Cyclical Premenstrual Psychosis - Sometimes It Is Your Hormones

Background: Menstrual psychosis is a broad term used to describe a number of disorders characterized by the acute onset of psychotic symptoms with brief duration, complete resolution of symptoms between episodes, with timing related to menses. This entity was first described in the 18th century, with only 27 confirmed cases using strict diagnostic criteria. While research into causation is limited, estrogen withdrawal is thought to precipitate psychotic symptoms. We describe a case of premenstrual psychosis successfully treated with use of transdermal hormonal contraception and extended menstrual cycling. Clinical Case: A 25-year-old non-binary biologic female (they/them/theirs) with bipolar disorder, anxiety, and psychogenic non-epileptiform seizures was referred to endocrinology for evaluation of recurrent psychotic symptoms associated with menses. They endorsed stable mental health symptoms on aripiprazole except during the seven days prior to their menstrual cycle. During this time they reported persistent auditory hallucinations along with dysmenorrhea, with symptoms resolving at the onset of menses. Timing of menarche was uncertain, however they reported oligomenorrhea until beginning oral contraceptives at age nineteen, after which they developed regular monthly cycles accompanied by psychotic symptoms. Pituitary and ovarian hormone levels were unable to be assessed due to hormonal contraception. Prolactin was 8.3 ng/mL (3-30 ng/mL). In order to limit hormonal fluctuations from daily oral contraceptive pills and monthly withdrawal, the decision was made to transition to transdermal norelgestromin and ethinyl estradiol patches changed weekly, with extended cycling to allow one menstrual cycle every three months. At follow-up visit nine months later they reported resolution of auditory hallucinations on this regimen, with symptoms recurring only during extreme stress. Conclusions: While the etiology of menstrual psychosis is unclear, described treatments include a combination of neuroleptics and hormonal therapy, including estrogen, progesterone, and GnRH agonists. As symptoms did not resolve until suppression of monthly menstrual cycles, this case supports the estrogen withdrawal hypothesis. Our case adds to the literature both in that transdermal, rather than oral or injectable therapy was used, and treatment was successful in alleviating the patient’s psychotic symptoms, improving their mental health and quality of life. References: (1) Brockington, I. Menstrual Psychosis. World Psychiatry 2005;4(1):9-17. (2) Reilly, T.J., Sagnay de la Bastida, V.C., Joyce, D.W., Cullen, A.E., McGuire, P. Exacerbation of Psychosis During the Perimenstrual Phase of the Menstrual Cycle: Systematic Review and Meta-analysis. Schizophrenia Bulletin 2020;46(1):78-90.

Psychiatric, cognitive functioning and socio-cultural views of menstrual psychosis in Oman: an idiographic approach

Background Most documented cases of menstrual psychosis have been from Euro-American populations with reports from cross-cultural populations being only a few. A primary aim was to determine whether the cyclical/episodic nature of menstrual psychosis among case series observed at a tertiary care unit in Oman fulfills the diagnostic criteria of the International Classification of Diseases (ICD-10) and diverge into Brockington’s sub-types (World Psychiatry. 2005;4(1):9–17). Related aims were to solicit measures of psychometric functioning of those with menstrual psychosis and associated idioms of distress. Methods A series of consecutive patients seeking psychiatric consultation from January 2016 to December 2017 were screened via structured interview—Composite-International Diagnostic Interview (CIDI) and Brockington’s sub-types. The identified patients (n = 4) also underwent psychometric evaluation including examination of affective functioning, intellectual capacity and neuropsychological functioning (i.e.attention and concentration, learning and remembering, executive function, processing speed and speech and language). The analysis of outcome measures was via an idiographic approach. Results The spectrum of distress among people with menstrual psychosis does not fit existing psychiatric nosology. Evaluations revealed that a majority of the participants displayed something akin to morbid phenomena relating to manic and psychotic symptoms. In the parlance of traditional Omani society, this would be termed “spirit possession”. In terms of classification by timing within the menstrual cycle as expounded by Brockington, the present case series in Oman fulfilled the definition of catamenial psychosis and paramenstrual psychosis. With regard to psychometric function, all participants performed adequately on indices of intellectual functioning but appeared to have impairments in neuropsychological functioning, including the dimensions of processing speed, episodic memory, and executive functioning. Within the given society, the periodicity of mind alteration has been attributed to spirit possession. Conclusions This is one of the first case series of its kind in the country elucidating whether the manifestation of menstrual psychosis among individuals in Oman fulfills the subtypes postulated by Brockington. The present case series suggests that menstrual psychosis is marked with neuropsychological impairments that were previously observed in other phasic manic episodes or brief psychotic disorders.

Menstrual condition and menstrual psychosis

The author first of all briefly examines the influence of the first menstruation and established blood on the body of a nervously healthy woman, noting that "the menstrual period of a healthy woman is not a disease, but it is not complete health." Menstruation in such cases, to a greater or lesser extent, upsets the balance of the nervous system in a woman. The influence of menstruation on the body of a woman with a nervous predisposition is more complex. In these cases, the influence of the appearance of the first menstruation is especially pronounced, when sometimes an insignificant moment is enough only for the girl to develop epilepsy, hysteria, atrial melancholy, etc. It also happens the other way around: the onset of menstruation improves the course of already existing nervous suffering, for example, chorea. The influence of each menstruation is less pronounced, when menstruation has already been established, while painful menstruation (amenorrhoea, menorrhagia) affect the nervous state of women more sharply

Psychiatric, Cognitive Functioning and Socio-cultural Views of Menstrual Psychosis in Oman: An Idiographic Approach

Background: Most documented cases of menstrual psychosis have been from Euro-American populations with reports from cross-cultural populations being only a few in number. Objective: To determine whether the cyclical/episodic nature of menstrual psychosis among case series observed at a tertiary care unit in Oman fulfills the diagnostic criteria of the International Classification of Diseases (ICD-10) and diverge into Brockington’s sub-types (World Psychiatry. 2005;4(1):9-17). Related aims were to solicit measures of psychometric functioning of those with menstrual psychosis and narrated idioms of distress. Results: The spectrum of distress among people with menstrual psychosis does not fit existing psychiatric nosology. Evaluations revealed that a majority of the participants displayed something akin to morbid phenomena relating to manic and psychotic symptoms. In the parlance of traditional Omani society, this would be termed “spirit possession”. In terms of classification by timing within the menstrual cycle as expounded by Brockington, the present case series in Oman fulfilled the definition of catamenial psychosis and paramenstrual psychosis. With regard to psychometric function, all participants performed adequately on indices of intellectual functioning but appeared to have impairments in neuropsychological functioning, including the dimensions of processing speed, episodic memory, and executive functioning. Within the given society, the periodicity of mind alteration has been attributed to spirit possession. Conclusions: This is one of the first case series of its kind in the country elucidating whether the manifestation of menstrual psychosis among individuals in Oman fulfills the subtypes postulated by Brockington. The present case series suggests that menstrual psychosis is marked with neuropsychological impairments that were previously observed in other phasic manic episodes or brief psychotic disorders.

Psychiatric, Cognitive Functioning and Socio-cultural Views of Menstrual Psychosis in Oman: An Idiographic Approach

Background : Most documented cases of menstrual psychosis have been from Euro-American populations with reports from cross-cultural populations being only a few. Objective : To determine whether the cyclical/episodic nature of menstrual psychosis among case series observed at a tertiary care unit in Oman fulfills the diagnosis criteria of the International Classification of Diseases (ICD-10) and diverge into Brockington’s sub-types (World Psychiatry. 2005;4(1):9-17). Related aims were to solicit measures of psychometric functioning of those with menstrual psychosis and narrated idioms of distress . Results : The spectrum of distress in people with menstrual psychosis does not fit into existing psychiatric nosology. Evaluations revealed that a majority of the participants displayed something akin to morbid phenomenon related to manic and psychotic symptoms or, in the parlance of Omani society, spirit possession. In terms of classification by timing within the menstrual cycle as expounded by Brockington, the present case series in Oman fulfilled the definition of catamenial psychosis and paramenstrual psychosis. With regard to psychometric function, all participants performed adequately on indices of intellectual functioning but appeared to have impairments in neuropsychological functioning, including dimensions of processing speed, episodic memory, and executive functioning. Within the given society, the periodicity of mind alteration has been attributed to spirit possession. Conclusions : This is one of the first case series of its kind in the country elucidating whether the manifestation of menstrual psychosis among individuals in Oman fulfills the subtypes postulated by Brockington. The present case series suggests that menstrual psychosis is marked with neuropsychological impairments that were previously observed in other phasic manic episodes or brief psychotic disorders.

Psychiatric, Cognitive Functioning and the Socio-cultural View of Menstrual Psychosis in Oman

Background: Most documented cases of menstrual psychosis have been from Euro-American populations with reports from cross-cultural populations being only few in number. Objective: To determine whether the cyclical/episodic nature of menstrual psychosis among case series observed at a tertiary care unit in Oman fulfills the diagnosis criteria of the International Classification of Diseases (ICD-10) and diverge into Brockington’s sub-types (World Psychiatry. 2005;4(1):9-17.). Related aims were to solicit measures of psychometric functioning of those with menstrual psychosis and narrated idioms of distress. Results: The spectrum of distress menstrual psychosis covers does fit into existing psychiatric nosology. Evaluations revealed that a majority of the participants displayed something akin to morbid phenomenon related manic and psychotic symptoms or, in parlance of Omani society, spirit possession. In terms of classification by timing within the menstrual cycle as expounded by Brockington, the present case series in Oman fulfilled the definition of catamenial psychosis and paramenstrual psychosis. With regard to psychometric function, all participants performed adequately on indices of intellectual functioning but appeared to have impairments in neuropsychological functioning, including dimensions of processing speed, episodic memory, and executive functioning. Within the given society, the periodicity of mind alteration has been attributed to spirit possession. Conclusions: This is one of the first case series of its kind in the country elucidating whether the manifestation of menstrual psychosis among individuals in Oman fulfills the subtypes postulated by Brockington. The present case series suggests that menstrual psychosis is marked with neuropsychological impairments that were previously observed in other phasic manic episodes or brief psychotic disorders.

Menstrual psychosis

In this report, we explore a case of symptoms consistent with menstrual psychosis. In order to do this, a review of the literature relating to this topic was conducted and a report was written. This is a case of a previously well adolescent female who experienced psychotic symptoms in the pre-menstrual phase of her cycle and became well soon after her menstrual period began. These episodes were prevented by aripiprazole, but recurred once medication was withdrawn. We conclude that psychosis in some women may have a relationship with the menstrual cycle. In women presenting with psychosis, it may be appropriate to note menstrual variation in symptoms. This could have a potential role in individualisation of treatment for women with psychotic disorders.