7.2 Menopausal Psychosis and Hormone Therapy: 1st Episode of Psychosis in Menopause Discussion

[00:00:00] In this episode, Dr. Wood not discuss our personal histories treating first lifetime episodes

[00:00:05] of psychosis occurring during perimenopause or the menopausal transition period which can last

[00:00:12] a decade or even longer. We talk a little bit about how first episode of psychosis in menopause relates

[00:00:20] to postpartum psychosis and finish off with the discussion of how we should classify these patients

[00:00:27] from a diagnostic standpoint. It was really eye-opening for me to see a handful of female

[00:00:34] patients with similar age demographics and clinical presentations during my four years of psychiatric

[00:00:40] residency. Hormonal influence is not to be taken lightly in the fact that simply balancing a

[00:00:46] woman's transition using hormone therapy may have prevented or less in the severity of their

[00:00:52] illnesses is a tough pill to swallow but even though I was ill equipped at the time to effectively

[00:00:58] manage their cases, the knowledge and insight gained from those experiences significantly impacts

[00:01:04] how I practice now. And I hope to continue to learn more about this phenomenon as I progress through my career.

[00:01:22] I do not fancy myself as somebody who's able to talk very intelligently about the microscopic

[00:01:33] details what's going on on a microbiologic level but I do think that I have a strength in looking at

[00:01:40] what's going on around me and drawing logical conclusions. And when I was an intern on the

[00:01:49] inpatient psychiatric unit, I saw a patient that was very paranoid to the delusional degree

[00:01:56] thinking her family was dead even though they were coming in to see her regularly talking on

[00:02:03] the phone to her. It wasn't sleeping very well. You work on the inpatient unit you see people who

[00:02:09] are very sick every day and you can get a little bit jaded to that but then when you see somebody

[00:02:15] and you get the collateral that this person has never seen a psychiatrist in their life

[00:02:21] they've never been treated for even the mildest depression or not to say that they haven't had it

[00:02:26] necessarily but they've never sought treatment in their life and now they have lost their ability

[00:02:33] to function with their job with their family completely lost their ability to function in life

[00:02:40] and seeing that triggered me to say what is going on here? I saw it one time

[00:02:47] and then within six months I saw it another time and by the end of my training there were

[00:02:54] four or five very consistent and obvious cases of somebody having a severe decomposition

[00:03:04] in that period of transition. It's so obvious when you see it with your eyes and you see patterns

[00:03:10] but there really is not a lot of knowledge amongst at least psychiatrists that I trained with.

[00:03:18] Did it ever come up in your training? Yes, I had actually a very similar experience in residency

[00:03:24] where I saw a woman no psychiatric history at all whatsoever came in frankly delusional actually

[00:03:30] to my outpatient clinic. She was in her late 40s and had already had two psychiatric hospitalizations

[00:03:38] within the past six months for this out-of-knowware delusion. She one day woke up for her and her husband's

[00:03:46] history and just thought that her kids were going to be kidnapped and killed. No history paranoia,

[00:03:53] no history substance use, no history of psychiatric illness but just this profound and all-consuming

[00:03:59] delusion and she was a really high-functioning lawyer. She stopped going to work because this delusion

[00:04:04] took over. She was so worried that someone was going to harm her kids whether it was her husband

[00:04:09] or a caretaker or family member that she just wouldn't let them leave her sight. One day actually

[00:04:15] she was becoming so enveloped in this delusion that she actually kidnapped her kids and she

[00:04:22] disappeared with both of them. The husband, family didn't know where she had gone.

[00:04:27] Like thinking that she was protecting them by kidnapping them herself.

[00:04:31] Yes exactly. So she took her kids one day, totally disappeared off the map and about 24 hours later

[00:04:37] they finally found her at a truck stop like two hours outside of town and she was operating under

[00:04:43] the assumption that she was protecting them from all these people who were after them. They

[00:04:47] called the police brought her into the psychiatric hospital and she was admitted that was her first

[00:04:52] admission. They put her on anti-psychotics there but didn't really have that much of an effect.

[00:04:58] She was hospitalized maybe for a couple weeks. I was discharged on the medications but stop taking

[00:05:04] them pretty soon after because she had zero insight into this subsequently. The paranoia,

[00:05:10] the delusions worsened, her behavior worsened and she was hospitalized again. By the time I saw her

[00:05:17] she had been out of the hospital, was not taking any anti-psychotic or antidepressant medicines

[00:05:23] but she got better and it wasn't really clear why that happened or what had changed but she

[00:05:28] developed a little bit more insight. She was still wary of her family and her husband but she no

[00:05:34] longer was paranoid to the extent that she was doing dangerous behaviors if she'd even tried

[00:05:39] going back to work a little bit. It was just so profound just the degree of this intense delusion

[00:05:46] the timing of it which was again right around the menopausal transition time. When I screened her

[00:05:50] later on in clinic we did talk about that. She noted that probably the months or so leading up to

[00:05:56] this her mencies were becoming more irregular. She was having some hot flashes, some more difficulty

[00:06:03] sleeping. Still having menci is not like fully menopausal yet but it was that transition period

[00:06:08] where she really just noticed that this was happening. I followed her for a couple years in residency and

[00:06:14] she pretty much was back to normal functioning. There wasn't a lot of treatment that we were doing

[00:06:19] other than monitoring but there was some residual impact on the family. I think it really put a lot

[00:06:26] of strain on her marriage. The kids who were relatively young and in 12 maybe they were scared. They

[00:06:32] didn't know what was happening, what she was doing and it put a lot of strain on their relationship.

[00:06:36] Don't have the ability to understand that this is something that has a large biological

[00:06:44] component to it. Correct, yeah. It's interesting because the cases that I've seen, the two that I

[00:06:50] remember most clearly were both that their husband and children were dead and what is the greatest

[00:07:00] fear for a mother? Did the prospect of using hormone therapy come up? Not in this case. During her

[00:07:08] hospitalizations it very well while may have been brought up but she had not been interested in that

[00:07:13] by the time she got to me. We hadn't really talked about it which may have been a missed opportunity.

[00:07:17] Yeah, if you look at it from a very narrow lens and think about the increased risk of breast cancer

[00:07:27] then you say well no of course not but if you see how impaired people's ability to function is

[00:07:35] then I think it really changes your mind about the role of hormone therapy and psychiatric

[00:07:42] treatment of these conditions. Yeah, sometimes in these circumstances it's helpful to ask

[00:07:49] the woman how she's perceiving her symptoms so if a woman is saying oh yes I'm going through

[00:07:54] my nappause like my depression I'm just feeling down it's just part of the change. I would rather

[00:08:00] approach it from an OBGYN standpoint a hormonal standpoint and then she might be more open to

[00:08:05] doing hormonal therapy or if she's really seeing it like okay like this depression is serious. Yes,

[00:08:10] it may be occurring in the context of my nappause but my symptoms are really impairing me

[00:08:14] then she might elect to go to more the anti-depressant treatment route. The professional

[00:08:19] recommendation literature out there nowadays like up to date says that both treatments are evidence

[00:08:25] based and effective for like a just a regular doctor looking at that both options are there

[00:08:30] and I can go with whichever route is more comfortable for me. So clearly for a psychiatrist you know

[00:08:37] I prescribe SSRIs all the time day in day out so it's one of those things that my bias is definitely

[00:08:43] going to be to treat that way but again it might be missing an opportunity because if and this is

[00:08:49] still an if but if it is truly the hormones that are causing this why not just treat the source.

[00:08:55] Go to the actual idea of the problem manage that and then see improvement. But yes again in a lot

[00:09:03] of us I think are uncomfortable at that risk. Oh yeah absolutely I mean I am a relative renegade in

[00:09:09] these issues but I would not feel comfortable prescribing hormone therapy but I agree with you

[00:09:17] replace what is missing if that is the cause of it and if you just look at

[00:09:24] this zebra looks like a zebra. I mean my eyes tell me that there's a period of transition where we

[00:09:32] know that the levels of estrogen and progesterone drop pretty dramatically over this period of

[00:09:39] parimenopause yet it's not something that crosses the mind of probably 95% of psychiatrists with

[00:09:48] your cases. Did they have postpartum symptoms? That's a great question I don't remember. Now just read

[00:09:56] a case study from a paper on a review of postpartum psychosis. It's actually a case history of a physician.

[00:10:04] Miss A is a 27 year old physician who delivered her baby seven days before evaluation at a

[00:10:11] teaching hospital. She underwent an uncomplicated delivery baby boy was full term and healthy.

[00:10:18] This was a planned pregnancy the family was excited about the birth. Within two days of delivery

[00:10:24] she told her husband that she thought he was poisoning her food and that the baby was

[00:10:29] staring at her strangely. She thought she smelled horses and heard them galloping outside her bedroom.

[00:10:35] She could not fall asleep even when her mother came to the house to care for their newborn and allow

[00:10:40] the patient to rest. At home she was only able to sleep two or three hours a night. Her husband

[00:10:46] noticed she would gaze out the windows in their apartment for hours without explanation. She had not

[00:10:53] bathed for six days. She required much help and simple tasks such as putting a diaper on the baby.

[00:11:00] She expressed guilt about being a terrible mother. Felt she did not deserve to have her family

[00:11:06] told her husband that she heard voices commanding her to go with her infant son to the subway

[00:11:12] and jump in front of the train. These hallucinations terrified her and became stronger after she returned

[00:11:18] home from the hospital. The husband became very concerned brought his wife to the ER and this case

[00:11:23] ultimately it ends up self-resolving which is a positive about postpartum psychosis and

[00:11:31] paramanopausal psychosis they tend to be short-lived psychoses weeks to maybe a couple of months or

[00:11:40] a few months maybe one of your cases was a little bit longer than that. About six months total.

[00:11:46] But changed to where maybe the person was able to function outside of the hospital after a couple

[00:11:52] of months. At the last time I saw her she had pretty much returned to her baseline level

[00:11:57] functioning. She was back to work and her thought process was linear no real further delusions

[00:12:03] so she pretty much made her full recovery. That's awesome that you were able to follow this person

[00:12:08] for two years. Yeah I know it was I was very lucky to be able to do that in residency especially

[00:12:13] but she would come in at the beginning it was every couple weeks to check in about safety

[00:12:18] and her symptoms and after that we spaced things out and actually taught me a lot about these

[00:12:22] kinds of cases due because I got the more launched to no picture. One of my patients denied any

[00:12:28] history of any postpartum problems but then we had a family meeting with her husband and her daughter

[00:12:34] and they both said oh you were very depressed and I got the impression that because she had such

[00:12:40] a hard time with it that was the only daughter that they had and like with your case there was

[00:12:47] zero insight and no memory either. Your family was just here do you remember that? Whatever is

[00:12:55] happening is not only removing any insight into whatever thought is there it's almost like that

[00:13:03] thought that id that impulse just goes totally unchecked which is similar to what you would see in

[00:13:11] somebody who was floridly manic. Yeah right come to find out the vast majority of postpartum

[00:13:18] depression and definitely postpartum psychosis patients there was a five year follow-up by a

[00:13:25] guy named whizner who found that of the postpartum patients he studied 95% ended up carrying a diagnosis

[00:13:35] at some point of bipolar disorder it might have been bipolar or major depression that idea that

[00:13:41] they're on that same spectrum but there is definitely some consistency across these cases.

[00:13:48] What do you make of the consistency in presentation? Yes it is interesting in something that

[00:13:54] struck me too about this case and a couple of others that I've treated or seen oftentimes it is

[00:14:01] kind of focused on family safety children that kind of nurturing role and keeping your children safe

[00:14:09] that has somehow gotten turned on its head or you know there's almost this intensification of

[00:14:14] this need but to a psychotic degree. And that actually happened with some of the postpartum

[00:14:20] psychosis cases that I've seen there's been some evidence to suggest that about 50% of women

[00:14:28] with postpartum psychosis who have delusions that involve the baby in some way. That is interesting

[00:14:33] because that's probably what's on the forefront of your mind at that time that's what you're thinking

[00:14:37] about, your life is changing in that way and so yes that kind of impulse that's probably that

[00:14:41] thought that's been there taking over your life in many ways is then what manifests as the delusion.

[00:14:47] And if you think about it brand new moms like I mentioned before probably their number one thought

[00:14:52] at all times is baby and like the safety of baby and taking care of baby and so that maybe fear of

[00:14:58] inadequacy there or fear of uncertainty not knowing what to do. Yes, is the nitrous for that psychotic

[00:15:05] transformation if you will. And interestingly yeah the menopausal part is interesting too I was just

[00:15:11] thinking about your cases and it was almost that I don't know the fear of abandonment is the

[00:15:16] underlying fear there but not even acknowledging that the family was there and having zero memory

[00:15:21] or insight into that what is that manifestation of is it the fact that they are getting older

[00:15:28] and family is dying off fear of loneliness. I think that these are themes that I often hear from

[00:15:34] my patients who are getting older and not to say that menopause is only for old women I think

[00:15:39] that there's still a lot of life to live and I don't really think that in your 40s or that old I

[00:15:44] certainly hope not but it is a period of time where people are having life changes and a big question

[00:15:51] at that focal point is what is my future you know what do I want what are my goals with the rest

[00:15:56] of my life who's going to be there for me. What am I without my family? Yes. Am I anything?

[00:16:02] Yeah. Where do I cease to exist without my family? Right and how does society see me as a woman who

[00:16:09] is now going through menopause do I have value to society society puts a lot of value on reproductive

[00:16:16] age women having children growing families and then yeah after that what value do you have?

[00:16:23] As a young parent you have a lot of value my mother-in-law is so good with my son.

[00:16:31] Spins it's so much time with him and I don't know where I would be if she wasn't around.

[00:16:37] I've had a couple other patients one very recently that hadn't really seen a psychiatrist she was

[00:16:45] mid-40s. I had seen some therapists in the past but wasn't big on medications. She had started

[00:16:53] having panic attacks about 10 years ago had one didn't have another one for three or four years

[00:17:00] and then started to have them in greater frequency. I got almost to the end of the appointment and

[00:17:06] I was like wait a second you're 45 years old right are you having regular periods it's always me asking

[00:17:12] an older woman she's having regular periods kind of odd but are you having any irregularities in

[00:17:18] your cycle? Oh yeah my cycle has been irregular for a while now. How long? Wow I don't six seven maybe

[00:17:27] eight years. Wow. Well this could be hormonally related if there's not any other causative factors

[00:17:36] that you can think of then it's something that we probably need to investigate and I think the

[00:17:42] only way that I can get more certainty about what the impact of hormones is is to refer my patients

[00:17:50] and to follow up with them and see how they do. Start with maybe some hormones by somebody who knows

[00:17:57] what they're doing and isn't going to put people at risk and then just be open to if they help

[00:18:04] maybe we're really on to something and if they don't help maybe this isn't as important as

[00:18:11] previously thought but I really do think it has a pretty big impact and part of me definitely

[00:18:16] hopes that it does so I can have that confirmation. But I've really have started to try to get people

[00:18:24] to the OB even though the treatment it might not be just hormones but the treatment may overlap.

[00:18:33] Right and I think one of the other things I've taken away from this too is just the societal

[00:18:38] view of menopause in general. We don't talk about it enough especially as it relates to mental health

[00:18:44] and I think you're right people tend to put it in one bucket like there's tendency to try to

[00:18:50] attribute psychiatric symptoms to either medical things or mental illness really when there's

[00:18:55] potential overlapping etiology here like hormones that we're talking about people really might

[00:19:01] miss out on a big part of treatment if they're solely depending on just one identity versus the other.

[00:19:08] There's so many different factors going on and it's almost inevitably a combination.

[00:19:14] Again I think it goes back to our desire for certainty. Yes. We want to say it's medical or it's

[00:19:20] mental when there's probably a decent amount of overlap. I mean there's all different hormone systems

[00:19:27] not just estrogen progesterone. There's your thyroid hormone. There's a lot of other

[00:19:36] there's so many things that could be out of whack one way or another. Yeah, not to mention all the

[00:19:42] social factors that are going on during these transition periods and women's lives,

[00:19:47] environmental actually that's been a really interesting thing to actually look at like the effects

[00:19:51] of climate change on especially young women's mood states. Political I mean there's just so many

[00:19:57] things you know going on during these very vulnerable periods. What are they called?

[00:20:01] The PFUs? Oh yes, whatever. I mean we are incorporating pieces of our synthetic environment

[00:20:10] into our bodies. What is the role of that on our mental and our medical health? You mentioned

[00:20:16] both of your cases were more consistent with a delusional disorder. In hindsight I'm like well the

[00:20:23] presence of this delusion was the most pressing and consistent aspect of the presentation. What do

[00:20:30] you make of where these women fall diagnostically? Yeah, that's a great question and I remember asking

[00:20:37] my mentor about that too when this was all going on when I was a resident. He ultimately

[00:20:41] recommended that we give her a brief psychotic disorder diagnosis because she did not meet criteria

[00:20:47] for schizophrenia. She didn't have the negative symptoms, the timeline didn't make sense

[00:20:51] and otherwise she returned to functioning and it was really just that isolated period.

[00:20:56] We also talked about is this some kind of psychodynamic conflict that's really manifesting in this way?

[00:21:03] Is she hysterical? That word came up! That word came up! Yes it did! Is there some kind of

[00:21:11] block within her that has just really manifested now that she cannot tolerate this phase or whatever

[00:21:17] it is that she's going through? I mean I didn't really buy that one. I was like okay.

[00:21:21] So then the question was what do we diagnose her with? The differential should be broad for anyone

[00:21:26] that you're seeing in this situation. Certainly thinking about depression with psychotic features,

[00:21:32] could this woman have an underlying bipolar disorder that is now just coming out? We do know that

[00:21:37] there are higher rates of first onset manic episodes around the paramedic menopausal transition.

[00:21:41] It's very possible. Or you know if you're looking at purely the symptoms that at least my patients

[00:21:46] have presented with, it's oftentimes very circumscribed delusions. She again didn't really

[00:21:52] paint a great picture of major depressive disorder with psychotic features. She had no real history

[00:21:57] of you know manic or even hypomanic episodes so I was really feeling in the dark. I didn't really

[00:22:02] know what to diagnose her with. Still to this day I don't exactly know if we describe this well

[00:22:08] enough. I don't think we have a term or a diagnosis or really a description at all that you know

[00:22:14] quite necessarily fits. They are almost a transient psychosis that gets better oftentimes relatively

[00:22:21] quickly compared to something more insidious like an actual manic episode. I think it might be a

[00:22:27] completely different entity, something we don't have a name for yet. Perhaps it is hormonal,

[00:22:34] perhaps it is influenced also by trauma but it's definitely something to investigate.

[00:22:42] My cases did have asleep disturbance as well. And again if you really are delusional think that

[00:22:48] your family is at imminent risk of dying or are dead, that could relate to asleep disturbance.

[00:22:56] But that fact that so many of the patients who experience the postpartum psychosis end up at some

[00:23:04] point carrying a diagnosis of bipolar disorder. And from what I saw, that was the most consistent

[00:23:09] diagnosis associated. I don't think I saw that in the perimenopausal psychosis literature though.

[00:23:16] Yeah I would say that's consistent with what I found to you there was not as strong of a link

[00:23:21] as with postpartum psychosis. It is interesting the way that I've seen that present and from what

[00:23:28] the literature describes it, it's almost more of a delirium than a psychosis that you might see in

[00:23:32] a schizophrenia or substance use intoxication. Women are very confused, disoriented. The delusions

[00:23:40] yes might still very much be there but it's almost this, yeah, delirium component that's more

[00:23:45] profound. That oftentimes gets missed because we're not necessarily looking for that maybe we'll say

[00:23:51] she just delivered, she's a little confused. Or oh she got a lot of pain medicine,

[00:23:54] she's confused but we're not identifying that as psychosis or high risk of bipolar disorder and then

[00:24:00] people get discharged and negative outcomes happen so it's something to stay very attuned to

[00:24:05] and also again highlights that biologic component to it. Yeah I think initially I was kind of

[00:24:10] anchoring on this is an undiagnosed or sub syndromeal bipolar disorder but the more that I've read about

[00:24:19] it I think maybe that there is just genetic predisposition to having one of these primary

[00:24:26] psychotic conditions that is influenced by hormonal transitions whether it is schizophrenia or bipolar

[00:24:34] disorder or delusional disorder. I'm starting to think it could really be any of these things

[00:24:40] just that change in hormone status causes fluctuation in mental state for everybody and if you are

[00:24:47] already predisposed genetically but you've never had that massive transition in the past

[00:24:56] then that could be the first time that you experienced that. The only thing that doesn't add up with

[00:25:00] that explanation is you would still think that people who have first episode in menopause,

[00:25:07] you'd be able to go back and look at the postpartum episodes and they would correlate.

[00:25:14] They'd have postpartum and there's probably not enough data period to make a concrete call on that

[00:25:21] but I think the challenge with really any transitional hormonal phase that we look at too is just

[00:25:26] the retrospective reports of individuals you know it's hard to know exactly what you were going

[00:25:31] through especially during a stressful time like postpartum or first mencise that we have to rely a lot

[00:25:38] on people's reports or reports from their parents for example and a lot of times we know that

[00:25:43] this information is not fully accurate. Three words that describe our conscious self I hear

[00:25:51] and now and our memories are notoriously bad. We like to think they're good and if we write things

[00:25:59] down it helps but we don't remember things as they happened. We tend to create stories in our brain

[00:26:07] that we pull out later when you get together with people at your 20 year high school reunion

[00:26:14] the same story will have 20 different versions and everybody's convinced that their version is correct

[00:26:21] but that kind of goes into that story that we tell ourselves about ourselves. Correct. But the

[00:26:27] the reality is that we live I hear and now and we rely on our minds to go to our past and predict

[00:26:34] our future. Right and part of the human experience is creating these narratives to make sense of

[00:26:39] things and again looking back at times that maybe we're very traumatic or stressful or confusing you

[00:26:46] know sometimes we do create these narratives that we truly fully believe but may not actually be real.

[00:26:52] Yeah and it's hard I mean uncertainty is hard to deal with it really is but it's so imperative in what

[00:26:59] we do because if you create certainty especially at our age in our field then you're really

[00:27:08] going to limit your ability to grow. Yes it's going to be frustrating sometimes and I'd say

[00:27:17] it also probably makes you come off as not as knowledgeable about things but in reality it's the

[00:27:25] wisest path so that when we do get to our menopausal transition years we have accumulated a lot more

[00:27:34] knowledge and we can have more certainty about things than we do now. I agree with that there's

[00:27:40] a certain humility that's needed when approaching these types of situations. Somebody get this guy some help!

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