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The Inclusion of PMDD in DSM-5

No, adding this diagnosis doesn’t mean women “go crazy” each month

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) have gotten a bad rap. Who can forget the dramatic PMDD ad that ran over a decade ago, where a woman kept struggling with her grocery cart exasperatedly, and angrily? The ads were for Sarafem, the first drug widely marketed to aid in the treatment of PMDD. The drug contained the same active ingredient found in Prozac. The FDA pulled the ads, allegedly citing that a distinction was not properly made between PMS and PMDD.

Currently, neither PMS nor PMDD are reflected as official diagnoses by DSM-IV. PMDD appears as a "depressive disorder not otherwise specified." In the DSM-IV, the criteria are as follows:

"In most menstrual cycles during the past year, symptoms (e.g., markedly depressed mood, marked anxiety, marked affective lability, decreased interest in activities) regularly occurred during the last week of the luteal phase (and remitted within a few days of the onset of menses). These symptoms must be severe enough to markedly interfere with work, school, or unusual activities and be entirely absent for at least 1 week post menses" (American Psychiatric Association [DSM-IV-TR], 2000).

According the American Psychiatric Association's website, the new proposed changes would actually recognize PMDD as a disorder. The criteria would be as follows:

A. In most menstrual cycles during the past year, five (or more) of the following symptoms occurred during the final week before the onset of menses, started to improve within a few days after the onset of menses, and were minimal or absent in the week postmenses, with at least one of the symptoms being either (1), (2), (3), or (4):(1) marked affective laibility (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection)
(2) marked irritability or anger or increased interpersonal conflicts
(3) markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
(4) marked anxiety, tension, feelings of being "keyed up" or "on edge"
(5) decreased interest in usual activities (e.g., work, school, friends, hobbies)
(6) subjective sense of difficulty in concentration
(7) lethargy, easy fatigability, or marked lack of energy
(8) marked change in appetite, overeating, or specific food cravings
(9) hypersomnia or insomnia
(10) a subjective sense of being overwhelmed or out of control
(11) other physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," weight gain

B. The symptoms are associated with clinically significant distress or interferences with work, school, usual social activities or relationships with others (e.g. avoidance of social activities, decreased productivity and efficiency at work, school or home).

C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as Major Depressive Disorder, Panic Disorder, Dysthymic Disorder, or a Personality Disorder (although it may be superimposed on any of these disorders).

D. Criteria A, B, and C should be confirmed by prospective daily ratings during at least two symptomatic cycles. (The diagnosis may be made provisionally prior to this confirmation.)

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism).

F. In oral contraceptives users, a diagnosis of Premenstrual Dysphoric Disorder should not be made unless the premenstrual symptoms are reported to be present, and as severe, when the woman is not taking the oral contraceptive.

Historically, there has been mixed reception as to whether or not these symptoms warrant such hefty and otherwise "pathological" designations. Some feminist theorists argue that inclusion of PDMM would essentially allow society to stigmatize women by pathologizing a normal part of their physiological makeup; further, this would only contribute to stereotypes about women as being emotionally unstable once a month (Daw, 2002).

The reality is that although it is estimated between 2-10% of women may suffer from PMDD, other menstrual-related conditions affect significant numbers of women. For example, dysmenorrheal (painful cramping) is estimated to affect anywhere between 25% of all women and 90% of adolescents (Durain, 2004). As such, while many women's rights activists are not keen on allowing such factors to be viewed as impairing or limiting women in any way, one may pose a controversial question. Does it really matter? Especially if it means more funding for research, and better understanding of women's reproductive health.

Having counseled some of the nation's brightest young women at academically rigorous institutions, my recommendation is often the same. Slow down, take a deep breath, and give yourself permission to take care of yourself.  Today, both men and women are pushing themselves to limits that often seem to go beyond human capacity, and into the superhero realm.  This idea that women have to keep up with the men and not allow anything to stand in their way can sometimes be detrimental. Women and men are biologically built differently, each with their own unique set of strengths.  Then why must we deny that for women of child-bearing age, that once a month they may deserve a chance to slow down? Yes, it's not fair that some males, and even females, use terms like "oh, she's PMSing" to write off a woman. That said, should women be discouraged from taking care of themselves because of what others may think? Disparities in women's health research has been problematic for decades. Despite evidence that issues such as menstruation are worthy of sustained research efforts, we still see limited progress. Inclusion of disorders such as PMDD can allow us to lift the fog around women's health.  This would open to the door to better treatments, both pharmacologically, and alternative therapies.

As Gloria Steinem's humorous essay entitled "If Men Could Menstruate" suggests, if men could menstruate many things would happen differently. For example, "to prevent monthly work loss among the powerful, Congress would fund a National Institute of Dysmenorrhea. Doctors would research little about heart attacks, from which men would be hormonally protected, but everything about cramps." Until that day comes, perhaps we'll hold out hope that PMDD makes it into DSM-5 without any problems. It has the potential to change factors about the way in which women's mental health is conceptualized for the better. Because after all, why should women suffer because of fears around stigma?

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