The historic inclusion of Premenstrual Dysphoric Disorder in DSM-5 represents a huge leap forward in access to diagnosis and treatment for patients suffering from cyclical affective symptoms. However, as usual for new diagnoses, there is a need for refinement as we learn more about the disorder over time. Below is my preliminary “wishlist” of changes for DSM-6 PMDD based on the lab’s work.
<aside> 💡 Note: for a thoughtful, well-researched description of the (frankly, petty dramatic!) history of the PMDD diagnosis, read The Cycle by Shalene Gupta.
</aside>
Elimination of the absolute clearance requirement would eliminate the need to differentiate those with higher vs lower mean levels of psychopathology, and make it so that anyone with distressing or impairing cyclical symptom change could receive a diagnosis and treatment.
<aside> 🌤️ The requirement of absolute symptom clearance could be eliminated to put greater focus on cyclical symptom change rather than mean levels of psychopathology.
</aside>
Cyclicity of mood similar to that of PMDD is normally distributed and commonly clinically significant in the population of cycling patients with affective disorders, undermining the notion that premenstrual exacerbation (PME) fundamentally different from PMDD, and suggesting that shared cyclical hormone sensitivities underlie female psychiatric risk in both cases.
Affective Risk Associated With Menstrual Cycle Symptom Change
Higher symptom intercepts (mean levels over time) are associated with greater symptom cyclicity, suggesting that greater cyclical hormone sensitivity is associated with LESS symptom clearance in the follicular phase. Logically, this indicates that those with the most cyclicity will always have comorbid affective disorders and fail to show absolute clearance in the follicular phase.
<aside> ⛅ A specifier denoting a high level of background symptoms (e.g., “with incomplete clearance”) could be added to ensure that treatments tested on those with COMPLETE follicular clearance (i.e., DSM-5 PMDD) would be applied to the correct population.
</aside>
The problem with the “treat the non-cyclic disorder first” approach
The DSM-5/-TR recommends (or is interpreted to recommend) that patients who meet criteria for other DSM disorders that do not fully remit in the follicular phase should always have those other disorders treated first, and hormone-related symptoms treated later. While this may be appropriate in many cases, I think that patients with impactful cyclical symptom change should be eligible (as appropriate) for direct, primary treatment of that hormone-related symptom change regardless of their mean level of symptoms or comorbidities— for example, when it is clear or seems likely that the hormone sensitivity is the primary kindling process that underlies the development and maintenance of other psychopathology. Integration of “PME” into the PMDD diagnosis would achieve this goal.
“Why not add a “with Menstrual Cycle Exacerbation” Specifier to each disorder that can be exacerbated and leave the PMDD diagnosis as-is”?
This is a nice idea, but the pleiotropic effects of steroids in the brain mean that pretty much ANY DSM disorder could be exacerbated by the menstrual cycle— and adding a menstrual cycle specifier to every DSM diagnosis would be a difficult task. Hypothetically, a particularly hormone-sensitive patient with high cyclicity and high mean levels of psychopathology might currently receive several different DSM diagnoses “with menstrual cycle exacerbation” (or maybe borderline PD with menstrual cycle exacerbation) that could be more parsimoniously diagnosed as a variant of PMDD (“with incomplete clearance”). This increases coherence and focus on the shared hormone sensitivities that underlie symptoms for many patients.
<aside> 🧮 The requirement of 5 cycling symptoms could be reduced or eliminated to allow for diagnosis of patients with a lower number of distressing/impairing symptoms.
</aside>
The requirement of 5 symptoms may be too high, since just 4 symptoms predict significant cyclicity of impairment (which isn’t required for DSM-5 diagnosis since distress OR impairment is sufficient).
This is a living document and will change over time. I am eager to discuss these ideas with colleagues and consider how we could further test these hypotheses/opinions with clinical data. These ideas have been influenced by several of my Collaborators (Co-Is), as well as patient advocates at About IAPMD (Nonprofit for PMDs).
My hope is that some of these ideas will eventually be shared in manuscript form.