Psychiatrists document extremely rare case of menstrual psychosis

Researchers in Japan have documented the case of a teenager whose psychotic symptoms consistently appeared before her menstrual period and resolved immediately after. A case report published in Psychiatry and Clinical Neurosciences Reports indicates that a medication typically used to treat seizures and bipolar disorder was effective after standard antipsychotic and antidepressant drugs failed to provide relief. This account offers a detailed look at a rare and often misunderstood condition.

The condition is known as menstrual psychosis, which is characterized by the sudden onset of psychotic symptoms in an individual who is otherwise mentally well. These episodes are typically brief and occur in a cyclical pattern that aligns with the menstrual cycle. The presence of symptoms like delusions or hallucinations distinguishes menstrual psychosis from more common conditions such as premenstrual syndrome or premenstrual dysphoric disorder, which primarily involve mood-related changes. Menstrual psychosis is considered exceptionally rare, with fewer than 100 cases identified in the medical literature.

The new report, authored by Atsuo Morisaki and colleagues at the Tokyo Metropolitan Children’s Medical Center, details the experience of a 17-year-old Japanese girl who sought medical help after about two years of recurring psychological distress. Her initial symptoms included intense anxiety, a feeling of being watched, and auditory hallucinations where she heard a classmate’s voice. She also developed the belief that conversations around her were about herself. She had no prior psychiatric history or family history of mental illness.

Initially, she was diagnosed with schizophrenia and prescribed antipsychotic medication, which did not appear to alleviate her symptoms. Upon being transferred to a new medical center, her treatment was changed, but her condition persisted. While hospitalized, her medical team observed a distinct pattern. In the days leading up to her first menstrual period at the hospital, she experienced a depressive mood and restlessness. This escalated to include delusional thoughts and the feeling that “voices and sounds were entering my mind.” These symptoms disappeared completely four days later, once her period ended.

This cycle repeated itself the following month. About twelve days before her second menstruation, she again became restless. Nine days before, she reported the sensation that her thoughts were “leaking out” during phone calls. She also experienced auditory hallucinations and believed her thoughts were being broadcast to others. Her antipsychotic dosage was increased, but the symptoms continued until her menstruation ended, at which point they once again resolved completely.

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A similar pattern emerged before her third period during hospitalization. Fourteen days prior, she developed a fearful, delusional mood. She reported that “gazes and voices are entering my head” and her diary entries showed signs of disorganized thinking. An increase in her medication dosage seemed to have no effect. As her period began, the symptoms started to fade, and they were gone by the time it was over. This consistent, cyclical nature of her psychosis, which did not respond to conventional treatments, led her doctors to consider an alternative diagnosis and treatment plan.

Observing this clear link between her symptoms and her menstrual cycle, the medical team initiated treatment with carbamazepine. This medication is an anticonvulsant commonly used to manage seizures and is also prescribed as a mood stabilizer for bipolar disorder. The dosage was started low and gradually increased. Following the administration of carbamazepine, her psychotic symptoms resolved entirely. She was eventually able to discontinue the antipsychotic and antidepressant medications. During follow-up appointments as an outpatient, her symptoms had not returned.

The exact biological mechanisms behind menstrual psychosis are not well understood. Some scientific theories suggest a link to the sharp drop in estrogen that occurs during the late phase of the menstrual cycle. Estrogen influences several brain chemicals, including dopamine, and a significant reduction in estrogen might lead to a state where the brain has too much dopamine activity, which has been associated with psychosis. However, since psychotic episodes can occur at various points in the menstrual cycle, fluctuating estrogen levels alone do not seem to fully explain the condition.

The choice of carbamazepine was partly guided by the patient’s age and the potential long-term side effects of other mood stabilizers. The authors of the report note that carbamazepine may work by modulating the activity of various channels and chemical messengers in the brain, helping to stabilize neuronal excitability. While there are no previous reports of carbamazepine being used specifically for menstrual psychosis, it has shown some effectiveness in other cyclical psychiatric conditions, suggesting it may influence the underlying mechanisms that produce symptoms tied to biological cycles.

It is important to understand the nature of a case report. Findings from a single patient cannot be generalized to a larger population. This report does not establish that carbamazepine is a definitive treatment for all individuals with menstrual psychosis. The positive outcome observed in this one person could be unique to her specific biology and circumstances.

However, case reports like this one serve a significant function in medical science, especially for uncommon conditions. They can highlight patterns that might otherwise be missed and introduce potential new avenues for treatment that warrant further investigation. By documenting this experience, the authors provide information that may help other clinicians recognize this rare disorder and consider a wider range of therapeutic options. This account provides a foundation for future, more systematic research into the causes of menstrual psychosis and the potential effectiveness of medications like carbamazepine.

The report, “Menstrual psychosis with a marked response to carbamazepine,” was authored by Atsuo Morisaki, Ken Ebishima, Akira Uezono, and Takashi Nagasawa.