Rachel V. Isreeli
Mental illness is a fluid construct that shifts across cultures and time periods. In Western society, mental illness is conceptualized as grounded in objective and neutral data that become enshrined in diagnostic codes such as the Diagnostic and Statistical Manual. This perception of mental illness obscures dynamics of power that shape beliefs about normality and deviance and serve to stigmatize and regulate those people who do not fit the cultural norm. Patriarchal values, which proscribe the roles and qualities of the ※ideal woman,§ have resulted in the medicalization and pathologization of women＊s bodies. The case of Premenstrual Dysphoric Disorder demonstrates how patriarchal values, combined with the capitalist pharmaceutical industry and the media, construct and pathologize women＊s regular experiences, which subsequently shapes the concept of the premenstrual body as disordered and validates pharmaceutical intervention and social control.
Social Construction, Medicalization and Pathology
Social constructionism is a conceptual framework that emphasizes the cultural and historical aspects of phenomena (Conrad & Barker, 2010). Social constructionists recognize that knowledge is not inherent, but constituted through interpersonal, institutional and social processes (Georgaca, 2013). Social constructionism highlights the social development of meaning and knowledge by examining how individuals and groups contribute to producing perceived reality (Conrad & Barker, 2010; Georgaca, 2013).
Scholars in the 1960s and 1970s increasingly distanced themselves from positivist interpretations of the world that claim knowledge to be neutral and objective, asserting that social problems and deviant behavior are produced in particular contexts with intentional use of categories for social control (Conrad & Barker, 2010). This production and organization of knowledge is integral to societal power relations (Bjorklund, 2006). Foucault (1977) identifies the regulatory function of knowledge: the guise of objectivity surrounding ※expert knowledge§ obscures the power dynamics in the classification of categories such as ※normality§ and ※abnormality§ (Foucault, 1977; Jutel, 2011).
Social Construction of Mental Illness
The medical model of mental illness presents diagnosis as objectively based in empirical data. In contrast, Georgaca (2013) describes the constructed process:
Clinical interviews are transformed into psychiatric reports through selecting only information that fits the psychiatric formulation, reformulating that information in psychiatric terms, objectifying clients through systematic deletion of their perspectives, [and] obscuring the professionals＊ participation＃in order to fit the standardized sections of a psychiatric report. (p. 57)
Thus, professionals have the power to privilege certain elements of a person＊s story while ignoring others in effort to present a factual and ※neutral§ representation of a person with mental illness.
In contrast to the medical model which posits mental illness as objectively present to be discovered by scientists or physicians, social constructionists view mental illness as developed by sociocultural systems, including advocacy groups, the pharmaceutical industry, medical professionals and elected officials (Conrad & Barker, 2010; Jutel, 2011). The rise of neoliberalism and globalization has produced increasing categories and prevalence of diagnosis due to interests of commodification and consumerism (Jutel, 2011). Medicalization of regular processes is increasing, which occurs when a social situation or personal experience is made into a medical or psychological problem that requires the attention of experts (Offman & Kleinplatz, 2004).
Jutel (2011) describes diagnosis and mental illness as a sociopolitical process involving an exchange between stakeholders that ultimately produces a label to which medicine can anchor its authority. This process of labeling is embedded within competing relationships of power, control and social and financial interests (Ebeling, 2011). In a Western medical context, social power produces knowledge and the ability to name disease and disorder (Ebeling, 2011; Foucault, 1977). In his seminal book delineating the social construction of mental illness, Thomas Szasz (1961) articulates:
Labeling people disabled by problems in living as ※mentally ill§ has in fact delayed recognition of the essential nature of the phenomena. At first glance, to advocate that troubled people are ※sick§ sounds like a great boon, for it bestows the dignity of suffering from a ※real illness.§ But a hidden weight is attached＃which drags the troubled people back to the same sort of disability from which this semantic and social switching was to rescue them. (p. 28)
The construction of illness serves to obscure underlying social problems 每 often due to power and oppression 每 and placate those who suffer by individualizing their experience and validating their issues in medical and psychological terminology.
Social Construction, Medicalization and Control of Women＊s Bodies
Social constructionists argue that ※expert§ medical knowledge reflects and reproduces existing forms of social inequality by acting as agents of social control and shoring up the interests of groups in power (Conrad & Barker, 2010; Foucault, 1988). This is accomplished through the control and elimination of problematic experiences that are defined as deviant and not adhering to social norms (Weisz & Knaapen, 2009).
In patriarchal societies, women＊s bodies are historically pathologized in response to cultural anxieties about women＊s sexual and social freedoms and in effort to proscribe women＊s culturally ※proper§ role and character in society (Conrad & Barker, 2010; Offman & Kleinplatz, 2004). Foucault (1978) describes a ※process whereby the feminine body was analyzed 每 qualified and disqualified 每 as being thoroughly saturated with sexuality§ and integrated into medical and psychological practices (p. 104). Women＊s natural reproductive functions such as pregnancy, menstruation, childbirth and menopause are routinely medicalized and pathologized (Callaghan, Chacon, Coles, Botts & Laraway, 2009; Conrad & Barker, 2010; Offman & Kleinplatz, 2004). Likewise, women＊s emotional and psychological experiences are systematically considered deviant (Ussher, 2011). As Foucault (1988) attests, ※the entire female body is riddled§ by ※the perpetual possibility of hysteria§ (p. 153-154).
The incorporation of assumptions about women＊s sexuality and femininity in ※objective§ medicine both reflects and reproduces power relations. The process of defining deviance and sanity serves to construct and enforce boundaries of ※good§ behavior and unrealistic social norms for women (Andermann, 2010; Ussher, 2011).
Premenstrual Dysphoric Disorder
The case of Premenstrual Dysphoric Disorder demonstrates the contingent and socially produced nature of mental illness and the commodification and pathologization of women＊s bodies and behavior.
History of PMS and PMDD
In 1931, the American gynecologist Robert Frank coined the term ※premenstrual tension§ (PMT) to describe a constellation of changes related to the menstrual cycle (Offman & Kleinplatz, 2004; Weisz & Knaapen, 2009). At the time, PMT provided a medical rationale for why women should stay out of the workforce and leave available jobs to men (Chrisler & Caplan, 2002). In 1953, British endocrinologist Katharina Dalton contributed to the medicalization of the menstrual cycle by introducing the term ※premenstrual syndrome§ (PMS) (Offman & Kleinplatz, 2004; Weisz & Knaapen, 2009).
By the 1980s, PMS was firmly established in North American culture through magazines, self-help books and media (Chrisler & Caplan, 2002). It is likely no accident that the pathology of women＊s bodies immediately followed gains by women＊s liberation movements in the 1960s and 1970s. In 1987 the ※disease§ was institutionalized in the DSM-III-TR as Late Luteal Phase Dysphoric Disorder (LLPDD), as an ※unspecified mental disorder§ presented for further study (Offman & Kleinplatz, 2004). The symptoms of LLPDD were identified as similar to PMS but more severe and debilitating. Feminist and women＊s groups immediately challenged LLPDD＊s inclusion in the DSM, claiming obscure, biased and inconsistent diagnostic criteria.
In 1994, the DSM-IV changed the name to Premenstrual Dysphoric Disorder (PMDD), still as a category for further study. The central debate at this time focused on where PMDD should be located in the DSM (Offman & Kleinplatz, 2004). PMDD is now included in the main body of the DSM-5 under ※Depressive Disorders§ (American Psychiatric Association [APA], 2013). The importance of PMDD＊s inclusion in the DSM cannot be understated: as the most widely known psychiatric handbook, the DSM convinces psychotherapists and ※patients§ that PMDD is a mental illness (Chrisler & Caplan, 2002).
Definition & Prevalence
The DSM-5 defines PMDD as a cluster of significantly distressing psychiatric, somatic and social symptoms such as marked affective lability (e.g. mood swings, sadness, sensitivity), irritability or anger, depressed mood, anxiety, decreased interest in activities, lethargy, change in appetite (e.g. overeating or specific food cravings) and physical symptoms (e.g. breast tenderness or swelling, ※bloating§ or weight gain). At least five of these symptoms must be present in the week prior to menses for at least two cycles, and must be absent during the week postmenses. Criterion D indicates that the symptoms must cause clinically significant interference with work, school, usual social activities or relationships with others. These symptoms must not be an exacerbation of another psychiatric ※disorder§ nor due to effects of a substance (APA, 2013).
There is a lack of consensus regarding the symptoms and prevalence of PMDD. Chrisler and Caplan (2002) have identified at least 150 changes associated with the premenstrual phase in professional and popular literature, while Halbreich et al. (2003) noted over 300 different premenstrual complaints. Offman and Kleinplatz＊s (2004) review of research studies indicates that anywhere between 2% to 100% of menstruating women experience symptoms associated with PMDD. The diagnostic prevalence of PMDD is inconsistent, ranging from 2-11% (Callaghan, Chacon, Coles, Botts & Laraway, 2009; Halbreich et al., 2003; Offman & Kleinplatz, 2004; Ussher, 2011).
Controversy: Culture & Constructs
In addition to lack of consensus regarding symptoms, there has been significant debate about the utility and validity of PMDD as a diagnostic category due to unclear etiology and criteria. There have been no biological, psychological or environmental factors that explain differences between women with and without PMDD symptoms (Callaghan et al., 2009; Offman & Kleinplatz, 2004). It is possible that women with higher stress, greater incidence of sexual assault and trauma, and those who adhere to traditional feminine gender roles are at greater risk of PMDD (Chrisler & Caplan, 2002; P谷rez-L車pez, Chedraui, P谷rez-Roncero, L車pez-Baena & Cuadros-L車pez, 2009). These correlations could suggest variables of culture, social control and marginalization, rather than pathology innate to women＊s psychology and biology.
Researchers have been unable to assess validity of diagnosis due to unclear operational definitions of PMDD criteria (Callaghan et al., 2009). For example, it has proven methodologically difficult to differentiate PMDD from the premenstrual exacerbation of other disorders (Criterion E) (Offman & Kleinplatz, 2004). Few studies have looked at the impact of PMDD on ※usual activities§ (Criterion D); rather than being operationally defined, ※significant interference§ is often assumed or defined arbitrarily by researchers＊ subjective standards (Offman & Kleinplatz, 2004).
Additional criticism concerns methodological flaws and lack of consistency in assessing, measuring and diagnosing symptoms: It is difficult to ascertain the exact phase of the menstrual cycle; there has been an absence of control groups in research; most studies are based on retrospective reports of symptoms that are influenced by cultural expectations and tend to exaggerate symptoms in Western societies (Callaghan et al., 2009; Chrisler & Caplan, 2002). Furthermore, there is controversy regarding the gendered diagnostic construct of PMDD. Callaghan et al. (2009) investigated the sex-specificity of PMDD and found that men also met provisional criteria, suggesting that the official diagnosis pathologizes women unnecessarily.
PMS and PMDD are generally considered culture-bound syndromes, which are ※constellations of signs, symptoms and/or experiences that have been categorized as a dysfunction or disease in some societies but not in others§ (Chrisler & Caplan, 2002, p. 284). Although notions of symptoms may exist worldwide, PMS and PMDD syndromes tend to exist in Western societies but are absent from discourse in non-Western countries (Pilver, Kasl, Desai & Levy, 2011). Ussher (2013) notes that in Eastern cultures such as Hong Kong or China, where change is accepted as a regular part of daily existence, women report physical symptoms but rarely report negative premenstrual moods.
Social Construction and Social Control
Premenstrual change is a normal female experience that is constructed as a psychological deficit (Ussher, 2011). The fact that the medical establishment treats premenstrual symptoms as a disorder, despite lack of consensus in research, suggests that it is a sociocultural construction rather than a scientific ※fact§ (Offman & Kleinplatz, 2004). The pervasiveness of PMS and PMDD in Western culture encourages women to internalize symptoms and attribute their unhappiness, difficulties and failures to internal and biological factors rather than external stressful causes (Chrisler & Caplan, 2002).
The construction of problematic premenstrual symptoms is rooted in patriarchal and capitalist values. The medicalized pathology of PMS and PMDD suggest how women ought to behave and thus contribute to policy and culture that authorize social control (Conrad & Barker, 2010). Western idealized femininity emphasizes women as calm, in control, slim, patient, nurturing and kind (Chrisler & Caplan, 2002; Ussher, 2011). Capitalist American culture encourages people to maintain control over their lives and ensure productivity. Since the medicalization of PMDD institutionalizes ※mood swings,§ ※irritability or anger,§ ※weight gain,§ ※lethargy§ and ※out of control§ as problematic, it reinforces traditional ideals of femininity and capitalist goals while repressing legitimate and normal feelings (APA, 2013; Weisz & Knaapen, 2009).
Pharmaceutical Industry and the Media
The conceptualization of women＊s premenstrual changes and emotional variability as inappropriate results in workplace policy, the pharmaceutical industry and the media reinforcing practices of women＊s self-surveillance in regards to moods, behaviors and expressions (Chrisler & Caplan, 2002; Ussher, 2011). The pharmaceutical industry has become a major stakeholder in the process of diagnosing and publicizing PMDD, as it has recognized the profitability of constructing, commercializing and disseminating ※knowledge§ about premenstrual symptoms (Conrad & Barker, 2010; Ebeling, 2011; Offman & Kleinplatz, 2004).
The pharmaceutical industry supports research regarding the symptoms, prevalence, etiology and treatment of PMDD; one article for this paper was written by doctors that receive funds from Eli Lilly and Bayer Healthcare Pharmaceuticals, two companies that make prescription drugs for PMDD (Cunningham, Yonkers, O＊Brien & Eriksson, 2009). In constructing and branding the ※disease,§ Eli Lilly repackaged its top-selling anti-depressant Prozac 每 just before the patent was due to expire 每 in pink and purple colors and renamed it Sarafem as a treatment for PMDD (Chrisler & Caplan, 2002; Ebeling, 2011). The industry then invests in media coverage about the ※condition§ for which it has a treatment: images of premenstrual problems are ubiquitous in magazines, films, television shows, songs and advertising (Chrisler & Caplan, 2002).
Together, media and the pharmaceutical industry brand the diagnosis and promote ※disorder§ awareness through direct-to-consumer marketing campaigns (Ebeling, 2011). These campaigns encourage self-diagnosis, as the vast majority of U.S. women of reproductive age become convinced that they suffer from PMS at least occasionally (Chrisler & Caplan, 2002; Ebeling, 2011). Bayer＊s website for Yaz, a birth control pill that is marketed for treatment of PMDD, provides a checklist tool for this purpose (Ebeling, 2011). With patient self-diagnosis, psychiatrists and pharmaceutical companies have an economic incentive to emphasize a psychiatric diagnosis that legitimizes the profession and validates pharmaceutical treatments (Offman & Kleinplatz, 2004).
Premenstrual change is a normal part of women＊s experience. However, Western culture constructs the premenstrual phase as a time of psychological disturbance, precisely because some of the symptoms 每 frustration, anger, erratic behavior, lack of ※productivity§ 每 defy norms about how women ought to behave (Conrad & Barker, 2010; Ussher, 2013). This sociomedical pathology identifies menstruation as a disorder in need of treatment, which justifies the use of psychiatric intervention that reinforces gender inequality and becomes a boon to the pharmaceutical industry with the help of the media (Conrad & Barker, 2010; Ussher, 2013). The construction of premenstrual change as a disorder serves to restrict women＊s behavior and ensure self-policing (Foucault, 1977): Only in a capitalist and patriarchal context does it make sense to label normal female biological processes as a disease that requires controlling. It is critical that practitioners and ※patients§ alike denaturalize psychiatric ※knowledge§ and explore the institutions and interests involved in creating and labeling pathologies.
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About the Author
Rachel Isreeli is a Brooklynite and second year Community Organizing student at Silberman School of Social Work at Hunter College. Rachel has worked in counseling, advocacy, education and program development. Her work and interests focus on issues of gender, sexuality, labor, trauma, criminal justice and the sex trade. She holds a BA from Dartmouth College and an MS from Pace University. She can be reached at email@example.com.