Cyclic psychosis and menstruation: Presentation of a case

To the Editor:

This article presents the case of an adolescent who developed psychotic episodes related to her menstrual cycle, with complete posterior remission. We consider that the clinical data presented could be compatible with a menstrual psychosis rather than a periodic psychosis in adolescence, both concepts being included within the bipolar disorder spectrum.

The patient had no relevant medical or psychiatric history and there was no evidence of family psychiatric history. At the age of 13, she began treatment at the Children's Mental Health Unit for a clinical picture consistent with severe anxiety secondary to persistent thoughts. The psychology department followed up for a year and a half. At the age of 14, the patient presented an increase of anxiety coinciding with her last 2 menstrual cycles. She reported that she was worried that her house might be robbed and that her parents might become financially ruined, partially critiquing these thoughts. The patient was referred to the Children's Psychiatry Department and treatment with risperidone 1 mg/day and fluoxetine 20 mg/day was prescribed. In spite of the treatment, she presented 5 more episodes, of varying intensity; these episodes coincided with her menses and consisted of confusion, anxiety, insomnia and delusional ideation. During one of these episodes, the patient went to emergency services because she presented symptoms of agitation secondary to Capgras syndrome. She was confused, disoriented and perplexed, with bradypsychia and bradylalia, tangential speech, nonsense answers and ideational-emotional block; she was frightened and suspicious, with questionable visual hallucinations, disorganised thinking and complete insomnia. The dose of risperidone was then increased to 2 mg/day.

The episodes presented after that (4 in all) were not so intense. It was observed that the episodes of confusion and delirious ideas repeated cyclically and that they were self-limiting, ending when the menstrual haemorrhage did. They had a mean duration of 5 days. The patient did not present psychotic signs and symptoms between episodes.

Throughout her evolution, the affective clinical picture was predominant. The patient reported apathy, hyposensitivity and hypohedonia. The neuroleptic treatment was cancelled 8 months after it was prescribed, maintaining the antidepressant treatment (fluoxetine 20 mg/day), because excessive sedation was observed without affecting the appearance of psychotic manifestations. The patient presented 7 episodes in all with these characteristics, during 7 consecutive menstrual cycles, and no psychotic episodes that did not coincide with the menstrual cycle were seen.

At present, after 2 years of follow-up, the patient has been asymptomatic without drug treatment for the past 5 months. She comes to the Children's Mental Health Unit to control her evolution.

The first observations of a possible connection between menstrual disorders and mental disorders arose in the 18th century.¹ A review of the literature reveals cases of cyclical psychosis, apparently associated with menstruation. These descriptions report psychotic symptoms that appear suddenly a few days before menstruation and resolve with the appearance of the haemorrhage, only to reappear with the following cycle.^2,3

The fluctuating, non-specific clinical picture, with notable psychomotor slowing, affective flattening and cognitive manifestations, at times presents with mild, transitory delirium and hallucinations, as well as marked anxiety, perplexity and disorientation.^2–5 The prognosis is usually favourable, with possible spontaneous remission.³ Between the psychotic episodes, patients are normally asymptomatic.^4,6 In 1963, Altschule and Brem⁷ called this entity “periodic psychosis of puberty”. According to various authors, it was not believed at that time to have any relationship with menstruation, given that cases of psychotic episodes with a cyclical pattern had also been observed in children.

A different nosological entity is “menstrual psychosis”. The term premenstrual psychosis was first described briefly by Amard in 1807.⁸ According to Bronckington, menstrual psychosis has the following characteristics: 1) severe onset, in a context of normality; 2) short duration, with complete recovery; 3) psychotic characteristics: confusion, stupor, mutism, delirium and hallucinations, or manic symptoms; and 4) a periodic cyclic course (more or less every month), coinciding with the menstrual cycle. Premenstrual tension and depression, or worsening of chronic mental disease during menstruation, are excluded. It is classified by when it is produced within the menstrual cycle and when it is produced in reproductive life. It resembles puerperal psychosis in the rate of patients that relapse to puerperal depression during the premenstrual phase, as well as in the clinical similarity. Given its cyclical clinical manifestations, it is included in the bipolar spectrum.⁹

Neither entity, periodic psychosis of the adolescent nor menstrual psychosis, is included in the DSM-IV and CIE-10 classifications. However, given their periodicity, their cyclic self-limited course, clinical manifestations and treatment (the remission of the episode does not appear to be related to neuroleptics^2,3,5,9), we can consider them similar to affective disorders, mainly to bipolar disorder in adolescence. Mood disorders in adolescents can have a more cyclic pattern and more numerous psychotic symptoms than in adults.^7,10