Premenstrual Dysphoric Disorder (PMDD)

Premenstrual dysphoric disorder as a mood disorder alongside depressive and bipolar disorders. While the same hormones as PMS cause it, it is not common and is much more likely to develop in women who have histories of other psychological conditions.

Premenstrual dysphoric disorder (PMDD) is unique among psychiatric disorders. Because PMDD relates to the menstrual cycle, it only affects women and is only active for one to two weeks every month. Even if it isn’t present all the time, the disorder carries significant risks and often requires long-term treatment.

What Is PMDD?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) classifies premenstrual dysphoric disorder as a mood disorder alongside depressive and bipolar disorders. While the same hormones as PMS cause it, it is not common and is much more likely to develop in women who have histories of other psychological conditions, especially other mood disorders.

To be diagnosed with PMDD, a woman must experience symptoms that interfere with her abilities to function and maintain activities of daily living. Women with PMDD may have to alter their schedules to accommodate monthly fluctuations in mood, sleep and cognition if they are severe enough to make it difficult to get through everyday stressors they normally can manage

Women with PMDD may have to regularly call out of work each month when their symptoms are most active or sit out of activities they enjoy. This behavior can put them at risk of job loss and cause them to lose progress on important personal goals. They may have to go to the emergency room to address sudden panic attacks or suicidal thoughts in severe cases.

PMDD vs. PMS

PMS symptoms are commonly known and frequently referenced in popular culture, but they are also typically misrepresented. The PMDD diagnosis is less known and is even poorly understood. The symptoms of PMS and PMDD are often mixed up. Women have to combat the misconception that the minor irritability associated with PMS affects their ability to function in everyday interpersonal contexts. Not every woman with PMDD experiences these functional impairments.

Both PMDD and PMS share similar causes and symptoms. The main difference is in the severity. While a woman with PMS might get irritated more easily than she usually does, a woman with PMDD is more likely to feel hopeless. Some women experience suicidal thoughts for the first time when they have PMDD. It’s crucial that women who experience such severe symptoms seek treatment with a trusted medical or mental health provider.

Symptoms of PMDD

Typical  premenstrual period symptoms vary widely in type and severity and include both physical and emotional effects:

• Fatigue
• Bloating
• Cramping
• Irritability
• Headaches
• Sleep problems
• Light sensitivity
• Digestive problems
• Changes to appetite
• Sudden shifts in mood

These PMS symptoms can occur any time between ovulation and menstruation but usually begin in the week before a woman starts her period.

While similar in timing to PMS symptoms, PMDD symptoms are more severe. For example, while a woman with PMS might be mildly depressed and experience minor sleep problems, someone with PMDD can feel extreme hopelessness, have suicidal thoughts and profound insomnia.

A woman with PMDD may have many of the same symptoms as someone with major depressive disorder (MDD) but in a more restricted timeframe. These symptoms can include:

• Suicidal thoughts
• Feelings of despair
• Feeling out of control
• Frequent crying episodes
• Severe anxiety and panic attacks
• Difficulty thinking or concentrating
• Anhedonia or lack of interest in daily activities

Women with a  history of major depressive disorder or other mood disorders are at an elevated risk of developing PMDD.

Causes of PMDD

Researchers are not entirely sure what causes PMDD, though hormones and neurochemicals play a significant role. Research suggests that progesterone levels have an especially powerful effect on mood and link with both minor mood changes in PMS and severe mood effects in PMDD.

Some women experience PMDD instead of PMS because their periods trigger significant changes to their hormone levels, especially their levels of progesterone, or it may be because they are sensitive to these hormone changes. The natural brain chemical gamma-aminobutyric acid (GABA) may play an essential role in a woman’s sensitivity to fluctuations in progesterone. Research shows that women with PMDD have lower levels of GABA or have developed a tolerance to it.

Just like  PMDD symptoms mirror symptoms of major depressive disorder, the causes of PMDD overlap with the cause of depression. An analysis shows that altered serotonin levels can cause PMDD. Research found similar evidence of the link between serotonin, PMS and PMDD symptoms.

How Is PMDD Diagnosed?

A clinician may diagnose PMDD through a series of clinical interviews. Clinicians use targeted questions or assessment scales to pinpoint symptoms in a precise and systematic way. To receive a PMDD diagnosis, a person must meet the specific DSM criteria for the disorder.

For a diagnosis of PMDD, the most recent, fifth edition of the DSM requires a woman to experience five or more PMDD symptoms in the week before her period and for those symptoms to improve within a few days of the onset of menstruation. They must also be minimal or absent within a week after her period ends.

To be diagnosed with PMDD, a woman must have at least one of the following symptoms:

• Marked affective instability
• Extreme edginess, anxiety or tension
• Seriously depressed mood, to the point of hopelessness
• Severe irritability, anger and episodes of verbal aggression

The patient I must also have one or more of the following symptoms, with a total of five PMDD symptoms overall to qualify for diagnosis:

• Lethargy or fatigue
• Hypersomnia or insomnia
• Feeling overwhelmed or out of control
• Difficulty concentrating or paying attention
• Significant changes in appetite or specific food cravings
• Anhedonia, loss of pleasure or interest in daily activities
• Physical symptoms like breast tenderness, bloating or joint or muscle pain

These symptoms need to have been present for most menstrual cycles in the previous year, must not reflect a worsening of symptoms of another disorder and must cause severe subjective distress or functional impairment.

Since PMDD is a mental health condition, a primary care physician may make a referral to a mental health professional to confirm the diagnosis.

Who Is at Risk for PMDD?

Risk factors for PMDD include the following:

• A family history of PMS or PMDD
• A history of physical or sexual abuse in childhood
• A history of other mood disorders, especially major depressive disorder

Even if a clinician has not given them a diagnosis in the past, women who frequently experience more severe fluctuations in mood or other serotonin-related symptoms are more likely to experience symptoms of PMDD.

PMDD Statistics

Approximately  90 percent of women experience symptoms of PMS every month, only 20 to 50 percent experience moderate to severe symptoms and only three to eight percent of women meet criteria for PMDD.

Approximately 20 percent of women have subthreshold PMDD, which means they have fewer than five PMDD symptoms or don’t experience marked functional impairment as a result of the symptoms. When women suffer such impairment, it is usually as severe as major depressive disorder.

If you or someone you know is struggling with a substance use disorder and a co-occurring disorder like PMDD, help is available. Call and speak with a representative at  The Recovery Village to learn more about which treatment program could work for you.

Editor – Jennifer Kopf

Jennifer Kopf is a Florida-based writer who likes to balance creative writing with helpful and informative pieces. Her passion for helping people has translated into writing about the importance of treatment for substance use and mental health disorders. Read more

Medically Reviewed By – Stephanie Hairston, MSW

Stephanie Hairston received her Bachelor of Arts degree in Psychology and English from Pomona College and her Master of Social Work degree from New York University. Read more