The nation's leading psychiatric organization has proposed labeling premenstrual syndrome a mental illness, triggering protests from feminists who fear such a move will stigmatize women professionally and personally.
The American Psychiatric Association, which represents about 80 percent of this country's psychiatrists, is now hearing arguments on whether PMS and two other controversial disorders should be included in The Diagnostic and Statistical Manual of Mental Disorders (DSM-III), a volume that describes mental illnesses and is used to diagnose patients. DSM-III is also widely used by lawyers, medical researchers and insurance companies.
PMS is usually considered the cyclic recurrance of mood changes, fluid retention and other symptoms related to the menstrual cycle. In December, the APA's board of trustees -- whose 18 members ultimately decide what is included in the manual -- tentatively approved the controversial revisions that include PMS, self-defeating personality disorder and paraphilic coercive disorder as mental illnesses.
If the revisions are approved, the Seattle-based Feminist Therapy Institute plans either to file suit seeking to bar publication of the manual or to organize legal assistance efforts to sue doctors who use the diagnoses improperly, according to institute chairwoman Lynne Bravo Rosewater.
"This is a book used by all mental health workers, and we feel the diagnoses are damaging to women," said Rosewater, a psychologist.
Both the Womens' Committees of the APA and the American Psychological Assocation have formally denounced the diagnoses as sexist, and say they will continue writing, speaking and gathering evidence against them. In addition, members of the Association for Women in Psychology, meeting in Oakland this week, plan to discuss possible strategies for stopping any manual that includes the controversial items.
Dr. Robert Spitzer, who heads the APA's work group to revise the manual, defended the new classifications. "I think the revisions all correspond to real clinical problems that need to be studied," he said. "Researchers have not said, 'Let's see if we can find something wrong with women.' "
Spitzer predicted that the PMS classification will clear up widespread misunderstanding about the condition. "One of the problems of studying PMS is there are too many definitions. We need an agreed-upon one," he said.
PMS should not be classified as a mental illness, contends Dr. Teresa Bernardez, head of the APA's Committee on Women and a psychiatry professor at Michigan State University. "The diagnosis could lead people to believe women are more vulnerable than men," she said, "that any woman in the pre-menstrual part of her cycle could lose control or be less effective."
Dr. Sally Severino, a psychiatrist currently conducting a PMS study at New York Hospital, Cornell Medical Center, advocates the diagnosis. She feels that classification in the manual confers legitimacy on a syndrome historically neglected by doctors and scientists.
"The PMS entity has been described for 50 years," Severino said. "We've known about it since the beginning of time. One reason we haven't studied it in a consistent way is it hasn't been included in the manual."
"It's a mental disorder," said Dr. David R. Rubinow, psychiatrist and PMS researcher at the National Institute of Mental Health, who supports the new revision. "Anyone who doesn't believe that hasn't worked with these people (PMS sufferers). They don't come in because their breasts are swollen; they come in because they have a change in perceptions and in their ability to deal with stressful situations."
Classifying PMS as a mental illness will have strong legal implications, said Brooklyn District Attorney Elizabeth Holtzman. "The APA's proposal to label PMS as a mental disorder may provide a spurious defense for some women who could claim that their violence was caused by it," she said.
Controversy also surrounds APA's proposal to include two other disorders in the manual -- self-defeating personality disorder, characterized by remaining in abusive or exploitative relationships, and paraphilic coercive disorder, which involves sexual arousal induced by persistent fantasies of committing rape.
The self-defeating personality classification could be used to diagnose battered women, unjustly attributing their victimization to a personality disorder, opponents from the APA and American Psychological Association charge.
"There is no research that a self-defeating personality exists," said Renee Garfinkel, administrative officer of women's programs at the American Psychological Association. She said research shows that separating victims from their abusers most effectively -- and quickly -- ends the abuse. But the self-defeating personality classification would require long-term psychoanalytic treatment of the problem instead.
Dr. Frederick Kass, director of adult psychiatric services at Columbia Presbyterian Medical Center in New York, and the disorder's primary researcher, defended it, saying: "My problem with opponents is they seem extreme and arbitrary. They say battering situations never have anything to do with personality. What would you say if you had a patient who married five times and was battered each time? Still, there are a lot of battered women who aren't masochistic.
"I share the concerns that have been raised. There is a potential for abusing this diagnosis, but no more than any other diagnosis," Kass said.
Sally Burns, adjunct professor of law at Georgetown University Law Center and assistant director of the sex discrimination clinic there, said the classification might be used against women in a legal battle.
"When you set up that category, you're blaming the victim," Burns said. "If the defense in a spouse abuse case chose to put a psychiatrist on the stand using that diagnosis, it would encourage the jury to see that, 'She asked for it.' "
Legal objections have also arisen to the inclusion of the paraphilic coercive disorder classification in DMS-III, because of its potential for use by the defense in rape cases.
The APA board of trustees will vote in December on whether or not to include the revisions in DMS-III, which is slated to be published in 1987. Since it was first published in 1952, the manual has been revised twice, in 1968 and 1980.
Until December, said APA president-elect Dr. Robert Pasnau the issue remains open.
"We are getting a lot more data," he said, "and the battle is still on."