Addressing concerns about the inclusion of premenstrual dysphoric disorder in DSM-5.

OBJECTIVE: Inclusion of premenstrual dysphoric disorder (PMDD) into the main text of the DSM has been a point of controversy for many years. The purpose of this article is to address the main concerns raised by opponents to its inclusion. Concerns are presented and countered in turn. LITERATURE SEARCH: To identify the most prevalent arguments against inclusion of PMDD, we searched MEDLINE (1966-2012), PsycINFO (1930-2012), the Internet, and reference lists of identified articles during September 1-17, 2012, using the keywords PMDD, premenstrual syndrome (PMS), DSM, DSM-5, concerns, controversy, women, political power, workforce, courts, and history. The search was restricted to English-language publications. A total of 55 articles were identified and included. The most pressing arguments against inclusion were grouped by similarity and addressed if they were reported 5 or more times. Our review of the sources yielded 38 concerns regarding PMDD; 6 concerns were reported at least 5 times and are addressed in this article. DISCUSSION: Evidence culled from historical and legal trends does not support the alleged societal use of PMS to harm women (eg, keeping women out of the workforce or using PMS against women in child custody disputes). Further, current epidemiologic research has answered all of the methodology criticisms of opponents. Studies have confirmed the existence of PMDD worldwide. The involvement of pharmaceutical companies in research has been questioned. However, irrespective of the level of association with industry, current research on PMDD has consistent results: PMDD exists in a minority of women. CONCLUSIONS: Historically, the pain and suffering of women have been dismissed, minimized, and negated. Similarly, women with PMDD have often had their experience invalidated. With the preponderance of evidence in its favor, PMDD has been placed in the main text of the DSM-5, opening the door for affected women to receive the attention full diagnostic status provides.

Premenstrual dysphoric disorder: evidence for a new category for DSM-5.

Premenstrual dysphoric disorder, which affects 2%­5% of premenopausal women, was included in Appendix B of DSMIV, "Criterion Sets and Axes Provided for Further Study." Since then, aided by the inclusion of specific and rigorous criteria in DSM-IV, there has been an explosion of research on the epidemiology, phenomenology, pathogenesis, and treatment of the disorder. In 2009, the Mood Disorders Work Group for DSM-5 convened a group of experts to examine the literature on premenstrual dysphoric disorder and provide recommendations regarding the appropriate criteria and placement for the disorder in DSM-5. Based on thorough review and lengthy discussion, the work group proposed that the information on the diagnosis, treatment, and validation of the disorder has matured sufficiently for it to qualify as a full category in DSM-5. A move to the position of category, rather than a criterion set in need of further study, will provide greater legitimacy for the disorder and encourage the growth of evidence-based research, ultimately leading to new treatments.

Criteria for premenstrual dysphoric disorder: secondary analyses of relevant data sets.

CONTEXT: There is substantial information that premenstrual dysphoric disorder (PMDD) is a clinically significant disorder with biological underpinnings that differ from other psychiatric disorders. However, data regarding the symptoms noted in DSM-IV and timing of their expression in the menstrual cycle have had little empirical support. OBJECTIVE: To provide evidence informing the definitional criteria for PMDD. DESIGN: Prospective surveys. SETTING: General community and clinical settings. PARTICIPANTS: Two cohorts that included a representative sample and a self-identified treatment-seeking cohort. Main Outcome Measure  Daily ratings of perimenstrual symptoms and functioning. RESULTS: Mood and physical symptoms were most severe and were accompanied by impairment in the 4 days before through the first 2 days of menses for the self-identified group and in the 3 days before through the first 3 days of menses in the community sample. The most problematic symptoms endorsed were those listed in DSM-IV, but depressed mood was less frequent than other affective symptoms. In the combined sample, 4 or more symptoms was the optimal cutoff point for maximizing both sensitivity and specificity when predicting impairment. CONCLUSIONS: This is informative for DSM-5 in that the most symptomatic period typically includes the few days before through the first 3 days of menses rather than only the premenstrual phase. Further, we validated the salience of PMDD symptoms included in DSM-IV. Although the number of symptoms most associated with distress and impairment differed between the 2 cohorts, results from the combined cohort suggest that 4 symptoms are linked with impairment from PMDD symptoms.

The prevalence of premenstrual dysphoric disorder in a randomly selected group of urban and rural women.

BACKGROUND: Premenstrual dysphoric disorder (PMDD) was included as a provisional diagnostic category in the appendices of Diagnostic and Statistical Manual of Mental Disorders (DSM)-III-R (then called late luteal phase dysphoric disorder) and remained as an appendix in DSM-IV. Our study aimed to determine the prevalence of PMDD using all four DSM-IV research diagnostic criteria in a representative sample of women of reproductive age in the United States. METHOD: Data were collected in the homes of women between the ages of 13 and 55 years in two urban and two rural sites using a random sampling procedure developed by the National Opinion Research Center. Women completed daily symptom questionnaires and provided urine specimens each day for two consecutive ovulatory menstrual cycles (ovulation was estimated for women taking oral contraceptives) and were screened for psychiatric disorders by trained interviewers. Symptoms were counted toward a diagnosis of PMDD if they worsened significantly during the late luteal week during two consecutive ovulatory menstrual cycles, occurred on days in which women reported marked interference with functioning, and were not due to another mental disorder. RESULTS: In the final analysis, 1246 women who had had at least one menstrual cycle and were neither naturally nor surgically menopausal nor pregnant were selected. Of the women in the study, 1.3% met criteria for the diagnosis as defined in DSM-IV. CONCLUSIONS: The prevalence of PMDD is considerably lower than DSM-IV estimates and all but one of the estimates obtained from previous studies when all DSM-IV diagnostic criteria are considered. We suggest a new process for diagnosing PMDD based on our findings.

The WOMQOL instrument measured quality of life in women of reproductive age with no known pathology.

BACKGROUND AND OBJECTIVES: The Women's Quality of Life Questionnaire (WOMQOL) was developed to measure aspects of the health of women of reproductive age with no known pathology. METHODS: Five experts in women's health and mental health rated a pool of 140 items as very significant, somewhat significant, or insignificant to women's health. Sixty-seven items were retained and formatted as a self-reported questionnaire with dichotomous responses to each statement ("true" and "false"). A total of 1,207 women completed the instrument during the follicular and late luteal phases of their menstrual cycles. Dichotomous response data from the follicular phases were analyzed using item response theory-based full-information item factor analysis to identify interpretable factors. Measurement invariance of the obtained factors across cycle phases and age cohorts was further evaluated using differential item functioning (DIF). RESULTS: Four primary factors, made up of the 10 items with highest factor loading in each factor, were found to measure physical, mental, social, and spiritual health. No items were found to display DIF across the phases of menstrual cycles or age cohorts. CONCLUSION: Although additional studies of diverse groups of women are advised, the final 40-item WOMQOL is a psychometrically sound measure that can be used to evaluate the quality of life of women of reproductive age in the general population.

Timing and severity of symptoms associated with the menstrual cycle in a community-based sample in the Midwestern United States.

This study describes the experience of menstruation among normal women, establishing a baseline for comparison with women reporting symptoms of a menstrual disorder. A community-based sample of 900 women kept a daily log of 50 physical, social, and psychological symptoms for a period of time that included two menstrual cycles. Twenty-five items were derived from the DSM-IV criteria for premenstrual dysphoric disorder (PMDD) and 13 from the premenstrual syndrome (PMS) literature. An additional 12 items were positively worded versions of some of the PMDD items. Women were told that the study was about women's health, with no specific reference to menstruation. Time sequence charts revealed that all symptoms peaked on the first day of menses, with severity levels more than 2 S.D. above the mean for each individual symptom. Women were more likely to endorse distress when symptoms were positively worded than when they were negatively worded. This study shows the importance of reducing bias in self-reports of menstrual symptoms, and illustrates the lag between hormonal changes in the luteal phase and the peak of symptom severity at onset of menses. Further research is needed to determine the nature and extent to which women with a presumed disorder vary from this baseline pattern.

Premenstrual dysphoric disorder and risk for major depressive disorder: a preliminary study.

Investigators examined whether premenstrual dysphoric disorder (PMDD) poses a risk for major depressive disorder (MDD). In an initial study, women rated premenstrual symptoms and functional impairment daily for two menstrual cycles. A semistructured diagnostic interview was given to obtain psychiatric histories and differentiate PMDD from premenstrual exacerbations of other disorders. Participants in this pilot study were eight women with PMDD and a random subgroup without PMDD (n = 9) initially. Another semistructured interview was given to diagnose psychiatric disorders occurring during a two-year follow-up interval. In all, seven of the eight women with PMDD developed MDD within two years, including all those who had never had MDD before. The odds that a woman with PMDD developed MDD were 14 times the odds that a woman without PMDD developed MDD ( p <.05). Premenstrual dysphoric disorder may be a prodrome of or causal risk factor for MDD. Preliminary evidence for the diagnostic validity of PMDD is provided.

Rural and urban Midwestern United States contraception practices.

To address a paucity of demographic data on rural United States contraception practices, 370 randomly selected menstruating women, age 13-55 years, living in rural and urban Illinois and Missouri answered interview questions. Women with relatively few children and living in urban areas were likely to practice contraception more than those with relatively few children and living in rural areas, p < 0.01. In Illinois, more rural (23%) than urban (2%) women chose sterilization, p < 0.01. Single status was more frequent in Chicago (41%) and rural Missouri (32%) than in rural Illinois (19%), p < 0.002, and extant research links single status with risk for HIV and other sexually transmitted diseases (STDs). Condom use did not differ significantly by locale, p > 0.05. Urban-rural differences in contraception practices may be a function of life style choices (e.g. urban women may practice contraception to postpone having children, whereas rural women may practice contraception to prevent having more children after families are complete). Results do not strongly support that locale differences in contraception practices are a function of concern about contracting STDs.

Relationships of premenstrual dysphoric disorder to major depression and anxiety disorders: a re-examination.

Clarifying the relationships of premenstrual dysphoric disorder (PMDD) to depressive and anxiety disorders may contribute to the understanding of risk factors and etiologies associated with the disorders. A current belief is that women with PMDD have a higher percentage of past psychiatric disorders than women without the disorder, an assumption that may be premature. This review carefully examines existing literature on the nature of the relationships between PMDD and major depression and anxiety disorders. A re-evaluation of the literature and the resulting implications for risk factors and etiology, as well as for obstetric and gynecological practice, are provided.

Symptom patterns of premenstrual dysphoric disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders-IV.

Premenstrual dysphoric disorder was included in an appendix of DSM-III-R (revised third edition of the Diagnostic and Statistical Manual of Mental Disorders) and DSM-IV to facilitate systematic research. Items contained in its set of research criteria were considered tentative. Only one previous study of premenstrual symptoms specifically addressed symptoms of premenstrual dysphoric disorder, and it did not use DSM-IV criteria. In the present study, prospectively measured symptoms of 99 women were analyzed using exploratory principal components analysis with orthogonal rotation on all 24 items derived from the 11 symptoms listed in DSM-IV. Variation was found across phases of cycle and groups, with five factors predominating: (1) anger/irritability, (2) depressed mood, (3) anxiety/tension, (4) decreased energy and interest with physical symptoms, and (5) eating problems.

Depressive personality characteristics: state dependent concomitants of depressive disorder and traits independent of current depression.

Depressive personality disorder (DPD) characteristics may reflect both state dependent concomitants and traits independent of current depression. In all, 30 clinically, 30 formerly, and 30 never depressed participants were given the Diagnostic Interview for Depressive Personality (J. G. Gunderson, K. A. Phillips, J. Triebwasser, & R. M. A. Hirschfeld, 1994). Negative reactivity, remorsefulness, a limited capacity for fun, gloominess, pessimism, difficulty being critical or angry, unassertiveness, self-denial, and seriousness differentiated depressed and nondepressed participants, indicating that they are primarily concomitants of depression. Self-criticalness differentiated formerly from never depressed participants after subclinical symptoms were controlled, suggesting that it is a trait independent of current depression. Low self-esteem, feeling burdened, and counterdependency manifested both state and trait components. If DPD is placed on Axis II, it should be defined by traits at least partly independent of depression.

A design for studying the DSM-IV research criteria of premenstrual dysphoric disorder.

The DSM-IV estimate that 3-5% of women have premenstrual dysphoric disorder (PMDD) is based on studies that: used non-representative samples, did not consider all research criteria, or were retrospective. In the present study, prospective data from a multiethnic sample of women were analyzed to develop an effective method of considering all DSM-IV research criteria for PMDD. One-hundred and seventeen subjects between the ages of 13 and 55 years who were neither pregnant nor menopausal were recruited from outpatient clinics at a teaching hospital for a study of changes in women's health through time. Daily urine samples were taken for two menstrual cycles, analyzed to establish phase of cycle, and correlated with daily symptom ratings. Subjects were assessed for psychiatric disorders. Four methods of symptom analysis were used. Prevalence rates ranging from 1.0% to 7.1% were determined that differed according to the method of measuring the symptom change. The group of women with PMDD did not differ from the sample as a whole on variables including age, parity and birth control pill use. When all criteria were considered as they appear in DSM-IV, prevalence estimates of the present study did not differ markedly from those in DSM-IV.

Establishing the diagnostic validity of premenstrual dysphoric disorder using rasch analysis.

Premenstrual Dysphoric Disorder (PMDD) has remained in appendices of the last two editions of The Diagnostic and Statistical Manual of Mental Disorders due to lack of empirical study. Items included in its set of research criteria are considered tentative pending evidence of diagnostic validity. The present study attempts to establish the construct validity of the PMDD criteria using the Rasch method to analyze the validity of individual items as contributors to the diagnosis, in contrast to the usual but less precise approach of using an external validator to establish the diagnostic utility of psychiatric conditions. Analysis of which items best differentiate participants with and without PMDD provides an idea of the relative ability of these items to distinguish PMDD. It is recommended that the areas of anger/irritability, depressed mood, and problems in interpersonal functioning be expanded in further studies and corresponding items added to symptom checklists.

Automatic and effortful processing in depression.

Automatic processes require few attentional resources, but effortful processes use attentional capacity. Research on cognitive processing by depressed individuals is reviewed and the following is concluded: (a) Depression interferes with effortful processing. The degree of interference is determined by the degree of effortfulness of the task, the severity of depression, and the valence of the stimulus material to be processed. (b) Depression interferes only minimally with automatic processes. Hypothetical causal mechanisms for interference in effortful processes by depression, whether interference in effortful processing is unique to depression or characteristic of psychopathology in general, and whether negative automatic thoughts are associated with current depression or depression proneness are also addressed. The effortful-automatic perspective has implications for understanding depressive clinical features, treating depression, and conducting future research.

Processing of ambiguous and unambiguous feedback by depressed and nondepressed college students: schematic biases and their implications for depressive realism.

Explored schematic processing as a mechanism for predicting (a) when depressed Ss would be negative relative to nondepressed Ss and (b) when depressed and nondepressed Ss would show biased or unbiased (i.e., "realistic") processing. Depressed and nondepressed Ss performed multiple trials of a task under conditions in which the two groups held either equivalent or different schemas regarding this task. Ss received either an unambiguous or objectively normed ambiguous feedback cue on each trial. In full support of schematic processing, depressed Ss showed negative encoding relative to nondepressed Ss only when their schemas were more negative, and both depressed and nondepressed Ss showed positively biased, negatively biased, and unbiased encoding depending on the relative feedback cue-to-schema match. Depressed and nondepressed Ss' response latencies to unambiguous feedback also supported the occurrence of schematic processing. We discuss the methodological, treatment, and "realism" implications of these findings and suggest a more precise formulation of Beck's schema theory of depression.

The hopelessness theory of depression: attributional aspects.

In this article, we clarify, expand and revise the basic postulates of the hopelessness theory of depression (Abramson, Alloy & Metalsky, 1988a; Abramson, Metalsky & Alloy, 1987, 1988b; previously referred to as the reformulated helplessness theory of depression: Abramson, Seligman & Teasdale, 1978) and place the theory more explicitly in the context of work in descriptive psychiatry about the heterogeneity among the depressive disorders. We suggest that the hopelessness theory hypothesizes the existence in nature of an, as yet, unidentified subtype of depression--'hopelessness depression'--defined, in part, by its cause. We then give a critique of work conducted to test the hopelessness theory and explicate the limitations in research strategy associated with this line of work. Our critique includes a logical analysis that deduces the conceptual and methodological inadequacies of the research strategies used to test the theory. Finally, we suggest more adequate research strategies for testing the hopelessness theory and discuss conceptual and assessment issues that will arise in conducting such tests with special emphasis on attributional styles.