Hypomanic episodes during menstrual periods: Bipolar II disorder?


ONLY RECENTLY HAS interest in premenstrual dysphoric disorder (PMDD) increased.1 The significant social and professional consequences to patient quality of life are often underestimated2 and symptoms insufficiently treated. Cases of PMDD with hypomanic symptoms, such as the following, have rarely been reported in the literature.

Ms I. (aged 17 years) was brought to psychiatric emergency for psychomotor agitation. Upon menarche (14 years), she first presented behavioral symptoms (hyperactivity, irritability, euphoria, insomnia, gregariousness and megalomania), recurring upon menstruation. Symptom duration was 8 days (6 days prior until day 2 of menstruation). No depressive symptoms were associated. She often had mastodynia, bloating and dysmenorrhea.

Although her grades remained satisfactory, her education suffered. Between episodes, the patient resumed her usual social and school activities.

No other somatic or psychiatric disorders, including psychoactive substance use, were present. There was no family history of affective disorder. Biochemical and hormonal work-up was normal.

PMDD with hypomania was diagnosed. Initial 8-week treatment with olanzapine (10 mg/day) was unsuccessful. The switch to sodium valproate (600 mg/day) resolved her symptoms and Ms I. remains asymptomatic at 14 months.

PMDD is currently listed in the DSM-IV-TR appendix. Its criteria include dysphoric symptoms (depressed mood, affective liability, hopelessness, self-depreciation, lack of energy etc.). The current description includes no manic symptoms.

Most psychiatric literature has focused on dysphoria related to menstrual cycles. Manic or hypomanic symptoms may be observed in PMDD.3 Parry et al. highlighted the frequency of hypomanic symptoms in this population.4 One small series reports rapid-cycling bipolar disorder in 41 patients, five of whom reported above-average mania scores during the luteal phase.5 Cases with a clear association between manic or hypomanic symptoms and menstruation are rare.

The premenstrual phase is associated with important hormonal changes that may favor the exacerbation or emergence of affective disorders; 40–70% of patients with PMDD have a history of depressive episodes.6 Miller et al. have evoked an association between premenstrual dysphoria and other mood disorders,7 although links with hormonal imbalance remain unclear. Irritability is a prevalent sign also present in manic, hypomanic, mixed and depressive states. Our patient clearly presented hypomania with irritability. Rapid-cycling disorders are more frequent in women (70–90%). However, they may also occur during menopause and are unrelated to hormonal modifications.

Diagnosis in this case was difficult, testing the limits of current classifications. The disorder could be classified as type II bipolar disorder with atypical features or rapid-cycling. It could also be categorized as recurrent, hypomanic episodes with intercurrent remission, menstruation being the stressor. Another possibility would be the creation of a specific category of bipolar disorders coinciding with menstruation.

Current pharmacotherapy is comprised of mood stabilisers for most manifestations of PMDD.8 Continuous mood stabiliser administration stabilizes symptoms, even in cases such as ours, with chronologically limited, but highly invalidating symptoms. This case raises new issues in diagnostic strategies and therapies for hypomanic episodes in PMDD.

Our patient provided informed consent for publication of her case.