Imagine going about life with everything going relatively smoothly and then waking up the next day to find yourself suddenly feeling extremely low, highly irritable and overwhelmed by the simplest task. You almost feel like a completely different person, as if a switch was flicked and you’re no longer able to recognize yourself. And then, almost as suddenly as it began, a week or so later the switch is flipped back and you return to inhabiting your usual self. The transformation is as unnerving to you as it is to those close to you.

For people with premenstrual dysphoric disorder (PMDD), this is a very familiar reality that frequently occurs in the last two weeks of the menstrual cycle. Some of the most commonly reported symptoms include fatigue, bloating, depression, anxiety and irritability, along with other typical symptoms of premenstrual syndrome (PMS). But unlike PMS, symptoms of PMDD are severe enough to affect functioning in everyday life; they might interfere with one’s ability to work or study, or may cause problems in interpersonal relationships. It is believed to be caused by a sensitivity to fluctuating levels of hormones such as progesterone and estrogen that may in turn affect neurotransmitters in the brain that control things like mood and the stress response.

The recognition of PMDD as a distinct and diagnosable mental health disorder is not without controversy, since some believe that it pathologizes the normal experiences of women and people who menstruate. However, others cite the importance of distinguishing between normal PMS, which the majority of menstruating people experience, and PMDD, which affects only around 3-8% of those individuals. For many people in the latter group, it is helpful and empowering to find a label for their more severe PMS, as it can increase their understanding of their experiences and help them access treatment options.

If you think you might have PMDD, speaking to a medical or mental health professional can help you make sense of your experiences, rule out other diagnoses and offer treatment options that may include medications and psychotherapy. There are also a number of online resources such as support groups, websites and podcasts for those who live with PMDD that can help you feel less alone.

Esztella Vezer, M.A., is a Registered Psychotherapist (Qualifying) and is currently completing her clinical residency at CFIR as part of her doctoral degree in clinical psychology. She works with individuals and couples experiencing a wide range of issues, including depression, anxiety, trauma, low self-esteem and relationship difficulties. She also provides fertility counselling and sex therapy, and helps couples who are looking to renew or restore emotional, physical or sexual intimacy, or to repair ruptures related to emotional injuries and interpersonal conflicts. Esztella takes an integrative approach to psychotherapy, drawing on a number of modalities such as emotion-focused therapy (EFT), accelerated experiential dynamic psychotherapy (AEDP), cognitive-behavioural therapy (CBT), psychodynamic psychotherapy (PDT), acceptance and commitment therapy (ACT) and mindfulness-based therapies.

Each year, millions of Canadians suffer from mild to debilitating bouts of depression and anxiety. “It’s so hard to figure out what next steps to take when your attention, concentration, emotional distress and basic sense of vitality are so affected by declining mental health” says Dr. Lila Z. Hakim, C.Psych, Centre Director at the Centre for Interpersonal Relationships in both downtown Ottawa and Toronto.

Figuring out your next steps isn’t so easy. Clients are often overwhelmed by the numerous choices and decisions that have to be made about treatment possibilities and who might be the appropriate mental health professional to help them.

Decades of research on depression and anxiety point to biological, attachment, developmental, childhood trauma, socio-cultural context, environment, emotional, cognitive, behavioural, personality and interpersonal factors as possible precipitators of symptoms. What’s causing you to be depressed and anxious can be complex to sort through.

“CFIR mental health clinicians employ a biopsychosocial model to understand and capture a broad picture of the factors that may be affecting your well-being. It’s not always so simple that there is only a sole factor underlying your symptoms—sometimes many factors have to be considered to address the different layers underlying a person’s distress” cautions Dr. Hakim, C.Psych., “and it’s important to find a practitioner that can understand your depression and anxiety in complex ways. For example, sometimes it’s not just about changing thoughts and how you are thinking about a situation.”

Choices and decisions also have to be made about treatment —medication and/or psychological treatment and what type of psychotherapy might be best for you. Adding to the burden of decision-making is the recent advent of computerized psychological treatments—where treatment involves minimal contact with a care provider. Dr. Hakim, C.Psych. offers several suggestions to help you wade through these complex waters.

“It’s always important to have a general physical health exam to rule out physical causes for your depression and anxiety. Your physician can help you with decisions about which medication might be best for you, and there’s even testing you can have done that can inform you about which medications might have lesser side effects for you. Physicians have different levels of training in mental health treatment and do provide medication options. You might want to also seek out a professional trained as a mental health practitioner along with your visit to your doctor”, according to Dr. Hakim, C.Psych.

Whether you decide to take medication or engage in psychotherapy as a first line treatment approach will depend on you. Numerous research studies, however, have been conducted to guide clients on this subject. Dr. Hakim, C.Psych provides insights from these studies; “Research shows that psychotherapy is effective for mild to moderate symptoms, and a combination of both medication and psychotherapy might be the way to go for individuals with severe and debilitating symptoms. Medication increases neurotransmitters in your brain and can make you feel better, and adding psychotherapy to the mix improves outcomes because the other possible factors underlying your depression and anxiety symptoms still have to be addressed.”

When it comes to choosing what type of psychotherapy might be right for you, clients have further complex decisions in front of them. Dr. Hakim, C.Psych. provides further guidance to help you sort through these decisions. “Some mental health care professionals provide clients with support to change the way they think about situations, or provide skills and strategies to deal with distress and symptoms (e.g., Cognitive-Behavioural Therapy). These types of approaches try to help the client to feel better by managing symptoms, yet there are often many potential factors underlying anxiety and depression. Other mental health care professionals will work with your past and present-day experiences to help you gain awareness and insight into your emotions, self and relationship patterns, self-protection and defences that interfere with healthy functioning. These approaches help you to find more adaptive responses to everyday life but requires a deeper exploration of and engagement with the individual’s emotions, self and past experiences (e.g., Psychodynamic Therapy).”

Some individuals may prefer to learn strategies to diminish symptoms and feel good without deeply understanding themselves by exploring their pasts and emotional reactions to every day life while others may want to understand themselves more profoundly. “The idea that our past influences our present-day experience is a commonly held notion in the field. The way we think and feel about ourselves, think and emotionally react and respond to others, and how we behave and relate to others in our present-day is highly influenced by our past experiences” according to Dr. Hakim, C.Psych. Her final word on this topic is “that finding a mental health clinician who can flexibly work with you and integrate different psychotherapy models might provide more opportunities to work on different factors underlying depression and anxiety symptoms.” This view of treatment is the basic philosophy that underlies the treatment approach offered by the over 75 mental health clinicians at Dr. Hakim, C.Psych.’s centre. They offer flexible treatment options to work with different factors underlying anxiety and depression, and can move between symptom and distress management to working with deeper underlying factors causing your distress.

Finally, Dr. Hakim, C.Psych. shares her perspective on computerized psychological treatment. ‘In Ontario, free computerized psychological treatment services are offered, which is good and I do refer my clients to these sites as an adjunct to the treatment I am providing. Computerized treatment isn’t for everyone and doesn’t necessarily capture the complex factors underlying a unique individuals struggles with depression and anxiety. Sitting alone in front of a computer with only intermittent meetings with a mental health care professional may not allow for the necessary support and treatment related to the numerous factors underlying symptoms. Depression and anxiety have attachment, developmental, emotional, personality and interpersonal factors that are difficult to address on a computer.”