Creation of a Psychiatric Disorder

I became interested in the history of Premenstral Dysphoric Disorder (PMDD) when I met two husbands in marital counseling who believed their wife’s mood changes during menstruation caused most of their fights. They even kept track of their wife’s menstrual cycle and charted it in conjunction with their marital conflict.

Robert Spitzer, the “creator of the modern DSM” was the first to propose that severe PMS symptoms should be classified as a psychiatric disorder. According to Alix Spiegel of NPR, Spitzer has personally conceived of more mental disorders “than any other living person on the face of the earth.” But despite his efforts, in June of 1986 the APA Board of Trustees voted against making PMDD (then known as Late Luteal Phase Dysphoric Disorder, LLPDD) an official DSM diagnosis. This outcome was largely through the efforts of people like Paula Caplan.

Caplan and others opposed adding LLPDD to the DSM–III-R and later the DSM-IV. They (rightly) felt it would pathologize women. Caplan gives a detailed description of her efforts to keep LLPDD and out of the DSM in her book, They Say You’re Crazy.

But LLPDD was added to a specially created appendix of the DSM-III-R for “provisional categories needing further study.” Following the advice of Robert Spitzer, it was also given an official number just like the approved diagnoses in the main part of the manual. Psychiatrists were encouraged to use the diagnosis as if it was official. LLPDD even appeared in the main text of the DSM-III-R, where only fully tested and scientifically supported diagnoses were supposed to be included.

When the DSM-IV was published in 1994, LLPDD was renamed as PMDD and kept in the appendix. But PMDD was still a pseudo-diagnosis in the sense that it was still in the appendix and not in the main section of the manual.

About one year before Eli Lilly’s patent rights were about to run out on Prozac (fluoxetine) in August of 2001, the FDA approved Serafem to treat the pseudo-diagnosis of PMDD. Although both Zoloft and Celexa had been used to “treat” PMDD, Serafem was the first prescription drug that the FDA said could be marketed specifically for treating PMDD. What were these changes that warranted the approval of a newly patented form of fluxetine for Eli Lily? In “Sarafem: The Pimping of Prozac for PMS” Alicia Rebensdorf said:

The company changed the color of the pill from green to girly pink and turned the depression-stigmatized label Prozac to the oh-so-feminine name Sarafem. Yet Sarafem/Prozac both require daily 20 mg. doses of fluoxetine hydrochloride. You don’t take Sarafem any less often. You don’t take it any smaller doses.

Here are the first two Serafem commercials.

With the publication of the DSM-5, PMDD finally came out of the closet appendix. In their recent article reviewing the DSM history of PMDD, Peter Zachar and Kenneth Kendler commented: “When the DSM-5 was published in 2013, PMDD was moved to the main section of the manual as a diagnosis approved for routine clinical use.” But functionally, it was approved for “routine clinical use” when Spitzer and the APA gave it a DSM number and created an appendix for it in 1987 as LLPDD. The reason that officially moving PMDD to the main section was not controversial was because the above actions placed it there in 1987, BEFORE THE RESEARCH INTO PMDD as a psychiatric disorder was done.

According to Caplan in a May 12 1986 press conference, Robert Spitzer admitted that there no proposed treatment for PMDD/LLPDD at that point. However, “that is the very reason we need to put the category in the DSM, because that will make it possible to conduct research to find out what will help.” So PMDD had to be coined as a disorder so research could be done to help women with a disorder … that wasn’t yet an official disorder. As Zachar and Kendler said:

By the time that the DSM-5 development process began, PMDD was no longer a new diagnosis, and conservatism favored keeping it a disorder subject to routine clinical use. The approval of Sarafem played a role, but so did giving PMDD an official code number in the DSM-IV and listing it in the main text as an example of mood disorder NOS.

This history of how PMDD became a DSM diagnosis illustrates the unscientific manner in which many psychiatric disorders are created. Paula Caplan cautioned that the danger of the DSM is that it is used with so little monitoring of when the line is crossed from normalcy to disorder in its decisions.

In his essay, “Mental Illness is Still a Myth,” Thomas Szasz said that psychiatrists have succeeded in persuading us that the conditions they call “mental disorders” are diseases—phenomena independent of human motivation or will. “Until recently, only psychiatrists—who know little about medicine and less about science—embraced such blind physical reductionism.”

Does the DSM need independent monitoring and accountability?