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Self-stigma of people with bipolar disorder is an underestimated problem, with serious consequences in terms of clinical severity and social and professional functioning.This study aimed to evaluate self-stigma in patients with bipolar disorder, to identify socio-demographic and clinical factors associated with it and to analyze the links between self-stigma and functioning in this population.We conducted a cross-sectional, descriptive and analytic study including 61 patients with bipolar disorder meeting criteria of remission. We used the internalized stigma of mental illness (ISMI) to investigate self-stigma, and the functioning assessment short test (FAST) to assess functioning.The mean age of patients was 43.4 years. The sex ratio was 2.4. Half of the patients were single or divorced (50 %). They had secondary or university education in 69 % of cases and were professionally inactive in 59 % of cases. The socioeconomic level was low or medium in 92 % of cases. A personal judicial record was found in 16 % of patients, a suicide attempt in 41 % of cases. Most patients in our series had bipolar I disorder (92 %). The mean age at onset of the disease was 23.5 years, with a mean duration of disease progression of 20 years. Patients were hospitalized an average of 5.9 times. Most patients (90 %) exhibited psychotic features during their mood relapses. The mean duration of the last remission was 27.9 months. Patients had regular follow-ups at our consultations in 87 % of cases. Among the patients included in the study, 8 % were on long-acting neuroleptics. The mean score on the internalized stigma of mental illness was 2.36±0.56. More than half of our patients (59 %) were self-stigmatized. Discrimination and alienation were found in 51 % of cases, followed by resistance to stigmatization (43 %) and assimilation of stereotypes (41 %). Regarding functioning, a global impairment was noted in more than two thirds of patients (71 %). An alteration in professional functioning was found in 82 % of cases and in cognitive functioning in 69 % of cases. Disruption of the financial sphere concerned 43 % of the patients, and the relational sphere 41 % of them. Autonomy was altered in 41 % of patients. Analysis of the relationships between self-stigma and characteristics of the study population revealed statistically significant associations between higher self-stigma scores and single or divorced status, low socio-economic level and judicial record. In terms of clinical parameters, the mean self-stigma score was significantly associated with a higher total number of thymic episodes and hospitalizations, a longer cumulative duration of hospitalizations and a shorter duration of the last remission. In addition, the mean self-stigma score was associated with significantly more impaired functioning.Our study underlines the need to work towards the implementation of management modalities aimed at combating the self-stigmatization of patients with bipolar disorder and mitigating its negative consequences during the course of the disease.

Resume La therapie interpersonnelle (TIP) est une therapie breve et structuree qui a initialement ete developpee par G. Klerman dans le cadre de la recherche sur le traitement de la depression de l’adulte dans les annees 1970. Elle a ete ensuite codifiee dans un manuel en 1984. Cette therapie, qui se base sur la theorie de l’attachement, vise l’analyse et la correction des modes relationnels interpersonnels de la personne souffrant de depression et elle ne se concentre pas sur les aspects intrapsychiques ou cognitifs de ce trouble psychiatrique. La TIP se fonde sur l’hypothese selon laquelle la majorite des personnes souffrant de depression ont des relations interpersonnelles perturbees qui declenchent ou suivent l’apparition du trouble de l’humeur. Il en decoule que le travail visant a resoudre les difficultes marquant ces relations interpersonnelles favorisera l’amelioration des symptomes depressifs. Cette demarche therapeutique va s’appuyer sur l’exploration des quatre domaines problematiques qui sont fortement correles a la depression selon G. Klerman : le deuil, les conflits interpersonnels, les transitions de role et les deficits interpersonnels. En fonction de l’exploration, un (ou deux maximum) de ces domaines va etre alors le centre de la therapie. Des etudes cliniques controlees ont demontre l’efficacite de cette approche therapeutique dans le traitement non seulement de la depression, mais aussi d’autres troubles psychiatriques aussi bien en phase aigue qu’en phase de maintien et dans differents formats therapeutiques, individuel, de couple ou de groupe. Plusieurs guidelines recommandent la TIP comme l’un des traitements de choix pour les troubles depressifs unipolaires. Cet article passe en revue les principes fondamentaux et les objectifs de ce modele therapeutique. Les concepts theoriques et les preuves resultant de la recherche sont egalement evoques. L’approche est brievement decrite et les differentes phases therapeutiques sont discutees.

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.

Resume Nous avons mene une etude retrospective a la fois descriptive et comparative sur une periode s'etalant du 1 er mars au 30 septembre 2000. La population a ete determinee a partir de 45 patients hospitalises presentant un trouble bipolaire de type I, dont 30 tunisiens et 15 francais.

In Arab and Islamic countries, domestic violence is not yet considered a major concern despite its increasing frequency and serious consequences. Surveys in Egypt, Palestine, Israel and Tunisia show that at least one out of three women is beaten by her husband. The indifference to this type of violence stems from attitudes that domestic violence is a private matter and, usually, a justifiable response to misbehaviour on the part of the wife. Selective excerpts from the Koran are used to prove that men who beat their wives are following God's commandments. These religious justifications, plus the importance of preserving the honour of the family, lead abusers, victims, police and health care professionals to join in a conspiracy of silence rather than disclosing these offences. However, a fair reading of the Koran shows that wife abuse, like genital mutilation and "honour killings" are a result of culture rather than religion.

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.

Interpersonal therapy (IPT) is a brief, structured psychotherapy initially intended to treat adult depression that was developed in the 1970s and manualized in 1984 by G. Klerman and his team. Two main theories served as a basis for its design: Bowlby's attachment theory and communication theory. Klerman theorized that tensions and problems in interpersonal relationships (i.e. disputes) cause psychological distress in vulnerable individuals that may lead to a major depressive episode. Clinical and epidemiological studies have shown that an insecure attachment style is strongly associated with lifetime depression. Severe depressive episodes have been correlated with avoidant attachment in women.IPT is based on the hypothesis that recent or ongoing disturbances in interpersonal relationships either trigger or follow the onset of mood disorder. In practice, IPT assists patients in analysing their interpersonal relationship modes, correlating their relational states with their mood and in learning to use better communication. Resolving difficulties in interpersonal relationships through the use of better communication skills promotes the improvement of depressive symptoms. Klerman identified four interpersonal areas that seem to be highly correlated with depressive episodes: grief (a close and important personal relation who has died), interpersonal disputes (conflicts with significant people such as a spouse or another close family member), role transition (significant life changes such as retirement, parenthood or chronic and invalidating illness) and interpersonal deficits (patients who have limited social contacts and few interpersonal relations). Classically, IPT is planned around 12-16 weekly sessions. During the initial sessions, the therapist will explore all existing interpersonal relations and any significant dysfunctions, both recent and ongoing. Following this interview, the area the patient considers as driving the current depressive episode will be designated as the focus of therapy. Evaluation of depressive symptoms by a quantitative measure (i.e. Visual Analogue Scale) and qualitative measures (activity, pleasure, quality of life) reoccurs at each session. During the intermediate sessions, therapy uses current situations and events in the designated area that particularly affect the patient's mood. Coping, communication and decision-making skills are gradually improved through a number of techniques. These include non-directive and directive exploration, clarification, encouragement of affect, and communication analysis. The therapeutic relationship is empathetic and encouraging of all progress the patient makes. The final phases close the therapy and help the patient to plan future actions and improvements.Several controlled clinical trials in adult populations have demonstrated the efficacy of IPT in treating Major Depressive Disorder (initial and recurrent episodes). It has been recommended as an appropriate treatment option in several guidelines. It can be provided in individual, couple or group formats. There remains an ongoing discussion of the efficacy of monthly maintenance sessions in recurrent depression. Since its conception, clinical trials have explored its use in specific populations such as adolescents and the elderly. IPT has also been the object of trial in other disorders such as post-partum depression, bipolar disorder, social phobia and eating disorders.This article reviews the basic principles and objectives of this therapeutic model. Theoretical concepts and results from research are also discussed. The approach is briefly described and the various therapeutic phases are discussed. Clinical trials have shown that IPT is effective in treating major depressive disorder in a wide variety of populations. Further trials are necessary to determine its efficacy in other psychiatric disorders.

IntroductionThe propensity of atypical antipsychotics (AAP) for having a therapeutic effect with fewer side effects and the balancing of these supposed benefits with tolerance are the subject of many studies.Aims and objectivesWe focused on adverse drug events (ADEs), occurred under AAP, in a population of patients with schizophrenia to assess the prevalences and describe how the practitioner deal with these ADEs.MethodsWe have used a retrospective and descriptive study of 63 Tunisian patients with schizophrenia, consulting in the adult outpatient of Razi hospital and treated by one type of AAP. The study period was 6 months from the 1st January 2015. We used the Birchwood Insight Scale (BIS), Positive and Negative Syndrome Scale (PANSS) and Udvalg for Kliniske Undersogelser (UKU) to assess the insight, psychotic symptoms and ADEs.ResultsTwenty-four patients were on risperidone, 22 on olanzapine, 8 on amisulpride and 9 on clozapine. Antiparkinsonism drug (15.9%) was associated because of neurological ADEs mainly Parkinsonism. Asthenia had a prevalence of 20.6%. Hypersalivation and palpitation were estimated at 7.9% both. Weight gain's prevalence was 25.4%, including 1 case associated with hypercholesterolemia and 1 case of unbalanced non-insulin-dependent diabetes. The erectile dysfunction's prevalence was 36.3% and decreased libido 27%. There were 2 cases of neutropenia and thrombocytopenia. The management of these ADEs was observed when they moderately began to influence the patient's daily activity.ConclusionADEs must be subject to an appropriate treatment and if necessary resort to a specialist consultation to confirm or deny imputability to AAP.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Introduction There is now an extensive body of data showing that depression is associated with a chronic low-grade inflammation. The obvious question is “What are the sources of this inflammation?” and “Could smoking be one of them?” Objectives The aim of the study is to investigate the association between depression and inflammation, and to highlight the role of smoking in this process. Methods The study included 65 depressed patients and 30 healthy controls. Blood samples of both groups were used for the measurement of the high-sensitivity CRP (hs-CRP) and the interleukin 6 (IL6). Results The mean value of hs-CRP was 2.02 mg/L among depressed patients and 1.42 mg/L among healthy controls (p=0.198). Higher values of hs-CRP (>=3mg/L) were found among depressed patients (20%) than among healthy controls (3.3%) (p=0.033). The mean value of IL6 was 4.12 ng/ml among depressed patients and 2.68 ng/ml among healthy controls (p=0.008). Higher values of IL6 (>=4ng/ml) were found among depressed patients (29.2%) than among healthy controls (3.3%) (p=0.004). The table below resume the relation between smoking and the elevation of inflammatory markers. Conclusion The causal relationship between smoking and depression is complex. Cigarette smoking increases the levels of inflammatory markers but did it leads to depression? Or did the depression increases smoking behavior? Or is there shared vulnerability factors for the both?

Introduction the relationship between hypothyroidism and mood disorder espacially depressive disorder is well described. However, there are few studies reporting psychotic symptoms (such as delusions, auditory or/and visual hallucination) in the setting of thyroid hormone defeciency. Objectives this study highlights psychosis as a possible presenting symptom in hypothyroidism. Methods case report and review Results we report the case of a female patient aged 36 years old with no family or personal psychiatric history, who presented with delusion, depressive disorder and auditory hallucination . the CT scan was without abnormality . the thyroid screening finds a severe hypothyroidism after 3 months of radiotherapy witn Iodine131 [FT4 = 2.49 ρmol/l, TSH 135.28 μUI/ml] Conclusion psychotic symptoms are an uncommun presentation of hypothyroidism and treatement choices are contreversial.

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.

Objectives Lithium is a drug which may cause thyroid dysfunction. The most widely known dysfunctions associated with long-term lithium treatment are goiter and hypothyroidism. Lithium associated thyrotoxicosis is however uncommon. This current review explores the common mechanisms of lithium induced hyperthyroidism. Methods A systematic review of database was made using PubMed. The search keywords used were lithium therapy, thyroid side effects, thyroid dysfunction mechanism, hyperthyroidism, thyrotoxicosis. Results Lithium induced hyperthyroidism is uncommon, the incidence rate varying from 0.1% to 1.7%. The mechanisms of lithium associated hyperthyroidism are uncertain. Recent studies have proved that high proportion of investigated patients experienced transient thyrotoxicosis and painless thyroiditis. Different mechanisms have been discussed, including autoimmune inflammation, direct cellular destruction, susceptible individuals with preexisting Grave’s disease, a rebound effect of lithium therapy interruption… The pathogenesis of painless thyroiditis is unclear but different studies suggest a possible direct toxic effect of lithium on the thyroid gland. Lithium stimulates thyroid autoimmunity: lithium treated patients presented more positive antithyroid peroxidase antibodies than not lithium treated patients. This could be explained by an increased activity of B-cell lymphocyte activity and reduced ratios of suppressor to cytotoxic T-cell lymphocyte. Conclusion Long term lithium treated patients should be monitored for the development of thyroid dysfunction. It’s recommended to perform thyroid function test, thyroid antibodies and thyroid ultrasonography with a closer follow-up for lithium-treated patients with thyroid antibodies, or family history of thyroid disease.

Background Dysfunction of the hypothalamus-pituitary-thyroid axis has been shown to play a role in the pathophysiology of bipolar disorder. Autoimmune thyroiditis is the most common cause of thyroid function alteration. Thus, auto-immune thyroiditis is likely associated with bipolar disorder. It might influence its course, prognosis and/or management. Objective To study the prevalence of positive anti-thyroid antibodies in patients with bipolar disorder and to examine the prognostic and the therapeutic implications of their presence. Methods Literature was reviewed using the Medline database and the following keywords: ‘bipolar disorder” ‘antithyroid antibodies” ‘thyroiditis”. Results PubMed research returned 12 results. After manual inspection, 10 articles were retained and examined. The prevalence of positive antithyroperoxydase antibodies (anti-TPO Abs) is higher in bipolar patients than in healthy controls, reaching 27%. The presence of positive anti-TPO Abs has been associated with rapid-cycling, with a higher risk of lithium-induced hypothyroidism as well as with poor prognosis. Auto-immune thyroiditis appears to be related not only to bipolar disorder itself but also to the genetic vulnerability to develop the disorder. Conclusion The presence of anti-TPO Abs is a possible endophenotype for bipolar disorder. Anti-TPO Abs should be obtained in many patients with bipolar disorder, especially in those on lithium.

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.

Background & aims Dementia is one of the most common neuropsychiatric disorders in nursing home residents. Despite a high prevalence and a major impact on daily activities, dementia remains largely underdiagnosed and therefore rarely treated in nursing homes throughout the world. This study aims to determine the prevalence of dementia among residents of Manouba nursing home (in Tunis) and to identify the proportion of recognised cases of dementia among this population. Methods A cross-sectional study was performed from September to October 2012 among all consenting residents of Manouba nursing home. Sociodemographic data were collected by the means of a semi-structured questionnaire. Cognitive functions were assessed using the Montreal Cognitive Assessment (MoCA) test in its Arabic version. We excluded subjects who could not take the MoCA test because of a severe sensory deficit or a severe psychiatric condition. Results At the time of the study, the population of Manouba nursing home residents consisted of 116 subjects. After applying the exclusion criteria, we retained 77 subjects: 48 males (62.3%) and 29 females (37.7%). The average age was 72.6 years. The average MoCA score was 14.4 +/− 6.5 (range: 3 to 29). The prevalence of dementia in our population was 58.4% (n=45). Among these 45 subjects with dementia, only three (or 6.7% of dementia cases) were already diagnosed as such. Of these three patients, only one was on anticholinesterase treatment. Conclusion Dementia is largely underrecognised and hence undertreated in nursing homes in Tunisia as in other countries. Routine screening for cognitive deficits seems paramount in order to ensure early diagnosis and treatment of this debilitating condition.

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.

Introduction La depression est souvent en relation avec l’apparition d’une dysfonction erectile (DE). Le but de ce travail est d’evaluer cette association chez le diabetique. Patients et methodes Nous avons releve le score de DE chez 50 diabetiques a l’aide d’un auto-questionnaire incluant l’indice international de la fonction erectile simplifie dans sa version arabe (IIEF-5). Les patients ont ete repartis en deux groupes : ceux avec DE (DE (+); IIEF-5 = 1–20; n = 34) ont ete compares a ceux sans DE (DE (−); IIEF-5 = 21–25; n = 16). Tous les patients font l’objet d’un depistage de la depression a l’aide de l’echelle Beck Depression Inventory - version abregee en arabe (BDI). Nos patients ont un âge moyen de 47 ans (extremes : 22 a 75). Il s’agit d’un diabete de type 2 dans 66 % des cas, et de type 1 dans 34 % des cas. La duree moyenne du diabete est de 8,12 ans. L’HbA1c moyenne est de 9,46 %. Resultats une DE est retrouvee dans 76 % des cas; elle est severe chez 4 % des patients, moderee dans 8 % des cas, legere a moderee dans 26 % des cas et legere dans 38 % des cas. Le score BDI moyen est de 6,69 (extremes : 0 a 24). Une depression est retrouvee chez 48 % des patients; elle est legere chez 11 %, moderee chez 26 % et severe chez 11 %. Les patients ayant une DE ont un score BDI moyen statistiquement plus eleve que les patients indemnes de DE (8,3 vs 3,5; p = 0,04). Conclusion La DE et la depression sont tres frequentes chez le diabetique. La depression peut etre a la fois un facteur etiologique et une consequence de la DE. La prise en charge optimale des DE devrait prendre en compte le profil psychologique du patient diabetique.

Introduction Schizophrenia is still one of the most difficult diseases to treat, whose direct and indirect costs remain high, both for the patient, family and society. The duration of the untreated psychosis is one of the factors likely to influence the evolution of this disease. To know the factors that may lengthen the period of care would improve the evolutionary course of the disease. Objectives Determine the factors contributing to the delay in treatment of schizophrenia within the Tunisian population. Methodology Retrospective study of patients in Razi hospital with schizophrenia admitted in 2004 and 2005. Results Our sample consisted of 91 patients. The poor family support (p = 0,032), the death of the mother (p Other factors that were correlated to longer period of support are: advanced age of onset of disorders (p = 0.013), family history of psychiatric illness (p = 0,03) and of schizophrenia (p = 0,04) and disorganized form of schizophrenia (p = 0,049). Conclusion We can stipulate that the application of certain measurements like the improvement and the extension of the social coverage to the poorest classes and most marginalized as well as the fight against the stigmatization of the schizophrenic patients and the mentally ills in general would be more than useful.

Introduction The use of monotherapy with mood stabilisers during bipolar disorder concerns only few patients. Neuroleptics, benzodiazepines and recently the new-generation antipsychotic molecules are widely used as adjuvant therapy to mood stabilizers, indeed beyond the indications held by the guidelines. Objectives Modalities of prescription of psychotropic medication during the first admission and over a three-year follow-up in subjects with bipolar disorder. Aims Evaluate the adequacy of prescribing practices in naturalistic conditions and international guidelines. Methods Retrospective study of all first-admitted patients with bipolar disorder in two psychiatric wards of Razi Hospital between 2006 and 2008 and over a three-year follow-up. Results Our sample consisted of 72 patients. Over 80% of patients had initially received an incisive antipsychotic drug in combination with mood stabilizer; it was a conventional antipsychotic in 65.3%. Sedative neuroleptics were prescribed in 40.3% of cases with a duration average of 19.21 ± 11.97 months. The combination of two antipsychotic drugs was found in 33.3% of patients. The most frequent association was “haloperidol-chlorpromazine” (79%). Benzodiazepines were prescribed in acute phase in the majority of the sample (94%) with a duration average of 27 mo is ±8.4 months; it was the lorazepam in 70.6%. Conclusions Theoretical recommendations do not always reflect the practical situations. Evaluating indications and conditions of polytherapy are critical issues in future studies on the biological treatment of bipolar disorder.