It is with this information in mind that the DSM-5 panel of experts proposed the inclusion of premenstrual dysphoric disorder as a full category in this next edition of DSM. The benefit of moving premenstrual dysphoric disorder from the research criterion stage to that of full-fledged diagnosis is considerable from both a scientific and a clinical perspective. The research criteria for the disorder have already led to more rigorous characterization of women participating in randomized clinical trials and studies focusing on pathophysiology. In addition, the Food and Drug Administration and similar authorities in other countries have approved several pharmacological agents for the treatment of premenstrual dysphoric disorder, making it a de facto diagnosis regardless of its position within DSM.
A category for premenstrual dysphoric disorder would describe individuals who are not well represented by other psychiatric diagnostic categories. Data from clinical as well as epidemiological cohorts show that many women experience symptoms that begin during the luteal phase of the menstrual cycle and terminate around the onset of menses. Prevalence rates vary considerably depending on study methods, particularly with respect to prospective or retrospective symptom reporting, consideration of symptom interference, and population sampling (). In the two studies conducted using probability sampling of the general population and using prospective daily ratings for two complete menstrual cycles and confirmed premenstrual interference in functioning, the mean prevalence of premenstrual dysphoric disorder was approximately 2% (14
). The mean prevalence is higher (5%) if all studies of the prevalence of premenstrual dysphoric disorder are included ().
A number of studies have found that women with premenstrual dysphoric disorder experience impaired functioning in various domains (9
) and that functional impairment improves during treatment (99
). Such impairment among those affected argues for the need to detect and treat women who meet criteria for the disorder. Without clear diagnostic boundaries for premenstrual dysphoric disorder, symptoms may be dismissed and the diagnosis missed by providers. Clinicians may assume, for example, that the patient suffers from milder premenstrual syndrome or from an ongoing mood disorder such as major depression or dysthymic disorder. Because the treatments for these various conditions are distinct, accurate diagnosis is important. Moreover, the acceptance of strict diagnostic criteria may counteract unwarranted overdiagnosis of mild cases.
An additional reason for the suggested change is that it would promote accurate collection of data regarding the treatment need and delivery of services for premenstrual dysphoric disorder that could be obtained from epidemiological and treatment delivery studies. Such collection would thus benefit from premenstrual dysphoric disorder having a code of its own rather than being coded as depression not otherwise specified. Alternatively, it may today be coded as premenstrual tension syndrome according to ICD, which is also unfortunate given the lack of stringent criteria for this condition.
The inclusion of premenstrual dysphoric disorder as a diagnostic category may further facilitate the development of medications that are useful for treatment and may encourage additional biological research on the causes of the disorder. Finally, while the inclusion of criteria for premenstrual dysphoric disorder in the appendices of DSM-III-R and DSM-IV facilitated research, the work group felt that information on the diagnosis, treatment, and validators of the disorder has by now matured to the point that the disorder should qualify as a category in DSM-5. A move to the position of category, rather than a condition in need of further study, would provide greater legitimacy for the diagnosis (102
The DSM-5 work group recognizes that some stakeholders may be concerned about the inclusion of premenstrual dysphoric disorder as a new diagnostic category. Some individuals and groups assert that a disorder that focuses on the perimenstrual phase of the menstrual cycle may “pathologize” normal reproductive functioning in women. Likewise, there may be concerns that since only women are at risk for the condition, they may be subject to inappropriate stigmatization and insinuation that they are not able to perform needed activities during the premenstrual phase of the cycle. Our group reviewed this literature and considered these points of view. However, because the prevalence statistics clearly indicate that premenstrual dysphoric disorder is a condition that occurs in a small minority of women, it would be inappropriate to generalize any premenstrual disability to women as a group. On the contrary, the inclusion of the diagnosis as a DSM-5 category, with its specific criteria and accompanying text, would emphasize that only a minority of women experience severe symptoms with accompanying distress and impairment. Analogously, while most individuals experience the feeling of sadness at some point in their lives, not all individuals have experienced a mood disorder. The overall health benefit for women of having an empirically based diagnosis would thus outweigh the potential for unfounded stigmatization or demeaning remarks that some groups fear.