Menstrual catatonia


THE SYNDROME IN which patients show psychotic symptoms associated with the menstrual cycle, is known as periodic psychosis of puberty1 or of adolescence2 (PPP/A) in the Japanese-language literature. It remains unfamiliar, however, internationally. Recently, Brockington gave a detailed description of the syndrome as menstrual psychosis, which included patients in a wider age range.3

The present article describes an 18-year-old woman with menstrual catatonia. She was misidentified as having catatonic schizophrenia, and the treatment for PPP/A was efficacious.

An 18-year-old woman was found wandering aimlessly around a metropolitan city. She was taken into custody by a policeman because she was crying near a police box. Her parents asked her what she had been doing, but her answers made no sense. Her body also seemed to be somewhat rigid.

On the third day her eyes were fixed on a point, she was rigid and motionless with her mouth wide open. She made no replies and her parents could not catch her eye. She lay down all day. At night her parents took her to the emergency department of Jichi Medical University Hospital, at which time she was admitted to a medical ward.

Infection of the central nervous system, organic brain disease, and epilepsy were ruled out on blood chemistry, cerebrospinal fluid examination, and brain imaging. On hospital day 5 the patient was referred to us, and we considered her to be in a substuporous state: she voicelessly gazed at the ceiling with immovable features and never shifted her gaze; her extremities were rigid; she exhibited waxy flexibility; and she would only sometimes exchange a few words. She was neither manic nor depressive. Her mood state was flat and superficial. We diagnosed her as having catatonic schizophrenia, and moved her to a psychiatric ward.

Intravenous haloperidol at a dose of 15 mg/day and diazepam at 5 mg/day seemed to improve her symptoms around day 15, but her symptoms worsened again on day 30. Similar improvement and deterioration repeated three times, and we became aware that her catatonic state worsened periodically. Her menstrual periods were between days 8 and 12, and between days 36 and 43: her catatonic state began approximately 7 days prior to menstruation and discontinued approximately 10 days after the end of menstruation. We therefore suspected that the patient had PPP/A and administered lithium carbonate at a dose of 600 mg/day, which gradually released her from the periodic illness.

It is rare that PPP/A manifests mainly catatonia. Brockington globally investigated 80 patients with menstrual psychosis, and found only three patients who had presented with catatonia as a salient symptom.3

A diagnosis of PPP/A, or menstrual psychosis is an important consideration in the differential diagnosis of adolescent patients with catatonic syndrome and should have an appropriate place in the diagnostic system.