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Is Premenstrual Dysphoric Disorder Really a Disorder?

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Abstract

Premenstrual dysphoric disorder (PMDD) was recently moved to a full category in the DSM-5 (the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders). It also appears set for inclusion as a separate disorder in the ICD-11 (the upcoming edition of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems). This paper argues that PMDD should not be listed in the DSM or the ICD at all, adding to the call to recognise PMDD as a socially constructed disorder. I first present the argument that PMDD pathologises understandable anger/distress and that to do so is potentially dangerous. I then present evidence that PMDD is a culture-bound phenomenon, not a universal one. I also argue that even if (1) medication produces a desired effect, (2) there are biological correlates with premenstrual anger/distress, (3) such anger/distress seems to occur monthly, and (4) women are more likely than men to be diagnosed with affective disorders, none of these factors substantiates that premenstrual anger/distress is caused by a mental disorder. I argue that to assume they do is to ignore the now accepted role that one’s environment and psychology play in illness development, as well as arguments concerning the social construction of mental illness. In doing so, I do not claim that there are no women who experience premenstrual distress or that their distress is not a lived experience. My point is that such distress can be recognised and considered significant without being pathologised and that it is unethical to describe premenstrual anger/distress as a mental disorder. Further, if the credibility of women’s suffering is subject to doubt without a clinical diagnosis, then the way to address this problem is to change societal attitudes towards women’s suffering, not to label women as mentally ill. The paper concludes with some broader implications for women and society of the change in status of PMDD in the DSM-5 as well as a sketch of critical policy suggestions to address these implications.

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Notes

  1. The APA contends that “[r]eplacing ‘disorder’ with ‘dysphoria’ in the diagnostic label is not only more appropriate and consistent with familiar clinical sexology terminology, it also removes the connotation that the patient is ‘disordered’” (American Psychiatric Association 2013b, 2). However, being classified in the Diagnostic and Statistical Manual of Mental Disorders attests to the fact that the American Psychiatric Association considers it a mental illness.

  2. Hysteria was the first mental disorder attributed solely to women and has a 4,000-year history. Different forms of “madness” and different “treatments” were recommended for it, but it was thought to have been caused by a “wandering womb” (Tasca et al. 2012). In the mid- to late 19th-century, hysteria took the form of a psychiatric diagnosis (again only applied to women) whose “symptoms” covered everything from faintness, too much or too little sexual desire, insomnia, fluid retention, irritability, nervousness, muscle spasm, loss of appetite, abdominal heaviness, and trouble-making. Treatment included genital massage to the point of climax by the doctor or with water sprays or vibrators (Maines 2001). With its similarity to PMDD, one could argue that PMDD is simply a modern version of hysteria, with all its misogynist origins.

  3. The serotonin hypothesis states that low levels of serotonin lead to depression and that SSRIs (selective serotonin reuptake inhibitors) alleviate depression by correcting serotonin levels.

  4. African-American slaves who ran away from their owners were said to suffer from a mental illness called drapetomania. It was used as a psychiatric diagnosis in the 19th century but has since been dropped. The analogy here is not made because the nature of the suffering of slaves and women with premenstrual distress is the same, but because both groups at different times were oppressed and their suffering significantly associated with their life situations.

  5. In contrast, a 2008 review of 16 studies of SSRIs and combined oral contraceptives (COCs) for treatment of PMDD found that the percentage of women who did not respond to SSRIs or COCs was actually greater than the percentage of women who did respond (Halbreich 2008). The study found that approximately 40 percent of women diagnosed with PMDD did not respond to SSRIs and that treatment with COCs did not substantially improve that percentage.

  6. According to the United Nations Office of the High Commissioner for Human Rights, intersex is defined as a person “born with sexual anatomy, reproductive organs, and/or chromosome patterns that do not fit the typical definition of male or female” (United Nations Office of the High Commissioner for Human Rights 2013, under “What is intersex?”).

  7. Charivaris were when the people of the village would sing loudly and bang on pots and pans outside the home of an individual/couple who had broken societal norms (e.g., adultery, wife beating, the marriage of an older woman to a young man) to express their disapproval (Warsh 2010).

  8. There is some debate concerning the suitability of GPs in diagnosing and treating psychiatric issues in the first place. For instance, several studies have found that GPs have trouble identifying cases of mental illness (Mitchell, Vaze, and Rao 2009; Schmaling and Hernandez 2005; Jackson, Passamonti, and Kroenke 2007; Cepoiu et al. 2008). As GPs represent the first port of call for psychiatric diagnosis, treatment, and referrals, there is reason to be concerned here, too.

  9. Thanks to one of the anonymous reviewers for this point.

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Acknowledgments

Thanks to Francoise Baylis, the Novel Tech Ethics team at Dalhousie University, and two anonymous reviewers for their helpful feedback on earlier drafts of this paper. This research has been partially funded through Canadian Institute of Health Research (CIHR) grant NNF: 80045 States of Mind: Emerging Issues in Neuroethics.

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Browne, T.K. Is Premenstrual Dysphoric Disorder Really a Disorder?. Bioethical Inquiry 12, 313–330 (2015). https://doi.org/10.1007/s11673-014-9567-7

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