PMDD in the DSM-5

With the arrival of the DSM-5, premenstrual dysphoric disorder (PMDD) is now an official diagnosis.¹ As a clinician and researcher in the area of women’s mental health, I see this change as a benefit of the new DSM. PMDD has been an operationalized diagnosis for research and a provisional clinical diagnosis whose time has come for this more formal recognition.

Many women who experience PMDD suffer greatly. Not uncommonly, women are affected for up to 2 weeks of each month, sometimes with symptoms that are so severe they have suicidal ideation and major disruption in functioning across arenas of life. The diagnosis is unique in terms of the distinct timing of symptoms being central to the diagnosis, with the temporal manifestations of PMDD and their relationship to the menstrual cycle being definitive. Many women who present for treatment for PMDD actually do not technically have it. Upon careful history taking and prospective tracking of mood and the menstrual cycle, many instead are found to have premenstrual exacerbation (PME) of another disorder. It is imperative to distinguish PMDD from PME, as optimal treatment is quite different. PMDD is unique in terms of its response to serotonergic antidepressants.

Women may have relief of symptoms with intermittent antidepressant dosing only during the luteal phase of the cycle or even shorter periods of time, sometimes with antidepressants being administered on a PRN basis. The ability for patients to achieve a response within a short time course and with intermittent use of medication is unique to PMDD among psychiatric disorders. Also, efficacious treatment with oral contraceptives is unique to PMDD among the mood disorders. Many women with PMDD or PME find that prospectively monitoring or tracking their moods and menstrual cycles is in itself therapeutic, in that they feel more in control of symptoms by knowing why and when they may experience them. Some women prefer keeping a paper calendar, and others prefer using apps that are now available for smart phones.

In my opinion, recognition of PMDD as a disorder is an important advancement in women’s health. The luteal phase of the menstrual cycle is often associated with premenstrual symptoms (such as irritability) that are minimized. However, many women experience a great burden of suffering on a monthly basis during the luteal phase. It is important for women to know that this is not normal and that treatments are available.

Financial disclosure:Dr Freeman has been a consultant for PamLab; has received grant/research support from Eli Lilly, Forest, and GlaxoSmithKline; and has been a member of advisory boards for Takeda, Lundbeck, and Otsuka.

Reference

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.