Received: 8 July 2020 | Revised: 27 September 2020 | Accepted: 10 October 2020

DOI: 10.1111/ppc.12656

ORIGINAL ARTICLE

Premenstrual disorders among young Turkish women:

According to DSM‐IV and DSM‐V criteria using the
premenstrual symptoms screening tool

Zeynep Daşıkan PhD, RN

Department of Women's Health and

Disease Nursing, Faculty of Nursing,
Ege University, Izmir, Turkey
Correspondence
Zeynep Daşıkan, PhD, RN, Department of
Women's Health and Disease Nursing, Ege
University, Faculty of Nursing, Izmir 35100,
Turkey.
Email: zdasikan@hotmail.com and
zeynep.dasikan@ege.edu.tr
Abstract
Purpose: This study aimed to determine the prevalence of premenstrual syndrome
(PMS) and premenstrual dysphoric disorder (PMDD) according to the DSM‐IV and
DSM‐V criteria using the premenstrual symptoms screening tool (PSST) in young
Turkish women aged 15–24 years.
Design and Methods: This descriptive study included 760 Turkish female students in
Izmir.
Findings: The prevalence of PMS was 61.1% and 26.1 and that of PMDD was 20.4%
and 10.0%, based on the DSM‐IV and DSM‐V criteria using PSST, respectively. In the
PMDD category, the most common symptoms were anger/irritability (97.4%). PMS/
PMDD prevalence is common in young women, especially in adolescents, and PMDD
prevalence was alarmingly high.
Practice Implications: Health professionals take an active role in the diagnosis and
management of PMS/PMDD.

KEYWORDS

adolescent, premenstrual dysphoric disorder, premenstrual syndrome, reproductive health

care, young women

1 | INTRODUCTION
Premenstrual syndrome (PMS) and premenstrual dysphoric disorder
(PMDD) affect most women of reproductive age. PMS and PMDD are
syndromes affecting a woman's emotions, physical health, and be-
havior during certain days of the menstrual cycle. These disturb
women in the luteal phase of the menstrual cycle and affect women's
physical and psychological wellbeing.1,2
PMDD is a more severe form of PMS. It is a depressive impair-
ment that can also cause functional impairment and includes cyclical
psychological, cognitive, and somatic symptoms.3–5 PMDD is part of
the depressive impairment category in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM‐V).2 The common
symptoms of PMDD are excessive tension, irritability, desperate
mood, depression, extreme anger, decreased interest in daily activity,
1,2,6,7
and low self‐esteem. Not all women with PMS symptoms
experience PMDD symptoms, but all women with PMDD symptoms
also experience PMS symptoms.3,8 PMS symptoms begin after
menarche between age 14 and 17 years, and the most serious
symptoms are observed between ages 25 and 35 years. Symptoms
usually fade during menopause.1,4,9
Between 50% and 95% of women of reproductive age experi-
ence at least one PMS symptom.9–11 The incidence of PMS world-
wide also varies from mild (70%–95%), moderate (20%–70%), and
severe PMS/PMDD (1%–20%).3,5,12–16
A difficulty with PMS diagnosis is identifying whether patients
need treatment. Different scales and methods for PMS diagnosis are
used worldwide. The Premenstrual Assessment Form (PAF/95 items),
which is used widely for PMS diagnosis, and Premenstrual Syndrome
Scale (PMSS/44 items), have many questions.17–19 For PMS/PMDD
diagnosis, a diary must be kept prospectively for at least two men-
strual cycles according to DSM‐V diagnostic criteria.2 PMDD was

Perspect Psychiatr Care. 2020;1–7. wileyonlinelibrary.com/journal/ppc © 2020 Wiley Periodicals LLC | 1

2 |
recently included in DSM‐V criteria as a full diagnostic category.
Women refuse to participate in PMS research because of the length
7,13
of the scale and difficulty of keeping a daily record. The pre-
menstrual symptoms screening tool (PSST/19 items) is a useful and
less time‐consuming screening tool.4,20 This tool has been adapted to
different cultures and has been used in many studies.5,7,10,13
Adolescence is a stormy period with changes that affect persons
physically, psychologically, and socially. In addition, PMS and PMDD
affect young women similarly. In this period, the social relationships
of young women who are affected deteriorate, and alcohol/substance
abuse, suicide, and accident rates increase, and school performa-
nce and academic achievement decrease.3,6,20,21
In Turkey, studies on the severity of PMS and PMDD in young
women are limited. These conditions need to be diagnosed and
managed in the early period. Currently, 15.8% of Turkey's population,
approximately 13 million people, are young people in the 15–24 age
group, and half of these are young women.22 This study aimed to
determine the prevalence of PMS and PMDD according to the DSM‐
IV and DSM‐IV diagnostic criteria using the PSST in young Turkish
women aged 15–24 years, as well as to determine the difference
between the prevalence of PMS and PMDD in adolescents aged
15–19 years and young women aged 20–24 years.
2 | METHODS
2.1 | Design
This study is a descriptive and cross‐sectional study. The study was
conducted at two different public high schools and two different
faculties (other than health areas) in Bornova, Izmir, Turkey, between
March and June 2016. The study sample consisted of 1,013 female
students in these two faculties (620 individuals) and two public high
schools (493 individuals), and 760 individuals from this sample met
the eligibility criteria.
2.1.1 | Participant criteria
In line with the literature, the participation criteria were age 15–24
years, at least 2 years from menarche, regular menstrual cycle
(22–35 days), not using oral contraceptives or antidepressants, no
existing medical and psychiatric disorders, and willingness to parti-
cipate in the research.1,3,9
2.2 | Instrumentation
2.2.1 | Sociodemographic questionnaire
This questionnaire developed by the researcher gathers informa-
tion on the individual characteristics of the participants (age,
school, marital status, etc.), menstrual characteristics (menarche
DAŞIKAN
age, cycle period, bleeding time, and dysmenorrhea), and medical
and psychiatric illness that may be associated with premenstrual
symptoms, and information, such as oral contraceptive and anti-
depressant use.
2.2.2 | Premenstrual symptom screening tool
The PSST is a questionnaire developed by Steiner et al.4 based on the
DSM‐IV diagnostic criteria.20 The PSST has also been tested as an
easy‐to‐use and effective screening tool to diagnose PMS and PMDD
in adolescents.20
The PSST is a 19‐item tool that includes two domains. The first
domain contains 14 items attributed to psychological, physical, and
behavioral symptoms, and the second domain (five items) measures
the impact of symptoms on women's functioning. Each item is
rated on a four‐point scale (not at all = 0, mild = 1, moderate = 2,
severe = 3) (Table 3).4,20
The Turkish version of PSST was based on the study
by Özdel et al.1 and Steiner et al.4DSM‐V diagnostic criteria were
used for PMDD in Turkish PSST adaptation. In the Turkish PSST
adaptation, two questions were added to the third domain group C
according to the DSM‐V criteria: (a) Whether symptoms had been
experienced in the time before menstruation in two consecutive
cycles and (b) whether the symptoms experienced were at the same
or similar level of discomfort as most months of the previous year.1,2
Questions in group C, the third domain, were scored as yes or no
(Table 3). According to the diagnostic criteria of PMDD in DSM‐V
says, “should be confirmed by prospective daily ratings during at least
2 symptomatic cycles.” A “provisional diagnosis may be made before
this confirmation” by prospective daily ratings.1,2
PSST scoring for PMS and PMDD according to DSM‐IV is in-
cluded in the appendix section of the study.4 In addition to this
scoring, the evaluation of two questions added to PSST scoring ac-
cording to DSM‐V diagnostic criteria for PMDD, both (a) and (b)
questions should be answered yes, and for a diagnosis of PMS, one of
the (a) or (b) questions should be answered yes.1 The PSST internal
consistency Cronbach's alpha test value was determined as 0.93 in
this study.
The subjects were divided into three categories based on
symptom scoring: “mild/no PMS,” “moderate to severe PMS,” and
“PMDD.” The mild/no PMS group does not meet the PMS and PMDD
criteria and consists of subjects with subthreshold symptoms.1,4,20
2.3 | Data collection
In this study, data were collected by face‐to‐face interviews and self‐
reported. The students filled out a form after the aims of the study
and questionnaire were explained. Permission was obtained from the
school administrations for the study. Data were collected during class
in high schools and lesson breaks in the faculties. It took approxi-
mately 5–10 min to fill out the questionnaires.
DAŞIKAN | 3

2.4 | Statistical analysis fatigue/lack of energy (84.4%), anger/irritability (83.6%), anxiety/

The IBM SPSS Statistics for Windows, version 23.0, was used to
analyze collected data. The mean and standard deviation for con-
tinuous variables were calculated. Categorical variables were pre-
sented as numerical and percentage values. The Pearson χ2 test was
used in group comparisons. Cronbach's alpha test was also used for
calculating the internal consistency of the scale.
2.5 | Ethical considerations
The research was approved by the Nursing Faculty Ethics committee
with approval number 02.26.2016/65‐66. Turkish version PSST ob-
tained permission from the authors. Informed consent was obtained
from all individual participants included in the study.
tension (79.5%), and physical symptoms (78.7%). The most common
symptoms in the “No or mild PMS category” were fatigue/lack of
energy (66.0%), anger/irritability (61.4%), and physical symptoms
(59.8%). The least reported symptom in all groups was insomnia. The
functional areas most affected in the PPDD category were relation-
ship with family (85.5%) and friends, classmates, and coworkers
(84.2%). A relationship was found with family (71.3%), social life ac-
tivities (69.7%), and school/work efficiency or productivity (68.9%) in
the moderate to severe PMS category. A statistically significant dif-
ference was found among PMS severity groups, the prevalence of
each symptom, and the degree to which functional areas were
affected according to DSM‐V criteria (p < 0.001) (Table 3).
4 | D IS C U S S I O N

In this study population (n = 760), the prevalence of PMS and PMDD

3 | RESULTS was 61.1% and 20.4%, and 26.1% and 10% by using PSST according
to DSM‐IV and DSM‐V criteria, respectively. The PMS and PMDD
The mean age of the young women was 18.70 ± 2.75 years; their rates in the adolescent group were higher than those in the 20‐ to
mean age at menarche was 13.02 ± 1.20 years, and the mean length 24‐year age group for both diagnostic criteria (p < 0.001). On the
of their menstruation period was 5.48 ± 1.23 days. Approximately basis of this result, the prevalence of PMS/PMDD was less than 50%
59.5% of the young women were in the adolescent group (age, 15–19 by using PSST according to DSM‐V criteria. Using PSST according to
years), and 45.9% were studying at a university. All participants were DSM‐V criteria was effective in distinguishing symptoms not asso-
single and had no children. Only 21.7% of the women reported that ciated with the menstrual cycle and in identifying serious cases be-
they had consulted a doctor for symptoms, but 58.4% reported ex- cause of two criteria; symptoms found in the majority of the
periencing dysmenorrhea. menstrual cycles of the previous year and occurring in at least two
consecutive cycles.
Most studies of young Turkish women have shown the pre-
3.1 | Prevalence of PMS and PMDD valence of PMS. The PMS prevalence in university students was
between 36% and 72%.11,19,21,23,24 The PMDD prevalence was 5.5%
In the study, 92% of the young women (age, 15–24 years) reported at by PAF assessment in university students.18 In one study, the
least one premenstrual symptom. In two separate PMS diagnosis
processes performed using the PSST according to DSM‐IV and DSM‐V,
the incidence of PMS was 61.1% and 26.1%, respectively (Table 1). T A B L E 1 Categorization of the severity of premenstrual
symptoms based on DSM‐IV, DSM‐V diagnosis criteria and using
The PMS range of the adolescent group (age, 15–19 years) was 67%
the PSST
(whereas that of the 20‐ to 24‐year age group was 52.3% according
to DSM‐IV PSST diagnosis. According to DSM‐V in the PSST diagnosis, DSM‐IV DSM‐V
criteria/PSST criteria/PSST
the PMS rate of the 15‐ to 19‐year and 20‐ to 24‐year age groups
was 30.8% and 9.1%, respectively (p < 0.001). On the basis of PMS group n % n %
the DSM‐IV and DSM‐V criteria, a statistically significant difference PMS prevalence
was found among the PMS severity groups, age groups, and school PMS/yes 464 61.1 198 26.1
groups (p < 0.001) (Table 2). PMS/no 296 38.9 562 73.9

PMS severity
No/mild PMS 296 38.9 562 73.9
3.2 | Premenstrual symptoms Moderate to 309 40.7 122 16.1
severe PMS
In this population, according to DSM‐V criteria and PSST, the most PMDD 155 20.4 76 10.0
common symptoms were anger/irritability (97.4%), anxiety/tension Total 760 100.0 760 100.0
(92.1%), and physical symptoms (92.1%), including breast tenderness, Abbreviation: DSM, Diagnostic and Statistical Manual of Mental Disorders;
headaches, joint/muscle pain, bloating, weight gain, and fatigue/lack PMDD, premenstrual dysphoric disorder; PMS, premenstrual syndrome;
of energy. Symptoms in the moderate to severe PMS category were PSST, premenstrual symptoms screening tool.
4 | DAŞIKAN

T A B L E 2 Comparison of PMS diagnosis with age groups and school characteristics according to DSM‐IV and DSM‐V criteria

DSM‐IV criteria/PSST (N = 760) DSM‐V criteria/PSST (N = 760)

Analysis
No/Mild Moderate to Severe No/Mild Moderate to Severe
PMS (n = 296) PMS (n = 309) PMDD (n = 155) PMS (n = 562) PMS (n = 122) PMDD (n = 76)
χ2
Characteristic n % n % n % n % n % n % p Value

Age groups (years)

15–19 149 33.0 193 42.7 110 24.3 313 69.2 92 20.4 47 10.4 <0.001*
20–24 147 47.7 116 37.7 45 14.6 249 80.8 30 9.7 29 9.4
15–24 296 38.9 309 40.7 155 20.4 562 73.9 122 16.1 76 10.0 <0.001**

School
High school 130 31.6 177 43.1 104 25.3 282 68.6 86 20.9 43 10.5 <0.001*
University 166 47.6 132 37.8 51 14.6 280 80.2 36 10.3 33 9.5 <0.001**

Abbreviations: DSM, Diagnostic and Statistical Manual of Mental Disorders; PMDD, premenstrual dysphoric disorder; PMS, premenstrual syndrome;
PSST, premenstrual symptoms screening tool; χ2, chi‐squared test.
*DSM‐IV criteria/PSST; **DSM‐V criteria/PSST; p < 0.001, row percentage taken.

prevalence of PMS and PMDD in college students was 53.6% and
12
19.5%, respectively, by using PSST according to DSM‐IV which was
consistent with the prevalence in our study. In a study conducted in
health workers using PSST according to DSM‐V criteria (mean age,
30 years), the prevalence of PMS and PMDD was 47.4% and 15.2%,
1
respectively. This was higher than our study results. In addition,
PMS prevalence in a study investigating working women was higher
than that in this study.9
Only few studies of PMS/PMDD in adolescents were conducted
25
in Turkey. In a study by Derman et al. using DSM‐IV diagnostic
criteria with adolescents aged 10–17 years, PMS and PMDD rates
were 50.5% and 13.4%, respectively, in Turkish girls.25 In another
study conducted in adolescents aged 18 years, the PMS rate was
17
like 56%.
In studies from different countries, the prevalence of PMS and
PMDD in university students was between 18.4% and 92.3% and
between 3.7% and 16.5%, respectively.3,5,6,10,10,16,26 Furthermore,
the prevalence of PMSS and PMDD in adolescents was between 13%
and 76.4% and between 3.1% and 8.3%, respectively.20,27,28
Different results were found depending on the tools used for
diagnosis, sample size, diagnostic criteria used, study methods (pro-
spective or retrospective), and cultural differences. PMS symptoms
are perceived differently in other cultures because some cultures
tend to focus on psychological complaints, religious factors, stress,
seeking treatment, and effects of symptoms on functions that can
affect this perception.8,10 PMS and PMDD rates were 46.1% and
10.2%, respectively, using PSST according to DSM‐IV in two different
studies with university students in India.5 Moreover, these rates
were 18.4% and 3.7%, respectively, using PSST according to DSM‐IV
and International Diseases Classification version 10.0.3 In an as-
sessment using the daily record of severity of problems, the PMS and
PMDD rates were 74.8% and 3.9%, respectively, in adult women in
Brazil. In a study with PSST assessment, the PMS and PMDD rates
were 41.7% and 34.6%, respectively.13 Thus, different PMS rates
were obtained by using different assessment tools worldwide.
In adolescent girls, feeling stressed over academic performance
increases the risk of PMS, which may be due to adolescents not
having adequate social and psychological capacity.21 In the literature,
moderate to severe PMS and PMDD rates in adolescents are higher
than those in young and adult women.3,6,8,13 The PMDD rates in
Brazil,26 India,5 and Iran10 were similar to our results. Therefore,
PMS screening, especially in adolescents and young women, should
be increased, and counseling should be provided for guidance on
coping methods.
In this study, anger/irritability symptoms were reported in al-
most all (97.4%) participants in the PMDD category, and the most
reported were fatigue/lack of energy in the moderate to severe PMS
category (84.4%) (Table 3). In some other studies, psychological
symptoms (anxiety/tension, anger/irritability, anxiety/tension, and
tearfulness) were the most reported. In the PMDD category, a study
in India and Nepal mostly reported anxiety/tension (100%), tearful-
ness (100%), and decreased interest in work (100%).3,15 Another
study showed mostly physical symptoms (91.4%), irritability (84.5%),
and anxiety/tension (79.3%).5 In a study in Iran, the most reported
symptom in PMDD and moderate to severe PMS category was an-
ger/irritability (99.2%; 88.7%).10 In the PMDD category, psychologi-
cal and cognitive symptoms were more common than physical
symptoms.
In a study of female Turkish high school students, the most
common symptoms were stress (87.6%) and nervousness
(87.6%). 25 In other studies in Europe and Asia, the most common
symptoms in PMS were physical symptoms and fatigue/lack of
energy.5,7,29 In this study, PMS mostly affected the functional
area of relationship with family (85.5%), and functional im
pairment was observed in all areas in four of five of the adoles-
cents. Furthermore, all functional areas deteriorated in two‐
thirds of the girls in the moderate to severe PMS category
(Table 3). An Indian study of university students reported max-
imum deterioration of relationships with family members in
PMDD (77.6%). 5
DAŞIKAN | 5

T A B L E 3 Frequency of premenstrual Moderate to

symptoms among three PMS groups No/mild severe PMDD
(according to DSM‐V diagnostic criteria) PMS (n = 562) PMS (n = 122) (n = 76) Analysis (χ2)
n (%) n (%) n (%) P Value

Group A. Symptoms
1. Anger/irritability 345 (61.4) 102 (83.6) 74 (97.4) <0.001
2. Anxiety/tension 284 (50.5) 97 (79.5) 70 (92.1) <0.001
3. Tearfulness 287 (51.1) 95 (77.9) 67 (88.2) <0.001
4. Depressed mood 247 (44.0) 93 (76.2) 67 (88.2) <0.001
5. Decreased interest in work 248 (44.1) 82 (67.2) 59 (77.6) <0.001
6. Decreased interest in home 228 (40.6) 85 (69.7) 61 (80.3) <0.001
activities
7. Decreased interest in social 200 (35.6) 72 (59.0) 54 (71.1) <0.001
activities
8. Difficulty concentrating 256 (45.6) 94 (77.0) 58 (76.3) <0.001
9. Fatigue/lack of energy 371 (66.0) 103 (84.4) 70 (92.1) <0.001
10. Overeating/food craving 308 (54.8) 82 (67.2) 55 (72.4) <0.001
11. Insomnia 189 (33.6) 61 (50.0) 38 (50.0) <0.001
12. Hypersomnia 205 (36.5) 76 (62.3) 51 (67.1) <0.001
13. Feeling overwhelmed or out 246 (43.8) 88 (72.1) 66 (86.8) <0.001
of control
14. Physical symptomsa 336 (59.8) 96 (78.7) 70 (92.1) <0.001

Group B. Functional impairment

A. School/work efficiency or 180 (32.0) 84 (68.9) 61 (80.3) <0.001
productivity
B. Relationship with friends, 174 (31.0) 76 (62.3) 64 (84.2) <0.001
classmates/coworkers
C. Relationship with family 185 (32.9) 87 (71.3) 65(85.5) <0.001
D. Social life activities 184 (32.7) 85 (69.7) 63(82.9) <0.001
E. Home responsibilities 192 (34.2) 83 (68.0) 63 (82.9) <0.001

Group C. DSM‐V diagnostic criteria questions

a. During the two consecutive 261 (46.4) 65 (53.3) 76 (100) –
periods, having the same or
similar discomfort as the
above symptoms.
b. Having experienced the same 237 (42.2) 57 (46.7) 76 (100) –
or close to the above
symptoms in most months of
last year.

Abbreviations: DSM, Diagnostic and Statistical Manual of Mental Disorders; PMDD, premenstrual
dysphoric disorder; PMS, premenstrual syndrome.
a
Including breast tenderness, headache, joint/muscle pain, bloating, and weight gain; column
percentage taken.

A study conducted with adolescents reported that symptoms
mostly affected relationships with the family; three‐quarters of
PMDD cases and nearly half of moderate PMS cases reported
symptoms that interfered with their relationships with their
classmates or work colleagues and with their work efficiency or
productivity.20 These findings are consistent with our results.
PMS and PMDD are common problems among young women.
Severe PMS negatively affects academic or work performance, psy-
chological status, self‐esteem, self‐reliance, social and family re-
lationships, and quality of life.3,17,20 Therefore, those who need
treatment should be detected early and managed. Patients with
PMS/PMDD should be managed by a professional health team, in-
cluding a gynecologist, psychologist, dietician, and consultant nurse.
5 | CON CLUSIONS
In this study, PMS/PMDD prevalence is common in young women,
especially in adolescents, and PMDD prevalence was alarmingly high.
The most common symptom reported by young women was anger/
irritability, and the most commonly affected functional area was
relationships with friends.
6 |
This study is based on the PSST questionnaire, a retrospective
screening tool, not the clinical diagnosis of PMS and PMDD. PSST is a
screening tool that evaluates retrospectively and a temporary diag-
nosis can be made. It is recommended to include prospective daily
symptom ratings of severe PMS/PMDD data or to use diagnostic
tools and compare results. The relationship between young women's
psychological status and PMDD should be examined in future re-
search. PMS/PMDD screening using PSST can be preferred as a more
practical method compared with the other scales.
5.1 | Limitations
PSST is a retrospective assessment method, and this may affect the
prevalence of symptoms. In addition, the clinical assessment was not
performed in PMS diagnosis. Physical and psychological health
assessment data were participants’ own personal statements. The
results of the study can be generalized only for young women in the
research population.
5.2 | Implications for Nursing Practice
Health professionals and nurses should take an active role in the
diagnosis and management of PMS/PMDD. Especially in adoles-
cents and young women, PMS awareness education should be held
to reduce the negative effects of PMS symptoms and increase
their functional effectiveness. It should be ensured that young
women diagnosed with PMS and PMDD get help from health
professionals to cope with symptoms. Especially for adolescents,
service units should be established to deal with PMS symptoms
within the scope of school health services. It is very important
that nurses use their protective, instructive, practitioner, and
counseling roles in the management of PMS symptoms. Health
professionals and nurses should advise young women diagnosed
with PMS about nonpharmacological method (dietary changes,
physical activity, stress management, relaxation techniques, and
cognitive and behavioral therapies). PMS/PMDD treatment
should be done with a multidisciplinary team with a biopsycho-
social approach.
A C K N O W L E D GM E N T S
I sincerely thanks, Nursing Faculty intern students who support the
data collection phase; Merve Güngür, Begüm Kahya, Kamile Taran,
and Duygu Barışoğlu, and those who participated in the research.
I am grateful to Ege University Planning and Monitoring Coordina-
tion of Organizational Development and Directorate of Library and
Documentation for their support in the editing and proofreading
service of this study.
CO NFLICT OF I NTERE STS
The author declares that there is no conflict of interest.
DAŞIKAN
ORCI D
Zeynep Daşıkan https://orcid.org/0000-0002-0933-9647
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How to cite this article: Daşikan Z. Premenstrual disorders
among young Turkish women: According to DSM‐IV and
DSM‐V criteria using the premenstrual symptoms screening
tool. Perspect Psychiatr Care. 2020;1–7.
https://doi.org/10.1111/ppc.12656