COGNITIVE AND BEHAVIORAL PRACTICE 2, 167-185, 1995

Cognitive Therapy for Premenstrual

Syndrome

Fiona Blake
John Radcliffe Hospital, Oxford

Premenstrual Syndrome (PMS) has been a subject of great interest in the last
few years and has attracted many theories and treatments. Most of these focus
on physical disturbance or imbalance. Less work has been done on psychological
mechanisms associated with PMS.
A cognitive model is described that considers a broad range of factors that con-
tribute to those premenstrual affective changes associated with Late Luteal Phase
Dysphoric Disorder (LLPDD) now called Premenstrual Dysphoric Disorder
(PMDD). It is proposed that the cognitive appraisal of premenstrual changes in
the context of a woman's current circumstances and personal assumptions deter-
mines whether she perceives them as distressing or as a normal and manageable
part of her life. Vicious circles of negative thinking magnify the symptoms and
increase anxiety, irritability, and low mood.
Cognitive therapy gives a sufferer of PMS the opportunity to review her re-
sponses and to experiment with more adaptive thoughts and behavior. The pro-
cess of therapy is described. This method was developed in the course of a treat-
ment study for women with PMS. The treated group had significant relief of
premenstrual symptoms.

It has long been noted that there are changes of well-being a n d behavior in
w o m e n associated with the m e n s t r u a l cycle, but it was in 1931 that F r a n k first
published case reports of what he called p r e m e n s t r u a l tension (Frank, 1931).
Interest increased with the publication of work by Dalton (1964, 1984), who
vigorously campaigned for the recognition of p r e m e n s t r u a l syndrome (PMS)
as a disorder, characterized by symptoms that occur specifically in the luteal
phase of the m e n s t r u a l cycle.

167 1077-7229/95/167-18551.00/0
Copyright 1995 by Association for Advancement of Behavior Therapy
All rights of reproduction in any form reserved.
168 BLAKE

In the last few years there has been greater consensus with the development
of the diagnostic category of Late Luteal Phase Dysphoric Disorder, now in-
cluded in D S M - I V as Premenstrual Dysphoric Disorder. Several recent drug
trials have shown relief of symptoms for well characterized PMS sufferers: es-
trogen (Watson, Savvas, Studd, Garnett & Baber, 1989); danazol (Watts, Butt
& Edwards, 1987); G n R H agonists (Hammerback & Backstrom, 1988); fluoxe-
tine (Wood, Mortola, Chan, Moossazedah & Yen, 1992). Investigations of the
biological mechanisms of PMS (Parry, 1994) reveal that the mechanisms under-
lying PMS are complex and cannot be fully explained by physiological factors
alone.
This article considers the relevance of cognitive factors to the premenstrual
syndrome, and how cognitive therapy can relieve symptoms and distress.

Definition and Clinical Presentation

As many as 150 symptoms have been associated with menstrual cycle change
(Moos, 1968). They can be physical, psychological, cognitive and behavioral.
They include irritability, depressed mood, tension, tearfulness, food craving,
bloating, headache, tender breasts, tiredness, and clumsiness. In addition, women
often describe feeling "out of control" or "not my usual self;' and being unable
to properly perform normal activities. There is a lack of consensus about which
symptoms are representative of the condition. Frequently an overlap occurs with
other problems, especially gynecological and psychological disorders. Diagnostic
criteria therefore emphasize the timing of symptoms. Such symptoms should
be prominent in the luteal phase of the cycle, relieved by menstruation, and
much reduced or absent in the follicular phase.
The media present PMS as a medical label explaining almost any fluctu-
ating disturbance of a woman's well-being in the reproductive years. This labeling
is influenced by cultural assumptions about the role and behavior of women,
for example, the unacceptability of female anger. As a consequence, some
feminists reject the concept of PMS and deny its existence altogether (Laws, 1985).
As there are no biological measures that distinguish PMS sufferers, diag-
nosis relies largely on the woman's report of symptoms and their severity. These
can be difficult to interpret because symptoms vary in nature and severity from
month to month, even in the same woman. In addition, women who retrospec-
tively report premenstrual problems recall more symptoms of greater severity
than when recording them prospectively on a daily basis (Clare, 1983; Slade,
1984). It is now regular practice to make the diagnosis on the basis of prospective
daily symptom ratings for at least two cycles. This regularly identifies a group
of women with distressing, recurrent, and mostly premenstrual symptoms. These
women can be said to have the premenstrual syndrome. Such women can be
distinguished from a much larger group whose symptoms are not strictly premen-
strual and whose symptoms are less specific. Up to 75% of women presenting
with PMS have been found to have other problems when full assessment (in-
cluding prospective charting) is completed (Mortola, 1992). The aim in assess-
 PREMENSTRUAL SYNDROME 169

ment is to distinguish between PMS, premenstrual exacerbation of an under-

lying disorder (e.g., depression), or a noncyclical problem. This distinction may
be unclear from the history but usually becomes evident from symptom diaries.
Controversy surrounds whether PMS should be a separate category in psy-
chiatric classifications. O f the two main systems of classification, ICD-10 does
not include PMS, but D S M - I I I - R includes Late Luteal Phase Dysphoric Disorder
(LLPDD) in the appendix as a condition requiring "further investigation" (APA,
1987). It appears in D S M - I V as Premenstrual Dysphoric Disorder (PMDD) as a
criteria set for further study. This category identifies a subgroup of patients with
PMS in whom affective symptoms are predominant and cause considerable so-
cial or relationship impairment for most cycles in the previous year. The pattern
had to have been confirmed by daily symptom ratings and not be part of on-
going psychiatric disorder (APA, 1994). Controversy remains about how daily
ratings are analyzed to arrive at the diagnosis. The D S M - I V Work Group con-
sidered the category and its use (Hurt, Scnurr, Severino, Freeman, Gise, Rivera-
Tovar, & Steege, 1992). They found that different statistical methods gave different
rates of LLPDD. Some researchers are not comfortable with the criteria for
L L P D D or PMDD. Some believe that it should exclude women with a history
of affective disorder (Mortola, 1992), others that it is too limited. For example,
it does not include women with moderate premenstrual changes or symptoms
that are few in number or largely physical (Bakhai & Halbreich, 1993).

Epidemiology
PMS is thought to be common and disabling. However prevalence in the
general population is difficult to determine. Inquiries have usually been by postal
survey with women answering retrospective questions. No definition of PMS
is specified for such queries, so rates from surveys vary enormously. It has been
suggested that more than 90 % of women can detect some cycle-related change,
but perhaps 5 to 10% have symptoms that regularly disrupt life. The use of
the category L L P D D identifies a severe subgroup of PMS that has been con-
firmed by prospective charting. One survey using prospective daily ratings found
that 4.6% of their group of women aged 17 to 29 met criteria for LLPDD (Rivera-
Tovar & Frank, 1990). The course of PMS is also uncertain. There is an associa-
tion between lifetime prevalence of affective disorder and dysphoric PMS (DeJong,
et al., 1985; Schmidt & Rubinow, 1993), but factors such as age, demographic
variables, menstrual cycle characteristics, childbirth, oral contraceptive toler-
ance, stress, and personality variables have not been clearly linked with the ex-
perience of PMS.

Etiology
Many theories have been proposed to explain premenstrual syndrome, but
as yet, none have been fully evaluated. It appears that the biological explanation
for PMS may be more subtle and multifactorial than was at first supposed. At-
tempts to establish hormonal differences between sufferers and nonsufferers of
170 BLAKE

PMS have been unsuccessful (Bancroft & Backstrom, 1985; Reid & Yen, 1981;
Rubinow & Schmidt, 1989). There is now some evidence supporting possible
differences in how neurotransmitter systems respond to hormones, prostaglan-
dins, and other body systems in women with PMS. A normal pattern of ovarian
hormones and ovulation are important in the development of PMS (Smith &
Schiff, 1993), but it is possible that they act upon the serotonin system, which
may be disturbed in women with PMS (Rapkin, 1992). In addition to possible
physical vulnerability factors, psychosocial and cultural factors need to be con-
sidered. It is acknowledged that many factors influence a woman's experience
of her menstrual cycle changes and that "the etiology of L L P D D may rest not
in one locus but in a dynamic equilibrium of all loci" (Severino, 1994). Regret-
tably there has been less investigation of these other factors. Ussher has postu-
lated that cognitive attribution may be important in the etiology of PMS dys-
phoria (Ussher, 1992) and Reading (1992) has proposed a cognitive model for
PMS.
PMS is gender specific, but some other disorders may have related etiolog-
ical factors, in particular functional syndromes such as irritable bowel syndrome
and pelvic pain. These sufferers are mostly female and often have attitudes and
experiences that are different from male sufferers. Toner, who has been inves-
tigating cognitive therapy for irritable bowel syndrome, suggests that women
with this disorder are socialized towards roles that make it more difficult to cope
adaptively with their own needs, and they may develop physical symptoms as
a result (Toner, 1994).

Psychological Factors and PMS

Clinicians recognize that understanding, education and support are perceived
as helpful by the sufferer of PMS (Bancroft & Backstrom, 1985), although very
little research has been undertaken to systematically evaluate this beneficial effect.
Psychological symptoms often dominate PMS complaints, and lead the woman
to seek help. Many women cope with the physical symptoms but cannot manage
the psychological ones, especially those that lead to interpersonal problems.
Women also report that PMS is more severe under stress, though this relation-
ship is complex. There is no clear relationship between personality and PMS
(Goudsmit, 1988), but there is overlap between PMS and affective disorders
(Schmidt & Rubinow, 1993).
Many nonphysical therapies are offered for PMS, although none have been
adequately evaluated. These include psychotherapy, counseling, hypnotherapy,
transcendental meditation, acupuncture, diets, hypoallergenic environments,
self-help groups, and psychodynamic psychotherapy. Two small uncontrolled
studies have shown promise in trying to measure psychological effects in well
characterized sufferers, using forms of cognitive therapy with individuals (Slade,
1989), or in groups (Morse & Dennerstein, 1986). There have been disserta-
tions describing successful treatment of PMS with cognitive therapy, but short
or focused therapy did not show an effect (cited by Rivera-Tovar, Rhodes, Pearl-
 PREMENSTRUAL SYNDROME 171

stein, & Frank, 1994). However these are not published studies. There are only
two published controlled trials of psychological treatments for PMS. The first
study (Morse, Dennerstein, Farrell, & Varnavides, 1991) compares group therapy
(called coping skills training), with relaxation training and hormonal treatment.
All the treatments relieved PMS during the study, but only the therapy group
maintained their gains at 3 month follow up. The other study (Goodale, Domar,
& Benson, 1990) uses relaxation training and compares it with leisure reading.
Relaxation training was superior to the control condition.
The Oxford study was an attempt to determine the effect of cognitive be-
havioral therapy for individuals with PMS. Preliminary results were favorable,
showing greater relief of symptoms for the treated group compared to a waiting
list control group.

A Cognitive Model
The characteristics of cognitive therapy make it particularly suitable to treat
a condition such as PMS. It is brief, time limited, educational, collaborative,
and structured. It integrates physiological and psychological components of PMS.
It is a common sense approach that is comprehensible and acceptable to people
who are wary about any implication that symptoms are "all in the mind"
The initial hypothesis was drawn from cognitive behavioral theory for other
disorders, in particular, depression and panic disorder. It is proposed that women
with PMS may be interpreting physiological changes in the luteal phase in a
negative way. Premenstrual physiological changes trigger negative thoughts based
on assumptions that the woman has about how she should feel and behave, and
what to expect of the world. If she regards the changes as threatening or depriving,
she will feel anxious and depressed. She will then tend to expect further ex-
periences to be negative, and the dysphoria intensifies.
The hypothesis suggests that if these negative cognitions can be modified,
then PMS dysphoria can be relieved. A set of definable treatment techniques
were selected, based on their effectiveness with other somatic symptoms. These
techniques were adapted for use in PMS, as it is similar in some respects to
hypochondriasis and panic (Clark, 1986; Salkovskis, 1989). In addition, tech-
niques for relief of depression were also relevant (Beck, Rush, Shaw & Emery,
1979).
The model assumes that some physiological change is associated with the
luteal phase of the cycle, triggering premenstrual distress. However, unlike the
physical explanations for PMS, this change is not considered to be the only factor
in causing symptoms and distress. The premenstrual physiological changes
happen on a background of other psychosocial stressors. These psychosocial
factors affect the way that the woman interprets the physical changes.
More specifically, the woman may find that the physical changes interfere
with her normal coping mechanisms. She perceives these physiological changes
as threatening and becomes apprehensive. She may predict that the changes
are going to create difficulties for her. These difficulties may appear to be un-
172 BLAKE

manageable. She focuses on her body and notices more symptoms associated
with anxious arousal. These increase her fear that things are getting worse. She
is influenced by previous experience of premenstrual symptoms. If the symp-
toms have been associated with unpleasant exchanges with her partner or family,
she will expect a negative outcome when these sensations recur. This negative
interpretation may go back to early experiences of criticism, which drive her
to set rigid standards of behavior and coping that may not be flexible enough
to allow for regular fluctuations in well-being, however mild.
For example, a woman may interpret physical changes as indicators that she
is about to lose control. These thoughts induce anxiety and tension that lead
to indecision and inability to concentrate. This is interpreted as further evi-
dence that she has indeed lost control. Vicious circles of negative thoughts and
self-defeating behavior develop and maintain the negative reaction (see Figure
1). A woman who reacts negatively to her bodily changes will feel more upset
by changes of physiology than a woman who has a more adaptive reaction.
When she asks herself "What does this mean?", the change of well-being is
filtered through a number of factors both internal and external that stress her
life system. Some of these are more fixed than others and may account for the
varying severity of symptoms from month to month. Some factors such as finan-
cial difficulties, sleeplessness, physical illness, bereavement, etc., raise the general
level of stress in a woman's life. Premenstrual change is the straw that breaks
the camel's back. Others are specific to the premenstrual experience such as
the response of others to her tiredness or tearfulness. She attributes a meaning
to her change in well-being that is either negative or adaptive. The adaptive
response minimizes or even utilizes the changes. She feels able to cope and work
with them. A negative attribution is associated with a cascade of negative thoughts
that increase her sense of helplessness and lack of control. The negative thoughts
are associated with psychological symptoms especially those of tension, anxiety,
and depression. Tension also increases the likelihood of irritability. These psy-
chological symptoms occur on top of the physiological trigger symptoms and
tend to intensify these negative symptoms as well. This feeds back to the original
influences that determined the attribution and maintains a negative pathway
(see Figure 2).
Until now, the only explanation for this change the woman is experiencing
is that she isphysically unwell at this time of the month, or neurotic, and there-
fore inadequate. Whatever is wrong, it is out of her control, it is unmanageable,
and she is spoiling others' lives as well as her own.
This psychological response to bodily change is the focus of therapy. A sec-
ondary consideration is the woman's response to her general circumstances. The
treatment goal is that at the end of treatment, the woman will still have cyclical
symptoms, but she will have the skills necessary to take care of herself. She will
also have some idea of how her circumstances contribute to her perception of
distress and what she can do to reduce this. Her cyclical changes will be manage-
able so that she no longer sees herself as a sufferer.
 PREMENSTRUAL SYNDROME 173

PMS Symptoms

"I'm less in control.

I won't )erform as well
as should." ~N~

Low mood Guilt, low mood

f
Perceives further Being out'of control
difficulty. is confirmed as
"I can't do it, so dreadful.
I am useless,
a failure."
t
Tries Irritable
harder outburst

Anxiety, ten sion x~,...~

depressed mood

Guilt: Resentment:
"I should be "There are too many
in control. I should demands on me. Nobody
be able to do this." cares about me or helps
me."

FmURE 1. Vicious circles of negative thinking in PMS.

Beliefs and assumptions about the female role that seem to be important in
PMS emphasize submission, self-sacrifice, and total availability. They are similar
to those described by Toner in her cognitive model for women with irritable
bowel syndrome (Toner, 1994). She believes that it is likely that these gender
issues are important in the presentation of other similar functional disorders.

Cognitive Therapy for PMS in Practice

Engagement
A client presenting for cognitive therapy is looking for a new approach to
PMS. Probably she will already have decided that she has PMS, and has tried
other treatments without success. If she has been referred by a gynecologist,
she may have exhausted the medical options. She may come looking for a non-
hormonal therapy because of fears about medication and will have been un-
happy for some time. It is important to acknowledge her distress and elicit and
accept fears of nonmedical approach.
174 BLAKE

PhysiologicalMonthlyFluctuation
Changein Well Being
Internal External
Influences S Influences
Personal vulnerability - ~ Social circumstances
Physical stressors Life events
Past experiences The response of others
Cultural factors

CognitiveAppraisal
"What is this? What does it mean?"

s Attribution~.,..~
Negative Adaptive
"I'm in trouble. It's 'Tm okay. It's some-
something bad that I can't thing I can handle, work
deal with, and I can't out, cope with."
control."
¢
DISTRESS ADAPTIVE COPING
Helplessness, Analysis, problem-solving,
low self esteem adequate self esteem

PMS- PMS-
An overwhelming illness A challenge to work out

Additional symptoms
Minimizing of symptoms
(an~ety, low mood, tension)
T
¢
Physiological changes PLUS Physiological changes
symptoms of stress contained and minimized

FIGURE2. A cognitivemodel of PMS.

Such a woman can be introduced to the cognitive model, and the style of
working can be explained. The collaborative approach may be very different
from the medical model usually found in gynecology clinics. The effectiveness
of therapy depends on establishing a good therapeutic relationship in which the
woman can feel understood and affirmed. In the Oxford study, women frequently
expressed their relief and confidence in seeing a female therapist. Where new
 PREMENSTRUAL SYNDROME 175

attitudes to the female role are being considered, the therapist serving as role
model is important. If a woman believes that men cannot understand PMS,
she will find it harder to relate to a male therapist.

Assessment
The assessment aims to identify the main areas of difficulty and discern some
differential diagnoses. First, note the symptoms and problems and attempt to
find out why the woman is presenting now. Explore her expectations, her ideas
about causation and past experience of help-seeking. A detailed account of a
specific premenstrual episode may most graphically reveal the underlying con-
cerns of the woman with PMS. A picture is obtained of the woman in her con-
text. This includes the pattern and severity of the symptoms and their impact
on her life. The response of others may be important as are her social circum-
stances and the demands of job and family. She may have particular expecta-
tions of how she should function that are disrupted by PMS. Note past treat-
ments, past outcomes, and the nature of the interactions with helping agencies.
Note also psychiatric disorder past and present.
It is wise to ensure that the woman has had a gynecological check, particu-
larly where there is irregular or heavy bleeding, or considerable premenstrual
pain.

Daily Symptom Diary

If PMS has not been ruled out immediately, encourage the woman to keep
a daily symptom diary. She will need to keep this record for at least two cycles
before the pattern of symptoms is apparent. Several versions of these are avail-
able for clinical use. Something simple and easy to complete and interpret is
required, such as the Calendar of Premenstrual Experiences (Mortola, Girton,
Beck & Yen, 1990), or O'Brien's PMS chart (O'Brien, 1987). A space for com-
ments is helpful. There may be relevantexplanations for symptom change on
particular days. The importance of the diary should be emphasized and com-
pletion rehearsed in the clinic. The woman must be convinced of its usefulness
and relevance. The diary will aid in diagnosis, and encourage the woman to
be active in the investigation of her problems. Self-monitoring will be a part
of therapy.
If a daily diary has not been kept for the 2 months before the assessment,
follow-up appointments should be suggested at 1 and 2 months after the initial
visit. Appropriate areas of concern can be explored from the diary records. It
will not only identify the PMS sufferer, but also allow the discussion of a non-
PMS pattern of symptoms. Once diary confirmation has been obtained, a con-
ceptualization of the problems can be drawn up with the client. This conceptu-
alization is based on the cognitive model as it applies to her life. I f she accepts
this perspective, therapy is offered.
176 BLAKE

T h e n u m b e r and frequency of sessions is set, and the length of each session

decided. In Oxford, the therapy offered was 12 sessions of one hour duration,
weekly on an individual basis. These women had very severe PMS. It may well
be possible to treat well motivated women with less severe P M S with fewer ses-
sions, and I have had some success in clinical practice with 4 or 6 sessions. There
is also scope for treating P M S in groups.

Education
The assessment interview provides the opportunity to inform the woman about
her cycle and the normal range of menstrual experiences. Anxiety and confu-
sion can be reduced if the w o m a n can be helped to make sense of the changes
in her body throughout the month, and learn that other women have similar
experiences. Her attention is drawn to the wide variety of external stressors that
may contribute to her premenstrual distress and maintain a high level of ten-
sion. Education about general measures to improve health and well-being are
often appropriate. W o m e n may not be aware of links between symptoms and
poor diet, lack of exercise, smoking, or excess alcohol or caffeine. Some women
find that once they have this information they feel more in control. Some im-
mediately make changes to the way they view their symptoms, and to the way
they think and behave, and become less distressed.

Intervention
Once the contract has been agreed upon, further clarification of the pattern
of symptoms is obtained by reviewing the diaries. T h e conceptualization is
reviewed, and the cognitive model reiterated.
Therapy builds on the therapeutic relationship started at the assessment. The
therapeutic processes described below are started at the assessment and are neces-
sary to make a conceptualization. Therapy may not start with a complete pic-
ture so the conceptualization is revised as new material unfolds.
A typical incident. Ask the woman to choose the most distressing problem. A n
example is drawn from upsetting premenstrual episodes. Often this will be an
irritable outburst, or a period of tearful despair. For example, one woman reports
an occasion when she burst into tears and began to shout and scream at her
husband when he was 15 minutes late home from work. She is bewildered by
her reaction, as logically she knows that traffic frequently holds him up on the
way home, and at other times she understands this and accepts it.
Take the w o m a n through the event in detail, including the course of the ex-
perience and the consequences for herself and for others. Ask her to describe
what feelings, value judgements and thoughts were associated with the experience.
Often "hot" cognitions will emerge that are associated closely with the symp-
toms. Attention is drawn to links between physical change, feelings, thoughts,
and behavior. This is often difficult at first because the experiences are frequently
disowned by the w o m a n because they are not like her. She may find it hard
 PREMENSTRUAL SYNDROME 177

to remember the details of how she responded. All she remembers is the bad
feeling and the consequent guilt and fear.
Thought records. The exercise above begins the process of drawing attention
to cognitions as mediators of distress. Thought records are used to obtain the
feelings, and then the thoughts accompanying the episode. They are then con-
tinued through the month, as homework, collecting automatic thoughts that
arise in situations of negative emotion. Usually the emotions are less intense
outside the premenstruum. However, frequently the content of the thoughts is
the same. During the intermenstruum, the woman successfully challenges the
negative thoughts with coping strategies. During the premenstruum, the change
in well-being interferes with normal coping and the strategies fail to some ex-
tent. This allows assumptions to surface that are making demands on the woman
that are becoming harder to meet. A small but meaningful trigger can lead to
a response that is catastrophic, with a cascade of negative thoughts that confirm
fears and resentments. This experience is so upsetting that often the woman
responds by trying to suppress her feelings even harder. She is then under fur-
ther tension before her next cycle begins.
For example, the woman whose husband came home late from work, real-
ized that on the day of the outburst she had been tired and frustrated by the
children. She thought that her husband would help and support her when he
got home. He was late and by the time he arrived she was thinking that he did
not care about how hard it was to cope with children in the early evening, and
did not wish to hurry home. She envied him his high status, orderly life, and
thought he must prefer it to being at home. By the time he arrived, she was
miserable and tense with many negative thoughts focused on him. When he
came home, she poured out her resentments and an argument ensued. Her fear
that home is an unwelcome place was confirmed as he backed offin indignation.
As she keeps thought records over the next sessions, she learns to identify
her thoughts and feelings both premenstrually and at other times. She identi-
fies attitudes that underlie her negative thoughts and vicious circles of negative
thinking that increase the intensity of her feelings.
Assumptions. There are several assumptions that create problems for women
with premenstrual changes in well-being. Such assumptions may have been adap-
tive when they were formed, as a child and young adult, but often no longer
serve her quite so well. She has not questioned whether they are appropriate
for her now. Often they restrict choice and convey a vague sense of guitt whenever
a rigid set of implicit rules are not obeyed. When examined these assumptions
can be challenged. The woman can choose whether to continue to cherish those
values but can also decide to experiment with alternatives. For example, one
sufferer had grown up to believe that it is selfish to say no to any request, and
that the way to gain approval is to be available to help anyone who asks. She
finds that helping others is rewarding, but when premenstrual, she finds herself
too tired and uncomfortable to enjoy all the commitments she has taken on.
She panics, and fears that she will be rejected if she turns things down, but also
178 BLAKE

finds that she cannot deliver the promises she has made. Her assumptions make
things worse as she compensates by pushing herself even harder.
Behavioralexperiments. Alternative thoughts and assumptions must be realistic
and believable if they are to displace the old ones. One way of testing these new
concepts out is by experimenting with behaviors that are based on the new as-
sumptions. The experiment is monitored using thought records. Feelings,
thoughts, and the response of other people are noted. Often this is a powerful
tool towards a more flexible state of mind. The client is in control and explores
the range of choices herself. There will be times when she makes a choice to
stay with situations and attitudes that are painful and not what the majority
of women would choose. However, great value is derived from realizing that
a choice has been made rather than feeling like a helpless victim. For example,
a woman may try to set some time aside for regular exercise. She then reviews
this to see whether this is acceptable to her family and herself, and whether
it helps to keep her calmer in her more difficult weeks.

S o m e Issues for W o m e n w i t h P M S

Negative Beliefs About PMS

Women who present with PMS do not like what is happening to them and
want to find relief. However, many women have beliefs about PMS that may
exacerbate the symptoms and prevent them from minimizing their impact on
their lives.
For example, the following beliefs may be held: "If I have PMS, it is a hor-
monal imbalance and there is nothing I can do to help myself. If I have PMS,
I am weak and neurotic. My body must be faulty if I have PMS. My mother
had PMS, so I am bound to suffer in the same way."
These ideas tend to increase the woman's sense of helplessness and hopeless-
ness about PMS and lead to anxiety and low mood in response to the physiolog-
ical changes.

Beliefs About Responsibility and PMS

Women often believe that they are responsible for the emotional well-being
of those around them. In the family the woman may think that she is the only
one who notices and cares for the hurts and fears of her partner and her chil-
dren. She may also be the one who smoothes things out at work. The premen-
strual changes that make her tired and more introspective interfere with this
function, and she feels guilty for letting others down. She may brush others off
in a way quite different to her usual style in an effort to limit the demands.
She may easily think that she has a problem, rather than that she sometimes
needs support (e.g., "Things that go wrong are probably my fault. Everyone
is upset if I am upset. I should be able to meet everyone's emotional needs. If
I get irritable I am at fault. I should be able to be kind and supportive at all
times.").
 PREMENSTRUAL SYNDROME 179

Perfectionism
Other assumptions that are often associated with PMS are high expectations
of personal performance. This perfectionism is interfered with by PMS because
each month the physiological changes that lower well-being (tiredness, pain,
bloating and an element of emotional lability) prevent fulfillment of goals. The
sense that it is more difficult to meet these goals, often results in increased striving,
more fatigue and panic (e.g., "People will approve of me only if I do everything
right. I should strive to get everything right and get everything done. If I do
not complete everything now, I may get overwhelmed, and I will never catch
up. If I don't do things the right way, I will be a disappointment to myself and
others.")

Beliefs About H e r Own Needs

Some women find it hard to accept their own need for support and attention.
When a woman is premenstrual and is not at her peak, she cannot ask for help,
or reduce the demands made by others. She may find herself overwhelmed (e.g.,
"If you take time for yourself you are selfish. A good woman puts other people
before herself. I will be liked and approved of if I say yes to as many requests
for help as possible. If I say no I will be rejected"

Beliefs About the Expression of Anger

PMS also activates fears about anger and assertiveness. Many women are
encouraged to avoid expressing anger. This may extend to any personal view
that is in conflict with another person. Such a woman is then unable to say when
she disagrees with someone, and resentments are kept hidden. The premen-
strual changes may make it harder to contain these needs and feelings and re-
sult in outbursts of distress and indignation (e.g. "Nice women do not get angry
or have arguments. Confrontations are always humiliating and to be avoided
at all costs. It is better to pretend that I do not have needs than make a fuss
about them.")

Case Illustration of Perfectionism and Underassertion

Julie complains of PMS, which has been getting worse for the last few years.
She is 39 years-old and has three children in their teens. She has a busy part-
time job as a school teacher. Her husband is kind and understanding, but is
frequently away with his job. He finds it hard to know how to deal with the
monthly round of shouting and mood swings.
She is living at a pace that is barely sustainable. Her lifestyle relies on her
being in top form all the time. She cannot say no. H e r need for approval and
her fear of causing offense or being seen as unhelpful or selfish, drive her to
accept more tasks than she can comfortably manage. When her well-being is
slightly compromised (premenstrual fatigue, headache, tension, etc.), she cannot
meet the demands. Everything becomes harder. She becomes anxious, tries
180 BLAKE

harder, finds herself struggling even more, and feels low, guilty, and even more
tired as her targets slip away while she runs out of steam. She becomes depressed,
and she blames herself and her body, but will also burst out with anger at those
around her who loaded her with tasks that, last week, she happily accepted.
Now she would like help, appreciation and support. She does not usually ask
for these, so instead finds herself overwhelmed with all the problems of the family.
She believes that it is her duty to sort them out with her usual finesse.

The Process of Change

Acceptance. Julie was encouraged to face and accept PMS as a difficult problem
that may yield to a new and active strategy. The physiological change was not
swept aside, but described as a trigger to a series of responses that add unhelpful
symptoms of stress to the physiological change. Her beliefs about the problem
were linked to maladaptive behaviors, such as taking on too many tasks to gain
approval, that had become habits. In order to have changes that are tolerable,
she identified and faced her underlying need to be accepted and loved, and her
need to avoid criticism. Therapy dealt with the responses to premenstrual hor-
monal changes that were raising her general levels of stress.
Analysis of clarification. At a symptomatic level, Julie began to notice and ac-
cept the changes in well-being through the month. Once she had unravelled
the content of her premenstrual thoughts and related them to her general pat-
tern of needs she started to address what she might do to meet them.
Self-monitoring allowed her to see how things linked together. The process
helped her to be more analytical and more problem-solving oriented. It gave
her clues about choice points. For example, she saw that she was often tired
and irritable when her husband was away, but only felt guilty about this when
she was premenstrual.
Taking care of herself. Julie was encouraged to learn more about herself and
her own needs so that she could take better care of herself. This was a challenge
for someone whose lifetime was characterized by a neglect of her own needs
and feelings. Culturally and within her own family, she had been taught to put
others first and not think about herself. It was a revelation to her to consider
how her body prefers to operate, e.g., how much sleep she really needed, and
how much she valued time alone. She learned to plan to have some margin of
energy and time throughout the month that would stop her from entering her
premenstrual time on the brink of collapse. She experimented with building
into her life some personal pleasure time. At first, she could not accept this for
herself alone, but as she saw that it helped everyone including herself, she began
to relish it.
Setting realistic goals. Julie looked at what was motivating her in life. She ex-
plored her current goals and whether they were set by herself or others. She
realized that she was driven by unrealistically high expectations of her coping
and capability that she had never questioned. In her case, they were based on
 PREMENSTRUAL SYNDROME 181

a need for approval. In therapy, she explored what she could realistically expect
of herself. Julie decided to set new goals that would challenge and stretch her,
but also increase her self-esteem. She decided to experiment with lowered ex-
pectations in certain parts of her life (e.g., not being the perfect, most attentive
mother) and to try something more adventurous in other ways (e.g., taking the
vocational training course she had always wished she had time for).
Assertiveness. Julie often wished to enlist the help of others or say no to more
demands. In therapy, she rehearsed stating her needs without fear of reprimand
or escalation. This was then tried at home and the strategy reviewed at the next
session. This process also reinforced the assumptions that she is worth listening
to and that she could speak of her needs without misunderstanding or confron-
tation.
Julie found anger and confrontation difficult, but learned that being asser-
tive and expressing needs is not necessarily a bad thing. She experimented and
found that it can be good, real, and necessary for healthy relationships. She
explored how this differed from destructive expressions of anger.
H e r family turned out to be willing to support and help her once she had
discussed it with them calmly, and helped them to know how to respond.
Realistic sharing of responsibilities. There is often a need to be more realistic in
the assignment of responsibility. In Julie's case, she assumed responsibility for
the emotional well-being of the whole family. When anything went wrong for
anyone she assumed she was at fault. A close look at areas of guilt and responsi-
bility revealed scope for a more realistic sharing of responsibility, especially dis-
ciplining the children. Review allowed her to stop worrying about things she
could not change, such as whether her parents has sorted out enough healthcare
for their declining years, and to let go of things that were not hers to put right
(such as whether her daughter could sort out her chaotic friendships).
The pace of change. Julie could not change her attitudes until she believed it
was safe to do so. In therapy, she experimented with new ideas and then new
behaviors, but at a pace and in a style that she had chosen and that did not
dislocate relationships at home. Therapy gave her skills to more realistically ap-
praise her situation and feelings so that she was more in control, had more un-
derstanding and had more choices.
With a little practice she learned to "Stop, think, and choose" between var-
ious thoughts and behaviors whether negative, neutral, or positive. This pause
for review in a situation was immensely helpful to her. She was used to acting
reflexively and had not believed that she had any choice about her response.

Case Illustration of Responsibility

Cathy had had PMS since the birth of her first child 4 years ago. Her hus-
band backed away and refused to discuss things when she was irritable with
him. She thought that she drove him away and was full of guilt and yet felt iso-
182 BLAKE

lated when she needed support most. She felt she was spoiling life for her hus-
band and child and there was nothing she could do to alter this. She tried to
make it up to them in her good weeks. In therapy, she realized that she was
trying too hard during her good weeks and ignoring the approach of her premen-
strual time. She was taking responsibility for all the negative feelings in the family
and getting tense about upsetting her partner throughout the month. She found
that she actually rarely said what she really felt to him because she believed
that he had enough to cope with and did not want to hear her moans, especially
frustrations with their little son.
She realized that she actually wanted to say more to her husband, but did
not know whether he would like to hear about her day. She decided to ask him.
She thought that the worst that could happen would be that he said he was not
interested. She asked him. He said that he did want to hear about her day, but
was afraid that it would get her worked up like she was on her horrible prernen-
strual days. They tried talking about the day in the good weeks. She was pleased
and felt closer to him and more valued. She told him about therapy. They began
to plan for the "bad weeks 3' He said he could not help backing off, but he would
try to give her more help with the baby so that she could have some time to
herself. She continued to experience symptoms, but they became shorter in du-
ration and she felt more supported and more in control. She stopped feeling
guilty about her difficulties as her partner had been willing to accept that he
had a role in improving things. She proved to herself that actually facing the
problem was of benefit to everyone.

S u m m a r y of Therapy

A. Acceptance
1) Normalization ("PMS is a problem like other problems")
2) Owning ("PMS is part of me and I can learn to deal with it")
3) Integration ("My PMS is related to how I deal with the other weeks")
B. Clarification
1) Analysis ("What is happening?")
2) Linkage of thoughts, feelings and behavior in particular situations of dis-
tress (homework-thought record)
3) How the situation developed (vicious circles of negative thoughts, maladap-
tive, self-defeating behaviors)
C. Active Participation
1) Self-monitoring (symptom diary, thought record)
2) Collaboration with the therapist ("What alternative thoughts or behaviors
could I use?")
D. Identifying unhelpful or exaggerated assumptions
1) High expectations: "I get approval if I get everything right and everything
done. I am a failure if I don't complete this. I will be overwhelmed if I
don't keep up with the work"
 PREMENSTRUAL SYNDROME 183

2) Fear of negative emotion: "It is unacceptable for me to get into conflict

with others. I will be rejected if I disagree with people. Good women are
not irritable"
3) Self-sacrifice: "Good women put others before themselves. It is selfish to
want time to myself. I should be totally available to my family"
E. Behavioral Experiments
The woman is encouraged to try alternative solutions and see what happens:
1) Moderating her expectations: "Will the house be filthy ifI leave the cleaning
until tomorrow?"
2) Facing negative emotion: "Would it be so awful to say I don't want him
to go out tonight?"
3) Self-care: "Would they all manage ifI went swimming on my own tonight?"
4) Challenging failure: "Am I really failing as a mother if I buy cakes for
the party instead of making them?"
She then learns to pace herself, assert herself, and look after herself while
answering her unhelpful assumptions convincingly.

Special Cases
On some occasions, patients with PMS disclose information that complicates
the formulation, such as delusional experiences, suicidal ideation, or a history
of childhood sexual abuse; these should be evaluated in their own right and treat-
ment aimed specifically at dealing with these issues. This may require revision
of the plan of management and further referral may be necessary. Some women
cannot accept or work with the cognitive approach especially if they have strong
negative beliefs about psychological treatment.

Conclusion

The experience of PMS is inextricably linked with self image, coping styles,
psychological resources, social circumstances, life events, and relationships. A
cognitive model considers these factors, as they affect the interpretation of phys-
ical and emotional changes during the menstrual cycle, particularly in the
premenstrual phase. Cognitive therapy challenges the common belief that the
PMS sufferer is victim of her hormones, and there is nothing she can do except
plead for pharmacological adjustment. Therapy encourages the woman to help
herself and to react positively to symptoms. It can help her cooperate in testing
the efficacy of medical treatments for PMS. She learns more about how her cir-
cumstances and relationships contribute to her distress, and what she can do
to change things. She learns to ask for help appropriately and to recognize and
accept more readily what she cannot change.
In our pilot study, we have demonstrated that cognitive therapy is an effec-
tive and acceptable way of helping women with PMS to help themselves.
184 BLAKE

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The author thanks Dr. Paul Salkovskis for invaluable help with the development of this treatment
model and Dr. Dennis Gath for making the study possible. I would also like to thank Mrs. Ann
Day and Mrs. Adrienne Garrod for their work in the study. Address correspondence to: Dr. F. Blake,
Department of Psychological Medicine, John Radcliffe Hospital, Headley Way, Oxford. OX3 9DU.
England.

RECEIVED: March 7, 1994.

ACCEPTED: September 20, 1994.