JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY

Volume 29, Number 5, 2019 Advanced Pediatric

ª Mary Ann Liebert, Inc.
Pp. 392–394 Psychopharmacology
DOI: 10.1089/cap.2019.29168.bjc

Brief Psychosis in the Premenstrual Phase

in an Adolescent Girl:
Adolescent Menstrual Psychosis?

Presenters: Samantha Langer, BS, Joshua Frankel, MD, Nicole Derish, MD, and Raul Poulsen, MD
Discussant: Barbara J. Coffey, MD, MS

Chief Complaint and Presenting Problem She stated ‘‘my mom is my light,’’ while pointing at a bottle of body
Downloaded by 76.71.221.254 from www.liebertpub.com at 01/18/20. For personal use only.

lotion on the table. Although she was cooperative, she could not

A . was a 14-year-old Hispanic girl with no known past psy-

chiatric history who was involuntarily admitted to the inpa-
tient Child and Adolescent Psychiatry unit for agitation, delusions,
fully engage in the interview.

Past Psychiatric History

and disorganized speech and behavior.
History of Present Illness
A was in her normal state of health until 1 week before admission
when she left her family’s apartment and went to a nearby gas
station to purchase ‘‘Gatorade.’’ She reported a strange man fol-
lowed her back to her apartment complex and blocked the entrance
gate. She asked him to move; he suggested that she come with him.
She became extremely upset and fearful, so she quickly ran into the
building. She arrived at home distraught and crying. This was the
first time her mother noticed a change in behavior. Mother reports
‘‘paranoid behavior’’ and anxiety for several days after this inci-
dent.
A reported increased fear involving a male friend, who had re-
cently joined a gang, with fears of being recorded and being framed
for some unspecified deed, although she presumed it related to
drugs (she denied substance use). A reported that the friend later
made thinly veiled threats against her family. This worried her,
disrupting her sleep, and resulted in her feeling compelled to stand
guard to protect her family, particularly her brother. She reported
also feeling compelled to spread word of the perceived danger.
Four days after this incident, A reported onset of sudden dizzi-
ness while at school. She was told she was having a panic attack, at
which point she was brought to the local pediatric emergency de-
partment for evaluation. While there, she became increasingly
agitated and aggressive and received chemical sedation. After
medical clearance, she was transferred to the Child and Adolescent
inpatient psychiatric unit displaying disorganized behavior, so-
cially withdrawn, visibly preoccupied with peers, hesitant with
anxious affect, and increasingly aggressive as per reports from
transferring personnel. Her grooming and hygiene were poor. She
was awake and alert, observed to be pacing the unit without a
purpose, while mumbling to herself. She presented as intrusive,
with odd behavior, grabbing other patients and providing an-
swers that were consistently incoherent with nonsensical speech.
A had no known past psychiatric history. She denied ever having
seen a psychiatrist, therapist or receiving any psychotropic medi-
cation. She denied any history of suicidal ideation, attempts, or
parasuicidal behavior, which was corroborated by mother during
evaluation.
Developmental History
Pregnancy and birth, and early developmental histories were
reported to be unremarkable. Mother reported no delays in motor
milestones or language acquisition. Mother reported no delays or
abnormalities in emotional and social development. A’s early
childhood was similarly reported to be uneventful.
School/Educational History
A was in the tenth grade at a large public high school. Mother
described her school performance as fair. She had had no major
disciplinary issues.
Social History
A grew up in the south eastern region of the United States with
her mother, one brother, and two sisters. Mother and father had
divorced several years before onset of A’s illness. She currently
lived with mother, stepfather, and siblings.
A reported trying marijuana once in the past year with a sibling.
She denied any further illicit substance use, including alcohol and
tobacco. She denied a history of sexual activity. She denied past or
current abuse or neglect.
Family History
A’s biological father had a history of depression and was cur-
rently taking unspecified medications. There was no known family
history of drug addiction, suicidal behavior, or general medical
conditions.

Department of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami, Miami, Florida.

392
 ADVANCED PEDIATRIC PSYCHOPHARMACOLOGY
Medical History
A had no history of medical illnesses, surgeries, seizures, loss of
consciousness, or traumatic brain injuries. She denied any previous
hospitalizations. Menarche was at 11 years of age. She described
her periods as irregular, heavy, and painful. She reported a past
history of increased anxiety and irritability for several days before
the onset of menses.
Medication History
A denied ever having taken medications, corroborated by mother
during the evaluation.
Mental Status Examination on Admission
A was a 14-year-old Hispanic girl who appeared her stated age;
she was thin with poor grooming and hygiene. She was disorga-
nized in appearance and paced aimlessly throughout the unit.
Psychomotor agitation was prominent. Eye contact was consis-
tently poor. Speech was slurred and incoherent. Language sug-
Downloaded by 76.71.221.254 from www.liebertpub.com at 01/18/20. For personal use only.
gested a poverty of thought content with nonsensical verbiage.
Mood was not revealed on questioning; her affect was flat and
nonreactive. Thought process was disorganized, tangential, and
with frequent thought blocking. Thought content, although difficult
to comprehend, revealed paranoid obsessions and delusions of
being ‘‘recorded and framed by a gang member.’’ A did not answer
questions about hallucinations, but she did appear to be responding
to internal stimuli. The presence of suicidal or homicidal thoughts
could not be ascertained. A was oriented only to self; memory and
attention were poor. Insight and judgment were both poor.
Hospital Course
A was admitted with a working diagnosis of unspecified psy-
chosis not due to a substance or known physiological condition, and
rule out substance-induced psychosis. Laboratories, including
comprehensive metabolic panel, complete blood count, and urin-
alysis, were within normal limits. Urine drug screen was negative.
Mother was contacted for collateral information and provided
consent for medications. CT of head without contrast revealed no
focal lesions or hemorrhages.
On the second day, A continued to wander the unit, mumbling to
herself. Still psychotic in appearance, she remained disorganized in
thought, speech, and behavior. She was also intrusive, grabbing
other patients’ belongings indiscriminately. Upon questioning, her
answers were consistently unintelligible and her speech nonsensi-
cal. Coherent phrases were limited to ‘‘my mom is my light’’ as she
pointed invariably to a bottle of body lotion. Risperidone 0.5 mg PO
hs was initiated for her psychosis, as well as benztropine 1 mg IM
QHS PRN for extrapyramidal symptoms of mild unilateral rigidity
on upper extremity movement. Olanzapine 5 mg IM q12 hours was
given as needed for agitation.
During the third day, A remained psychotic and exhibited erratic
behavior. She was found climbing chairs, speaking incoherently,
and grabbing other patients by their shirts. She could not be re-
directed and was given one dose of the olanzapine 5 mg IM.
A’s fourth day on the unit showed marked improvement in her
symptoms. Although anxious, she was able to follow directions and
answer some questions. Her speech was more coherent and thought
process increasingly linear. She remained oriented to person.
Psychomotor retardation was observed, and no signs of acute
dystonia were noted. She reported her mood as sad, pointed to the
light switch, and again said that it represented her mother. Notably
393
A reported abdominal discomfort and fatigue due to the onset of
menses the night before.
A showed continued improvement on day 5. She was oriented to
person, place, and time, and appeared in no acute distress. Mild left
arm rigidity on passive movement with contralateral distraction,
initially noted, resolved within 2 days She reported feeling ‘‘good’’
after getting a restful night of sleep. She reported some continued
anxiety, but felt much better than previous days. She endorsed
feeling bloated and reported abdominal cramping related to her
menses but no other symptoms. She denied auditory or visual
hallucinations. She did not appear to be responding to internal
stimuli. She had no memory of the events leading to the admission.
She did not remember the treatment team who had been taking care
of her for the past 5 days. She agreed to continue medication due to
her perceived improvement. She adamantly denied recent drug use,
suicidal, or homicidal ideation.
A was discharged on day 6 on risperidone 0.5 mg PO hs with
scheduled psychotherapy and psychiatry appointments. Benz-
tropine was discontinued after akinesia resolved.
Brief Formulation
A was a 14-year-old Hispanic girl with no psychiatric history
admitted to the inpatient Child and Adolescent Psychiatry unit for
acute onset of psychotic symptoms, including paranoid delusions
and disorganization of behavior and speech. Associated symptoms
included tangential thoughts, reduced sleep, worsening anxiety,
and agitation that required emergency medication. The onset of
symptoms, nearly a week before admission, occurred without ev-
idence of substance use or a general medical condition. Before
onset of psychotic symptoms, A had experienced premenstrual ir-
ritability and anxiety, but had not sought care. With the onset of
menses, the symptoms promptly resolved.
Without a prodromal phase suggestive of schizophrenia or his-
tory of depressive or manic episodes, the diagnosis evaded speci-
fication. Given the short duration of treatment and acute
presentation, Unspecified psychosis led the differential, with ru-
le/out diagnoses, including brief psychotic disorder; psychotic
disorder due to another medical condition (given the more elaborate
and longer term medical evaluation still to be completed on an
outpatient basis); substance-/medication-induced psychotic pi-
sorder (despite the negative drug screen and history, substances
might have been either unknown, undetected).
Multiaxial Diagnoses
Axis I: unspecified psychosis
R/O menstrual psychosis
R/O brief psychotic disorder
R/O substance-/medication-induced psychotic disorder
Axis II: none
Axis III: R/O psychotic disorder due to another medical condition
Axis IV: problems related to the social environment: separation
of parents, and poor social support with limited family support.
Axis V: 20 on admission; 100 on discharge
Discussion
Menstrual psychosis, a condition described within the psychi-
atric canon as early as the 18th century, has long been described as a
brief psychotic episode acute in its onset, rapid in its resolution, and
marked by variable temporal boundaries within the menstrual
 394
cycle. Although the onset sometimes occurs with such develop-
mental events as menarche (Brockington 2009), the course more
commonly demonstrates abnormal menstrual cycles that could be
related to hormonal imbalances, particularly with anovulatory cy-
cles (Vengadavaradan et al. 2018). Once described as hysteria, a
blend of psychotic features, manic symptoms, altered cognition,
and agitation (Brockington 2017), and although such passé termi-
nology has faded, the condition has not yet found its place among
the numerous diagnostic categories within DSM-5, despite many
case studies. Antipsychotic medications have proven useful for
acute treatment by shortening the duration of the episode, but
maintenance treatment response has been less clear.
A reported premenstrual psychotic symptoms and mood dis-
turbance, with agitation, delusions, and disrupted sleep, all ebbing
within a day of the onset of menses. This course is consistent with
previous case reports of premenstrual psychosis; other temporal
boundaries include catamenial psychosis, with symptoms begin-
ning concurrently with menstruation. Alternatively, the onset may
occur at other times (paramenstrual psychosis). Epochal psychosis,
Downloaded by 76.71.221.254 from www.liebertpub.com at 01/18/20. For personal use only.
with symptoms beginning mid-cycle, is associated with bipolar
disorder spectrum, lasting throughout the entire cycle with pre-
dictable changes related to the onset of menstruation (Thippaiah
et al. 2018).
Given this is the initial episode of psychosis, there is not yet a
pattern supporting a direct relationship between the A’s psychotic
symptoms and her menstrual cycle. However, her description of
historic premenstrual anxiety and irritability shows a predisposition
to premenstrual mood fluctuations. Whether this derives from
hormonal fluctuations or the stress of menstruation is unclear. In-
terestingly, studies have documented women with schizophrenia
experiencing psychotic symptoms that fluctuate with the menstrual
cycle (Ray et al. 2019).
After hospitalization, it was recommended that A and her psy-
chiatrist monitor mood and psychotic symptoms, with attention
devoted to any temporal patterns within the menstrual cycle.
A further endocrine workup may reveal a hormonal etiology.
Menstrual psychosis, although in need of further study, lacks a
diagnostic categorical home, although the emerging literature
warrants at least a debate over whether menstrual psychosis is
better defined as its own distinct disorder apart from schizophrenia
or bipolar disorder (Brockington 2011), or whether instead it might
more appropriately serve as a specifier within either of those two
spectra. At this time, we suggest a specifier within mood and
psychotic illnesses ‘‘with premenstrual onset’’ or ‘‘with catamenial
ADVANCED PEDIATRIC PSYCHOPHARMACOLOGY
onset,’’ since currently patients with this condition have no specific
diagnosis within the DSM to provide diagnostic clarity to patients,
providers, and researchers alike. Given the severity of the symp-
toms, menstrual psychosis deserves its place among the mental
disorders, including the DSM, to help promote more widespread
knowledge, scientific investigation, and targeted intervention to
relieve or prevent psychotic episodes in the affected women.
Disclosures
R.P. is affiliated with Teva/Nuvelution, Neurocrine, and Ema-
lex. B.J.C. is on the Scientific Advisory Board of Abide Ther-
apeutics and Teva/Nuvelution, received honoraria from the
American Academy of Child and Adolescent Psychiatry, and re-
ceived research support from Neurocrine Biosciences and NIM-
H/UCSF. She is cochair of the Medical Advisory Board of the
Tourette Association of America (TAA), and on the speakers’
bureau for the TAA-CDC Partnership. The other authors have no
other disclosures.
References
Brockington I: Runge psychoses. Arch Womens Ment Health 20:83–
85, 2017.
Brockington IF: Menstrual psychosis with onset after childbirth. Arch
Womens Ment Health 12:265–266, 2009.
Brockington IF: Menstrual psychosis: A bipolar disorder with a link to
the hypothalamus. Curr Psychiatry Rep 13:193–197, 2011.
Ray P, Mandal N, Sinha VK: Change of Symptoms of Schizophrenia
across phases of menstrual cycle. Arch Womens Ment Health 2019.
DOI:10.1007/s00737-019-0952-4
Thippaiah SM, Nagaraja S, Birur B, Cohen AW: An interesting pre-
sentation about cyclical menstrual psychosis with an updated re-
view of literature. Psychopharmacol Bullet 48:16–21, 2018.
Vengadavaradan A, Sathyanarayanan G, Kuppili PP, Bharadwaj B: Is
menstrual psychosis a forgotten entity? Indian J Psychol Med 40:
574–576, 2018.
Address correspondence to:
Barbara J. Coffey, MD, MS
University of Miami Miller School of Medicine
1120 Northwest Fourteenth Street, Suite 1442
Miami, FL 33136
E-mail: bjc134@miani.edu