strange case of Dr. Jekyll and Ms. Hyde: How PMS become a cultural phenomenon and a psychiatric disorder, The

The psychiatric version of PMS, initially named late luteal phase dysphoric disorder (LLPPD), first appeared in the DSM-III-R (American Psychiatric Association, 1987). The proposal to include it in the DSM was met with an outpouring of protest from the feminist community in general (e.g., the National Organization for Women), as well as from women's professional organizations (e.g., the Association for Women in Psychology, the Feminist Therapy Institute), and many individual members of the American Psychiatric Association, who objected to the diagnosis on either political or scientific grounds. Despite the protest, LLPPD was included in the DSM, but the association announced that it was only given provisional status and would appear in an appendix with other categories that needed further study. The claim of provisional status was an attempt to reassure the public that psychotherapists would not use the diagnostic label until its scientific validity was well established. However, LLPPD was given a numerical code and a complete list of diagnostic criteria (including cut-off points), which is all that is actually necessary for it to be used. Furthermore, the category was listed not only in the Appendix but also in the main text with the categories that are assumed to be scientifically valid and ready for use by diagnosticians. The DSM-IV subcommittee (Gold et al., 1993), which was charged with the examination of post-DSM-III-R evidence to support LLPPD, reviewed 400 studies and concluded that only a few of them had any bearing on the question of whether there is a mental illness that is sufficiently different from PMS to warrant a diagnostic category and that those few relevant studies were preliminary and had many methodological problems. Nevertheless, after a name change to premenstrual dysphoric disorder, PMDD was listed in the DSM-IV under "depressive disorders," although again the association claimed that its status was still provisional. The inclusion of PMDD under depressive disorders is questionable, despite the word "dysphoric" (which can mean negative feelings of any kind) in its name, because women need not be depressed in order to meet its diagnostic criteria. The criteria can be met primarily by the presence of physical symptoms, which is unusual for an alleged mental illness. The physical symptoms, of course, are some of the same ones included in most descriptions of PMS, and there is no empirical or clinical basis for the choice of those, rather than other, premenstrual symptoms.

The Economics of PMDD

Because there is no established cause or cure for PMS, it has never been clear which experts are best suited to treat women with premenstrual symptoms. Most PMS clinics have been established by gynecologists, endocrinologists, nurse practitioners, or nutritionists. Aside from those followers of Katharina Dalton's or John Lee's progesterone theories, most therapy for PMS has consisted of advice for healthy living (e.g., adequate sleep, good nutrition), stress management (e.g., exercise, coping techniques), and treatment of individual symptoms (e.g., diuretics, anti-depressant, or anti-anxiety medications). Many women, especially those whose symptoms were primarily affective and/or those who had a history of trauma or stressful life circumstances, benefitted from individual or group psychotherapy. With the vast majority of U.S. women of reproductive age convinced that they suffered from PMS at least occasionally, psychiatrists had a powerful economic incentive to develop a psychiatric diagnosis that would legitimize their profession as the experts best suited to assess and treat women's premenstrual complaints (Figert, 1996).