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Resume Introduction La prison, etant un lieu de privation de liberte, ou la dimension sexuelle fait egalement faute et les pratiques sexuelles sont strictement defendues, les etudes portant sur la sexualite en prison sont encore tres rares. Les objectifs de ce travail etaient de tracer un premier etat des lieux de comportements sexuels en detention au sein de l’etablissement penitentiaire en Tunisie, d’evaluer la sexualite d’une population de femmes detenues ainsi que d’etudier l’impact de la detention sur certains parametres de la sexualite. Sujets et methodes Nous avons mene une etude transversale, a visee descriptive et analytique, entre mars et aout 2013 au sein de la prison des femmes de la Manouba. Elle a consiste en une enquete evaluant la vie affective et sexuelle des femmes detenues a l’aide d’un hetero-questionnaire preetabli comportant 27 items et portant sur differents themes relatifs au comportement sexuel avant et apres l’incarceration. Les items ont consiste en des affirmations a choix simples ou multiples, et des questions ouvertes pour quelques-uns. Resultats Trente femmes ont ete incluses avec un âge moyen de 30,77 ans. Trois femmes (10 %) etaient en attente de jugement. Plus de la moitie des sujets (56,7 %) decrivent une sexualite anterieure pauvre et peu investie. Suite a la detention, 73,3 % des femmes constatent une modification du desir sexuel et 53,3 % signalent un appauvrissement des fantasmes. Un tiers des detenues disent avoir eu une activite masturbatoire et 23,33 % ont avoue avoir eu des relations homosexuelles pendant la periode de leur incarceration. Conclusion Les resultats de notre etude ont permis d’engager une reflexion sur les actions a proposer, ciblant ce tabou, afin d’ameliorer les conditions carcerales.

La therapie interpersonnelle a ete introduite en 2011 en Tunisie. Depuis, plus de cent patients ont beneficie de cette therapie. Nous allons etudier une serie de cent patients pris en charge depuis 2011. Il s’agissait dans 88 % de femmes, prise en charge pour un conflit interpersonnelle dans plus de la moitie des cas. Des echelles de depression Hamilton et d’attachement RSQ ont ete passe a ces patients a la date d’admission et a la fin de la therapie. Les resultats ont retrouve des attachements insecures dans 80 % des cas une depression d’intensite moyenne dans 20 % des cas. L’amelioration a ete remarquable dans plus de 80 % des cas.

Summary Introduction Prison is by definition a place where freedom is removed, and where the sexual dimension is also missing and sexual practices strictly prohibited. Studies concerning sexuality in prison are still few and far between. The aim of the present study was to make a first report on sexual behaviour in a Tunisian prison, and assess sexuality in a population of women prisoners and the impact of detention on some parameters of sexuality. Method We conducted a horizontal study for descriptive and analytical purposes, between March and August 2013 at the women's detention centre in Manouba. The women inmates were interviewed about their affective and sexual life using a hetero questionnaire with 27 items referring to various themes related to sexual behaviour before and after imprisonment. The items consisted of statements with single or multiple choices, and in some cases, open questions. Results Thirty women were included with mean age of 30.77 years. Three women (10%) were awaiting trial. More than half of the subjects (56.7%) describe their previous sex-life as poor and without commitment. Following their imprisonment, 73.3% of women reported a change in sexual desire and 53.3% reported a lack of fantasies. A third of inmates reported masturbatory activities and 23.33% admitted to having homosexual intercourse during their period of imprisonment. Conclusion The results of our study have enabled a process of reflection to be engaged on the actions to be proposed, targeting this taboo, in order to improve prison conditions.

IntroductionIn the Tunisian cultural context, the mother is in charge of childcare, housekeeping and the well-being of the whole family, which can lead to exhaustion and depression.ObjectiveTo estimate the frequency of depression among mothers aged between 20 and 40 years, its consequences and the possible solutions.MethodTransversal study using an anonymous questionnaire of 26 questions published through social media sites to mother with young aged children.ResultsThree hundred and twenty-seven mothers participated in the study: 20% of them aged between 20 and 30 years and 80% between 30 and 40. Ninety-seven percent of the participants were married; 96% of them had university education. Seventy-nine percent of them were working mothers and 50% of them did not get any help in childcare. Forty-two percent of the participants had only 1 child, 49% had 2 children, 8% 3 children and only 1 mother had 4 children. Depressive symptoms were present in 73% of the participants and were significantly higher among mothers aged between 30 and 40. However, depression was certain in only 36% of them and there was no significant difference between the two age groups. Eighteen percent of the participants noticed an increase in consummation of cigarettes, 31% resorted to tranquilizers, 25% needed sick leaves, and 2% resorted to alcohol use. Less working hours was suggested as a solution in 36% cases, sharing house chores in 30% cases.ConclusionDepression among young mother is a public health problem in Tunisia. It is underestimated and not always treated, which can have a serious impact on the whole family well-being.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionStroke is an important cause of morbidity and is responsible for 9% of all deaths worldwide. The most frequent neuropsychiatric consequence of stroke is post-stroke depression (PSD). It has been shown to be associated with both impaired recovery and increased mortality. The aim of our study is to determine the benefits of antidepressant prescription after a stroke.MethodThe databases from Medline and PubMed were reviewed for articles related to post-stroke depression (PSD), antidepressant treatment and stroke, post-stroke depression and functional recovery, stroke related impairment.ResultsAntidepressant drugs have been shown to be effective in treating PSD in six double blind randomized studies. Patients treated with antidepressants had better recovery from disability than patients who did not receive antidepressant therapy: it was proved that antidepressant drugs cause an improvement in cognitive skills and functional recovery in PSD patients. In patients with ischemic stroke and moderate to severe motor deficit, the early prescription of fluoxetine with physiotherapy enhanced motor recovery after 3 months. Some studies showed that PSD can be effectively prevented: nortriptyline, fluoxetine, milnacipran and sertraline appeared to be efficacious in preventing depression after stroke and are to use without significant adverse effects in stroke patients.ConclusionAntidepressant treatment plays an increasing role in the management of patients with acute stroke. Therefore, early initiation of antidepressant therapy, in non-depressed stroke patients, may reduce the odds for development of PSD, and improve cognitive and functional recovery.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionThe course of medical studies is a long route asking for a lot of breath. It is enclosed by the national examination for specialisation, which allows to access professional training. This examination requires a diligent preparation over several months in difficult conditions for the most part of the candidates who are in practical training.Objectivesand aims We suggest estimating the degree of anxiety and depression at the candidates in the week following the national examination for specialization of 2016.MethodsWe have put online on the pages of the various Tunisian Faculties of Medicine an anonymous questionnaire intended for the candidates who took the national examination for specialization of 2016. We used the scale HAD (Hospital Anxiety and depression scale).ResultsWe recruited 220 participants. More or less half of the participants declare to be rather often in a good mood, that they take little only of the pleasure in the same things as before, that they laugh and see the highly-rated voucher of things really less than before, that they are made of the concern very often and that they sometimes experience sensations of fear. A third of the participants feel tense or irritated most of the time feel sudden sensations of panic rather often and have the impression to work in slow motion rather often.ConclusionTaking the national examination of specialization rhymes with stress and anxiety. It leads us to question: is it necessary to assure a psychological coverage during the preparation and upstream of the competition?Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionThe narcissistic perversion is a psychoanalytical term resulting from the association of 2 Freudian notions: perversion and narcissism. The concept of narcissistic pervert has no clinical validity. The companions of the narcissistic perverts undergo moral suffering, often unknown by their entourage.ObjectivesWe suggest studying the trajectory of life of two wives of narcissistic perverts.AimsEmphasize the peculiarities of the narcissistic perverse personality.MethodsWe are going to postpone 2 clinical cases of spouses of narcissistic perverts.ResultsCase 1: Mrs. A., 60-year-old, divorced once. Mother of a girl. She met her current husband during the marriage of her daughter. At the beginning of their common life, Mr. M. was loving and in the small care with his wife. After three months of the marriage, Mrs. A. reported the change of character of her husband who became aggressive, decreasing her and taking her away from her family. He seized all her goods. She is actually getting a divorce.Case 2: Mrs. R., 27-year-old, married Mr. C. after 9 months of knowledge. At the beginning of their marriage, they had a good agreement. Forced to stay at home to take care only of domestic spots, she reported a real-life experience of neglect and emotional carelessness, she felt belittled and isolated. At present engaged in a divorce procedure after been physically assaulted threatened with death.Both women consulted for depression.ConclusionThe narcissistic perversion is a personality problem which affects as well the person involved but especially his entourage. When you are in connection with a narcissistic pervert, even after leaving him, you never recover from it.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Introduction Mental illness has a large effect on sexual function and the expression of sexuality. Many studies have illustrated that sexual dysfunction is significantly associated with depression. Objectifs Assess the quality of sexual response in a population of depressed women. Search factors associated with impaired sexual function. Aims Investigate the degree of correlation between sexual dysfunction and depression. Methodes Analytical and descriptive Study involving 30 sexually active women seen for the first time at the Razi hospital. They presents a first major depressive episode according to DSM IV. Exclusion criteria were the presence of psychotic symptoms, the use of antidepressants in the last three months and inflammatory or neoplastic comorbidity. The severity of depression was assessed by the Beck Depression Scale. The evaluation of sexuality was made ??by Aziona sexual experience scale Results The middle-age was 37 years, 80% were married. Depression was severe in 60% of cases and the average time of care was 3.7 months. Sexual function was altered in 70% of cases with a positive correlation between the severity of depression, the depressive episode duration, and the sexual dysfunction. Sexual desire was the most affected by depression, distorted in more than half of patients. Sexual arousal and vaginal lubrication were also altered in respectively 40% and 36.7% of cases, while orgasm and satisfaction with orgasm were more conserved. Conclusion Taking into account the dimension of sexuality is important in the management of a depressive episode. Early treatment is a protective factor from sexual dysfunction in depressed women.

Introduction Tramadol is an atypical, centrally acting, synthetic, analgesic. Its anti-nociceptive effects are mediated by a combination of μ-opioid agonist effects, and norepinephrine and serotonin reuptake inhibition. Initially, tramadol was said to have a low-abuse potential. However, its abuse liability and diversion were soon recognized, with several reports on physical dependence. Methods A case report and review of literature by a research on medline database. Key words: 'Tramadol”, 'opiate dependence”, 'tramadol withdrawal”, 'tramadol addiction” Case Report Mr. L.M. is a 24 year-old man without past history of substance abuse. In 2012, he underwent leg surgery after gunshot wounds. He was started on Tramadol treatment for his pain. He progressively increased Tramadol dosage and was taking 250mg to 750mg intravenous injections per day. He tried several times to stop taking Tramadol but each time his developed nausea, muscle aching, dysphoric mood and insomnia. His withdrawal symptoms had bad impact on his daily life and resulted in family life breakdown. Discussion Tramadol has long been considered to have a very low abuse potential. According to the US Food and Drug Administration, the rate of addiction was 1 in 100,000 during the last 18 months period of surveillance. Most of the cases had been in patients with a prior history of substance abuse. This case shows that Tramadol addiction may also occur in patients with no psychiatric or substance abuse history.

Introduction Trihexyphenidyl (THP) is an anti-Parkinson and anticholinergic drug, indicated in the treatment of parkinson disease, abnormal movements and parkinsonism induced by neuroleptic. The prophylactic use of anticholinergics in patients on neuroleptic treatment isn't recommended and may be justified only early in treatment. Howerver, in usual practice, the THP, is widely prescribed and used by patients. Recent observations suggest the existence of THP abuse linked to its hallucinogenic and euphoric effects. Aims to assess the tunisian psychiatrists perception on abuse and dependence potential of THP and their attitude toward this misuse. Methods A descriptive study among 100 tunisian psychiatrists (76: the public sector and 24: the private sector) who responded to a questionnaire, investigating the subject (dependence potential of THP, efficacy of THP, opinions about banning the THP from the tunisian pharmaceutical market). Results 87% of whole psychiatrists think that THP is associated with dependence potential. In the public sector, 77,63% of psychoatrists don't think that THP is more efficient than other anticholinergics and 78,94% agree to introduce other anticholinergic drugs in the hospital pharmacy. 3/4 of whole psychiatrists are for banning the THP from the national pharmaceutical market, espacially in the public sector, whose 80% of them approve the exclusion of THP from all public structures. Conclusions The majority of tunisian psychiatrists think that trihexyphenidyl is associated with a high risk of addiction. Many of them consider that banning THP and substitue it with other anticholinergics may be the solution. Is that really the best solution ?

Background Sexuality is a basic need of every human being. However, it can somrtimes become deviant. Unlike alcohol or drug abuse, suppression of sexual behavior is not an option, only compulsive character must be suppressed in order to allow a full and satisfying sexuality. Objectives The purpose of this observation is to explore the psychological and physical consequences of sexual addiction. Methods We report the case of a patient with sexual addiction, in order to describe the impact of this addiction on his psychological and physical health. Results Mr. JG is 28 a years old man, he has no particular habits and no significant pathological history. He was addressed by his general practitioner for “excessive masturbation”. His sexual history is characterized by: - An excessive interest in pornographic films since the age of 13, - An extremely rich fantasy life, - Frequent compulsive masturbation, going up to ten times a day. Through the years, this hyper sexuality has become more important, and masturbation more frequent, which resulted in: - Permanent feeling of embarrassment and shame, - Ideas permanently focused on sexual thoughts, - Fatigue and chronical physical exhaustion, - Constant muscle pain and headache, diminished visual acuity. - Relationship difficulties, and social maladjustment, - Depression and suicidal thoughts. The evaluation by the Carnes scale found a score of 16/25, which corresponds to a severe sexual addiction. Conclusions The boundary between normal and pathological depends on the models and taboos of society, but for physicians, the major criteria for sexual addiction are mental suffering, social maladjustment, and demand of care.

Introduction Suicidal behaviors are increasing in our country and they can be influenced by several factors such as social and cultural factors. It is important for physicians to better elucidate the risk factors in order to develop better strategies for prevention and management. Objectives and Aims To determine socio-demographic and clinical features in Tunisian patients who committed suicide attempts. Methods Retrospective and descriptive study using medical files of patients referred to the outpatients clinic of Razi hospital. Included patients have made a suicide attempt in the period from january to september 2014. Socio-demographic and clinical features were collected. Results Thirty-three patients were included (19 men and 14 women). The mean age was 30.6 years. Most of these patients were single (n=20; 60.6%), unemployed (n=19; 57.6%), with a low education level (n=19; 57.6%) and a low financial income (n=18; 54.5%). Nine of our patients went to jail (27.3%) and 8 had a personal history of suicide attempt (24.2%). Eighteen patients had addictive behavior (54.5%) and 7 of them were addicted to many substances (21.2%). Most prevalent psychiatric disorders in our population were adjustment disorder (57.6%) and depression (39.4%). Personality disorders were found in 18 patients (54.5%). 57.6% of patients used drugs for their suicide attempts Four patients were hospitalized and 82.2% of patients were lost afterward. Conclusions Suicidal attempts were associated with a disturbed and unsettled social and familial life leading to personality disorders. Furthermore, we noticed the high prevalence of addiction behaviors and bad treatment compliance.

The psychiatric disorders are the most frequent cause of the long term sick leave not only in Europe but also in Tunisia. Four diseases have been fixed by the Tunisian national register since 1959, give the right to the public employees institution of this type of vacation. These disease are: tuberculosis, cancer, paralysis and mental diseases. The aim of this study was to describe the evolutionary profile of these patients. Patients and methods The study was a comparison of two retrospective studies led in the department of emergency and external consultation of the Razi hospital. The first study had concerned 300 patients examined within the framework of a medical supervision during year 2001. The second study had concerned 430 patients having consulted for the first time in our department during the year 2012 and benefited from a long term sick leave. Results Forty was the age the most represented with a net feminine ascendancy in both studies. More than 60% of the patients were married in both study but a decrease of the number of single men has been reported in2012. The middle manager was the most represented professional category: the transport had been the most represented body employer in 2012. Depression was the most represented diagnosis. Conclusion The economical impact of the long term sick leave can be important but never considered. The low social support, the dissatisfaction, the workload and the indistinctness of the professional task are at the same time inductive but also aggravating factors.

Introduction Movement disorders are a frequent finding in psychiatric practice, even in emergency. Studies on acute movement disorders in psychiatric emergency are rare. Objectives To determine characteristic features of patients presenting with movement disorders in psychiatric emergency. Methods We conducted a retrospective study over one year period including all patients presenting in psychiatric emergency of Razi Hospital for movement disorders (from October2012 to September2013). Clinical, etiological and therapeutic features were analyzed. Results We included 335patients consulting in emergency for movement disorders (3.36% of all consultations in psychiatric emergency; sex-ratio: 3.53; mean age of 37.8 years). Main movement disorders (unique or in association) were acute and tardive dyskinesia(40%), Parkinsonian syndrome(34%), tremor(28%), acute dystonia(16.2%) (Mainly torticolis(22%), orofacial dystonia(17%)), akathisia(5.7%), oculogyric crisis(2.4%). Only one patient presented with neuroleptic malignant syndrome. Etiologies were mostly iatrogenic causes (drug abuse, weaning, errors, incomplinace). Most of patients had chronic psychosis (38.5%); 6.8% had simulated mevement disorders and 3.9% hysterical conversions. Anticholinergics (Trihexyphenidyle chlorhydrate in 64.5%) and benzodiazepines(14.3%) were the most used drugs in emergency. Only 3.9% of patients were admitted in hospitalization in emergency. Conclusion Our series shows the relative frequency (>3%) of movement disorders as a chief complaint in psychiatric emergency. The predominance of young male adults may be explained by the higher prevalence of dyskinesias in our series, for which younger age and masculine sex are risk factors. It is necessary to distinguish authentic movement disorders from psychogenic ones and simulations to avoid abusive prescriptions of anticholinergics, often explicitly claimed by simulators.

Introduction Psychotic symptoms such as hallucinations and delusions are common in patients with Parkinson's disease (PD). The estimated prevalence of hallucinations ranges from ~10% to 48%, and the prevalence of delusions ranges from 3% to 80%(ref 1–9). The various of the prevalence depends of the diagnostic criteria used. The etiologies of these symptoms are multiple and treatments are different. Through a clinical observation of a patient treated for a Parkinson disease (PD) and who develop two years ago a behavior disorder, irritability, visual hallucination and illusion, we suggest discussing the etiologies and the therapeutic difficulties of this disorder. Case report Y.N., a 64 year-old man, with family history of dementia, and personal history of diabetes and tuberculosis. He is followed for Parkinson's disease since the age of 57 years. He received Trihexyphenidyle (5 mg per day), Piribedil (200mg per day) and levodopa (500mg per day) with a progressive increase and excessive consumption of levodopa (more than 1000mg per day). Since the age of 62 years old, he presented with elaborated and invalidating auditory hallucinations with ideas of persecution and prejudice. The neuropsychological evaluation showed no other signs of dementia (MMSE=30/30). The diagnosis of dopaminergic psychosis was established. Levodopa was decreased; Trihexyphenidyle and Piribedil were discontinued with a notable improvement of hallucinations. Conclusion The psychotic symptoms in PD should be searched, such as systemic illness and other psycho-active medications. If none are identified or can be eliminated, the PD medications should be reduced to the lowest levels that allow tolerable motor function. Once this level has been reached we can use either acetylcholinesterase inhibitors or typical anti-psychotics

Introduction Primary polydipsia is an eating disorder which is often sub-diagnosed particularly in psychotic patients. Through a clinical observation of a patient who was treated for schizophrenia since 28 years and has presented a primary polydipsia, we suggest discussing the diagnostic and the therapeutic difficulties of this disorder. Case report Mr D.R, 46 years old, followed up since the age of 18 for a schizophrenia and a mental retardation. Despite the important dose of classic neuroleptic treatment and different association of classic neuroleptics, we never noted an improvement of the psychotic symptoms. One year ago, he had been hospitalized in a reanimation department for a metabolic encephalopathy secondary to a severe hyponatremia due to a primary polydipsia. Discussion The eating disorder associated with a psychotic illness doesn’t usually fill all the criteria of the DSM IV classification and is often classified as an eating disorder not otherwise specified. It's important to notice that the early beginning of schizophrenia is one of major risk factors of primary polydipsia. Besides, many other mechanisms are involved to explain primary polydipsia Psychotropic substances can lead polydipsia especially neuroleptics because of an inappropriate secretion of the ant diuretic hormone or by their anticholinergic effect by increasing oral drought. Clozapine remains the best indication because it permits the stabilization of psychotic signs and the decrease of primary polydipsia at the same time. Conclusion Primary polydipsia has to be diagnosed and treated at time in psychotic patients to avoid serious complications of hyponatremia which can be fatal.

Introduction The addiction to buprenorphine hight dose (Subutex®) is a new plague of drug addiction in Tunisia. The absence of a substitute treatment in this substance as well as the only ambulatory care of these drug addicts, make that is the weaning in the BHD is difficult. The aim of this study was to describe the follow-up and the weaning of these patients. Patients and methods A retrospective study was conducted on the records of 23 patients who consulted the outpatient service of Razi hospital, addicted to BHD, since January 2012 until now. Results Forty eight percent of patients (11 patients) were lost sight at the end of the first consultation. Only 13% of patients (3 patients) are followed up until now. Most of the patients had been put under classic neuroleptic essentially chlorpromazine in association with a benzodiazepine. 2 patients have weaned at the end of 13 months. These 2 patients are at present in relapse but in lesser doses than their initial dose of BHD. Conclusion The coverage of the patient dependent on drug was upset by the substitution treatments. But BHD don’t benefit from it and this hinders the care of the patients.

Introduction Buprenorphine haut dosage (Subutex) est le medicament le plus couramment utilise dans le traitement de medicament de substitution. Mais cette molecule est egalement bien connu pour son usage detourne ou abusif. Depuis la revolution tunisienne, le trafic de plusieurs medicaments a ete une montee tres dangereux. Objectifs Pour etudier la prevalence de la dependance a la buprenorphine haute dose en consultation psychiatrique en 2010 (avant la revolution tunisienne) et 2012 (apres la revolution). Comparer les caracteristiques cliniques du patient accro a la buprenorphine haut dosage avant et apres la revolution tunisienne. Methodologie Une etude retrospective, descriptive et comparative a ete effectuee sur les fichiers de patients qui ont consulte le service de consultation externe de l’hopital Razi a Tunis depuis deux ans: 2010 et 2012 dont diagnostic etait la dependance a la buprenorphine haut dosage. Resultats 34 patients dependants a la buprenorphine haute dose ont ete recrutes: six patients en 2010 et 28 patients en 2012. Tous etaient des hommes. L’âge moyen etait de 31,83 annees en 2010 et 32,13 annees en 2012. 44,11% de l’ensemble de la population de l’etude a developpe une symptomatologie depressive: quatre patients en 2010 et 11 patients en 2012. Les groupes d’âge, la periode de chomage et le montant des benzodiazepines consommees ont ete correles avec l’annee de consommation. Conclusion Ces resultats confirment l’impact de la revolution tunisienne sur la prevalence et le profil de dependance a la buprenorphine haute dose dans notre pays. D’ou la necessite de mesures generales de gestion de ces toxicomanes est imposee.

Introduction Women take sick-leave more often than men, in general and especially because of psychiatric disorders. Objective The aim of the present study was to describe and analyse sick-leave due to psychiatric morbidity and its relation to age and occupation, with a special focus on sex differences. Method We conducted a retrospective and descriptive study in external consultation of the psychiatric hospital Razi. We collected the records of patients seen between 01/07/2011 and 30/09/2012 and who received sick leave for psychiatric illness. Results 92 patients were included (78 female, 14 male) with mean age of 43,6 years. Sick-leave duration was longer for women. The greatest gender differences were found in the youngest and oldest age-groups. Women had higher incidence also in the longest spells (86% vs 14%). Depressive disorders were found among 73% of cases. Highest incidence of sick-leave was found among those with a combination of psychiatric and physical morbidity. Conclusion Psychiatric disorder is an important factor in sick-leave among women, especially regarding length of absence. Further studies on the influence of sex integration on sickness absence need to be done.

Introduction Incest may be defined as sexual relations between close blood relatives. It is found in all walks of life and all cultures. Incest is a taboo in all populations. This “secret” lived in childhood raises questions about the future of such a psychological trauma. Father-daughter incest is the most common. It has psychological, social, medical, and legal ramifications. Recently, it was reported that being the victim of paternal incest during childhood might be a significant predictor of a borderline personality disorder and complex posttraumatic stress in adults. Tunisia is among the countries from which incest cases are rarely reported. Objectives Browse the impact of this early trauma on victims to become adult and difficulties the therapeutic approach. Clinical case We propose from a clinical case of a family, in which five girls were victims of father-daughter incest. Conclusion This would suggest that father-daughter incest is the most traumatic experiences which deserves attention and that we cannot afford to ignore. In-depth knowledge of the dynamics and effects of father-daughter incest suggest specific treatment strategies are indeed necessary.

Introduction Discussions about the limitation of the prescription and dispensing of buprenorphine hight dose (Subutex ®) emphasize the need for a systematic and formalized cooperation between the various contributors in health. Objective Describe the course of caring for patients addicted to Subutex followed at the outpatient service of Razi hospital. Methods A retrospective study was conducted on the records of patients who consulted the outpatient service of Razi hospital during a six-month period and whose diagnosis of dependence to Subutex was retained. Results Twenty three patients were addicted to Subutex. 100% male. The mean age of the patients was 32.13 years. Almost 82.6% of patients had a low socioeconomic level and 78.3% of them did not have insurance. 16 were unemployed. A history of incarceration was found in 82.6% of patients. The duration of use of Subutex ranged between 2 and 168 months. Places of acquisition of this molecule were precised only by 26% of consumers. Fifteen consultants do not have any history of detoxification cure and 8 of them had 1 or 2 cures. In addition, 78.3% of patients reported being motivated to stop their addiction. Regarding collaboration of physicians, 8 patients (34% of the patients) were referred by generalist physicians, 7 patients by specialist physicians, 4 patients by emergency and 2 by psychiatrists. Conclusion The management of patients addicted to Subutex in our country is deficient. These results argue for the necessity of general measures of support dependent on psychoactive substances.

Introduction Delusions, hallucinations, aggression, and agitation affect more than half of patients with dementia. Antipsychotic drugs are used to treat these behaviors and symptoms. They are among the most frequently used psychotropic drugs in this disease, but their benefits are uncertain and concerns about safety have emerged. We assessed the current practice in use of antipsychotics medication in outpatients with dementia. Method We conducted a retrospective cohort study involving patients older than 65 years who began outpatient treatment with antipsychotic drugs following a dementia diagnosis. Results 22 patients were included (16 female, 6 male) with mean age of 78.6 years. All patients consulted for behavioral problems. Most received typical aantipsychotic drugs (72,8%), while 36,4% received atypical antipsychotic drugs. 13 patients (59,1%) were receiving haloperidol. Improvement was observed in 54,5% of patients. The comparisons of haloperidol with risperidone suggest no difference in efficacy for the treatment of global behaviour disturbance. On the other hand, use of haloperidol is, however, associated with a higher incidence of extrapyramidal and other side effects. Conclusion The treatment of elderly patients requires daily careful management and monitoring because of their polypathology, polymedication and of their greater sensitivity to the toxic effects of drugs. Overall, the study findings suggest that there is a need to monitor antipsychotic drug use by elderly patients in light of recent efficacy and safety data on atypical agents.

Introduction Tramadol, initially introduced in Germany in 1977, is a synthetic analgesic and appears to have a dual mechanism of action; a weak μ-opioid receptor agonism and a reuptake inhibition of serotonin and noradrenaline. It is marketed in Tunisia since 2001. Generally, Tramadol is considered to have a very low risk of dependence and abuse, but rare cases of tramadol dependence have been described in patients without prior substance abuse history. We describe one such case in a relatively young, otherwise healthy patient. Case report Mr AR, a 47-year-old man, presented to get help with tramadol addiction. He had no previous history of illicit drug use, did not smoke cigarettes or drank alcohol. Mr AR was started on tramadol treatment about 2 years earlier for back pain. He did have better pain control with tramadol, but he gradually started taking more and more. Ultimately, his pain resolved but he was unable to stop taking tramadol: he was taking up to 1700 mg/d of tramadol and had made multiple efforts to stop. When he stopped taking tramadol, he had dysphoria, muscle cramps, anxiousness, restlessness, and a sensation of insects crawling all over his body. His withdrawal symptoms were severe enough to interfere with his work and family life. Conclusion Tramadol dependence is very rare but can happen in a patient without substance abuse history. We, as medical practitioners, should be open to the possibility of tramadol dependence and should resort to optimal and judicious use of such a substance.

Introduction High dosage buprenorphine (Subutex) is actually the principal treatment for substitution medication. Some misappropriations and wrong uses have been seen; the most frequent and sever being using tablets for injections. Since the introduction in different countries, the high dose buprenorphine as a substitition treatment for opioid drug dependence, the number of overdose deaths and heroin users are significantly declined. But the existence of non-use replacement of this processing, mainly intravenously, was born a new scourge of addiction, especially in Tunisia. Besides the risk of overdose, there is a risk of viral contamination. Objectives To study the sexually transmitted diseases among patients addicted to high dose buprenorphine in Tunisia and followed in the outpatient hospital Razi. Materials and methods It is a retrospective study of twenty-three (23) patients (23 men), injection of high dose buprenorphine, having consulted the outpatient clinic of Razi Hospital between January and July of 2012. Results 8 patients had a communicable disease: 1HIV, 5 Hepatitis C, 1Hepatitis B, 1 syphilis. 4 patients had infectious complications: 3 cases of skin infections and 1 case of endocarditis. 9 had never been screened. 8 recognized using a used needle. Conclusion The addiction to high dose buprenorphine is a widespread phenomenon in Tunisia. Lack of information and awareness of companion in Tunisia is at the origin of serious infectious complications. Health professionals have to play an important role in drug addict patients’ education and supervision, to prevent addiction to buprenorphine and related infectious complications.