Premenstrual dysphoric disorder, or PMDD, has been one of the more controversial additions to the disorders listed in the DSM-IV (it appeared in the DSM-III-R as Late Luteal Phase Dysphoric Disorder), not least because the distinctions between it and premenstrual syndrome (PMS), a perfectly normal, biological part of the menstrual cycle for most women, remain unclear to many people. PMS is a term that has come into common use since the early 1980s to refer to the mood changes, poor concentration, and physical discomfort that frequently precede the start of menstruation by several days. Some studies have suggested that up to 80 percent of women experience these kinds of cyclic symptoms, and so many women were upset to hear that something sounding very much like PMS, widely considered a medical condition, was now to be listed as a psychiatric disorder worthy of treatment.
What ultimately distinguishes many psychological disorders from most people’s ordinary experiences is the severity of the symptoms and the degree to which they interfere with their ability to function. Anxiety, for example, is experienced by everyone, but only a few have anxiety disorders. In much the same way, most women experience PMS occasionally, but it has been estimated that only about 3 to 5 percent have symptoms so severe that their ability to function socially or at work is signiﬁcantly impaired. In PMDD, the mood changes that occur are comparable in severity to a major depressive episode and may even be accompanied by suicidal thoughts. An actual diagnosis of PMDD requires that ﬁve or more of the following symptoms, including at least one of the ﬁrst four, were present for most of the last week of most menstrual cycles in the past year, and that they were absent in the week following menstruation (adapted from DSM-IV):
- Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
- Marked anxiety, tension, feelings of being “keyed up” or “on edge”
- Marked sudden emotional changes and increased sensitivity
- Persistent and marked anger or irritability or increased interpersonal conﬂicts
- Decreased interest in usual activities
- Difﬁculty in concentrating
- Lethargy, fatigue
- Changes in appetite
- Sleeping too much or too little
- Feeling overwhelmed or out of control
- Physical symptoms including bloating, headaches, weight gain, joint or muscle pain, breast tenderness
Note that, apart from the physical symptoms characteristic of PMS, the entire list strongly resembles the criteria for Major Depression.
Many feminist psychologists, including the membership of both the APA’s Committee on Women and the National Coalition for Women’s Mental Health, strongly objected to the inclusion of this disorder in the DSM-III-R. They felt that including PMDD stigmatizes women, since menstruation is a normal female bodily function, and thus psychological changes that occur as a result of this function are also a normal part of being female. Furthermore, no parallel diagnosis exists for men, such as post-football loss psychosis, nor are there any gender-neutral diagnostic categories for dysphoria caused by hormonal changes. This is therefore a psychiatric diagnosis that can only be made for women.
Since deﬁnitive criteria do not exist for distinguishing normal from abnormal changes in estrogen levels, the diagnostic criteria for distinguishing between PMS and PMDD are necessarily quite subjective, and women have also objected to treating something caused by normal physical changes as a psychiatric disorder rather than a physical one. The controversy over this disorder was so heated that the committee originally assigned to determine whether it should be included in the DSM-IV was unable to come to an agreement, and the disorder was ultimately put to a vote of the APA’s legislative assembly. This is an unusual way to decide on whether something is an illness or not.
A larger problem with PMDD stems from its resemblance to depression, which has led to similar treatment recommendations. The U.S. Food and Drug Administration has approved the drug Serafem speciﬁcally for the treatment of PMDD, based on two double-blind trials in which it was shown to be effective in relieving the symptoms of the disorder. This is problematic because the Serafem brand is simply a relabeling of ﬂuoxetine, better known as Prozac, already the most widely prescribed antidepressant. This is also problematic because ﬂuoxetine is a selective serotonin reuptake inhibitor (SSRI), meaning it acts selectively on serotonin, a neurotransmitter found in the brain (see Nervous System). It is not known, however, to have any impact whatsoever on levels of estrogen, the hormone that is presumed responsible for the symptoms of PMDD. Since depression is one of the symptoms of PMDD, it is not surprising that Prozac (under the other name) may relieve the symptoms, but it raises questions about what is really causing the symptoms. If the cause of PMDD is elevated estrogen levels, a drug that has no effect on those levels is an odd ﬁrst-choice treatment for the disorder.
- Kutchins, H., and Kirk, S. A. Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders. Chicago: Free Press, 1997.