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Let’s Talk About Premenstrual Dysphoric Disorder

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The menstrual cycle isn’t just about the days when your period starts and ends. Natural hormonal changes occur throughout the cycle, and some people may notice differences in their bodies, energy levels, or emotions as a result of these changes. For example, some individuals might feel more tired as their period approaches; some experience changes in sleep or appetite; some have trouble concentrating; and some might notice that emotions feel a bit more intense, or all of these can be experienced simultaneously. Because experiences vary from person to person. Even the same person’s experience may not be exactly the same every month. For this reason, when discussing premenstrual experiences, it is not possible to speak of a single, universal experience that applies to everyone. (Hantsoo & Payne, 2023; Nappi et al., 2022). 

And for some, these changes may be more pronounced and have a greater impact on daily life. For example, it may take more effort to concentrate, changes in energy levels may affect daily plans, or emotional symptoms may become more noticeable in relationships, at work, or at school. A person may also notice that these symptoms do not occur randomly but follow a recurring pattern during a specific phase of the menstrual cycle.

Premenstrual Dysphoric Disorder (PMDD) is a cyclical mood disorder in which these types of emotional, cognitive, behavioral, and physical symptoms follow a distinct pattern associated with the menstrual cycle. However, experiencing some premenstrual symptoms does not mean that a person has PMDD. When evaluating PMDD, it is also important to consider when they appear during the cycle, when they subside, and how much they affect the person’s daily life in addition to the type of symptoms. For this reason, tracking the pattern of symptoms over time plays a key role in understanding and evaluating PMDD. In this therapy sketch, we will discuss the symptoms of PMDD, its relationship to the menstrual cycle, and how various treatment options, particularly psychotherapy, can support.

What Is PMDD?

Premenstrual Dysphoric Disorder (PMDD) is a cyclical mood disorder associated with the menstrual cycle and can be experienced across several areas of daily life. PMDD is a condition involving significant emotional, cognitive, behavioral, and physical symptoms that follow a clear pattern across the menstrual cycle.

According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders by APA), symptoms typically appear during the final week before menstruation, begin to improve within a few days after the period starts, and become minimal or absent during the following week. Some of the experiences associated with PMDD may include:

  • Emotional: Noticeable mood swings or feeling more emotionally sensitive, increased irritability or anger, feeling depressed, hopeless, or overly critical of yourself, or feeling anxious, tense, or on edge.
  • Cognitive: Difficulty in concentrating and staying focused
  • Behavioral and motivational: Losing interest in activities you usually enjoy and feeling unusually tired can be common. Some changes can also include feeling overwhelmed or out of control and experiencing increased conflict with others.
  • Physical: Changes in our body, including breast tenderness or swelling, headaches, joint or muscle pain, bloating, or a feeling of weight gain, can be more prominent. Appetite and sleep changes may also occur.

For an official PMDD diagnosis, the impact these symptoms have on our everyday lives is also considered, including our jobs or school and also relationships.

But these experiences can vary in both intensity and combination, which has made defining PMDD a complex process. So, how did PMDD come to be recognized as a diagnosis? 

How Did PMDD Become a Part of Diagnostic Guidelines?

Although the changes associated with the menstrual cycle have long been recognized, a long-standing debate has centered on when these experiences should be considered a clinical condition. A significant part of the debate centered on how to distinguish between natural changes that may occur before menstruation and symptoms that significantly impact daily life and recur regularly.  

The need to make this distinction more clearly has also shaped how PMDD has been defined and evaluated over time. PMDD first appeared in the DSM-III-R, published in 1987, under the name “Late Luteal Phase Dysphoric Disorder.” However, at that time, it was not an official diagnosis; it was listed in an appendix of conditions requiring further research (Cirillo et al., 2014) . 

With the publication of the DSM-IV in 1994, the term “Premenstrual Dysphoric Disorder (PMDD)” began to be used, though PMDD was still listed among diagnoses requiring further research. At this point, there was still not enough research to clearly understand premenstrual experiences or how consistently it could be assessed (Cirillo et al., 2014) .

Consequently, with the publication of the DSM-5 in May 2013, PMDD moved out of the appendix and became an official diagnosis within the Depressive Disorders chapter. This change aimed to provide a clearer framework for determining what counts as PMDD and what does not. For example, having premenstrual symptoms alone is not enough for a PMDD diagnosis. DSM-5 requires a pattern of at least five symptoms, including at least one core mood symptom, such as affective lability, irritability, depressed mood, or anxiety. The symptoms must also be associated with clinically significant distress or interference with daily life. Timing is equally important, as the diagnostic criteria require daily symptom tracking across at least two symptomatic menstrual cycles (Cirillo et al., 2014). 

But becoming an official diagnosis did not mean that research was no longer needed. It also brought new debates around PMDD and its diagnosis.

Debates Surrounding the Diagnosis of PMDD

The acceptance of PMDD as an official diagnosis has sparked some long-standing debates. A significant portion of these debates has centered on how to draw the line between natural changes that can occur with the menstrual cycle and symptoms that cause clinically significant distress or impairment in functioning.

On one hand, there are concerns about the over-medicalization or pathologization of emotional and physical changes experienced during the premenstrual period (Schroll & Lauritsen, 2022). The menstrual cycle can bring a variety of emotional, cognitive, behavioral, and physical experiences that vary from person to person, and these changes alone do not indicate a diagnosis.

On the other hand, dismissing PMDD-related symptoms as merely an expected part of the menstrual cycle may lead to overlooking the distress experienced by some individuals or the impact on their daily lives. Arguments in favor of officially recognizing the diagnosis contend that a clearer definition of PMDD could contribute to the research of these experiences, their more reliable assessment, and ensuring that those in need have access to appropriate support.

At this point, it might be important to acknowledge that these two perspectives do not have to be mutually exclusive. It is possible to acknowledge that an experience can be challenging for a person and may require support without pathologizing it. At the same time, the presence of a diagnosis does not mean that everyone experiencing the same symptoms has the same experience.

For this reason, the evaluation of PMDD focuses not only on the presence of symptoms but also on the pattern they follow throughout the menstrual cycle, how long they last, and their impact on the person’s life. How the person makes sense of their own experience and what kind of support they need are also important parts of this process.

What Kinds of Support Are Available for PMDD?

As mentioned, the support needed may not be the same for everyone. Symptom type and intensity, their pattern throughout the menstrual cycle, and their impact on daily life can all shape which approaches are most appropriate.

Support options for PMDD generally include lifestyle and daily routine adjustments, psychotherapy, and medical treatments. Behavioral changes, such as exercise, dietary adjustments, and stress management, can help some people manage their symptoms. Medical treatments include options such as serotonin reuptake inhibitors (SRIs/SSRIs) and hormonal therapies. These approaches can be used alone, or multiple types of support can be considered together depending on the individual’s needs (Carlini et al., 2022; Tiranini & Nappi, 2022).

The Role of Psychotherapy in PMDD

PMDD may not be an experience limited solely to the days when symptoms appear. Recurring symptoms can affect daily routines, relationships, work or school life, the time a person can devote to themselves, and their overall well-being in various ways.

Psychotherapy can provide a space where a person can make sense of these experiences within the context of their own life and needs. In therapy, work can focus on recognizing how symptoms have changed over time, identifying challenging periods and needs, evaluating current coping strategies, and developing new strategies that might be helpful. These studies can be addressed in different ways depending on the therapeutic approach. For example:

  • Cognitive Behavioral Therapy (CBT): One of the psychotherapy approaches studied for PMDD is CBT. CBT may help individuals notice thought and behavior patterns that come up alongside PMDD symptoms and explore coping strategies that may be useful in managing their impact. Research indicates that cognitive-behavioral therapy is associated with greater shifts in attribution of premenstrual symptoms, use of cognitive-behavioral coping strategies, and good maintenance of treatment effects (Kleinstäuber et al., 2012).
  • Emotion-Focused Therapy (EFT): EFT focuses on helping individuals recognize and make sense of their emotional experiences and relate to their emotions in more functional ways. In a 2024 study conducted by Dehnavi and colleagues, EFT was found to address the emotional and behavioral symptoms associated with PMDD (Dehnavi et al., 2024).
  • Dialectical Behavior Therapy (DBT): The DBT-informed approach developed by Liveri and colleagues integrates DBT skills with a feminist, trauma-informed, and multidisciplinary framework (Oliveri et al., 2025). This approach centers on validating the individual’s experience, developing awareness of symptoms and needs, and building skills that can be applied in daily life. The model consists of four stages:
    • Assessment: Symptoms are tracked, and the individual’s clinical history, current needs, and therapy goals are evaluated together.
    • Empowerment: Space is created for the individual to make sense of their own experience; their experience is validated; and psychoeducation about PMDD is provided.
    • DBT Skills: Skills such as mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness are addressed according to the individual’s needs.
    • Review: The therapy process and current needs are reassessed; additional or alternative support options are planned as needed.

In summary, when working with PMDD, psychotherapy can be part of a support plan according to the person’s needs. For example, therapy may be the primary focus for some individuals, but others may benefit from medical treatments or a combination of different approaches. It is important to understand that there is not one size-fits-all plan, and even the needs may also change over time for the same person. Regardless of the diagnosis, a personalized approach helps individuals understand their own experiences and discover what works best for them.

Takeaways

  • PMDD is a cyclical mood disorder involving significant emotional, cognitive, behavioral, and physical symptoms that follow a clear pattern across the menstrual cycle and can affect daily life.
  • PMDD symptoms can include mood changes, irritability, anxiety, low mood, difficulty concentrating, fatigue, changes in sleep or appetite, physical discomfort, and feeling overwhelmed or out of control, with experiences varying across individuals and cycles.
  • Discussions around PMDD highlight the importance of recognizing people’s experiences while also considering concerns around the pathologization of menstrual experiences and the role diagnosis can play in recognition and access to care. 
  • Support for PMDD often includes lifestyle and daily routine adjustments, medical treatments, and psychotherapy, with multiple types of support considered together depending on the individual’s symptoms, needs, and their impact on daily life.
  • Psychotherapy can also provide support by creating a space to understand PMDD experiences, recognize patterns and needs, and develop coping strategies, with approaches such as CBT, EFT, and DBT-informed work offering different forms of support.

References:

  • Hantsoo, L., & Payne, J. (2023). Towards Understanding the Biology of Premenstrual Dysphoric Disorder: From Genes to GABA. Neuroscience and biobehavioral reviews, 149, 105168 – 105168. https://doi.org/10.1016/j.neubiorev.2023.105168
  • Nappi, R., Cucinella, L., Bosoni, D., Righi, A., Battista, F., Molinaro, P., Stincardini, G., Piccinino, M., Rossini, R., & Tiranini, L. (2022). Premenstrual Syndrome and Premenstrual Dysphoric Disorder as Centrally Based Disorders. Endocrines. https://doi.org/10.3390/endocrines3010012
  • Tiranini, L., & Nappi, R. (2022). Recent advances in understanding/management of premenstrual dysphoric disorder/premenstrual syndrome. Faculty Reviews, 11. https://doi.org/10.12703/r/11-11
  • Carlini, S. V., Di Scalea, T. L., McNally, S., Lester, J., & Deligiannidis, K. (2022). Management of Premenstrual Dysphoric Disorder: A Scoping Review. International Journal of Women’s Health, 14, 1783 – 1801. https://doi.org/10.2147/ijwh.s297062
  • Cirillo, P., Passos, R., Lopez, J. R., & Nardi, A. (2014). Will the DSM-5 changes in criteria for premenstrual dysphoric disorder impact clinical practice?. Revista brasileira de psiquiatria, 36 3, 271 . https://doi.org/10.1590/1516-4446-2013-1332
  • Cirillo, P., Passos, R., Lopez, J. R., & Nardi, A. (2014). Will the DSM-5 changes in criteria for premenstrual dysphoric disorder impact clinical practice?. Revista brasileira de psiquiatria, 36 3, 271 . https://doi.org/10.1590/1516-4446-2013-1332
  • Pearlstein, T. (2016). Treatment of Premenstrual Dysphoric Disorder: Therapeutic Challenges. Expert Review of Clinical Pharmacology, 9, 493 – 496. https://doi.org/10.1586/17512433.2016.1142371
  • Kleinstäuber M, Witthöft M, Hiller W. Cognitive-behavioral and pharmacological interventions for premenstrual syndrome or premenstrual dysphoric disorder: a meta-analysis. J Clin Psychol Med Settings. 2012;19:308–19. doi: 10.1007/s10880-012-9299-y. 
  • Oliveri A, Muir S, Mu E, Kulkarni J. Advancing psychological interventions for premenstrual dysphoric disorder: A dialectical behaviour therapy-informed treatment model. Aust N Z J Psychiatry. 2025 Aug;59(8):670-673. doi: 10.1177/00048674251348370. Epub 2025 Jun 27. PMID: 40576068; PMCID: PMC12375139. 
  • Dehnavi, S.I., Mortazavi, S.S., Ramezani, M.A. et al. Emotion-focused therapy for women with premenstrual dysphoric disorder: a randomized clinical controlled trial. BMC Psychiatry 24, 501 (2024). https://doi.org/10.1186/s12888-024-05681-8 
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