Premenstrual dysphoric disorder (PMDD)

Friday lunch in the old house in Armanitola means four generations, a handi of kacchi from the shop at the corner, and an argument about the potato. This Friday, Dola, 31, a lawyer, snaps at her cousin over the last piece so sharply that the table goes quiet. Her little brother, Tanim, unhelpful as ever, has drawn a cartoon weather chart on the fridge. “Dola apa forecast: storm warning. Do not discuss politics.”

Everyone laughs, and Dola laughs too, because he is not wrong. For about a week each month she is irritable, tearful, sure that her colleagues despise her, and too tired to read a brief. Then her period starts, and within days she is herself again, apologising. She tells her friend at the court canteen, over cha: “One week a month, I become someone else.”

An illustration drawn from common experience. The person is invented; the pattern is not.

Understanding PMDD

Premenstrual dysphoric disorder is a severe, cyclical condition in which marked mood symptoms, such as irritability or anger, low mood, anxiety, mood swings and feeling out of control, appear in the week or so before a period, improve within a few days after it starts, and are minimal in the week after. Physical symptoms such as bloating, breast tenderness, tiredness and sleep changes often come with them. It is more severe than ordinary premenstrual syndrome and interferes with work and relationships. DSM-5-TR lists it among the depressive disorders. A confirmed diagnosis needs daily symptom ratings over two cycles, because memory alone can mislead.

How common is PMDD?

In a meta-analysis of 44 studies with 50,659 participants, the pooled prevalence of PMDD was 3.2% when the diagnosis was confirmed with daily ratings, and 7.7% when it was provisional. Restricted to community samples with a confirmed diagnosis, it was 1.6%. The authors note that studies relying on provisional diagnosis are likely to overestimate it.

Signs and symptoms of PMDD

• The same mood changes arriving at the same point each month
• Irritability or anger that surprises you and others
• Sudden sadness, tearfulness or feeling rejected
• Relief within a few days of the period starting
• Arguments, missed work or regret that follow the calendar

Treatment for PMDD

The first step is a daily diary of symptoms across two cycles, which shows the pattern clearly. A psychiatrist also looks for depression, anxiety or bipolar disorder that may be present all month and worsen before a period, and checks physical health, including the thyroid. A Cochrane review of 31 randomised trials found that SSRI antidepressants reduced premenstrual symptoms, whether taken only in the second half of the cycle or every day. Side effects such as nausea and low energy were common and depended on the dose, so the choice is made together. Some women also see a gynaecologist about other options.

What getting better can look like

In Dola’s case it might be a diary that turns a mystery into a pattern, a treatment that takes the edge off, and a Friday when Tanim’s forecast says “clear skies”, and is right.

Common questions about PMDD

What is the difference between PMS and PMDD?

Many women have some premenstrual symptoms. PMDD is a more severe condition in which mood symptoms such as irritability, low mood or anxiety are strong enough to disrupt work and relationships, then ease after the period starts. Tracking symptoms daily over two cycles helps confirm it.

What is the treatment for PMDD?

A Cochrane review of 31 trials found that SSRI antidepressants reduce premenstrual symptoms, whether taken only in the two weeks before a period or every day. Side effects such as nausea and tiredness are common and depend on the dose. A doctor will also check for other mood conditions and discuss options with you.

When to see a psychiatrist

If the same week every month brings mood changes that damage your work, relationships or sense of yourself, it is worth an assessment. If those days ever bring thoughts of suicide, call 999.

Care here is personal: built around your history, your health and what you want to change, and reviewed with you as it goes.

Sources

• Reilly et al., Journal of Affective Disorders, 2024 (PMID 38199397)
• Marjoribanks et al., Cochrane Database of Systematic Reviews, 2013 (PMID 23744611)