Menstrual Epileptoid Psychosis in an Adolescent Girl

Abstract

\s=b\An adolescent girl with a previous history of trance-like states and a strong family history of epilepsy developed a pattern of recurrent brief psychotic episodes. These episodes seemed to coincide with her monthly menstrual periods, and after four to seven days of bizarre, catatonic behavior, she would return to a normal state. These episodes have been virtually eliminated by maintenance of a therapeutic blood level of phenytoin. The case is discussed in the light of the complex interrelationship of seizures, menstrual hormonal changes, and behavior.(Am J Dis Child 131: [316][317] 1977) The medical literature is replete with reports of menstrual and premenstrual manifestation or exa¬ cerbation of various behavior distur¬ bances ranging from minor irrita¬ bility and "tension"' to frank periodic psychosis.23 The relationship between epilepsy, especially temporal lobe epi¬ lepsy, and psychosis is also one that has been extensively explored and studied. Some authors4 have sug¬ gested some underlying cerebral dys¬ function expressing itself as either seizure activity or psychosis, while others5 maintain that the psychosis represents an atypical manifestation of the seizure itself. Finally, the concept of menstrual or "catamenial" epilepsy, ie, seizure disorders in which the seizures become more frequent, or perhaps only occur, during the pre¬ menstrual and menstrual phases of the cycle, is well described6 and gener¬ ally accepted. The adolescent girl whose case is reported here represents an unusual periodic menstrual psycho¬ sis occurring on a background of temporal lobe seizures. Her psychotic episodes have disappeared following institution of anticonvulsant ther¬ apy. REPORT OF A CASEThe patient had been in excellent health until 13 years of age, when she had the onset of "fainting spells," characterized by falling, assumption of a trance-like state, and occasional myoclonic jerks, but without aura, fecal or urinary incontinence, or tongue biting. No automatisms, hypnagogic phenomena, or periods of bizarre behavior were recognized, but she was extremely sleepy for several hours after each episode. Family history was signifi¬ cant in that her mother had had seizures as a child, and her maternal aunt was epileptic and was receiving phenytoin ther¬ apy·'The patient began having two or three of these episodes per week, with frequent visits to the emergency room, occasioning referral to a pediatrie neurologist. A diag¬ nosis of temporal lobe seizures was made despite a normal EEG. Treatment with phenytoin, then phénobarbital plus pheny¬ toin, was followed by no sustained improvement in the frequency or severity of the episodes. However, the patient and her mother both admitted to poor com¬ pliance. Blood levels of anticonvulsants were not obtained. A second EEG obtained during a "trance" several months after the onset of her illness was also normal. A diagnosis of hysterical conversion reaction was then made, and she discontinued the medication.The episodes decreased in frequency during the ensuing months. Howe...

Gonadotropin-Associated Psychosis in Perimenstrual Behavior Disorder

“…However, the behavioral patterns reported are not wide spread in patients with seiuzures [8] or epilepsy [3]. Hence, we do not think that the seizures are specific cau sal elements per se but may be additional features of perimenstrual behavior disorder (syndrome).…”

“…On the basis of individual case reports, a relationship has been postulated between cyclic hormonal changes and behavior in girls [1,2], Some investigators have described the association of psychotic episodes with a specific elec troencephalogram pattern, typical of catamenial epilepsy, [3] and suggested therapy with anticonvulsant agents to eliminate the patients' catatonic behavior [4,5]. Despite reports of these episodes being closely related to the patients' monthly menstrual periods, attempts to corre late them with specific hormonal patterns within the men strual cycle have been inconclusive [6], We describe two patients who developed psychotic behavior at the time of menarche.…”

Catamenial Epilepsy: A Review

“…In other, more exact investigations, premenstrual exacerbations within 2 days of the onset of menses were reported (Buntner and RoSciszewska, 1975). Exacerbations primarily restricted to the time of menstrual flow were observed by Toulouse and Marchand (1913), Zimmerman et al (1973), and Kramer (1977), and both premenstrual and menstrual exacerbations were noted by Ansell and Clark (19566) in 63% of 42 patients, by Gordon (1909) in 23 patients, and by Laidlaw (1956) in 50 patients. In an extensive analysis of a single patient by Helmchen et al (1964), seizure frequency increased slightly from the 14th to 16th days after the onset of menses, possibly correlating with ovulation.…”

Periodic Catatonia Marked by Hypercortisolemia and Exacerbated by the Menses: A Case Report and Literature Review

“…Brockington, an expert in the effects of menses and psychosis [ 37 ], has published an encyclopedic review [ 38 ] of menstrual psychosis including 80 patients who were previously published by or reported to him. He highlighted 3 patients with catatonic symptoms; none of them had stuporous episodes [ 36 , 39 , 40 ], but 2 of them appeared to have menstrual exacerbations of epilepsy [ 39 , 40 ]. Kobayashi and Kato [ 41 ] described an 18-year-old woman diagnosed with catatonic schizophrenia who had repeated catatonic stuporous episodes of premenstrual onset (7 days before).…”