Postpartum Depression

Liang A

Clinical Cases Applicability: Antepartum mood disorders, postpartum blues, postpartum depression

Learning Objectives:

1. Understand the neurobiological mechanisms underlying postpartum depression

2. Describe the pharmacology of SSRIs

What are some sex differences in depression?

-Women 2x more likely to develop depression, greatest difference in reproductive years – suggests sex hormones (estrogen, progesterone, oxytocin) and reproductive events play some role in etiology of depression

What is the definition of PDD? prevalence? Risk factors? Natural history?

-DSM 5 defines peri-partum depression as symptom onset during pregnancy or <4 weeks PP – but greatest incidence of new PPD occurs 2-3 months postpartum, and can occur within 1 year

-Prevalence ~10-15%

-Risk factors: antenatal depression (↑ prevalence in 2nd/3rd trimesters) & depression prior to pregnancy; stressful life events (marital conflict, emigration), poor social & financial support

– Often remits on its own within 12 months after giving birth, 6x increased risk for depression later in life

What are proposed neurobiological mechanisms underlying PPD? Pathogenesis unknown

Genetics: increased risk with family history of PPD

Abnormal neurotransmitter levels/activity: ↑ brain monoamine oxidase  ↑ metabolism of neurotransmitters such as dopamine, norepinephrine, serotonin  more rapid depletion of these neurotransmitters  depression

Significant changes in neural activity in brain regions important for self-regulation, empathy & emotion; fMRI studies identify brain regions affected by postpartum depression at rest and in response to infant or non-infant emotional cues

–Decreased corticortical and corticolimbic connectivity

-Weaker connectivity among the amygdala (processes emotions), anterior cingulate cortex (connects the “emotional” limbic system and the “cognitive” prefrontal cortex), dorsal lateral prefrontal cortex (working memory) & hippocampus (long term memory, emotional responses)

-decreased connectivity between the amygdala and right insular cortex w/ positive infant cues

Abnormal growth factors: ↓ Brain-derived neurotrophic factor (supports differentiation, maturation and survival of neurons) concentrations in PPD

What hormones may play a role in PPD? women with a predisposition for depression may be more sensitive to large fluctuations in steroid hormone levels

Estradiol: estradiol levels continue to ↑ in 3rd trimester, but drop dramatically after birth “estradiol-withdrawal state”

Cortisol: high levels of cortisol during pregnancy secondary to placentally-derived CRH; cortisol stimulates CRH production in placenta (positive feedback); withdrawal from excess cortisol postpartum (figure 1)

Oxytocin: hypothesized to have anti-depressant properties; women at risk for PPD have lower oxytocin concentrations in 3rd trimester; BUT administering oxytocin does not improve mood

Why is treatment of PPD important?

Negative outcomes for mothers and infants: ↓ breastfeeding, lack of maternal emotional and behavioral sensitivity to the infant, poor bonding, negative infant temperament, atypical neurodevelopment, and later emotional and behavioral problems for the children

What are pharmacological treatment options for PPD? Mechanism of action? women with PPD take longer to recover & require more therapies than in non-postpartum MDD women

SSRIs – paroxetine and sertraline usually undetectable levels in breast-fed infants; SSRIs block the SERT transporter to ↓ presynaptic serotonin reuptake↑ serotonin concentration (figure 2) Postpartum Depression

Liang A

Figure 1

Figure 2

References:

-Pawluski J, Lonstein J, Fleming A. The Neurobiology of Postpartum Anxiety and Depression. Trends in Neurosciences. 2017 Feb;40(2):106-120

-Brummelte S, Galea LA. Postpartum depression: Etiology, treatment and consequences for maternal care. Hormones and Behavior. 2016 Jan;77:153-66

-Viguera, A. Severe unipolar major depression: Treatment. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2017)

-Viguera, A. Postpartum unipolar major depression: Epidemiology, clinical features, assessment and diagnosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (2016)

00:00
hey guys I’m sorry it has been a little
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while since I filmed a YouTube video but
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I just wanted to sit down today and do
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one because I’m finally feeling a little
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bit better I just had no motivation
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there for a while
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you guys know how it is with PMDD um it
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gets really rough so I’m just now like
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getting off of my period so I’m feeling
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a little bit better and I asked you guys
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on Instagram what YouTube videos you
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guys wanted to see and I got a lot of
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really good suggestions so thank you
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guys for that I’m going to be you know
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working my way through the list but one
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of the suggestions stuck out to me it
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was um what are your worst PMDD symptoms
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and so I figured today I would share
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with you my top 5 worst PMDD symptoms
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and the reason I’m doing this is because
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I just think it’s interesting like to
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hear each woman’s like worse symptoms
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and how we you know get different things
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or how we can relate at this like the
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same things and all of that stuff so I’m
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just gonna go in order from like not as
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as bad to like the very very worst so
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like 5 4 3 2 1 if that makes sense all
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of these symptoms are terrible
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they’re my top 5 so they’re really bad
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and it’s almost hard to rate them on a
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scale of like not as bad to worse
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because they’re all just so bad
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but I am going to just jump right in to
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number 5 and that is sore breasts I get
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the worst breast tenderness and pain and
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they swell up like a whole cup size and
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they feel like they’re bruised like like
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I’m carrying sandbags around in them and
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they’re bruised like it hurts so bad and
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I can feel it when I walk like I can
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literally feel it when I take a step
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it’s that like sensitive and severe now
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I just wear really tight bras honestly
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during that time and sometimes I’ll even
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ice my boobs like I’m not even getting
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it it gets really really bad and for me
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it happens for ten days of every month
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so 10 days warm period I’ll start
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getting breast tenderness and it will
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last all the way up until I start my
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period
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so that is no fun at all and I’m sure a
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lot of you can relate to that but yeah
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not a good time my second art number
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four I guess I would say is my increase
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in appetite I get the worst cravings and
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they are horrible it’s mostly for pizza
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and chocolate I will literally go out of
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my way to seek out pizza and I’m not
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even supposed to eat pizza I’m gluten
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and dairy intolerant and I will eat it
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anyway that’s how much I want it like
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that’s how bad and overbearing my
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cravings get I’m just like fuck the food
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allergies like I’m gonna get pizza and
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then I end up paying for it later but
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yeah I eat pizza a lot when I’m PMSing
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it just sucks because like I really do
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try hard with my fitness and my healthy
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eating and I don’t have a problem with
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it during the rest of the month but then
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like that two weeks before my period I
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get so like almost out of control and I
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just crave everything and like it’s
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normal for us to have cravings but with
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PMDD it’s like PMS on steroids so
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everything is way way worse and I
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honestly could not even like Express to
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you guys how strong my cravings get it
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really sucks and that’s just that was
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that one’s worse for me than the sore
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breasts because I can handle the sore
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breasts but the appetite thing drives me
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fucking nuts because I’m already bloated
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I’m already miserable and then to add
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like all that food into my stomach and
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all the bad food and for me to try to
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process that like and it’s like well why
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don’t you just control what you eat it’s
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like I almost nearly can’t like it’s
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just it’s so overbearing and that’s
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something I’m excited about to get my
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hormones leveled out hopefully with this
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new birth control that I’m about to try
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which I can make a video on later but I
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just literally can’t stand how bad the
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appetite is like it’s it I will gain I
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think I go up six pounds within two
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weeks like I will gain six pounds and
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then I’ll lose six pounds and I’ll gain
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six pounds and lose six pounds it’s like
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this vicious cycle that I’m always in
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because
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I can’t stop my cravings okay so the
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next one number three is gonna be lack
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of motivation
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this one’s horrible because I can’t get
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anything done when I’m doing when I’m in
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my PMDD time like my two weeks I just I
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I can do the bare minimum but that’s all
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I have the motivation for it’s all I
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have the energy for I’m sure a lot of
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you can relate to that one as well it’s
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just like nothing interests me nothing
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even fun like I don’t even have the
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motivation to go do something fun so
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that’s like how bad it gets you know
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it’s like I just have the motivation to
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lay in bed that’s about it I still do
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try to get myself to the gym and I
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obviously get myself to work because I
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have to but other than that like that’s
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kind of like where I keep it at and
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that’s why a lot of times I can’t bring
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myself to make youtube videos during
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that time or post on Instagram because
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I’m just so overwhelmed with how sad and
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exhausted and depressed I am that I have
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no motivation and it’s a typical symptom
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of depression so it makes sense that
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like with how depressed we get as PMDD
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sufferers that we would experience a
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lack of motivation but that one just
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really sucks they all suck
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Who am I kidding okay and number two
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what so Mike this is close to my worst
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one is the fatigue I wrote them all down
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on my phones that’s why I keep laying
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down is the fatigue that I get so this
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kind of goes along with lack of
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motivation but it’s a different symptom
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because it’s just in and of itself it’s
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a whole entity like I get so tired
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people like will make fun of me because
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I’m sleeping so much and it kind of
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sucks because honestly I can’t help it I
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can’t help that I get that overwhelm and
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tire like fatigue and I will sleep 14
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hours a night and then take naps during
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the day and that’s no exaggeration like
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I was just texting someone the other day
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and he was like 14 hours like you slept
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14 hours and I was like yeah like cuz I
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had texted him before bed and I texted
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him when I woke up when he was like you
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just woke up and I was like yeah like I
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can’t help it it’s just like and he
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wasn’t like making fun of me or you
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but um people will like be like oh my
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god you sleep so much and I’m like I’m
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sorry like if you had PMDD you would
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understand like because our bodies are
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so intolerant to the hormone shifts that
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we just get so wiped out and I remember
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even before I developed PMDD as like a
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13 year old I when I first got my period
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I I remember like the first time I was
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on my period I like came home from
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school and just fell asleep on the
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loveseat like in the weirdest position
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like I was in the Hat tired and I have a
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lot of energy as a young girl so that
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was really unusual for me so I’ve always
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been someone that’s just completely
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wiped out by PMS slash period the
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fatigue will last like the two weeks
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before my period and then like halfway
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through my period and then finally one
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day I’ll wake up and be like okay I have
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a little bit of energy and not so so
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tired that I can’t do anything so that
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is number two then finally number one
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and this one is hard to talk about this
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one is triggering so I’m just gonna put
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a trigger warning right here just
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audibly say trigger warning is the
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suicidal ideation and thoughts and you
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know thoughts of harming myself I get
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them almost every month
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pretty much every month and they do last
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a couple weeks I have to just push them
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out of my brain or just wait until they
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go away and kind of just chill and you
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know do something that soothes my mind
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like watch a show or you know read a
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book or talk to a friend something that
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distracts me from like thinking like I
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want to die because it’s an awful
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thought and when you have that thought
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it’s really really overbearing you can’t
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really think about anything else no
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matter how hard you try so it’s just
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really hard to feel that way for half of
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the month every month because it adds to
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the fatigue it adds to the lack of
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motivation it just adds to the heaviness
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that we feel as PVE sufferers and I
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can’t even express to you how low I get
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during these times
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like like last month I woke up for work
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I was feeling absolutely atrocious I
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didn’t think that I could make it
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through my shift I ended up making it
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through but it was really really hard
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and I was sobbing to my mom and I said I
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can’t go to work today like I want to
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die I just want to die and now it’s like
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every month when I feel better and I
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look back at that version of myself I
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think how could I possibly feel that bad
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but then I feel that bad again and again
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and again and again and I remember how
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awful it is and I hate it I hate it with
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everything I have I would never wish
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this upon my worst enemy like it is the
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worst absolute worst feeling to feel
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like you don’t want to be on this earth
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anymore
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yeah that’s a heavy one and I’m sorry
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about that I know that’s hard to hear
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and it’s hard to talk about because it
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can be triggering and it can be really
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heavy to put on somebody to hear that
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and to talk about but it is necessary
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that we do talk about it because it’s
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something that a lot of women with PMDD
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experience regularly and so to talk
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about it is to bring awareness to it and
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so hopefully you know we can get more
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awareness and reduce the stigma of pmed
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and suicidal ideation and all that but I
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have to say that’s my number one where
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symptom it it’s the worst feeling I I
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come in I can’t even put it into words
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how bad that feeling is where you want
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to die yeah
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I’m that’s just pretty much all I have
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to say about that sorry to end on a
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heavier note but yeah that was my worst
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symptom for sure and it’s it’s my worst
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symptom it’s what I meant to say and
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yeah so those are my top five worst
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cambini symptoms
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let me know what you guys think I want
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to hear what your top five worst ones
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are I want to hear if they’re similar to
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mine if you have different one there’s a
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lot of symptoms I didn’t mention in this
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video
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that I get so don’t think that I don’t
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experience other things just because I
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didn’t mention them I just wanted to
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mention the top five that I think are
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the worst for me personally but I would
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love to hear you guys opinions and
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thoughts and all that so leave a comment
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below I would love to hear it and give
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this video a thumbs up if you enjoyed it
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I love you guys so much thank you for
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tuning into my videos and subscribing
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I’ve noticed some new faces around here
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lately and it makes me really really
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happy that you guys are interested in my
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content so thank you and thank you so
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much for all your love and support on
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Instagram okay that’s enough gushing for
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now I love you and I’ll talk to you in
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my next video bye