PMS, PMDD Can Be Considered on a Continuum


KOLOA, HAWAII — The DSM-IV criteria for diagnosing premenstrual dysphoric disorder need to be improved, Dr. Meir Steiner said at the annual meeting of the American College of Psychiatrists.

“What is wrong with the DSM criteria for PMDD?” he asked rhetorically. All the questions listed have just yes-or-no answers, indicating that the criteria are too rigid. As a result, in the 17 years since the DSM criteria were formed, the Food and Drug Administration has not allowed “any studies on PMS because they claim there are no criteria that define or identify PMS,” he said.

“I believe PMS and PMDD are on a spectrum. PMDD is primarily what we psychiatrists are dealing with, which are primarily the mood syndromes, whereas PMS is something [obstetricians and gynecologists] see more of, which are primarily physical symptoms,” said Dr. Steiner, professor of psychiatry and behavioral neurosciences, and ob.gyn. at McMaster University in Hamilton, Ont.

Dr. Steiner and his colleagues decided to try assessing DSM-IV criteria on a spectrum. With this approach, the physician would look at the symptom irritability, for example, and ask patients, “Is it severe, is it moderate, is it mild, or does it not exist at all?”

“By doing that, you have actually taken the DSM-IV criteria and transformed them from a yes/no to a continuum,” he said. (See box.) They did the same with the DSM-IV questions regarding the burden of illness.

The investigators then created the following formula: If at least one of the first four criteria is severe (which is what the DSM-IV requires); at least four of the questions from 1 to 14 is moderate to severe; and at least one of the burden criteria is severe, then a patient qualifies for PMDD. Then they went a step further: “If you are missing one step on each of these [criteria], you will still qualify for what we have identified as severe PMS,” he said.

They tested their new instrument on women who were at least 18 years of age, asking them to fill out a questionnaire that listed the 14 DSM-IV criteria for PMDD and to rate their symptoms as “not at all,” “mild,” “moderate,” or “severe.” A total of 5.1% of women qualified as having PMDD, and 20.7% had severe PMS.

To fulfill the diagnosis of PMS, “they had the burden of illness and they had symptoms of PMDD, but were short one severity criterion,” said Dr. Steiner, who is also founding director of the Women's Health Concerns Clinic for St. Joseph's Healthcare in Hamilton.

Because the FDA was not convinced that these symptoms occurred in girls younger than 18 years of age, Dr. Steiner and his associates tried the questionnaire on girls aged 12–17 years. They interviewed 604 girls from three high schools. Of those girls, 9% qualified as having PMDD and 31% had severe PMS. Of the latter, “what was missing was the burden of illness,” he said, noting that “four of the girls eventually came to the clinic for treatment.”

Premenstrual Symptoms Questionnaire



Tearful/increased sensitivity to rejection.

Depressed mood/hopelessness.

Decreased interest in work activities.

Decreased interest in home activities.

Decreased interest in social activities.

Difficulty concentrating.

Fatigue/lack of energy.

Overeating/food cravings.



Feeling overwhelmed or out of control.

Physical symptoms: breast tenderness, headaches, joint/muscle pain, bloating, weight gain.

Source: Dr. Steiner

Diagnostic Criteria for PMDD

Symptoms must occur during the week before menses and remit a few days after onset of menses. Five of the following symptoms must be present and at least one must be 1, 2, 3, or 4.

Depressed mood or dysphoria.

Anxiety or tension.

Affective lability.


Decreased interest in usual activities.

Concentration difficulties.

Marked lack of energy.

Marked change in appetite, overeating, or food cravings.

Hypersomnia or insomnia.

Feeling overwhelmed.

Other physical symptoms, such as breast tenderness or bloating.

Symptoms must interfere with work, school, usual activities, or relationships.

Symptoms must not be merely an exacerbation of another disorder.

Criteria A, B, and C must be confirmed by prospective daily ratings for at least two consecutive symptomatic menstrual cycles.

Source: DSM-IV, Text Revision

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