Premenstrual Dysphoric Disorder (PMDD) is defined as a psychiatric disorder that emerges during the luteal phase of the menstrual cycle and subsides with the onset of menstruation, characterized by severe mood disturbances. Unlike premenstrual syndrome (PMS), PMDD causes symptoms severe enough to significantly impair social, occupational and interpersonal functioning.

This disorder is typically observed in individuals who develop heightened sensitivity to hormonal fluctuations associated with the menstrual cycle. Classified under depressive disorders in DSM-5, PMDD can seriously affect women’s quality of life. The onset usually occurs after the age of 20, though symptoms may be noticeable as early as adolescence.

DSM-5 Diagnostic Criteria for Premenstrual Dysphoric Disorder

According to DSM-5, the diagnosis of PMDD is based on the following criteria:

• The emergence of mood and physical symptoms during the week preceding menstruation, which subside within a few days after the onset of menstruation.
• Symptoms must occur recurrently during the luteal phase and must affect daily functioning.
• At least five of the following symptoms must be present, with at least one being mood-related:
  • Marked emotional lability, sudden crying spells
  • Increased irritability or anger
  • Depressed mood, hopelessness
  • Marked anxiety, tension or inner restlessness
  • Loss of interest (personal, social or occupational)
  • Difficulty concentrating
  • Fatigue or lack of energy
  • Marked changes in appetite
  • Sleep disturbances (insomnia or hypersomnia)
  • Physical symptoms (breast tenderness, joint or abdominal pain etc.)

Symptoms must be tracked daily for at least two consecutive menstrual cycles and must not be better explained by another psychiatric disorder (for example major depressive disorder).

What Are the Symptoms of Premenstrual Dysphoric Disorder?

PMDD manifests with emotional, behavioral, cognitive and physical symptoms. Common emotional symptoms include sudden crying spells, anger outbursts, intense restlessness and inner tension. In some individuals, depressed mood, pessimism and hopelessness may become prominent.

Cognitive symptoms may involve distractibility and difficulty making decisions. Behavioral changes include withdrawal, social distancing and increased sensitivity in interpersonal relationships. Physical symptoms such as appetite changes, sleep disturbances and fatigue are common. Additionally, breast tenderness, headaches, bloating and muscle pain may accompany the condition.

Symptom severity varies among individuals and may, in some cases, severely restrict daily activities.

What Are the Causes of Premenstrual Dysphoric Disorder?

Although the exact causes of PMDD remain unclear, current evidence suggests an interaction between biological, hormonal and neurotransmitter-level changes.

Sensitivity to the natural fluctuations of estrogen and progesterone during the menstrual cycle may affect central nervous system mechanisms regulating mood. This is particularly associated with serotonergic system changes. Decreases in serotonin levels may play a role in anxiety, irritability and depressive symptoms.

Genetic factors may also be involved. A higher frequency of similar histories is observed among first-degree relatives of individuals with PMDD. Furthermore, past postpartum depression, traumatic life events and personality traits may contribute to the development of the disorder.

Risk Factors for Premenstrual Dysphoric Disorder

Certain risk factors may increase susceptibility to PMDD, including:

• Family history of PMDD or other depressive disorders
• History of major depression, anxiety disorder or postpartum depression
• High stress levels and lack of social support
• Smoking and alcohol consumption
• Sleep disturbances
• Predisposition to hormonal imbalances

The presence of multiple risk factors may increase the likelihood of PMDD onset, though none alone can definitively determine its development.

How Is It Diagnosed?

Diagnosis of PMDD involves clinical evaluation of symptom timing, severity and cyclical pattern. The most critical factor is that symptoms appear during the luteal phase and remit with the onset of menstruation.

To establish diagnosis, daily symptom monitoring for at least two consecutive menstrual cycles is recommended. Patient-completed records, such as the Daily Record of Severity of Problems (DRSP), may be used.

Differential diagnosis must exclude major depressive disorder, bipolar disorder, generalized anxiety disorder and other mood disorders. Hormonal assessments, thyroid function tests and psychiatric rating scales may be used if necessary.

How Is Premenstrual Dysphoric Disorder Treated?

PMDD treatment may adopt a multidimensional approach including biological and psychosocial interventions. The treatment plan is tailored to symptom severity and its impact on quality of life.

1. Pharmacological Treatment

Medications targeting the serotonergic system are the mainstay of PMDD treatment. Selective serotonin reuptake inhibitors (SSRIs) may be administered continuously or only during the luteal phase. Fluoxetine, sertraline and paroxetine are among the most commonly used options.

Hormonal treatments (for example oral contraceptives) may reduce symptoms by suppressing ovulation. GnRH agonists may be considered in resistant cases, though long-term use is limited due to side effects.

2. Psychotherapy

Cognitive Behavioral Therapy (CBT) may be beneficial in regulating emotions, coping with stress and restructuring maladaptive thought patterns. Psychoeducation may improve awareness of the disorder and enhance coping strategies.

3. Lifestyle Changes and Supportive Interventions

Regular exercise, healthy nutrition and good sleep hygiene may alleviate PMDD symptoms. Reducing caffeine and alcohol intake may help control mood fluctuations. Yoga, meditation and breathing exercises may also decrease stress levels.

Social support groups and family education may reduce feelings of isolation and improve treatment adherence.

Impact on Daily Life

PMDD may cause significant disruptions in academic, occupational and social life. Mood swings and physical discomforts may strain relationships and lead to social withdrawal. Concentration difficulties and loss of energy may reduce productivity.

Over time, PMDD may contribute to decreased self-esteem, anxiety disorders and suicidal ideation. Research indicates that a significant proportion of individuals with PMDD experience serious functional impairment. Therefore, early diagnosis, effective treatment and comprehensive support are of critical importance.