ADHD is a neurodevelopmental condition that is often viewed as ‘distinct’ from mental illnesses, particularly those with affective mood components. However, emotional dysregulation—alongside attentional dysregulation—and features such as ‘rejection sensitivity’ are increasingly recognised in ADHD (Ginapp et al., 2023). Less is known, though, about how longitudinal mood disorders such as depression and anxiety may present in individuals with ADHD (Fu et al., 2025).
The association between ADHD and hormonally linked mood changes is even more under-studied. This reflects both the limited research on ADHD in people assigned female at birth and the lack of focus on severely impairing hormonal mood disorders such as premenstrual dysphoric disorder (PMDD).
Where research does exist, some teams deliberately discount self-reported symptoms or ‘provisional diagnoses’ (Reilly et al., 2024). This likely underestimates the incidence and severity of difficulties experienced by women seeking help for ADHD and/or PMDD. Such selective ‘objectivisation’ in research contributes to delayed diagnosis in women, often only later in life, with associated increases in functional impairment, comorbidity, and disability (Skoglund et al., 2024; Nayak et al., 2025).
Given the prevalence of ADHD in women (4.2%; CDC, 2021) and PMDD (1.8% to 5.8%; APA, 2013), research into neuroendocrine links (Kooij et al., 2025) and personalised pharmacotherapy (de Jong et al., 2023) is finally emerging. At the same time, new transdiagnostic frameworks are developing unified theories on sex steroids and psychopathology (Peters et al., 2025).
Most recently, a phenomenological survey by Broughton et al. (2025) sought to directly understand and quantify the cross-sectional population risks of:
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PMDD emerging in women with or without ADHD; and
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PMDD in women with ADHD, with or without another major mood disorder such as depression or anxiety.
Is there any relationship between an existing diagnosis of ADHD and a mood disorder, and the debilitating features of Pre-menstrual Dysphoric Disorder (PMDD)?
Methods
This project focused on 715 people assigned female at birth, aged 18 to 34 years, residing in the United Kingdom, recruited through the Prolific online platform.
Recruitment methods
First, the project asked individuals to self-report any diagnosis of ADHD. Second, researchers utilised the previously validated high-specificity moderate-sensitivity self-report tool, the Adult ADHD Self-Report Scale (ASRS), to identify people who fell above the DSM-5 cut-off for ADHD (experiencing ≥5 symptoms, with functional impairment in ≥2 domains. Finally, they also included survey items for participants to self-report a previous diagnosis of either Depression or Anxiety. Hence, three subgroups were created:
- Participants without ADHD (self-reported or ASRS-scored) – control group (n=305);
- Participants with ADHD, self-reported (n=102) or ASRS-scored (n=229); and
- Participants with ADHD and a diagnosis of anxiety or depression as subsets of the second group.
Participants were screened by retrospective reporting to identify premenstrual symptoms, using the Premenstrual Symptoms Screening Tool (PSST). The cut off, across symptoms of irritability/anger, anxiety/tension, tearfulness/rejection sensitivity, and depressed mood/hopelessness, was ≥1 rated as severe, with ≥4 rated as moderate-severe; and a need for severe functional impairment in one of 3 (occupational, personal, and interpersonal) domains. functional domains.
Of note, meeting the above threshold could only imply a ‘provisional diagnosis’ of PMDD features – as the gold-standard for diagnosis is prospective symptom tracking for at least 2 months, using trackers such as the Daily Record of Severity of Problems (‘DRSP’).
Relevant demographic data was also collected, including age, educational attainment, current or historic use of ADHD pharmacotherapy, and current use of hormonal contraceptives and any details of same.
Statistical methods
The team utilised a Poisson regression with a robust error variance, to calculate a relative risk for provisional PMDD associated with a reported ADHD diagnosis, ASRS-scored ADHD, or without ADHD. A separate Poisson regression evaluated the contribution of comorbid mood disorders, to the relationship between ADHD, ASRS-scored ADHD or no ADHD, and provisional PMDD.
Profile analysis of PMDD symptoms between ADHD and non-ADHD cohorts was carried out, by reviewing the prevalence of each symptom rated moderate to severe on the PSST, in each of the 3 subgroups. Additional sensitivity analysis was carried out to identify whether use of hormonal contraceptives had any effect on rates of ADHD, PMDD and mood disorders in the cohort.
The study used a mixture of self-reporting survey questions, and validated scales for identification of ADHD and PMDD symptoms, to stratify 715 female participants into 3 study subgroups.
Results
ADHD features
- There were no significant differences in age, educational attainment or hormonal contraceptive use, between people with a diagnosis or ASRS-based presentation of ADHD, and controls.
- People who reported a diagnosis of ADHD, scored higher (13.55) on the ASRS, than those who solely scored on the ASRS (13.26), and those without ADHD (4.52).
- People who were diagnosed with ADHD were around 3x more likely to have taken medication (60.78%) than those with ASRS reported ADHD alone (20.09%).
- Interestingly, people with ASRS-based ADHD had higher rates of mood disorder diagnoses, than the non-ADHD cohort.
PMDD and ADHD
- There was a 3.19x elevated risk of provisional PMDD in diagnosed ADHD (31.4%), compared to the non-ADHD control group (9.8%).
- This was further elevated in the the ASRS-based ADHD group (41.1%), indicating a 4.17% higher risk of PMDD relative to control.
PMDD and ADHD with Comorbid Mood Disorder
- The highest prevalence of PMDD occurred in those with diagnosed ADHD and mood disorder (35.1%), compared to diagnosed ADHD alone (20%), and those without ADHD (9.8%). Similar patterns were seen in ASRS-based ADHD and mood disorder (), or ASRS-based ADHD alone.
- There was a 3.56x higher relative risk of provisional PMDD, in participants with diagnosed ADHD and a mood disorder, which increased to a 4.53x relative risk for ASRS-based ADHD and a mood disorder.
- Those with diagnosed ADHD alone had a 2.03x higher relative risk of provisional PMDD, which increased to a 3.09x higher relative risk for those with ASRS-based ADHD alone.
Symptom patterns
The most common PMDD features were largely similar between individuals with or without ADHD. However, insomnia was twice or more commonly rated as moderate to severe in individuals with either ASRS-based (~45%) or diagnosed (~40%) ADHD, relative to control (~20%).
Sensitivity analyses
Those taking hormonal contraceptives did have a non-significant elevated association between self-reported clinical ADHD diagnosis and provisional PMDD (relative risk 3.65 [2.05 to 6.50]) relative to those not taking a hormonal contraceptive (relative risk 2.62 [1.29 to 5.30]).
People with ADHD may spend more sleepless nights with PMDD, and may be 3- to 4-times as likely to have provisional PMDD – up to 3.5- to 4.5-times if they have a diagnosed mood disorder.
Conclusion
In this large cross-sectional study of 715 people assigned female at birth:
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Participants were split fairly evenly between:
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those with diagnosed or ASRS-based ADHD, and
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a control group without ADHD.
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Higher rates of provisional PMDD were found in the ADHD group compared to controls.
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The highest prevalence of provisional PMDD occurred in participants who had both:
Strengths and limitations
The study benefits from multiple strengths, firstly its design of the population-based sampling of people assigned female at birth who experience symptoms of ADHD or PMDD, rather than solely sampling individuals already receiving clinical care. Given the significant inaccessibility to both ADHD and PMDD diagnosis, and the selection biases that may result from only researching diagnosed populations (e.g. higher severity of symptoms or comorbidities identified), the team’s sampling may offer more naturalistic representation of ADHD and PMDD symptoms, distributed across the population.
The researchers’ survey of the population is deepened by salient choices of demographic data sought for sensitivity analysis. However, there is likely digital literacy and self-selection bias, as participants were recruited using an online platform only, who self-selected based on experiencing ‘mood changes and the menstrual cycle’. Further, key demographic data such as ethnicity are not sought in the survey – despite known ethnic disparities in ability to access healthcare for menstrual and perinatal mood disorders, particularly among South Asian women (Prajapati & Liebling, 2021).
Another strength, is the use of validated identification tools such as the ASRS and the PSST for identifying disorder symptoms. However, a significant limitation was that the PSST could not provide more than a cross-sectional provisional PMDD identification, as the gold-standard prospective daily recording of symptoms for 2 months could not be applied.
Nonetheless, unlike other recent studies (e.g. Reilly, 2024) which consider any sub-threshold symptom data to be a distraction from ‘true’ prevalence rates, Broughton et al identify rightly in this study that even if more PMDD false-positives are captured in their ‘provisional PMDD’ category, experience of sub-diagnostic threshold menstrual mood symptoms still cause impairment, and warrant investigation in future research.
Similarly, the authors identify limitations to be addressed in future studies – seeking age of ADHD diagnosis and whether some participants may have aged out of ADHD-related impairments, underlying reproductive conditions affecting participants separate to PMDD features, and participants’ use of other interventions associated with mood disorders, not asked about in the study.
However, this study still provides data from a robust proof-of-concept population-based cross-sectional survey, to act as a roadmap for future research into ADHD, mood disorders and PMDD, with:
- Prospective gold-standard validation of PMDD;
- Deeper consideration of mediating and modifying effects of psychiatric and hormonal medications; and
- Utilising transdiagnostic frameworks such as the Dimensional Affective Sensitivity to Hormones across the Menstrual Cycle (DASH-MC).
It is important to pay attention to all women with ADHD reporting menstrual mood symptoms, but future studies should assess PMDD rigorously and prospectively, across women from diverse communities.
Implications for Practice
Patient: “I’m struggling with my ability to function, and I’m having dark thoughts.”
Doctor: “Are you just saying this for attention?”
Patient: “Yes. Medical attention.”
As a person who lived with both ADHD and PMDD, undiagnosed and eventually diagnosed, long before I became a psychiatric clinician, I have first-hand experience of the difficulty people assigned female at birth experience, ‘seeking attention’ for functional impairments – attentional regulation, physical features of hormonal sensitivity, emotional regulation, significant periodic thoughts of self-harm or suicidal ideation – without being dismissed as ‘attention-seeking.’
The related occupational, personal and interpersonal fall-outs, are significant, continuous and compounding, without appropriate intervention. Research highlights mis/diagnoses, medical mistreatment, and misunderstandings of episodic disability (Habib, Bailey and Griffin, 2024) as particular difficulties in PMDD – which can be further complicated with a pre-existing diagnosis of another mood disorder, as well as ADHD.
A lack of clinician awareness of PMDD and its gold-standard assessment, can leave debilitating mood and functional difficulties inappropriately attributed to other diagnoses, creating theranostic delay. A lack of widespread education on PMDD, or targeted educational resources for ADHD and other neurodivergent persons, can also add knowledge and communication barriers, between individuals seeking help and their care providers.
In this context, this study by Broughton et al, makes a novel evidence-based effort to collect cross-sectional experiences of people experiencing menstrual mood symptoms in the general population, stratified by those who do/do not know they have ADHD, or a previous diagnosed mood disorder.
The findings – a 3- to 4-fold risk of provisional PMDD among ADHD individuals relative to controls, and a 3.5- to 4.5-fold relative risk among people with ADHD and a mood disorder, relative to controls – cannot be ignored.
Urgent action is needed in research and clinical practice, assessing the repeatability and reproducibility of these findings, when evaluated with gold-standard prospective PMDD testing. Additional stratification of future outcomes is needed, for a more complete picture of supports required by people with additional demographic vulnerabilities, like minority ethnic status, to seek appropriate care for both PMDD and ADHD.
With better public and clinician education, timely assessment could bypass several years of diagnostic and interventional delay, for women with ADHD and PMDD.
Statement of interests
None to declare.
Links
Primary paper
Broughton T, Lambert E, Wertz J, Agnew-Blais J. Increased risk of provisional premenstrual dysphoric disorder (PMDD) among females with attention-deficit hyperactivity disorder (ADHD): cross-sectional survey study. The British Journal of Psychiatry. 2025;226(6):410-417. doi:10.1192/bjp.2025.104
Other References
Centers for Disease Control and Prevention. (2021). Attention-Deficit/Hyperactivity Disorder (ADHD): Data and Statistics. https://www.cdc.gov/ncbddd/adhd/data.html
American Psychiatric Association. (2013) DSM-5 diagnostic classification Diagnostic and Statistical Manual of Mental Disorders. https://doi.org/10.1176/appi.books.9780890425596.x00diagnosticclassification
de Jong M, Wynchank DSMR, van Andel E, Beekman ATF, Kooij JJS. Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Front Psychiatry. 2023 Dec 13;14:1306194. doi: 10.3389/fpsyt.2023.1306194.
Fu X, Wu W, Wu Y, Liu X, Liang W, Wu R, Li Y. Adult ADHD and comorbid anxiety and depressive disorders: a review of etiology and treatment. Front Psychiatry. 2025 Jun 6;16:1597559. doi: 10.3389/fpsyt.2025.1597559.
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Habib, S., Bailey, K. A., & Griffin, M. (2024). Off-Label: Lived, Embodied, and Temporal Experiences of Premenstrual Dysphoric Disorder (PMDD) in Canada. Women’s Reproductive Health, 12(2), 310–329. https://doi.org/10.1080/23293691.2024.2436925
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Nayak A, Wood SN, Hantsoo L. Barriers to Diagnosis and Treatment for Premenstrual Dysphoric Disorder (PMDD): A Scoping Review. Reprod Sci. 2025 Jun;32(6):1757-1767. doi: 10.1007/s43032-025-01861-3.
Peters, JR, Schmalenberger, KM, Eng, AG, Stumper, A, Martel, MM, Eisenlohr-Moul, TA. Dimensional Affective Sensitivity to Hormones across the Menstrual Cycle (DASH-MC): a transdiagnostic framework for ovarian steroid influences on psychopathology. Mol Psychiatry 2025; 251: 62.
Prajapati R, Liebling H. Accessing Mental Health Services: a Systematic Review and Meta-ethnography of the Experiences of South Asian Service Users in the UK. J Racial Ethn Health Disparities. 2022 Apr;9(2):598-619. doi: 10.1007/s40615-021-00993-x.
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