Premenstrual Dysphoric Disorder: Can You Relate?

This past year has not been easy for anyone. There has been constant uncertainty, disruptions in routines, and a dampening of the connections, traditions, and seasonal joys we may have taken for granted prior to the global pandemic.

Women, in particular, are facing considerable challenges as they attempt to nurture careers with little childcare support, take on significant caregiving roles they may not have anticipated, and manage their own emotional upheaval from political unrest, health fears, and natural disasters.

It is not surprising that rates of depression, anxiety, and alcohol use have been on the rise for women in their 20s, 30s, and 40s. There are only so many opportunities to take a step back from the increased stress they face, and access to treatment is patchy at best.

In addition to these challenges, women in this age group are also at risk of a cyclical worsening of their mood, anxiety, or irritability, as well as physical pain in the form of premenstrual dysphoric disorder (PMDD).

Is Premenstrual Dysphoric Disorder (PMDD) Real?

PMDD, which affects millions of women worldwide, was recently added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), providing important diagnostic support for insurance coverage of treatment.

Though the prevalence of PMDD is between 1.8% to 5.8% of menstruating women, which is comparable or greater than national rates of men and women with panic disorder or obsessive-compulsive disorder (OCD), awareness of the diagnosis can be a primary barrier to treatment, even for individuals seeing a psychiatric provider.

What Symptoms Should I Be Looking For?

PMDD is a cyclical mood disorder characterized by recurrent symptoms in the final week before menstruation (menses), referred to as the luteal phase, with improvement within a few days of menses onset, and minimal or absent symptoms in the first 2 weeks post-menses, during the follicular phase. Importantly, this cyclical pattern needs to have occurred repeatedly over at least the prior 12 months.

The experiences that women with PMDD have during this one- to two-week timeframe before menses typically include at least one of the following primary symptoms:

1. Mood swings and increased emotional sensitivity
2. Increased irritability, anger, or conflict
3. Significant depressed or hopeless mood
4. Noticeable anxiety, physical tension, or feeling “on edge"

In addition, they may also notice decreased interest in their activities, poor concentration, lethargy or low energy, significant change in appetite, increased or decreased sleep, feeling out of control or overwhelmed, and physical symptoms such as breast tenderness, joint or muscle pain, or bloating.

Wait, Is This the Same Thing as Premenstrual Syndrome (PMS)?

Differentiation between a diagnosis of PMDD and premenstrual syndrome (PMS), which is not a DSM-IV diagnosis, is a matter of the degree and number of these symptoms. For example, women with PMS may experience irritability, low mood, and physical bloating in the days just prior to menses, but do not reach the criteria for PMDD due to fewer than five of the described symptoms, or perhaps they have not been experiencing these for a full year.

Understanding Your Symptom Pattern

An important component of a PMDD assessment involves asking women to keep a record of their symptoms throughout the month in the form of prospective daily ratings, for at least two symptomatic cycles. Often I ask them to complete the Daily Record of Severity of Problems (DRSP).

A crucial part of this kind of prospective tracking is the review of symptoms that may persist into the follicular phase, or throughout the entire month. Continued symptoms outside of the one to two weeks prior to menses suggest a different diagnosis, such as major depressive disorder or generalized anxiety disorder.

In subsequent posts, I will share some of the recommended treatments for this illness, including medication and psychotherapy. For now, let’s just agree that it warrants our field’s attention, investigation, and care. The monthly suffering women with PMDD experience does not need to continue, and we can make a huge difference in their lives.