, well maybe it's not that bad. So totally, if that makes sense.

Jennifer: So as we are wrapping up here, what's one final piece of information or advice you want us to know?

Jaime: I think just to know that, women are cyclical beings. So this is just a very important component of treatment planning or looking, even if let's say they don't have PMDD, how is your cycle like asking that in the assessment or like, do you notice any kind of shifts? Maybe they don't have PMDD, but they have PMS or they just have a hormonal imbalance. So being aware of those things, I think is so important, ‘cause it just helps the whole, you know, holistic picture of treating someone in their mental health

Jennifer: I love it. All right Jamie, thank you so much for being on today.
How can people connect with you?
Jaime: Yeah, they can get a hold of me on my website. It's O P E N I V I T

Jennifer: Thank you so much for being on today. And if you would like to connect more with me, with our retreats, with our trainings or the podcast, has all the information. We also are on all the socials, including TikTok. So I hope to see you around and get out there and live your best dang life.