The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), established 4 research criteria (A through D) for the diagnosis of PMDD.
Criterion A is that in most menstrual cycles during the past year, at least 5 of the following 11 symptoms (including at least 1 of the first 4 listed) were present:
- 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, 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 is that the symptoms must be severe enough to interfere significantly with social, occupational, sexual, or scholastic functioning. For example, the patient may avoid social activities or exhibit decreased productivity and efficiency at work or school.
Criterion C is 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).
Criterion D is that criteria A, B, and C must be confirmed by prospective daily ratings during at least 2 consecutive symptomatic menstrual cycles. The diagnosis may be made provisionally before this confirmation.
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.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.
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
Premenstrual dysphoric disorder (PMDD) is underdiagnosed and undertreated. No definitive laboratory or ancillary procedure aids in the diagnosis, and no definitive treatment is available for the symptoms associated with the syndrome; however, many options are available.
Identifying and treating PMDD is challenging for a primary care physician. On one hand, a patient with another mood disorder may have preconceptions that she has premenstrual syndrome (PMS) or PMDD, and consequently, the diagnosis of PMDD may be incorrect. On the other hand, a patient may not have intellectually connected her symptoms to her menstrual cycle, and the diagnosis of PMDD may be missed. The correct diagnosis depends on extended patient education and correction of previously received misinformation.
In addition to the conditions listed in the differential diagnosis (see below), other problems to be considered include the following:
- Eating disorder
- Disorders of adrenal system
- Catamenial migraine
- Catamenial epilepsy
- Collagen-vascular disease
- Anxiety Disorders
- Bipolar Affective Disorder
- Chronic Fatigue Syndrome
- Dysthymic Disorder
- Panic Disorder
- Personality Disorders
- Physical Medicine and Rehabilitation for Systemic Lupus Erythematosus
- Somatic Symptom Disorders
The initial steps in evaluating a patient for premenstrual dysphoric disorder (PMDD) are aimed at excluding organic syndromes with manifestations similar to those of PMDD, such as thyroid disorders, anemia, perimenopause, and menopause. The role of laboratory studies is limited to screening for medical conditions considered in the differential diagnosis. Although some tests may be needed to reassure the patient, excessive testing can be counterproductive by making the patient more anxious.
Laboratory studies should include the following:
- Thyroid function tests
- Complete blood count (CBC)
- Follicle-stimulating hormone (FSH) level