Premenstrual dysphoric disorder: out of the appendix.

Both the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) are in development to produce revised diagnostic categories and updated diagnostic coding. Optimally, the new classification systems would increase the ability to match DSM codes with ICD codes for mental disorders. In general, the process for updating psychiatric disorders in DSM-V involves literature reviews, research plans for field trials, secondary data analyses and revision of the DSM-IV-TR text. The DSM has traditionally utilized a categorical classification system of disorders, and there is consideration of classifying disorders along symptom dimensions. Controversies exist about the addition of new disorders (e.g. internet addiction) and removal of current disorders (e.g. gender identity disorder). The approach planned for updating premenstrual dysphoric disorder (PMDD) in DSM-V has not been revealed. Currently the “Research Criteria for Premenstrual Dysphoric Disorder” is included in the “Criteria Sets and Axes Provided for Further Study” in Appendix B of the DSM-IV-TR. Women who meet the PMDD criteria are coded on axis I with 311, Depressive Disorder Not Otherwise Specified (NOS). PMDD is an example of the mismatch between the ICD and DSM classification systems. ICD-10 defines premenstrual tension syndrome as the presence of one or more emotional or physical premenstrual symptoms. Symptom severity and duration are not specified. ACOG published diagnostic criteria of premenstrual syndrome (PMS) in 2000 that requires at least one emotional or physical premenstrual symptom, the symptom(s) must resolve postmenses, and the symptom(s) must be severe enough to interfere with social or work functioning. In addition, prospective confirmation of the symptoms by daily ratings for two menstrual cycles is required. The DSM-IV-TR PMDD criteria require at least 5 of 11 potential symptoms, one of which must be marked depressed mood, anxiety, affective lability or irritability. Symptoms must remit following menses, be present in most menstrual cycles, interfere with social and work functioning, and be confirmed by prospective daily ratings over two menstrual cycles. Women who meet criteria for PMDD are viewed as the severe end of the spectrum of PMS. At this point, the criteria for PMDD should be its own diagnostic classification outside of the appendix. Since the inclusion of research criteria for late luteal phase dysphoric disorder in the DSM-III-R in 1987, many studies have been conducted in women with PMDD evaluating etiology, comorbidity, burden of illness and treatment. Studies of pathophysiology suggest serotonin abnormalities, allopregnanolone and GABAA receptor dysfunction, and heightened sensitivity to normal fluctuations of estrogen and progesterone (Cunningham et al. 2009). The link between gonadal hormones, neurotransmitters, and neurosteroids may also underlie perinatal and perimenopausal depression (Payne et al. 2009). The existence of PMDD criteria has led to two decades of pharmacological and nonpharmacological treatment studies (Pearlstein and Steiner 2008; Cunningham T. Pearlstein Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02912, USA