Q&A

Premenstrual Dysphoric Disorder

How can clinicians tell premenstrual dysphoric disorder apart from bipolar disorder? Dr. Jayashri Kulkarni explains.

Jayashri Kulkarni is Professor of Psychiatry at Monash University and The Alfred in Melbourne, and Head of the Department of Psychiatry at Monash’s Central Clinical School. She graduated in medicine from Monash in 1981 and became a Fellow of the Royal Australian and New Zealand College of Psychiatrists in 1988. She was made a Member of the Order of Australia in 2019 and won the 2026 Australian Mental Health Prize in the professional category.

Jayashri Kulkarni founded HER Centre Australia, a Monash center for women’s mental health, and her research focuses on how reproductive hormones shape mental illness. Her best-known trial tested estrogen as an added treatment for schizophrenia. She also helped establish Australia’s first women’s mental health hospital.

In this Q&A, Dr. Kulkarni explains why PMDD is often misdiagnosed as bipolar II, how a menstrual cycle history guides diagnosis, how she sequences the contraceptive pill and SSRIs, and why she links PMDD with early trauma and borderline personality disorder.

How long does it generally take to get a premenstrual dysphoric disorder diagnosis?

Too long! We need to get clinicians to understand that reproductive hormones impact on mood/cognition. Once we stop splitting mind off from the body and understand that it is all integrated, then PMDD would be better diagnosed. It is done by taking a good history of cyclical mood shifts with rapid onset and offset- related to menstrual cycles

What disorders (other than PMS) is premenstrual dysphoric disorder misdiagnosed as?

PMDD is commonly misdiagnosed as Bipolar Disorder type 2, and women are treated with a number of mood stabilisers, antipsychotics, antidepressants - all with shocking side effects and little actual response. The missing factor here is taking a good history - including a menstrual cycle history - from the woman. AND listening to her view - many women tell clinicians that they notice cyclical mood changes that are rapid in onset and offset - this is a big clue to the biological, hormonal trigger

Are you aware of therapists using DBT to (successfully) help with PMDD?

Given the increased number of women with that dreadfully named diagnosis - Borderline PD - have PMDD, it makes sense to use DBT to help with both conditions.

Is there a link between borderline personality disorder and PMDD?

This important question is the subject of some of my research. And the answer is 'yes'. Personally, I dislike the label "Borderline Personality Disorder (BPD)" , preferring 'complex PTSD". Because many women with BPD have awful stories of early life trauma - often not revealed. This trauma resets the cortisol hormone regulation, which in turn has other hormone effects - such as making the person more mentally sensitive to reproductive hormone fluctuations. Hence there is more PMDD in some women with early life trauma - who have received the poor diagnosis of Borderline Personality Disorder. NOT ALL PMDD sufferers have BPD/ early life trauma though.

Does PMDD include a change of mood around the time of ovulation as well as the end of menstrual cycle?

Technically the very rigid definition of PMDD in DSM 5 doesn't allow this - but in real practice, PMDD is a diagnosis underpinned by fluctuating reproductive hormone levels in the brain triggering mood/behaviour/cognition alterations. So - at ovulation, with a spike in pituitary Luteinising Hormone and then oestrogen - it is not difficult to imagine that some women have mood shifts at ovulation.

Is PMDD typically treated with the OCP or an SSRI or both?

First line treatment of PMDD should be the oral contraceptive pill- but often the menstrual cycle pattern isn't asked about or believed. So antidepressants - usually SSRIs are commonly used I suggest OCP first, then intermittent SSRI- usually sertraline plus OCP as a second line treatment

Dear Dr Kulkarni, I have a client who along with mood symptoms, experiences obsessive thoughts around harm to herself and her children around the time of her period. Are obsessions part of the PMDD picture or should I be querying OCD as well?

Yes obsessions can be part of the PMDD picture. The underlying cause of PMDD is the fluctuation in brain oestrogen, progesterone and the flow on effect of these hormone shifts on brain neurochemistry (dopamine, serotonin, glutamate and others) and neurocircuitry. The hormone changes set off mood changes - usually depression, but can be cognitive changes such as obsessive thoughts, or 'brain fog'. Anxiety can worsen along with depression in the premenstrual phase - and some women use compulsive behaviours to get 'control' over excessive worrying thoughts/ obsessions at this time. A rapid onset and offset usually tips off the PMDD diagnosis - including obsessional thoughts

Can you talk through a differential diagnosis between PMDD and bipolar?

PMDD is a cyclical change in mood that has a rapid change in mood - usually depression - that occurs commonly in the week or ten days before menstruating. Then just as suddenly the mood improves as bleeding occurs or soon after a period starts. BUT many women with PMDD do not have regular cycles - so it can be hard to work out if the depression is occurring in the same part of the cycle. Look for the sudden onset and offset. Bipolar Mood Disorder - type 1 - in old terminology is "Manic- Depressive Disorder". The person has either depression or manic mood that is sustained for several weeks to months, with associated behavioural changes. True mania is associated with profound increased energy, increased talking (to the point where people cannot cut in), grand ideas about one's capacity in any domain, increased libido, recklessness, rapid thoughts, excessive spending, fast moving - unable to settle, sit down or sleep. True mania is hard to miss. Then after weeks to months of mania , the person may then experience depression with a plunge into despair, sadness, no energy, little speech, decreased libido, poor self esteem. Both conditions are sort of cyclical - but PMDD is around menstrual cycles, whereas Bipolar Disorder is a mix of mania and depression. Unfortunately, many psychiatrists do not consider the role of female reproductive hormones in the onset/offset of mental disorders. Oestrogen, progesterone are potent brain steroids and changes in their brain levels impacts heavily on mood, cognition in some women.