Premenstrual dysphoric disorder

PMDD shows up when a client's mood problems seem to "come and go," and the exam tests whether you check the timing against the menstrual cycle and confirm it prospectively before diagnosing.

Criteria at exam depth. In the majority of menstrual cycles over the past year, at least five symptoms appear in the final week before menses onset, start to improve within a few days after menses begins, and become minimal or absent in the week after menses. At least one symptom must be affective: marked mood lability, marked irritability or anger or increased interpersonal conflict, marked depressed mood or hopelessness, or marked anxiety or tension. At least one more comes from a second group: decreased interest in usual activities, difficulty concentrating, lethargy or low energy, marked appetite change or food cravings, hypersomnia or insomnia, feeling overwhelmed or out of control, and physical symptoms such as breast tenderness, bloating, weight gain or joint and muscle pain. The two groups together total five or more. Symptoms cause clinically significant distress or interfere with work, school, social activity or relationships. They are not merely an exacerbation of another disorder (such as MDD, panic disorder or a personality disorder), though PMDD can co-occur with them. Diagnosis is confirmed by prospective daily ratings over at least two symptomatic cycles; until then it is provisional. Symptoms are not due to a substance (including hormonal treatments) or medical condition.

Hinge differentials.

• Major depressive disorder or PDD: symptoms persist through the follicular phase (after menses); PMDD symptoms clear.
• Premenstrual exacerbation of another disorder: an underlying disorder is present all month and simply worsens premenstrually.
• Premenstrual syndrome: milder and does not require the five-symptom, affective-symptom threshold.
• Bipolar disorder: episodic mood elevation not tied to the cycle.
• Hormonal treatment effects, thyroid disease: medical or medication causes.

On the NCMHCE. The counselor's key move is assessment: ask the client to complete daily symptom ratings across two cycles rather than relying on retrospective recall, which can be inaccurate. Screen for suicidal ideation during the luteal phase, since hopelessness can be intense even if brief. Refer to a medical provider or gynecologist to rule out other causes and to discuss options; SSRIs and hormonal approaches are prescriber decisions. Counseling supports CBT, stress management, sleep, exercise and planning around predictable symptomatic days. Respect cultural and personal attitudes toward menstruation, and avoid dismissing symptoms as "just hormones."

Clinical Pearl: Timing is the diagnosis: symptoms in the last week before menses, improving within days of onset, minimal the week after, confirmed by prospective daily ratings over two cycles. Symptoms that persist after menses point to a depressive disorder instead.