Defining Dysphoric Milk Ejection Reflex: using Premenstrual Dysphoric Disorder as a framework for proposing preliminary diagnostic criteria

Dysphoric Milk Ejection Reflex (D-MER) is a distinct neurobiological condition characterized by negative alterations in mental state in response to milk letdown during lactation. Symptoms vary by patient and can include feelings of sadness, anxiety or agitation. Importantly, the symptoms are brief, typically lasting no more than 5 minutes. Prevalence has been found between 6 and 27% of lactating women, but studies show heterogeneity, due in part to inconsistent definition. D-MER is not currently classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD), which presents a challenge for researchers of the condition. The pathophysiology of D-MER is not well understood, but may be mediated by hormonal changes. In an attempt to begin to formalize classification of this condition, the authors explore the association with another recently classified, hormonally mediated and time sensitive condition: premenstrual dysphoric disorder or PMDD. Like D-MER, PMDD is characterized by heterogeneous symptoms that occur on a predictable timeline. The recent addition of a formal diagnostic category into the DSM helped facilitate an expansion of research into etiology and treatment of the condition. This paper will explore a pathway to classification of D-MER based on the current research using the framework of the DSM-5 diagnostic criteria for PMDD. We will conclude by outlining future research priorities that will help to better define this condition and differentiate it from other causes of emotional distress during lactation.

Introduction

Dysphoric milk ejection reflex (D-MER) is the momentary experience of negative emotions during milk letdown in lactation. D-MER was first described in case reports as an emotional “drop” that coincided with milk letdown (1, 2). These early reports noted a variety of emotions experienced, broadly categorized into “depression,” “anxiety” and “anger” (2). These symptoms are notable for their frequency and brevity: most patients report that they occur with the majority of lactation episodes and correspond specifically to milk letdown, resolving in under 5 minutes (3).

Despite the brevity of symptoms, D-MER has significant impacts on both breastfeeding and mental health outcomes. Many patients discontinue breastfeeding (4), resulting in feelings of guilt, isolation, shame, and inadequacy as a mother (5). D-MER has also been linked with lower breastfeeding self-efficacy, increased difficulty with bonding, and higher depression (4, 6, 7). Nearly 30% of patients reporting D-MER symptoms experienced thoughts of hurting themselves or others directly connected with milk letdown (3), and D-MER patients are twice as likely to report thoughts of self-harm than those without (4). In contrast, typical experiences during milk letdown include positive emotional responses, reduced stress, increased bonding, and the feeling of calmness (8).

There has been a growing awareness of D-MER in the psychiatric literature, and a call for further study and clear definition (9, 10), as it is not currently included in the Diagnostic and Statistical Manual for Mental Disorders (DSM). There is an awareness of the importance of mental health conditions in the management of breastfeeding and lactation (11), however, D-MER is not formally recognized with a clinical protocol from the Academy of Breastfeeding Medicine (12), nor included as relevant content for certification through the International Board of Lactation Consultant Examiners (13). Thus, women with this condition to go undiagnosed and untreated whether they present to psychiatry or lactation professionals. Additionally, the lack of standardized definition hinders efforts to better understand the condition through rigorous research.

The goal of this paper is to describe D-MER from a thorough review of the literature, to discuss the rationale for including D-MER as a mental disorder, and to propose a preliminary definition for the condition. Because the timing of D-MER symptoms is the key defining criteria, we based the diagnostic criteria on those for premenstrual dysphoric disorder (PMDD), another condition defined by specific timing of symptoms. While research into D-MER remains preliminary, this definition will be a step forward to promote clinical recognition and systematic scientific inquiry into this condition.

Approach

A thorough review of the literature was conducted to ensure completeness of data regarding D-MER. Medline and Psychinfo were searched using a search strategy developed in consultation with a medical librarian. Because the phrase “dysphoric milk ejection reflex” may not be universally recognized, the terms dysphoria, dislike or disgust were included, and any papers that used these terms within 5 words of various lactation terms in the title, abstract or key words were included. Search was limited to 2010 or later and to studies conducted in humans. A total of 41 articles were retrieved after elimination of duplicates. Titles and abstracts were examined for relevance, and 12 were determined to be not relevant. Six references were focused specifically on Breastfeeding Aversion Response (BAR), and these were reviewed separately. The remaining 29 articles were reviewed in full text and included.

Review of D-MER literature

Timing of D-MER symptoms

The specific timing of D-MER symptoms sets it apart as a distinct clinical entity; symptoms are characteristically brief and correspond with milk letdown. Pooling the data of five studies reporting duration of D-MER symptoms shows that approximately 24% of respondents indicate that their symptoms last less than one minute, and an additional 55% report resolution in one to five minutes (Figure 1) (3, 4, 6, 7, 14).

Figure 1

Figure 1. Pooled data regarding duration of D-MER symptoms reported: represents pooled data from five studies (3, 4, 6, 7, 14) for a total n of 381 patients.

Letdown, also known as the “milk ejection reflex” is a physiological process mediated by oxytocin, which is released from the posterior pituitary, triggering the contraction of myoepithelial cells, releasing milk from alveoli into milk ducts (15). It is triggered most commonly by infant suckling or mechanical stimulation of the nipple by a breast pump, though it can occur spontaneously or be triggered by visual or emotional stimuli. Multiple case reports have described women with D-MER symptoms that are triggered by spontaneous letdowns as well as breastfeeding and pumping (2, 16). Studies which have asked women to compare symptoms elicited by breastfeeding to those elicited by pumping show that approximately half of respondents find their symptoms are less intense with mechanical expression of milk rather than direct breastfeeding (Figure 2) (3, 6, 7, 15), although it is unclear why this may be.

Figure 2

Figure 2. Pooled data regarding D-MER symptoms in response to breastfeeding vs pumping: Symptom change with direct breastfeeding as compared to milk expression using a breast pump. Represents pooled data from four studies (3, 6, 7, 14) for a total n of 289 patients.

The specificity of the timing of D-MER and its relationship to letdown suggests a role for oxytocin as a mediator (17), though this is yet to be definitively established through biological studies. Other proposed mechanisms include momentary drops in dopamine (2) or involvement of vasopressin, an anxiogenic hormone with a reciprocal relationship with oxytocin which tends to predominate in situations of adversity (18, 19).

The onset and progression of D-MER symptoms through the postpartum are variable but often begin soon after delivery. Most women report symptom onset within the first month postpartum (6), and in one study nearly 40% of mothers reported symptom onset with the first feeding (4). Symptoms tend to improve or even resolve with time for many women (6, 14). Duration of symptoms varies, though in all reports, symptoms resolve with weaning (1, 2, 16, 20).

Differential diagnosis

D-MER is frequently misdiagnosed as postpartum depression (PPD) (2, 21). PPD is classified by the DSM as a Major Depressive Episode with perinatal onset (onset during pregnancy or within 4 weeks after delivery) (22). Symptoms occur for most of the day, more days than not for a minimum of two weeks (22). While there is significant overlap in the symptoms experienced in PPD and D-MER, the timing of the symptoms is different, as most women with D-MER report feeling happy between letdowns (3).

Another condition that is sometimes confused for D-MER is breastfeeding aversion response (BAR), which is characterized by feelings of agitation and disgust while breastfeeding, often associated with the urge to unlatch or a sensation of the skin crawling (23, 24). The symptoms of BAR occur throughout the time that the baby is latched, and have not been described in pumping or spontaneous letdowns. This is distinct from D-MER where symptoms are limited to the time around letdown, and can occur with spontaneous letdowns as well as pumping (2, 20, 21).

Epidemiology

Little is currently known about D-MER risk factors. Several studies have shown a correlation between D-MER and any pre-pregnancy psychiatric diagnosis (4, 25). Correlations have also been found with current postpartum depression (25), panic attacks (26), and “another mood disorder” (not depression or anxiety) (7). One cross-sectional study of lactating women found that factors such as higher education and immigration status also correlated with elevated D-MER risk (25).

The prevalence of D-MER has been reported in the literature between 6-27% of lactating parents (Table 1) (3, 4, 6, 7, 14, 26–28). These studies have been performed in widely disparate patient populations, and the timing postpartum ranges from 2 days to 3 years. There is also no consensus definition to identify D-MER cases. Not surprisingly, those studies with more stringent criteria for identifying D-MER report lower prevalence. For instance, the two studies that required D-MER symptoms to occur most or all of the time had the two lowest prevalence rates at 6% and 5.9% (4, 7). This highlights the need for a standardized definition of D-MER.

Table 1

Table 1. Summary table for D-MER prevalence studies.

Working toward a D-MER diagnosis

Proposal of diagnostic criteria for D-MER implies its existence as a distinct diagnostic entity. D-MER is a disturbance in emotion regulation, associated with significant distress and frequently resulting in premature weaning, consistent with the DSM definition of a mental disorder (22). Robins and Guze postulated a 5-phase approach to defining a disorder in their seminal 1970 paper (29). These phases included 1. Clinical description, 2. Laboratory studies, 3. Delimitation from other disorders, 4. Long term studies, and 5. Family studies. They additionally note that progression through the phases is neither linear nor chronological, and that the five phases interact with one another. The literature on D-MER has thus far focused on clinical description of the condition, with a focus on the quality of symptoms. Laboratory studies or biomarker studies in clinical samples have been lacking, and these studies are needed to move the field forward. However, clearly defining D-MER is a prerequisite for further biological studies, because without a consensus definition, study of biomarkers is unlikely to be meaningful. We propose these criteria in an effort to distinguish D-MER from other disorders, with the awareness that much research remains to be done in order to develop them more fully.

The hallmark of D-MER is the specific timing of the symptoms in relation to letdown. Another condition with timing of symptoms as a characteristic feature is PMDD. This paper uses the diagnostic criteria for PMDD as a framework from which we have developed preliminary diagnostic criteria for D-MER. Both PMDD and D-MER are linked to fluctuations in female sex hormones, however there is not currently evidence to suggest a correlation in these two conditions. Rather, we have drawn upon the structure of the DSM criteria for PMDD because of the emphasis in those criteria on the very specific timing of the symptoms. Both conditions also share cyclical, transient patterns of symptom manifestations with symptoms minimal or absent at other times (3, 22). Importantly, both conditions include heterogeneous affective symptoms that may include sadness, anxiety or irritability as well as somatic symptoms, such as bloating for PMDD and nausea or hollowness in the stomach for D-MER (3, 30).

Premenstrual dysphoric disorder

Currently, the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) defines Premenstrual Dysphoric Disorder (PMDD) by the presence of at least five symptoms that occur specifically in the week before menses and become minimal or absent after menses (22). Symptoms must include one or more core symptoms plus one or more additional symptoms for a total of at least five symptoms (Table 2). These symptoms must result in clinically significant distress or functional impairment, must not be better explained as an exacerbation of another psychiatric disorder, and must be confirmed by prospective daily ratings.

Table 2

Table 2. Proposed diagnostic criteria for dysphoric milk ejection reflex.

The symptoms of PMDD are understood to be the result of an abnormal sensitivity in the brain to normal hormonal fluctuations, particularly estradiol and progesterone (30). Neuroimaging and biomarker studies suggest that individuals with PMDD have altered GABAergic and serotonergic signaling, especially in the amygdala and prefrontal cortex, which are involved in mood regulation (31). These changes are not due to abnormal hormone levels, but rather to differential neurobiological responses to the hormonal fluctuations which occur in the luteal phase of the menstrual cycle. While similar hormonal fluctuations occur in all naturally cycling women, those with an underlying predisposition may become symptomatic.

Diagnosis of hormonally-mediated conditions and the DSM

It has been only in the past 30 years that the DSM began to recognize conditions that are precipitated by reproductive events. The DSM-IV, published in 1994, was the first version to include the "postpartum onset" specifier for major depressive disorder, updated in DSM-5 to the “peripartum onset” specifier. Premenstrual disorders, described in medical literature as early as the 4^th century BC, were first included in the appendix of DSM-III (32). The prospect of moving PMDD from DSM-III’s appendix to DSM-IV’s main text in 1993 was met with opposition and controversy and ultimately, the DSM-IV task force decided to maintain PMDD in the appendix, despite agreeing upon PMDD symptomatology, course of symptoms and the potential benefits of treatment. PMDD was transitioned from DSM-IV’s appendix to DSM-5’s main text in 2014 (22).

Six years prior to DSM-5’s recognition of PMDD as a standalone diagnosis, the International Society for Premenstrual Disorders provided a unified approach to diagnosing premenstrual disorders in hopes of informing discussion for the next editions of ICD and DSM (33). In 2012, The Mood Disorders Work Group for DSM-5, which was comprised of representatives from various countries, evaluated previous diagnostic criteria for PMDD and found the criteria to be aligned with additional data that had become available (34). There were several other factors that supported this smooth transition including United States Food and Drug Administration’s recognition of PMDD as a distinct disorder and research findings showing consistent prevalence rates of PMDD across countries (35). Following DSM-IV’s recognition of PMDD, the magnitude of scientific evidence on PMDD has burgeoned and individuals afflicted with this condition can now receive research-informed care (32).

While research into D-MER is still in early stages, establishing preliminary diagnostic criteria will allow this condition to be reliably distinguished from other conditions, facilitating further clinical and scientific progress. As with PMDD, we anticipate that further study will result in the modification of these criteria to continue to reflect the state of science and to promote further diagnostic validity of this condition.

Proposal of diagnostic criteria for D-MER

Proposed diagnostic criteria for D-MER are listed in Table 2. Criterion A for the diagnosis of PMDD defines the timing as occurring primarily in the week before menses, improving after the onset of menses and becoming minimal or absent in the follicular phase of the menstrual cycle. For D-MER, we propose defining the timing to occur in the moments before and/or during milk letdown and improving within five minutes, becoming minimal or absent between letdowns as has been consistently described in the literature (2, 3, 20, 21). PMDD is also defined as occurring in the majority of menstrual cycles. For D-MER, we do not yet have clear evidence that most letdowns must be symptomatic for the syndrome to impact a patient’s life.

Criterion B for the diagnosis of PMDD defines the core symptoms of affective lability, irritability/anger, depressed mood, and anxiety/tension. The DSM notes that one or more must be present, with a total of 5 symptoms which include at least one from the additional symptoms listed in criteria C. It is noteworthy that three of the four symptom categories described in the diagnostic criteria for PMDD correspond to three symptoms categories originally described for D-MER: depression, anxiety and anger (2). These categories have continued to capture additional D-MER symptoms described, and have been used in various studies to categorize symptoms (6, 20).

Criterion C describes additional symptoms, including a number of somatic symptoms such as appetite changes, breast tenderness and bloating. Different physical symptoms have been described for D-MER including breast pain and a sensation of nausea or churning/hollowness in the stomach (3, 26). One important area for future research is to further explore the contribution of breast/nipple pain to D-MER symptoms.

Criterion D for PMDD requires clinically significant distress or impairment to functioning. The evidence thus far supports an association with D-MER symptoms and impaired bonding, breastfeeding and mental health outcomes (4), however it is possible that this is a bidirectional relationship and merits a more nuanced examination. To define distress and impairment for D-MER, we have included diminished breastfeeding satisfaction or impairment in bonding, though further research may reveal other outcomes that are impacted by D-MER. Further research is also needed to define how D-MER may impact relationships other than that between the breastfeeding dyad.

Criteria E and G for PMDD both involve ruling out other medical or psychiatric conditions that may cause similar symptoms. Our proposed criterion E for D-MER emphasizes that symptoms should not be caused primarily by other mental health conditions including depression and anxiety. Importantly, these disorders may co-occur with D-MER, however the D-MER symptoms are defined by an abrupt change to a patient’s baseline mental state. Criterion F also highlights that the mood disturbance is not based solely on physical discomfort or pain associated with breastfeeding.

Finally, Criterion F for PMDD describes confirmation of the disorder by prospective daily rating during at least 2 symptomatic cycles. Currently, there are no studies that have examined prospective ratings of D-MER symptoms. More research is needed to determine if such ratings are useful in the diagnosis of D-MER and to determine cutoffs for frequency and duration of symptoms.

Discussion

There is clear precedent in both DSM and ICD systems that reproductive life events that lead to alterations of sex hormones can precipitate distinct psychiatric conditions characterized by heterogeneous symptoms that occur with specific timing relative to hormonal changes. The evolution of PMDD as a distinct diagnostic category and the addition of peripartum specifiers in diagnostic systems has facilitated standardization in research and allowed clinicians to recognize and treat these clinically impactful psychiatric conditions.

Existing data regarding D-MER supports it as a distinct psychiatric condition given its specific onset, phenotype, phenomenology and prognosis. Familiarity and genetic vulnerability have yet to be established, similar to PMDD prior to its inclusion in the DSM. The current lack of standardized diagnostic criteria for D-MER presents a major limitation to identification of D-MER cases in clinical and research settings. Thus, clearly delineating this condition is a critical step in legitimizing and advancing scientific inquiry, allowing for development of effective interventions, investigation of biomarkers and identification of risk factors.

While the DSM diagnostic criteria are widely used for both clinical and research purposes, the level of evidence currently available for D-MER is not at a point where it is reasonable to propose inclusion in the DSM. The criteria proposed are intended to be specific enough for both research and clinical use and flexible enough to incorporate additional information as it accumulates. As research into D-MER progresses, these criteria may be adapted into DSM or ICD frameworks. As noted by Robins and Guze (1970), “the process [of establishing diagnostic validity] is one of continuing self-rectification and increasing refinement” (29).

We propose that next steps in research on D-MER focus on further characterization of the condition to support the ongoing development of an evidence-based definition, including exploration of additional cognitive and somatic symptoms; the utility of prospective daily ratings; and the impact of D-MER on important breastfeeding and maternal mental health outcomes. It is our hope that these criteria will provide an important step forward in defining D-MER to facilitate the research needed to better characterize the disorder, establish evidence-based treatment, and ultimately to improve clinical outcomes.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

Author contributions

MH: Conceptualization, Writing – original draft, Writing – review & editing. TD: Writing – original draft, Writing – review & editing. NC: Writing – original draft, Writing – review & editing.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Conflict of interest

The authors declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

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References

1. Cox S. A case of dysphoric milk ejection reflex (D-MER). Breastfeed Rev Prof Publ Nurs Mothers Assoc Aust. (2010) 18:16–8.

PubMed Abstract | Google Scholar

2. Heise AM and Wiessinger D. Dysphoric milk ejection reflex: A case report. Int Breastfeed J. (2011) 6:6. doi: 10.1186/1746-4358-6-6

PubMed Abstract | Crossref Full Text | Google Scholar

3. Ureño TL, Berry-Cabán CS, Adams A, Buchheit TL, and Hopkinson SG. Dysphoric milk ejection reflex: A descriptive study. Breastfeed Med. (2019) 14:666–73. doi: 10.1089/bfm.2019.0091

PubMed Abstract | Crossref Full Text | Google Scholar

4. Žutić M, Matijaš M, and Nakić Radoš S. Dysphoric milk ejection reflex: measurement, prevalence, clinical features, maternal mental health, and mother–infant bonding. Breastfeed Med. (2024) 20:133–9. doi: 10.1089/bfm.2024.0172

PubMed Abstract | Crossref Full Text | Google Scholar

5. Lynn Herr S, Devido J, Zoucha R, and Demirci JR. Dysphoric milk ejection reflex in human lactation: an integrative literature review. J Hum Lact. (2024) 40:237–47. doi: 10.1177/08903344241231239

PubMed Abstract | Crossref Full Text | Google Scholar

6. Kacir A, Karabayir N, Karademir F, Basibuyuk M, Ocal O, Buke O, et al. Impact of dysphoric milk ejection reflex on mental health. Breastfeed Med Off J Acad Breastfeed Med. (2024) 19:547–53. doi: 10.1089/bfm.2024.0055

PubMed Abstract | Crossref Full Text | Google Scholar

7. Nguyen L, Stokes S, Alsup K, Allen J, and Zahler-Miller C. Dysphoric milk ejection reflex: characteristics, risk factors, and its association with depression scores and breastfeeding self-efficacy. Breastfeed Med Off J Acad Breastfeed Med. (2024) 19:467–75. doi: 10.1089/bfm.2023.0241

PubMed Abstract | Crossref Full Text | Google Scholar

8. Ohmura N, Okuma L, Truzzi A, Esposito G, and Kuroda KO. Maternal physiological calming responses to infant suckling at the breast. J Physiol Sci JPS. (2023) 73:3. doi: 10.1186/s12576-023-00860-w

PubMed Abstract | Crossref Full Text | Google Scholar

9. Deif R, Burch EM, Azar J, Yonis N, Abou Gabal M, El Kramani N, et al. Dysphoric milk ejection reflex: the psychoneurobiology of the breastfeeding experience. Front Glob Womens Health. (2021) 2:669826. doi: 10.3389/fgwh.2021.669826

PubMed Abstract | Crossref Full Text | Google Scholar

10. Schildkrout B, MacGillivray L, Raj S, and Lauterbach M. Dysphoric milk ejection reflex (D-MER): A novel neuroendocrine condition with psychiatric manifestations. Harv Rev Psychiatry. (2024) 32:133–9. doi: 10.1097/HRP.0000000000000402

PubMed Abstract | Crossref Full Text | Google Scholar

11. Rosen-Carole CB, Prieto E, AlHreashy F, AlJaafar F, Cornelio MC, DeLeon C, et al. Current scope of practice for breastfeeding and lactation medicine physicians and providers: description of an emerging subspecialty. Breastfeed Med. (2025) 20:601–14. doi: 10.1089/bfm.2025.65870.abm

PubMed Abstract | Crossref Full Text | Google Scholar

12. PROTOCOLS. Available online at: https://www.bfmed.org/protocols (Accessed November 18, 2025).

Google Scholar

13. International Board of Lactation Consultant Examiners. International Board Certified Lactation Consultant Detailed Content Outline (2023). Available online at: http://www.iblce.org (Accessed November 18, 2025).

Google Scholar

14. Cappenberg R, Garcia JG, Liolios I, Happle C, and Zychlinsky Scharff A. Dysphoric Milk Ejection Reflex: Prevalence, persistence, and implications. Eur J Obstet Gynecol Reprod Biol. (2025) 308:127–31. doi: 10.1016/j.ejogrb.2025.02.051

PubMed Abstract | Crossref Full Text | Google Scholar

15. Lawrence RA. Breastfeeding: a guide for the medical profession. Ninth edition. Philadelphia, Pennsylvania: Elsevier (2021).

Google Scholar

16. Ureno TL, Buchheit TL, Hopkinson SG, and Berry-Caban CS. Dysphoric milk ejection reflex: A case series. Breastfeed Med Off J Acad Breastfeed Med. (2018) 13:85–8. doi: 10.1089/bfm.2017.0086

PubMed Abstract | Crossref Full Text | Google Scholar

17. Uvnas-Moberg K and Kendall-Tackett K. The mystery of D-MER: what can hormonal research tell us about dysphoric milk-ejection reflex? Clin Lact. (2018) 9:23–9. doi: 10.1891/2158-0782.9.1.23

Crossref Full Text | Google Scholar

18. Ahmed M, Mahmud A, Mughal S, and Shah HH. Dysphoric milk ejection reflex - call for future trials. Arch Gynecol Obstet. (2024) 310:627–30. doi: 10.1007/s00404-024-07503-4

PubMed Abstract | Crossref Full Text | Google Scholar

19. Kraus V, Čižmárová B, and Birková A. When your body tells you to not breastfeed—The connivance of oxytocin, prolactin, and dopamine. Int J Mol Sci. (2025) 26:5909. doi: 10.3390/ijms26125909

PubMed Abstract | Crossref Full Text | Google Scholar

20. Liu H, Li J, Li X, and Lu H. Dysphoric milk ejection reflex: report of two cases and postulated mechanisms and treatment. Breastfeed Med. (2023) 18:388–94. doi: 10.1089/bfm.2022.0206

PubMed Abstract | Crossref Full Text | Google Scholar

21. Middleton C, Lee E, and McFadden A. Negative emotional experiences of breastfeeding and the milk ejection reflex: a scoping review. Int Breastfeed J. (2025) 20:13. doi: 10.1186/s13006-024-00692-3

PubMed Abstract | Crossref Full Text | Google Scholar

22. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5-TR™. Fifth edition, text revision. Washington, DC: American Psychiatric Association Publishing (2022). 1050 p.

Google Scholar

23. Morns MA, Steel AE, McIntyre E, and Burns E. Breastfeeding aversion response (BAR): A descriptive study. J Midwifery Womens Health. (2023) 68:430–41. doi: 10.1111/jmwh.13474

PubMed Abstract | Crossref Full Text | Google Scholar

24. Morns MA, Steel AE, McIntyre E, and Burns E. It Makes My Skin Crawl”: Women’s experience of breastfeeding aversion response (BAR). Women Birth J Aust Coll Midwives. (2022) 35:582–92. doi: 10.1016/j.wombi.2022.01.001

PubMed Abstract | Crossref Full Text | Google Scholar

25. Zychlinsky Scharff A, Cappenberg R, Liolios I, Garcia Garcia J, and Happle C. Risk factors for dysphoric milk ejection reflex. Am J Obstet Gynecol. (2024) 232:e37–e39. doi: 10.1016/j.ajog.2024.09.102

PubMed Abstract | Crossref Full Text | Google Scholar

26. Howard M, Goulding AN, Muddana A, Fletcher TL, Cirino N, and Stuebe AM. Dysphoric milk ejection reflex: prevalence and associations with self-reported mental health history. Arch Womens Ment Health. (2025) 28:1319–23. doi: 10.1007/s00737-025-01571-4

PubMed Abstract | Crossref Full Text | Google Scholar

27. Moriyama Y, Nakao Y, Yamamoto N, and Oki T. Dysphoric milk ejection reflex among Japanese mothers: a self-administered survey. Int Breastfeed J. (2024) 19:21. doi: 10.1186/s13006-024-00625-0

PubMed Abstract | Crossref Full Text | Google Scholar

28. Solmonovich RL, Kouba I, Bailey C, Andria W, Demertzis K, Blitz MJ, et al. Incidence and awareness of dysphoric milk ejection reflex (DMER). J Perinat Med. (2024) 53:258–61. doi: 10.1515/jpm-2024-0299/html

PubMed Abstract | Crossref Full Text | Google Scholar

29. Robins E and Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry. (1970) 126:983–7. doi: 10.1176/ajp.126.7.983

PubMed Abstract | Crossref Full Text | Google Scholar

30. Epperson CN and Hantsoo LV. Making strides to simplify diagnosis of premenstrual dysphoric disorder. Am J Psychiatry. (2017) 174:6–7. doi: 10.1176/appi.ajp.2016.16101144

PubMed Abstract | Crossref Full Text | Google Scholar

31. Stickel S, Wagels L, Wudarczyk O, Jaffee S, Habel U, Schneider F, et al. Neural correlates of depression in women across the reproductive lifespan - An fMRI review. J Affect Disord. (2019) 246:556–70. doi: 10.1016/j.jad.2018.12.133

PubMed Abstract | Crossref Full Text | Google Scholar

32. Paul S and Pal A. Premenstrual syndrome and premenstrual dysphoric disorder: A review of their history with an eye on future. Ann Indian Psychiatry. (2022) 6:393. doi: 10.4103/aip.aip_16_22

Crossref Full Text | Google Scholar

33. O’Brien PMS, Bäckström T, Brown C, Dennerstein L, Endicott J, Epperson CN, et al. Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders: the ISPMD Montreal consensus. Arch Womens Ment Health. (2011) 14:13–21. doi: 10.1007/s00737-010-0201-3

PubMed Abstract | Crossref Full Text | Google Scholar

34. Epperson CN, Steiner M, Hartlage SA, Eriksson E, Schmidt PJ, Jones I, et al. Premenstrual dysphoric disorder: evidence for a new category for DSM-5. Am J Psychiatry. (2012) 169:465–75. doi: 10.1176/appi.ajp.2012.11081302

PubMed Abstract | Crossref Full Text | Google Scholar

35. Zachar P, Kendler KS, and diagnostic A. and statistical manual of mental disorders history of premenstrual dysphoric disorder. J Nerv Ment Dis. (2014) 202:346–52. doi: 10.1097/NMD.0000000000000128

PubMed Abstract | Crossref Full Text | Google Scholar