Neurodivergent clients and the terror of PMDD
With thanks to our member, Ruth Morgan, for this blog.
Perhaps you often find yourself with a client who has had a sudden and extreme deterioration in their welfare? We are all trained to contain these moments, to both risk assess and support our client’s regulation through the largest waves of emotion, or processing of trauma. We might find ourselves working with grounding tools or looking for triggers or patterns and helping our client to spot these. All of this can help, yet sometimes the most obvious patterns go totally unnoticed or misunderstood. I certainly don’t recall very much about hormones in my training. Maybe it came up in supervision, where the emphasis was on how a client might have encountered the medical or societal misogynies of their distress being down to ‘women’s troubles’.
Although it has become clearer to me that for many of my late-diagnosed neurodivergent clients, there is an additional psychological burden placed by hormones each month in ways that need understanding. Their distress is not always caused by hormones alone, but is at its most intense in cyclical patterns that can inform better understanding.
Premenstrual Dysphoric Disorder (PMDD) is listed in the DSM and you may have clients arrive with a diagnosis already. The symptoms are in the luteal phase of the menstrual cycle and ease off once menstruation begins. They include intense anxiety, cognitive disruption, and affect instability. In Neurodivergent clients such symptoms can be experienced with deep intensity, and the client may not know what is happening to them or why.
PMDD impacts a small proportion of the whole population at a diagnostic level, but like many conditions more people will experience significant premenstrual distress just below the diagnostic thresholds. Recent research is also informing our understanding of the intersection with neurodivergence. People with ADHD have been shown more likely to experience severe mood change pre-menstrually, and in the autistic population there is a marked increase in sensory intensity and likelihood of shutdown in the luteal phase.
This research is something I have seen in real life in my therapy room. Clients whose nervous systems are already managing sensory overwhelm and challenging emotional and relational experiences find themselves knocked totally sideways with cyclical regularity. In that overlap things can simply be too disorientating. My clients don’t come to me with language from a diagnostic manual, but they do speak of distress that feels like a ‘switch’ or that feels sudden like being under a ‘tidal wave’. They feel they lose touch with their sense of self.
When the self feels so suddenly altered and then a few days later a mysterious return occurs it becomes something which a client seeks to make sense of. One client noticed this pattern, and what was the most worrying for her was the sudden onset of the change. It combined with the internalised narrative of being ‘too much’ and ‘overdramatic’ to become a terrifying and tortured experience. She had an app which tracked her cycle and over time what had felt totally unpredictable, took on a new meaning. The total psychological sense of collapse might have a physiological element, and that was of comfort to my client as well as giving her the information she needed to talk to her GP about, prompting changes to her antidepressant medication. She felt like she had regained agency over something which had felt so mysterious and paralysing.
For some of my clients, the shift around the menstrual cycle includes deep moments of hopelessness and suicidal ideation. Naming all this takes a great deal of care, and I found myself on such occasions caught between validating the depth of feeling whilst trying to help my client hold onto the transient nature of the experience.
Having now seen several clients with a PMDD diagnosis, or those who have sought assessment for it during therapy, I have some awareness that tracking cycles in some way might be a supportive element. If a client dips with regularity every 4 weeks or so then, a conversation with a client could be of great value if it is handled with care. You may find yourself cautious about these conversations in your work. Rightly so, in my view, as so many clients have had their distress minimised or attributed to their hormones as a veil for dismissiveness. The last thing I wanted to do as a therapist was restrict meaning making around the body. Yet, with my neurodivergent clients these risks were ever present. For my client group sensitivity has been too-often treated as an excess, they’ve heard calls for them to be ‘more resilient’ as code for being tougher in the face of extreme hardship, and too often their emotional landscape has been framed as dysfunctional. Well, in such a context, to suggest hormonal influences on mood, if not well handled, could echo these earlier relational harms.
So, as well as identifying if there is a risk that PMDD may be present, I also needed to find the clinical confidence in how to go about speaking about it. Finding that my neurodivergent clients often prefer clarity over implicit meaning has shaped the particular ways in which I might approach a subject. To be able to hold curiosity together is the first good indicator that the counselling relationship is ready to explore difficult questions.
Holding in my mind a bio-psycho-social understanding to help maintain curiosity about how a client is experiencing themselves and the world around them informs my approach. I introduce open questions around patterns such as ‘are there times when this feels more intense?’ or ‘sometimes there are elements of suffering that combine from the body, the mind and our social situation – can we explore all three?. Taking this layered look is intended to reduce shame. It also appeals to people that they can use a framework of body, mind and social as a bit of a tick list to use as a tool for understanding contributory factors when something is challenging them outside of therapy. You can have these conversations in other ways, depending on your counselling style. If your client is interested in family history, why not ask about how hormones were understood in their family, were they spoken about at all, and how were they experienced?
What has previously been experienced as an internal turbulence can start to take a more flexible shape, as something which fluctuates, and is an interplay between body and mind. You can open a space for exploring on a practical level what kind of support and structures might be helpful to get the client through the toughest days. Is it a change in medication? Is it a change in self-care plans? Is it about conversations with those around them or their employer? One astute person noticed how the time blindness of neurodivergence meant that they ‘always’ felt like the worst symptoms were present. The noticing of patterns that changed and keeping a track of them created the safety of knowing it was neither permanent nor the same every month.
For clients who have started to explore any patterns in their cycles I have seen few down sides. They may not have difficult symptoms and just become more aware of the times in the month that feel especially generative, creative or when they feel most ready to socialise. At the other extreme, they may have a better understanding of what it is that is combining to create terrifying experiences, and in such recognition, you can help your client to begin to find relief.
Ruth Morgan:
References:
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th edn). Washington, DC: APA.
Broughton, J. et al. (2025) ‘Premenstrual dysphoric disorder and ADHD: emotional regulation and executive functioning across the menstrual cycle’, Journal of Affective Disorders, 345, pp. 112–120.
Ellis, K. et al. (2025) ‘Menstrual experiences in autistic adults: a qualitative study of sensory and functional changes’, Autism Research, 18(2), pp. 233–245.
Oxford University (2024) Premenstrual disorders: epidemiology and clinical overview. Oxford: Oxford University Press.
