Guest Post by Joan Chrisler, Connecticut College
I have to admit that I have not been closely following the news about the forthcoming edition (5th) of the Diagnostic and Statistical Manual of Mental Disorders, which is expected to be published by the American Psychiatric Association in May 2013. So, when our blog editor Elizabeth Kissling asked me to take a look at a recent update on PMDD in Psychiatric News, I was intrigued. As I read the article I found myself becoming irritable, very irritable, even angry – but, don’t worry about me; I couldn’t possibly have PMDD, as I no longer menstruate. No, my emotional lability has more to do with the psychiatrists’ tendency to play fast and loose with facts than it does with my physiology.
The “news” begins with a statement that PMDD has been “proposed” to be included in the section on depressive disorders rather than in the appendix, which is reserved for disorders that need more study and shouldn’t yet be used clinically. This is a canard. PMDD appears in both the appendix and the depressive disorders section of the current edition – the DSM-IV-TR, which was published in 2000. As a result, it is already being used clinically. Perhaps what they really mean to say is that it is being removed from the appendix because we already know enough about it. Hmmm.
Next, we are told that there has been an “explosion” of research on PMDD in the “past 20 years.” Why 20 years? PMDD was originally named Late Luteal Phase Dysphoric Disorder and proposed for listing in the DSM-II-R (1987); early research that was intended to support the new diagnosis was not convincing, which probably factored into the decision to change its name. The current edition of the DSM was published 12 years ago, and the original DSM-IV in 1995 (17 years ago). According to PsycINFO, the largest psychology database, there have only been 259 articles published since the most recent edition of the DSM appeared, which hardly seems like an explosion, especially if we consider that many of them are about PMS, not PMDD. Others are not empirical reports of studies about PMDD; they are literature reviews, critiques of the diagnosis, and articles about psychotherapy for women with the diagnosis. The 259 even include random studies of migraines, schizophrenia, bipolar disorder, and menopause. The psychiatrists believe that these studies provide “greater legitimacy” for the diagnosis. Sorry, but I am not convinced.
The news report indicates that the criteria have been sharpened to require the presence of at least five of eleven symptoms during “most” menstrual cycles of the previous year. Prospective daily ratings are recommended, but it seems unlikely to me that most patients would be willing to wait or that most doctors would really insist that women rate themselves daily for a year before prescribing medication for PMDD. Another change is that the symptoms must produce “clinically significant distress” and “interference” with work, school, relationships, or social activities. These require judgment calls: “clinical significance” is the doctor’s call, and “interference” is the patient’s call.
I predict that these “sharper” descriptions are still vague enough to be overused. Example: A student in one of my classes told me in all seriousness that her menstrual cramps interfered with her daily life because she had to take an aspirin occasionally. Did she have to skip class and lay down with a heating pad? No, she took her pill and went about her business. “Then, how is that interference?”, I asked. “I don’t usually have to take an aspirin!”, she insisted. Now, I hope that that young woman is unusual, but I ask you to consider that the youth culture seems to value anything “extreme” and consider much of their experience to be unusual. My students think that (almost) everything is “awesome”, “incredible”, and “amazing”. If they were asked if their irritability is “extreme”, I suspect they would be much more likely than I would be to say “yes”.
Perhaps the most interesting (well, in a bad way) part of the news is that symptoms have been reordered to give priority to emotional lability, irritability, and anger and to deemphasize depressed mood. Why? “The work group agreed that clinically depressed mood is not the first thing you think of when you think of PMDD”. Perhaps the work group is thinking about cultural stereotypes of premenstrual women! If depressed mood is no longer a key criterion for PMDD, why is it still called PMDD? Shouldn’t the work group have proposed a name change that would drop “dysphoric disorder”? Why will it be continue to be classified with depressive disorders if it isn’t one?
Finally, the news report notes that how much distress and/or interference premenstrual symptoms produce depends on women’s personality, coping style, and life circumstances. Well, of course. There are many studies in the literature that show this. Stress, trauma, and even frequency of perceived discrimination (Pilver et al., 2011) predict severity of premenstrual complaints. There is much that psychotherapists can do to help women to manage their symptoms, but all the DSM suggests is drug treatment: SSRIs (selective serotonin reuptake inhibitors — the most commonly prescribed anti-depressants in the U.S.).
In conclusion, I refer readers to the SMCR’s resolution dated June 2001. Women should continue to be cautious about whether their premenstrual symptoms constitute a mental illness and whether they want to take a strong anti-depressant medication for the rest of their menstrual lives. Other types of help, without potentially serious side effects and the stigma of a psychiatric diagnosis, might be effective.
For more information about PMDD and the DSM, see:
Caplan, P. J. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. Reading, MA: Addison Wesley.
Chrisler, J. C., & Caplan, P. (2003). The strange case of Dr. Jekyll and Ms. Hyde: How PMS became a cultural phenomenon and a psychiatric disorder. Annual Review of Sex Research, 13, 274-306.