Menstrual psychosis

Definition

This is a comparatively uncommon form of severe mental illness, with the following characteristics:

• Abrupt onset against a background of normality.
• Brief duration, with full recovery.
• Psychotic features such as confusion, mutism and stupor, delusions, hallucinations or a manic syndrome. Premenstrual tension, premenstrual syndrome, premenstrual (late luteal phase) depression or dysphoric disorder or menstrual mood disorder do not qualify.
• A circa-mensual (approximately monthly) periodicity, in rhythm with the menstrual cycle.

History

Abnormal behaviour linked to menstruation was first noticed in the 19th century, and, as early as 1825, menstrual mood disorder was used to acquit a mother convicted of infanticide.^[1] The first descriptions of psychosis appeared about 1850.^[2] In 1902, the renowned forensic psychiatrist and sexologist, Richard v. Krafft-Ebing published a monograph with many case descriptions and a temporal classification.^[3] About 250 cases have now been described, of which 80 have substantial evidence.^[4]

Examples

A German woman had her first attack of mania at 27. She then began to suffer from brief episodes lasting only 10 days, that returned every month for two years. For 15 episodes the onsets of psychosis and the menses were precisely dated. Cycle length averaged 25 days. The spread of episode onsets was from 2 days before to 6 days after the beginning of menstrual bleeding. The probability that such a close connection could arise by chance is less than .000001.^[5] Another German woman, at the age of 36 and 8 children, suddenly expressed the idea that her husband was the King of Bavaria and then lapsed into stupor. She recovered after 12 days, without the slightest trace of illness. But she had 53 recurrences during the next 12 years, with a variety of clinical pictures including delusional depression, stupor, mania and acute polymorphic episodes. Those accurately dated started between six days before the onset of menstrual bleeding to one day after it. Irradiation and surgical removal of the ovaries had no effect.^[6]

Clinical features

The overwhelming majority of these patients have evidence of manic depressive (bipolar disorder). Many have conventional manic and depressive phases, or recurrent mania, or schizoaffective mania. A minority have atypical forms, such as catatonia, extreme anxiety associated with delusions or hallucinations, or acute polymorphic psychosis. Thus the clinical features resemble those of the common form of postpartum psychosis, and (like puerperal psychosis) menstrual psychosis is not a disease in its own right, but a member of the group of bipolar disorders. In women who have the bipolar diathesis (lifelong susceptibility), menstruation is one of the triggers of episodes. In fact there is evidence of two menstrual triggers - at the mid-cycle associated with ovulation, and in the late luteal (necrotic) phase just before menstrual bleeding.

As in postpartum psychosis, acute organic syndromes are occasionally seen, associated with epilepsy,^[7] urea cycle disorders ^[8] and perhaps endometriosis.

Epidemiology

There have been no state-of-the-art population-based surveys. The fragmentary data at present available suggest that this psychosis is much less common than puerperal psychosis (whose frequency is rather less than 1/1,000 pregnancies), and very much less common than menstrual mood disorder (which, strictly defined, affects about 5% of women). Its frequency at the threshold of hospital admission is probably about 1 in 10,000 women.

Most cases have been published by French, German, Japanese or American clinicians, but occasional reports of Indian, Iraqi, Egyptian, Vietnamese, Taiwanese and Bangladeshi women suggest a worldwide disorder.

Course

Many cases start early in reproductive life, and it is of great interest that some girls have developed monthly psychoses before the menarche.^[9] This phenomenon has also been seen in diabetes, epilepsy, migraine and hypersomnia. Some recover at the first menstrual bleed, but most continue to have a periodic psychosis in timing with the menstrual cycle. Another epoch of increased susceptibility is after childbirth, when the menstrual cycle is starting up again.^[10] In some women an established pattern of menstrual episodes has continued, month by month, even though the menses have stopped. Occasional patients have experienced monthly psychoses that occur only during amenorrhoea.^[11] There is, however, no evidence of an increase at the menopause.

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

Cause

A family history of mental illness is common. There is a strong association with abnormal menstruation - amenorrhoea, anovulatory cycles or luteal cell defects.^[12] There is much evidence of a link with puerperal psychosis, and there may be an association with seasonal affective disorder.

The present evidence suggests that menstrual psychosis and menstrual mood disorder (premenstrual tension and its synonyms)—which is not associated with bipolar disorder or abnormal menstruation—are distinct disorders.

The occurrence of episodes before the menarche, during amenorrhoea and after destruction or removal of the ovaries or pituitary all point to the hypothalamic gonadorelin neuronal system as the site of the pathological interaction with the bipolar diathesis.

Treatment

It is essential that the diagnosis is firmly established by precise dating of episodes and the menses. Two cycles of prospective daily ratings (recommended for the diagnosis of menstrual mood disorder) is not sufficient for menstrual psychosis. It is also important to obtain a gynaecological opinion, because correction of abnormal menstruation may be important in treatment.

Standard tranquillizing drugs or electroconvulsive treatment may be effective in the acute episode, but are ineffective in arresting the cyclical illness. This, with its pattern of monthly relapses, offers an opportunity for single patient sequential trials. Many unconventional treatments have been tried and claimed to be effective. At present, the most promising appear to be thyroid and clomiphene.

References

1. ^ Hitzig J E (1827)Mord in einem durch Eintreten des Monatsflusses herheifuehrten unfreien Zustande. Zeitschrift fuer Criminal-rechts-pflege in den Preussischen Staaten 12: 239-331.
2. ^ Brière de Boismont (1851). Recherches bibliographiques et cliniques sur la folie puerpérale, précédées d'un aperçu sur les rapports de la menstruation et de l'aliénation mentale. Annales Médico-psychologiques 2nd series 3: 574-610.
3. ^ v. Krafft-Ebing R (1902). Psychosis Menstrualis. Eine Klinisch-forensische Studie. Stuttgart, Enke
4. ^ Brockington I F (2008). Menstrual Psychosis and the Catamenial Process. Bredenbury, Eyry Press
5. ^ v. Krafft-Ebing R (1878) Untersuchungen ueber Irresein zur Zeit der Menstruation. Archiv fuer Psychiatrie 8: 65-107
6. ^ Ewald G. Fraktionerte Kastration mittels Roentgenstrahlen und operation bei einer menstruell rezidivierten Psychose. Muenchener Medizinische Wochenschrift 71: 336-338.
7. ^ Kramer M S (1977). Menstrual epileptoid psychosis in an adolescent girl. American Journal of Disease in Childhood 131: 316-317
8. ^ Wakutani and colleagues (2001)A case of late onset carbamoyl phosphate synthetase 1 deficiency, presenting periodic psychotic episodes coinciding with menstrual periods.Rinsho Shinkeigaku 41: 780-785.
9. ^ Friedmann M (1894) Ueber die primordiale menstruelle Psychose (die menstruale Entwicklungspsychose. Muenchener Medizinische Wochenschrift 41: 4-7, 27-31, 50-53 & 69-71
10. ^ Delay J, Corteel A, Boittelle G (1946) Hypolutéinie rélevée par les biopsies cyto-hormonales dans une psychose du post-partum. Annales Médico-psychologiques 104: 183-188
11. ^ Guiraud P, Boittelle G, Roualt de la Vigne A (1946) État manique périodique, remplaçant les règles: action de la progesterone et de la radiothérapie diencephalique. Annales Médico-psychologiques 104: 254-256
12. ^ Nomura J, Hatotani N, (1981)Periodic psychosis as a chronobiological disorder. In C Perris, G Struwe, B Jansson (editors) Biological Psychiatry. North Holland, Elsevier, pages 1235-1238