Premenstrual Dysphoric Disorder Clinical Presentation

Updated: Sep 15, 2021
  • Author: Thwe T Htay, MD, FACP; Chief Editor: Ana Hategan, MD, FRCPC  more...
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The most common primary symptom of premenstrual dysphoric disorder (PMDD) is irritability. The common symptoms of breast pain and bloating differ from those of women with a major depressive disorder.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), established 5 criteria (A through E) for the diagnosis of PMDD. [17]

Criterion A defines that in the majority of menstrual cycles, at least 5 symptoms of the following 11 symptoms (including at least 1 of the first 4 listed) must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.

  • Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

  • Marked anxiety, tension, feelings of being “keyed up” or “on edge”

  • Marked affective lability (eg, mood swings; feeling suddenly sad or tearful or experiencing increased sensitivity to rejection)

  • Persistent and marked anger or irritability or increased interpersonal conflicts

  • Decreased interest in usual activities (eg, work, school, friends, and hobbies)

  • Subjective sense of difficulty in concentrating

  • Lethargy, easy fatigability, or marked lack of energy

  • Marked change in appetite, overeating, or specific food cravings

  • Hypersomnia or insomnia

  • A subjective sense of being overwhelmed or out of control

  • Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain

The symptoms must have been present for most of the time during the last week of the luteal phase, must have begun to remit within a few days of the onset of menstrual flow, and must be absent in the week after menses.

Criterion B stipulates that the symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others. 

Criterion C stipulates that the symptoms must be discretely related to the menstrual cycle and must not merely represent an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although the symptoms may be superimposed on those of any of these disorders). [18]

Criterion D is that criteria A should be confirmed by  prospective daily ratings during at least 2 consecutive symptomatic menstrual cycles. The diagnosis may be made provisionally before this confirmation.

Criterion E is that the symptoms are not due to the physiological effects of a substance (e.g., drug abuse, medication or other treatment) or another medical condition (e.g., hyperthyroidism).

Of the 11 symptoms listed in DSM-5, 10 are emotional and behavioral in nature; only 1 includes multiple common physical symptoms. Thus, PMDD defines a narrow group of women with the most severe premenstrual emotional symptoms, with functional impairment, and without a concurrent Axis I or Axis II disorder that is exacerbated premenstrually.

Women who meet the PMDD criteria are coded on Axis I as depressive disorder not otherwise specified. Obviously, this classification excludes many women presenting with predominantly physical premenstrual symptoms or with premenstrual exacerbation of underlying Axis I or II disorders. The DSM-5 criteria do state that PMDD may be superimposed on Axis I or II disorders; however, it is not clear how to differentiate between exacerbation of an Axis I or II disorder and superimposition on the symptoms of such a disorder.

Because depression is a common symptom of PMDD, suicide is a risk. A case-control study of fertile females with regular menstrual cycles who attempted suicide (with blood donors used as controls) showed that attempts during the luteal phase were no more frequent in females with PMDD than in those without. [19] However, PMDD was more prevalent in those who attempted suicide than in those who did not. This suggests that PMDD may not be associated with suicidal acts during the luteal phase, when premenstrual symptoms are present.

Several scoring systems are available for symptom quantification. It has been suggested that a within-cycle increase from follicular to luteal phase score (demonstrating “on-offness”) of at least 50% is necessary to confirm the diagnosis of PMDD and to warrant psychopharmacologic intervention. The within-cycle percentage change is calculated by subtracting the follicular score from the luteal score divided by the luteal score and multiplying the result by 100, as follows:

[Luteal score – (follicular score/luteal score)] × 100

More than 60 instruments have been used for symptom recording. Visual analog scales have been used in some studies. It is also common to score symptoms on a Likert scale ranging from “not present” to “severe.” A 24-item form called the Daily Record of Severity of Problems incorporates all of the DSM-5 symptoms of PMDD. As might have been expected from the large number of scoring instruments in use, a review of the scoring methods used in most studies did not find any of them to offer unique advantages.


Physical Examination

The findings from the physical examination are usually unremarkable. Mild swelling of the ankles, feet, and fingers may occur secondary to fluid retention. Breast tenderness may be present.

A Mental Status Examination (MSE) may be abnormal only during the latter part of the luteal phase as described below. The following findings usually are not apparent during other phases of the menstrual cycle

  • General appearance may be affected; patients may appear anxious or frustrated

  • Behavior may be altered; patients may appear irritable

  • Orientation is normal

  • Memory is normal

  • Concentration may be affected

  • Impulse control may be normal or poor

  • Speech rate and flow may be slow if the depressive symptoms are predominant.

  • Mood and affect changes (eg, depression, anxiety, tension, self-depreciation, and anger) are common

  • Thoughts and perception are not affected

  • There is a theoretical danger of suicidal ideation and behaviors in patients with severe depression