TLR4 Polymorphisms (T399I/D299G) Association with Schizophrenia and Bipolar Disorder in a Tunisian Population

Immune dysregulation has been widely described in the pathophysiology of schizophrenia (SCZ) and bipolar disorder (BD). Particularly, TLR4-altered activation was proposed as one of the underlying processes of psychosis onset. Since TLR4 activation was altered by T399I and D299G polymorphisms, we hypothesized that those variants could present common genetic factors of SCZ and BD. A total of 293 healthy volunteers and 335 psychotic patients were genotyped using PCR-RFLP. Genotype, allele, and haplotype distribution between controls and patients were evaluated according to clinical parameters. Statistical analyses were adjusted by logistic regression. In dominant model, T399I CT + TT and allele frequency were significantly higher in controls compared to psychotic population (p = 0.004, p = 0.002, respectively), SCZ (p = 0.02, p = 0.01, respectively), and BD (p = 0.03, p = 0.02, respectively). Similarly, D299G AG + GG and allele frequency were significantly higher in controls compared to psychotic population (p = 0.04, p = 0.04, respectively) and SCZ (p = 0.04, p = 0.03, respectively). T399I CT + TT and T allele were overrepresented in controls compared to paranoid subgroup (Padjusted = 0.04, p = 0.04, respectively) and type I BD (p = 0.04). Moreover, T399I and D299G were less prevalent in SCZ late-onset age (p = 0.03, p = 0.02, respectively). TA haplotype was associated with protection from psychoses (p = 0.02) and particularly from schizophrenia (p = 0.04). In conclusion, TLR4 polymorphisms could present a preventive genetic background against psychoses onset in a Tunisian population. While T399I could be associated with protection against SCZ and BD, presenting an overlapping genetic factor between those psychoses, D299G was suggested to be associated with protection only from schizophrenia.

Association between polymorphisms of TLR2-1-6 and bipolar disorder in a tunisian population

BACKGROUND

Bipolar disorder (BD) is a complex neuropsychiatric disease that has been strongly linked to immune dysregulation. In particular, an abnormal inflammatory response mediated by toll-like receptor 2 - 1/6 (TLR2-1/6) was described in BD. Nevertheless, genetic factors' contribution is still unknown. Thus, we suggested that functional polymorphisms of TLR2, 1 and 6 could be involved in BD predisposition.

METHODS AND RESULTS

TLR2, 1 and 6 polymorphisms were genotyped by PCR-RFLP in 292 controls and 131 patients from a Tunisian population. Polymorphisms and haplotype associations were explored in BD and binary logistic regression analysis was performed for more powerful associations. In dominant model, we found a significantly higher genotype and minor allele frequencies in healthy females compared to patients for TLR2-196-174Ins/Del (p = 0.04; OR = 0.3, p = 0.04; OR = 0.3, respectively) and for TLR6-S249P only with minor allele (p = 0.03; OR = 0.2). In contrast, TLR2-R677W CT + TT and T allele frequencies were significantly higher in BD (padjusted<10- 4; ORadjusted =46.6, p < 10- 4; OR = 6.3, respectively), specifically in females (CT + TT: 100%). Similarly, TLR1-R80T showed significantly increased GC + CC and C allele frequencies in patients compared to controls (padjusted=0.04; ORadjusted=4, p = 0.009; OR = 4.3, respectively). Moreover, haplotype investigation demonstrated that InsGTCGT (p < 10- 4, OR = 275) and delGCCGT (p = 0.03, OR = 18.5) were significantly overrepresented in BD patients compared to controls.

CONCLUSIONS

We suggest that TLR2-196-174Ins/Del and TLR6-S249P could be protective factors of females against BD. However, TLR2-R677W and TLR1-R80T could be strongly associated with higher risk of BD. Interestingly, TLR2-R677W could be a genetic marker for BD in females. However, further studies with larger groups are needed to confirm these findings.

Depression among medical students in Tunisia: Prevalence and associated factors

BACKGROUND

Medical school is known for its lengthy process, which is both physically and emotionally draining. Students' mental balance would shrink as they progress in their medical training. A systematic review and meta-analysis reported that the prevalence of depressive symptoms among medical students remained relatively constant at 27.2%.

AIM

To assess the prevalence of depressive symptoms among Tunisian medical students and evaluate its associated factors.

METHODS

This is a descriptive cross-sectional study that was carried out in the second semester of the academic year 2017/2018, between April 2018 and July 2018 among 1138 medical students. Data were collected using a socio-demographic questionnaire and the Beck Depression Inventory-II (BDI-II).

RESULTS

Sixty-four percent (n = 728) of the participants had depressive symptoms, of which 266 (23.4%) met the criteria for mild, 271 (23.8%) for moderate, and 191 (16.8%) for severe depressive symptoms. Female gender, low socio-economic level, smoking habits and history of mental disorder, performing leisure and physical activities, satisfaction toward a career choice, and happiness perception were the main prognostic factors for depression among medical students. Although academic grades may not be considered a prognostic factor, final-year students appeared to be less depressive than their colleagues.

CONCLUSION

These findings give insight into mental health issues and comorbidities among Tunisian medical students. It is a hopeful request for decision-makers and academic authorities to set serious measures and draw effective interventions to minimize the currency of psychological distress among this subpopulation.

Case control study: G-allele of rs4244165 in JAK1 gene correlated with high-level brief psychiatric rating scale in bipolar patients

Bipolar disorder (BD) is a chronic and clinically complex disease, characterized by pathological disturbances in mood and energy. Cytokines can access the brain and their signaling pathways affect brain functions, such as neurotransmitter metabolism, neuroendocrine function, neural/synaptic plasticity, and mood neural circuitry. JAK 1 is the most common phosphorylation protein combined with the tyrosine kinase cytokine receptors; therefore, we investigated the association between the Janus family kinase 1 (JAK1) gene polymorphisms (rs2780895, rs4244165, and rs17127024) and susceptibility to BD. The case study population included 93 patients diagnosed with BD and 112 healthy controls, selected from the central coastal region of Tunisia. Polymerase chain reaction-restriction fragment length polymorphism was used to investigate these 3 JAK1 polymorphisms. We compared the sociodemographic and clinical parameters of 3 genotypes of this single nucleotide polymorphisms rs2780895, rs4244165, and rs17127024 of the JAK1 gene. The frequencies of the 3 genotypes were similar in the patient and control groups. One-way analysis of variance revealed a significant variation in rs4244165. After hospitalization, the average of the brief psychiatric rating scale score was significantly higher for the wild-type GG genotype than that for the double-mutation TT genotype (31.23% vs 22.85%, P = .043). The least significant difference post hoc test also showed a significant difference between the GG and TT genotypes at both hospital admission (P = .001) and after hospitalization (P = .012), with the GG genotype being associated with a higher brief psychiatric rating scale score. Haplotypic analysis revealed that the wild-type haplotype with the highest frequency (46.62%) was CTG. Our results showed no association between the 3 studied positions and bipolar disorder. However, the G-allele of rs4244165 in JAK1 is associated with the highest level of the brief psychiatric rating scale in patients with bipolar disorder. The JAK/signal transducer and activator of transcription pathway is an interesting therapeutic route that requires further investigations. Studying their regulatory regions can provide a clearer picture of all the interactions involved in the regulation of genetic expression in response to treatment.

Clinical correlates of anxiety disorders : Tunisian study about 436 subjects

Introduction

Anxiety disorders are very common and burdensome mental illnesses worldwide, characterized by exagerated feelings of worry and fear. These disorders are highly comorbid with other conditions.

Objectives

The aim of our study is to explore the physical and psychiatric comorbidities and their clinical correlates. The second objective is to identify the predictors of recurrence of anxiety disorders.

Methods

Our study concerned 436 outpatients who met DSM-V diagnostic criteria for anxiety disorders and were followed in the Department of Psychiatry of Monastir (Tunisia) between 1998 and 2017. Selective mutism and seperation anxiety were excluded for lack of cases.

Results

Our results demonstrated that Generalized Anxiety Disorder (GAD) was significantly associated with cardiovascular comorbidity (OR=3.208). Social Anxiety Disorder (SAD) was significantly correlated to avoidant personality disorder (OR=17). Patients with suicide attempts are more likely to have a comorbid personality disorder (OR=11.606). Being married and having a later age of onset are predictors of having comorbid depressive disorder. Furthermore, being married, having an anxiety-anxiety comorbidity and a longer duration of untreated illness (DUI) are predictors of recurrence.

Conclusions

Our study highlights the fact that comorbidities (physical and psychopathological) call for a closer follow up due to the higher risk of recurrence, the higher risk of suicide attempts and the poorer treatment response.

Disclosure

No significant relationships.

Factors Associated with Mental Health Outcomes and the Level of Work Engagement Among Health Care Workers Exposed to Coronavirus Disease 2019 in Tunisia

Introduction

Heath workers especiallyin the emergency rooms and emergency medical services are exposed to sustained stress which had increased due to the Pandemic situation

Objectives

To search for factors associated with mental disorders among health workers during the Covid 19 pandemic

Methods

Data were collected through a questionnaire,with demographic variables anddifferentscales to evaluate the degree of symptoms of depression, anxiety, insomnia, distress, and the level of work engagement(PHQ-9,GAD-7,ISI,IES-R,UWES-9).

Results

Of the 217 participants, 46% were physicians, 42% were nurses and 12% were emergency medical technicians. We also found a femalepredominance of 66%, 55% were single and a total of 155 participants of whom 71% were frontline health workers. In our study, 54.8% of the HCWs had symptoms of depression, 68.2% had symptoms of anxiety and insomnia and 71.4% had symptoms of distress. Binarylogisticregressionanalysisshowedthat being married was associated with depression, anxiety, and insomnia, and being a frontlineworkerappeared to be a risk factor for depression and insomnia. Psychiatric support was an independentrisk factor for all psychiatric symptoms.In addition, living in a rural area was associated with depression, and age 31 or older was associated with anxiety. In addition, having a history of psychiatric illness was a risk factor for insomnia. Being a nurse was identified as a risk factor for psychiatric distress. We also found a moderatelevel of professional commitment to be a protective factor.

Conclusions

Protecting healthcare workers is a crucial part of the public health response to the COVID-19 outbreak.

Disclosure

No significant relationships.

Tobacco dependence and schizophrenia: Tunisian cross-sectional study of 50 cases

Introduction

Tobacco-use is currently one of the major public health problems and is more common among patients with schizophrenia.

Objectives

We aimed in this study to estimate the prevalence of smoking in a population of patients with schizophrenia, to assess tobacco dependence and to identify its correlated factors.

Methods

This is a descriptive and analytical cross-sectional study carried out on 50 outpatients at the Department of Psychiatry (Tunisia) over a period of two months. For the data collection, we used: a general questionnaire on sociodemographic characteristics and tobacco consumption and the Fagerström test for nicotine dependence.

Results

All the patients were male with a mean age of 32.7±7.02 years and 84% of them were tobacco consumers. More than half of the sample were single (68%) and had a primary school level (52%). A professional irregularity and low socio-economic level were found successively in 84% and 78% of cases. Half of the patients (52%) were diagnosed with paranoid schizophrenia and 46% of them were treated by atypical antipsychotics. Cigarette dependence was strong or very strong in 82% according to the Fagerstrom test. A positive correlation was found between strong tobacco dependence on the one hand and low socio-economic level, professional irregularity, smoking in a first-degree relative and treatment with a typical neuroleptic on the other hand.

Conclusions

Our study and data from the literature show that subjects with schizophrenia constitute a population of highly dependent smokers. A smoking cessation assistance program for this vulnerable population is a priority to improve their quality of life.

Disclosure

No significant relationships.

Mandatory containment of COVID-19 patients in Monastir: Legislative framework and impact on freedoms

Introduction

Tunisia found itself in an exceptional situation during the covid 19 pandemic requiring a legal regime of exceptionality and sanitary necessity with a double challenge: the fight against the sanitary crisis, and the preservation of democratic gains

Objectives

To describe the legislative framework put in place concerning patients with COVID-19 who stayed at the compulsory containment and to discuss the legality of these emergency decisions

Methods

The authors conducted a descriptive cross-sectional study of patients with COVID-19 staying in the compulsory containment centre of Monastir, with a review of the literature The data were collected through telephone calls. A review of the literature as well as a consultation of the different legislative

Results

The average age was 41.39 ± 1.26 and the sex ratio was 1.17.Imported cases represented 45.3% of the sample and 23% of them expressed a desire to consult a specialist. The duration of mandatory confinement was on average 35.86±1.31 days with extremes ranging from 7 to 86 days. Concerning the legislative framework of the emergency decisions taken during the first wave, the President of the Republic and the Head of Government used Articles 80 and 70 of the Tunisian Constitution, respectively, to issue legislative texts announcing the state of emergency and accompanying. Thus, these legislative measures were restrictive of rights and freedoms and seriously threatened the fragile gains of our democracy

Conclusions

COVID-19 redefined not only the health system but also the economic conditions, as well as the normative and legislative system 2014

Disclosure

No significant relationships.

Trainees between theoreticalknowledge and the initiative takingat the hospital

Introduction

The internshipis a period in which the studentimplements what they have learned from their training to obtain or certification and to promote their professionalintegration, the difficulty of taking initiative and the lack of self-esteemrepresenting an obstacle to their training

Objectives

This is a quantitative descriptive study conducted at the different placement departments among all 2nd-year students in all sections. Our data collection was done using two questionnaires administered, one for the supervisors and the other for the students.

Methods

Theoretical Framework: Theorist Patricia Benner

Results

According to the results found, in oursample, thereis a predominance of females 89.17%, with a sex ratio of 0.121. 88.34% are aged between 20 - 21 years and an averageage of 22.4 years. According to the interpretation of the Rosenberg Self-Esteem Scale scores, 17.5% of the trainees have a “Very Low Self-Esteem”, 47.5% have a “Low Self-Esteem”, 25.83% have an “Average Self-Esteem”, and only 9.17% have a “High Self-Esteem”. In addition, more than half of the respondents, 53.33%, state thatthey “often” have difficultytaking the initiative in the traineeshipenvironment, while 30.83% do not have such difficulty but “rarely”. Indeed, 53.33% of confirmedsupervisorssaythatthey “often” have difficultytaking the initiative in the placement environment

Conclusions

It isnecessary to take into account these obstacles to the trainee’s training through better psychological supervision, which could be the first steptowardssolving the problem

Disclosure

No significant relationships.

Prevalence and clinical features of anxiety disorders: Tunisian study about 436 subjects

Introduction

Anxiety disorders represent one of the most common mental disorders following a chronic course.

Objectives

The aim of our study is to determine the prevalence, incidence and clinical characteristics of these disorders.

Methods

We conducted a retrospective and descriptive study about 436 outpatients fulfilling the DSM-V diagnostic criteria for anxiety disorder and followed in the department of psychiatry of Monastir (Tunisia) between 1998 and 2017. Selective mutism and separation anxiety were excluded for lack of cases.

Results

The overall prevalence was 5.51%. Panic Disorder was the most prevalent anxiety disorder subtype (3.2%). The incidence of anxiety disorders in the last years has increased from 3.31% in 1998 to 7.5% in 2017. The mean age at diagnosis was 37.76±12.87 years [16-77]. Female gender was the most prevalent in overall anxiety disorders with a sex ratio of 0.78, however, a significant male predominance was recorded in Social Anxiety Disorder (SAD) with a sex ratio of 1.85. Generalized Anxiety Disorder patients were more likely to have low educational level (OR= 1.879), to be laborers (OR=2.55), to be married (OR=2.418) and to have children (OR=2.564) whereas SAD patients were more likely to have higher education (OR=9.118), to be students (OR=5.565), to be single (OR=11.325) and have no children (OR=7.464).

Conclusions

This study highlignts the frequency of anxiety disorders and the fact that being a middle-age married woman with kids make oneself more prone to have an anxiety disorder. Specific attention should be paid to these anxiety disorders with early preventive programs.

Disclosure

No significant relationships.

First episode-psychosis: Short- and long-term outcomes and related features predicting the transition to schizophrenia

Introduction

The occurrence of a first episode-psychosis in adolescents or young adults represents a difficult struggle with an uncertain and divergent outcome, since the clinician does not have at his disposal the clinical elements sufficient to predict these different disease trajectories.

Objectives

Our aims are to describe the socio-demographic, clinical characteristics and the short and long-term outcomes of a first episode-psychosis and to identify the predictive factors of the transition to schizophrenia.

Methods

We conducted a retrospective study about 117 patients hospitalized for a first episode-psychosis in the Psychiatric Department of Monastir (Tunisia). Sociodemographic and clinical features were collected using a pre-established form.

Results

First-episode psychosis affected young male subjects with low educational level. Stressors were present in 54.7%. An 8-week prodromal phase preceded the onset of the disorder in 59%. The disorder course included diagnosis of: Brief psychotic disorder (32.5%), schizophrenia (31.6%) and bipolar disorder (18.8%). The short-term outcome was characterized by a complete remission rate of 58.1% at 3 months and 37.6% at 6 months. The long-term outcome was marked by a high rate of lost to follow-up: 70.8% after 5 years. The transition to schizophrenia was linked to the presence of delirium of influence and the absence of favorable course at 3 months.

Conclusions

Our results led to the identification of the profile of patients with a first episode-psychosis and the factors correlated with a diagnosis of schizophrenia. Indeed, the determination of risk factors would make it possible to adapt earlier the care.

Disclosure

No significant relationships.

Depression and quality of life in Tunisian institutionalized elderly subjects

Introduction

Depression in the elderly is common and closely interrelated with the deterioration of the quality of life, especially in the institutionalized elderly.

Objectives

In this work, we propose to determine the prevalence of depression in the elderly in institution, to assess their quality of life and to evaluate the correlations between depression and the quality of life.

Methods

Our study concerned 30 elderly subjects institutionalized at the retirement home(Sousse, Tunisia). Three validated Arabic version scales were used: The 30-item GDS (Geriatric Depression Scale), the MMSE (Mini Mental State Examination) and the SF36 (assessing the quality of life).

Results

The mean age of our population was 75±7.3 years, the sex ratio was 1.73. The prevalence of depression was 37%. The elderly had a cognitive impairment in 16.7%. The mean global SF36 score were 11.2, attesting an altered quality of life in all our subjects: the mental component (9.43) were more altered than the physical one (13.03). No correlation between depression and quality of life was found. Depression was significantly correlated with the presence of a medical history (p=0.05). Depression had a negative and statistically significant correlation with the physical score of SF36 (r=-0.41, p=0.02) and tended towards significance for the “general health” dimension of SF36 (r=-0.32, p=0.08).

Conclusions

Our study shows a high frequency of depression in the institutionalized elderly as well as a deterioration in their quality of life. Depression is strongly linked to deterioration in physical condition.Our results underline the influence of somatic diseases as a major risk factor for depression in the elderly.

Disclosure

No significant relationships.

prevalence of addictions among students at the High School of The Health Sciences and Techniques of Sousse

Introduction

Addiction isfrequent in youngsubjects, particularly in students, who are in contact with psychoactive substances such as drugs, tobacco, alcohol, and cannabis

Objectives

The objectives of our study were to investigate the prevalence of addictions among ESSTSS students and to determine the factors associated with addictions.

Methods

A descriptive correlational cross-sectional study was conducted at ESSTSS among 122 students for 2 months (March and April 2021). The data was collectedusing a questionnaire administered to the students.

Results

There were 102 women and 20 men with an averageage of 20.96 years. theprevalence of drug use was 56.6% according to DAST-10, with addiction notedin 5.7% of cases. The prevalence of tobacco use was 35.3% according to the Fagerstörm test, with 23.3% of the students being highlyaddicted to tobacco. The prevalence of alcohol use was 29.5%, 35% for men, and 28.43% for womenaccording to the AUDIT, alcoholdependence was notedin 14.3% of men and 6.9% of women. The prevalence of cannabis use was 16.4% according to the CAST test, a high risk of dependence was observedin 20% of cases. The analytical study showedthat the factors associated with addiction were age, gender, year of study, and specialty

Conclusions

The prevalence of substance use among health science students is significant and since the use of these substances has a detrimental effect on health itisbetter to understand the associated factors and this obliges us to establish appropriate preventive interventions

Disclosure

No significant relationships.

Value of psychological counseling for trainees exposed to the death of a patient in emergency and resuscitation departments

Introduction

Trainee emergency and resuscitation technicians are not prepared during their academic training to deal with their psychological reactions to the death of a patient, we wanted to describe their feelings and understand the aggravating factors and highlight the need for intervention.

Objectives

Our study aims to describe the psychological reactions of traineesexposed to the death of a patient on the internship grounds and to demonstrate the usefulness of specific psychological counseling

Methods

It is a prospective interventional study carried out with 2nd and 3rd-year students of the emergency and resuscitation section, our collection was done using a self-administered questionnaire with a validated PDI scale before the training, and a satisfaction questionnaire with the same scale after the training.

Results

Our population isyoung, with an averageage of 20.05 years, and ispredominantlyfemale, with a sex ratio of 0.12. Eighty-seven percent of the population statedthatthey were not prepared to deal with their feelings about the death of a patient, and thiseventharmed the quality of care for 68% of the students. According to the scores of the PDI scale in pre-training 77.33% of the students are at risk of developing PTSD, this percentage decreases to 30.67% according to the same scale in post-training.

Conclusions

it is important to take into consideration the suffering of traineesexposed to traumaticevents such as the death of patients and to prepare them psychologically to deal with these situations

Disclosure

No significant relationships.

Association between TLR2 polymorphisms (- 196-174 Ins/Del, R677W, R753Q, and P631H) and schizophrenia in a Tunisian population

Since immune dysregulation has been well studied in schizophrenia pathophysiology, recent studies showed a potent role of TLR2 in neuroinflammation process underlying schizophrenia pathogenesis. However, the genetic predisposition is still unclear. Thus, we hypothesized that TLR2 polymorphisms - 196-174 Ins/Del (rs111200466), R753Q (rs5743708), R677W (rs121917864), and P631H (rs5743704) could be involved in schizophrenia predisposition. A case-control study was performed on a Tunisian population composed of 250 healthy controls and 250 patients genotyped by PCR-RFLP. Genotype and allele distribution were evaluated with sex, schizophrenia subtypes, and other clinical features. We also assessed a haplotype analysis for TLR2 polymorphisms with schizophrenia. Our results showed higher ins/del genotype frequency in healthy women compared to patients (p = 0.006; OR = 0.2). In the other hand, logistic regression showed higher ins/del genotype frequency in controls compared to paranoid patients (p = 0.05; OR = 0.48, adjusted). Frequencies of CT and T allele of R677W were significantly higher in patients compared to controls (p < 10^-4, OR = 10.39; p < 10^-4, OR = 4, adjusted, respectively). R753Q polymorphism was exclusively detected in patients (GA + AA = 2.5%) particularly in men with disorganized subtype. P631H did not show any association with schizophrenia. Finally, haplotype analysis showed that InsGTC and delGTC were associated with higher risk of schizophrenia (p = 0.0001, OR = 8.58; p = 0.04, OR = 5.01, respectively). In the Tunisian population, our results suggested that TLR2 R677W could be associated with susceptibility for schizophrenia, while - 196-174 Ins/Del suggested a trend of protection in women. Otherwise, R753Q could have an effect on schizophrenia especially for disorganized subgroup.

The psychological impact of the COVID-19 pandemic and confinement period on a tunisian sample

Introduction

Coronavirus disease 2019, is now a global pandemic that has spread rapidly causing many deaths. Most countries have opted for compulsory confinement which had repercussions on mental health and well-being.

Objectives

The purpose of this study is to assess mental health consequences during the confinement period.

Methods

This is a cross-sectional descriptive study of 360 Tunisians in April and May 2020. We used an anonymous E-questionnaire that included a socio-demographic fact sheet, The HAD questionnaire, and a Q-EDD questionnaire to explore eating disorders.

Results

The subjects of our sample were mostly males with a mean age of 31. The body mass index was 25.5 (range 16.10 -46.24), 15% suffered from obesity. Half of the subjects were single and 6.7% spent the confinement time alone. 11.1% were smokers while 4.4% were alcohol users. The HAD-A and the HAD-D scores had an average of 9.1 and 8.48 respectively.A pathological threshold of anxiety and depression was found in 20% and 30% of the sample respectively.15% had an eating disorder: 76% had binge eating, 20% had bulimia and 17% had anorexia. In our study, we found an association between eating disorder and obesity, single marital status (p=0.007), living alone (p=0.001), history of depression (p=0.046), anxiety (p=0.049) and depression (p=0.038).

Conclusions

Reduced social interactions, decreased physical activity and increased stress are potentially harmful causes for our brain. Confining the population for several weeks has a negative impact on our physical and mental health. A crisis unit has been formed in Tunisia to help subjects overcome these psychological difficulties.

Pain perception in schizophrenia: A neglected phenomenon with a great impact

Introduction

A decrease in pain sensitivity has been observed in patients with schizophrenia since the beginning of the twentieth century. This hypothesis further emerged during the last decades due to many clinical findings.

Objectives

To study pain responsiveness in patients with schizophrenia and explore its physiopathological mechanism through a review of the literature.

Methods

We searched the Medline database with no time restrictions, and we hand searched the references of all retrieved reviews. After removing duplicates, we selected Full-text articles in both French and English languages. Keywords: “schizophrenia”, “pain”, “pain threshold”, “nociceptors”, “opioid receptors”, “opioid peptides”

Results

We have collected 399 references, we finally included 50 Articles only. Many case reports with heterogeneous types of pain concluded that despite the high prevalence of somatic comorbidities in patients with schizophrenia, there was no significant difference in pain complaints between patients with schizophrenia and controls. There was a positive correlation between the decrease in pain sensitivity and schizophrenia. Experimental studies supported a decrease in pain perception and a high pain threshold in those patients. The neurobiological hypothesis suggested the lack of pain transmission by the dysfunctional glutamatergic system and the involvement of the opioid system. these findings have been reported in patients even before starting treatment. The psychopathology theory pointed to the impact of psychotic defenses such as denial and cleavage in the phenomenon of pain insensitivity.

Conclusions

The meticulous research of pain symptoms should be systematic in patients with schizophrenia and the hypoalgesia should be considered when dealing with somatic conditions in this specific population.

When healing becomes a burden: The feedback of tunisian psychiatrists

Introduction

Psychiatry is a fascinating medical specialty. Many reasons may motivate early career doctors to choose this field. However, this experience could have a different impact on their quality of life and social functioning.

Objectives

we aimed to assess the impact of psychiatry as a medical career, on the psychiatrist’s quality of life, and to evaluate their feedback on their experience and how it effects their life.

Methods

This is a cross-sectional descriptive study of 68 psychiatrists. An E-questionnaire has been sent via a psychiatrist’s closed groups on social media. We collected sociodemographic data, we also used the stress perceived scale, and we explored the quality of life using the SF-12 questionnaire.

Results

The participants were mostly females with a mean age of 32 years (range25-65). Only 10% of psychiatrists had psychiatric history mostly depression. Concerning substance use, 15% were smokers, 17% used alcohol, 10% smoked occasionally cannabis and 23 % used different psychotropic drugs. 73% our sample were interested in psychiatry during their studies. 60% of our population considered the role of psychiatrists ambiguous among other colleagues. A very high perceived stress was noted in 90 % of our sample. Physical health status was in the average of standard deviation wether mental health status was below average among psychiatrists. The most frustrating situation mentioned was the absence of intermediate structures to receive psychotic patients.

Conclusions

Tunisians psychiatrists are facing many obstacles during the practice of their job, that would transform their passion into demotivation and a desire to leave the country.

Tunisian revolution and the demand of healthcare in psychiatry outward department

Introduction

Tunisian revolution has been a major upheavel in the tunisian history and has brought many political, social and economic changes. Little were found about the revolution’s potential impact on the psychiatric demand.

Objectives

Compare the clinical profile of all the new consultants in the out ward psychiatry department before and after the revolution.

Methods

The study had a retrospective descriptive design including all the new consultants in the outpatient psychiatry department in the general hospital Fattouma Bourguiba in Monastir, Tunisia before (during 2007) and after (during 2016) the revolution. We used a pre-established questionnaire including sociodemographic and clinical data.

Results

After the revolution, an increase in the number of new patients (p<10^-3) 438 to 451 were found. In 2016, there were more unemployed consultants(p=0.004), having criminal record (p=0.01) and having a problematic substance use (p<10^-3). An increase also concerned patients consulting for anxiety(p=0.002) and suicidal ideation (p=0.022). Considering the clinical diagnosis, there were also a significant increase regarding anxiety disorders (p=0.001) and mood disorders (p=0.011) essentially major depressive disorder (p=0.002). Although a significant decrease concerned somatoform disorder (p<10^-3).

Conclusions

Our study showed a change in the profile of consultants after the Tunisian revolution. A study in the general population could find specific etiological factors. Thus highlight the importance of implementing preventive measures in general population in crisis’ times.

Disclosure

No significant relationships.

Late-Onset Psychiatric Manifestations Revealing Limbic Encephalitis: a Case Report of a 48 Years Old Man

Psychiatric symptoms of late-onset are often atypical and an organic origin that remains to be eliminated at first. Still, many somatic etiologies like encephalitis remains poorly understood and multidisciplinary management is necessary. We present the case of a man hospitalized for the first time in the psychiatric ward of Monastir Tunisia at the age of 48 for behavioral disorders with atypical symptoms, Brain Magnetic resonance imaging showed bilateral signal abnormalities of the internal temporal region and hippocampal left lesions, suggestive of encephalitis. The autoimmune origin has been strongly suspected and the determination of "onco-neuronal" antibodies and specifically the assay of anti Ma1 and anti Ma2 antibodies were positive. These elements lead us to evoke autoimmune encephalitis and immunotherapy was initiated for the patient.

Eating disorders: Prevalence and associated factors among health occupation students in Monastir University (Tunisia)

BACKGROUND

Despite their high prevalence and severity among youth, national researches concerning eating disordered behavior among undergraduate students remains rare. Hence, it is imperative to determine the amplitude and to identify the risk factors of eating disorders (ED) to enable effective interventions.

AIM

To assess prevalence and associated factors of (ED) among health occupation students in the university of Monastir during 2013.

METHODS

A cross sectional study using a self-administered questionnaire which was distributed by approaching directly students. The following items were collected: demographic, socioeconomic and educational characteristics; self-esteem; previous dieting; perceived stress score(Cohen's scale); depression (Beck Depression); sleep quality; sport practice; cyber addiction (Orman scale) and alcohol regular use (CRAFT-ADOPSA questionnaire). SCOFF questionnaire was used to identify students at risk of ED.

RESULTS

A total of 974 students were included in the study. The mean age of students was 22.8 (Standard Deviation=2.2) with a sex ratio of 0.43. The prevalence of ED according to SCOFF questionnaire was 35%; 95% CI [32.0-38.5]. It was higher among female (39.8; 95% CI [35.8-43.7]) compared to male (24.3; 95% CI [18.8-29.7]) with a statistically significant difference (p<10-3). The risk factors associated independently with an eating disorder were "Previous dieting" (aOR=4.13; 95% CI [2.79-6.12]),"Sex" (aOR=1.77. 95% CI [1.13-2.77]) and "Repeat a year" (aOR=1.76; 95% CI [1.09-2.85]).

CONCLUSION

The prevalence of health occupation students at risk of ED was high. These results emphasizes the need for diversified and adapted prevention and health education policies as well as a need for a systematic screening of ED among students in order to start an early treatment that can improve their prognosis.

Hashimoto’s Encephalopathy Revealed by Hypochondriacal Delusion: A Case Report Involving a Male Patient

Hashimoto’s encephalopathy (HE) is a rare autoimmune disorder. It associates encephalopathy with autoimmune thyroiditis, presenting abnormal elevations of thyroid antibodies. It is more common in females. It can present with various symptoms, including seizures, myoclonus, psychosis, hallucinations, and mood disturbances. Hypochondriacal delusion is an unusual clinical presentation of this disorder. The authors report a case of HE in a male patient whose clinical presentation was dominated by hypochondriacal delusion. The absence of response to antipsychotics, high serum antithyroid peroxidase antibodiesof about 199 UI/ml, the normality of magnetic resonance imaging, and improvement with corticosteroids confirmed the diagnosis. This neuroendocrine disorder is often misdiagnosed and it represents a diagnostic challenge for clinicians. It should be considered in patients presenting a refractory or an atypical neuropsychiatric disorder and having a family history of autoimmune disease.

Unipolar Mania: A Particular Aspect of Bipolar Disorder in Tunisia

Objective

Unipolar mania is a clinical reality in our daily practice. Many authors suggested that bipolar patients can have only manic episodes without depressions. These findings lead us to explore more this particularity.

Methods

We conduct a retrospective, descriptive and comparative study including 173 patients, followed for bipolar disorder type I, according to the Diagnostic and Statistical Manual of Mental Disorders fifth edition criteria, during the period between January 2008 and December 2015. Two groups were identified. The first one was composed of 98 patients who had presented only manic episodes. The second group contained the rest of the sample. Unipolar mania was defined as the presence of three or more manic states without a depressive episode during the period of the study.

Results

One hundred seventy three patients were included in the study. The average age of the sample was 43 years old. The first episode was manic in 129 patients (74.6%). The dominant polarity was manic in 90.8% of the cases. Seasonal characteristic and psychotic symptoms were observed in respectively 11.0% and 53.2% of the sample. Rapid cycling evolution was observed among 2.3% of patients. The unipolar manic profile accounted for 56.6% of the population. This result is equivalent to an annual incidence of 8%. Comparing the two groups, we did not find a significant difference concerning the sociodemographic and clinical variables except for the number of suicide attempts (p=0.014).

Conclusion

Our study shows that unipolar mania is clinical evidence. More studies should be conducted in order to understand its nosological and psychopathological foundations.

IFNGR2 genetic polymorphism associated with sex-specific paranoid schizophrenia risk

BACKGROUND

Considering current scientific evidence about the significant role of chronic low grade inflammation in the physiopathology of schizophrenia, it has been hypothesized that changes in pro-inflammatory cytokines such as interferon gamma may have a significant role in the predisposition to schizophrenia.

AIM

This study focuses on identifying whether the functional polymorphism of interferon gamma receptor 2 (IFNGR2) is a risk factor for the development of schizophrenia.

METHODS

This study was conducted by the RFLP-PCR on a Tunisian population composed of 225 patients with different sub-types of schizophrenia and 166 controls.

RESULTS

The IFNGR2 (Q64R) polymorphism analysis showed higher frequencies of minor homozygous genotype (RR) and allele (R) in all patients compared to controls (21.8% vs 10.2%; p = .006, OR = 2.54) and (44% vs 34.9%; p = .01; OR = 1.46), respectively. This correlation was confirmed only for males. This study also noted a significant increase of the mutated homozygous (RR) genotype and (R) allele frequencies of IFNGR2 in paranoid schizophrenics compared to controls (31.4% vs 10.2%; p = .001; OR = 3.34 and 47.2% vs 34.9%; p = .009; OR = 1.66, respectively). This increase remains significant after using binary logistic regression to eliminate confounding factors such as age and sex. Additionally, carriers of RR genotype have significant lower scores on the Scale of Assessment of Positive (SAPS) and negative (SANS) symptoms comparatively to the carrier of the QQ + QR genotypes, suggesting that the R recessive allele carriers could have milder symptoms.

CONCLUSION

The IFNGR2Q64R polymorphism is correlated with male sex and paranoid schizophrenia. It is suggested that a chronic neuroinflammation may predispose to the paranoid schizophrenia development in men.

Toxoplasma gondii infection in schizophrenia and associated clinical features

The belief that latent toxoplasmosis is asymptomatic has been questioned, in particular due to the repeated highlighted link between the Toxoplasma gondii infection and an increased incidence of schizophrenia. However, to understand this relationship, the effect of infection with Toxoplasma gondii on the severity of schizophrenia has been poorly studied. Our work focused on comparing the prevalence of Toxoplasma infection between schizophrenic patients and healthy controls, as well as comparing the clinical features and the demographic characteristics between Toxoplasma-seronegative and Toxoplasma-seropositive patients with schizophrenia. The rate of IgG antibody in the schizophrenia patients was 74.8% compared 53.8% in controls. Patients with schizophrenia had a significantly higher mean of serum IgG antibodies to T. gondii compared to controls. The seropositive male patients had a higher age of disease onset, a higher BPRS score, a greater negative PANSS score and a lower GAF score than the seronegative male patients. These results suggest a higher severity of clinical symptoms in the male patients with schizophrenia. This study provides further evidence to the hypothesis that exposure to Toxoplasma may be a risk factor for schizophrenia. Moreover, toxoplasmosis in men with schizophrenia may lead to more severe negative and cognitive symptoms and a less favorable course of schizophrenia.

Association of the IFN-γ (+874A/T) Genetic Polymorphism with Paranoid Schizophrenia in Tunisian Population

Since growing evidence suggests a significant role of chronic low-grade inflammation in the physiopathology of schizophrenia, we have hypothesized that functional genetic variant of the IFN gamma (IFN-γ; +874A/T; rs2430561) gene may be involved in the predisposition to schizophrenia. This research is based on a case-control study which aims to identify whether polymorphism of the IFN-γ gene is a risk factor for the development of schizophrenia. The RFLP-PCR genotyping of the IFN-γ gene was conducted on a Tunisian population composed of 218 patients and 162 controls. The IFN-γ (+874A/T) polymorphism analysis showed higher frequencies of minor homozygous genotype (TT) and allele (T) in all patients compared with controls (11.5 vs. 4.9%; p = 0.03, OR = 2.64 and 30.7 vs. 24.1%, p = 0.04, OR = 1.4, respectively). This correlation was confirmed for male but not for female patients. Also, the T allele was significantly more common among patients with paranoid schizophrenia when compared with controls (25.8 vs. 4.9%, p = 0.0001; OR = 6.7). Using the binary regression analysis to eliminate confounding factors as age and sex, only this last association remained significant (p = 0.03; OR = 1.76, CI = 1.05-2.93). In conclusion, our results showed a significant association between +874A/T polymorphism of IFN-γ and paranoid schizophrenia, suggesting that this single nucleotide polymorphism (SNP) or another at proximity could predispose to paranoid schizophrenia. Since the minor allele of this polymorphism was correlated with an increased expression of their product, our study validates the hypothesis of excessive pro-inflammatory cytokine in the physiopathology of paranoid schizophrenia.

Use of Clozapine for Borderline Personality Disorder: A Case Report

Patients with borderline personality disorder (BPD) show significant impairment in functioning, particularly in the interpersonal and social domains. Prior reports suggest that clozapine may be effective in the management of BPD. We present the case of a patient with BPD who experienced persistent suicidal ideation and was treated with clozapine at a state psychiatric hospital. After treatment failure with other psychotropic medications, clozapine medication was initiated; not only did suicidal ideation cease, but social and professional functioning also greatly improved to the point of no longer requiring intensive levels of observation or restrictive procedures. Clozapine appears to be efficacious in the management of suicide attempts and self-injurious behavior. Moreover, it appears to be promising as a therapeutic measure for ameliorating the global functioning of patients with severe BPD. Larger, randomized, blinded, and controlled prospective studies are needed to confirm these findings and to determine optimal dosage.

Le syndrome prémenstruel: revue générale

Premenstrual syndrome (PMS) is a recurrent disorder that occurs in the luteal phase of the menstrual cycle. It is characterized by intense physical, psychological, and behavioral changes that interrupt interpersonal relationships and disrupt the lives of affected women. Premenstrual syndrome is believed to affect 75% of women of childbearing age. Because no tests can confirm PMS, the diagnosis should be made on the basis of a patient-completed daily symptom calendar and the exclusion of other medical disorders. PMS symptoms occur during the luteal phase of the menstrual cycle and remit with the onset of menstruation or shortly afterward. The aetiology of PMS is still unknown uncertain, but are likely associated with aberrant responses to normal hormonal fluctuations during the menstrual cycle. A wide range of therapeutic interventions has been tested in the treatment of premenstrual symptoms. Most non-pharmacological interventions that have been proven efficacious require a series of interventions. If non-medical approaches are ineffective, drug therapy may be appropriate. Several pharmaceutics agents have been shown to relieve symptoms. Calcium carbonate and selective serotonin reuptake inhibitors have demonstrated excellent efficacy.

[Repeat suicide attempts: characteristics of repeaters versus first-time attempters admitted in the emergency of a Tunisian general hospital]

Repeat suicide attempts constitute a special problem in suicidology. It seems that the excess mortality by suicide is even higher among the suicide repeaters. The objectives of this study were to estimate repeat suicide attempts frequency among a sample of suicide attempters admitted in the University Hospital Emergency of Monastir (Tunisia), to compare their features to those of first-time attempters and to determine factors associated with repeat suicide.

METHOD

A transversal survey involves a review of all patients committing suicide attempt and who are admitted in the emergency service during the second semester of 1999. Study variables included: demographic parameters, family and personal psychiatric history, axis I psychiatric disorder and circumstances of the present suicide attempt. Also, subjects were evaluated with the following scales: Montgomery and Asberg Depression Rating Scale (MADRS) and The Social Readjustment Rating Scale of Holms and Rahe.

RESULT

Among the 90 suicide attempters, 42.2% (n = 38) had made at least one previous suicide attempt. More repeaters than first-time attempters were divorced or separated: 21.1% versus 5.8% (p = 0.05). Belonging to a numerous family (n > or = 4) was more frequent in the repeaters group: 73.7% versus 46.2% (p = 0.01). The two groups did not differ as to level of education but were significantly different with regard to their professional activity: 60.5% of repeaters were unemployed versus 34.6% of first-time attempters (p = 0.01). Repeaters had more loaded family psychiatric disorders: 26.3% versus 7.7% (p = 0.03). However there were practically no differences between repeaters and first-time attempters in regard of suicide in their families. Personal previous history of repeaters was characterized by frequency of psychiatric hospitalization: 50% versus 11.5% (p = 0.00005). Sexual abuse was more frequent in repeaters group but this difference was not significant. Alcohol and drug abuse were not frequent in the two groups. Concerning the actual suicide attempt, the most frequently diagnosed disorder was adjustment disorders. However depressive and psychotic disorders were significantly more frequent in the repeaters group: 34.2% versus 13.4% (p = 0.05). Repeaters had more frequently elevated scores (> 14) in MADRS: 71.1% versus 48.1% (p = 0.01), and raised intensity of stress factors lived during the six months preceding actual suicide attempt: 68.4% versus 42.3% (p = 0.04). Nevertheless we hadn't noticed any differences between the two groups regarding the methods used or the motives.

CONCLUSION

Differences in the characteristics of repeaters and first-time attempters are therefore of interest when discussing future suicidal risk and should clear on preventive actions in order to face the increase of suicidal recidivism. A broad based, multidisciplinary intervention approach is recommended.

[Bipolarity correlated factors in major depression: about 155 Tunisian inpatients]

The distinction between the depressive troubles according to their inclusion in bipolar disorders or in recurrent depressive disorders offers an evident practical interest. In fact, the curative and mainly the preventive treatment of these troubles are different. So it is necessary to identify the predictive factors of bipolar development in case of inaugural depressive episode. In 1983, Akiskal was the first who identified those factors: pharmacological hypomania, puerperal depression, onset at early age (<25 years), presence of psychotic characteristics, hypersomnia and psychomotor inhibition. Through this study, the authors try to compare the epidemiological, clinical and evolution characteristics of major depression in bipolar disorders to recurrent depressive disorders in order to indicate the correlated factors with bipolarity. It is a retrospective and comparative study based on about 155 inpatients for major depressive episode during the period between January 1994 and December 1998. These patients were divided into two groups according the DSM IV criteria: bipolar group (96 patients) and recurrent depressive group (59 patients). Both groups were compared according to socio-demographic data, life events in childhood, personal and family history, clinical and evolution characteristics of the index depressive episode. The predictive factors proposed by Akiskal were systematically examined. It was found out that the following factors were correlated with bipolarity: high rate of separation and divorce (17.7% versus 5.1%; p=0.02), family history of psychiatric disorders (56.3% versus 35.6%; p=0.012) especially bipolar ones (29.2% versus 3.4%; p=0,00008), onset at early age (mean age of onset: 24.8 8.2 years versus 34.1 12.6 years; p=0.000004), number of affective episode significantly more frequent (mean 3.6 versus 2.5; p=0.03), sudden onset of depressive episode (44.8% versus 15.9%; p=0.0003) and presence of psychotic characteristics (69.8% versus 16.7%; p=0.0001) catatonic characteristics (37.3% versus 20.3%; p=0.03), hypersomnia (51% versus 20.3%; p=0.03) and psychomotor inhibition (83.3% versus 42.4%; p=0.00007). Negatively correlated factors of bipolar depression were: somatic comorbidity such as diabetes, hypertension and rhumatismal diseases (12.5% versus 28.8%; p=0.012) and association with dysthymic disorders (2.2% versus 12.1%; p=0.029). No correlation was found between bipolarity and life events in childhood, seasonal character, alcoholic dependence and suicide attempt. Concerning the validity of predictive factors of bipolarity proposed by Akiskal, we found: history of bipolar disorders (Sensibility: 29.2%, specificity: 96.6%, Positive Predictive Value (PPV): 93%), hypersomnia (Sensibility: 51%, specificity: 80%, PPV: 80%), onset before the age of 25 years (Sensibility: 62.5%, specificity: 70%, PPV: 77%), psychomotor inhibition (Sensibility: 83.3%, specificity 58%, PPV: 76%), and psychotic characteristics (Sensibility: 69.8%, specificity: 62.7%, PPV: 75%). In spite of methodological differences, our results tallied with the other studies. We focus on the importance of the bipolar family history criterion, which has the highest PPV, and the limits of psychotic characteristics criterion which has the lowest PPV. This may be explained by the frequency of these characteristics of affective disorders in our cultural context. The association of the hypersomnia and psychomotor inhibition in one criterion in order to increase their diagnostic power. Our study helps us to identify the factors that would predict the bipolar evolution of a depressive episode allowing the use of specific treatment and ensuring the improvement of prognostic.

[Acute nuptial psychosis: apropos of 16 cases]

The marriage, an over-invested social event in our Maghrebin cultural context, can, in certain cases, generate major psychiatric disorders especially of psychotic types. The aim of our study is to describe the clinical specifications of these psychotic disorders and to discuss the surroundings and individuals factors incriminated in their genesis. Our retrospective study concerns sixteen patients suffering from acute psychotic disorders precipitated by marriage. Male subjects represented 75% of cases with an average age of 26.8 years. 62.5% of them have no psychiatric background. The disorders first appeared after the marriage in 75% of cases, often during the first week. 68% of cases have delirious syndrome. Schizophreniform and brief psychotic disorders were often reported. The importance of the cultural factors was particularly prominent in the starting of these disorders.