The American Psychiatric Association has pushed back their timeline for the 5th version of the Diagnostic and Statistics Manual. The new psychiatric bible was originally scheduled to come out in 2011, but has now been delayed to 2013 .

Initial drafts have been posted to the web page, but the controversial and provisional (that is, not yet officially accepted) diagnosis of premenstrual dysphoric disorder (PMDD) does not yet appear ready for comment. Which is a shame, because traditionally SMCR and its members have had a lot to say about PMDD, and we’re looking forward to the opportunity to consider and critique its new incarnation. Here’s a recent post as an example.

PMDD was first introduced in the DSM-III-R as Late Luteal Phase Dysphoric Disorder. The “late luteal” was meant to include cycling women who did not bleed, for example, those with a hysterectomy but preserved ovaries, but was criticized because “luteal phase” implies ovulation, and assessing ovulation was not part of the diagnosis.

Paula Caplan (e.g. this article) and other members of the SMCR were vocal in their challenge to the psychiatric label. Paula Caplan wrote a book about her experiences with the DSM process (They Say You’re Crazy), and the SMCR produced the following position statement:

June 2001 / Resolution #1: PMDD and Sarafem
Whereas the Society for Menstrual Cycle Research has since 1977 been the pre-eminent organization that focuses on scientific research on the menstrual cycle;

Whereas there is no empirical evidence that there is premenstrual illness that is separate or different from other forms of depression or anxiety or responses to stressful life circumstances;

Whereas there is good empirical evidence the Premenstrual Dysphoric Disorder does not exist;

Whereas the widespread use of Sarafem and related drugs results in both the masking of real causes of women’s suffering and the production of negative drug effects;

Therefore, be it resolved the the Society for Menstrual Cycle Research calls upon the Food and Drug Administration

a) to reconsider its approval of Sarafem for the treatment of “Premenstrual Dysphoric Disorder” and

b) to enjoin Eli Lilly from airing or publishing advertisements for Sarafem to lay and professional audiences until such reconsideration is completed.

In the end, The FDA approved Sarafem (Prozac, re-colored lavender and repackaged, with a brand new patent and a new lease on life) for the treatment of this newly minted psychiatric disorder; a panel from the European Agency for the Evaluation of Medicinal Products declined to follow suit, recognizing that PMDD was not a widely accepted diagnostic label in Europe, and concluding that

There was considerable concern that women with less severe premenstrual symptoms might erroneously receive a diagnosis of PMDD resulting in widespread inappropriate short- and long-term use of fluoxetine [Prozac].

Psychiatrists in the USA require an official DSM label to be paid by insurance companies for the services they provide to women with cyclic mood issues; insured treatment-seeking women in the USA require those who hold the medical purse strings to recognize their distress. And having an entry in the DSM meets both of those needs.

Here are some points that I think are helpful to start a discussion:

  1. We acknowledge that some women, at some times in their lives, experience significant increases in negative mood and physical symptoms around the time of menstrual bleeding, that for some these changes are extreme and seriously interfere with their lives, and that this experience needs to be recognized and treated.
  2. We challenge whether this constellation of symptoms properly belongs in a psychiatric diagnosis, because of the stigma and possible legal ramifications (e.g., child custody) that such a diagnosis may have, and because of the endocrine component of the experiences which may be less well understood by those trained as psychiatrists.
  3. Psychiatric treatment often amounts to adminstration of prozac (either directly, or repackaged as Sarafem), rather than an appreciation of the other aspects in a woman’s life (abuse, financial hardship) that may be contributing to her distress. Prozac may or may not be effective, and has significant (e.g. sexual) side-effects.
  4. We also want to clearly distinguish between the normal, non-clinical, changes that most women experience over the course of their menstrual cycle and the severe, debilitating symptoms that might be considered a clinical disorder demanding treatment. Population based studies (Ramcharan, Sveinsdottir) estimate the prevalence of severe premenstrual mood symptoms at 1-5%.
  5. There are other ways to approach treatment. For an overview and some practical recommendations, Diana Taylor’s book, Taking back the month, is a good start. A good start is to track; CeMCOR also has free tracking tools, and lots of information.
  6. This is a power-play on several levels (a) by psychiatrists, to stake out therapeutic territory (b) by pharmaceutical companies, who want a new market for their old drug, and who then use advertising to suggest that a woman frustrated by shopping carts might have PMDD. The FDA issued a warning letter about the offending ad, which was later pulled.

  7. PMDD is still a provisional category in the DSM as requiring further study.

PMDD gives women a familiar choice between being told our issues are “all in our head”, or being called crazy, with all the stigma that entails.

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