MEDELLIN, Columbia – After years of debate and controversy, premenstrual dysphoric disorder could be closer to getting recognized as a full category of mood disorder in the DSM-5, a leading researcher in women’s mental health predicts.
Dr. Meir Steiner, who served as an adviser to the DSM-5’s Mood Disorders Work Group dealing with PMDD, sees the possible repositioning of PMDD within the revised manual as something of a triumph.
The new criteria for PMDD, a severe variant of premenstrual syndrome estimated to affect up to 5% of premenopausal women (Am. J. Psychiatry 2012;AiA:1-11), differ somewhat from those described in the DSM-IV. The order of symptoms likely will be shuffled, with mood swings and irritability now at the top of the list, where "markedly depressed mood" had topped the DSM-IV’s, Dr. Steiner said at the International Congress of Medicine and Women’s Mental Health.
PMDD first appeared as "late luteal phase dysphoric disorder" in Appendix A of the DSM-III-R in 1987, over the objections of some women’s groups and clinicians, who viewed its inclusion as pathologizing the menstrual cycle. The name of the disorder was changed to PMDD for the DSM-IV. Debate over PMDD intensified in 2000, when the Food and Drug Administration approved the rebranding of the selective serotonin reuptake inhibitor (SSRI) fluoxetine under the marketing name Sarafem to treat PMDD. Critics saw in the new indication an example of "disease mongering" benefiting pharmaceutical manufacturers (PLoS Med. 2006;3:e198).
Proponents of PMDD such as Dr. Steiner counter that the menstrual fluctuations in physical and emotional symptoms most women experience would not be considered pathological under the DSM-IV or DSM-5 diagnostic criteria, which require that 5 or more of 11 listed symptoms occur in most menstrual cycles during the luteal phase, begin to improve within a few days after the onset of menses, and are minimal or absent in the week post menses.
Moreover, they say, the criteria can prevent affected women from being incorrectly diagnosed with a depressive or personality disorder.
In the past decade, the debate on PMDD has calmed considerably, thanks in part to evidence from randomized controlled trials using the DSM-IV criteria for PMDD. The European Medicines Agency, which long refused to validate the indication, changed its position in 2010, opening up the possibility for PMDD treatments to be tested and marketed in the European Union.
Research has shown that PMDD can be treated with oral contraceptives containing drospirenone and ovarian suppression with GnRH agonists. It can also be treated with a wide range of SSRIs, which a meta-analysis of 29 randomized controlled trials involving a total of 2,964 patients showed to be effective in alleviating the mood and physical symptoms associated with PMDD (Obstet. Gynecol. 2008;111:1175-82). Unlike in depression, "you can actually accomplish improvement with a few days of treatment" with SSRIs, allowing for intermittent treatment, said Dr. Steiner. He served on an advisory body for the DSM-IV, where PMDD is not listed as a diagnostic category but in an appendix of criteria warranting further study.
In a separate talk at the congress, Dr. Steiner described other women-specific changes that he hopes to see in the DSM-5. He said the DSM-5 should include a category for childbirth-related posttraumatic stress disorder, in which the act of birthing is the triggering trauma.
"There is also no specific category for perinatal bereavement. This should be corrected," said Dr. Steiner, professor emeritus in the departments of psychiatry and behavioural neurosciences and obstetrics and gynecology at McMaster University in Hamilton, Ont.
Additionally, Dr. Steiner said that he would like to see changes to the diagnostic criteria for postpartum depression, and that the DSM-5 should extend the diagnostic window for its onset to 6 months post partum. And finally, he said, the DSM-5 also should identify depression onset during perimenopause as something distinct from depression in other periods of life. "We would like to identify perimenopause as a new window of vulnerability and risk," he said.
Despite his optimism about PMDD and the DSM-5, Dr. Steiner remained critical of the diagnostic manual as a whole, describing the DSM-IV as a "failure" for women. "Right now we’re looking at how we can prevent another failure," he said.
Dr. Steiner disclosed recent financial support from several pharmaceutical companies, including AstraZeneca, Azevan, Bayer Canada, and Servier.