Premenstrual dysphoric disorder

Neither Premenstrual Dysphoric Disorder (PMDD) nor Premenstrual Syndrome (PMS) is a medical or mental disorder or illness. Premenstrual changes are a normal part of life. Belief in PMS/PMDD is a result of conditioning, not biological processes, and best treated as such.

Premenstrual dysphoric disorder (PMDD) is not a disorder, illness, or disease, but an extreme point on the continuum of premenstrual tension. Nor is "premenstrual syndrome" (PMS) an illness or disorder. Premenstrual physical changes related to the menstrual cycle are a normal part of female life.

Emotional and behavioral problems associated with menstruation in some women are a result of basic conditioning processes--reinforcement and modeling. Expressions of PMS symptoms are negatively reinforced when they result in sick days from work or school or allow the "sufferer" to escape or avoid anxiety-provoking or unpleasant social situations. PMS provides an excuse for what would otherwise be unacceptable behavior. PMS behaviors are positively reinforced when expression of symptoms result in social comfort or medical care. PMS symptoms develop when they are modeled by others as expected patterns of female behavior. Cognitive-behavioral therapy, nutrition, and exercise, are the most rational and the most effective treatment for PMS symptoms. Drugs given for PMS produce many side effects (e.g., anxiety) that are the same as reported "symptoms" of PMS.

Physiology of Menstruation

The body's hormone interactions are responsible for the menstrual cycle. Seven to ten days prior to the onset of menstruation, many women report symptoms of "premenstrual syndrome" (PMS). "The most common physical complaints include breast tenderness, bloating, weight gain, headache, and fatigue. Common emotional and mental symptoms include irritability, difficulty concentrating, moodiness, depressed feeling, anxiety, anger, and food cravings" (Premenstrual Syndrome 2001). The psychological community, the medical-psychiatric community, and feminists all have varying opinions on the validity of PMS and PMDD as mental or physical illnesses. The consensus among psychiatrists, who consider PMS/PMDD to be a valid disorder, is that drugs should be the first line of treatment. However, neither PMS nor PMDD has been scientifically established as an illness.

A Brief History of PMS

"The notion that women's reproductive systems affect their lives is ancient," notes Linda Brannon in Gender: Psychological Perspectives (Brannon 1996, 62). Historically and across cultures, as recently portrayed in Anita Diamant's award-winning novel The Red Tent, (2001) menstruation was celebrated: "how my mothers celebrated the new moon [menstruation] with cakes and songs and stories, leaving ill will outside" (133). Menstruation was seen as a reconfirmation of "womanhood," and eagerly looked forward to by many women--a gift to women that is not known among men, and this is the secret of blood...to men this is flux and distemper, bother and pain. They imagine we suffer and consider themselves lucky. We do not disabuse them.... In the red tent, the truth is known ... women give thanks--for repose and restoration, for the knowledge that life comes from between our legs, and that life costs blood" (158). Once, menstruation was seen as the essential part of life that it is. How did normal menstrual symptoms come to be viewed by some as an illness?

In Psychobbable and Biobunk, Carol Tavris concludes that PMDD is "just ancient superstition in pompous new jargon" (2001). The problem of whether or not severe PMS-PMDD--is a real mental disorder is actually a particular case of the general problem of when any set of conditions constitutes a mental disorder. In Creating Mental Illness (2002) Rutgers sociologist Allan Horwitz argues that "psychiatrists, epidemiologist, and clinicians simply accept as mental disorders whatever conditions the DSM [a psychological diagnostic manual] lists. They do not ask how these conditions came to be regarded as mental disorders there is no reason to accept that any particular group of symptoms represents a valid form of mental disorder" (pp. 19-20).

"Premenstrual tension" was first described in 1931. In 1953 Katherine Dalton introduced the term "premenstrual syndrome," and in subsequent years promoted and researched PMS (see Dalton 1987). The list of PMS symptoms, some directly contradicting others, has grown to over 150. Dalton notes that "The symptoms themselves are commonplace and also occur with great frequency in men, children, and postmenopausal women (1987, 717). How can this vast group of common "symptoms" that occur in all people represent a valid mental disorder?

Tavris argues that PMS is a "manufactured" problem (e.g., a fiction). To support this claim Tavris notes that although described in 1931, it wasn't until 1964 that the first article on PMS appeared in a medical journal, and 1966 for the first psychological journal article. But by 1989 there were 305 medical journal articles and 120 psychological journal articles on PMS (Tavris 1992, 140). Women have always ovulated and menstruated, but research on PMS "erupted" in the 1970s, according to Tavris, because "When women's participation in the labor force is seen as a threat instead of a necessity, menstruation becomes a liability" (141). Pdong the way, as noted by Tavris, PMS was "coopted" by biomedical researchers--"The big money, the big grants" (141). Indeed, today the pharmaceutical companies are the biggest promoters of PMSI PMDD. Do real medical problems need promoting?

In 1987, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, third edition-revised (DSM-III-J?), labeled those with severe PMS symptoms as meeting the criteria for "late luteal phase dysphoric disorder." In 1994 the DSM-IV task force (literally a group of psychiatrists that decide, not by scientific data, but by consensus what to call a "disorder") put late luteal phase dysphoric disorder in the appendix as "premenstrual dysphoric disorder" (PMDD) under "disorders needing further study." This inclusion legitimized PMDD for women, the medical community, and the insurance industry. It wasn't long until Prozac, repackaged in pretty purplish pills and called "Sarafem," was being readily offered to women for mentioning "commonplace symptoms.

For example, when Melissa (the second author) casually asked her doctor how a new birth control pill was with "PMS symptoms," before she could finish her sentence the doctor offered her Sarafem. Melissa did not say she had severe symptoms or was depressed. The doctor didn't ask what symptoms Melissa was referring to. He simply offered her a powerful pharmaceutical. This occurrence is not unique. Like millions of other women, Melissa's sister was given a free sample of Sarafem from a different doctor for a different "problem" -- she had a baby.

Conditioning of PMS

Reports of subjectively experienced premenstrual pain are not a product of actual physical severity, but of basic conditioning processes--reinforcement and observational learning. In an article "Modeling and reinforcement of the sick role during childhood predicts adult illness behavior," the authors, led by William E. Whitehead of the Division of Digestive Diseases of the University of North Carolina, studied 382 women and found that "subjects were most likely to report the symptoms and to rake disability days for the symptoms that their parent reinforced and modeled" (Whitehead et al. 1994, 548). Specifically: "Childhood reinforcement and modeling of menstrual illness behavior had a significant influence on the number of physician visits for menstrual symptoms" (547). Similarly, Canadian researchers Melanie Thompson and Mary Glick found that among college students: "Consistent with previous research, care-seekers reported more reinforcement for adolescent menstrual illness behaviors than non-care-seekers. C are-seekers also reported their symptoms as more serious and more difficult to ignore. The perceived seriousness and severity of symptoms were both correlated with reinforcement for adolescent menstrual symptoms" (2000, 137).

Mexican researchers Luisa Marvan and Claudia Escobedo (1999) studied PMS with eighty-six healthy Mexican women who had no higher than a sixth grade education. A "Menstrual Distress Questionnaire" (MDQ) was given to all women one week after menstruation. Then half the women were shown a video describing the menstrual cycle. The other women were shown a video describing PMS and its negative consequences. All the women were again given the MDQ after their next menstruation. There were no changes in the women who simply learned about the menstrual cycle, but the women who watched the PMS video reported more severe premenstrual symptoms after watching the tape. Would watching a video about measles produce measles?

These results show that viewing premenstrual symptoms as problematic is not the result of physical conditions. Through observational learning and reinforcement women are taught that premenstrual symptoms are problematic. The converse is that if girls are taught that menstruation is normal--nonproblematic, then as women they are unlikely to perceive the symptoms as problematic.

Misattribution and Illusionary Correlations

The mote salient different stimuli or events are, the more likely they are to be associated. Therefore, once women come to believe they "have PMS," other salient physical states, emotional states, and behaviors are likely to be believed to be caused by PMS. A University of Texas-Houston Department of Psychiatry and Behavioral Sciences study (Dougherty et al. 1998) found that aggression did not vary across the menstrual cycle. They did find that women with high MDQ scores (PMS) were almost twice as aggressive as women without PMS during all menstrual cycle phases (premenstrual, menstrual, mid-follicular, and ovulation).

The Houston study shows that the link between aggression and premenstruation is an illusion. Aggressive women are aggressive across the cycle, believing they have PMS just gives them an excuse for much of their aggression. Indeed, an earlier study of violent women offenders found that only 29 percent committed their crimes during the premenstrual phase (71 percent were committed during other phases), indicating menstrual phase has no effect on the likelihood of a woman behaving violently (d'Orban and Dalton 1980). The premenstrual phase is not a cause of aggression.

Studies that find relationships between premenstrual phase and inappropriate behaviors or psychological problems are retrospective self-report surveys, often with the intent of the study known to the participants. Such findings suggest PMS is an illusion due to women's (learned) expectations and (mis)attributions, not biology. Other studies (such as Aubuchon and Calhoun 1985) find that symptoms are exaggerated if women believe menstruation is the focus of the study.

But when the purpose of a PMS study is disguised there is little evidence of PMS. For example, when Maria Marvan and Sandra Corres-Iniestra compared disguised-purpose daily reports with retrospective reports of premenstrual changes they found much higher retrospective reports of premenstrual change than actually occurred according to the daily reports. The researchers concluded that "many women have a misperception about the meaning of PMS: consequently, they amplify their premenstrual changes in recall, reflecting women's cultural stereotypes rather than their actual experiences" (2001, 276).

In addition to cultural stereotypes, experimentally produced biases ("expectancy effects") cause changes in reported premenstrual symptoms. There are several questionnaires other than the MDQ that evaluate premenstrual changes, and the amount of reported distress depends on the questionnaire given. Indeed, compared to women who first complete a MDQ and then a Menstrual Attitude Questionnaire (MAQ), women who first complete a Menstrual Joy Questionnaire (MJQ) report more positive cyclic changes on the MAQ (Chrisler et al. 1994). The MJQ asks subjects to evaluate the experience of positive symptoms (such as increased sexual desire, sense of euphoria, and feelings of power) the week preceding menstruation. Menstruation is a fact, but whether it is interpreted as joyful or distressful depends on what one is taught to expect (see also Diamant 1997).

Studies that do not inform the participants that the study is looking at PMS but simply ask people to chart their moods and physical state daily for extended periods of time fail to find any correlation between "symptoms" of PMS or PMDD and impending menstruation (Mcfarland, Ross, and DeCourville 1989). Studies find that both men and women regularly cycle though mood changes, on both daily and monthly cycles (McFarlane et al. 1988).

Treating PMS and PMDD

Irritability, anxiety, and depression associated with the onset of menstruation is very real for the woman even if the suffering is the result of conditioning and misattribution. PMS distress deserves effective treatment. To dismiss PMS as "all in you head" would be as dismissive as telling a depressed person "don't worry, be happy." How then should PMS be treated?

Exercise

Water retention and abdominal discomfort may occur premenstrually, and decreasing the physical symptoms through regular exercise in turn decreases the behavioral and emotional symptoms. Regular exercise improves psychological functioning for all individuals regardless of the "diagnosis" of the individual suffering. A research review by Australian researchers Byrne and Byrne (1993) found that exercise was successful in producing antidepressant, anti-anxiety, and mood-enhancing effects across mood disorders. A team of Duke University medical researchers (Babyak et al. 2000) recently found that exercise was as effective as antidepressant medications such as Prozac in treating major depressive disorder at six months, and at ten months fewer exercisers relapsed into depression than drug takers. That is, exercise is more effective than SSRI drugs in treating major depression. Exercise is equally effective in treating PMS/PMDD. Strength training produces general improvement in premenstrual symptoms (e.g., Steege and Blumenthal 1993). Aerobic exercise produces even greater improvements, and is "protective" against both physical symptoms such as water retention and psychological symptoms including dysphoric mood (depression) anxiety, pain, and functional impairment (Bibi 1996; Stoddard 1999).

The protective nature of exercise against PMS provides a clue as to why premenstrual tension became a problem. Since the early 1 900s, people in the "developed world" have become increasingly sedentary. Obesity is at epidemic levels. Before modern labor-saving devices, living required regular exercise. As a result, problems such as obesity and PMS were rare. Therefore it is not surprising that women who exercise have significantly fewer PMS symptoms than non-exercisers (Johnson, Carr-Nangle, and Bergeron 1995).

Nutrition

Corresponding to the decrease in the amount of exercise required by daily life there has been an increase in food availability and food consumption--particularly consumption of high fat and high sugar foods. An increase in fat consumption and a decrease in low-fat vegetable consumption contributes to PMS symptomology. Improving nutritional habits effectively decreases premenstrual distress.

Because "anecdotal reports indicate that a low-flit, vegetarian diet might reduce menstrual pain," and because several research findings have established that "plant-based and vegetarian diets increase serum concentration of sex-hormone binding globulin, which binds and inactivares estrogens (245), Georgetown University researchers (Barnard, et al. 2000) studied the effects of a vegetarian diet on dysmenorrhea (painful menstruation) and premenstrual symptoms. The vegetarian diet resulted in weight loss, decreased dysmenorrhea, decreases in pain and water retention, and other premenstrual symptoms. Following the Federal Drug Administration's recommended diet of five servings of fruits and vegetables and minimal animal fat would result in greatly improved menstrual health including a decrease in PMS symptoms.

Cognitive Behavioral Therapy

Although effective, exercise and diet alone may not address the misattriburions that problematic behaviors (e.g., aggression) and emotions are caused by premenstrual tension. Fortunately, education and therapy directed at changing these beliefs is effective (Christensen and Oei 1995). Cognitive therapy that includes diet and exercise recommendations has shown to be an effective treatment for PMS. Fiona Blake and her coworkers (1998) treated women diagnosed with PMS with cognitive therapy that included: treatment goals, education, engaging in new behaviors for homework, and gaining new skills (p. 311). Results showed that "cognitive therapy fot premenstrual syndrome (PMS) was found to be associated with significant improvements in a range of measures, which included measures of PMS symptoms, associated impairments, and depression... there was no sign of any tendency to lose the gains made" (316).

Dissertation work by Susan Koons indicates that the best treatment for PMS may involve a combination of exercise, diet, and cognitive-behavioral therapy (CBT). When women who were diagnosed with severe PMDD completed a CBT treatment package that included diet and exercise, the scheduling of pleasant events, and stress management, symptoms were alleviated and gains were maintained at six month follow up (Koons 1999).

Drug "Treatment"

Despite the fact that exercise, dietary changes, and CBT have been shown to be equally effective as (or more effective than) drugs in treating mood disorders including PMDD, drugs are considered to be "the first line treatment option" (Pearlstein and Steiner 2000) by psychiatrists. Clearly, if womens' best interest was the primary consideration then the suggestions mentioned thus far would be the first line of treatment. But psychiatrists are medical doctors, trained to give diagnosis and treat problems with drugs. Thus if the disorder is diagnosed, then it is only logical that doctors would to look to drugs to treat the illness. However, the data suggests that drug treatment is short-sighted.

The first drug approved specifically for PMDD by the FDA is Sarafem (previously marketed as Prozac). Prozac is a selective serotonin reuptake inhibitor (SSRI). SSRIs work by preventing the reuptake of the neurorransmitter molecule serotonin by the neuron that released it. Preventing reuprake increases serotonin's concentration in the synapse between communicating neurons and thus increases neuronal communication. Prozac was developed for depression. SSRIs were not developed for, or assumed to have anything to do with, menstruation. With the impending expiration for the patent on Prozac, Eli Lilly's multibillion-dollar drug, the color of the pill was changed and on July 6, 2000, the FDA approved the "new" drug Sarafem for PMDD. As listed on the "information for the patient" insert included in packets of Sarafem, some of the side effects include "tiredness, upset stomach, nervousness, dizziness, and difficulty concentrating." These side effects are among the very "symptoms" of PMDD!

One of the impetuses for Sarafem/Prozac being approved by the FDA was a 1995 study (Steiner, Steinberg, Stewart, et. al.), funded by Eli Lilly, that found that for 52 percent of sufferers drug treatment produced "moderate improvement." Obviously, yet ignored, this means the drug did not help (or only slightly helped) 48 percent. The efficacy of Prozac also decreased considerably after four months.

Furthermore, taking drugs for PMS is likely to produce misattributions--e.g., "If I'm feeling good now, it must be because I'm on Sarafem. It couldn't be due to my own actions and of those around me. I'm not aggressive now because I'm on drugs." Such misattributions are likely to foster further drug dependence--e.g., "I need Sarafem or I'll be a real bitch." The side effects of SSRIs such as Sarafem arc detrimental, whereas the side effects of improved diet and exercise are beneficial.

In contrast to drug treatment, behavioral approaches including lifestyle changes (involving diet, exercise, social skills, and education) directly confront the sources of PMS (poor diet, lack of exercise, poor social skills, misattributions, and ignorance about menstruation). While the initial costs of changing one's lifestyle may be higher than simple pill popping, the results are much greater (e.g., Babyak et al. 2000). Diana Taylor (1999) of the University of California at San Francisco investigated the effectiveness of a symptom management intervention involving self-monitoring/regulation (diet regulation, vitamin supplementation, and exercise), and self/environment modification ("lifestyle alterations, ... change in daily activities, and interpersonal competency training") with ninety-one women with severe PMS. Treatment produced "dramatic reductions in premenstrual symptom severity (75-85 percent)" (507). Results were maintained or enhanced at follow up. Taylor (1999) compared these results with those of drug treatment:

a 75-85 percent reduction in PMS severity in women [results from] using a combination of dietary, exercise, and behavioral, cognitive, and environmental stress management strategies (Goodale et al. 1990; Kirby 1994). When compared to antidepressant drug therapy, the PMS-SMP [Symptom Management Program] was more effective in reducing premenstrual symptom severity and distress than studies testing fluoxetine [Sarafem/Prozac], which demonstrated 40-50 percent improvement in PMS severity, but up to one third of women will discontinue medication use due to drug side effects such as nausea, disturbed sleep, fatigue, and dizziness" (Steiner et al. 1995).

Thus, there is only one rational conclusion concerning treatment for the so called "disorder" of PMS/PMDD: Behavioral, educational, and cognitive-based treatment should be the first line treatment option. Ignorance, convenience, and the profit motive, nor women's health, are why drug treatment is advocated.

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Stephen Ray Flora is an associate professor of psychology at Youngstown State University. Melissa Sellers is a writer and psychology major at Youngstown State. Correspondence concerning this article can be sent to srflora@ysu.edu.

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