Understanding PMS and PMDD: From DSM-5-TR Criteria to Cultural and Historical Contexts

Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) affect millions of women worldwide but remain widely misunderstood. Though both are linked to the menstrual cycle, PMS and PMDD differ significantly in symptom severity, diagnostic criteria, treatment approaches, and cultural interpretations. This comprehensive guide explores the clinical definitions, latest DSM-5-TR updates, and the historical and cultural contexts that shape our understanding of these conditions.

If you or someone you know struggles with PMS or PMDD, this post provides valuable insights on when to seek professional help and the latest evidence-based treatment options.

What Is Premenstrual Syndrome (PMS)?

PMS is a common condition marked by a cluster of physical and emotional symptoms that occur cyclically with the menstrual cycle. Symptoms typically arise 1 to 2 weeks before menstruation and subside within a few days after menstruation begins.

Common PMS Symptoms Include:

• Mood swings and irritability

• Breast tenderness and swelling

• Bloating and abdominal discomfort

• Fatigue and sleep disturbances

• Headaches

• Food cravings and appetite changes

• Mild anxiety or sadness

For most individuals, PMS symptoms are mild to moderate and do not significantly interfere with daily functioning. It is estimated that 70–90% of menstruating women experience some form of PMS during their reproductive years (Baker & Kronenberg, 2020).

What Is Premenstrual Dysphoric Disorder (PMDD)?

PMDD is a more severe and disabling form of premenstrual distress. Unlike PMS, PMDD causes intense emotional and physical symptoms that can seriously impair daily life and interpersonal relationships.

Key Features of PMDD:

• Severe mood swings, including irritability, anger, anxiety, or deep sadness

• Marked depressive symptoms, including hopelessness and suicidal ideation

• Physical symptoms similar to PMS but more debilitating

• Symptoms cause clinically significant distress and functional impairment

• Symptoms follow a cyclical pattern, worsening in the luteal phase and improving after menstruation starts

PMDD affects approximately 1.8–5.8% of women of reproductive age globally (Steiner et al., 2022), making it less common than PMS but more impactful in terms of mental health.

Understanding the DSM-5-TR Diagnostic Criteria for PMDD

The DSM-5-TR (American Psychiatric Association, 2022) classifies PMDD as a depressive disorder, emphasizing its psychiatric significance.

Diagnostic criteria include:

• Symptom Quantity and Type: At least five symptoms during the final week before menses, including at least one core mood symptom (affective lability, irritability/anger, depressed mood, or anxiety).

• Timing: Symptoms appear in the luteal phase, improve within a few days after menstruation begins, and are minimal or absent postmenses.

• Severity: Symptoms cause clinically significant distress or impairment in work, school, social activities, or relationships.

• Confirmation: Diagnosis confirmed by prospective daily symptom ratings over at least two menstrual cycles to rule out other disorders.

PMS lacks formal DSM diagnostic criteria and is typically diagnosed based on symptom history.

How Common Are PMS and PMDD?

• PMS affects about 70–90% of menstruating individuals during reproductive years (Baker & Kronenberg, 2020).

• PMDD affects approximately 1.8–5.8% of reproductive-age women worldwide (Steiner et al., 2022).

The high prevalence highlights the need for awareness, accurate diagnosis, and effective treatment.

The Biological and Hormonal Science Behind PMS and PMDD

Contrary to common belief, PMS and PMDD are not caused by abnormal hormone levels. Instead, the brain’s increased sensitivity to normal hormonal fluctuations, especially progesterone and its metabolite allopregnanolone, plays a key role. These interact with GABA receptors, affecting mood regulation and stress response (Schmidt, Rubinow, & Roca, 2023).

Additional biological factors include:

• Altered serotonin signaling, explaining SSRI efficacy (Epperson, Steiner, & Hartlage, 2021)

• Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis

• Genetic predisposition (Huo et al., 2023)

This understanding has paved the way for novel treatments targeting brain neurotransmitters and hormonal pathways.

Comparing PMS and PMDD Symptoms

Symptom Category	Premenstrual Syndrome (PMS)	Premenstrual Dysphoric Disorder (PMDD)
Mood	Mild irritability, sadness, mood swings	Severe anger, anxiety, depression, affective lability
Physical	Bloating, fatigue, breast tenderness	Similar symptoms but more intense and disabling
Impact	Temporary discomfort, mild interference	Major functional impairment, daily life disruption
Diagnosis	Clinical observation, symptom history	DSM-5-TR criteria with prospective symptom tracking

Risk Factors and Triggers

Genetic and Biological Factors

• Family history of PMS/PMDD increases risk.

• History of mood disorders like depression and anxiety.

Environmental and Lifestyle Factors

• Chronic stress and trauma worsen symptoms.

• Poor sleep quality exacerbates mood symptoms.

• Nutritional deficiencies and lack of exercise contribute to severity.

Evidence-Based Treatments

Managing PMS

• Lifestyle changes: Regular exercise, stress management, yoga, and meditation.

• Supplements: Calcium, magnesium, vitamin B6.

• Medications: NSAIDs for pain relief.

Treating PMDD

• SSRIs: First-line treatment, taken daily or during the luteal phase (Borenstein et al., 2022; Epperson, Steiner, & Hartlage, 2021).

• Cognitive Behavioral Therapy (CBT): Mood regulation and coping.

• Hormonal contraceptives: Ovulation suppression reduces symptoms.

• GnRH agonists: For severe, treatment-resistant cases.

• Emerging neurosteroid modulators show promise (Schmidt, Rubinow, & Roca, 2023).

• Combining therapies often yields the best results (Rapkin & Akopians, 2021).

Historical Perspectives

• Ancient Greece: Premenstrual symptoms were misattributed to “wandering womb” and hysteria (Canguilhem, 1991).

• Mid-20th Century: Dr. Katharina Dalton coined “Premenstrual Syndrome” and introduced hormone treatments (Dalton, 1953).

• Modern Psychiatry: Formal recognition of PMDD in DSM-5 (2013) and DSM-5-TR (2022) legitimized severe premenstrual mood disorders (American Psychiatric Association, 2022).

Cultural Perspectives

In many cultures, menstrual symptoms are normalized and discussed informally, reflecting diverse cultural attitudes (Barry, Lawson, & King, 2019). Western medicine tends to medicalize PMS/PMDD, sparking debate about pathologizing normal hormonal changes (Lowe & Lee, 2021). Ethnic differences in symptom reporting reflect cultural attitudes toward mental health (Yen et al., 2017). Access to treatment varies globally: herbal remedies are common in some regions, while SSRIs and therapy predominate in others. Stigma remains a barrier to seeking help.

Final Thoughts: A Holistic Approach

Understanding PMS and PMDD requires medical expertise, cultural sensitivity, and compassion. The DSM-5-TR provides clarity, but each woman’s experience is unique.

If you or someone you know is struggling, effective treatments and professional support can make a meaningful difference.

Professional Support: Meet Dr. Nguyen My Phon, M.D.

Dr. Nguyen My Phon specializes in the evaluation and treatment of PMS and PMDD. She completed fellowship training in Women’s Mental Health and Reproductive Psychiatry at the University of Illinois at Chicago Medical School, the largest program of its kind in the U.S., under the mentorship of Dr. Marcela Almeida, M.D., who is now at Harvard Medical School’s Department of Psychiatry at Brigham and Women’s Hospital.

Dr. Nguyen integrates the latest DSM-5-TR criteria with a nuanced understanding of biological and cultural factors to provide personalized care through medication, psychotherapy, and lifestyle guidance.

Contact YOU Psychiatry Clinic

At YOU Psychiatry Clinic, we provide personalized, compassionate, and culturally respectful care designed around you. Ready to take the next step? Schedule a consultation or connect with us on Instagram, TikTok, Facebook, and LinkedIn @youpsychiatryclinic for psychoeducation and to join the movement to destigmatize mental health.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Baker, F. C., & Kronenberg, F. (2020). Premenstrual syndrome and premenstrual dysphoric disorder. In R. L. Nussbaum (Ed.), Women’s health and mental health (pp. 123–142). Springer.

Barry, J. A., Lawson, D. M., & King, S. (2019). Cross-cultural perspectives on premenstrual symptoms and disorders. International Journal of Women’s Health, 11, 281–291. https://doi.org/10.2147/IJWH.S176099

Borenstein, J., Dean, B., Endicott, J., Yonkers, K. A., & Pearlstein, T. (2022). Premenstrual dysphoric disorder: Evidence-based treatments and future directions. Journal of Women’s Health, 31(1), 12–20. https://doi.org/10.1089/jwh.2021.0195

Canguilhem, G. (1991). The normal and the pathological (C. R. Fawcett, Trans.). Zone Books. (Original work published 1943)

Dalton, K. (1953). Premenstrual syndrome: A biocyclic phenomenon in women. The Practitioner, 170(1023), 81–87.

Epperson, C. N., Steiner, M., & Hartlage, S. (2021). Premenstrual dysphoric disorder: Evidence for a neurobiological basis and treatment with serotonin reuptake inhibitors. Current Psychiatry Reports, 23(5), 30. https://doi.org/10.1007/s11920-021-01252-4

Huo, L., Korten, N. C. M., Toenders, Y. J., Bot, M., & Penninx, B. W. J. H. (2023). Genetic and environmental contributions to premenstrual dysphoric disorder. Psychological Medicine, 53(4), 633–640. https://doi.org/10.1017/S0033291722003016

Lowe, P. A., & Lee, S. H. (2021). Medicalization of premenstrual symptoms: A review of cultural and clinical perspectives. Culture, Medicine and Psychiatry, 45(2), 305–322. https://doi.org/10.1007/s11013-021-09704-8

Rapkin, A. J., & Akopians, A. (2021). Premenstrual syndrome and premenstrual dysphoric disorder: Evidence-based treatments. Obstetrics and Gynecology Clinics of North America, 48(4), 645–662. https://doi.org/10.1016/j.ogc.2021.08.003

Schmidt, P. J., Rubinow, D. R., & Roca, C. A. (2023). Neurosteroid modulation of GABA-A receptors in the treatment of PMDD. Neuropsychopharmacology Reviews, 48(1), 20–32. https://doi.org/10.1038/s41386-022-01450-9

Steiner, M., Pearlstein, T., Cohen, L. S., Endicott, J., Kornstein, S. G., Roberts, C., … & Yonkers, K. A. (2022). Premenstrual dysphoric disorder: Burden of illness and treatment update. Journal of Psychiatry & Neuroscience, 47(3), 159–171. https://doi.org/10.1503/jpn.210160

Yen, J. Y., Hu, H. F., Ko, C. H., Chang, Y. P., & Yen, C. F. (2017). Cross-cultural comparison of premenstrual symptoms in East Asian women: Emotional vs. physical symptom reporting. Archives of Women’s Mental Health, 20(4), 507–514. https://doi.org/10.1007/s00737-017-0703-3