Is menstrual Psychosis a Forgotten Entity?

The connection between menstruation and psychosis has been recognized since the 18^th Century. However, there are few case reports available in modern times describing about 30 patients with this condition. The psychosis may occur in the premenstrual phase in some patients and in others it begins with the onset of menses. Polymorphic psychosis is the commonly described clinical picture in these patients with an admixture of mood symptoms and psychotic symptoms. We describe a 42-year old lady who developed psychotic symptoms with the onset of her menses. The patient had irritability and aggression, persecutory ideas, hallucinatory behavior, increased religiosity, formal thought disorder, disorganized behavior and poor self-care lasting for about 20 days after which she will spontaneously remit for about 10 days till the onset of her next menses. These symptoms began about 13 years after her last childbirth and were present in this cyclical manner for the last seven years. She was admitted in view of gross disorganization and was treated with 4 mg per day of risperidone. She did not develop symptoms with onset of her next menstrual period and was discharged. She maintained well on the prophylaxis for a period of three months. After that, she discontinued medications and had a relapse of symptoms lasting the first two weeks of her menstrual cycle and remained well for about two weeks thereafter. Hormonal assays did not reveal abnormal levels of gonadal hormones. We discuss the association between menstrual cycles and the potential association of psychosis with estrogen levels. Various conditions that lead to fluctuation in estrogen levels, such as menopause, postpartum period as well as post-oopherectomy period have been described to lead to a risk for psychotic symptoms. Similarly, the cyclical changes in estrogen levels during the course of a menstrual cycle leads to psychosis in some women.