Navigating PMDD Through a Trauma-Informed Lens
This article was first published in Therapy Today, the journal of the British Association for Counselling and Psychotherapy. The case study presented in this article is fictional and intended for illustrative purposes only. Any resemblance to real persons, living or dead, is purely coincidental.
Claire sat in my office, her eyes brimming with frustration and exhaustion. “Every month,” she said, “It’s like clockwork. I become someone else. I can feel the anger boiling inside me over the smallest things. It’s not just mood swings. One moment, I’m sobbing uncontrollably and having such dark thoughts of taking my life, and the next, I’m lashing out at the people I love. Then my period starts, and I feel like myself again. But by then, the damage is done, and I have to start to try to repair my world. I can’t keep living like this, it’s exhausting and it’s not who I am. “ Claire’s story is a poignant example of how unresolved trauma can amplify the already debilitating effects of PMDD, creating a cycle of emotional turmoil that feels insurmountable.
For Claire, and countless other women like her, this cyclical emotional chaos isn’t just difficult – it’s paralysing. What Claire described was more than premenstrual syndrome (PMS). Claire was suffering from premenstrual dysphoric disorder (PMDD), a condition that magnifies the emotional and physical symptoms of the menstrual cycle to the point where they disrupt relationships, work, and self-worth. Despite this, Claire’s experience was at times dismissed by doctors and misunderstood by those around her.
Understanding PMDD and Trauma
PMDD is still a largely under-recognised condition by medical professionals. In the therapeutic community, there is also a lack of awareness about PMDD and the link between trauma and PMDD. Research suggests that individuals with a history of trauma, particularly childhood trauma, may have a more pronounced reaction to hormonal shifts, making the emotional distress of PMDD more intense. 1,2,3 For clients with trauma histories, PMDD may act as a trigger for unresolved emotional wounds, exacerbating anxiety, dissociation, or hypervigilance.
As therapy progressed, Claire began to share more of her story. She revealed a history of childhood trauma, marked by emotional neglect and intermittent verbal abuse. While she had worked hard to build a life far removed from her past, certain patterns emerged during our sessions. The intensity of her symptoms during her menstrual cycle seemed to unearth unresolved wounds. It became evident that her PMDD was not only a response to hormonal shifts but also a trigger for buried trauma. The anger, sadness, and feelings of hopelessness she experienced each month mirrored emotions she had long suppressed. Claire described feeling “out of control” and dissociated during the luteal phase (the time between ovulation and menstruation) of her cycle; we explored how this echoed the powerlessness she had felt as a child. Her heightened reaction to hormonal changes made her emotional distress even more pronounced, compounding her sense of alienation and frustration. The recurring emotional upheaval during her cycle seemed to act as a magnifying glass, amplifying the unresolved grief, fear, and anger that her trauma had left behind. Through our discussions, Claire began to see how her past influenced her present. For example, the critical inner voice she struggled with during the luteal phase echoed the verbal abuse she had endured as a child. Similarly, her feelings of being overwhelmed and unable to cope mirrored the helplessness she had experienced growing up. By linking these experiences to her trauma history, Claire started to disentangle her identity from her symptoms. She began to recognise that her emotional struggles were not a reflection of who she was, but rather a product of both her trauma and PMDD.
Distress and Invalidation
PMDD is a severe and debilitating form of premenstrual syndrome (PMS), characterised by significant emotional and physical symptoms that disrupt daily life. Often clients feel dismissed or misunderstood both by medical professionals and in their personal lives. They may have heard statements like “It’s just PMS” or “Everyone gets moody sometimes”, which can exacerbate feelings of frustration and alienation. But unlike PMS, where symptoms may be uncomfortable but manageable, PMDD’s mood-related symptoms can be intense, leading to deep emotional distress, irritability, and anxiety, alongside physical symptoms like bloating, fatigue, and joint pain. Tracking these symptoms over several menstrual cycles can help confirm whether PMDD is a possible diagnosis. 4 It is crucial to recognise that PMDD can affect anyone who experiences cyclical hormonal fluctuations, including transgender men. For transgender men, the experience of PMDD can be particularly complex and distressing. The physical and emotional symptoms associated with the menstrual cycle can trigger gender dysphoria and exacerbate existing mental health challenges. Furthermore, accessing appropriate healthcare and support can be difficult due to a lack of awareness and understanding among healthcare professionals.
As a couples counsellor, I became increasingly aware of how PMDD and trauma intersected to impact relationships. I’ve witnessed partners struggle to understand the cyclical nature of PMDD and the emotional volatility it can bring. Often, women would attend sessions feeling isolated, misunderstood, and deeply frustrated by the strain their symptoms placed on their relationships. My decision to specialise in PMDD and trauma stems from both professional experience and a personal encounter. I’ve seen how PMDD can disrupt the fabric of connection between couples, often leading to resentment, miscommunication, and feelings of inadequacy on both sides. Over time, I realised that many of these challenges were compounded by unresolved trauma, which amplified the emotional impact of hormonal fluctuations. This realisation motivated me to delve deeper into how trauma and PMDD interact and how therapy can provide a path to healing. By focusing on this niche, I aim to create a safe, validating space for clients to explore how their experiences affect both their individual well-being and their relationships. I’m passionate about bridging the gap between understanding and support, helping women and their partners navigate these challenges with empathy and practical tools.
Psychoeducation: Understanding the Biological Basis
In the early sessions with Claire, I make time for psychoeducation, as understanding the hormonal sensitivity that underpins PMDD helps to demystify its cyclical nature and sheds light on why it is such a complex condition to manage. I explained to Claire that PMDD is believed to result from an abnormal response to the normal hormonal fluctuations of the menstrual cycle, particularly sensitivity to oestrogen and progesterone. Research shows that women with PMDD have a heightened reaction to these hormones, which affects neurotransmitters in the brain, particularly serotonin. The drop in serotonin levels during the luteal phase (the period between ovulation and menstruation) can lead to emotional instability, depression, and anxiety. 5,6,7,8
The common physical impacts of PMDD include fatigue, bloating, headaches, joint pain, sleep disturbances, and breast tenderness. But what many clients who come to me say is more challenging is its profound impact on mental health. Identifying PMDD in clients can be difficult due to its similarity to other mental health conditions such as depression, anxiety and bi-polar. Women with PMDD may experience deep feelings of sadness, hopelessness, irritability, or anxiety. These emotional shifts can mimic major depressive episodes but are distinguishable by their cyclical nature – arising in the luteal phase and easing once menstruation begins. The emotional symptoms are so severe that many women describe it as feeling like a completely different person for half of each month. These mood swings can lead to significant disruptions in relationships, work performance, and overall quality of life. Research has shown that women with PMDD are at a higher risk of developing more severe mental health conditions, including suicidal thoughts or behaviour. 9,10
When Claire first sought help, she had been offered selective serotonin reuptake inhibitors (SSRIs) by her GP. While SSRIs are effective for some women with PMDD, Claire found little relief and felt frustrated by the lack of deeper exploration into her symptoms. She shared that she felt dismissed, with her concerns reduced to “just PMS” or “stress.” This sense of being unheard was compounded by the invalidation she had experienced as a child, deepening her sense of isolation. SSRIs, which help stabilise serotonin levels, are often prescribed as part of a treatment plan for PMDD. Additionally, hormonal therapies aimed at regulating oestrogen and progesterone levels can be considered in collaboration with medical professionals.11
Trauma - Informed Interventions
For clients with a history of trauma, it’s crucial to explore the ways in which PMDD may be re-triggering unresolved emotional responses. Trauma-focused therapies can help clients heal from past experiences and develop resilience in managing PMDD symptoms. 12 Suitable trauma-focused interventions include Eye Movement Desensitisation and Reprocessing (EMDR) and trauma-informed CBT. 12 Recognising the role of trauma in Claire’s PMDD symptoms, we incorporated elements of trauma-informed cognitive behavioral therapy (CBT) to help Claire identify and challenge the negative thought patterns that surfaced during her luteal phase. For instance, feelings of worthlessness that emerged during this time were directly tied to the critical voices from her past. By addressing these connections, Claire began to replace self-criticism with self-compassion. Mindfulness and grounding techniques were introduced to help Claire manage the intense emotional surges during her cycle. She practiced body scans and focused breathing to stay connected to the present moment, reducing dissociation. The use of muscle relaxation helped Claire stay connected to the present moment, reducing dissociation and promoting emotional regulation. Over time, these tools became integral to her ability to weather the storm of her symptoms without feeling consumed by them. As therapy progressed, Claire reported feeling more equipped to navigate her emotions. While the physical symptoms of PMDD persisted, the emotional upheaval became less overwhelming. She developed a deeper understanding of her triggers and was able to communicate her needs to loved ones more effectively, fostering stronger relationships. One breakthrough moment came when Claire recognised that her anger during the luteal phase was often a response to feelings of powerlessness. By addressing these underlying emotions, she learned to assert herself in healthier ways, reducing the sense of “damage” she had previously experienced.
Therapy eventually came to an end, with Claire feeling more empowered and resilient. She took away a comprehensive understanding of her condition, a toolkit of strategies to manage her symptoms, and a renewed sense of self-worth. While PMDD remains a part of her life, it no longer defines her.
PMDD is a challenging condition, but with proper diagnosis, support, and therapeutic
interventions, counselling clients can learn to manage its effects and regain control of their lives. By increasing our understanding of PMDD’s scientific basis and offering trauma-informed, compassionate care, we can help clients feel validated, supported, and empowered. As counsellors, we play a vital role in shining a light on this often-overlooked condition. By expanding our knowledge, offering empathy, and working collaboratively with clients, we can help them navigate the storm of PMDD with greater resilience and hope.
References
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