Premenstrual Dysphoric Disorder (PMDD)
Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome characterized by intense mood symptoms, somatic symptoms, and cognitive symptoms that begin several days before menstruation, improve within days after onset, and become minimal or absent within one week following the onset of menses.
Definition and Classification
PMDD is officially recognized as a distinct psychiatric condition in modern diagnostic classifications:
- Formally established as a depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013 1
- Included in the International Classification of Diseases 11th Revision (ICD-11) as a distinct diagnostic entity 2
Epidemiology
- PMDD affects approximately 3-8% of women of reproductive age 3
- In contrast, milder premenstrual syndrome (PMS) affects 20-40% of menstruating women 1
Clinical Presentation
PMDD is characterized by a specific pattern of symptoms:
Timing pattern: Symptoms begin several days before menstruation, start improving within days after onset, and become minimal or absent within one week following menses 2
Core symptom categories:
- Mood symptoms (e.g., depressed mood, irritability)
- Somatic symptoms (e.g., bloating, breast tenderness, overeating)
- Cognitive symptoms (e.g., forgetfulness, difficulty concentrating) 2
Severity: Symptoms are severe enough to significantly impact daily functioning, relationships, and quality of life 1
Pathophysiology
While the exact cause remains unclear, several mechanisms have been proposed:
- Heightened sensitivity to normal hormonal fluctuations during the luteal phase 1, 3
- Abnormal serotonergic activity 1
- Aberrations in progesterone and gamma-aminobutyric acid (GABA) neurotransmission 1
- Possible genetic predisposition affecting sensitivity to hormonal changes 4
Diagnosis
The diagnosis of PMDD requires:
- Prospective symptom tracking using daily symptom ratings (e.g., Daily Record of Severity of Problems) 3
- Documentation of symptoms occurring specifically during the luteal phase with resolution after menstruation begins
- Confirmation that symptoms significantly impair functioning 1
- Exclusion of other psychiatric disorders that may be exacerbated premenstrually
Treatment Options
First-line treatments:
Selective Serotonin Reuptake Inhibitors (SSRIs):
Combined Oral Contraceptives (OCPs):
- Primarily improve physical symptoms 3
- Work by suppressing ovulation and stabilizing hormone levels
Additional treatment options:
Non-pharmacologic approaches:
- Lifestyle modifications (diet, exercise)
- Cognitive behavioral therapy
- Vitamin and herbal supplements (e.g., chasteberry)
- Acupuncture 1
Other pharmacologic options:
- GnRH agonists (for severe cases)
- Non-contraceptive estrogen formulations 1
Differential Diagnosis
PMDD should be distinguished from:
- Premenstrual exacerbation of underlying psychiatric disorders
- Premenstrual syndrome (PMS) - milder form with less impact on functioning
- Major depressive disorder
- Anxiety disorders
Despite some symptomatic overlap with depression and anxiety disorders, PMDD is considered a distinct diagnostic entity with irritability and affect lability as its most characteristic features, rather than depressed mood or anxiety 6.
Clinical Pearls
- PMDD symptoms are cyclical and specifically tied to the menstrual cycle, unlike other mood disorders
- Prospective symptom tracking is essential for accurate diagnosis
- SSRIs show a more rapid onset of action in PMDD than in depression or anxiety disorders 6
- Cultural factors may influence the prevalence, expression, and reporting of symptoms 2
- Women with a history of mood disorders may be at higher risk for developing PMDD 4