DSM Criteria for Premenstrual Dysphoric Disorder (PMDD)
Core Diagnostic Criteria
PMDD is characterized by a pattern of mood symptoms (e.g., depressed mood, irritability), somatic symptoms (e.g., breast tenderness, bloating), or cognitive symptoms (e.g., forgetfulness) that begin several days before menses onset, start to improve within a few days after menses begins, and become minimal or absent within 1 week following menses onset 1.
Specific DSM Requirements
The DSM-IV/DSM-5 criteria for PMDD require the following elements 2, 3:
- At least 5 specified symptoms must be present during the luteal phase of most menstrual cycles 3, 4
- At least one symptom must be a core mood symptom from the following four: markedly depressed mood, marked anxiety or tension, marked affective lability (mood swings), or persistent anger or irritability 2, 4
- Additional symptoms may include: decreased interest in activities, difficulty concentrating, lack of energy, change in appetite or sleep, feeling out of control, and physical symptoms such as breast tenderness, headache, joint and muscle pain, bloating, and weight gain 2
Temporal Pattern Requirements
The diagnosis mandates specific timing characteristics 2, 3:
- Symptoms must occur regularly during the luteal phase (the 2 weeks prior to menses) 2
- Symptoms must remit within a few days following onset of menses 2
- Symptoms must be minimal or absent in the week following menses 1, 2
- The disturbance must markedly interfere with work, school, usual social activities, or relationships with others 2
Critical Diagnostic Requirements
Prospective daily symptom charting over at least two consecutive menstrual cycles is the diagnostic standard to confirm the temporal relationship between symptoms and the menstrual cycle 3, 5. Retrospective recall alone is insufficient for diagnosis 3.
- Meaningful change between postmenstrual and premenstrual symptom severity 3
- Clinically significant severity of symptoms that differentiates PMDD from normal menstrual cycle changes 3
- Exclusion of other medical and psychiatric conditions through differential diagnosis 3
- Recognition that no hormone or laboratory test indicates a PMDD diagnosis 3
Common Diagnostic Pitfalls
Do not diagnose PMDD based on retrospective recall alone—while 77% of women with premenstrual complaints retrospectively report irritability as impairing, prospective daily ratings are required to confirm the diagnosis 6, 3.
Be cautious about counting somatic symptoms toward the 5-symptom threshold—somatic symptoms are commonly reported but seldom cause functional impairment, and may not represent manifestations of the same syndrome as mood symptoms 6.
Rule out premenstrual exacerbation of underlying mood or anxiety disorders—these represent a different clinical entity requiring different treatment approaches 4, 3.
Recognize that literal application of DSM criteria (symptoms simply "present or absent") correctly identifies only 28% of symptomatic cycles—operational thresholds requiring 30% increase in premenstrual symptoms and 50% decrease in postmenstrual symptoms improve diagnostic accuracy to 92% 5.
Treatment Implications
First-Line Pharmacologic Treatment
Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacologic treatment for PMDD 7, 4. The FDA has established sertraline's efficacy in two placebo-controlled trials over 3 menstrual cycles 2.
SSRIs can be administered in two effective dosing patterns 2, 4:
- Continuous daily dosing throughout the menstrual cycle: Sertraline 50-150 mg/day was significantly more effective than placebo on all outcome measures 2
- Luteal phase dosing only: Sertraline 50-100 mg/day administered only during the last 2 weeks of the cycle (late luteal phase) and discontinued at menses onset was significantly more effective than placebo 2, 4
Unlike treatment of major depression, SSRIs for PMDD need not be given daily and can be effective when used cyclically, only in the luteal phase, or even limited to the duration of monthly symptoms 4.
Additional Treatment Options
Other evidence-based treatments include 7, 4:
- Oral contraceptive pills (OCPs) for ovulation suppression 7
- GnRH agonists for severe, refractory cases 7
- Calcium supplementation (1200 mg daily) as an adjunct 4
- Cognitive behavioral therapy as an adjunct to pharmacotherapy 7, 4
Treatment Monitoring
Reassess symptom patterns after 3 menstrual cycles of treatment to determine efficacy, as this was the duration used in FDA approval trials 2. The effectiveness of sertraline beyond 3 menstrual cycles has not been systematically evaluated in controlled trials 2.