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Mind health One percent of menstruating women are unable to function normally Diagnosis debate If your PMS stands for 'Pass Me a Shotgun', you may have PMDD. It's been classified a mental disorder, and you can get help. By Glynis Horning

rill heryY knew she grew moody at 'that time of the month' — a succession of boyfriends made it clear. But it took staff complaints to her boss about lif her outbursts and bullying behaviour to show the 25year-old Durban boutique manager that her PMS was out of hand. 'It was like an alien force took over my body each month,' she says. 'Certainly that Monday...' 'That Monday' was late last year, when a customer defended a changeroom attendant who Cheryl was dressing down for not returning clothes to the shop floor fast enough. 'I lost it completely,' she says. 'I screamed at the customer, threw the pile of frocks she'd been trying on at her, and told her to get out. Of course, I was fired.' The British Medical Journal reports that, while 95% of women have at least some symptoms of PMS — from cramps, breast tenderness, bloating and food cravings to anger, irritability, fatigue and depression — five percent have them severely. And according to the American College of Obstetricians
and Gynecologists, one percent of menstruating women are unable to function normally. They have premenstrual dysphoric disorder (PMDD) — or 'PMS on steroids'. The latest edition of the Diagnostic And Statistical Manual Of Mental Disorders (DSM-5), which provides the criteria for the classification of mental disorders, includes PMDD — which means that if you have it, you are now considered mentally ill. But is this helpful or just stigmatising?

The most outspoken critic of the new classification is Dr Allen Frances, a US psychiatrist who oversaw the revision of DSM-IV. In Saving Normal: An Insider's Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, And The Medicalization Of Ordinary Life (William Morrow),
he expresses concern about 'normal' conditions like PMS being 'medicalised'. And he suggests the main beneficiaries may be the manufacturers of the drugs used to treat them. Others, such as Dr Nada Stotland, a former president of the American Psychiatric Association, argue that it could enforce the 'cultural stereotype' that accepts men's moods and anger as normal but labels those of women as mental illness. Most people believe the menstrual cycle causes negative changes in women's mood and behaviour, and 'reflexively attribute all such behaviour to the menstrual cycle', she says in a Psychiatric Times podcast. 'Well, women in our society still bear a disproportionate share of domestic and dependent-care responsibilities, and society provides little support and little respect for those responsibilities. Women are still paid less for the same work and are grossly underrepresented in positions of leadership and authority — but at the same time, women are expected to be pleasant and compliant all the time. The anger and irritation you could expect given the situation I've described are not accepted as men's anger and irritation are.' Stotland suggests that research into the relationship between hormones, mood and behaviour should include both sexes. After all, the effects of male hormones can be easily deduced from car-insurance rates for adolescent males, 'who cause a greatly disproportionate percentage of collisions and resulting injuries and deaths,' she writes in Psychiatric News (Psychnews.psychiatryonline.org). Local mental-health practitioners are less concerned about the classification. 'The DSM provides guidelines for those of us who treat conditions — we need it to narrow the possibilities of what disorder we're dealing with so we can be more accurate and effective in our treatment,' says Cathrin Venter, a clinical psychologist in Port Shepstone. 'Diagnosis doesn't define your identity.' 'We know that women are twice as vulnerable as men to developing depression, so there has to be something about the fluctuating levels of hormones that sets us up for mood fluctuations,' says Dr Rykie Liebenberg, a Gauteng psychiatrist who works with the South African Depression and Anxiety Group (SADAG), and sees women with PMDD. 'The most vulnerable times are premenstrual, pregnancy and birth, and perimenopause.' She doesn't think the DSM-5 classification of PMDD will cause problems for women in the workplace generally, 'although patients with any mental disorder aren't treated that well — better to break your leg, or have pneumonia or breast cancer than depression or anxiety. Employers tend to view letters from psychiatrists with suspicion and disdain.' But if the classification helps women receive the right treatment, she believes it's worthwhile.
The right stuff
Treatment for PMDD is usually with antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) such as Prozac, while treatment for PMS centres on diet, exercise and stress reduction. 'PMDD treatment with antidepressants is successful for the most part, side effects are mild or absent, and most women are very grateful for the relief,' Liebenberg says.
Sandie Craddock, 29, a bartender, escaped a murder charge after stabbing a work colleague to death, pleading diminished responsibility because extreme PMS transformed her into 'a raging animal each month'.
Christine English, 27, killed her married lover by driving her car into him.A murder charge was reduced to manslaughter when the court was told extreme PMS had contributed to a drop in her blood sugar and over-production of adrenaline.
Anna Reynolds, 20, beat her mother to death with a hammer. Again, a murder charge was reduced to manslaughter when it was argued extreme PMS had lead to temporary loss of control and impairment of judgment.
In South Africa, criminal lawyers COSMO approached know of no such instances, although extreme PMS could possibly be considered a contributory factor in a defence of automatism, 'a non-pathological temporary state of involuntary conduct', says Durban attorney Jacques Botha. It would be 'extremely difficult' to establish the legal basis of PMDD as a complete defence — 'it's more of a diminished- responsibility issue'. Courts would be reluctant to accept it as it could set a precedent with far-reaching consequences. 'For instance, if you concede that at certain stages of a woman's menstrual cycle she's not responsible for her actions, should she be allowed to drive, or have a pilot's licence or a firearm? You can't have your cake and eat it...'
Venter advises a multidisciplinary approach. 'I don't think antidepressants are enough because there can be many contributing factors to PMDD, medical to psychosocial.' She recommends consulting a team: a psychiatrist for medication, a psychologist who can use Cognitive Behavioural Therapy to help you feel better about life events or give you relationship counselling, and a gynae to correct hormonal imbalances, possibly with oral contraceptives. A dietitian can also help. Eating well may improve mild-to-moderate PMS and help reduce PMDD, says dietitian Suna Kassier, a lecturer in dietetics and human nutrition at UKZN. 'This is because irregular eating habits such as skipping meals and using food as a crutch when anxious or depressed can worsen your mental wellbeing. Any health problem is multifactorial, but a good place to start is to eat small, frequent meals to sustain your bloodglucose levels and prevent cravings.' Focus on dietary variety by having whole grains, fruit and vegetables, as some women battle with premenstrual constipation, she says. Lean animal protein, legumes and low-fat dairy products help you follow a low-fat diet, and have been found of benefit to women with PMS. 'As insurance, a good multivitamin and mineral supplement can be helpful.' Studies of college-aged women have shown those with the highest food-sourced calcium intake (low-fat dairy, fortified orange juice) are the least likely to develop PMS, reports researcher Elizabeth Bertone-Johnson, associate professor of epidemiology at the University of Massachusetts, Amherst, who has studied the role of nutrition in PMS. Another study suggests food rich in the B vitamins riboflavin (eggs, green vegetables, milk) and thiamine (whole grains, beans and nuts) helps prevent PMS. Go easy on processed food — it tends to be high in sugar (which causes a bloodsugar drop after an initial high) and salt (which causes bloating), says Kassier.
Both PMS and PMDD can be marked by cramps, bloating, breast tenderness and mood changes - but there are significant differences
PMDD You have at least five of the following symptoms over at least three consecutive months, beginning the week before your period and lessening once the period starts, lasting about six days, and severe enough to disrupt your normal activities: Depression (intense sadness, despair, suicidal thoughts) Tension, anxiety Mood swings, frequent crying
Irregular eating habits can worsen your mental wellbeing
And aim to get 150 minutes a week of moderate-intensity exercise as a stress reliever and to aid weight loss. 'This results in a healthier body image and better self-esteem — and so better mental wellbeing.' Finally, quit smoking — in another UMass Amherst study, young women who smoked were twice as likely to develop PMS. It appears that smoking affects hormone levels. Cheryl was put on antidepressants, and credits them with 'saving my sanity — I'm a different person'. But she is also focusing on eating well and exercising 'because I didn't want to stay on medication forever. I thought I was a terrible person but now I see I was unwell — PMDD can destroy your life.' She is getting on well with colleagues at her new job, and says her current relationship is 'the smoothest in years. It's early days but he could be a keeper!'
Irritability or anger that impacts other people Lethargy (lack of interest in daily activities and relationships) Trouble thinking/focusing Insomnia Feelings of being out of control
PMS Your symptoms are milder and you can generally cope.
DEPRESSION If your depression doesn't
correspond with your menstrual cycle, you may have another type of depression, from major depressive disorder to bipolar disorder. Contact SADAG on Vi 0800 567 567 or the Mental Health Information Centre of Southern Africa on Vi 021 938 9229.1f you have any menstrual symptoms that interfere with your daily activities, discuss them with a GP, gynae or psychologist.

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