"I'm so bloated.""I'm so depressed.""I'm so irritable.""One minute I'm fine, the next I'm crying." "I'm so tired."
The list of complaints that goes with many women's menstrual cycle can be long. Most women--and men for that matter--are quick to diagnose these symptoms as premenstrual syndrome (PMS)--a catchall diagnosis that's tossed around to describe all sorts of minor mood and menses-related maladies in women.
But approximately 3 to 9 percent of women experience premenstrual changes so severe they can't keep up their daily routines. Some experts say these women suffer from premenstrual dysphoric disorder (PMDD), a condition characterized by intense emotional and physical symptoms that occur between ovulation and menstruation. In other words, PMDD is like supercharged PMS.
"It's a real biological condition for which women seek treatment--and for which effective treatment is available," says Jean Endicott, PhD, director of the premenstrual evaluation unit at Columbia Presbyterian Medical Center. Eight years ago it was included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). But many health professionals say PMDD does not exist, that it can be confused with other mental health disorders, such as depression. Psychologists in this camp contend women shouldn't have to be diagnosed with a mental illness in order for others to believe they are uncomfortable or unhappy or to get help and support.
"PMS and PMDD are both 'culture-bound' syndromes," says Joan Chrisler, PhD, a psychology professor at Connecticut College and president of the Society for Menstrual Cycle Research. "There is no evidence [that PMDD exists], though people have to find such evidence," says Paula Caplan, PhD, author of "They Say You're Crazy" (1995, Perseus Books). "It is really appalling that using PMDD for women who want recognition for discomfort is a very clear message that goes something like: 'OK, OK, we'll believe you are feeling bad if we get to call you mentally ill for feeling bad.' Can you imagine if we did that to men?"
"Women are supposed to be cheerleaders," she adds. "When a woman is anything but that, she and her family are quick to think something is wrong."
Meanwhile, for women, the controversy can be frustrating and confusing. Those who experience severe premenstrual changes just want some relief.
Defining the condition
PMDD is listed in the DSM-IV as a "depressive disorder not otherwise specified." The symptoms of PMDD are remarkably similar to those of Major Depressive Disorder (MDD). PMDD symptoms include:
Markedly depressed mood. A symptom of MDD is depressed mood most of the day, nearly every day.
Decreased interest in usual activities. One criterion for MDD is markedly diminished interest or pleasure in all activities.
Lethargy, fatigability or lack of energy. Similarly, patients with MDD have fatigue or loss of energy.
Hypersomnia or insomnia--also symptoms of MDD.
The difference between PMDD and MDD is that PMDD symptoms are cyclical, subsiding with onset of menses, points out Endicott. The DSM-IV also notes that some mood disorders, somatoform disorders, personality disorders and general medical conditions, such as thyroid and other endocrine disorders, migraine, anemia or various infections can be exacerbated during the premenstrual phase.
Endicott and a panel of experts determined in 1999 that PMDD is a distinct clinical entity, based on studies they examined that suggested that PMDD sufferers have "normal functioning of the hypothalamic-pituitary-adrenal axis, show biologic characteristics generally related to the serotonin system, and a genetic component unrelated to major depression." The roundtable group--which included psychiatrists, psychologists and a representative from Eli Lilly--also cited studies that showed that at least 60 percent of patients respond to selective serotonin reuptake inhibitors (SSRIs) as evidence of PMDD's distinct clinical entity.
Interestingly, a 1998 (American Journal of Obstetrics and Gynecology, Vol. 179, No. 2) study showed that calcium carbonate could improve PMDD symptoms. Out of approximately 500 women, 55 percent experienced some relief from some symptoms within three months.
Some research suggests a link between depression and PMDD. Psychologist Shirley Ann Hartlage, of Rush Medical College in Chicago, who is a principal co-investigator on an epidemiological study of PMDD sponsored by the National Institute of Mental Health, and colleagues found that women with PMDD appear to be at greater risk for developing major depression (Journal of Clinical Psychology, Vol. 57, No. 12).
Most experts insist that daily self-ratings by the patient for two or more menstrual cycles must be completed before a PMDD diagnosis can be confirmed. "It's the timing of the symptoms that makes a difference," Hartlage notes. "And very few women, if they are rating their symptoms every day, have symptoms as severe as required [by the criteria]."
Bad for women?
Some feminist psychologists like Caplan believe that the language surrounding PMDD is misleading and that its classification as a psychiatric disorder stigmatizes women as mentally ill and covers up the real reasons of women's anguish. "It's a label that can be used by a sexist society that wants to believe that many women go crazy once a month," Caplan explains.
By including PMDD in the DSM-IV, she says, emotional displays that are considered normal in men are seen as a mental disorder in women. "Any normal hormonal change in people of either sex can exacerbate migraines, thyroid problems, etc., but no one suggests calling...men's hormonal changes kinds of mental illness."
Chrisler agrees, noting that not only is the diagnosis part of a "backlash against feminism," it undermines women's self-concepts and feeds into stereotypes about women. "It's convenient for women to use this," says Chrisler. "The discourse is me, not me, my real self, my PMS self. It allows you to hold onto a view of yourself as a good mother who doesn't lose her temper."
Caplan cites research by Sheryle Gallant and colleagues "that demonstrates without question that the category of PMDD is neither valid nor helpful to women." The study (Psychosomatic Medicine, 1992) asked women--a group that said they had severe symptoms and a group with none--to keep a checklist of PMDD symptoms. In the end, the checklist responses failed to differentiate the two groups.
Perhaps most interesting, some men were asked to participate in the study and their checklist results didn't differ from the women's. Caplan says that's "dramatic proof" that classifying PMDD as mental disorder is "unjustified."
Chrisler and Caplan say that health professionals are all too ready to diagnose women with PMS or PMDD. "The diagnosis is vastly overextended," Chrisler says. "The definition says it has to be severe and interrupt your life. No one thinks about that anymore."
Caplan says that when someone believes they have PMDD, a psychologist should say, "'Yes, maybe that's it. But let's look at your life, maybe it's something else.'"
Indeed, some research seems to show that many women who seek treatment for PMS or PMDD are often abused. At the least, Chrisler says, they might be experiencing stress that exacerbates premenstrual changes--but they don't really have PMDD. She adds: "We're conditioned to want a pill. Instead of something you might need more, like a nap or a divorce, or the ERA."
Enter the drug treatments
Two medications are approved by the Food and Drug Administration to treat PMDD: Sarafem (fluoxetine) and Zoloft (sertraline HTL). Sarafem--repackaged Prozac--was marketed heavily by its manufacturer, Eli Lilly, for PMDD treatment after it acquired another patent--Prozac's patent was due to expire. Lilly spent more than $33 million promoting the drug to consumers. In the seven-month period after the medication's approval, physicians doled out more than 200,000 prescriptions for Sarafem.
And this year, Zoloft, manufactured by Pfizer, was also approved to treat the condition. Some research (Journal of Women's Health and Gender-based Medicine, Vol. 10, No. 8) suggests that both fluoxetine and sertraline are more effective than placebos in treating PMDD.
But drug treatments for PMDD draw controversy. Critics like Caplan think drug companies are taking advantage of women's health concerns and fears to increase their bottom lines. She thinks the decision to accept Sarafem as a treatment for PMDD just furthers "the misleading and dangerous assumption that the condition even exists"--women's underlying problems, such as depression or abuse go untreated, she says. Caplan also asserts that many drug companies have funded studies, "then insisted that, as reported by the editors of major medical journals in the past two years, researchers publish only those studies that showed their drug works, and they have suppressed the publication of others." And she notes that if a company does enough studies, "one will by statistical chance get some that seem to show the drug makes a difference.
Others, like Endicott, who was involved in some of the clinical trials, believe that the treatments work, and that some women do find relief. "It's treatable--you don't have to put up with this," she says. In response to criticism of the research, "The companies did not do large scale studies involving hundreds of women until smaller studies conducted by independent researchers had indicated that a particular treatment might have a sizable therapeutic benefit."
Hartlage, meanwhile, fears that, without the psychiatric-disorder classification, women who are truly suffering may be discounted. "Sometimes to receive the diagnosis is more helpful to women," she says. Endicott agrees, saying that many women whose lives are adversely affected by their premenstrual symptoms are relieved to find someone who knows what they are experiencing and takes them seriously. She thinks that the disbelief of PMDD belittles women and "increases the stigma of mental disorders--where problems with mood and behavior are the defining characteristics--and can discourage women from seeking help."
Regardless of their positions on PMDD, psychologists like Chrisler, Caplan, Hartlage and Endicott say it's crucial not to jump to conclusions with patients. "If a woman tells you she has PMS or PMDD, [therapists] should be supportive and shouldn't assume that it's just hormonal and nothing can be done about it," says Chrisler. "Ask about stress, ask about relationships. Explore some other things."
Whether PMDD is a mental disorder or not, the most important thing is to give women who seek help validation. "Whatever they're experiencing, they're experiencing," she says.
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