A Counter Argument: Why Recognising PMDD Matters. Not "Traps", But Real Health Challenges

I was recently made aware of the following blog post by Dr Jess Taylor: "PMDD: The New Psychiatric Trap Women Are Being Told To Walk Into". The post argues that PMDD is merely a psychiatric label used to pathologise women, a "trap" created by diagnostic manuals, and a modern reincarnation of hysteria. Jess argues that a PMDD diagnosis risks stigmatising women both legally and societally, and that distress linked to the menstrual cycle should not be medicalised.

However, Jess' framing mispresents the scientific reality and lived experience of people with PMDD. This post will look at the scientific research countering these points, highlighting the importance of improving recognition and treatment of PMDD. It is also grounded in lived experience, something which was lacking in Jess' post.

Diagnostic Criteria And Clinical Distinctiveness

PMDD is not diagnosed on the basis of general emotional distress. Diagnostic criteria requires daily symptom rating across at least two menstrual cycles, demonstrating that symptoms occurs during the luteal phase, and that remission of these symptoms occurs shortly after menstruation begins (APA, 2013). This stop/start of symptoms is key to differentiating PMDD from other mental health disorders, such as depression, anxiety, bipolar, or merely situational stressors.

Indeed, large clinical reviews emphasise that people with PMDD are typically asymptomatic or minimally symptomatic during other phases of the menstrual cycle, a pattern that is inconsistent with other mood disorders (Epperson et al., 2012; Yonkers et al., 2018). While mild premenstrual mood changes are common, severe impairment affecting a person's daily functioning, work, and relationships is not, and forms the basis for PMDD's diagnostic distinction.

Neurobiological Evidence and Hormonal Sensitivity

Contrary to the belief that PMDD lacks biological grounding, substantial evidence suggests that PMDD involves abnormal central nervous system (CNS) responses to normal hormone fluctuations (Schmidt et al., 1998). Particular attention has been focused on allopregnanolone, a progesterone metabolite that modulates GABA-A receptor activity. Sensitivity to this has been implicated in mood destabilisation during the luteal phase (Bäckström et al., 2014). Pharmacological studies using progesterone receptive modulators further supports that PMDD reflects a neurobiological vulnerability, rather than a reaction to psychosocial stress (Schmidt et al., 2017).

Functional Impairment And Morbidity

Epidemiological studies demonstrate significant impairment in daily functioning, interpersonal relationships, occupational functioning, and overall quality of life for people with PMDD (Halbreich et al., 2003; Yonkers et al., 2008).

And we need to talk about suicide risk. A systematic review and meta-analysis of the evidence demonstrated that people with PMDD are almost seven times at higher risk of suicide attempt, and almost four times as likely to exhibit suicidal ideation, than people without PMDD (Prasad et al., 2021). What is important in PMDD is that this is restricted to the luteal phase alone, further emphasising the cyclical nature of PMDD (Hantsoo & Epperson, 2015).

Arguments that frame PMDD as merely contextual or situational distress risk mirroring a familiar pattern in women's health research: the dismissal of symptoms that do not conform to existing biomedical models (let's not forget that women were not included in clinical trials until the 1990s). For many, the absence of recognition has historically resulted in misdiagnosis and inappropriate treatment. On average, it takes around 12 years, and contact with 11 different healthcare providers, to get an accurate diagnosis of PMDD (Divine et al., 2019).

Treatment Response In PMDD

Research has shown that, for many, the use of SSRIs demonstrates significant symptom improvement that is markedly different to how other disorders respond to the same treatment (Steiner et al., 2006). For others, treatments that suppress ovulation or impact on progesterone exposure (such as contraceptives) show positive symptom reduction (Hantsoo & Epperson, 2015). It is important that healthcare providers work with people with PMDD to find a treatment option that works for them. It is not a "one size fits all" approach.

Feminist Concerns And Misplaced Causality

Concerns that PMDD diagnoses could be misused in legal, occupational, or interpersonal contexts are legitimate and should not be dismissed. However, such harm arises from structural gender bias rather than from the recognition of PMDD itself. Diagnostic erasure does not protect people from discrimination. Instead, it removes a framework through which suffering can be legitimised and addressed (Epperson et al., 2012).

A feminist approach to PMDD should emphasise ethical diagnostic practices, informed consent, and safeguards against misuse, rather than rejecting the diagnosis outright. International classification systems explicitly caution against the stigmatising use of mental health diagnoses, further reinforcing the need for responsible application rather than denial (WHO, 2019).

Lived Experience

Now for the bit about me. I personally have a diagnosis of PMDD. It has been life changing. I was diagnosed in 2022. After coming off hormonal contraception a few years before, I experienced a pattern of complete self-destruction for one week every month. I did not recognise myself. I would feel incredibly low and suicidal, countered only by feeling a level of rage I don't even have the words to describe. I believed everyone hated me, that I was terrible at my job, and that friends and family would be better off without me. I'd end my relationship and sabotage friendships. And I suffered in silence. I thought this was a "me" problem. I clearly had a huge character flaw that meant I was a horrible person, unhinged even. And then my period would start, and symptoms would completely vanish. However, what I now had to do was try to put my life back together, alongside horrendous guilt and shame for everything I had done over the past week. I couldn't explain to anyone why I was like two completely different people from one week to the next. Eventually, after coming across PMDD in the book "Period Power"(by Maisie Hill), I had a bit of a lightbulb moment. I recognised myself immediately in the description. I started to track my daily symptoms and a pattern soon emerged. I approached my GP with this evidence, fearful that I would be dismissed (as women's health so often is), or misdiagnosed. Instead, I had a wonderful GP who recognised exactly what was happening to me, and worked with me to explore treatment options. I chose to start Sertraline. Because my cycles are somewhat irregular, I opted to take it continuously rather than just during my luteal phase. My life changed. Whilst I am still impacted by the low mood and interpersonal sensitivity during my luteal phase, my symptoms have significantly improved. I am no longer on a one woman path of self destruction. My quality of life is significantly better, and my relationship quality has improved (as my loved ones now also have the understanding of what is happening, and know how to help). Because of my own experience, I now focus part of my work on supporting people with PMDD. Because if I can help just one person to manage this more effectively and help rid them of the burden of self-blame and character flaw, then it will all be worth it.

In Summary

PMDD should not be misunderstood as a modern version of hysteria, or as a mechanism for labelling or medicalising people's emotions. While vigilance against over-medicalisation remains of key importance, denying the legitimacy of PMDD risks silencing those who are suffering the most (Epperson et al., 2012; Schmidt et al., 2017; Yonkers et al., 2018). The task that faces us today is not diagnostic erasure, but refinement. We need to improve diagnostic accuracy, expand neurobiological research, and ensure that recognition empowers those who find themselves living with PMDD.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing https://doi.org/10.1176/appi.books.9780890425596

• Bäckström, T., Haage, D., Löfgren, M., Johansson, I. M., Strömberg, J., Nyberg, S., … Bengtsson, S. K. (2014). Paradoxical effects of GABA-A modulators may explain sex steroid induced negative mood symptoms in some persons. Neuroscience, 256, 46–57. https://doi.org/10.1016/j.neuroscience.2013.10.061

• Epperson, C. N., Steiner, M., Hartlage, S. A., Eriksson, E., Schmidt, P. J., Jones, I., … Yonkers, K. A. (2012). Premenstrual dysphoric disorder: Evidence for a new category for DSM-5. American Journal of Psychiatry, 169(5), 465–475. https://doi.org/10.1176/appi.ajp.2012.11081302

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• Internal Association on Premenstrual Disorders: UK Women's Health Strategy https://www.iapmd.org/uk-womens-health-strategy?rq=12%20years%20

• Prasad, D, Wollenhaupt-Aguiar, B, Kidd, KN, de Azevdeo Cardsoso, T, & Frey, BN. (2021). Suicidal Risk in Women with Premenstrual Syndrome and Premenstrual Dysphoric Disorder: A Systematic Review and Meta-Analysis. J Womens Health 30(12), 1693-1707. https://pmc.ncbi.nlm.nih.gov/articles/PMC8721500/

• Schmidt, P. J., Nieman, L. K., Danaceau, M. A., Adams, L. F., & Rubinow, D. R. (1998). Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. New England Journal of Medicine, 338(4), 209–216. https://doi.org/10.1056/NEJM199801223380401

• Schmidt, P. J., Martinez, P. E., Nieman, L. K., Koziol, D. E., Thompson, K. D., Schenkel, L., … Rubinow, D. R. (2017). Exposure to a progesterone receptor modulator in women with premenstrual dysphoric disorder. American Journal of Psychiatry, 174(10), 980–989. https://doi.org/10.1176/appi.ajp.2017.16101113

• Steiner, M., Pearlstein, T., Cohen, L. S., Endicott, J., Kornstein, S. G., Roberts, C., & Yonkers, K. A. (2006). Expert guidelines for the treatment of severe PMS, PMDD, and comorbidities. Journal of Women’s Health, 15(1), 57–69. https://doi.org/10.1089/jwh.2006.15.57

• Yonkers, K. A., O’Brien, P. M. S., & Eriksson, E. (2008). Premenstrual syndrome. The Lancet, 371(9619), 1200–1210. https://doi.org/10.1016/S0140-6736(08)60527-9

• Yonkers, K. A., Simoni, M. K., Premenstrual disorders. (2018). American Journal of Obstetrics and Gynecology, 218(1), 68–74. https://doi.org/10.1016/j.ajog.2017.05.045

• World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/