Menstrual psychosis

Menstrual psychosis is a term describing a periodic psychosis with acute onset in a particular phase of the menstrual cycle. Most psychiatrists are skeptical that the symptoms indicate a distinct disorder.[3] Over the last few decades some case studies have been published in medical literature with an accompanying argument that the condition is under recognized by practicing psychiatrists.[4]

Menstrual psychosis
Image showing hormonal changes during mestruation,main trigger of the disorder
SpecialtyPsychiatry
SymptomsHallucinations, delusions, stupor, confusion, mania[1]
ComplicationsSuicide
CausesHormonal changes
Risk factorsHistory of other psychotic disorders (eg.schizophrenia, bipolar disorder),[2] unknown, epilepsy, endometriosis
Differential diagnosisSchizoaffective disorder, schizophrenia, bipolar disorder, premenstrual dysphoric syndrome
TreatmentMedication, cognitive behavioral therapy
MedicationAnti-psychotics

Definition

Menstrual psychosis is a rare form of severe mental illness. Episodes have a sudden onset in a previously asymptomatic person, and are usually of brief duration, with full recovery. The psychotic symptoms can include confusion or hallucinations, mutism and stupor, delusions, or a manic syndrome; these are distinct from premenstrual dysphoric disorder. These episodes occur in rhythm with the menstrual cycle.

Clinical features and nosology

Most of these patients have evidence of bipolar disorder.[5] Many have manic and depressive phases, recurrent mania or schizoaffective mania. A minority have atypical forms, such as catatonia, extreme anxiety associated with delusions or hallucinations, or cycloid (acute polymorphic) features. Thus, the clinical features resemble those of the common form of postpartum psychosis, and (like this form of puerperal psychosis) menstrual psychosis is not a ‘disease in its own right’, but a part of the bipolar spectrum; one of the reasons for its scientific interest is the insight it might give into the triggers of episodes in women with the bipolar diathesis.

There is evidence of two triggers – at the mid-cycle associated with ovulation, and in the late luteal phase (necrotic phase).[6]

As in the postpartum group of psychoses, a minority of cases have organic causes, associated with epilepsy,[7] urea cycle disorders[8][9] and cerebral endometriosis.[10] Cases associated with learning difficulties and early infantile autism have also been reported.[11]

Onset and Course

About two thirds of cases start in the second decade,[12] and it is of great interest that 30 cases have had their first episode before the menarche,[13] a phenomenon has also been seen in three medical disorders – diabetes,[14] epilepsy[15] and hypersomnia[16] – and in migraine psychosis.[17] Another epoch of increased susceptibility is the postpartum period, at the restart of the menstrual cycle after childbirth.[18] An established pattern of menstrual episodes has also continued, month by month, during a phase of amenorrhoea; occasional patients have experienced monthly psychoses only during amenorrhoea.[19] Two patients have developed, or continued, periodic episodes after the destruction of the pituitary gland.[20][21]

In most patients, menstrual psychosis is a self-limiting disorder, affecting only a small proportion of the 400 menstrual cycles in a woman’s life.[22] Since menstruation is one of many triggers of bipolar episodes, it is not surprising that some women, at other times of their lives, suffer manic phases, or a chaotic bipolar illness, without a menstrual link.

Investigation and treatment

It is essential that the diagnosis is firmly established by the precise dating of episodes and the menses.[23] Two cycles of prospective daily ratings (standard for the diagnosis of menstrual mood disorder[24]) are not appropriate; a daily narrative diary is the best method of establishing the temporal pattern. Because the correction of abnormal menstruation may be important in treatment,[25] it is recommended to obtain a gynaecological opinion.

Once a baseline has been established, the pattern of monthly relapses offers an opportunity for single-patient sequential trials seeking a bespoke therapy for the patient. Conventional neuroleptic or mood-stabilising agents are appropriate to control episodes, if prolonged, but seem ineffective in preventing periodic recurrences. This is the therapeutic challenge. There have been no therapeutic trials, but success has been claimed with unconventional treatments, including clomifene, thyroid and progesterone;[26] the concept of menstrual psychosis is useful in directing sufferers to these treatments, which are not commonly used in psychiatry.

Cause

A family history of mental illness is common. There is an association with abnormal menstruation, such as amenorrhoea, anovulatory cycles[27] or luteal phase defects.[28] There is much evidence of a close relationship to childbearing psychoses.[29]

The occurrence of episodes before the menarche, during amenorrhoea, and after destruction or removal of the ovaries and pituitary, together with periodic monthly cases in men,[30] all suggest the involvement of the hypothalamic nucleus governing the menstrual cycle – the neuronal complex that produces gonadotropin releasing hormone.[31]

History

The first indications of abnormal behaviour linked to the menses were two reports[32][33] in the same early French journal: one described a paroxysmal ‘’délire’’, which was at its height when the menses were expected, but suppressed; and the other described monthly attacks of demonic possession. Adequate description of menstrual psychosis had to wait almost 100 years until a thesis written in 1848:[34] it reported a patient with 13 episodes, starting with the menarche. In 1851 Brière de Boisment[35] described four cases. The second half of the 19th century was the heyday of publications on this subject, including Ellen Powers’ thesis,[36] Icard’s monograph,[37] Wollenberg’s description of mid-cycle psychosis,[38] and the accounts by Schönthal [39] and Friedmann [40] of episodes starting before the menarche. This productive period came to an end with the publication, in the year of his death (1902), of v. Krafft Ebing’s Psychosis Menstrualis.[41] Since then only one new variant has been described – Runge’s periodic psychosis during pregnancy.[42] Many of the papers were French or German, but in the mid-20th century, Japanese clinicians began to publish extensive studies. In 2008 a monograph[43] reviewed over 1,000 works, identifying 80 cases with substantial evidence and setting out the principles of the clinical study of this disorder. In 2017, a second monograph[44] revised this analysis, identifying 119 cases with at least five dated episodes. The trickle of case reports continues unabated from all over the world - more than 35 possible cases since 2000.

Menstruation and other mental disorders

Premenstrual dysphoric disorder

This is the name given to a severe form of the premenstrual syndrome; its synonyms include premenstrual tension, late luteal phase dysphoric disorder and menstrual mood disorder. It is a common disorder – two orders of magnitude more common than menstrual psychosis. The present evidence suggests that it is distinct from menstrual psychosis.[45] Premenstrual dysphoric disorder has different symptoms (irritability and tension being the most characteristic), is defined by its luteal timing, responds to SSRIs and is not strongly associated with abnormal menstruation; indeed it may only occur in normal cycles.[46] Menstrual psychosis is defined by various psychotic symptoms, may occur at the mid-cycle and during menstrual bleeding, is associated with anovulation and other menstrual disorders, and probably responds to the induction of ovulation.

Bipolar disorder

Premenstrual exacerbation is the triggering or worsening of otherwise defined conditions during the late luteal phase of the menstrual cycle; it may be a clinical marker predicting a more symptomatic and relapse-prone phenotype in reproductive-age women with bipolar disorder. Bipolar women with premenstrual exacerbation have been found to have more episodes (primarily depressive) than those without, but are not more likely to meet criteria for rapid cycling.[47] Rapid cycling has a female preponderance, and occurs with greater frequency premenstrually, at the puerperium and at the menopause. While the symptom of rapid cycling is typically associated with bipolar disorder, there are a number of other conditions which also precipitate very rapid cycling between moods (emotional lability), including premenstrual dysphoric disorder, other endocrine issues, sleep disorders, borderline personality disorder, post-traumatic stress disorder, acquired brain injury and substance abuse. Mood stabilizers are often used to address these effects.[48]

The existence of menstrual psychosis means that some bipolar women, at a certain time in their lives (most commonly adolescence), are extremely and exclusively prone to the provocation of episodes by menstruation. One might expect, therefore, a general relationship between menstruation and manic depression, with many sufferers experiencing mild menstrual episodes in addition to those provoked by other triggers. But this does not seem to be true; on the whole no general association has been demonstrated. Instead, studies have shown that a subgroup of bipolar women experience a menstrual effect.[49] Three small studies have shown that 5/47,[50] 8/25[51] and 13/41[52] were susceptible. They agree that the majority experience no effect of the menses, and therefore no susceptibility to the menstrual trigger(s).

Schizophrenia

The meaning of the term ‘schizophrenia’ has varied from time to time and country to country, but it is now reserved for chronic psychoses with symptoms like auditory hallucinations, delusions of control and other bizarre delusions, and ‘negative symptoms’ such as incongruous affect.[53] Admission of women to psychiatric hospitals is increased by about 50% in the last few premenstrual days and during menstrual bleeding;[54][55][56] most of these women had a diagnosis of schizophrenia. There is evidence that the serum level of oestrogens is correlated with symptom severity.[57][58][59]

Menstruation is controlled by the hypothalamic gonadorelin neuronal complex, via the pituitary and ovaries; the interaction between the menstrual cycle and schizophrenia could be at any of these levels, but there is support for the role of oestrogens. Oestrogens, among their many cerebral effects, have actions on dopaminergic receptors similar to neuroleptic agents.[60][61] Oestrogen levels are high in the mid-luteal phase and fall shortly before menstrual bleeding,[62] coinciding with the increase of symptoms and hospitalization in the perimenstrual phase. This hypothesis is supported by a relative dearth of new onsets of schizophrenia in younger women, with a second peak after the mid-forties,[63] and by the milder severity and better anti-psychotic treatment response in female patients.[61] Several randomised controlled trials have shown that oestrogens augment the action of antipsychotic agents.[64]

Menstruation and brain diseases

A number of medical and surgical diseases are affected by the menstrual cycle.[65][66] The best established are allergies to progesterone and oestrogen, asthma, diabetes mellitus, endometriosis, migraine, porphyria and (among the brain disorders) epilepsy and hypersomnia, which will be summarized here.

Catamenial epilepsy
Main article: Catamenial epilepsy

It is known that the menstrual cycle has a modest effect on the frequency of seizures in epileptic women.[67] There are three patterns – a paramenstrual increase (from two days before to three days after the onset of menstrual bleeding), during ovulation and throughout the whole luteal phase in anovulatory cycles.[68] One of the reasons why the menstrual cycle has this effect is that progesterone and its metabolites, especially allopregnanolone, are ligands of gamma-aminobutyric acid receptors, and resemble benzodiazepines in their anticonvulsant actions; oestrogens have the opposite effect.[69] Natural progesterone has been shown to be effective in reducing seizures in the paramenstrual group.[70] Other forms of catamenial epilepsy may benefit from suppression of the menstrual cycle.[71] As mentioned above, cyclical epilepsy has been reported before the menarche.

Menstrual hypersomnia

In this rare disorder, women or girls sleep before or during their menstrual bleeding. About 20 cases have been described, and of these 6 started at or before the menarche.[72][73] This is probably a hypothalamic disorder.

Citations
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  2. Reilly, Thomas J; Sagnay de la Bastida, Vanessa C; Joyce, Dan W; Cullen, Alexis E; McGuire, Philip (January 2020). "Exacerbation of Psychosis During the Perimenstrual Phase of the Menstrual Cycle: Systematic Review and Meta-analysis". Schizophrenia Bulletin. 46 (1): 78–90. doi:10.1093/schbul/sbz030. PMC 6942155. PMID 31071226.
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References
  • Brockington, Ian (2017). The Psychoses of Menstruation and Childbearing. Cambridge University Press. ISBN 978-1-316-72076-9.CS1 maint: ref=harv (link)
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