Does PMDD belong in the DSM? challenging the medicalization of women's bodies

Canadian Journal of Human Sexuality, The, Spring, 2004 by Alia Offman, Peggy J. Kleinplatz

Abstract: Many believe in the existence of a class of symptoms experienced prior to menses labelled as Premenstrual Dysphoric Disorder (PMDD), however, the research findings on PMDD have been tenuous. In this paper, the validity and utility of the PMDD diagnosis is" called into question and it is argued that PMDD is a socially constructed diagnosis rather than a psychiatric disorder. The distinction between physiological experiences and pathology is investigated in addition to the implications of a PMDD diagnosis for patients, clinicians, researchers and pharmaceutical companies. Finally, the paper explores the relation between PMDD and sexuality offering an additional voice in the developing discourse on the medicalization of women's experiences of sexuality.

Key words: Premenstrual Dysphoric Disorder (PMDD) Women's bodies DSM Sexuality Social construction

An earlier version of this paper was presented at the November 2002 meeting of the Society for the Scientific Study of Sexuality in Montreal, Quebec, Canada.

INTRODUCTION

Premenstrual Dysphoric Disorder (PMDD) is identified in the current Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-TR) as a severe form of premenstrual distress (American Psychiatric Association, 2000). It is presented as a diagnostic category proposed for further study because of controversy surrounding the diagnosis. While the clinical and pharmacological literature reports on symptomatology and treatment of PMDD (e.g., Freeman & Sondheimer, 2003), another body of literature questions the consistency of research on premenstrual disorders in general and the reliability of the empirical support for the PMDD diagnostic category in particular (e.g., McFarlane & Williams, 1990; Rodin, 1992; Steiner & Born, 2000). A central theme in the debate is the utility and validity of the diagnostic category. Another is the extent to which categorization of menstrual cycle-related changes as PMDD represents a continuation of the medicalization of women's experiences of their bodies (Chrisler & Caplan, 2002).

This paper explores the concept of the medicalization of women's experiences of their bodies within the context of the continuing debate over the pathologizing of menstrual cycle-related changes in general and PMDD in particular. We review the history of research on premenstrual diagnostic categories and present literature that calls into question the utility and validity of PMDD as a psychiatric disorder and suggest, instead, that it might be better viewed as a socially constructed diagnosis. The paper also explores the relation between PMDD and women's sexuality and the implications of PMDD diagnosis for women, researchers, and clinicians.

From a medical perspective, physical and psychological experiences associated with the menstrual cycle become symptoms when they appreciably affect quality of life and day-to-day functioning. Our intent in this review is not to deny that women experience such changes, which can include bloating, weight gain, breast tenderness and swelling, appetite changes and sleep disturbances (Davis & Yonkers, 1997), or that they report the more severe, and less common, experiences identified as PMDD. Rather, we examine the longstanding debate over the labelling of menstrual cycle-related changes as symptoms and the extent to which a history of such labelling has influenced the meaning attached to these experiences and our responses to them. For example, Tavris (1992) notes that,

   ... the changes associated with the menstrual
   cycle are "real," are felt physically, and that
   they provide a fuel for moods and feelings.
   But the content of those moods and wishes
   often depends on a woman's attitudes,
   expectations, situation, personal history, and
   immediate problems or concerns (p. 153).

Tavris (1992) does not suggest that all biomedical premenstrual research should be viewed as adding to this negative discourse.

   Hormone studies are part of an ongoing tidal
   wave of biological research in general, and
   much of this research has benefitted women.
   Women should know that the physiological
   changes of the menstrual cycle vary
   enormously, that normal women range from
   having no pain or discomfort to having
   considerable though temporary pain (p. 132).

However, she cautions against the "over psychologizing of normal biological processes" but also warns against the "dangers of reducing all of our feelings, problems, and conflicts to them" (p. 133).

This caution is pertinent in the context of the diagnosis of PMDD which is reported to affect 2-9% of women and to include severe symptomatology including depression (Freeman & Sondheimer, 2003). The use of serotonin reuptake inhibitors (SSRIs) for treatment of depressive symptoms in women diagnosed with PMDD (for review, see Ackerman and Williams, 2002) appears to be shifting the balance of discourse even further toward the notion of a biological disorder (e.g., defects in the serotonergic system in the brain) in the face of what some consider to be insufficient evidence and without due consideration of alternative views. As Caplan (2004) states, "The problem with PMDD is not the women who report that they have premenstrual emotional problems; the problem is with the diagnosis of PMDD itself" (p. 62). In this respect, it is the diagnosis of PMDD that leads to the medicalization of women's experiences of the menstrual cycle and not the cycle-related changes themselves.