Definition

This is a comparatively uncommon form of severe mental illness

Mental illness

A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...

, 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

Infanticide

Infanticide or infant homicide is the killing of a human infant. Neonaticide, a killing within 24 hours of a baby's birth, is most commonly done by the mother.In many past societies, certain forms of infanticide were considered permissible...

. The first descriptions of psychosis

Psychosis

Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...

 appeared about 1850. In 1902, the renowned forensic psychiatrist and sexologist, Richard v. Krafft-Ebing published a monograph with many case descriptions and a temporal classification. About 250 cases have now been described, of which 80 have substantial evidence.

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.
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.

Clinical features

The overwhelming majority of these patients have evidence of manic depressive (bipolar disorder

Bipolar disorder

Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...

). Many have conventional manic and depressive phases, or recurrent mania, or schizoaffective mania. A minority have atypical forms, such as catatonia

Catatonia

Catatonia is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor. It was first described in 1874: Die Katatonie oder das Spannungsirresein ....

, extreme anxiety associated with delusion

Delusion

A delusion is a false belief held with absolute conviction despite superior evidence. Unlike hallucinations, delusions are always pathological...

s or hallucination

Hallucination

A hallucination, in the broadest sense of the word, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid,...

s, or acute polymorphic psychosis. Thus the clinical features resemble those of the common form of postpartum psychosis

Postpartum psychosis

Postpartum psychosis is a term that covers a group of mental illnesses with the sudden onset of psychotic symptoms following childbirth. In this group there are at least a dozen organic psychoses, which are described under another heading "organic pre- and postpartum psychoses"...

, 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

Cognitive bias

A cognitive bias is a pattern of deviation in judgment that occurs in particular situations. Implicit in the concept of a "pattern of deviation" is a standard of comparison; this may be the judgment of people outside those particular situations, or may be a set of independently verifiable...

 (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

Ovulation

Ovulation is the process in a female's menstrual cycle by which a mature ovarian follicle ruptures and discharges an ovum . Ovulation also occurs in the estrous cycle of other female mammals, which differs in many fundamental ways from the menstrual cycle...

, and in the late luteal (necrotic) phase just before menstrual bleeding.

As in postpartum psychosis

Postpartum psychosis

Postpartum psychosis is a term that covers a group of mental illnesses with the sudden onset of psychotic symptoms following childbirth. In this group there are at least a dozen organic psychoses, which are described under another heading "organic pre- and postpartum psychoses"...

, acute organic syndromes are occasionally seen, associated with epilepsy

Epilepsy

Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...

, urea cycle disorders and perhaps endometriosis

Endometriosis

Endometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...

.

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. This phenomenon has also been seen in diabetes, epilepsy, migraine

Migraine

Migraine is a chronic neurological disorder characterized by moderate to severe headaches, and nausea...

 and hypersomnia

Hypersomnia

Hypersomnia is a disorder characterized by excessive amounts of sleepiness.There are two main categories of hypersomnia: primary hypersomnia and recurrent 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. 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. There is, however, no evidence of an increase at the menopause

Menopause

Menopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining...

.

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. There is much evidence of a link with puerperal psychosis, and there may be an association with seasonal affective disorder

Seasonal affective disorder

Seasonal affective disorder , also known as winter depression, winter blues, summer depression, summer blues, or seasonal depression, is a mood disorder in which people who have normal mental health throughout most of the year experience depressive symptoms in the winter or summer, spring or autumn...

.

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

Tranquilizer

A tranquilizer, or tranquilliser , is a drug that induces tranquility in an individual.The term "tranquilizer" is imprecise, and is usually qualified, or replaced with more precise terms:...

 or electroconvulsive treatment

Electroconvulsive therapy

Electroconvulsive therapy , formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown...

 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

Thyroid

The thyroid gland or simply, the thyroid , in vertebrate anatomy, is one of the largest endocrine glands. The thyroid gland is found in the neck, below the thyroid cartilage...

 and clomiphene.