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I’m currently on a waiting list to see an endocrinologist. I’m wondering if anyone has had success with a PRN med for PMDD? Something other than SSRI’s? I've had bad side effects with SSRI’s & antipsychotics.

I'm so desperate I'm worried I might have to go on Prozac or Celexa due to no other options....Celexa was an OK med, however, it increased my lethargy and kills my sex drive/ability to O (as all other SSRI's). I also don't know if SSRI's are actually effective if you only take them 1 week per month?

Lamictal has been a great mood stabilizer, however, it doesn't work at all the week before menstruation, I become SEVERELY depressed, uncontrollable crying spells, irritable, angry, anxious with suicidal ideation to the point of practically checking myself inpatient. Once my period arrives, I'm fine/normal. It’s unbearable.

Previous hormone tests come out normal (I will test again). My thyroid is in normal check also. I’m wondering if anyone has tried something different that has helped? Perhaps I could increase my Lamictal that week? I have read that Lamictal can reduce effectiveness of birth control- but I have not heard about vice-versa (whether your hormones can reduce the amount of Lamictal)?

Edited by cloudmonger

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I've just read that Effexor might be the best PRN to take (only the week prior to menstruation) because of the shortest half-life. I've read that (unlike Prozac or Zoloft) it works right away and clears your system within 3 days.....However, with this method, I worry that it could cause further mood dysregulation or possible withdrawals since I'd take it irregularly..

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FWIW ...

I just wanted to say that I've had friends with PMDD, and the med they were both taking was prozac.  I know you can't take it because of side effects, but for them at least, it worked.  I don't think they took it all month though.  Idk the times they took it in terms of their cycle, but I don't think it was every day. 

 

http://www.medicinenet.com/premenstrual_dysphoric_disorder_pmdd/page4.htm

Quote

SSRI medications to treat PMDD may be prescribed to be taken continuously or only during the 14-day luteal phase (second half) of the menstrual cycle.

Quote

SSRIs that have shown to be effective in the treatment of PMDD include:

 

Edited by melissaw72

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As a male, I feel a bit of an outsider commenting on this thread, but I figured I would offer what Epocrates has to say about the serotonergic meds as a PRN. I'm sorry if this is information that you already know and would, therefore, be redundant.

  • Fluoxetine (Prozac) (there's actually a brand name for PMDD called Sarafem that comes in 10 mg and 20 mg tablets I believe)
    • PMDD
      [20 mg po qd]
      Max: 80 mg/day; Alt: 20 mg po qd on cycle days 15-28 and first day of menses; Info: no proven benefit at doses > 20 mg/day; taper dose gradually to D/C (<—?)
  • Citalopram (Celexa)
    • No indications given in Epocrates, unfortunately...
  • Sertraline (Zoloft)
    • PMDD
      [daily dosing]
      Dose: 50-150 mg po qd; Start: 50 mg po qd, may incr. by 50 mg/day /w each menstrual cycle; Max: 150 mg/day; Info: taper dose gradually to D/C
      [luteal phase dosing]
      Dose: 50-100 mg po qd on cycle days 15-28; Max: 100 mg/day; Info: if 100 mg/day dosing established, cont. to start 50 mg po qd x3 days w/ each luteal phase before incr. dose to 100 mg/day
  • Paroxetine (Paxil) (it appears the Paroxetine CR (Paxil CR) version is the only one indicated for PMDD)
    • PMDD
      [12.5-25 mg ER po q AM]
      Start: 12.5 mg ER po q AM, may incr. to 25 mg ER po q AM after 1wk; Info: do not crush/chew ER tab; taper dose gradually to D/C
    • There's another brand of Paxil, Pexeva, that is also indicated for PMDD, it's dosages are different, and I don't know if it's extended or instant release
      PMDD
      [20 mg po q AM]
      Start: 20 mg po q AM, may incr. by 10 mg/day qwk; Max: 60 mg/day; Info: no proven additional benefit at doses > 20 mg/day; do not crush/chew tab; taper dose gradually to D/C
  • That's it for Epocrates and the serotonergic meds, unless you want me to get into the weird, exotic meds like Lupron or Eligard (same medicine I think). I don't understand how they work, nor do I understand how they would work for PMDD.

I assume this is common knowledge to you as women, but I figured I'd mention it anyway. This comes from this website.

Quote

 

Hormone therapy:

  • Oral contraceptives: Although frequently prescribed for PMDD because they regulate and stabilize reproductive hormones, oral contraceptives have seldom been studied for this purpose, and it's not clear if they are effective.
    The one exception is YAZ, a contraceptive approved by the FDA in 2006 that combines ethinyl estradiol (an estrogen) with drospirenone. Clinical trials have demonstrated that this drug is effective for treating PMDD.
  • Estrogen: Another option is to inhibit ovulation with estrogen, which can be delivered via a skin patch or via subcutaneous implant. Doses of estrogen tend to be higher than those prescribed for hormone therapy during menopause, but lower than those used for contraception in childbearing years. If estrogen is prescribed, it should be taken along with a progestogen to reduce risk of uterine cancer — except for women who have had a hysterectomy.
  • GnRH agonists: Gonadotropin-releasing hormone (GnRH) agonists, which are usually prescribed for endometriosis and infertility, suppress the hormonal cycle‚ and may be helpful for women whose PMDD symptoms have not responded to other drugs.
    Examples of GnRH agonists include buserelin (Suprefact) and goserelin (Zoladex). But these agents can induce a menopausal state, triggering hot flashes and increasing risk of osteoporosis, so they are often supplemented with estrogen and a progestogen — which may trigger PMDD symptoms again in some women.

Under investigation

  • Supplements: Vitamin B6, calcium, magnesium supplements, and herbal remedies have all been studied for use in PMDD — but as of yet there is no consistent or compelling evidence leading to consensus about their efficacy.
 

I hope this is of some use for you, and I hope you get relief as soon as possible.

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9 hours ago, mikrw33 said:

As a male, I feel a bit of an outsider commenting on this thread, but I figured I would offer what Epocrates has to say about the serotonergic meds as a PRN. I'm sorry if this is information that you already know and would, therefore, be redundant.

  • Fluoxetine (Prozac) (there's actually a brand name for PMDD called Sarafem that comes in 10 mg and 20 mg tablets I believe)
    • PMDD
      [20 mg po qd]
      Max: 80 mg/day; Alt: 20 mg po qd on cycle days 15-28 and first day of menses; Info: no proven benefit at doses > 20 mg/day; taper dose gradually to D/C (<—?)
  • Citalopram (Celexa)
    • No indications given in Epocrates, unfortunately...
  • Sertraline (Zoloft)
    • PMDD
      [daily dosing]
      Dose: 50-150 mg po qd; Start: 50 mg po qd, may incr. by 50 mg/day /w each menstrual cycle; Max: 150 mg/day; Info: taper dose gradually to D/C
      [luteal phase dosing]
      Dose: 50-100 mg po qd on cycle days 15-28; Max: 100 mg/day; Info: if 100 mg/day dosing established, cont. to start 50 mg po qd x3 days w/ each luteal phase before incr. dose to 100 mg/day
  • Paroxetine (Paxil) (it appears the Paroxetine CR (Paxil CR) version is the only one indicated for PMDD)
    • PMDD
      [12.5-25 mg ER po q AM]
      Start: 12.5 mg ER po q AM, may incr. to 25 mg ER po q AM after 1wk; Info: do not crush/chew ER tab; taper dose gradually to D/C
    • There's another brand of Paxil, Pexeva, that is also indicated for PMDD, it's dosages are different, and I don't know if it's extended or instant release
      PMDD
      [20 mg po q AM]
      Start: 20 mg po q AM, may incr. by 10 mg/day qwk; Max: 60 mg/day; Info: no proven additional benefit at doses > 20 mg/day; do not crush/chew tab; taper dose gradually to D/C
  • That's it for Epocrates and the serotonergic meds, unless you want me to get into the weird, exotic meds like Lupron or Eligard (same medicine I think). I don't understand how they work, nor do I understand how they would work for PMDD.

I assume this is common knowledge to you as women, but I figured I'd mention it anyway. This comes from this website.

I hope this is of some use for you, and I hope you get relief as soon as possible.

Thanks to you both. I'm not familiar with Epocrates (do you need to pay for a membership or something?)

I have read that the usual treatments are Prozac, Zoloft, Paxil or Birth Control (makes me worse) and hormones (will wait to discuss with endo)  I was really hoping to only do a half-dosing schedule in order to avoid long term side effects that SSRI's have on me (sexual side effects, weight gain and blunting of emotion and motivation).

I'm quite curious why they would suggest Prozac/Sarafem intermittent dosing, because it takes the longest to have any consistent effect. I know with Celexa the half-life is shorter.......Paxil I refuse to take due to bad withdrawal effects and Zoloft made me completely crazy.

Wish I could  find something I could only take for a week per month!
 

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4 hours ago, cloudmonger said:

I was really hoping to only do a half-dosing schedule in order to avoid long term side effects that SSRI's have on me (sexual side effects, weight gain and blunting of emotion and motivation).

I wrote this above ... does it help?  You don't take it all month long.

15 hours ago, melissaw72 said:
Quote

SSRI medications to treat PMDD may be prescribed to be taken continuously or only during the 14-day luteal phase (second half) of the menstrual cycle.

It is more than a week, but it also isn't for the whole month.

 

I know you are going to talk to endo about this, but have you considered talking to an OBGYN also?

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Oh sorry - I missed that on the half-dosing thing. Everywhere I read that only the 4 SSRI's are really used/approved for PMDD luteal phase dosing. It's also more complicated if you are diagnosed with a co-morbid mood disorder (like depression or anxiety) When you already have a diagnosis, doctors seem to want to put you on psych meds everyday (not intermittently) I think my pdoc also has this view.

My OBGYN is terrible & knows absolutely nothing about psych medications or hormone interactions. She claims that birth control never contributes to depression (when I've read tons of studies that say otherwise & experienced it myself) and is unwilling to put me on a trial of estrogen to see if that helps. She is literally useless - I basically just go to get my annual tests and avoid her.

 

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46 minutes ago, cloudmonger said:

She is literally useless - I basically just go to get my annual tests and avoid her.

I see what you mean.  Any chance there are others in your area who you could change to?  I dont think it is as hard starting with a new OBGYN as it would be with a pdoc, for example.  I mean it is hard starting over with any DR, but maybe it is worth it with the DR you have now?

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On 1/8/2017 at 8:46 PM, melissaw72 said:

I just wanted to say that I've had friends with PMDD, and the med they were both taking was prozac.  I know you can't take it because of side effects, but for them at least, it worked.  I don't think they took it all month though.  Idk the times they took it in terms of their cycle, but I don't think it was every day. 

http://www.medicinenet.com/premenstrual_dysphoric_disorder_pmdd/page4.htm

 

I just met with my pdoc and she believes it does sound like PMDD - in addition to my Major Depression (great...yet another diagnosis). I was smart to bring in my 6 month mood-tracking/cycle notes to show her the pattern.

To start, she prescribed 10mg Celexa/Citalopram for 10 days before menstruation, with possible increase after a month or 2. I've been on Celexa before, so I was most comfortable trying this route. No idea if it will actually work if I only take for 10 days per month.......but we shall see. Fingers crossed.

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Sounds like the appt went well and that you got questions answered.  I hope the Celexa works out for you. 

If you have to increase it, and if it makes a difference increased, maybe there would be more pros than cons to continue to take the increased dose. 

 

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We shall see....I was on it a year ago and stopped because it was increasing my lethargy/apathy. I would just lay in bed for hours during the day. I didn't have the same issue taking only 10mg, however, that dose was sub-therapeutic and not doing a thing for my depression. It did seem to be good for anxiety though.

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On 1/9/2017 at 1:23 AM, cloudmonger said:

I'm not familiar with Epocrates (do you need to pay for a membership or something?)

Wish I could  find something I could only take for a week per month!
 

1

I got my Epocrates account for free. It's a mobile app and it's a website. You can pay for it, but you have to pay faaaar out the ass for it.

Xanax was one of the medicines listed under PMDD in Epocrates... don't know if that would be of any help?

8 hours ago, cloudmonger said:

We shall see....I was on it a year ago and stopped because it was increasing my lethargy/apathy. I would just lay in bed for hours during the day. I didn't have the same issue taking only 10mg, however, that dose was sub-therapeutic and not doing a thing for my depression. It did seem to be good for anxiety though.

2

Celexa binds to the histamine receptor, hence the lethargy/apathy, and the subtherapeutic dose helping with anxiety.

You might try Lexapro, which is the (S)-enantiomer of Celexa (EScitalopram). It doesn't have any affinity for the H1 histamine receptor.

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3 hours ago, mikrw33 said:

Xanax was one of the medicines listed under PMDD in Epocrates... don't know if that would be of any help?

Celexa binds to the histamine receptor, hence the lethargy/apathy, and the subtherapeutic dose helping with anxiety.

You might try Lexapro, which is the (S)-enantiomer of Celexa (EScitalopram). It doesn't have any affinity for the H1 histamine receptor.

Wow you are soooo smart :D I knew Celexa & Lexapro were slightly different, but wasn't sure in which way! I will have a think on this. Does Prozac also bind to the Histamine receptor? I've been on Prozac in the past (low dose) and I honestly can't recall how it effected my energy level. I just remember it had a flattening effect.

Pdoc will most likely not prescribe Valium...not sure. I'm quite sensitive to benzos and only would take them occasionally before bedtime. During the day would probably make me too drowsy.

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5 hours ago, cloudmonger said:

Wow you are soooo smart :D I knew Celexa & Lexapro were slightly different, but wasn't sure in which way! I will have a think on this. Does Prozac also bind to the Histamine receptor? I've been on Prozac in the past (low dose) and I honestly can't recall how it effected my energy level. I just remember it had a flattening effect.

Pdoc will most likely not prescribe Valium...not sure. I'm quite sensitive to benzos and only would take them occasionally before bedtime. During the day would probably make me too drowsy.

 

Aww shucks, thanks! :) Fluoxetine has negligible affinity for the histamine receptor. The flattening of affect you were probably feeling was the serotonin stimulating the 5-HT2C receptor, which inhibits production of norepinephrine and dopamine. However, Prozac, in higher doses, becomes a 5-HT2C antagonist, which disinhibits the release of norepinephrine and dopamine, so you get a 3-in-1 action with Prozac. In addition, in the higher doses, you also get some slight norepinephrine reuptake inhibition. So Prozac may not be that stimulating in low doses (10 mg, maybe 20 mg), but it definitely becomes stimulating at 40 mg and above, at least for me.

Have you tried oxazepam (Serax)? It is a pretty good benzo (it takes a while to start working though), and is a short-acting one at that. It seems to help anxiety in the presence of depression without worsening depression. In the US it comes 10 mg, 15 mg, and 30 mg capsules. If you're sensitive to benzos, you could start with 10 mg and take it as needed.

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2 hours ago, mikrw33 said:

Aww shucks, thanks! :) Fluoxetine has negligible affinity for the histamine receptor. The flattening of affect you were probably feeling was the serotonin stimulating the 5-HT2C receptor, which inhibits production of norepinephrine and dopamine. However, Prozac, in higher doses, becomes a 5-HT2C antagonist, which disinhibits the release of norepinephrine and dopamine, so you get a 3-in-1 action with Prozac. In addition, in the higher doses, you also get some slight norepinephrine reuptake inhibition. So Prozac may not be that stimulating in low doses (10 mg, maybe 20 mg), but it definitely becomes stimulating at 40 mg and above, at least for me.

Have you tried oxazepam (Serax)? It is a pretty good benzo (it takes a while to start working though), and is a short-acting one at that. It seems to help anxiety in the presence of depression without worsening depression. In the US it comes 10 mg, 15 mg, and 30 mg capsules. If you're sensitive to benzos, you could start with 10 mg and take it as needed.

Seriously, Are you a genius or something with a photographic memory?! You would make an incredible pdoc of the best kind, due to your experiences with just about every medication! All can say is wow.

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2 hours ago, cloudmonger said:

Seriously, Are you a genius or something with a photographic memory?! You would make an incredible pdoc of the best kind, due to your experiences with just about every medication! All can say is wow.

 

Aww now I'm blushing!! (*'.'*) Thanks so much! That means so much to me! No I'm no genius with a photographic memory lol. I just read about this kind of stuff a lot. It seriously interests me, and I actually have given thought into going back to school for med school so I can become a psychiatrist. Thanks though, that complement made my day from frowny to smiley. :) 

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On 1/11/2017 at 12:56 PM, mikl_pls said:

Aww now I'm blushing!! (*'.'*) Thanks so much! That means so much to me! No I'm no genius with a photographic memory lol. I just read about this kind of stuff a lot. It seriously interests me, and I actually have given thought into going back to school for med school so I can become a psychiatrist.

Thanks though, that complement made my day from frowny to smiley. :) 

Totally support the decision to become a psychiatrist ASAP. 😉

You And Browri would be simply fantastical!

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Interesting thread. When the worst mood episodes happen only a few days before your cycle (like PMDD), my Obgyn says she typically uses Zoloft (only the week before period). She also uses in cases of post-natal depression or depression during pregnancy.

I thought SSRIs always took like 10 days to build up in your system? Not quite sure how taking it only 1 week per month would work...

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      I am also curious if anyone else has experienced PMDD to this extent, what has helped (beyond the traditional treatments-- SSRIs, BC pills, diet and exercise regulation, etc... which I've tried and which I do currently except the BC pills-- and even some less conventional treatments-- mood stabilizers, antipsychotics).    I am also wondering if anyone has ever required hospitalization due to PMDD or even if they require regular repeated hospitalization during PMDD times.  Has anyone done ECT for the PMDD mood-symptoms?
       
      This is a "snapshot" of a typical day in the life of my PMDD, at its worst (like the 3 days before my period, though I am progressively symptomatic in about the 10 days before my period).  This is what I wrote yesterday: (assume trigger warnings everywhere... I cannot get the emoticons to come up)
       
      "I have had some recent life changes and triggers, and my PTSD symptoms are now through the roof.  I am also having a lot of paranoid thoughts about my boyfriend not being interested in me anymore and people just hating me in general.  I feel disgusting and ashamed.  I am shaking and have accidentally knocked my beverage over 3x today at work due to my jittery-ness.  I am having constant intrusive thoughts of self-harm, then dissociating a lot, and then engaging in some self-harm quite impulsively (in an attempt to "snap out of it" though I feel like some part of me thinks I deserve it).  I am having thoughts/images of attempting suicide, but I don't actually want to die.  
       
      It is a couple days before my period.  I have PMDD, and the ONLY times in which I feel depressed to this caliber (or suicidal at all) is right before my period (i.e. the 10 days before my period, escalating into quasi-suicidality and self-harm in the couple days before my period.  
       
      The onset of my period generally brings instant relief and complete cessation of my depression.  Not to be too gross, but I can often tell I've gotten my period before even "checking myself in the bathroom," just based on how relieved I feel, my drastic improvement in mood, and the physical and psychological tension leaving my body.  PTSD symptoms make my PMDD worse, and being premenstrual makes my PTSD worse.  I don't believe I have depression separately from PMDD and from what's triggered by PTSD.  
       
      I have a therapist, and I am on a slew of meds as noted in my signature.  I have been on a slew of other meds and various combinations.  Medications are minimally helpful to me anyway, it seems.  I have tried BC pills, various SSRIs at various doses, various AAPs, and various ACs/mood stabilizers.  I have not found anything that helps at all with the the PMDD (in fact, the Lamictal seems to make it worse).  And I have only had minimal med response with regard to PTSD.
       
      I self-harmed at work today, rather impulsively (hit/punched self in face and head repeatedly, burned self with hot coffee on purpose).  That is the only way in which I self-harm-- not planned but rather as a knee-jerk response to a trigger.  I also really want to OD on on the PRN Vistaril I have in my purse.  I am also having urges/images (have NEVER acted on this whatsoever) of hurting others in a non-lethal way when my symptoms are agitated by interpersonal interaction-- like wanting to throw things at people, hit people, dump hot beverages on people-- pretty much the stuff I do to myself but directed at others).  I have had to be fairly up front about my issues at work... due to symptoms (like this) occurring at work in the past.  (I work as a therapist in an addiction treatment facility so my boss is at least somewhat understanding of MI stuff).  I told my supervisor about it (well, the self-harm shortly after it happened-- the pill impulses didn't come until a couple hours later).  I was fairly certain he'd tell me to go to the ER but instead focused on ways I can be functional in other ways at work today (aside from seeing clients). I think that's because it looks bad (on him AND me) with how much time I've been out due to symptoms in the past and because I really don't have any more accrued time off to take.  
       
      If I even step foot into an ER with my present symptoms, I believe they would admit me.  However, the cycle of my past hospitalizations (3 in total) goes like this... I present in the couple days before my period with symptoms like above, they admit me, and then I get my period while IP and feel instantly better.  However, the staff doesn't necessarily believe that I could be instantly better and think that I am pretending to be better so I can leave and kill myself or something.  Then, after a couple days in, I actually get worse PTSD-wise (due other patients' behavior triggering me, due to the hospital reminding me of being trapped at work because its similar to the work I do, due to being invalidated/not believed by staff, due to confinement in and of itself.)
       
      And I don't know if I am ACTUALLY suicidal or if I just fear becoming suicidal.  It's kind of hard to explain, and sometimes when I am like this, I can't tell the difference.  It's like I am paranoid of becoming suicidal (though I haven't attempted suicide since age 15, which is half of my life span).
       
      I really wish I could just quarantine myself until I get my period so that I am not exposed to additional stressors (like just about any stress whatsoever, like having to file something in a chart that I can't find, or even mis-perceived stress-- like me reading into a slight grimace on someone's face and assuming they hate me and I'm the most annoying human being on the planet.  Also, this quarantine would help so that I don't risk damaging my interpersonal relationships due to my behavior or risk losing my job further.  (Of course, I feel like my job is at risk due to my absences, but I feel it's less at risk than me losing control and accidentally self-harming in front of a client, like I have actually done in front of a co-worker and in front of a supervisor, on two separate occasions.)  During this time, I would take my PRNs and distract myself with mindless activity (TV, internet, chores as I can handle it, gentle yoga as I can handle it).  
       
      But what I really wish is that I could take something or do something to induce my period at will, so that the unmanageable/out-of-control aspect would go away and it would no longer severe interfere with my functioning."
       
      OK, so I wrote all of that yesterday.  I went home from work at about 11:30 and cancelled my 3pm tdoc appointment for yesterday.  I know that was really stupid considering my level of distress, but my level of distress was so high that I was having difficulty verbalizing it while in the midst of it without it escalating my distress to point of becoming unsafe., This was just our 3rd session, and I didn't want her to mis-read my symptoms or take action based on something that is transient and temporary (like admit me to IP when the symptoms are going to go away soon...and honestly my motivations in avoiding IP are also largely financial).
       
      (Plus, I presented in that state at a previous therapists' office, and that therapist was completely invalidating, saying I was using my PMDD symptoms as an "excuse" to not work on my PTSD that day.  I stormed out rather than do something violent to myself or throw something.  I also presented like that early in my relationship with pdoc and she was also somewhat un-empathetic, stating, "Is this the way the rest of our interactions are gonna go?"  to which I said, "No, but it's possible we may have more interactions like this if I happen to see you the day before my period.")
       
      So, is being hospitalized and/or quarantining myself in the couple days before my period really a sustainable option?  I do not have the funds for that (no sick time at work to be missing work, high hospital deductible, living paycheck to paycheck as I just moved out of my abusive parents' household). But I don't know what the lesser of the evils are, and I have yet to find treatment that works.  I don't feel that way today as I did yesterday (I am still in a crappy mood but not hurting myself), but I also called out today because I feared having symptoms at work (we have a state audit today, and the last thing anyone needs is for me to self-harm or act out in front of the state mental health department). I have a pdoc appointment tomorrow and HOPEFULLY I will get my period before then so I can have a rational discussion with her.  In any event, I am printing this out and showing her (and will show to tdoc next week at our session).  
       
      It just really sucks to truly not be in control of my behavior/thoughts/moods for a few days and feel like an alien creature has hijacked my body.  Thanks for reading.
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