Demystifying Disorders: Premenstrual Dysphoric Disorder

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We explore premenstrual dysphoric disorder (PMDD), a frequently misunderstood and misdiagnosed condition that therapists should understand for their licensing exams. PMDD is characterized as a severe form of PMS that significantly disrupts daily functioning with symptoms emerging during the luteal phase and improving shortly after menstruation begins.

• PMDD must be distinguished from other mood disorders by its cyclical pattern
• DSM criteria require at least five symptoms present in the week before menses, improving within days after onset
• Symptoms include marked affective lability, irritability, depression, anxiety, decreased interest in activities, and physical symptoms
• PMDD typically emerges after puberty with peak incidence in late 20s to early 30s
• Symptoms abate during pregnancy but typically return after delivery
• Common comorbidities include mood disorders, anxiety disorders, borderline personality disorder, and eating disorders
• First-line treatments include SSRIs and hormonal contraceptives
• Cognitive behavioral therapy shows strong outcomes for managing symptoms
• Assessment tools like the Daily Record of Severity of Problems help track symptoms over multiple cycles
• A multimodal approach combining medication, therapy, and lifestyle modifications is most effective

Remember that PMDD is in the DSM and represents a severe condition with significant functional impairment that distinguishes it from more common premenstrual symptoms.

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Episode Transcript

LINTON (00:00):
Welcome you, wonderful therapists, to the Licensure
Exam Podcast.
I'm Dr Linton Hutchinson andI'm joined today by my colleague
, stacey Frost.
Today we're exploringpremenstrual dysphoric disorder,
or PMD, a condition you'll needto understand just in case it
shows up on your licensing exam.

STACY (00:22):
PMDD is frequently misunderstood and misdiagnosed.
Let's distinguish it from otherconditions and understand its
unique characteristics.
Are you sure that's a diagnosisin the DSM Linton?

LINTON (00:33):
It sure is Stacey.
And if all you therapists outthere remember anything about
this podcast, remember that PMDDis a severe form of
premenstrual syndrome thatsignificantly disrupts daily
functioning.
Let me say that again,significantly disrupts daily
functioning.
The symptoms emerge during theluteal phase, which occurs after

(00:56):
ovulation and beforemenstruation begins.
What makes PMDD distinct is theintensity of emotional and
physical symptoms that canseverely impact a person's
quality of life.

STACY (01:09):
And the emotional symptoms include severe
depression, anxiety and markedirritability.
Women often report feelingcompletely overwhelmed by these
symptoms, leading todifficulties maintaining
relationships and meeting workobligations and meeting work
obligations.
The cyclical nature of thesesymptoms, with marked
improvement during or shortlyafter menstruation, creates a
unique pattern that helpsdistinguish PMDD from other mood

(01:31):
disorders.

LINTON (01:32):
The severity of symptoms can be so intense that many
women find themselveswithdrawing from social
activities and struggling withbasic daily tasks.
The anticipation of theserecurring symptoms can create
additional anxiety, leading to acycle of distress that affects
multiple areas of life.
The DSM outlines specificcriteria for diagnosing PMDD.

(01:52):
To meet the diagnosis, at leastfive symptoms must be present
in the final week before mensesstart improving within a few
days after onset and becomeminimal or absent in the week
post-menses.

STACY (02:08):
These symptoms must occur in the majority of menstrual
cycles.
The criteria specify that oneor more symptoms must include
marked affective lability,irritability or anger, depressed
mood, anxiety or tension.
Additional symptoms mightinclude decreased interest in
usual activities.
Difficulty concentratinginclude decreased interest in
usual activities, difficultyconcentrating, fatigue, appetite
changes, sleep problems,feeling overwhelmed, and

(02:30):
physical symptoms like breasttenderness or bloating.

LINTON (02:32):
It's important to note that these symptoms must cause
significant distress orinterference with work, school,
usual social activities orrelationships.
The disturbance shouldn'tmerely exacerbate another
disorder.
Disorder symptoms and symptomsmust be confirmed prospectively
during at least two symptomaticcycles.
Understanding the developmentand course of PMDD is essential

(02:55):
for accurate diagnosis andtreatment planning.
While PMDD typically emergesafter puberty, symptoms often
become more pronounced as womenprogress through their
reproductive years, with peakincidents occurring in the late
20s to early 30s.

STACY (03:11):
The cyclical nature of PMDD is a defining
characteristic.
Symptoms gradually increaseduring the luteal phase, peak
before menstruation and thenrapidly improve when
menstruation begins.
This pattern can persist formany years, potentially until
menopause, when hormonalfluctuations cease.

LINTON (03:29):
An interesting aspect of the course is that symptoms
typically abate during pregnancy, but tend to return after
delivery.
The severity can vary over time, influenced by factors such as
stress, lifestyle changes andunderlying health conditions.
Some women experienceprogressive worsening with age,
while others have periods ofremission followed by relapses.

(03:49):
The associated features of PMDDextend well beyond the core
diagnostic criteria.
Women often report significantdifficulty managing stress and
emotional reactivity, which canstrain relationships and
complicate conflict resolution.
Cognitive impairments affectingfocus, memory and
decision-making frequently occurduring symptomatic phases.

STACY (04:12):
Self-harm and suicidal ideation are serious concerns,
particularly during thesymptomatic phases.
Self-harm and suicidal ideationare serious concerns,
particularly during thesymptomatic phase.
Physical symptoms likemigraines and gastrointestinal
problems often accompany thecondition.
The intense discomfort cancreate a sense of physical
vulnerability and lead to socialisolation.

LINTON (04:30):
Feelings of shame and guilt about symptom severity are
common, potentiallycomplicating the clinical
picture and treatment engagement.
The impact on professional lifecan be substantial, with many
women reporting decreasedproductivity and challenges
maintaining stable employmentduring symptomatic periods.

STACY (04:49):
PMDD frequently co-occurs with other psychiatric
conditions, making accuratediagnosis and treatment planning
more complex.
Mood disorders, particularlymajor depressive disorder and
bipolar disorder, are commoncomorbidities.
The cyclical nature of PMDD cansometimes mirror bipolar
disorder's presentation,requiring careful differential
diagnosis.

LINTON (05:10):
Anxiety disorders, including generalized anxiety
disorder, panic disorder andsocial anxiety disorder, often
accompany PMDD.
The prevalence of borderlinepersonality disorder is also
increased in women with PMDD,characterized by emotional
instability and interpersonaldifficulties that can intensify

(05:30):
during the premenstrual phase.

STACY (05:32):
Eating disorders, especially binge eating disorder
and bulimia nervosa, frequentlyco-occur with PMDD.
Some women may use maladaptiveeating behaviors as a way to
cope with emotional distress.
Substance use disorders arealso more common, as individuals
might attempt to self-medicatetheir symptoms.
Evidence-based treatmenttypically involves a combination

(05:53):
of pharmacological andnon-pharmacological
interventions.
Selective serotonin reuptakeinhibitors are considered
first-line pharmacologicaltreatment.
They are effective when takeneither continuously or during
the luteal phase only.

LINTON (06:07):
Hormonal contraceptives have shown effectiveness in
stabilizing symptoms byregulating hormonal fluctuations
.
The continuous use of thesemedications can help suppress
ovulation and reduce symptomseverity.

STACY (06:20):
Cognitive behavioral therapy has demonstrated strong
outcomes in managing PMDDsymptoms.
This approach helps identifyand challenge negative thought
patterns while developingeffective coping strategies.
Additionally, mindfulness-basedinterventions and lifestyle
modifications, including regularexercise and dietary changes,
play significant roles incomprehensive treatment.

LINTON (06:39):
A multifaceted approach typically yields the best
results when implementinginterventions.
This includes medicationmanagement, psychotherapy and
lifestyle modifications tailoredto individual needs.
The goal is to address both thephysical and emotional aspects
of PMDD.

STACY (07:00):
Key therapeutic techniques include cognitive
restructuring, which helpsidentify and challenge negative
thought patterns related to PMDDsymptoms.
This involves examiningautomatic thoughts about the
condition and developing morebalanced perspectives.

LINTON (07:14):
Behavioral activation strategies help people maintain
engagement in daily activitiesdespite symptom-related
challenges.
These strategies might involvescheduling pleasant activities
during vulnerable periods anddeveloping contingency plans for
high-stress situations.

STACY (07:31):
Emotional regulation techniques such as deep
breathing exercises andprogressive muscle relaxation
provide practical tools formanaging intense emotions.
These skills becomeparticularly valuable during the
luteal phase, when emotionalreactivity typically increases.
The daily record of severity ofproblems is a primary
assessment tool that trackssymptoms over multiple menstrual

(07:52):
cycles.
This detailed tracking helpsestablish the temporal
relationship between symptomsand menstrual phases.

LINTON (08:00):
The premenstrual symptom screening tool provides
standardized measurements ofsymptom severity, helping
differentiate PMDD from otherconditions.
This tool is handy for initialscreening and monitoring
treatment progress.

STACY (08:14):
Additional instruments include the Calendar of
Premenstrual Experiences, whichrecords both symptom severity
and functional impact.
The Hamilton Depression RatingScale and Beck Anxiety Inventory
help assess concurrent mood andanxiety symptoms.
Let's summarize the key pointsabout PMDD.
This condition represents asevere form of premenstrual

(08:35):
syndrome with a significantimpact on functioning, requiring
careful differential diagnosisfrom other mood disorders.

LINTON (08:41):
Accurate diagnosis relies on prospective symptom
tracking and careful attentionto the timing of symptoms in
relation to the menstrual cycle.
The presence of significantfunctional impairment
distinguishes PMDD from morecommon premenstrual symptoms.

STACY (08:58):
Treatment typically combines pharmacological
approaches like SSRI withtherapeutic interventions such
as CBT and lifestylemodifications.
This multimodal approachaddresses both the biological
and psychological aspects of thecondition.

LINTON (09:13):
Understanding common comorbidities and differential
diagnoses is essential foraccurate diagnosis and treatment
planning.
Regular assessment andmonitoring help ensure treatment
effectiveness and guidenecessary adjustments to the
treatment plan.

STACY (09:30):
And remember it's in there.