Does PMDD belong in the DSM? challenging the medicalization of women's bodies.
Abstract: Many believe in the existence of a class of symptoms experienced prior to menses menses /men·ses/ (men´sez) the monthly flow of blood from the female genital tract.
n. labelled as Premenstrual Dysphoric Disorder Premenstrual Dysphoric Disorder Definition
Premenstrual dysphoric disorder (PMDD) is a collection of physical and emotional symptoms that occurs 5 to 11 days before a woman's period begins, and goes away once menstruation starts. (PMDD PMDD
premenstrual dysphoric disorder
Premenstrual dysphoric disorder (PMDD)
Premenstrual syndrome (PMS); symptoms including back and abdominal pain, nervousness and irritability, headache, and breast tenderness ), 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 medicalization Social medicine A term for the erroneous tendency by society–often perpetuated by health professionals–to view effects of socioeconomic disadvantage as purely medical issues of women's experiences of sexuality.
Key words: Premenstrual Dysphoric Disorder (PMDD) Women's bodies DSM 1. DSM - Data Structure Manager.
An object-oriented language by J.E. Rumbaugh and M.E. Loomis of GE, similar to C++. It is used in implementation of CAD/CAE software. DSM is written in DSM and C and produces C as output. 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 The Society for the Scientific Study of Sexuality, formed in 1957, claims to be "the oldest organization of professionals interested in the study of sexuality in the United States." It claims to have some 900 members and has a quarterly newsletter, Sexual Science. in Montreal, Quebec, Canada.
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 premenstrual /pre·men·stru·al/ (pre-men´stroo-al) occurring before menstruation.
Of or occurring in the period just before menstruation. 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 symptomatology /symp·to·ma·tol·o·gy/ (simp?to-mah-tol´ah-je)
1. the branch of medicine dealing with symptoms.
2. the combined symptoms of a disease.
n. 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 menstrual cycle
The recurring cycle of physiological changes in the uterus, ovaries, and other sexual structures that occur from the beginning of one menstrual period through the beginning of the next. 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 bi·o·med·i·cal
1. Of or relating to biomedicine.
2. Of, relating to, or involving biological, medical, and physical sciences. 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 reuptake /re·up·take/ (re-up´tak) reabsorption of a previously secreted substance.
n. 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 se·ro·to·ner·gic or se·ro·to·ni·ner·gic
Activated by or capable of liberating serotonin, especially in transmitting nerve impulses.
containing or activated by serotonin. system in the brain) in the face of what some consider to be insufficient evidence insufficient evidence n. a finding (decision) by a trial judge or an appeals court that the prosecution in a criminal case or a plaintiff in a lawsuit has not proved the case because the attorney did not present enough convincing 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.
Since this paper reviews literature that shares Caplan's concerns, it is important to define what medicalization means in this context. Medicalization occurs when a social situation or personal experience is made into a medical problem that requires the attention of medical experts (Conrad & Schneider, 1980). Tiefer (2002) states that,
The involvement of doctors, diagnostic tests, medical language, surgeries and drugs has mystified women's experiences of life events such as menstruation, menopause, pregnancy and childbirth and not improved them as much as an uncritical view of modern medicine would have us believe (p. 128).
The effect has been that women's subjective experiences of menstrual cycle-related changes have been marginalized or negated (Ussher, 2002). The debate surrounding the clinical categorization of menstrual cycle-related changes as PMDD is the most recent aspect of a continuing discourse on this issue.
A HISTORY OF RESEARCH ON PREMENSTRUAL DIAGNOSTIC CATEGORIES
The first mention of menstrual cycle-related changes in the medical literature is attributed to Frank (1931) who used the term "premenstrual tension premenstrual tension n (MED) → tensión f premenstrual
premenstrual tension n → irritabilité f avant les règles
" to describe a constellation of menstrual cycle-related changes experienced by women during the second half of the menstrual cycle. Dalton and Greene (1953) coined the term "premenstrual syndrome premenstrual syndrome (PMS), any of various symptoms experienced by women of childbearing age in the days immediately preceding menstruation. It is most common in women in their twenties and thirties. ," initiating what Chrisler and Caplan (2002) characterize as a major step forward in the medicalization of the menstrual cycle. It was not until the 1980s that a disorder based on menstrual cycle-related changes appeared in the DSM. Late Luteal Phase Dysphoric Disorder late luteal phase dysphoric disorder Premenstrual syndrome, see there, aka premenstrual dysphoric disorder (LLPDD LLPDD Late Luteal Phase Dysphoric Disorder ) was included as an "Unspecified Mental Disorder mental disorder
Any illness with a psychological origin, manifested either in symptoms of emotional distress or in abnormal behaviour. Most mental disorders can be broadly classified as either psychoses or neuroses (see neurosis; psychosis). Psychoses (e.g. " presented for further study in the DSM-III-R in 1987. LLPDD was not a replacement for PMS (Pantone Matching System) A color matching system that has a unique number assigned to more than 500 different colors and shades. This standard for the printing industry has been built into many graphics and desktop publishing programs to ensure color accuracy. but a new category that was characterized by recurrent dysphoria dysphoria /dys·pho·ria/ (-for´e-ah) [Gr.] disquiet; restlessness; malaise.dysphoret´icdysphor´ic
gender dysphoria in synchrony synchrony /syn·chro·ny/ (-krah-ne) the occurrence of two events simultaneously or with a fixed time interval between them.
atrioventricular (AV) synchrony with the luteal phase of the menstrual cycle. Symptoms were similar to those of PMS but represented a more severe and debilitating de·bil·i·tat·ing
Causing a loss of strength or energy.
Weakening, or reducing the strength of.
Mentioned in: Stress Reduction form with a smaller percentage of women being covered by the category (Fink, 1987).
The LLPDD category was met with controversy (Caplan, 2004). Although some researchers felt that the category of LLPDD provided a more standard definition and would facilitate better understanding of premenstrual symptoms as a single disorder, others felt that the category might allow for misinterpretations and misuse (Rodin, 1992; Ussher, 1996). Indeed, in response to pressure from women's groups (i.e., Women in Psychology, the Association of Women Psychiatrists, APA (All Points Addressable) Refers to an array (bitmapped screen, matrix, etc.) in which all bits or cells can be individually manipulated.
APA - Application Portability Architecture Division 35 and, the Feminist Therapy feminist therapy Psychiatry Psychotherapy that incorporates feminist/women's rights–I am woman, HEAR ME ROAR–philosophy into therapeutic goals; FT attempts to empower ♀ and battle societal barriers to self-actualization Institute), the American Psychological Association, opposed the inclusion of the LLPDD category in the DSM-III-R (Ussher, 1996). As a result, the LLPDD category was placed in the appendix "for categories requiring further study" (Caplan, 2004). This background to LLPDD reflects a strong tradition of questioning premenstrual disorders (Caplan, McGurdy & Gans, 1992; Chrisler & Caplan, 2002; Endicott, 2000; Figert, 1996; Severino, 1996). The imminent release of the DSM-V is likely to see continuation of the debate over premenstrual diagnostic categories.
LLPDD remained in the DSM until it was replaced by PMDD in the DSM-IV, also as a category for further study, in 1994. Although the name for the diagnostic category changed from LLPDD to PMDD in the DSM-IV, there was little difference between the two categories. The minor changes to the category included: changing sections, reordering the symptoms and adding a new symptom (a subjective sense of being overwhelmed or out of control). Although some controversy existed over the classification of PMDD as a mental disorder, as with LLPDD in the DSM-III-R, the main debate over PMDD focused on the symptoms and how these symptoms would determine location of PMDD in the manual.
Research revealed that the most frequently reported symptom of LLPDD was depression; therefore, work group members felt it should top the list of symptoms for diagnosing PMDD (Severino, 1996). This emphasis on depression created controversy within work group members when determining PMDD's placement in the DSM. Some of the work group members felt that it should remain in the same section as was LLPDD in the DSM-R-III, while others felt it should be placed in the section of "Depressive Disorders not otherwise specified" (Frank & Severino, 1995), thereby linking menstruation menstruation, periodic flow of blood and cells from the lining of the uterus in humans and most other primates, occurring about every 28 days in women. Menstruation commences at puberty (usually between age 10 and 17). with depression. In the end, the category of PMDD was placed in the Appendix B "Criteria and Axes Provided for Further Study."
THE CHALLENGES IN PREMENSTRUAL-RELATED RESEARCH
While the categories of LLPDD and PMDD have been identified as advances in the provision of "operationally defined diagnostic criteria for PMS" (Freeman & Sondheimer, 2003, p. 30), the history of research in this area reflects difficulty with categorization and with precise identification of definitive symptoms for different categories (McFarlane & Williams, 1990). This section cites research published before the LLPDD category appeared, after LLPDD but before PMDD, and post-PMDD. Distinctions will be drawn accordingly although the continuity of earlier challenges surrounding PMS with current debates about PMDD will be apparent. Premenstrual-related research has been characterized by an inability to find significant biological differences in women who experience premenstrual symptoms that distinguish them from women who do not. Richardson (1995) points out that no consistent endocrinological pattern has been established for women presenting with PMS that can differentiate them. Alberts and Alberts (1990) made a similar claim in relation to possible biological factors associated with PMS.
Researchers seeking psychological explanations for PMS have had similar difficulty in distinguishing between women with and without symptoms (Rubinow & Roy-Byrne, 1984). Olasov & Jackson (1987) reported a general inability to find cyclical changes in affect associated with the menstrual cycle and Schnurr, Hurt and Stout (1994) found no significant psychological differences between women with and without LLPDD. Much of the psychological research done on women with premenstrual symptoms is correlational, thereby making it impossible to determine whether or not the psychological symptoms are causes or consequences of the menstrual cycle-related changes. However, causality has often been assumed when only a correlation exists (Caplan et al., 1992). Although significant correlational findings exist between some psychological disorders and premenstrual disorders, a number of researchers have pointed out the methodological limitations of such studies (Caplan et al., 1992; Pearlstein, Frank, Rivera-Yovar, Thoft, Jacobs, & Mieczkowski, 1990). Although some findings suggest that women who experience PMS may have higher rates of affective disorders, these studies do not help to clearly differentiate women who experience PMS from those who do not (Ussher, 1996). Depression is a significant symptom in the current PMDD diagnostic category, but here too the mixed benefits of antidepressant treatment raise questions. In their review of treatment options, Ackermann & Williams (2002) conclude: "There are considerable areas of uncertainty regarding all aspects of minor depression and PMDD. The most pressing needs are for better studies of the natural history and validated clinical predictors of poor outcome" (p. 299).
PMDD AND THE DSM PROCESS FOR DEFINING PSYCHIATRIC DISORDERS
In order for any mental disorder to be included in the DSM it must go through a process of definition that includes: peer reviews, conferences and workshops, semiannual newsletters, and communication with the American Psychiatric Association (APA) and non-APA affiliated organizations interested in DSM development (APA, 2000). Despite the expectation of an "extensive empirical foundation" (APA 2004, p. xxiii) for DSM-IV diagnostic categories, some authors have been critical of the DSM process (Caplan, 1991) and, according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. Caplan (2004), even the DSM's own subcommittee on LLPDD concluded that "(1) very little research supported the existence of a premenstrual illness [that could be separated from the physical signs associated with PMS]; and (2) the most relevant research was preliminary and methodologically flawed" (Caplan, 2004, p. 58). Quoting from their personal communication with a member of the PMDD Work Group, Frank and Severino (1995) wrote: "... we have taken a vague diagnosis, validated it by instruments designed to find it and then announced that this population exists" (p. 25).
EVALUATING THE EMPIRICAL FOUNDATION OF PMD (Polarization Mode Dispersion) The type of dispersion that occurs in singlemode fiber due to a lack of perfect symmetry in the fiber and from external pressures on the cable. Light travels over singlemode fiber in two polarization states.
Some authors have challenged inclusion of LLPDD in the DSM, even as an unspecified disorder requiring further study, because "... few epidemiological studies have documented true incidence and prevalence of LLPDD in the general population" (Blumenthal & Nadelson, 1988, p. 471), Gehlert, Chang & Hartlage (1999) voiced similar concerns about the empirical basis for PMDD: "Factor analysis of the group of women who met the diagnosis of PMDD was not possible. Few women meet the diagnosis of PMDD when the criteria set forth in the DSM-IV are adhered to strictly" (p. 78).
Despite extensive research and many clinical reports, "proof" of menstrual cycle-related condition that could be defined as an illness has not been provided (Caplan, 2004). As noted by Halbriech (1993) in a review of earlier literature,
It is disheartening that 40 years after the panel And 60 years after Frank's, 1931, pioneering reports on PMT, literally dozens of papers include statements like "the etiology of Premenstrual syndrome, PMS, is still obscure" (p. 25).
While there are many conditions, accepted as such, for which the aetiology aetiology
see etiology. is not known, it may also be, as Walker (1992) suggests, that problems of documentation arise
... because researchers and clinicians are attempting to define and study a phenomenon which does not exist. The lack of comparability between studies, which is attributed to methodological factors, could also be attributed to an attempt to impose a hypothetical syndrome on behavioral and emotional changes which are not related to reproductive functioning (p.75).
As noted previously, this is not to say that women do not experience difficult symptoms associated with their menstrual cycles, but rather that the diagnosis has been and remains in question (Caplan et al., 1992; Caplan, 2004).
PMDD DIAGNOSTIC CRITERIA
The DSM criteria for diagnosing PMDD are intended to serve as a template to conduct further studies by creating a unified research base from which to understand the disorder. Contrary to this, Breaux, Hartlage and Gelhert (2000) point out that very few studies have applied all of the diagnostic criteria. Two of the diagnostic criteria that deserve particular attention are comorbidity and the measurement of impairment of functioning.
Comorbidity. Diagnosing PMDD is complicated when women who present with PMDD also have a history of mood, personality and anxiety disorders, substance abuse and exacerbated symptoms of ongoing mood disorders premenstrually (Breaux et al., 2000; Steiner & Born, 2000). Although the PMDD criteria explicitly state that PMDD can be diagnosed only when other disorders are not present, it is unclear how often PMDD occurs alone. For example, Steiner and Born (2000) estimated PMDD to range from 3-8% of women, but none of the literature reviewed clearly specified rates of Pure-Pure PMDD (no past or present psychiatric disorders) or Pure PMDD (no current psychiatric disorder, but history of psychiatric disorders). However, Wittchen, Becker, Lieb & Krause (2002) found high rates of comorbidity between PMDD and other mental disorders. The authors point out that their sample of young adults (15- to 24-year-olds followed for 4 years) missed a second group over age 35 thought to have high incidence of PMDD based on previous literature.
Hartlage and Gehlert (2001) reported, "Differentiating PMDD from premenstrual exacerbation of other disorders has proven to be difficult methodologically" (p. 250). This statement suggests that it may be difficult to conduct research on PMDD without confounding the results with the effects of other mood disorders. Further complicating the issue, Halbriech and Endicott (1987) report that prospective ratings of premenstrual symptoms correlated better with past mood disturbance than with PMS. McMillan and Pihl (1987) also found that women who sought treatment for PMS often had premenstrual exacerbation of depression or dysthymia dysthymia /dys·thy·mia/ (-thi´me-ah) dysthymic disorder.
A mood disorder characterized by despondency or mild depression. and not PMS. Moreover, many of the symptoms of PMDD overlap with those of PMS (Chrisler & Caplan, 2002), despite the fact that the DSM states that PMDD should be distinguished from PMS (APA, 2000).
Impairment of Functioning. The DSM states that in order for PMDD to be diagnosed, there must be a marked interference in a woman' s regular behaviour including the areas of work, school, usual social activities and relationships. This is known as Criterion B for diagnosis. However, few studies have looked at the impact of PMDD symptoms on functioning (Freeman & Halbreich, 1998) and "Few investigators have reported evidence of impaired functioning in women diagnosed with PMDD. Instead, impairment is assumed when symptoms are rated as severe" (Hartlage & Gehlert, 2001, p. 249). This assumption of impairment makes the diagnostic criteria arbitrary. It is based upon the researchers' standard as opposed to the woman's. Often researchers do not state how they measured or defined impairment of functioning in areas of work, school, usual social activities and relationships for the women in the study. For example, Gehlert, Chang and Hartlage (1999) state that they included only symptoms that occurred on days when functioning was impaired, but they do not state how they measured impaired functioning. In an earlier report dealing with PMS, MacFarlane MacFarlane or Macfarlane is a surname shared by:
When impairment in functioning is measured, a change in symptoms from the luteal score to follicular fol·lic·u·lar
1. Relating to, having, or resembling a follicle or follicles.
2. Affecting or growing out of a follicle or follicles. score is sometimes used as a measure of functioning. According to Steiner and Born (2000), a within-cycle change in symptoms is Calculated by subtracting follicular scores from luteal scores, dividing by the luteal score and then multiplying by 100 to get a percentage change rating. A change of 50% from follicular to luteal phase scores is suggested for diagnosis. This system of diagnosis is unsatisfactory. The lack of agreed-upon measures for PMDD is controversial (Rodin, 1992). Currently, there are no questionnaires that measure levels of psychosocial functioning that are specific to PMDD (Freeman & Halbreich, 1998). The diagnosing of PMDD is therefore complicated by the lack of objective diagnostic tests and consensus among investigators/ clinicians concerning the reliability of instruments for confirming PMDD prospectively (Steiner & Born, 2000). Although the Moos Menstrual Distress Questionnaire (MDQ MDQ Maximum Daily Quantity
MDQ Mar Del Plata, Buenos Aires, Argentina (Airport Code)
MDQ Mood Disorder Questionnaire
MDQ Market Driven Quality
MDQ Minimum Detectable Quantity ) is often used, there remain problems with the test due to its use of only closed ended questions (McFarlane & Williams, 1990) as well as its previously reported lack of reliability or external consistency data (Parlee, 1973).
The 50% indiscriminate cut-off level also calls into question the usefulness of the PMDD category for women presenting with a range of symptoms. Although this may be a useful tool for identifying large groups of women quickly for research purposes, it represents an arbitrary cut-off point that may not be sensitive enough to distinguish the needs of an individual woman (MacFarlane & Williams, 1990). Even if a 50% cut-off level is not applied in a clinical setting, the process of diagnosing women with PMDD based on marked change in functioning is highly subjective. As Caplan (2004) points out, the subjective nature of the diagnosing of PMDD is in conflict with the APA's descriptions of the DSM's "... impressive record of the manual in ensuring readability and uniformity among therapists in their decisions about who meets the criteria for PMDD" (p. 59).
THE SOCIAL CONSTRUCTION OF PMDD
The preceding review of research on menstrual cycle-related changes highlight methodological questions about the PMDD diagnosis and about its continuing placement in the DSM. The following section examines the social construction of PMDD within the context of medical discourse on PMDD, the associated interests of pharmaceutical companies in creating drugs to treat PMDD, and the influence of these factors on women's experiences of their bodies. We suggest that PMDD is a socially constructed disorder rather than a psychiatric disorder.
THE CONSTRUCTION OF A MEDICAL DISCOURSE ON PMDD
The history of PMDD developed within a medical context of women's reproductive health Within the framework of WHO's definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene (Nicolson, 1995; Rodin, 1992). As discussed earlier, this has led to the medicalization of women's experiences of menstrual cycle-related changes. Juxtaposed to this, a strong feminist critique exists on the medical understanding of menstrual cycle-related changes. As Rodin (1992) states in a report on the social construction of PMS:
The fact that the medical establishment treats PMS as a legitimate disease category (by applying for research funds, proceeding with research, treating patients, and maintaining PMS clinics) despite the lack of an agreed upon definition and contradictory research findings, suggests that shared cultural knowledge, as opposed to scientific facts, informs researcher understanding of what constitutes PMS (p.52).
Oudshoorn (1994) suggests that much of what is known of the female body are social constructs defined through scientific research. She argues that scientific facts are created in a social context and become embedded in popular beliefs. Nevertheless, health researchers continue to minimize the role of social influences on their work (Caplan et al., 1992) and proponents of the DSM overlook the fact that psychiatric disorders are cultural constructs (Chrisler & Caplan, 2002).
Often it is assumed, from the use of predominant research paradigms, that PMDD is a valid and well-established category of mental disorder. Our culture bases much of its belief system on the quest for Verb 1. quest for - go in search of or hunt for; "pursue a hobby"
quest after, go after, pursue
look for, search, seek - try to locate or discover, or try to establish the existence of; "The police are searching for clues"; "They are searching for the knowledge through scientific, positivist pos·i·tiv·ism
a. A doctrine contending that sense perceptions are the only admissible basis of human knowledge and precise thought.
b. , explorations making it hard to question scientific "facts." This use of positivist research methods has dominated premenstrual research and has lead to the existence of PMDD as a "taken-for-granted-fact" (Ussher, 1996). But to the extent that scientific knowledge is constructed, there exists a reciprocal relationship between scientific and social beliefs (Oudshoom, 1994). Rodin (1992) upholds this view when she states, "... PMS is a recreation of tacit cultural knowledge about the effect of the reproduction system on women's behaviors as value free scientific fact" (p. 50).
The relation between scientific and social beliefs is strengthened when discoveries about norms and disorders become news stories and are incorporated into common sense beliefs about the world and a person's own relationship to psychological norms (Nicolson, 1995). Cosgrove and Riddle (in press) speak to this relationship when they state, "In print ads in all of the major women's magazines this is a list of women's magazines, magazines that have been published primarily for a readership of women. Currently published
THE ROLE OF PHARMACEUTICALS
Tavris (1992) points out that it was not until the media started reporting that PMS was costing billions of dollars per year in lost productivity that it became known as a "disorder" or "disease". With this label came a thriving industry focused on a cure. The support of psychiatric research by pharmaceutical companies enables clinical research in the area of PMDD and the development of PMDD validates the use of pharmaceutical treatments in the management ofpremenstrual symptoms. By identifying PMDD as a psychiatric disorder, a pathological condition has been constructed which demands clinical intervention and treatment. According to Caplan (2004), a strong relationship has thus been developed between the legitimacy of PMDD as a mental disorder, the prescription and marketing of fluoxetine fluoxetine /flu·ox·e·tine/ (floo-ok´se-ten) a selective serotonin reuptake inhibitor used as the hydrochloride salt in the treatment of depression, obsessive-compulsive disorder, bulimia nervosa, and premenstrual dysphoric disorder. for treatment, and social beliefs about the menstrual cycle. Caplan (2002) notes that the only psychiatric therapy for PMDD is fluoxetine and women have been asking for the drug they have seen advertised in the media to treat PMDD.
When PMDD was moved into the "Depressive Disorders not Otherwise Specified" section of the DSM-IV the editors of the DSM reinforced the view that PMDD is depression (Frank & Severino, 1995). The fact that fluoxetine is a treatment for depression, and now the only approved treatment for PMDD, further reifies this connection. Gold (1994) suggests that this connection could provide further clarification of the PMDD diagnostic entity: "It is hoped the results of studies demonstrating the effectiveness of antidepressant medications will assist researchers in their search for the etiology underlying premenstrual complaints and elucidate why some women note premenstrual changes and others become ill" (p. 1025). If the PMDD-depression connection is made, is it not possible that fluoxetine is treating depressed women rather than women with PMDD? Indeed Caplan (2004) argues
Certainly, if fluoxetine is given to any group of depressed or upset people, some will feel better. But that reveals nothing about the causes of their upset and, in this case [PMDD], it doesn't provide that the upset is related to menstrual cycle-related changes (p. 61).
The linking of PMDD with depression, while legitimizing of the use of fluoxetine to relieve symptoms, provides little information on the nature of the disorder and raises the problem of comorbidity discussed earlier in the paper.
DEFINING WOMEN'S EXPERIENCES OF PMDD
Research in the area of menstrual cycle-related changes has had a major influence on the social construction of premenstrual diagnostic categories (Johnson, 1987). It can be argued that research has primed women and society, for the last 70 years, to believe in and expect menstrual complications. Indeed, research has found that women's perceptions of what happens in the premenstruum becomes more pathological when they are introduced to the diagnostic definition of PMDD (Hash & Chrisler, 1997). This link is exemplified in research that highlights and recreates social expectations of premenstrual experiences. For example, pharmaceutical companies sponsor research conferences and educational seminars on premenstrual symptoms, media coverage follows, and women are reinforced in their perceptions of their condition and in use of medications as a treatment (Tavris, 1992).
The category of PMDD can be thought of as an extension of long-held social beliefs that place an emphasis on abnormality and discontent between women and their bodies (Ussher, 1996). If a diagnostic category only applies to one gender and is based in gender stereotypes, there is a possibility that it will lead to discrimination and bias (Chrisler & Nash, 1997). Indeed, Blake (1995) states, "The media present PMS as a medical label explaining almost any fluctuating disturbance of a woman's well being in the reproductive years. This labelling is influenced by cultural assumptions about the role and behavior of women ..." (p. 168). When the language surrounding menstrual cycle-related changes is pathologized, it becomes difficult for women to explain their experiences outside of a medical discourse. The biomedical model The biomedical model of medicine, has been around since the mid-nineteenth century as the predominant model used by physicians in the diagnosis of disease.
This model focuses on the physical processes, such as the pathology, the biochemistry and the physiology of a disease. validates these feelings, taking women seriously because of their "medical condition" and this can be empowering (Tavris, 1992).
McFarlane, Martin and Williams (1988) suggest that negative bias relating to relating to relate prep → concernant
relating to relate prep → bezüglich +gen, mit Bezug auf +acc women's menstrual-cycle related changes is subtle and complex. They explain
It seems unlikely that women are complete dupes of socially-produced expectations. Perhaps most women do not usually Experience mood problems, but occasionally, if a number of other factors converge (and those factors may vary for individual women), they feel or behave in ways that are out of character (p. 218).
They further suggest that when negative moods coincide with the premenstruum, even if this happens occasionally, this would be sufficient to maintain the belief in PMS because people selectively attend to information congruent with their stereotypes. Indeed, Chrisler and Johnston-Robledo (2002) suggest that research should begin to look at the stresses women experience in their lives as possible contributors to experiences of menstrual cycle-related changes.
THE LINK BETWEEN PMDD ANN THE MEDICALIZATION OF FEMALE SEXUALITY
It can be argued that the inclusion of PMDD in the DSM contributes to the further medical classification of women's sexuality. In opposition to this, the medicalization of women's experiences of their sexuality is beginning to be challenged and the search for a new understanding of women's sexuality has begun to develop. This alternate view point provides an important forum for debate over the construction of women's experiences of their menstrual bodies. A full issue of Women and Therapy: A Feminist Quarterly was devoted to "A New View of Women's Sexual Problems" (2001), which challenges the current medical view of women's sexuality. The authors of the title article state, "We believe that a fundamental barrier to understanding women's sexuality is the medical classification scheme in current use, developed by the American Psychiatric Association [APA] for its Diagnostic and Statistical Manual of Disorders (DSM) ..." (The Working Group For A New View of Women's Sexual Problems, 2001, p. 2).
Experiences of menstrual cycle-related changes have been linked to female sexuality and its expression through sexual scripts. Gagnon (1990) states, "What has been confused in this debate [on gender and sexual behavior sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life. ] is the difference between reproductive conduct, gender conduct and sexual conduct" (pp. 5). How young women are taught about menstruation influences not only their beliefs about menstruation but also how they learn about other aspects of their sexuality (Beausang & Razor, 2000). Unfortunately, many young girls are influenced by cultural beliefs that menstruation is associated with negative physical effect, emotional instability and negative thoughts (Koff & Rierdan, 1995). These influences can be powerful given the fact that discussions on some sexual areas, including menstruation, are still taboo in North American North American
named after North America.
North American blastomycosis
see North American blastomycosis.
North American cattle tick
see boophilusannulatus. culture (Beausang & Razor, 2000) leaving young women unable to question these beliefs. A society that helps young girls to get a basic understanding of their physical functioning and offers them information they need to make healthy decisions about their sexuality, will foster their ability to own their sexual/reproductive experiences.
If young women are not able to own their own sexual/ reproductive experiences, who does? Unfortunately, this lack of personal ownership and accompanying sense of disconnection is exacerbated by the medical discourse surrounding women's bodily experiences leading to the medical ownership of women's experiences and ultimately the medicalization of these experiences (Kleinplatz, 2001). One example of medicalization leading to discontent is seen in the possible sexual side effects Side effects
Effects of a proposed project on other parts of the firm. experienced by women who take SSRIs for treatment of PMDD. Steiner (2000) lists the most troublesome side effects of SSRI SSRI selective serotonin reuptake inhibitor.
Selective serotonin reuptake inhibitor; a class of drugs that inhibit the reuptake of serotonin in the central nervous system, used to treat depression and other treatment, including delayed or absent orgasm.
The link between menstrual cycle-related changes and sexuality is not entirely negative. Stewart (1989) states that sexual arousal sexual arousal Horny/horniness, randy/randiness Physiology A state of sexual 'yellow alert' which has a mental component–↑ cortical responsiveness to sensory stimulation, and physical component–↑ penile sensitivity, neural response to stimuli, , pleasure and orgasm are high during the premenstrual period, and that sexual responsiveness actually increases during ovulation ovulation /ovu·la·tion/ (ov?u-la´shun) the discharge of a secondary oocyte from a graafian follicle.ov´ulatory
The discharge of an ovum from the ovary. and during the premenstruum. Halbriech (1993) mentions that there can be an increase in energy prior to menstruation. Ussher (1996) states that cultural restrictions on the expression of female sexuality have been cited as a possible cause of adverse menstrual cycle-related changes. The positive aspects of menstrual cycle-related changes warrant more research attention as one aspect of a movement toward comprehending the female body as cyclical, fluctuating and normal and away from research that further medicalizes women's experiences of their bodies.
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Correspondence concerning this paper should be addressed to Alia Offman, Ph. D., 97 Pigeon Terrace, Ottawa, ON K1V 9H6.
Carleton University Carleton University, at Ottawa, Ont., Canada; nonsectarian; coeducational; founded 1942 as Carleton College. It achieved university status in 1957. It has faculties of arts, social sciences, science, engineering, and graduate studies, as well as the Centre for
Peggy J. Kleinplatz
University of Ottawa