Fighting the Pathologizing of PMS

Are you unhappy? Bloated? Is it hard to concentrate? Do you have food cravings? Breast tenderness?

If you read the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, you will find your symptoms listed under "premenstrual dysphoric disorder" (PMDD). In other words, because of those symptoms, a therapist or doctor could label you as having a mental disorder.

The DSM is the bible of psychiatric diagnosis, used by nearly every hospital, clinic, doctor and insurance company, as well as Medicare and Medicaid. Since PMDD first was mentioned in the DSM in 1987, people have received the mistaken impression that it's real and that it's a mental illness. With the manual's fifth edition currently in preparation, that notion seems likely to be strengthened rather than discouraged.

Contrary to popular opinion, the creation and use of psychiatric categories is rarely based on solid science, as I learned when I served on two DSM committees. The absence of science leaves a void into which every conceivable kind of bias has been found to flow -- including sexism. The DSM's own PMDD committee reviewed more than 500 studies for the 1994 edition and concluded that no high-quality research supported the existence of PMDD, yet PMDD was placed in the manual anyway.

Do some women report feeling worse before their periods than at other times of the month? Certainly, although in some countries and cultures more than others. Premenstrual discomforts are also more often reported by women who were sexually abused as children, are struggling with abuse or harassment, or are just plain overburdened. But that is worlds away from a mental illness.

Two powerful DSM authors proposed adding PMDD in the mid-1980s and proposed adding it to the next edition of the manual. It would represent an extreme form of PMS -- the popularly accepted "syndrome" of physical and emotional symptoms between ovulation and menstruation. To qualify, it would have to include five familiar PMS-type symptoms, at least one of them a "mood disorder" such as feeling hopeless, "on edge," self-deprecating, irritable, angry or tearful. No one keeps comprehensive records of how often a PMDD diagnosis is given, but based on PMDD committee estimates, approximately half a million American women could be given the PMDD label.

Hundreds of researchers have tried unsuccessfully to prove that women are more likely to have mood problems premenstrually than at other times. University of British Columbia researcher Christine Hitchcock says, "Something like half of women say they have premenstrual problems, but when you ask them to keep daily ratings of their moods, the data don't reflect that." Another study showed that men identified PMDD symptoms in themselves as commonly as women did.

Despite this, when Eli Lilly and Company's patent on antidepressant Prozac was about to expire, the pharmaceutical giant successfully asked the Food and Drug Administration to approve it to treat PMDD, providing a patent extension worth millions. Eli Lilly repackaged Prozac in pink and purple and rechristened it the feminine-sounding "Sarafem." Other drug companies rushed to market similar products. They deliberately listed physical problems associated with menstruation for some women, such as breast tenderness or bloating, and added a list of mood problems from the PMDD list that virtually every human being experiences.

The PMDD mood symptoms are also listed for menopause, although they are supposedly caused at menopause by deficiency in the hormones whose increase supposedly causes PMDD. I half-jokingly predicted that we would soon hear about premenarcheal dysphoric disorder between a baby girl's birth and her first period, thus pathologizing women's moods from birth to death.