What's in the mind's eye of individuals with bipolar disorders: an exploration of the content and characteristics of mental images in different thymic phases.

BACKGROUND: Mental imagery, or 'seeing with the mind's eye' (Kosslyn et al. ), provokes strong emotional responses (Ji et al., ). To date, there is a lack of data on the content and clinical characteristics (e.g. vividness, likelihood, emotional effects) of spontaneous mental images (MI) in people with bipolar disorder (BD) according to their thymic states. AIM: The current study sought to assess the characteristics associated with the contents of MI in people with BD. METHOD: Forty-two euthymic individuals diagnosed with BD (American Psychiatric Association, ) were asked to self-report their MI during depression, (hypo)mania and euthymia. Participants also rated levels of vividness, likelihood and emotional activation related to MI (i.e. valence, arousal, type of emotion). RESULTS: The contents of the MI revealed phenomenological aspects of BD. Different themes were associated with each thymic phase. In (hypo)mania and in euthymia, the mental images were assessed as being as vivid as probable (p>.05). (Hypo)manic and euthymic-related MI activated more pleasure than displeasure (p<.001) and were mainly associated with joy. In depression, MI were assessed as more vivid than likely (p<.05). In depression, MI activated more displeasure than pleasure (p<.0001) and induced mainly sadness. DISCUSSION: Overall, a congruence between the contents of images and the three thymic phases was found. The content of the MI was related to self-reported emotional effects that were congruent with the thymic phases concerned. The results add new clinical information for the use of imagery-based cognitive therapy in individuals with BD.

Key findings on bipolar disorders from the longitudinal FondaMental Advanced Center of Expertise-Bipolar Disorder (FACE-BD) cohort.

BACKGROUND: The FACE-BD cohort is an observational cohort of individuals with bipolar disorders (BD) who benefited from a systematic evaluation with evidence-based treatment recommendations and who were followed-up every year for 3 years in France. The objectives were to describe the lifetime course of BD, associated psychiatric and somatic comorbidities, and cognition profile. This cohort aims to identify clinical/biological signatures of outcomes, trajectories of functioning and transition between clinical stages. This article summarizes 10 years of findings of the FACE-BD cohort. METHOD & RESULTS: We included 4422 individuals, all having a baseline assessment, among which 61.2% had at least one follow-up visit at either one, two or three years. A subsample of 1200 individuals had at least one biological sample (serum, plasma, DNA). Assessments include family history of psychiatric disorders, psychiatric diagnosis, current mood symptoms, functioning, hospitalizations, suicidal attempts, physical health, routine blood tests, treatment history, psychological dimensions, medico-economic data and a cognitive assessment. Studies from this cohort illustrate that individuals with BD display multiple coexistent psychiatric associated conditions including sleep disturbances, anxiety disorders, substance use disorders and suicide attempts as well as a high prevalence of metabolic syndrome. During follow-up, we observed a 55% reduction of the number of days of hospitalization and a significant improvement in functioning. CONCLUSIONS: The FACE-BD cohort provides a strong research infrastructure for clinical research in BD and has a unique position among international cohorts because of its comprehensive clinical assessment and sustainable funding from the French Ministry of Health.

[Exploring Early Maladaptative Schema (EMS) in adults with bipolar disorder: A systematic review of the scientific literature]. / L'exploration des Schémas Précoces Inadaptés (SPI) chez les personnes adultes atteintes de troubles bipolaires: une revue systématique de la littérature scientifique.

OBJECTIVES: Clinical heterogeneity during euthymic states is a crucial issue in bipolar disorders. Indeed, actual data are not sufficient to understand why some patients are unharmed by subthreshold symptoms and have functional impairments whereas others have a functional remission but have subthreshold symptoms. Based on the Ball model, cognitive and schematic vulnerability interact with genetic vulnerability and trigger affective symptoms with the intervention of stressful life events. Furthermore, according to this model, adjustment and adaptation to illness assessed by functional outcome and illness experience are associated with this cognitive and schematic vulnerability. So, theoretical arguments support that childhood adversity and temperamental deregulation characterize patients with bipolar disorders. Thus, the aim of this study is to systematically review studies of Early Maladaptive Schemas in bipolar disorder, to determine whether Early Maladaptive Schemas have specificity in bipolar disorder in comparison with other populations, and to identify which Early Maladaptive Schemas could be activated. The challenge of this review is to identify if the taking of early maladaptive schemas into account could allow us to better identify, understand and manage bipolar disorders. METHODS: This systematic review was led according to the Preferred Reporting Items for Systematic review and Meta-Analysis statement on the electronic databases Cochrane, PsycArticles, Psychology and Behavioral Sciences Collection, PsycInfo, PubMed, ScienceDirect and Scopus with « early maladaptive schemas ¼ AND « bipolar disorder ¼ as keywords. Only studies meeting eligibility criteria concerning publication status, language, population and outcomes were included after several screenings on basis of title, abstract and full-text. Then, we carried out data extraction in accordance with criteria defined in principle (about characteristics of participants, objectives, materiel and methods, principle results and bias). RESULTS: Among 39 records identified, a total of 10 studies met eligibility criteria for inclusion in this review. Synthesizing findings across the studies revealed three important topics. First, early maladaptive schemas appear as potential cognitive characteristics that clinicians have to investigate in clinical practice. Indeed, patients with bipolar disorders present greater activation of the early maladaptive schemas in comparison with people who have no disorder. This point supports the first part of Ball's theoretical model that considers schemas as a vulnerability to bipolarity. Secondly, early maladaptive schemas are relevant to distinguish bipolar disorders from unipolar depression and borderline personality disorder. A greater and a lower activation are respectively identified among bipolar disorders. Thirdly, supporting the second part of Ball's model, early maladaptive schemas play a key role in recovery regarding their impact on the course of bipolarity, in particular on suicidality and functional impairment. Finally, these dysfunctional schemas allow us to understand the clinical heterogeneity of bipolar disorder, and among others, about the type of bipolarity. These results have several implications, but there are some limits in this systematic review. First, no French study has been done. Then, reduced sample sizes in these studies increased the risk to conclude wrongly to an activation difference between groups. Furthermore, probably due to the variety of methods and populations, we could not identify an homogeneous pattern of early activated maladaptive schemas. Overall, scientific approaches used in these studies are based on statistical models using mean and standard deviation. These types of statistical analyses are the main limit because they cannot represent the heterogeneity of early maladaptive schemas profiles. CONCLUSIONS: Schema theory proves to be a relevant approach in bipolar disorders, and early maladaptive schemas appear to be important to take into account in clinical practice. Nevertheless, in order to propose schemas therapy appropriately, it is necessary to specify if early maladaptive schemas are activated and to specify therapeutic indications because of clinical heterogeneity. Moreover, data do not yet allow us to understand the disparity of profiles during the inter-episode period. Indeed, a French research perspective is being considered that will prefer a person-oriented approach.

[Therapeutic education: A lever to change perceptions of bipolar disorder in family caregivers]. / L'éducation thérapeutique : un levier pour modifier les perceptions du trouble bipolaire chez les aidants familiaux.

OBJECTIVES: The patient with bipolar disorder and his family are caught in a reciprocal interaction: on one hand, the pathology leads to family sufferings and on the other hand, family behavior affects the disease of the patient and its development. Therefore, it seems of core importance that the psychologist should work with the family on their perception of bipolar disorder, that is to say, on their knowledge and psychological representations of the pathology. The aim of our study is to assess whether the initial perception of bipolar disorder evolves after a therapeutic education program. METHOD: Our research was conducted at the Bipolar Expertise Centre in Bordeaux/Centre Expert Bipolaire in Bordeaux on a sample of 145 participants (78patients and 67 family caregivers). They were all interviewed before and after the therapeutic education program (12 sessions in 6months). The Brief Illness Perception Questionnaire Revised (Moss-Morris, 2002) measures the perception of bipolar disorder and the BP Quizz (Fondation Fondamental) assesses the degree of knowledge of the disorder. RESULTS: Results show that therapeutic education helps families to level up their knowledge about bipolar disorder. Furthermore, representations on bipolar disorder have globally changed so that on average, bipolar disorder is viewed as less threatening by families after 12 sessions of therapeutic education. More precisely, after the program, families have a better understanding and a better insight of the disorder, which is then perceived as being less severe. On the emotional level, anxiety and stress have decreased. So there are an increase of knowledge and a change in perception. CONCLUSION: Our study shows that the therapeutic education program enables families to change their perception of the disease, that is to say, their knowledge but also their representations of the disease, which is a fundamental element according to the models of therapeutic education. Our results point out one of the active processes of therapeutic education at work in the sessions: in the perception of the disease, which is composed of both knowledge and representations of the disease, just a change in representations constitutes a lever for therapeutic education. Therefore, working on representations should be a therapeutic target. As a conclusion, we can say that therapeutic education of families cannot be reduced to an educational dimension which would only consist of gaining knowledge. Then, the right posture of the psychologist is to hold each participant's own development and changing process of representations.

Emotional hyper-reactivity and cardiometabolic risk in remitted bipolar patients: a machine learning approach.

OBJECTIVE: Remitted bipolar disorder (BD) patients frequently present with chronic mood instability and emotional hyper-reactivity, associated with poor psychosocial functioning and low-grade inflammation. We investigated emotional hyper-reactivity as a dimension for characterization of remitted BD patients, and clinical and biological factors for identifying those with and without emotional hyper-reactivity. METHOD: A total of 635 adult remitted BD patients, evaluated in the French Network of Bipolar Expert Centers from 2010-2015, were assessed for emotional reactivity using the Multidimensional Assessment of Thymic States. Machine learning algorithms were used on clinical and biological variables to enhance characterization of patients. RESULTS: After adjustment, patients with emotional hyper-reactivity (n = 306) had significantly higher levels of systolic and diastolic blood pressure (P < 1.0 × 10-8 ), high-sensitivity C-reactive protein (P < 1.0 × 10-8 ), fasting glucose (P < 2.23 × 10-6 ), glycated hemoglobin (P = 0.0008) and suicide attempts (P = 1.4 × 10-8 ). Using models of combined clinical and biological factors for distinguishing BD patients with and without emotional hyper-reactivity, the strongest predictors were: systolic and diastolic blood pressure, fasting glucose, C-reactive protein and number of suicide attempts. This predictive model identified patients with emotional hyper-reactivity with 84.9% accuracy. CONCLUSION: The assessment of emotional hyper-reactivity in remitted BD patients is clinically relevant, particularly for identifying those at higher risk of cardiometabolic dysfunction, chronic inflammation, and suicide.

[A therapeutic education program for parents of children with ASD: Preliminary results about the effectiveness of the ETAP program]. / Un programme d'éducation thérapeutique destiné à des parents d'enfant avec un TSA : résultats préliminaires concernant l'efficacité du programme ETAP.

Autism Spectrum Disorders (ASD) are characterized by particularities of cognitive and socio-adaptive functioning. Daily, they require specific interventions for the disabled person as well as support for parents who often report deterioration in their physical and mental health. To this end, the latest Autism Plan 2013-2017 highlights the need "to help families to be present and active alongside their loved ones, to avoid situations of exhaustion and stress and to enable them to play their role fully in the long term". The support devices must therefore be based on an analysis of the parents' needs and propose multiple intervention modalities, which respond to the complexity of the caregiving mission. Therapeutic education (TE) seems to answer to these different elements by proposing a global approach improving the development of child-centered skills and the educational challenges (self-care skills) but also of skills centered on the projects and the fulfillment of the parent (psychosocial skills). The ETAP (Therapeutic Education Autism and Parenting) program is an initial TE offer intended for parents of children with ASD aged between 3 and 10years. It consists of seven group sessions and two semi-structured interviews, called educational diagnosis. A booster session is also proposed three months after the last session. It was developed following rigorously the guidelines on program construction, published by the High Authority of Health. In addition, it is based on an assessment of the needs of the parents, an in-depth analysis of the literature and the opinion of nine experts in this area. The objective of this study is to evaluate the effectiveness of the ETAP program on the quality of life and anxio-depressive symptoms of parents of a child with ASD. To our knowledge, the ETAP program is the first TE program in France for parents of children with an ASD that has been evaluated. Our sample is composed of 40 participants, including 30 parents who participated in the ETAP program ("ETAP Group"), compared to ten controls who did not participate, but who are on a waiting list ("Control Group"). Each participant completed a Quality of Life Questionnaire (WhoQol-Brief) and an Anxiety-Depressive Symptomatology Questionnaire (HADS) prior to the start of the program (T1) and after the session 7 (T2). Preliminary analyses show a good intergroup matching on socio-demographic and medical data. Moreover, the two groups are not significantly different at T1 over the set of dependent variables measured. Our results show an improvement in the quality of life of the depressive symptomatology in the participants. On the other hand, we did not notice any significant decrease in anxiety symptoms. However, when we consider the proportion of parents with a significant anxiety state (in terms of the clinical threshold of HADS, score ≥10), we see that it tends to decrease after the program only for the group ETAP. These data should be interpreted with caution because of their preliminary nature and the small size of our sample. However, the first steps are encouraging and confirm the value of the therapeutic education model for parents of children with ASD. The different information given during the sessions takes into account the previous representations, knowledge and skills of the parent. Thus the program promotes the upholding and the development of individual resources in parents. In addition, the psychosocial skills targeted also to make access easier to available environmental resources. Finally, in a more indirect way, the ETAP program also aims to maintain or restore a positive parenthood and individual identity and the progressive development of new ways of to interact with the environment. An adaptation of the Hobfoll resource conservation model is proposed by the authors to formulate hypotheses on the mechanisms of action of the ETAP program.

Revisiting the association between childhood trauma and psychosis in bipolar disorder: A quasi-dimensional path-analysis.

BACKGROUND: Childhood trauma has been associated with a more severe clinical expression of bipolar disorder (BD). However, the results that specifically associated traumatic events and psychotic features in BD have been inconsistent, possibly due to the low resolution of the phenotypes being used. METHODS: 270 normothymic patients with BD completed the Childhood Trauma Questionnaire (CTQ) and the Peters Delusion Inventory (PDI) that assessed 21 delusional beliefs. Patients were characterized for the lifetime presence of psychotic features during episodes and cannabis misuse in accordance with DSM-IV. We performed a series of path analyses to investigate the links from three types of childhood abuse (physical, sexual and emotional) directly to delusional beliefs and psychotic features, and indirectly through cannabis misuse. RESULTS: A first path analysis showed no link between any of the childhood abuse types and psychotic features when only a categorical definition of psychosis was used. When incorporating the quasi-dimensional measure of delusional beliefs in a second path analysis, we found that emotional and physical abuse and cannabis misuse were each directly associated with PDI score. PDI score and psychotic features were strongly correlated. Childhood abuse did not operate through cannabis misuse to increase delusional beliefs. Including type of BD in the model did not alter the results. CONCLUSION: Emotional and physical abuse, but also cannabis misuse, increased delusional beliefs in patients with BD. Using a quasi-dimensional measure of psychotic symptoms in BD provided higher resolution of the psychosis phenotype and helped reconcile ambiguous findings from previous studies.

The Need for an Ecological Approach to Parental Stress in Autism Spectrum Disorders: The Combined Role of Individual and Environmental Factors.

This study aimed to identify parental stress predictors in ASD by considering individual and environmental factors in an ecological approach. Participants were 115 parents of children with ASD aged from 3 to 10 years. Multiple regression analyses were conducted to determine the best predictors of parental stress among child-related, parent-related and environmental factors. Poor quality interactions within the extended family, high levels of expressed emotion and absence of children's schooling were associated with higher stress, regardless of the child's age and developmental quotient [F (3) = 37.051; p < 0.001; Adj. R(2) = 0.457]. This study highlights the importance of considering environmental factors, specifically family variables, to understand parental stress. These key findings should be considered when designing support programs.

Affect intensity measure in bipolar disorders: a multidimensional approach.

BACKGROUND: Emotional dysregulation, characterized by high levels of both arousal and intensity of emotional responses, is a core feature of bipolar disorders (BDs). In non-clinical populations, the 40-item Affect Intensity Measure (AIM) can be used to assess the different dimensions of emotional reactivity. METHODS: We analyzed the factor structure of the AIM in a sample of 310 euthymic patients with BD using Principal Component Analysis and examined associations between AIM sub-scale scores and demographic and illness characteristics. RESULTS: The French translation of the AIM demonstrated good reliability. A four-factor solution similar to that reported in non-clinical samples (Positive Affectivity, Unpeacefulness [lack of Serenity], Negative Reactivity, Negative Intensity), explained 47% of the total variance. Age and gender were associated with Unpeacefulness and Negative reactivity respectively. 'Unpeacefulness' was also positively associated with psychotic symptoms at onset (p=0.0006), but negatively associated with co-morbid substance misuse (p=0.008). Negative Intensity was positively associated with social phobia (p=0.0005). LIMITATIONS: We cannot definitively exclude a lack of statistical power to classify all AIM items. Euthymia was carefully defined, but a degree of 'contamination' of the self-reported levels of emotion reactivity may occur because of subsyndromal BD symptoms. It was not feasible to control for the possible impact of on-going treatments. CONCLUSIONS: The AIM scale appears to be a useful measure of emotional reactivity and intensity in a clinical sample of patients with BD, suggesting it can be used in addition to other markers of BD characteristics and sub-types.

[Emotional reactivity in euthymic bipolar patients]. / Réactivité émotionnelle chez les patients bipolaires en phase de normothymie.

BACKGROUND: Euthymic states in bipolar disorders are usually considered to be lacking serious psychiatric disorders. Moreover, recent results prove the need to take an interest in a potential emotional dysregulation during these intercrisis periods. Therefore, it seems relevant not only to focus on the emotions tonality (sadness/euphoria) felt by patients, but also on the intensity of their emotional background. Several reasons argue for a disturbance of emotional reactivity in euthymic bipolar patients. First, most bipolar patients spontaneously claim they have a higher sensitivity than average, which may lead to extreme emotional reactions, even during intercrisis periods. Secondly, the emotional reactivity is a way to raise the question of the bipolar patients' vulnerability to stress in euthymic periods. Several studies have shown the impact of stressful life events on the rate of relapse into bipolar disorders. The aim of this study is to examine the emotional reactivity of euthymic bipolar patients in comparison with a control group, using a test of emotional induction. Our hypothesis is that euthymic bipolar patients have a higher emotional reactivity than controls. METHOD: One hundred and forty-five subjects were recruited: 90 controls and 55 euthymic bipolar patients. The patients were interviewed by a trained psychologist using the French version of the DIGS providing DSM-IV diagnosis. The euthymic state was confirmed with both MADRS (score<12) and Bech's Manic Scale (score<4). The subjective emotional reactivity of the subjects was assessed using a method of emotional induction, based on viewing a set of 18 (positive, negative or neutral) pictures. The subjects have to appreciate the valence (pleasant, neutral or unpleasant thoughts) and assess the arousal (degree of emotion triggered by each picture). RESULTS: On average, euthymic bipolar patients report the same valence and arousal to positive (F [1.143]=0.18, p=0.68) and negative (F [1.143]=0.52, p=0.47) pictures as control subjects. Neutral pictures, however, were considered more pleasant and moving by euthymic bipolar patients than by control subjects (F [1.143]=8.40, p=0.004). CONCLUSION: Euthymic bipolar patients seem to present an emotional hyperactivity which occurs especially in neutral situations. These results partly corroborate outcomes of other authors, while providing a new methodology through the emotional induction test. The highlight of emotional hyperreactivity during intercrisis periods allows us to understand differently the topic of specific vulnerability to stress of bipolar patients. This hypersensitivity could lead to thymic decompensations and could be linked with an emotional dysregulation, potential endophenotype of the bipolar pathology. Beyond the interest in understanding the physiopathology of the bipolar disorder, it could be associated with several clinical applications as well as in the psychoeducational field and in the screening of the individual risk within the family of bipolar subjects.

[Construction and validation of a dimensional scale for mood disorders: multidimensional assessment of thymic states (MAThyS)]. / Construction et validation d'une échelle dimensionnelle de l'humeur: multidimensional assessment of thymic states (MAThyS).

BACKGROUND: The heterogeneity of mood episodes in bipolar disorders makes it difficult in some cases to define appropriate therapeutic strategies. Therefore, we proposed a new tool based on a dimensional approach, with five a priori subscales (emotional reactivity, thought processes, psychomotricity, motivation and sense perception) expected to help define subgroups of mood episodes predictive of the response to treatment. This study was designed to validate this multidimensional assessment of thymic states (MAThyS) scale. METHOD: One hundred and ninety six subjects were included: 44 controls and 152 bipolar patients in various states: euthymic, manic or depressed. The MAThyS is a visual analog scale consisting of 20 items, ranging from inhibition to excitation. These items corresponded to five dimensions, namely: emotional reactivity, thought processes, psychomotricity, motivation and sense perception. They were selected since they represent clinically relevant quantitative traits. RESULTS: Confirmatory analyses demonstrated a good validity for this scale, fair convergent and divergent validity (multitrait multimethod analyses (MTMM)), good internal consistency both at global and dimensional level (Alpha Cronbach ranging from 0.70 to 0.93). The MathyS scale is moderately correlated with both the Montgomery and Asberg depression rating scale (MADRS) (depression score; r=-0.45) and the mania rating scale (MAS) (manic score; r=0.56). Some dimensions were linked (emotional reactivity and thought processes, r=0.71; psychomotricity and motivation, r=0.70). Analysing the divergent validity of items led us to redefine three of them. Following this validation step, exploratory analyses suggest that a four-dimension factorial structure is more appropriate. However, the statistical model is very close to the clinically relevant five-dimensional model. Further studies are needed to explore the relevance of retaining this dimension as a useful descriptive element.

[Multiplicity of syndromes associating manic and depressive symptoms: the need for a dimensional approach]. / Multiplicité des syndromes associant symptômes dépressifs et maniaques: nécessité d'une approche dimensionnelle.

The heterogeneity of mood states in bipolar disorders leads to some confusion in diagnostic and therapeutic strategies. Apart from the classical syndromes characterizing euphoric mania and melancholic depression, recent literature has pointed to alternative mood states associating both manic and depressive symptoms. This resulted in the definition of various syndromes including mixed states, dysphoric mania, agitated depression and more recently the depressive mixed state. This consequently raises the question of the best therapeutic strategies. As the boundaries between the various states associating both depressive and manic symptoms have yet to be clarified, there is a need to further discuss whether dimensional rather than categorical approaches could help to further refine their definitions and define the best therapeutic strategies. As stated by Kraepelin, mood episodes in manic-depressive illness were defined according to three dimensions: mood, cognitive processes, and motor and motivational drive. Cognitive and motor processes were regarded as quantitative items whose alterations may correspond to either an increase or a decrease. The current definitions are far from this dimensional approach. Thus, the current diagnostic criteria make it difficult to define mixed states. Such poorly convincing diagnostic criteria may account for the description of many other states exhibiting both manic and depressive symptoms. A dimensional approach could be useful to define mood states in bipolar disorders. These dimensions should progressive, from inhibition to excitation. Because tonality affects is not a dimension, the emotional reactivity (hyper-reactivity versus hypo-reactivity) represents an additional dimension that would help characterize these states better.

[Baby blues: characterization and influence of psycho-social factors]. / Le baby blues: caractérisation clinique et influence de variables psycho-sociales.

BACKGROUND: Within days following birth, most women are showing signs of mood changes, commonly named baby blues. Due to the frequency of this condition, baby blues is considered as a physiological state probably associated to biological modifications. Some studies have shown an existing link between the intensity of the baby blues and post-partum mood disorder. Therefore, it seems important to report and explore in more details the clinical background related the condition. The aim of this study was to demonstrate the possibility of a link between the intensity of the baby blues and some specific factors like maternal self-esteem, maternal childcare stress and social background, and also to define the symptoms of the baby blues from core dimensions in mood disorders. METHOD: Mothers were recruited few hours before giving birth in a teaching hospital. At the third day following birth, an appointment was made to obtain the necessary information (past medical history and social history) and history of previous mood disorders. The mood was evaluated from the scale of the intensity of baby blues from Kennerly and Gath (1989). Moreover, evaluations at day 3 and week 6 post birth of self-esteem in relation to motherhood (Maternal self-report Inventory from Shea and Tronick, 1988), stress in relation with the care of the baby (Childcare Stress Inventory from Cutrona, 1983) and the social support (Social Support scale from Bruchon-Schweitzer, 1998) were undertaken. RESULTS: 95 women were included in the final sample. The intensity of the baby blues was explained by the type of pregnancy (p=0.002), a low maternal self-esteem (p=0.025), high levels of stress in relation to the care of the baby (p=0.074). The basic clinical characteristic of the baby blues seems to be due to an increase in the emotional reaction with a sharp feelings, leading to a lability rather than an affect sad tonality. CONCLUSION: The baby blues seems to be a physiological process whereby the intensity is influenced by psychological factors. Consequently the diminution of self-esteem with motherhood and the increase of stress in relation to the care of the baby appeared to be significant factors in the intensity of the baby blues. Moreover, the clinical characteristics found in this study implies that the baby blues is more related to hypomania rather than to depression syndrome. This non-pathological state could be the first stage leading to a puerperal psychosis in predisposed women, which is mainly characterized by manic symptoms.