Adam and PMDD

“Is it really hot right now, or is it just me?”

Lately I’ve been asking that more often when I feel oppressively hot and sweating, wondering if I’m diabetic… or suffering from ADAM.

You’ll have to read the rest of my column to find out what ADAM means but, in the spirit of the month of March, I can tell you it’s gender-related. I just wrote about transgenders (which generated some heat) and today I’ll talk about matters that affect all genders but, more specifically, women.

It all started with discussions around a forthcoming fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM), which lists mental disorders, together with diagnostic criteria. The DSM is constantly being reviewed, with some disorders getting delisted (for example, homosexuality in 1973) while new ones getting included.

The inclusion or exclusion of mental disorders is based on extensive reviews of clinical experiences and reports with expert committees having long meetings. For this new edition of DSM, the APA turned to the Internet to solicit views from the public, by putting up a site, dsm5.org, where proposed revisions were posted.

Some of the revisions have elicited strong responses from the public. For example, Asperger’s syndrome, where a person has difficulty reading other people’s emotions, will no longer be listed separately and will instead be considered part of autism spectrum disorders. That has drawn protests from people with Asperger’s, some of whom do not want to be bunched together with people with autism. Others are protesting because if Asperger’s is no longer in DSM, then they may not be able to get reimbursements for their medications or treatment from Medicare (the equivalent of our PhilHealth) or health maintenance organizations. People with Asperger’s argue that the condition can be so serious that it adversely affects their interpersonal relationships—people with Asperger’s will seem tactless and confrontational—and makes it difficult for them to hold sustained employment.

PMS

The case of Asperger’s is an intriguing example of people insisting that they do have a mental disorder (or at least a problem) that needs to be included in the DSM. In other cases, controversies come about because of opposition to a proposed listing. This is the case with a proposal for a new entry called PMDD or Premenstrual Dysphoric Disorder.

You read it right, the term sounding like PMS or premenstrual syndrome. Predictably, the protests are coming from women who say this is an example of a medicalization of a natural part of life. Menstruation is indeed a normal physiological process but, proponents of PMDD argue, the fluctuations in hormonal levels can bring about quite severe physiological and emotional changes, affecting a woman’s work and social relationships.

The PMDD entry in DSM will be under “major depressive disorders,” and someone is said to have PMDD if she has five of the following criteria: mood swings, marked irritability or anger or increased interpersonal conflicts, feelings of hopelessness, marked anxiety and decreased interest in usual activities, a subjective sense of difficulty in concentration, lethargy, a marked change in appetite, insomnia, a subjective sense of being overwhelmed. Physical criteria include breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” weight gain. (I’ve changed some of the wording. Visit dsm5.org and search for PMDD for the exact listings and more details on using the criteria.)

This is not the first time the APA has thought of including a pre-menstrual entry in the DSM. Many years ago, there was an even fancier, or intimidating, acronym that was proposed to describe this condition: LLDD or late luteal dysphoric disorder, “late luteal” referring to the pre-menstrual period and “dysphoric” meaning extreme discomfort and distress, as opposed to euphoria.

Opponents to the inclusion of PMDD say this is another ploy to create a market for pharmaceuticals. At present, PMS is usually treated with pain-killers, sometimes in combination with diuretics or drugs that increase urination, to reduce the edema. The pain-killers are quite ordinary, the same ones used for fever and various body aches but pharmaceutical companies do try to segment the market and what better way to do this than by sex. They did this quite successfully with Midol, which at one time had the same analgesic, ibuprofen, as Alaxan, but I never heard of a super-macho basketball player throwing in the towel after a tough game and going, “P’re, I need a Midol.”

Describing PMDD as a depressive disorder could mean a shift to newer, and more expensive, drugs. As early as 1999, as the patent on the anti-depressant drug Prozac (generic name: fluoxetine), was about to expire, its manufacturer Eli Lilly sought approval from the US Food and Drug Administration for the extension of its patent because of a new use for the drug: PMDD. Although PMDD was not listed in DSM, the US FDA approved this new use and Eli Lilly came out with a new version of Prozac with the brand name Sarafem, properly gender-coded as pink and purple capsules.

And so the debates—and suspicions of  conspiracies between doctors and pharmaceutical companies—will continue. Similar controversies crop up around “preconditions,” for example “prehypertension,” where a measurement of 120/80, previously considered normal, can now be considered as a danger signal meriting the use of anti-hypertensive medicines.

And if women’s groups now have to deal with menstrual conditions and labels, there are more discussions among health professionals as well as lay people, about andropause, a loose male equivalent of the menopause. As testosterone levels drop with age, do we begin to “suffer” symptoms, some similar to those of menopause, like the hot flashes (if you’re American) or hot flushes (if you’re Canadian). There are even proposed medical labels now for this condition, someone apparently giving enough thought to come up with the catchy ADAM or Androgen Deficiency in Aging Males. Some physicians prefer calling it PADAM, “p” for “partial.” I am sure there will be more debates, even on the name itself. Aging males? I beg your pardon. I like an American feminist friend’s idea about thinking of hot flashes as “power surges.”

Now where did I put the remote control for the air-conditioner?

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