Menstrual psychosis

It has been suggested that this page be merged into Ian Brockington. (Discuss) Proposed since July 2020.

Menstrual psychosis is a proposed term for a medical condition that displays periodic psychosis with acute onset in a particular phase of the menstrual cycle.^[4] The literature describes nearly 200 proposed cases as of 2020.^[3]

Classification

Menstrual psychosis is proposed as a form of severe mental illness, whose periodic episodes occur in rhythm with the menstrual cycle.^[4] The clinical features resemble those of the common form of postpartum psychosis; since most cases are considered to belong to the bipolar disorder spectrum, menstrual psychosis, like postpartum bipolar disorder, is not a "disease in its own right". Its study might provide insight into triggers of episodes in women with the bipolar diathesis, and its clinical value is the indication for intervention with agents affecting the menstral cycle.^[4]

Signs and symptoms

Episodes of menstrual psychosis have a sudden onset in a previously asymptomatic person, and are usually of brief duration, with full recovery.^[4] The psychotic symptoms can include confusion, mutism and stupor, delusions and hallucinations, or a manic syndrome.^[1]

Most people with menstrual psychosis 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.^[6]

There is evidence of two triggers – at the mid-cycle associated with ovulation, and in the late luteal phase (necrotic phase).^[7]

About two thirds of cases start in the second decade,^[8] and some cases have had their first episode before the menarche.^[9] Another epoch of increased susceptibility is the postpartum period, at the restart of the menstrual cycle after childbirth.^[10] An established pattern of menstrual episodes has also continued, month by month, during a phase of amenorrhoea;Template:MEDCN occasional patients have experienced monthly psychoses only during amenorrhoea.^{[11] [12]}

Diagnosis

The diagnosis is established by history, clarified by a psychiatric examination, of the patient's symptoms, if possible collaborated by an account by the spouse or a relative, and a study of the medical records. The diagnosis is established by precise dating of episodes and the menses.^[13] Two cycles of prospective daily ratings 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, a gynaecological opinion is recommended.^[14]

Differential

Menstrual psychosis must be distinguished from the more prevalent premenstrual dysphoric disorder, the name given to a severe form of premenstrual syndrome.^[15] It 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; it may only occur in normal cycles.^[16] This contrasts with menstrual psychosis, which 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.^[17]

The other main differential diagnosis is bipolar disorder without menstrual precipitation of episodes.^{[citation needed]} In most cases of menstrual psychosis, it is appropriate to diagnose bipolar disorder, which will lead to effective treatment of the acute episode; but, in an illness with a monthly periodicity, failure to recognize a menstrual link may be ineffective in prophylaxis against recurrent episodes.^{[citation needed]} According to Reilly (2020), studies of bipolar disorder related to exacerbation of menstrual symptoms are limited, "there is some evidence that menstrual exacerbation of psychotic symptoms occurs", and a possibility that individuals "incorrectly ascribe premenstrual dysphoric symptoms to an exacerbation of their psychotic illness".^[3]

Causes

A family history of mental illness is common.^[18] There is evidence of a relationship to childbearing psychoses.^[2]

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,^[19] suggest the involvement of the hypothalamic nucleus governing the menstrual cycle.^[20]

Although the overwhelming majority of affected women have manic depressive (or related) symptoms, only a subgroup of bipolar women experience a menstrual effect.^{[21][22][23][24]}

As in the postpartum group of psychoses, a minority of cases have organic causes, associated with epilepsy, urea cycle disorders, and cerebral endometriosis.^[25] Cases associated with learning difficulties and early infantile autism have been reported.^[26]

Individuals have developed, or continued, periodic episodes after the destruction of the pituitary gland.^[27][28][29]

Management

Once a baseline is established, the pattern of monthly relapses allows for single-patient sequential trials seeking a bespoke therapy.^[30] Conventional neuroleptic or mood-stabilising agents are appropriate to control episodes, if prolonged, but seem ineffective in preventing periodic recurrences. There have been no therapeutic trials as of 2017, but success has been claimed with unconventional treatments, including clomifene, thyroid and progesterone;^[31] the concept of menstrual psychosis may direct individuals to these treatments, which are not commonly used in psychiatry.^[30]

Prognosis

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.^[32] 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.^[4]

Epidemiology

There have been no high-quality population-based surveys. This psychosis is much less common than the closely related postpartum bipolar disorder, whose frequency is about 1 in 1,000 pregnancies.^[33] The majority of cases reported in the literature are from Germany, Japan, France, the United KIngdom and the United States; single cases have been reported from many nations, suggesting a worldwide disorder.^[34]

History

The first indications of abnormal behaviour linked to the menses were two reports^[35][36] 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:^[37] it reported a patient with 13 episodes, starting with the menarche. In 1851 Brière de Boisment^[38] described four cases. The second half of the 19th century was the heyday of publications on this subject, including Ellen Powers’ thesis,^[39] Icard’s monograph,^[40] Wollenberg’s description of mid-cycle psychosis,^[41] and the accounts by Schönthal^[42] and Friedmann^[43] 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.^[44] Since then only one new variant has been described – Runge’s periodic psychosis during pregnancy.^[45]

The literature encompasses about 500 works.^[46] Many of the early papers were French or German, but in the mid-20th century, Japanese clinicians began to publish extensive studies.^[47][48] In 2008 a monograph reviewed over 1,000 works, identifying 80 cases and setting out principles for the clinical study of this disorder.^[49] In 2017, a second monograph revised this analysis, identifying 119 cases with at least five episodes.^[50]

Citations

References

• Brockington, Ian (2017). The Psychoses of Menstruation and Childbearing. Cambridge University Press. ISBN 978-1-316-72076-9. 

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