Summer 2025 Issue

Neurodiversity: The Intersection of Autism, ADHD, and PMDD
By Jami Imhof, DSW, LCSW-C, LICSW
Social Work Today
Vol. 25 No. 3 P. 28

Case Example
Jasmine is a 20-year-old, cisgender woman who comes to a counseling center to seek support with anxiety symptoms. She has a previous diagnosis of ADHD, reporting that symptoms are well managed with stimulant medication. While the clinician is collecting background information on her presenting concern, Jasmine shares that she experiences feelings of “extreme anxiety” before the onset of her period, which manifests as panic attacks and engaging in self-injury behavior. Jasmine denies suicidal ideation and engages in self-harm behaviors as a way to cope with her anxiety at these times. Jasmine shares that once her period starts, she “mellows out” and “feels normal again.” She shares that she has experienced anxiety before her period for the past few years, which is how she knows her period is approaching. She shares that she does not experience anxiety throughout other times of the month, and cannot identify any triggers to her anxiety. Jasmine’s clinician will work with her to create a treatment plan to address the increased levels of anxiety Jasmine is experiencing during these times.

What Is PMDD?
If this client were on your caseload, would you diagnose an anxiety disorder? Or does she meet criteria for another condition? From the description of the case above, this client likely meets criteria for premenstrual dysphoric disorder (PMDD). PMDD is a mood disorder that can affect menstruating individuals. About 3% to 8% of individuals assigned female at birth (AFAB) are affected by the condition, but this percentage may not accurately reflect the PMDD population due to a lack of appropriate diagnosis.1 Many factors can impact the accuracy of reporting the diagnosis, including professionals dismissing symptoms, a lack of understanding about PMDD within the medical and mental health community, and patients underreporting the severity and impact of their symptoms.

Premenstrual syndrome (PMS) can also cause emotional and physical symptoms prior to the start of an individual’s menstrual cycle. The hormonal changes that occur prior to the start of the menstrual cycle may create a serotonin deficiency for individuals who experience PMDD symptoms. The serotonin deficiency can be noted as well in PMS; the key difference is that PMDD symptoms are much more intense and impactful on an individual compared with PMS. Risk factors for developing PMDD include a family history of either PMDD or PMS, as well as a personal or family history of mood disorders.2

DSM-5-TR Criteria
To meet the criteria of PMDD, according to the DSM-5-TR, symptoms must be tracked for at least two menstrual cycles. Confirmation of symptoms can be done through various organizational methods that are convenient for the client, such as apps, digital notebooks, or written down in a journal or calendar. If a client has suspected PMDD, they should be encouraged to see a gynecological provider to rule out any other possible medical conditions. To meet criteria for diagnosis, a total of at least five symptoms from Criteria A and Criteria B must be present. These symptoms will typically present in the week prior to menstruation, and then minimize or disappear after menstruation has started.3

At least one symptom from Criteria A must be present, but you may find that a client reports multiple symptoms. Criteria A symptoms include anxiety, depression, irritability or anger, and labile affect.3 Due to the nature of PMDD and severity of symptoms compared with PMS, clients may report experiencing suicidal ideation or panic attacks just prior to menstruation, while they do not experience those symptoms at any other time. They may also share that they experience extreme difficulty with interpersonal relationships, due to feelings of anger and irritability during this time, while being able to manage positive relationships at other points throughout their cycle.

Symptoms from Criteria B include a client report of decreased interest in activities, difficulty concentrating, fatigue/lethargy, changes in appetite, hypersomnia or insomnia, and feeling overwhelmed/out of control; physical symptoms of bloating, joint pain, breast tenderness, and muscle pain may be present as well.3 A client who is experiencing multiple symptoms from Criteria A and B may report that their ability to successfully carry out responsibilities may be impacted. Again, the impact on an individual will be more severe with PMDD symptoms compared with PMS.

To receive a diagnosis of PMDD, other medical conditions must be ruled out, and the symptoms cannot be attributed to another condition. Use of substances must also be explored with the client; if symptoms are attributed to substance use or abuse, a PMDD diagnosis may not be accurately made. Comorbid conditions may also exist, such as depression, bipolar disorder, generalized anxiety disorder, and seasonal affective disorder. A condition called premenstrual exacerbation (PME) can make the symptoms of conditions such as these worse; the difference is that symptoms with PME do not resolve completely with the start of menstruation, while PMDD symptoms do stop.4

Neurodivergent Conditions and PMDD
While PMDD affects AFAB individuals at a low rate on average (3% to 8%), when comorbid neurodivergent conditions are present, the rates of PMDD occur at a much higher rate. Among autistic AFAB individuals, about 92% meet criteria for PMDD, according to a small, nongeneral study, while ADHD and PMDD occur together in about 40% to 46% of menstruating individuals.1,5 Neurodivergent individuals who experience sensory sensitivity may experience higher levels of distress regarding menstrual-related symptoms, compared with neurotypical individuals who experience the same symptoms.

There is a genetic component to PMDD, just like neurodivergent conditions such as autism and ADHD. When working with menstruating individuals who report an increase in symptoms just before starting a menstrual cycle, it is important to gain an understanding of other symptoms or concerns that they may have. The individual may have a previous diagnosis of ADHD or autism, or they may be undiagnosed, even well into adulthood. Understanding that these conditions intersect can help guide psychoeducation and the individual’s plan for addressing the concerns. It is the responsibility of the clinician to be aware that these conditions intersect to be able to develop a well-informed treatment approach.

Treatment
A mental health clinician can provide therapeutic services that address those feelings of distress that an individual experiences around the time that the menstrual cycle begins. Whether that distress manifests as anxious thoughts, depressed mood, or suicidal ideation, understanding the cause of the fluctuating symptoms can help the individual understand their patterns throughout the month. Clinicians may suggest tracking mood throughout the month so that the individual sees patterns of how they are feeling associated with their menstrual cycle, and can employ coping strategies when they start to feel an increase in their distress. A clinician may also collaborate with a medication provider who treats the symptoms with selective serotonin reuptake inhibitors or with continuous birth control to suppress ovulation and menstruation.2,6

Conclusion
Understanding PMDD and intersecting conditions, such as ADHD and autism, can help an individual understand more about their body and fluctuations in mood at different times throughout their cycle. A mental health clinician who is informed on the topic of PMDD can help guide education and treatment for individuals who would like to manage their symptoms of PMDD. Being aware of the impact that intersecting conditions may have on PMDD, as well as the increase in occurrence, can help clinicians remain more aware of conditions to evaluate upon meeting a new client.

— Jami Imhof, DSW, LCSW-C, LICSW, is a clinical social worker living in Maryland. She currently serves as the coordinator for neurodiversity services within mental health services at Johns Hopkins University. She is also an adjunct instructor with University of Kentucky’s Doctor of Social Work program.

References
1. Rogers AL. We demand attention on the elevated risk for PMDD and PPD among women with ADHD. Additude website. https://www.additudemag.com/adhd-and-pmdd-postpartum-depression-research/. Published May 21, 2024.

2. Premenstrual dysphoric disorder (PMDD). Johns Hopkins Medicine website. https://www.hopkinsmedicine.org/health/conditions-and-diseases/premenstrual-dysphoric-disorder-pmdd

3. Diagnostic criteria for premenstrual dysphoric disorder (PMDD). In: Feingold KR, Ahmed SF, Anawalt B, et al, eds. Endotext [Internet]. South Dartmouth, MA: MDText.com, Inc.; 2017.

4. Eccles H, Sharma V. The association between premenstrual dysphoric disorder and depression: a systematic review. J Affect Disord Rep. 2023;12: 100504.

5. Morales T. PMDD, autism, and ADHD: the hushed comorbidity. Additude website. https://www.additudemag.com/pmdd-autism-adhd. Published February 9, 2024.

6. Reid R. Premenstrual dysphoric disorder (formerly premenstrual disorder). In: Feingold KR, Ahmed SF, Anawalt B, et al, eds. Endotext [Internet]. South Dartmouth, MA: MDText.com, Inc.; 2017.