Premenstrual Syndrome

   (PMS)

   Although some observers are troubled by the notion that a bodily function so universal as menstruation could have an intrinsic psychiatric pathology, menstruation is in fact disrupted in some psychiatric illnesses, such as in late schizophrenia. There are menstrual anomalies in about 40% of the cases of epilepsy. Yet, the extent to which menstruation produces psychiatric illness remains unclear. The whole subject of mind–body relations in gynecology is so drenched in prejudice that Helen Flanders Dunbar (1902–1959), a psychiatrist at Columbia University with a specialty in psychosomatic matters, wrote in 1935 in her magisterial overview Emotions and Bodily Changes, "Physicians since the time of Hippocrates and Galen have been dominated by the idea that diseased genital organs were the sedes morbi for the manifold hysterical disturbances of bodily function" (p. 330 of 2nd ed.). One must therefore be wary of identifying "landmark" scientific findings in this wasteland of bias. What one can say is that physicians have long believed in the existence of a premenstrual syndrome, assigning to it such terms as "menstrual insanity." As Emil Kraepelin noted in the fifth edition of his textbook in 1896, "In women the physiological process of menstruation is regularly accompanied by a mild increase in nervous and psychic irritability that in certain individuals may reach an almost pathological level (depression, excited agitation)." "We even see cases of periodic mania [Tobsucht] that are so narrowly coupled to the menses that one is entitled to speak of ‘menstrual insanity’ " (p. 53).

   In 1931, Robert T. Frank (1875–1949), a New York gynecologist with a Park Avenue practice (he had founded the endocrine research laboratory at Mt. Sinai Hospital in 1925), turned a page in the Archives of Neurology and Psychiatry by arguing that "premenstrual tension" was caused by hormonal changes, rather than by local changes in the uterus: "Continued circulation of an excessive amount of female sex hormone in the blood may in labile persons produce serious symptoms, some cardiovascular, but the most striking definitely psychic and nervous (autonomic). These periodic attacks are incapacitating and lead occasionally to extreme unhappiness and family discord. They can be directly ascribed to the excessive hormonal stimulus" (p. 1056).

   The term "premenstrual syndrome" was coined in 1953 by (Charles) Raymond Greene (1901–1982), an endocrinologist at the Royal Northern Hospital in the London suburb of Hampstead (and brother of novelist Graham Greene), and Katharina Dorothea (Kuipers) Dalton (1916–2004), a London family doctor, in the British Medical Journal. They said, " ‘Premenstrual tension,’ as it has hitherto been called, is the commonest of the minor endocrine disorders." It was no longer necessary for women to "pass through one week of discomfort in every month, usually without complaining to their doctors but not necessarily without disturbing the tranquility of their homes" (p. 1007). The authors recommended treatment with the progestogen hormones. In 1953, Dalton established at University College Hospital the first "Premenstrual Syndrome Clinic" in the world. (She later wrote the bestselling Premenstrual Syndrome [1964]. In 1971 she became the first woman to serve as president of the general practice section of the Royal Society of Medicine.)

   With the cornucopia of psychoactive medications hitting the market in the 1960s and after, "PMS" soared in popularity as an indication for drug therapy. The whole concept of premenstrual complaints has undergone some bizarre contortions in the DSM series. DSM-III in 1980 contained nothing on it. DSM-III-R in 1987 proposed in an appendix the diagnosis "late luteal phase dysphoric disorder," a "pattern of clinically significant emotional and behavioral symptoms that occur during the last week of the luteal phase" (p. 367). Nothing was said about PMS. The clunky diagnosis did not catch on. Then, in DSM-IV in 1994, the disease designers tried again, with "premenstrual dysphoric disorder" (quickly abbreviated as PMDD). Although the diagnosis was intended for the mood disorders section of the Manual, the American Psychiatric Association once again consigned it to an appendix after a protest campaign by feminist organizations.

   In 1993, in work published in the International Journal of Psychiatry in Medicine, psychiatrist Uriel Halbreich (1943–) at the State University of New York at Buffalo, discovered "altered serotonergic activity in women with dysphoric premenstrual syndromes." This suggested a possible role for selective serotonin reuptake inhibitor (SSRI) drugs. Thus, a seal of approval of a kind for PMDD came rather via the back channel, as in November 1999, the Psychopharmacologic Drugs Advisory Committee of the U.S. Food and Drug Administration accepted PMDD as a legitimate indication for Lilly’s SSRI antidepressant drug fluoxetine (Prozac).