sadwomanAmong the changes found in the recently released fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the addition of premenstrual dysphoric disorder, or PMDD. During the two-week span between ovulation and the first day of their period, women with PMDD typically feel symptoms which include severe depression, anxiety and tension. But whether the addition of PMDD into the DSM-5 constitutes a positive step for women’s mental health is somewhat of a contentious debate.

Laura Choate, a licensed professional counselor and author of the American Counseling Association-published books, “Girls and Women’s Wellness: Contemporary Counseling Issues and Interventions” and “Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment,” spoke with Counseling Today about the debilitating disorder and how its addition into the DSM-5 will impact counselors whether they support the change or not.

What were your thoughts upon hearing that the DSM-5 would be featuring PMDD?

Honestly, I was not surprised, given that it was already included under the Depressive Disorder, Not Otherwise Specified category in the DSM-IV-TR. However, it is getting a lot of additional attention now that it has been upgraded to a stand-alone, full diagnosis.

Was this a good decision? Why?

In short, yes. I agree with the DSM-5 work group’s analysis that the small but significant group of women who do experience PMDD on a monthly basis (around two to eight percent), need support regarding appropriate diagnosis and treatment so that their needs can best be met. According to the work group, recognizing PMDD as a disorder sets it apart as a clinically significant problem that warrants treatment for the group of women who experience it; it is not to be considered a normal part of all women’s menstrual cycles. I think the controversy related to this decision comes when there is a lack of public understanding of the difference between a disorder, which indicates that something is out of the “normal” realm of functioning, and women’s normal, healthy menstrual cycles.

How will the inclusion impact counselors?

The inclusion can help counselors in conceptualizing and treating women’s depressive symptoms when they can’t be explained by other depressive disorders. If counselors can encourage their women clients who have unexplained episodes of depression to keep a monthly mood chart, perhaps they can start to recognize the relationship between their cycles and their moods. If a pattern emerges, then counselors can assess for whether a woman may be experiencing Premenstrual Syndrome (PMS) or the more severe PMDD. The counselor can then consider the implementation of treatment options based on severity of symptoms.

What can counselors do for clients with PMDD?

First, as with other types of depression, psychotherapy and lifestyle change may be considered first. If symptoms are mild, counselors can first work with women to keep a monthly mood chart; many women are helped just by understanding the relationship between their symptoms and cycles. It helps to understand why she is feeling as she is, and it also helps to know that the symptoms will end when her period begins. Counselors can also implement CBT techniques; helping women change their perception of the disorder can change the way they experience their symptoms (“It’s unbearable” or “I’m going crazy” versus “I can provide myself with extra self-care during the next week until my symptoms subside”). Many professionals also recommend simple lifestyle changes such as changes in diet, exercise, and stress management.

Finally, for moderate to severe symptoms, medical professionals recommend selective serotonin reuptake inhibitors (SSRIs) as the first- line treatment to consider. This of course requires referral to her physician who can assess her symptoms and make the decision as to whether medications are warranted.

What does the addition of PMDD into the DSM say about the state of women and mental health in society?

On the one hand, some feminist groups have criticized the inclusion of PMDD as a move that pathologizes women’s normal physiological makeup and their healthy menstrual cycles. Opponents of the inclusion claim that some critics might use this move to claim that women are inferior or incompetent because they are inherently emotionally unstable, that women are “PMS-ing” whenever they are assertive or direct, or that women can’t be promoted to elected offices or high levels of responsibility because they might become unstable on a monthly basis.

While these dangers of public miseducation do exist, on the other hand, the inclusion of PMDD as a full diagnosis in DSM-5 represents advances in research that can provide a sizeable group of women with sorely needed recognition and more effective treatments for symptom relief.  With increased recognition, more research funding may be generated for new studies in this area.

Overall, I believe that there is a potential for general misunderstanding about PMDD unless the public is educated about the fact that PMDD represents not just a constellation of mild PMS symptoms (which many women experience and cope with well) but a large set of severe symptoms that significantly impacts a woman’s life functioning. A group of women do experience symptoms at this level, but they do not represent women’s “normal” functioning. Instead, they are experiencing high levels of distress that warrant our support and the provision of effective treatment.



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