Demystifying Premenstrual Dysphoric Disorder (PMDD)

Clients with premenstrual dysphoric disorder (PMDD) say:

“I feel like I’m going crazy.” 

“I feel like I’ve become a completely different person during this time.”

“I actually think this has been going on for my whole life.” 

I hear statements like this all the time in my practice from women or individuals assigned female at birth (AFAB) who are struggling with premenstrual dysphoric disorder, or PMDD.

For those unfamiliar with PMDD, the International Association of Premenstrual Disorders (IAPMD) defines PMDD as “a cyclical, hormone-based mood disorder with symptoms arising during the premenstrual, or luteal, phase of the menstrual cycle and subsiding within a few days of menstruation.” 

Premenstrual dysphoric disorder falls underneath the reproductive mental health umbrella—but many mental health providers aren’t familiar or comfortable with this diagnosis, or what it means for their clients. 

What Is Premenstrual Dysphoric Disorder (PMDD)?

While contentiously debated in the past, recent research has shown that premenstrual dysphoric disorder is a very real and debilitating condition.

In fact, approximately five to ten percent of women or people AFAB who are of reproductive age struggle with this condition, which wreaks havoc on someone’s emotions, mood, interpersonal relationships, and how they function at work, among other things.

Common symptoms of PMDD include depressed mood, severe irritability or anger, hopelessness, self-deprecating thoughts, brain fog, and appetite changes—just to name a few. 

When in the luteal phase, some people with premenstrual dysphoric disorder may even experience suicidal thoughts—as was highlighted in the case of Gia Allemand, an American actress, model, and television contestant from the Bachelor, who suffered with PMDD throughout her life and, unfortunately, died by suicide nearly a decade ago in 2013. 

Her death sparked widespread interest in PMDD and its huge impact on people struggling with it. 

What Causes PMDD?

Contrary to earlier beliefs, premenstrual dysphoric disorder isn’t caused by a hormone imbalance.

Rather, research now points toward a cellular disorder in the brain, which results in the individual’s brain reacting severely and negatively to the normal rise and fall of hormones throughout the menstrual cycle. While it’s common for women or people AFAB who are of reproductive age to report at least one premenstrual change during menstruation—like dysphoria, irritability, bloating, or fatigue—the number of people who experience PMDD is much smaller. 

Here’s a simple analogy to help break it down: premenstrual syndrome, or  PMS, is to a headache as PMDD is to a migraine. For those experiencing PMDD first-hand, this may feel like an understatement. Some people in the PMDD community even refer to the luteal phase as “hell week”—to give you an understanding of the suffering brought on by this condition. 

The Challenges of Assessing PMDD

Premenstrual dysphoric disorder is a complex diagnosis, and can be extremely difficult to assess and successfully treat. However, as mental health providers, we have a responsibility to educate ourselves and consider it where appropriate. PMDD and its diagnostic relatives are frequently missed, overlooked, or dismissed by healthcare providers.

This could be for a variety of reasons, but in my experience, it’s because of a lack of training and knowledge, as well as being guided by gender and cultural biases and stereotypes. 

Female or AFAB clients can often be seen and labeled as dramatic or intense, or even borderline. A Black woman can easily be perceived and dismissed as “the angry Black woman” stereotype, or a Latinx client as the “spicy Latina.” Part of our responsibility as mental health providers is to conduct a disciplined inquiry when assessing, diagnosing, and treating all our clients, and do our due diligence to rule out PMDD as a possibility.

This is especially true when the presenting symptoms are cyclical in nature, or when there’s a history of trauma. 

There are other challenges when it comes to diagnosing PMDD—including difficulty gathering objective data from clients, or a client’s inconsistent treatment engagement and participation. This can be especially challenging when a client is experiencing the worst of their symptoms, which may result in things like missing appointments during their luteal phases, dysphoric thoughts regarding the usefulness of treatment, or feeling hopeless that they’ll ever find relief. Some clients even report being misdiagnosed with bipolar disorder or other disorders—and when they’re treated for those disorders, they experience no improvement, or worse, exacerbation of their symptoms. 

How Therapists Can Help Support Clients With PMDD

While premenstrual dysphoric disorder may not be a particular area of focus within your practice, routinely screening for it can be advantageous for your clients. The quicker an individual is accurately diagnosed, the sooner they can begin appropriate treatment or be referred to a provider who specializes in reproductive mental health, if that’s what’s necessary. 

During the screening and diagnostic process, you can gather helpful data by obtaining daily ratings for at least two consecutive symptomatic cycles. This can also help you further clarify and differentiate the symptoms your client is experiencing from other mood disorders, anxiety disorders, or premenstrual exacerbation (PME) of underlying mood and anxiety disorders. 

When it comes to treatment for PMDD and PME of underlying mood disorders, every client is unique—so it’s important to take a tailored approach and make sure you’re meeting the unique needs of each client. But, here are a few resources and steps you can take to learn more. 

1. Get Informed

If this is your first time hearing or learning about premenstrual dysphoric disorder, I’d encourage you to start with the basics. Review the DSM-5 criteria for PMDD, and familiarize yourself with what to watch for and what would meet diagnostic criteria. The International Association of Premenstrual Disorders is a great resource to learn more about PMDD and the current evidence-based management of premenstrual disorders.

2. Stay Informed

Although educating yourself is a good start, it’s important to keep up that knowledge as the field evolves. Seek out training opportunities in the area of reproductive mental health if that’s something you want to work with more in your practice. These trainings can help deepen your knowledge about PMDD and give you tools to diagnostically differentiate PMDD from other reproductive mental health conditions. 

3. Connect With Others

Whether this is a new area for you or not, all clinicians can benefit from the expertise and experience of others who are doing the same work. Find ways to connect with providers in your area that give consultation or supervision on these topics, so you can expand your knowledge and better serve your clients. The IAPMD has a variety of different peer support groups you can use as a starting point. 

Although we’ve seen dramatic progress in awareness and proper training for some reproductive mental health issues—like perinatal mood and anxiety disorders—in the past few years, we still have a way to go for others, like PMDD.

This article is by no means exhaustive, but I hope it serves as a springboard for the continued development of your own education, knowledge, skills, and self-awareness.

In the words of Goethe, “Knowing is not enough; we must apply. Willing is not enough; we must do.”

Together, we can cast wider, see further, and listen deeper. 

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