Le trouble dysphorique prémenstruel : trouble mental ou difficulté d’adaptation ?

Abstract

Premenstrual dysphoric disorder (PMDD) is characterized by thymic (irritability, depressed mood, anxiety), physical (breast swelling, muscle pain), and behavioural (decreased interest, lethargy) cyclical symptoms that appear approximately one week before menstruation and begin to decrease after the luteal phase. Diagnosis considers the degree to which these symptoms have altered social or professional functioning during the year preceding consultation. DSM-III (Diagnostic and Statistical Manual of Mental Disorders) and DSM-IV working groups have successively decided not to attribute an official disorder status to PMDD, apprehending its possible negative impact (e.g., potential increase in prejudice against women through pathologization of natural female functioning and a risk of misuse). Since its inclusion in the DSM-5 (the latest edition of the American Psychiatric Association's DSM) in 2013, it has achieved official status of mental disorder. It is also expected to be included in the 11th revision of the International Classification of Diseases (ICD-11) according to the beta draft of the World Health Organisation. The current paper challenges the validity and relevance of PMDD inclusion in diagnostic textbooks through an argument from both sides on this issue. Criticism about PMDD largely comes from feminist groups, worried about the implications of including the diagnosis and its associated treatments, which are firmly rooted within the medical paradigm. The scientific community, however, is divided, and while some welcome the DSM-5 work group initiative, others are less enthusiastic. The DSM-5 work group identified sufficient empirical support to justify inclusion of PMDD in the Depressive disorders category. Their decision was based on an examination of the four requirements necessary for including any disorder in diagnostic textbooks, that is: (a) a clear distinction of PMDD from other disorders, (b) the presence of antecedent validators (environment and cultural consideration), (c) concomitant factors (biomarkers) and (d) predictive validator (PDMM's stability over time and drug treatment response). The current paper reviews these requirements. A first consideration leading to the inclusion of PMDD in DSM-5 is that it could clearly be distinguished from other mood disorders by the concordance between the premenstrual phase and the symptoms’ onset. Indeed, the symptoms begin at the luteal phase and tend to disappear when menstruation ends. However, a meta-analysis reveals some issues in how symptoms ratings have been used in PMDD's studies. Furthermore, it appears that PMDD present high comorbidity with other disorders. A majority (73%) of PMDD cases are combined with another mental disorder (anxiety disorder, mood disorder, etc.). Secondly, PMDD work group advocates the importance of heritability, compared to what they describe as a very modest impact of environmental issues on symptoms’ onset. That said, some studies highlight the association between PMDD and various life events and suggest that PMDD is a culture-bound phenomenon. Women who met PMDD criteria would have had experienced significantly more physical and sexual abuse, interpersonal problems, and mistreatment at work than women who did not meet the diagnostic criteria. In addition, women in Western Europe and North America appear to be at greater risk of having PMDD. Third, although no biological markers have systematically been associated with PMDD, notable differences on some gene of women with PMDD have recently been identified. However, biological markers that are characteristic of women with PMDD could be the result of traumatic antecedents rather than the unique cause of this psychological distress. Finally, the work group claims that some predictive factors, which predict the PMDD symptoms’ and response to drug therapy, tend to confirm its existence. The fact that symptoms reappear at each cycle would demonstrate the disorder's periodicity and stability. Furthermore, the effectiveness of medications (Selective Serotonin Reuptake Inhibitors- SSRI) in treating this disorder has been a significant factor in the decision of its inclusion in the DSM-5. Nevertheless, the central role played by treatment response in PDMM validation has been challenged by some researchers. Scientific literature review urges to be careful regarding PMDD's place in the diagnostic textbook. Indeed, additional studies concerning discrimination of PMDD from other disorders, life event's role, intercultural issues, and biological correlates are warranted to confirm its validity. To conclude, the arguments raised in the current paper are not intended to invalidate the existence of women's premenstrual symptoms or emotional distress that some women may experience, but rather to debate on the legitimacy of PMDD's inclusion as a “disorder” in psychiatric textbooks and diagnostic manuals.