Distinction between Premenstrual Dysphoric Disorder (PMDD) & PMS

Institute for the Study of Healthcare Organizations and Transactions

Introduction

An article in the Wall Street Journal (July 7, 2000) reports that the antidepressant, fluoxetine, marketed as an antidepressant by Eli Lilly under the trade name “Prozac”, will also be marketed under the new trade name “Sarafem” for treatment of premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome (PMS), a cluster of emotional, motivational, cognitive, and behavioral changes which occur in regular association with elevated estrogen levels immediately prior to, or during the early phases, of menstruation. For a discussion of the distinction between PMDD and PMS, click on.

What is Premenstrual Dysphoric Disorder? Considerable controversy exists over the status of PMDD and PMS as valid diagnostic categories.  For extensive discussions of the debate, see Paula J. Caplan, They Say you’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal (Addison Wesley, 1995); Anne E. Figert, Women and the Ownership of PMS: The Structuring of a Psychiatric Disorder (Aldine De Gruyter, 1996); Herb Kutchins & Stuart A. Kirk, Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders (Free Press, 1997); and Carol Tavris, The Mismeasure of Woman (Simon & Schuster, 1992).

Even when there was agreement about the diagnostic entity, there was disagreement about its name. In preparing the 1987 revision of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-IIIR), the syndrome was variously referred to as “Premenstrual Dysphoric Disorder” (PMDD) and “Periluteal Phase Dysphoric Disorder” (PPDD), before the responsible committee settled on “Late Luteal Phase Dysphoric Disorder” (LLPDD ). In the most recent edition of DSM (DSM-IV, 1994), the label reverted to PMDD.

It should be noted that “Periluteal Phase Dysphoric Disorder” greatly expanded the scope of the diagnostic category – a problem that frequently crops up in psychiatric diagnosis. PMDD was originally intended to cover women who experienced severe mental and behavioral symptoms during a particular phase of the menstrual cycle. But the adjective “periluteal” would permit a psychiatric diagnosis to be made in the case of a woman who experienced particular symptoms at any phase of her cycle. Not only would this designation have freed PMDD from its tie to periodic changes in the woman’s hormonal endowment, thus undermining the implicit theory of the etiology of PMDD; it would also have extended the number of women for whom Serafem/Prozac would be the treatment of choice. (See the discussion of Prozac and Serafem below.) To the extent that economic considerations play a role in psychiatric practice, we may anticipate the rediscovery of PPDD, with Serafem/Prozac as the treatment of choice, sometime in the not-too-distant future.

To return to the history of PMDD, some feminist professionals, including the APA’s Committee on Women and the National Coalition for Women’s Mental Health, objected to the inclusion of such a syndrome under any label. From their point of view, menstruation is a normal bodily function, and any psychological changes associated with this function should be seen as normal as well. Classifying PMS or PMDD as a mental disorder stigmatizes women, and may have other undesirable social consequences by laying additional foundations for disability claims and the insanity defense. Setting ideology and politics aside, PMDD raises fundamental questions about the nature of psychiatric diagnosis. What are the standards for distinguishing between “normal” PMS and “pathological” PMDD? Even if there were solid criteria for distinguishing between normal and abnormal changes in estrogen levels, why should the mental and behavioral consequences of these physiological changes be construed as symptoms of a mental disorder? What is the difference between a “physical” disorder and a “mental” one?

As with the APA’s debate over homosexuality in the 1970s, the debate over PMDD raises questions about the social construction of mental illness. A 1992 review by Paula J. Caplan, Joan McCurdy-Myers, and Maureen Gans concluded that there no compelling empirical justification for identifying any particular cluster of symptoms as PMDD, nor for considering PMDD a form of mental disorder (Feminism & Psychology, 2:27-44, 109). There was no link between the symptoms ascribed to PMDD and premenstrual changes in hormonal levels. And there was no evidence that any pharmacological adjustment of hormonal levels had any effect on PMDD

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Not sure when this article was posted on the Internet – but it is too interesting too ignore.

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Author: Leslie Carol Botha

Author, publisher, radio talk show host and internationally recognized expert on women's hormone cycles. Social/political activist on Gardasil the HPV vaccine for adolescent girls. Co-author of "Understanding Your Mood, Mind and Hormone Cycle." Honorary advisory board member for the Foundation for the Study of Cycles and member of the Society for Menstrual Cycle Research.