Development of Persistent Psychosis After Catamenial Epilepsy

Dear Editor,

Catamenial epilepsy refers to a pattern of seizure exacerbation occurring in relation to specific phases of the menstrual cycle. Fluctuations in ovarian hormones are believed to play a key role in this phenomenon: Oestrogens are considered proconvulsant, increasing neuronal excitability, whereas progesterone has anticonvulsant properties through enhancement of γ-aminobutyric acid-mediated inhibition. ¹ Additionally, psychiatric manifestations associated with the menstrual cycle have also been described. Catamenial psychosis is considered a subtype of menstrual psychoses, characterized by the cyclical emergence of psychotic symptoms with a return to baseline functioning between episodes. ² These inter-episodic periods may be difficult to identify, particularly in patients with underlying psychiatric vulnerability, making the temporal relationship between symptoms and the menstrual cycle challenging to establish. ³

However, there are no reports describing psychosis developing subsequent to the onset of catamenial epilepsy. We report the case of catamenial epilepsy with subsequent persistent psychosis that did not fluctuate with the menstrual cycle and showed no inter-episodic recovery.

A 25-year-old woman presented with a five-year history of recurrent seizures that occurred regularly in relation to her menstrual cycle. The episodes typically began on the second day of menses and continued until the cessation of menstrual bleeding, a pattern that remained consistent across cycles. The seizure semiology was suggestive of complex partial seizures, with each episode lasting approximately 1–2 minutes. Over the years, she had been treated with multiple antiepileptic medications; however, the seizures remained poorly controlled.

Approximately six months after the onset of these catamenial seizures, the patient developed behavioral changes suggestive of psychosis. She began expressing persecutory beliefs that her family members and neighbors were plotting to harm her and reported hearing voices commenting on her actions in the form of running commentary. These symptoms gradually became persistent and caused significant distress and dysfunction. Notably, there was no significant past medical or psychiatric history before the onset of seizures. A family history of psychosis was present in her mother, who had been receiving regular antipsychotic treatment.

At the time of presentation, the patient was receiving brivaracetam 50 mg and lacosamide 200 mg twice daily, along with phenytoin 100 mg three times daily. Mental status examination revealed well-systematized persecutory delusions with third-person auditory hallucinations, and insight into her illness was absent. Importantly, the psychotic symptoms did not show temporal fluctuation in relation to seizure occurrence or phases of the menstrual cycle.

Laboratory investigations, including complete blood counts, serum electrolytes, liver function tests, and renal function tests, were within normal limits. Electroencephalogram and magnetic resonance imaging of the brain were reportedly normal. The Brief Psychiatric Rating Scale (BPRS) score at presentation was 64, indicating severe psychopathology.

The patient was initiated on aripiprazole 10 mg daily for psychotic symptoms, and clobazam 10 mg at night was added due to persistent seizures. During follow-up, there was significant clinical improvement. At the last visit, the BPRS score had reduced to 20. She was maintained on ongoing antiepileptic therapy and aripiprazole and had an uneventful follow-up period of three months. Although she continued to experience occasional catamenial seizures once every two to three menstrual cycles, there was no worsening or recurrence of psychotic symptoms during these episodes. She was subsequently referred to the neurology department for further management of refractory seizures.

The present case demonstrated a clear catamenial pattern of seizures, with episodes consistently occurring around the onset of menstruation. Intermittent benzodiazepines such as clobazam are commonly employed in the management of intractable catamenial epilepsy, and were added in this patient to address persistent seizures. Hormonal approaches may also be considered in selected cases. ⁴

An important feature of this case is the emergence of persistent psychosis following the onset of catamenial epilepsy. This presentation differs from menstrual psychosis, which typically shows a cyclical pattern of psychotic symptoms with remission between episodes. In contrast, our patient’s psychotic symptoms were continuous and did not fluctuate with the menstrual cycle. Similarly, postictal psychosis was considered as a differential diagnosis; however, it was unlikely because the psychotic symptoms persisted throughout the interictal period and were not temporally related to seizure episodes. ⁵

With this case, we highlight a rare clinical scenario in which persistent psychosis developed after the onset of catamenial epilepsy. The case underscores the complex interplay between epilepsy, hormonal influences, and psychiatric manifestations. Early recognition and appropriate management with antipsychotic medication, having a low seizure risk, is crucial when encountering similar cases.