Diagnostic Process for Premenstrual Dysphoric Disorder (PMDD)
PMDD diagnosis requires prospective daily symptom tracking for at least two consecutive menstrual cycles to confirm that symptoms occur exclusively during the luteal phase and resolve during or shortly after menstruation. 1, 2
Core Diagnostic Requirements
Prospective symptom charting over 2 menstrual cycles is mandatory to confirm the diagnosis and rule out other psychiatric conditions that may worsen premenstrually. 2, 3 This is non-negotiable because symptoms can vary significantly from cycle to cycle, and retrospective recall is unreliable. 1
Validated Tracking Tools
- Use the Daily Record of Severity of Problems (DRSP), a validated prospective survey instrument specifically designed for PMDD diagnosis. 1
- Alternative validated instruments or symptom-tracking diaries designed by clinicians can also be used to document the cyclic pattern. 2
Symptom Timing Pattern (Critical Diagnostic Feature)
Symptoms must occur only during the luteal phase of the menstrual cycle (the approximately 2 weeks before menstruation) with a symptom-free interval after menstrual flow begins and before ovulation. 4 This timing is the key distinguishing feature of PMDD. 4
- Symptoms should resolve during menstruation or within the week following it. 1
- The presence of symptoms throughout the entire month rules out PMDD and suggests another underlying psychiatric or medical condition. 1
DSM-5 Diagnostic Criteria Application
For PMDD diagnosis, symptoms must substantially interfere with work, school, social activities, or relationships, or cause significant distress. 1 This distinguishes PMDD from milder premenstrual syndrome. 5
The American Psychiatric Association's DSM-5 and the World Health Organization's ICD-11 both recognize PMDD as a distinct diagnostic entity with specific criteria including irritability and affect lability. 6
Essential Differential Diagnosis Workup
Rule out medical and psychiatric conditions that cause similar symptoms before confirming PMDD:
- Medical conditions to exclude: diabetes, hypothyroidism (check thyroid function tests). 4
- Psychiatric conditions to exclude: major depressive disorder, dysthymia, generalized anxiety disorder, bipolar disorder. 4
- These conditions may worsen premenstrually (premenstrual exacerbation) but do not have the symptom-free follicular phase that characterizes PMDD. 5
Required Clinical Assessment
- Complete family and personal history of mental disorders and medical diseases. 2
- Thorough physical examination. 2
- Basic laboratory tests to identify or rule out potential medical causes of symptoms. 2
Common Diagnostic Pitfall
The most common error is diagnosing PMDD based on retrospective patient recall alone without prospective symptom tracking. 2 Many women with bothersome premenstrual symptoms go undiagnosed either because they don't report symptoms or because clinicians fail to require the mandatory 2-cycle prospective documentation. 2
When to Reassess the Diagnosis
If symptoms persist throughout the month or do not respond to appropriate PMDD treatments, reassess for another underlying cause. 1 This indicates the diagnosis may be incorrect and another psychiatric or medical condition is present.