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The billion-dollar debate over premenstrual syndrome heats up

The debate centers on what to do about so-called Premenstrual Dysphoric Disorder (PMDD).

Despite the lack of good studies on this topic, many women insist that Premenstrual Dysphoric Disorder is a real disorder.

Salon magazine ran an interesting piece  last weekend that describes yet another of the contentious debates involving the fifth revision (currently underway) of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM), psychiatry’s official bible for identifying and diagnosing mental illnesses.

This debate centers on what to do about so-called Premenstrual Dysphoric Disorder (PMDD).

As with so many of the other battles involving the DSM, billions of dollars are at stake.

“Since 1987,” writes Salon contributor Natasha Vargas-Cooper, “PMDD has lingered in the ghetto of the DSM: the appendix pages where proposed diagnoses are deemed in need of ‘further study.’ But right now, it appears as though PMDD will ascend in the ranks from a hypothetical ailment to illness to become a full-blown depressive disorder; taking a place alongside Major Depression and Bi-Polar Depression. The upgrade in status — which will be determined in the next several months — has become the latest flash point in an ongoing controversy between psychiatrists, academics, activists, pharmaceutical giants and women who insist they suffer from the disease, as well as doctors and women who refute the existence of PMDD all together.”

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And what exactly is PMDD? That definition, as Vargas-Cooper notes in her article, is at the heart of the controversy:

The current criteria being proposed for PMDD includes mood swings, marked irritability or anger or increased interpersonal conflicts, feelings of hopelessness, marked anxiety and decreased interest in usual activities. Also: a subjective sense of difficulty in concentration, lethargy, a marked change in appetite, insomnia, a subjective sense of being overwhelmed and other physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” weight gain.

Those physical ailments are the most controversial of the new proposed criteria. Some argue this would shove physiological or gynecological issues into the psychiatric realm, scrambling a mind and body separation that keeps mental health issues discreet from physiological ones. If the newest proposal makes it into the DSM a woman will need to have had five of the symptoms during the past year, including the physical ones.

Pharmaceutical companies are eager for the DSM to update PMDD to a depressive disorder so they can sell more medications for it.

And that has PMDD skeptics fuming. They argue, says Vargas-Cooper, “that this debate is about selling drugs, not science”:

“PMDD is an invented ‘mental illness,’” argues Dr. Paula J. Caplan, a research associate at the Du Bois Institute at Harvard University, and author of “They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal.”

Caplan, who chaired a DSM work committee during its fourth revision, said she was appalled not only by the aggressive lobbying done by Eli Lilly [maker of the PMDD drug Sarafem, which is essentially Prozac (fluoxetine)] to push PMDD through the committee, but also how much hard cash the company put into the research and trial groups. Caplan and others contend that PMDD has too much overlap with other mood disorders, such as depression. Creating a new diagnosis, they fear, would mostly benefit big pharma and not suffering women. Caplan argues that women “learn to pathologize themselves, often ignoring the real causes of their upset,” such as a failing relationship, a history of abuse or depression.

Additionally, critics of PMDD believe that the diagnosis is just another way to medicalize the female experience. PMDD, it’s argued, plays into ancient notions of women as overly emotional and unpredictable and needing to be contained by forces other than themselves. From puberty to PMS [premenstrual syndrome] to PMDD to pregnancy to postpartum depression to menopause, opponents argue that throughout history there has been a one-sided conversation between doctors and women about the female body. …

Caplan argues that women who self-diagnosis themselves as having bad PMS or PMDD are suffering from depression for internal or external reasons, not because their menstrual cycle is wonky.

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In Europe, as Vargas-Cooper points out, public health officials decided “there was not enough research to establish PMDD as a medical diagnosis” and told Eli Lilly that it couldn’t put PMDD on the list of indications for fluoxetine.

But despite the lack of good studies on this topic, many women insist that PMDD is a real disorder.

“Those in favor of PMDD being absorbed into the mood-disorder section of the DSM argue that the mood swings and irritability and depressive symptoms amount to a separate diagnosis from regular depression because it is linked to the menstrual cycle and only appears days before the uterine lining is shed and disappears days afterward,” writes Vargas-Cooper.

“Historically,” she adds, “differences in the sexes have been used as a tool of oppression, there is no doubt of that. However, what if there is a difference between men and women when it comes to the way hormones affect their moods and bodies? Even if women are the only ones who can get diagnosed with PMDD, even if people call it sexist, does that make it less real?”

No, it wouldn’t make it less real. But just saying PMDD exists doesn’t make it real, either.

Right now, the leading theory about what causes PMDD is the same theory that’s being discredited as the cause of depression: a serotonin deficiency.

Before we start telling up to 8 percent of women that they should be taking PMDD medications (essentially anti-depressants) every month, let’s get some solid scientific evidence that PMDD as a psychological condition exists.

“There is no evidence [that PMDD exists], though people have to find such evidence,” Caplan has said elsewhere. “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 added. “When a woman is anything but that, she and her family are quick to think something is wrong.”

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You can read Vargas-Cooper’s article on the Salon website.