October 28, 2025 • 21 mins
Dr. Elise Fallucco welcomes Laurina, a pediatric nurse practitioner and mom of four. Laurina shares her experience parenting her teenage daughter, Beth, who has ADHD and anxiety. The discussion covers Beth's initial symptoms, her treatment journey and the discovery of Beth's premenstrual dysphoric disorder (PMDD). Laurina offers insights on tracking symptoms and treatment options, providing valuable advice for clinicians and parents alike. Tune in to learn about managing ADHD, anxiety, and hormonal changes in teenage girls.
00:00 Introduction WHAT TO EXPECT and Guest Welcome
01:13 Lorena's Clinical Background
02:10 Recognizing ADHD and Anxiety in Beth
04:55 Medication for ADHD and ANXIETY
07:36 ADHD and Anxiety PLUS HORMONAL CHANGES
14:20 DEPRESSION or PMDD?
19:00 Beth's Transformation and Creative Talents
Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Elise Fallucco (00:22):
Welcome back to Child Mental Health for
Pediatric clinicians, thepodcast formerly known as
Psyched for peds.
I'm your host, Dr.
Elise Fallucco, childpsychiatrist, and mom.
Thanks so much to all of you.
Who sent messages on our websiteor through our newsletter about
how much you enjoyed the mysterycase last week.
And as a follow-up, we have atreat.
(00:42):
This week we're gonna share areal life example of the
clinical symptoms we discussedin our mystery case.
And to do that, we have thehonor of talking with a parent
who.
Is a pediatric nursepractitioner.
She has four children and she'sgonna tell us about her journey
parenting a teenage girl with aDHD and anxiety, and in
(01:03):
particular how her daughter'ssymptoms changed and fluctuated
once she started getting herperiod.
So without further ado, let'sgive a great big welcome to the
podcast to Laurina.
Laura (01:15):
Thank you so much for having me.
I'm excited to be here.
Dr. Elise Fallucco (01:17):
Yeah.
I'm really grateful that we getthe chance to really talk about
your experience as a parentraising a daughter with a DHD.
And I think it's, I'm extraexcited because you can share
the perspective as a parent andalso you're a clinician.
why don't you tell our listenersa little bit about your clinical
(01:39):
role
Laura (01:40):
So I am a pediatric nurse practitioner and I've been a
nurse since 2007 and I only havebeen a nurse practitioner for
practicing for the past year.
But I feel like I finally landedin my calling because my
experience with my kids hasbrought me to where I feel like
(02:04):
I was meant to be.
It was through getting themdiagnosed and learning and
fighting for them and learninghow to help them in these
battles is what prompted me towant to go back to school and
help other kids and otherfamilies.
So they didn't have to gothrough the same struggles that
(02:26):
we did and that I could helpthem in ways that we didn't
have.
Dr. Elise Fallucco (02:31):
And I am sure your patients are
benefiting from all theexperiences you've had with your
own family in addition to yourclinical training.
So now let's talk about yourjourney as a parent of a teenage
daughter with a DHD and anxiety.
Can you tell us about whatsymptoms that she had that first
made you concerned about A DHDand anxiety?
Laura (02:52):
Beth, my oldest daughter, she's my second child, and her
older brother had been diagnosedwith A DHD when he was much
younger and he was the typical ADHD zooming around, very
inattentive driven by a motor.
And Beth was much more subduedand she just would stare off
(03:16):
into space a little bit and alittle bit forgetful.
It wasn't until I was in her IEPmeeting for speech.
When she was in the fourthgrade, that her teachers and the
school guidance counselor lookedat me and they said, we're
really concerned that she mayhave a DHD.
(03:37):
And we're seeing a lot of signsof anxiety when we move on to
different subjects in the class.
She starts to panic and she getsreally upset and she'll even cry
when we are moving on to thenext subject.
And she's not done with herwork.
she was in the gifted andtalented classes in school and
(03:58):
had always done extremely wellin her schoolwork.
And so this was just a reallybig surprise actually to me.
Dr. Elise Fallucco (04:07):
While she had some of the inattentive
symptoms, she was would stareoff into space and was forgetful
sounds like she was prettybright.
But the thing that the teachersnoticed was just that she
seemed, easily overwhelmed bymoving from one subject to the
next
Laura (04:24):
She she wasn't getting stuff done.
So I think it was more of aprocessing kind of a thing.
And and then there was thatanxiety piece as well.
And I, that will slow you downwhen you're worried about it.
And you see everybody else beingdone, and then you're like, I'm
not done.
Then you get more nervous and itslows you down more
Dr. Elise Fallucco (04:45):
You describe it really well.
It's this combination of A DHDand the anxiety and some
processing issues.
So it's taking longer to processwhat she's reading and to think
about how to answer things orhow to write things.
And then also she's worriedabout, am I gonna run out of
time and, oh no, people areleaving and I wanna do the best
that I can.
(05:06):
And so you go into a panic modeand then that makes it harder
for your brain to think and toprocess the information.
And then it cycles over andover.
So that must have been miserablefor her.
Yeah.
Laura (05:17):
so we started with some Concerta when she was in fourth
grade.
And that worked pretty well, butshe would forget to take it
because it was first thing inthe morning.
And about that time her youngersister was already taking
medicine that was a little neweron the market, called Jornay PM
Dr. Elise Fallucco (05:39):
and as a reminder, JORNAY PM is delayed
extended releasemethylphenidate.
You typically dose at 10 hoursbefore you expect it to begin
working.
So for example, you could giveit at 8:00 PM and it would start
working about 6:00 AM the nextmorning and should last
throughout most of the day.
Laura (05:58):
We loved that because we dosed it at night, which was
easy to be very consistent withand it's worked wonderfully for
her.
It definitely made the morningsa lot easier.
Instead of us nagging go getyour breakfast, go brush your
teeth, and like constantlychasing after them with the next
thing that they have to do tomake sure that they got ready,
(06:20):
they would go do things and thencome back and run a checklist.
It completely transformed ourmorning routine.
The other thing that has beengreat is that they have not
required booster doses becauseas you increase the dose, it
increases the longevity throughthe day.
So they haven't needed to takea, a booster dose at school,
(06:41):
which has been huge becauseespecially girls, they're really
conscious about having to go tothe nurse and take their meds
and
Dr. Elise Fallucco (06:48):
you just don't wanna be different than
anybody else in your class.
You don't wanna draw attentionto yourself.
Some people have aha momentsafter they start treatment for A
DHD and they're like, wow, thisis really different.
What was her reaction totreatment?
Laura (07:03):
I honestly, I feel like it was just, just relief.
She was like, ah, I can get myschoolwork done in class.
She was just so happy to be ableto get done with everyone else
and not come home to two hoursof homework because they only
had homework if they didn'tfinish their working class.
So she went from having all thishomework to not having homework,
(07:26):
and so she loved that becausenow she could come home and read
and play outside.
So she really liked that.
So once we started the Jornay,we noticed that she still had
some anxiety symptoms and wehad, been able to do a gene site
test actually and the onlymedication that was in the
(07:49):
green, was Pristiq.
And so we we tried a little ofthat and it helped
significantly.
Dr. Elise Fallucco (07:57):
So Beth had anxiety and A DHD and they
seemed to be fairly wellcontrolled for a while with,
JORNAY for the A DHD and thenPristiq for anxiety.
What happened next
Laura (08:09):
When she got be about 14 or so, that's when she started
her cycle and we did see alittle difference in her focus
and her mood and anxiety thatwas waxing and waning through
the month.
Dr. Elise Fallucco (08:25):
Waxing and waning focus throughout the
month.
Laura (08:28):
It felt like her focus, anxiety, everything was under
control.
And then two weeks later NOT..
So at that point, we werelooking to try to fix two
things, at once.
And so we looked into Qelbreeactually.
Dr. Elise Fallucco (08:46):
And just as a review, QELBREE is an NRI
noradrenergic reuptakeinhibitor.
That is used for A DHD.
It's generic name is VILOXAZINEer.
It works similarly to Strateraor Atomoxetine.
Another NRI.
The two main differences arethat Kere tends to work a little
(09:07):
bit faster.
Some people can see a responsewithin the first week of
treatment as opposed to three tofour weeks in, and also QELBREE
or VILOXAZINE can be sprinkledfor those kids who have trouble
swallowing pills.
Laura (09:20):
We started with a little bit of Qelbree and that helped
for a little while.
Then over time it wasn't enoughand we kept having to tweak
doses.
Every month it just seemed likethere were different points in
the month where she was reallystruggling and we're like, but
this was working a couple weeksago.
(09:40):
Why is it not working now?
I started to notice that she wascomplaining a lot of being
really tired and having bodyaches On the weekends, she would
just kind of collapse on thecouch and say that she didn't
feel good and she didn't evenwant to go out with us to do
(10:02):
something fun because she felttoo exhausted and she seemed
like she had the flu.
She was very irritable and verysnappy and, then, she wouldn't
eat.
She would have no appetite.
When I was speaking with herabout this, this morning, she
told me that for the week beforeshe would start her period, she
(10:25):
said she actually avoidedmirrors because she, if she saw
herself in the mirror, she wouldstart to cry.
Dr. Elise Fallucco (10:31):
I wonder why that was.
Laura (10:33):
Just being so emotionally overwhelmed, I think is how what
she described it as she said,she was just so exhausted and,
and tired.
I remember in December, Bethcame to me one night and she was
just in meltdown mode, and itwas right before she was
supposed to go to bed, eight 30at night and just absolutely
(10:56):
falling apart and saying, Ican't do this anymore.
I don't want to exist.
I want the world to just swallowme up.
I can't do this.
It was very out of the blue forme to see her that way.
It I confirmed that she didn'thave any plans or anything for
(11:17):
self-harm.
It wasn't that she actuallywanted to hurt herself, she
just.
Was so emotionally overwhelmed.
She said she had lost all themotivation to do the things she
enjoyed.
She felt like she couldn'tthink, very low self-esteem.
And she just felt hopeless, shesaid.
I talked to her for a whilethat, that night, and I remember
(11:40):
telling her, we were gonna fixit.
We were gonna make it right, andI gave her a little bit of
VISTARIL to help calm her downand help her be able to sleep.
And that next morning I starteddoing some research and of
course I knew about PMS But thenwhen I started reading the DSM
(12:02):
five criteria for PMDD, I wasshocked.
She actually hit every singlediagnostic criteria listed all
the way down to the thoughts ofhopelessness.
Dr. Elise Fallucco (12:17):
All these things are peaking in the week
before her period.
And then what's happening tothose feelings and thoughts?
After she's had her period or inthe week after her period?
Laura (12:28):
They describe it as the symptoms resolve once your
period start.
It is not a magic wand though.
It doesn't just go away as soonas you start your period.
It takes a couple days.
it would usually take two tothree days into her cycle before
she started to feel normalagain.
Dr. Elise Fallucco (12:46):
That's so hard.
You bring up a really good pointbecause I think when people
think PMS we believe that themoment you start bleeding, like
it all gets better.
What we know when you actuallytrack estrogen levels throughout
your cycle, if day one is yourfirst day of bleeding, that your
estrogen levels continue to codedown until day two and three.
And it's not until really daythree of bleeding that all of a
(13:07):
sudden you take a turn upwardsand your estrogen, your
serotonin, your dopamine allstart turning around and you
start feeling much better.
And it's very biologic.
And, recent studies haveactually tracked hormone levels
with these mood symptoms andthey found exactly what you're
describing with Beth, that it's,it is really very neurobiologic
(13:28):
and yet.
So hard to figure it out andfigure out this pattern.
I wonder what made you or Bethbegin to think I think that
there's a monthly pattern orthat there's some, I,'cause I
feel like there are people whoprobably experienced this, who
have gone their whole liveswithout realizing it.
Laura (13:45):
Yeah.
So we had two months back toback where she had these
meltdown and crashes the nightbefore.
She would start her cycle andthey were just, heart
wrenchingly.
Do I take her to the hospital?
She's not in a crisis of selfharm, but it just, she felt so
(14:06):
hopeless what do I do to helpher?
That depth of depression kind ofthing.
So when we hit the second round,that when I said, there's a
cycle here.
So that was in January.
And then I started mapping out alittle bit of her symptoms.
(14:26):
Three days into her cycle, shewould start feeling better, and
then she would have about a weekbefore she started having any
symptoms of the body aches orthe irritability or things.
So she would have about a weekthat she, felt normal.
Dr. Elise Fallucco (14:41):
And just a clinical comment here, I imagine
some of our listeners arehearing about all of these
depressive symptoms andthinking, you know, could this
just be comorbid depression thathas some sort of premenstrual
exacerbation, but the way thatyou've described it is that the
symptoms really completely goaway a couple of days.
Into her period, and we wouldn'texpect that if it were major
(15:03):
depressive disorder.
Regardless when we're thinkingtreatment for premenstrual
dysphoric disorder, first linetreatment is with SSRIs.
And our studies have shown thatit's pretty much equally
effective to do continuousdosing of SSRIs, just like you
would use to treat depression oranxiety or for premenstrual
(15:24):
dysphoric disorder.
You can also only dose the SRIin the 12 days preceding menses,
or what's known as the lutealphase, and then stop it.
During the two week follicularphase, so first line treatment
would be SSRIs, and then secondline treatment would be
considering combined OCPs,something like yas, which
(15:46):
contains both progestin andestrogen.
And YAS is FDA approved for thetreatment of premenstrual
dysphoric disorder, and thestudies have used dosing 24 days
of the active hormone followedby four days of placebo.
Laura (16:00):
So we went to see my GYN and.
He was so wonderfully kind toBeth and explained everything so
thoroughly and validated herfeelings and what was going on
with her so completely One ofthe best medications that they
(16:21):
use and is actually FDA approvedis Yas, and so it's very low
dose.
And really well tolerated, butthey'll skip the placebos.
And so you take the packs backto back,
Dr. Elise Fallucco (16:37):
And just to recap, Lorena, how you guys used
it is, you gave the combinationprogestin and estrogen dosing
and then skipped the placeboweek, which would be when you
would have the drop in levels.
And so then Beth was able tohave a steady state of hormones
and avoid that premenstrualcrash of estrogen.
And progesterone.
(16:58):
And how long did it take afterstarting Yaz before you and Beth
noticed a difference?
Laura (17:04):
I think we started to notice, a little bit of impact
by the second month, but by thethird and fourth month we were
really starting to notice moreof an impact.
By the time we got to monthfive, she was much more even her
skin had cleared up just overallher hormone levels were just
(17:27):
much more steady.
We weren't having any of thepoor appetite.
The body aches, the mood swings,all of that had resolved.
Dr. Elise Fallucco (17:37):
Just to recap her premenstrual symptoms
were like a really intense PMS,feeling like you're having the
flu with the body aches andextreme fatigue collapsing on
the couch, feeling like I'm doneat the end of the day.
And then the suppressed appetitealong with the irritability and
the snappiness.
It sounds like her physicalsymptoms and her mood symptoms
(17:59):
were the most dramatic and themost intense.
But you had mentioned that someof her A DHD symptoms also were
worse premenstrually, is thatright?
Laura (18:08):
It is.
And when I was doing research onthis I found something really
interesting.
So there is a correlationbetween PMDD and patients that
are neurodivergent, whether theyhave a DHD or autism, so it's
something that I start lookingfor in my A DHD patients.
(18:30):
I even keep it in my educationwith my parents.
Hey.
Keep an eye on this.
If you start to notice some ofPMS symptoms starting to get a
little bit extra, let me know.
Keep an eye on it, track it alittle bit for me because this
could be something that we needto look at in the future.
Dr. Elise Falluc (18:48):
neurodivergent kids with a DHD and or autism
spectrum are at much higher riskof being very sensitive to
hormonal fluctuations and havingreally intense symptoms.
Premenstrually.
I love that you've used yourexperience with your own family
and your own daughter to try toeducate and help other patients,
other families, so that otherkids when they're experiencing
(19:11):
this will know that this is notnormal or typical and that there
are things that you can do totry to address these symptoms
and you don't have to live thatway.
How is Beth doing now?
Laura (19:24):
She is doing great.
She is, in her sophomore year,she has a great group of quirky
friends and they are all fun anddo their own thing and are
quirky together and I love that.
And she is a big BrandonSanderson fan and she has been
(19:48):
reading all of his books and sheis in the middle of writing one
of her own fan novels and she isgetting lots of, letters from
colleges and governor schoolstrying to recruit her and she's
looking forward to studyingpsychology.
Dr. Elise Fallucco (20:08):
What a long way she's come.
So glad to hear that.
And I can tell you're so proudof her.
Thank you Lorena, so much forsharing about your journey and I
really appreciate yourvulnerability.
It's hard to talk about the downparts and the ups and the downs
and all of the in between, andit's so helpful.
And I'm really I know that thestory that you shared and your
(20:29):
insights are gonna help a lot ofother pediatric clinicians
hopefully identify this in thegirls that they're treating and
to think about, treatmentoptions and how to get people
help.
And to our listeners, I hopethat last episode's mystery case
and this episode's real lifeexample, will get you thinking
about premenstrual exacerbationof A DHD symptoms and mood
(20:51):
symptoms and as a helpfulresource.
I'm gonna share an A DHD andmood symptom tracker that was
put out by a DD Aude that helpspatients track their symptoms to
help them and you identify ifthere really is a pattern that
could be related to hormonalchanges.
I will share this on ourwebsite, psyched the number four
(21:12):
peds.com.
Thanks for listening.
See you next time.
Welcome back to Child Mental Health for
Pediatric clinicians, thepodcast formerly known as
Psyched for peds.
I'm your host, Dr.
Elise Fallucco, childpsychiatrist, and mom.
Thanks so much to all of you.
Who sent messages on our websiteor through our newsletter about
how much you enjoyed the mysterycase last week.
And as a follow-up, we have atreat.
(00:42):
This week we're gonna share areal life example of the
clinical symptoms we discussedin our mystery case.
And to do that, we have thehonor of talking with a parent
who.
Is a pediatric nursepractitioner.
She has four children and she'sgonna tell us about her journey
parenting a teenage girl with aDHD and anxiety, and in
(01:03):
particular how her daughter'ssymptoms changed and fluctuated
once she started getting herperiod.
So without further ado, let'sgive a great big welcome to the
podcast to Laurina.
Laura (01:15):
Thank you so much for having me.
I'm excited to be here.
Dr. Elise Fallucco (01:17):
Yeah.
I'm really grateful that we getthe chance to really talk about
your experience as a parentraising a daughter with a DHD.
And I think it's, I'm extraexcited because you can share
the perspective as a parent andalso you're a clinician.
why don't you tell our listenersa little bit about your clinical
(01:39):
role
Laura (01:40):
So I am a pediatric nurse practitioner and I've been a
nurse since 2007 and I only havebeen a nurse practitioner for
practicing for the past year.
But I feel like I finally landedin my calling because my
experience with my kids hasbrought me to where I feel like
(02:04):
I was meant to be.
It was through getting themdiagnosed and learning and
fighting for them and learninghow to help them in these
battles is what prompted me towant to go back to school and
help other kids and otherfamilies.
So they didn't have to gothrough the same struggles that
(02:26):
we did and that I could helpthem in ways that we didn't
have.
Dr. Elise Fallucco (02:31):
And I am sure your patients are
benefiting from all theexperiences you've had with your
own family in addition to yourclinical training.
So now let's talk about yourjourney as a parent of a teenage
daughter with a DHD and anxiety.
Can you tell us about whatsymptoms that she had that first
made you concerned about A DHDand anxiety?
Laura (02:52):
Beth, my oldest daughter, she's my second child, and her
older brother had been diagnosedwith A DHD when he was much
younger and he was the typical ADHD zooming around, very
inattentive driven by a motor.
And Beth was much more subduedand she just would stare off
(03:16):
into space a little bit and alittle bit forgetful.
It wasn't until I was in her IEPmeeting for speech.
When she was in the fourthgrade, that her teachers and the
school guidance counselor lookedat me and they said, we're
really concerned that she mayhave a DHD.
(03:37):
And we're seeing a lot of signsof anxiety when we move on to
different subjects in the class.
She starts to panic and she getsreally upset and she'll even cry
when we are moving on to thenext subject.
And she's not done with herwork.
she was in the gifted andtalented classes in school and
(03:58):
had always done extremely wellin her schoolwork.
And so this was just a reallybig surprise actually to me.
Dr. Elise Fallucco (04:07):
While she had some of the inattentive
symptoms, she was would stareoff into space and was forgetful
sounds like she was prettybright.
But the thing that the teachersnoticed was just that she
seemed, easily overwhelmed bymoving from one subject to the
next
Laura (04:24):
She she wasn't getting stuff done.
So I think it was more of aprocessing kind of a thing.
And and then there was thatanxiety piece as well.
And I, that will slow you downwhen you're worried about it.
And you see everybody else beingdone, and then you're like, I'm
not done.
Then you get more nervous and itslows you down more
Dr. Elise Fallucco (04:45):
You describe it really well.
It's this combination of A DHDand the anxiety and some
processing issues.
So it's taking longer to processwhat she's reading and to think
about how to answer things orhow to write things.
And then also she's worriedabout, am I gonna run out of
time and, oh no, people areleaving and I wanna do the best
that I can.
(05:06):
And so you go into a panic modeand then that makes it harder
for your brain to think and toprocess the information.
And then it cycles over andover.
So that must have been miserablefor her.
Yeah.
Laura (05:17):
so we started with some Concerta when she was in fourth
grade.
And that worked pretty well, butshe would forget to take it
because it was first thing inthe morning.
And about that time her youngersister was already taking
medicine that was a little neweron the market, called Jornay PM
Dr. Elise Fallucco (05:39):
and as a reminder, JORNAY PM is delayed
extended releasemethylphenidate.
You typically dose at 10 hoursbefore you expect it to begin
working.
So for example, you could giveit at 8:00 PM and it would start
working about 6:00 AM the nextmorning and should last
throughout most of the day.
Laura (05:58):
We loved that because we dosed it at night, which was
easy to be very consistent withand it's worked wonderfully for
her.
It definitely made the morningsa lot easier.
Instead of us nagging go getyour breakfast, go brush your
teeth, and like constantlychasing after them with the next
thing that they have to do tomake sure that they got ready,
(06:20):
they would go do things and thencome back and run a checklist.
It completely transformed ourmorning routine.
The other thing that has beengreat is that they have not
required booster doses becauseas you increase the dose, it
increases the longevity throughthe day.
So they haven't needed to takea, a booster dose at school,
(06:41):
which has been huge becauseespecially girls, they're really
conscious about having to go tothe nurse and take their meds
and
Dr. Elise Fallucco (06:48):
you just don't wanna be different than
anybody else in your class.
You don't wanna draw attentionto yourself.
Some people have aha momentsafter they start treatment for A
DHD and they're like, wow, thisis really different.
What was her reaction totreatment?
Laura (07:03):
I honestly, I feel like it was just, just relief.
She was like, ah, I can get myschoolwork done in class.
She was just so happy to be ableto get done with everyone else
and not come home to two hoursof homework because they only
had homework if they didn'tfinish their working class.
So she went from having all thishomework to not having homework,
(07:26):
and so she loved that becausenow she could come home and read
and play outside.
So she really liked that.
So once we started the Jornay,we noticed that she still had
some anxiety symptoms and wehad, been able to do a gene site
test actually and the onlymedication that was in the
(07:49):
green, was Pristiq.
And so we we tried a little ofthat and it helped
significantly.
Dr. Elise Fallucco (07:57):
So Beth had anxiety and A DHD and they
seemed to be fairly wellcontrolled for a while with,
JORNAY for the A DHD and thenPristiq for anxiety.
What happened next
Laura (08:09):
When she got be about 14 or so, that's when she started
her cycle and we did see alittle difference in her focus
and her mood and anxiety thatwas waxing and waning through
the month.
Dr. Elise Fallucco (08:25):
Waxing and waning focus throughout the
month.
Laura (08:28):
It felt like her focus, anxiety, everything was under
control.
And then two weeks later NOT..
So at that point, we werelooking to try to fix two
things, at once.
And so we looked into Qelbreeactually.
Dr. Elise Fallucco (08:46):
And just as a review, QELBREE is an NRI
noradrenergic reuptakeinhibitor.
That is used for A DHD.
It's generic name is VILOXAZINEer.
It works similarly to Strateraor Atomoxetine.
Another NRI.
The two main differences arethat Kere tends to work a little
(09:07):
bit faster.
Some people can see a responsewithin the first week of
treatment as opposed to three tofour weeks in, and also QELBREE
or VILOXAZINE can be sprinkledfor those kids who have trouble
swallowing pills.
Laura (09:20):
We started with a little bit of Qelbree and that helped
for a little while.
Then over time it wasn't enoughand we kept having to tweak
doses.
Every month it just seemed likethere were different points in
the month where she was reallystruggling and we're like, but
this was working a couple weeksago.
(09:40):
Why is it not working now?
I started to notice that she wascomplaining a lot of being
really tired and having bodyaches On the weekends, she would
just kind of collapse on thecouch and say that she didn't
feel good and she didn't evenwant to go out with us to do
(10:02):
something fun because she felttoo exhausted and she seemed
like she had the flu.
She was very irritable and verysnappy and, then, she wouldn't
eat.
She would have no appetite.
When I was speaking with herabout this, this morning, she
told me that for the week beforeshe would start her period, she
(10:25):
said she actually avoidedmirrors because she, if she saw
herself in the mirror, she wouldstart to cry.
Dr. Elise Fallucco (10:31):
I wonder why that was.
Laura (10:33):
Just being so emotionally overwhelmed, I think is how what
she described it as she said,she was just so exhausted and,
and tired.
I remember in December, Bethcame to me one night and she was
just in meltdown mode, and itwas right before she was
supposed to go to bed, eight 30at night and just absolutely
(10:56):
falling apart and saying, Ican't do this anymore.
I don't want to exist.
I want the world to just swallowme up.
I can't do this.
It was very out of the blue forme to see her that way.
It I confirmed that she didn'thave any plans or anything for
(11:17):
self-harm.
It wasn't that she actuallywanted to hurt herself, she
just.
Was so emotionally overwhelmed.
She said she had lost all themotivation to do the things she
enjoyed.
She felt like she couldn'tthink, very low self-esteem.
And she just felt hopeless, shesaid.
I talked to her for a whilethat, that night, and I remember
(11:40):
telling her, we were gonna fixit.
We were gonna make it right, andI gave her a little bit of
VISTARIL to help calm her downand help her be able to sleep.
And that next morning I starteddoing some research and of
course I knew about PMS But thenwhen I started reading the DSM
(12:02):
five criteria for PMDD, I wasshocked.
She actually hit every singlediagnostic criteria listed all
the way down to the thoughts ofhopelessness.
Dr. Elise Fallucco (12:17):
All these things are peaking in the week
before her period.
And then what's happening tothose feelings and thoughts?
After she's had her period or inthe week after her period?
Laura (12:28):
They describe it as the symptoms resolve once your
period start.
It is not a magic wand though.
It doesn't just go away as soonas you start your period.
It takes a couple days.
it would usually take two tothree days into her cycle before
she started to feel normalagain.
Dr. Elise Fallucco (12:46):
That's so hard.
You bring up a really good pointbecause I think when people
think PMS we believe that themoment you start bleeding, like
it all gets better.
What we know when you actuallytrack estrogen levels throughout
your cycle, if day one is yourfirst day of bleeding, that your
estrogen levels continue to codedown until day two and three.
And it's not until really daythree of bleeding that all of a
(13:07):
sudden you take a turn upwardsand your estrogen, your
serotonin, your dopamine allstart turning around and you
start feeling much better.
And it's very biologic.
And, recent studies haveactually tracked hormone levels
with these mood symptoms andthey found exactly what you're
describing with Beth, that it's,it is really very neurobiologic
(13:28):
and yet.
So hard to figure it out andfigure out this pattern.
I wonder what made you or Bethbegin to think I think that
there's a monthly pattern orthat there's some, I,'cause I
feel like there are people whoprobably experienced this, who
have gone their whole liveswithout realizing it.
Laura (13:45):
Yeah.
So we had two months back toback where she had these
meltdown and crashes the nightbefore.
She would start her cycle andthey were just, heart
wrenchingly.
Do I take her to the hospital?
She's not in a crisis of selfharm, but it just, she felt so
(14:06):
hopeless what do I do to helpher?
That depth of depression kind ofthing.
So when we hit the second round,that when I said, there's a
cycle here.
So that was in January.
And then I started mapping out alittle bit of her symptoms.
(14:26):
Three days into her cycle, shewould start feeling better, and
then she would have about a weekbefore she started having any
symptoms of the body aches orthe irritability or things.
So she would have about a weekthat she, felt normal.
Dr. Elise Fallucco (14:41):
And just a clinical comment here, I imagine
some of our listeners arehearing about all of these
depressive symptoms andthinking, you know, could this
just be comorbid depression thathas some sort of premenstrual
exacerbation, but the way thatyou've described it is that the
symptoms really completely goaway a couple of days.
Into her period, and we wouldn'texpect that if it were major
(15:03):
depressive disorder.
Regardless when we're thinkingtreatment for premenstrual
dysphoric disorder, first linetreatment is with SSRIs.
And our studies have shown thatit's pretty much equally
effective to do continuousdosing of SSRIs, just like you
would use to treat depression oranxiety or for premenstrual
(15:24):
dysphoric disorder.
You can also only dose the SRIin the 12 days preceding menses,
or what's known as the lutealphase, and then stop it.
During the two week follicularphase, so first line treatment
would be SSRIs, and then secondline treatment would be
considering combined OCPs,something like yas, which
(15:46):
contains both progestin andestrogen.
And YAS is FDA approved for thetreatment of premenstrual
dysphoric disorder, and thestudies have used dosing 24 days
of the active hormone followedby four days of placebo.
Laura (16:00):
So we went to see my GYN and.
He was so wonderfully kind toBeth and explained everything so
thoroughly and validated herfeelings and what was going on
with her so completely One ofthe best medications that they
(16:21):
use and is actually FDA approvedis Yas, and so it's very low
dose.
And really well tolerated, butthey'll skip the placebos.
And so you take the packs backto back,
Dr. Elise Fallucco (16:37):
And just to recap, Lorena, how you guys used
it is, you gave the combinationprogestin and estrogen dosing
and then skipped the placeboweek, which would be when you
would have the drop in levels.
And so then Beth was able tohave a steady state of hormones
and avoid that premenstrualcrash of estrogen.
And progesterone.
(16:58):
And how long did it take afterstarting Yaz before you and Beth
noticed a difference?
Laura (17:04):
I think we started to notice, a little bit of impact
by the second month, but by thethird and fourth month we were
really starting to notice moreof an impact.
By the time we got to monthfive, she was much more even her
skin had cleared up just overallher hormone levels were just
(17:27):
much more steady.
We weren't having any of thepoor appetite.
The body aches, the mood swings,all of that had resolved.
Dr. Elise Fallucco (17:37):
Just to recap her premenstrual symptoms
were like a really intense PMS,feeling like you're having the
flu with the body aches andextreme fatigue collapsing on
the couch, feeling like I'm doneat the end of the day.
And then the suppressed appetitealong with the irritability and
the snappiness.
It sounds like her physicalsymptoms and her mood symptoms
(17:59):
were the most dramatic and themost intense.
But you had mentioned that someof her A DHD symptoms also were
worse premenstrually, is thatright?
Laura (18:08):
It is.
And when I was doing research onthis I found something really
interesting.
So there is a correlationbetween PMDD and patients that
are neurodivergent, whether theyhave a DHD or autism, so it's
something that I start lookingfor in my A DHD patients.
(18:30):
I even keep it in my educationwith my parents.
Hey.
Keep an eye on this.
If you start to notice some ofPMS symptoms starting to get a
little bit extra, let me know.
Keep an eye on it, track it alittle bit for me because this
could be something that we needto look at in the future.
Dr. Elise Falluc (18:48):
neurodivergent kids with a DHD and or autism
spectrum are at much higher riskof being very sensitive to
hormonal fluctuations and havingreally intense symptoms.
Premenstrually.
I love that you've used yourexperience with your own family
and your own daughter to try toeducate and help other patients,
other families, so that otherkids when they're experiencing
(19:11):
this will know that this is notnormal or typical and that there
are things that you can do totry to address these symptoms
and you don't have to live thatway.
How is Beth doing now?
Laura (19:24):
She is doing great.
She is, in her sophomore year,she has a great group of quirky
friends and they are all fun anddo their own thing and are
quirky together and I love that.
And she is a big BrandonSanderson fan and she has been
(19:48):
reading all of his books and sheis in the middle of writing one
of her own fan novels and she isgetting lots of, letters from
colleges and governor schoolstrying to recruit her and she's
looking forward to studyingpsychology.
Dr. Elise Fallucco (20:08):
What a long way she's come.
So glad to hear that.
And I can tell you're so proudof her.
Thank you Lorena, so much forsharing about your journey and I
really appreciate yourvulnerability.
It's hard to talk about the downparts and the ups and the downs
and all of the in between, andit's so helpful.
And I'm really I know that thestory that you shared and your
(20:29):
insights are gonna help a lot ofother pediatric clinicians
hopefully identify this in thegirls that they're treating and
to think about, treatmentoptions and how to get people
help.
And to our listeners, I hopethat last episode's mystery case
and this episode's real lifeexample, will get you thinking
about premenstrual exacerbationof A DHD symptoms and mood
(20:51):
symptoms and as a helpfulresource.
I'm gonna share an A DHD andmood symptom tracker that was
put out by a DD Aude that helpspatients track their symptoms to
help them and you identify ifthere really is a pattern that
could be related to hormonalchanges.
I will share this on ourwebsite, psyched the number four
(21:12):
peds.com.
Thanks for listening.
See you next time.
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