Menstrual psychosis

As defined by Ian Brockington, "menstrual psychosis" is a rare form of severe mental illness, with the following characteristics:[1]

• Sudden onset in a previously asymptomatic person.
• Brief duration, with full recovery.
• Psychotic symptoms that can include confusion or hallucinations, mutism and stupor, delusions, or manic state. These are distinct from premenstrual tension, premenstrual syndrome, premenstrual (late luteal phase) depression or dysphoric disorder or menstrual mood disorder.
• Occurrence in rhythm with the menstrual cycle.

It shares clinical features with, and presents similarly to, postpartum psychosis.[1] Researchers Deuchar and Brockington proposed that a sudden drop in levels of estrogen in the brain could be the trigger for both conditions.[9] Others have found a similar connection.[10][11][12][13][14]

In most, the clinical picture is within the bipolar spectrum, but a few have cycloid or catatonic features. A minority have an organic cause, and there may be a variant associated with learning disability. About one-third have onset in the mid-cycle and two-thirds in the late luteal phase.[7]

3-8% of women who are of reproductive age meet the premenstrual dysphoric disorder (PMDD) criteria.[15] An estimated 40% of women who seek treatment for PMDD are found to not have PMDD, but rather a premenstrual exacerbation of an underlying mood disorder.[2]

The specific condition "menstrual psychosis" is uncommonly cited, with as of 2005, only 80 established cases reported in medical literature and incomplete evidence of a further 200.[1]

In the treatment of menstrual psychosis, there is some evidence for the efficacy of progesterone, clomiphene and thyroid stimulating hormone.[7]

Estrogen has been used effectively as an adjunctive treatment in women with schizophrenia. Women's estrogen levels often dip in the days prior to menstruation.[16][17] In some cases where psychotropic treatment has not helped with psychosis, hormonal treatment has brought about a full remission.[18][19] In another case, hormonal treatment was successful without psychotropic treatment being attempted.[20][21] The effect of estrogen appears to be moderated by a woman's genetic predisposition to psychotic conditions.[22]

Estrogen is believed by some to have a dopamine dampening effect similar to pharmaceutical anti-psychotics, and also modulates serotonin levels.[13][22][23][24][25][26][27][28][29] Others believe that estrogen levels have no direct effect on psychotic symptoms, but do improve mood, which in turn can reduce psychosis.[30][31][32]

Studies with animals have shown that estrogen has antidopaminergic properties, inducing stereotypy and prolonging cataleptic episodes. Like neuroleptics, estrogen increases the density of dopamine receptors and attenuates the development of dopamine receptor supersensitivity.[33]

Local application of estrogen in the rat hippocampus has been shown to inhibit the re-uptake of serotonin. Contrarily, local application of estrogen has been shown to block the ability of fluvoxamine to slow serotonin clearance, suggesting that the same pathways which are involved in SSRI efficacy may also be affected by components of local estrogen signaling pathways.[34]

Tricyclic antidepressants and MAOIs, both of which increase functional monoamines norepinephrine, dopamine and serotonin, are known to induce mania or rapid cycling of mood in an estimated 20-30% of affectively ill patients.[35]

Sulpride during the late luteal phase was an effective treatment for one woman in the United States with the condition.[36] Olanzapine treatment worked well for one woman in Taiwan,[37] and in conjunction with hormonal treatment for a woman in the United States.[38] Risperidone and valproic acid treated the symptoms in another case.[39]

Typical antipsychotics were found to work better for low-estrogen schizophrenic psychotic women in one study than atypical antipsychotics.[40]

One practitioner has found success with use of the norepinephrine-dopamine reuptake inhibitor bupropion for women with menstrual-linked bipolar-like symptoms.[41]

Hsiao et al reported that of 50 female Chinese patients with schizophrenia, 52% had PMS and 20% experienced premenstrual exacerbation (mild in 70%) of schizophrenia symptoms.[42]

Premenstrual exacerbation 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.[43]

Rapid cycling has a female preponderance, and occurs with greater frequency premenstrually, at the puerperium and at menopause.[35] 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.[44]

Abnormal behaviour linked to menstruation was first noticed by published science in the 18th century.[45]

There is a case study of someone with the condition in a book by Louis Amard published in 1807.[46]

As early as 1825, menstrual mood disorder was used to acquit a mother convicted of infanticide.[47]

Brière de Boismont published a major work on the topic in 1851.[48]

In 1902 forensic psychiatrist and sexologist Richard von Krafft-Ebing published a monograph with many case descriptions and a temporal classification.[49] He had also published earlier on the subject.

Founder of modern psychology, Emil Kraepelin, included an entry for "menstrual psychosis" in his 1909-1915 encyclopedia "Psychiatrie". This encyclopedia has been a major influence on the categories of the DSM and ICD. Kraepelin believed menstrual psychosis to have a hormonal cause.[50][27]

In 1939 Therese Benedek and Boris Rubenstein established a link between the ovarian cycle and increased psychotic activity in women with bipolar disorder or schizophrenia.[51][52]

Katharina Dalton coined the term premenstrual syndrome and did much to study the premenstrual phase in women. In 1959 she found that 47% of female schizophrenic patients were admitted to a certain London hospital during menstruation or just prior to menses.[53] She believed that severe premenstrual symptoms were best treated with progesterone derived from sweet potatoes, rather than that generated synthetically.[54] She once said, "Some of you may feel that I've got tunnel vision, that I can just see progesterone when I look into the PMS picture. In my practice, it is simply that I have found this to be the most effective."[54]

In the 1980s and early 1990s, an era when researchers "largely excluded women from neuroendocrine studies, citing menstrual cycle effects as major confounding factors,"[55] Mary Seeman and Heinz Häfner each helped turn research back into this direction with a series of papers linking the menstrual cycle and estrogen to psychosis.

In 1998 Neil Deuchar and Ian Brockington published an extensive review of 275 case studies of women having a cyclic psychosis in rhythm with their menstrual cycles.[9] Brockington went on to publish "Menstrual Psychosis and the Catamenial Process" in 2008,[56] which was revised and released as "The Psychoses of Menstruation and Childbearing" in 2016.[57]

In 2005, Niels Bergemann and Anita Riecher-Rössler edited a collection of chapters entitled "Estrogen Effects in Psychiatric Disorders", with nearly half the book describing the relationship between estrogen and schizophrenia.[14]

The condition received significant public exposure through an article in New York magazine in December 2018.[58][59]

• Catamenial epilepsy, seizures that are similarly triggered by menstrual cycle linked hormone changes