Diagnosis: Premenstrual Dysphoric Disorder (PMDD)
The diagnosis is D. Premenstrual Dysphoric Disorder (PMDD), based on the characteristic temporal pattern of severe mood symptoms (irritability, insomnia, suicidal thoughts) beginning 5 days before menstruation in a patient with dysmenorrhea. 1
Diagnostic Reasoning
Temporal Pattern is Pathognomonic
The key diagnostic feature distinguishing PMDD from other psychiatric disorders is the luteal phase timing: symptoms must begin several days before menses onset, improve within a few days after menses begins, and become minimal or absent within one week following menses. 1 This patient's 5-day premenstrual onset perfectly matches this pattern.
Symptom Profile Matches PMDD
The patient presents with the classic triad of PMDD symptoms:
- Mood symptoms: Irritability is the hallmark feature of PMDD, more characteristic than depressed mood itself 2
- Cognitive/neurovegetative symptoms: Insomnia is a recognized neurovegetative symptom 1
- Severe affective symptoms: Suicidal thoughts represent the severe end of the PMDD spectrum, affecting 3-8% of menstruating women 3, 4
Why Not the Other Options?
- Bipolar Disorder (A): Would show mood episodes lasting days to weeks independent of menstrual cycle timing, not strictly confined to the luteal phase 5
- Generalized Anxiety Disorder (B): Presents with persistent worry and anxiety symptoms throughout the month, not cyclical luteal-phase-only symptoms 2
- OCD (C): Characterized by obsessions and compulsions present continuously, not menstrually-linked symptoms 2
Clinical Significance
PMDD is a distinct clinical entity, not a variant of depression or anxiety disorder, despite sharing treatment modalities with both. 2 The disorder affects 3-8% of menstruating women and represents the severe, disabling end of the premenstrual disorder spectrum. 3, 4
Critical Diagnostic Pitfall
Do not confuse PMDD with premenstrual magnification/exacerbation of an underlying psychiatric disorder. 6, 7 The distinguishing feature is that PMDD symptoms become minimal or absent within one week after menses, whereas premenstrual magnification involves worsening of baseline symptoms that persist throughout the cycle. 1
Confirmation Strategy
Prospective daily symptom charting for at least two consecutive menstrual cycles is essential for accurate diagnosis, as retrospective reporting can be unreliable. 6 The patient should document when symptoms begin relative to menses onset and when they resolve.
Treatment Implications
First-line treatment is selective serotonin reuptake inhibitors (SSRIs), which can be administered either continuously or intermittently during the luteal phase only. 3, 6, 4, 7 Unlike depression treatment, SSRIs for PMDD have a rapid onset of action and need not be given daily. 3, 2