À propos du post-partum blues
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Since postpartum blues was described by Savage in 1875, the controversy regarding its nature and cause has been sustained. In a first part, the author reviews the conventional clinical assessment of the blues as described in international medical literature. Its constitutive symptoms are mundane, of an affective, emotional, cognitive or psychosomatic nature. On the other hand, their originality resides in the mildness, unusual nature and progressive profile of their expression. Some elements speak in favour of the normality of this phenomenon, such as its mildness and great frequency. But others give indication of a pathological process, notably its links with various entities or illnesses such as the premenstrual syndrome, acute psychoses and postpartum depressive moods. This aspect has moreover led to search for shared causes to these different co-morbidities, such as a constitutional predisposition, somatobiological disorders, a psychosocial condition or psychodynamic mechanisms. This debate, however, is far from being settled. In a second part – and in continuity with a previous work – the author adds three other symptoms to this classical approach: drop in intrinsic weight, decrease of activity and positivity to the dexamethasone test. In order to do so, he defines the notion of “gross prepartal weight” (weight as measured before delivery) and “neat prepartal weight” (resulting from the substraction of the foeto-annexial package from the gross prepartal weight). At the same time, he compares these data with those resulting from a questioning of twenty-one new mothers out of a university hospital ward on obstetrical difficulties, end-of-pregnancy psychic disorders or PMS case history. These analyses establish no specific link between the appearance of blues, the average age of the parturients, the notion of previous blues, lacteal inhibition under bromocryptine. On the other hand, as stated in the literature, the appearance of postpartum blues is closely connected to previous PMS history, a painful delivery, or a psychologically difficult end of pregnancy. The originality of these results consists of two elements: (1) the correlation between the intensity of the blues and the weight gain during pregnancy; (2) a probable increase of neat weight, as the author has defined it, in the first days following postpartum. In a more general way, the role of weight variation stands out distinctly if the weight curves during gestation and the aggravation of psychiatric morbidity are observed in parallel. In the analysis of surgical blues by Illes, the severity of cluster scores of decrease of activity and of vigilance is noted, along with a culmination of the pathology on the second day (and not on the fifth day as in postpartum), which can justifiably be attributed to the suddenness and precocity of weight drop. Also related to the role of weight, numerous quasi-experimental, historical or clinical situations of weight loss and their psychiatric impact can be quoted. On another level, one should consider the decrease of activity in the approached situations. While basic metabolism increases during pregnancy progressively to 20 % , delivery occurs through short but intense efforts. Postpartum implies a sudden deceleration in the course of which a physiological bradycardian phase around the fifth day can be underlined, as Magnin well described it. Some authors have positively correlated the blues to the intensity of labour, which corresponds to the degree of deceleration. In the same way, symptoms of sleep apnea syndrome have been linked to its fragmentation and to O2 desaturation induced intellectual lapses, but an involvment of diurnal fits of sleepiness cannot be rejected. In the same spirit, the activating role, prior to their mood stabilizing effect, of antidepressants is well known and the role of the musculorespiratory peak of the convulsive crisis in sismotherapies can be looked into. Finally, the nearly constant positivity to the dexamethasone suppression test (DST) is a symptom devoid of causal participation. Since Carrol's study, the frequent positivity of this test has been observed in depressed subjects. But there are multiple causes for positivity, starting with immediate postpartum, to such an extent that some authors have considered the test as more characteristic of the postnatal period than of any psychic disorder. However, the frequency of denutrition complications in DST – positive cases (insufficiently controlled diabetics, alcoholics, the aged and postpartum of course) is to be underlined. Numerous Anglo-Saxon authors have moreover put the emphasis on the link between weight loss and DST positivity, although they underlined the limits of this explanation. This is how the variations of activity may constitute an additional etiology. Actually, even if Weitzman has privileged the level of hypnic inhibition in regulating plasma cortisol, the inverted correlation between the latter's variations and those of activity is indeed striking. In this hypothesis, depressed subjects’ curves would diverge mostly in the daytime to the extent of a difference in activity or a lack of activity more distinct than at night. To support this thesis, we will also point out the lower sensitivity of the test in ambulatory care, which may reflect a relative mildness of these cases but also a better activity, the standardization of the test when a depressive phase changes to excitement, the early standardization of the DST before the improvement of the mental state during sismotherapy or sleep deprivation. Weight loss and decrease in activity, which are of a physiological nature, would thus have a causal value, and the DST would only reflect these two elements. In the last part, the author engages in various physiopathological hypotheses and some commentaries. In his physiopathological hypotheses, he takes up Delay's idea of a regulating centre of mood, potentially subjected to variations of weight and activity. He mentions in particular that these variations may compensate each other, as with anorectics, or increase each other, as in postpartum blues. In his commentaries, he expands the previous ideas into his favourite theme, the deep motive for his research, which is the consubstantiality of acting and of being as the cornerstone of the holistic unity of the living, this concept being otherwise developed in an additional work quoted in reference.

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