A. In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week postmenses, with at least one of the symptoms being either (1), (2), (3), or (4):
- markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
- marked anxiety, tension, feelings of being "keyed up," or "on edge"
- marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)
- persistent and marked anger or irritability or increased interpersonal conflicts
- decreased interest in usual activities (e.g., work, school, friends, 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," weight gain
Note: In menstruating females, the luteal phase corresponding to the period between ovulation and the onset of menses, and the follicular phase begins with menses. In nonmenstruating females (e.g., those who have had a hysterectomy), the timing of luteal and follicular phases may require measurement of circulating reproductive hormones.
B. The disturbance markedly interferes with work or school or with usual social activities and relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work or school).
C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as Major Depressive Disorder, Panic Disorder, Dysthymic Disorder, or a Personality Disorder (although it may be superimposed on any of these disorders).
D. Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. (The diagnosis may be made provisionally prior to this confirmation.)
In DSM-IV, individuals whose presentation meets these research criteria would be diagnosed as having Depressive Disorder Not Otherwise Specified.
The transient mood changes that many females experience around the time of their period should not be considered a mental disorder. Premenstrual dysphoric disorder should be considered only when the symptoms markedly interfere with work or school or with usual social activities and relationships with other (e.g., avoidance of social activities, decreased productivity and efficiency at work or school). Premenstrual dysphoric disorder can be distinguished from the far more common "premenstrual syndrome" by using prospective daily ratings and the strict criteria. It differs from the "premenstrual syndrome" in its characteristic pattern of symptoms, their severity, and the resulting impairment.
Other mental disorders
Premenstrual dysphoric disorder must be distinguished from the premenstrual exacerbation of a current mental disorder (e.g., Mood Disorders, Anxiety Disorders, Somatoform Disorders, Bulimia Nervosa, Substance Use Disorders, and Personality Disorders). In such situations (which are far more common than premenstrual dysphoric disorder), there is a premenstrual worsening of the symptoms but the symptoms persist throughout the menstrual cycle. Although this condition should not be considered in females who are experiencing only a premenstrual exacerbation of another mental disorder, it can be considered in addition to the diagnosis of another current mental disorder if the woman experiences symptoms and changes in level of functioning that are characteristic of premenstrual dysphoric disorder and are markedly different from the symptoms experienced as part of the ongoing disorder.
General medical conditions
Some individuals with general medical conditions may present with dysphoria and fatigue that are exacerbated during the premenstrual period. Examples include seizure disorders, thyroid and other endocrine disorders, cancer, systemic lupus erythematosus, anemias, endometriosis, and various infections. These general medical conditions can be distinguished from premenstrual dysphoric disorder by history, laboratory testing, or physical examination.
A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.
B. One (or more) of the following symptoms must be present:
- Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
- Marked irritability or anger or increased interpersonal conflicts.
- Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
- Marked anxiety, tension, and/or feelings of being keyed up or on edge.
C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.
- Decreased interest in usual activities (e.g., word, school, friends, hobbies).
- Subjective difficulty in concentration.
- Lethargy, easy fatigability, or marked lack of energy.
- Marked change in appetite; overeating; or specific food cravings.
- Hypersomnia or insomnia.
- A sense of being overwhelmed or out of control.
- Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," or weight gain.
Note: The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year.
D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).
E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.)
If symptoms have not been confirmed by prospective daily ratings of at least two symptomatic cycles, "provision" should be noted after the name of the diagnosis (i.e., "premenstrual dysphoric disorder, provision").
Premenstrual syndrome differs from premenstrual dysphoric disorder in that a minimum of five symptoms is not required, and there is no stipulation of affective symptoms for individuals who have premenstrual syndrome. This condition may be more common than premenstrual dysphoric disorder, although the estimated prevalence of premenstrual syndrome varies. While premenstrual syndrome shares the feature of symptom expression during the premenstrual phase of the menstrual cycle, it is generally considered to be less severe than premenstrual dysphoric disorder. The presence of physical or behavioral symptoms in the premenstruum, without the required affective symptoms, likely meets criteria for premenstural syndrome and not for premenstrual dysphoric disorder.
Dysmenorrhea is a syndrome of painful menses, but this is distinct from a syndrome characterized by affective changes. Moreover, symptoms of dysmenorrhea begin with the onset of menses, whereas symptoms of premenstrual dysphoric disorder, by definition, begin before the onset of menses, even if they linger into the first few days of menses.
Many women with (either naturally occurring or substance/medication-induced) bipolar or major depressive disorder or persistent depressive disorder believe that they have premenstrual dysphoric disorder. However, when they chart symptoms, they realize that the symptoms do not follow a premenstrual pattern. Women with another mental disorder may experience chronic symptoms or intermittent symptoms that are unrelated to menstrual cycle phase. However, because the onset of menses constitutes a memorable event, they may report that symptoms occur only during the premenstruum or that symptoms worsen premenstrually. This is one of the rationales for the requirement that symptoms be confirmed by daily prospective ratings. The process of differential diagnosis, particularly if the clinician relies on retrospective symptoms only, is made more difficult because of the overlap between symptoms of premenstrual dysphoric disorder and some other diagnoses. The overlap of symptoms is particularly salient for differentiating premenstrual dysphoric disorder from major depressive episodes, persistent depressive disorder, bipolar disorders, and borderline personality disorder. However, the rate of personality disorders is no higher in individuals with premenstrual dysphoric disorder than in those without the disorder.
Use of hormonal treatments
Some women who present with moderate to severe premenstrual symptoms may be using hormonal treatments, including hormonal contraceptives. If such symptoms occur after initiation of exogenous hormone use, the symptoms may be due to the use of hormones rather than to the underlying condition of premenstrual dysphoric disorder. If the woman stops hormones and the symptoms disappear, this is consistent with substance/medication-induced depressive disorder.