The name has changed, but the situation hasn't really progressed very far since the days when Hippocrates ascribed delusions, mania, thoughts of suicide and other symptoms to "retained menstrual blood," in his treatise on "The Sickness of Virgins."
Premenstrual syndrome -- or syndromes, as most researchers now believe is more accurate -- is still the subject of great controversy and has recently become a topic of increased study. One researcher, Dr. David R. Rubinow, chief of the unit of peptides studies at the National Institute of Mental Health, now suggest that it is not the result of a hormonal imbalance. His theory is that it is a result of altered brain activity.
For more than two years, Rubinow has been following a group of women who have clear behavioral, mood and physiological changes that recur in tandem with their menstrual cycles. Preliminary results indicate that the so-called "raging hormone" thesis raised a few years ago has no merit. This invalidates many of the hormone therapies for PMS that have been widely touted but, said Rubinow, poorly tested. (Several studies do show, however, that one popular therapy -- Vitamin B6 -- may be useful in some types of PMS.)
"We've looked at a number of hormones that are related to the female reproductive system including progesterone, estradiol, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, cortisol, testosterone and a bunch of others," Rubinow said. "But it does not appear that the premenstrual syndrome is characterized by any baseline hormonal abnormality."
The hormonal measurements in the women with a premenstrual syndrome were not significantly different from those in a group of controls who were followed over several months, Rubinow said.
Rubinow now hypothesizes that PMS "can best be described as a state-related disorder. The menstrual cycle may be acting not as a cause of these up to 150 symptoms, but as a director or choreographer of the state."
By "state," Rubinow means a state of mind -- or, more accurately, a state of brain activity -- that includes a set of different characteristics -- moods, perceptions, thoughts, ideas, self-confidence, self-image. These, said Rubinow, are "integrated and tend to appear in concert with one another with some degree of frequency and, in the case of PMS, predictability."
"If that model is true," he said, "what we need to do is develop ways of helping people change their state so that they don't feel trapped and helplessly confined to what they would describe as their dysphoric unhappy premenstrual state."
This suggestion, however, puts Rubinow right in the center of a controversy that has been raging fiercely, but mostly out of the public eye, in the cerebral conference rooms of the American Psychiatric Association.
The APA is engaged in revisions of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the most widely accepted criteria for diagnosing mental problems.
The APA is proposing that "premenstrual dysphoric disorder" be listed in the forthcoming DSM-III-R, encompassing some of the mood and behavioral symptoms linked to PMS. However, some female psychiatrists, psychologists and other mental health professionals have objected, maintaining that this new category -- along with two others unrelated to PMS -- could be interpreted as official license to discriminate against women because they may be subject to a monthly "mental illness."
Rubinow, a psychiatrist who is avowedly sympathetic to the feminist cause, says he believes that the DSM-III-R controversy is one of ideology rather than medicine. He sees the so-called premenstrual dysphoric disorder as one of a number of syndromes, or clusters of symptoms, that can correlate with menstrual cycles.
A number of disorders with clearly biological symptoms -- manic-depression, for example -- are listed in DSM-III. And, Rubinow said, "It is because their major symptoms are behavioral or cognitive and, as such, they are felt to be within the province of psychiatry. I would submit that premenstrual dysphoric disorder as defined, characterized primarily by mood and behavioral disorders that are of sufficient severity so as to interfere with one's life, is an attempt to impose some degree of order on what is a rather chaotic scheme for PMS.
"It seems to me it is a step in the direction of, first of all, respect for PMS, rather than viewing it as some sort of pseudo-disorder. And it is a step in the direction of ensuring some accuracy of diagnosis.
"It also makes it clear that PMS is not a feature of being a woman, but is a specific diagnostic entity that presumably affects a relatively small percentage of people.
"I think, this would actually work toward defusing the myth that all women have PMS."
Finally, Rubinow said, "I think right now, lots of people [with PMS] are being treated for such things as 'atypical anxiety disorder' or 'atypical depression,' and I think it works to everyone's benefit if we can be somewhat more diagnostically precise."
Rubinow says he sees his emerging "state" theory of PMS as potentially useful in a number of ways.
"What it suggests," he said, "is that PMS can tell us a tremendous amount about how all of us change states under normal conditions. It may tell us about pathological disorders of state like manic-depression or panic-anxiety syndrome and it really offers a fantastic opportunity to investigate the relationship between biology and behavior."
Some other new research being done by Rubinow and others is aimed at proving or disproving a suggestion that PMS represents an addiction to -- or perhaps a cyclic withdrawal from -- the body's natural opiates, the feel-good brain chemicals such as the endorphins or enkephalins. To test this, investigators will administer drugs that either are known to block the body's opium-like chemicals or other drugs used to help addicts withdraw from opiate drug addictions.
Rubinow and his team are also testing changes in glucose tolerance in hopes of explaining the common PMS-associated craving for sweets and chocolates.
His studies are indicating some similarities in the development of premenstrual syndromes with the development of so-called "learned helplessness" as has been applied to laboratory rats. Classically, one group of rats is given electric shocks which individual rats can learn to control. The other group of rats is stimulated exactly the same way, but has no way to control the shocks. Characteristically, the rats who cannot control their environment develop pronounced behavioral and biological changes.
Rubinow suggests the possibility that women with PMS may, rightly or wrongly, have perceived that the symptoms that precede their menstrual periods are not controllable.
Using another model, he theorizes that the body may have become sensitized and over-respond to the repetition of symptoms that were initially only mildly irritating.
Both models, Rubinow said, "indicate that the relationship between biology and behavior is not unidirectional." Biological events can shape behavior and perceptions can change biology.
"One of the most frightening elements of PMS," Rubinow said, "is the sense of being out of control."
Through careful screening of self-diagnosed sufferers of PMS, Rubinow has found that nearly two thirds are either "stable as the rock of Gibraltar" or are suffering from cycles of mood states that are not really concurrent with menstrual cycles. Or there may be menstrual-cycle-related mood shifts, but too mild to be seriously disabling.
"What is so fascinating," said Rubinow, "is that the people with PMS often experience the same kind of amazingly dramatic mood shifts you see in major manic-depressive disorders or that most people normally experience from time to time when one minute they feel terrible, unable to cope, and a few minutes later, as a result of who-knows-what, they feel pretty doggone good." Treatment Groups
Women who believe they experience premenstrual syndrome may be eligible to participate in NIMH treatment groups. Call 496-9675 for a free evaluation.