IntroductionOld people with diabetes are more likely to develop cognitive impairment, Alzheimer's disease and vascular dementia. However, the determinants of the association between diabetes and cognitive impairments are only partially known.ObjectivesTo evaluate cognitive disorders in elderly diabetic patients and to identify risk factors of cognitive impairment in this population.MethodsIt was a cross-sectional study. It involved outpatients aged 65 and older, who were followed for diabetes in the endocrinology department at the Hedi Chaker University Hospital in Sfax (Tunisia), from October 1 to December 31, 2015. For each patient, we collected sociodemographic, clinical and therapeutic data. We used the Montreal Cognitive Assessment (MoCA) to identify mild cognitive decline (score < 26/30).ResultsWe identified 70 patients, all with type 2 diabetes. The average age was 66.8 years. The sex ratio (M: F) was 0.7. The mean duration of diabetes was 14.76 years. The average MoCA score was 20.68 ± 6. Forty patients (57%) had cognitive decline. The cognitive impairment was statistically correlated with female sex (P = 0.02), low level of education (P = 0.00), high levels of glycated hemoglobin (Hb A1c ≥ 7%) (P = 0.00), presence of hypoglycemic episodes (P = 0.05) and presence of dyslipidemia (P = 0.00).ConclusionOur study confirmed the high rate of cognitive decline in older type 2 diabetes patients. The profile of subjects at risk was consistent with the literature: poorly controlled diabetes, severe recurrent hypoglycaemia and associated dyslipidemia. Acting on these risk factors would prevent cognitive decline and therefore progression to dementia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

BackgroundCognitive deficits impair patients working and functioning status and may have negative impact on other aspects of thinking.ObjectivesAssess the prevalence of cognitive dysfunction in patients with bipolar disorder in euthymic state and to explore cognitive style problems.MethodCase-control naturalistic study, 60 patients with bipolar I disorder in euthymic state according to DSM-IV were recruited and subdivided into two groups each contains of 30 patients; (Group BPM) euthymic patients with recent manic episode, Group BPD euthymic patients with recent depressive episode. Both groups were further compared with control group (Group C) consisted of 30 frequency matched healthy volunteers. Groups were subjected to the following: (1) clinical psychiatric examination, (2) (HAMD-17) and Bech–Rafaelsen Melancholia Scale (MES) for (BPD), (3) (YMRS) and Bech–Rafaelsen Mania Scale (MAS) for (BPM), (4) assessment of euthymic state of mood included both MAS and MES, (5) MMSE, MTS and CDT were performed to assess cognitive functions, (6) cognitive styles evaluation the Social Dysfunction and Aggression Scale SDAS-9 and Arabic Anger Scale.ResultsDefinite cognitive function impairment and different patterns of cognitive style were detected in case groups. MMSE, MTS and CDT scores were statistically significant. Fear of Failure Scale Scores were higher in BPM; 16 (53.33%) reported severe intensity compared to 16 (53.33%) of BPD Group reporting moderate intensity and 30 (100%) of the control group reporting only mild intensity of fear of failure with statistically significant differences.ConclusionsPatients in euthymic state suffer from cognitive dysfunction and some aspects of cognitive styles that negatively interfere with their performance.Disclosure of interestThe authors have not supplied their declaration of competing interest.

phenomenon is due to an increased central dopaminergic activity.[4] However, in our case, tics preceded the onset of psychotic symptoms. It appears that the order of onset with TS occurring first and schizophrenia later has been reported in rare cases.[2,5] Similarly, Müller et al.[2] have reported five adults with comorbid TS and schizophrenia. All of their patients first showed symptoms of TS, followed by symptoms of schizophrenia. Four of these had an adult onset of their schizophrenia, and one had an onset in later adolescence. In addition, Takeuchi et al.[5] described a TS patient who experienced schizophrenic episode 11 years after TS onset. Another case report diagnosed with tic syndrome at the age of 9.5 years developed schizophrenia at the age of 20 years.[6]

IntroductionThe haemodialysis, one of the main treatment modalities of chronic renal failure, imposes a great psychosocial burden on elderly patients, which may cause many psychological impacts.ObjectiveThe aim of this study was to screen anxiety and depression in elderly patients on haemodialysis, taking into account factors that may contribute to.MethodsOur study was transversal, descriptive carried out among 38 elderly patients aged more than 60 years with chronic kidney failure on haemodialysis. The structured questionnaire used in this study was gathered information on socio-demographic and disease characteristics. We used the hospital anxiety and depression scale (HADS) to access anxiety and depression.ResultsThe mean age of our sample was 71 years. The sex-ratio (♂/♀) was 1.92.,patients were mainly married (73.7%), and have a low school level (76.3%). The mean haemodialysis duration was 5 years ± 4.68. The most common cause of renal failure was polycystic kidney disease (18.4%), diabetes (15.8%), while in 28.9% the cause was unknown. Anxiety was found in 18.4% of patients and it was associated with both low school (P = 0.02) and socio-economic level (P = 0.04). The prevalence of depressive symptoms was 42.1%. It was correlated to the unknown cause of kidney failure and the short duration haemodialysis (P = 0.03).ConclusionThese data suggest that depression and anxiety are highly prevalent in elderly patients with renal failure on dialysis. This result shows the need for interdisciplinary teamwork in improving the quality of life of those patients.Disclosure of interestThe authors have not supplied their declaration of competing interest.

ObjectivesTo assess suicide risk in elderly psychiatric outpatients and to identify potential suicide risk factors in this population.MethodsThis was a cross-sectional, descriptive and analytical study, including 50 psychiatric outpatients, aged 65 years or more and attending the Hédi Chaker University Hospital, in Sfax (Tunisia), between November and December 2015. We used a hetero questionnaire including epidemiological and clinical data and three scales: the Suicidal Risk Assessment Scale of Ducher (RSD), the Hospital Anxiety and Depression Scale (HADS) and the Mini Mental State Examination (MMSE).ResultsThe sex ratio (M/F) was 1. The average age of patients was 68.62 years. The majority of them were married (68%), unemployed (98%), living in urban area (58%) and within their family (88%); they had at most a primary degree (80%) and a low socioeconomic level (74%).The prevalence of patients at risk of suicide (RSD ≥ 3) was 26%. This risk was high (RSD ≥ 7) in 18% of cases.The presence of suicidal ideation (RSD ≥ 3) was correlated with: a family history of suicide attempt (58.3% vs. 15.8%; P = 0.003), a personal history of suicide attempt (80% vs. 12.5%; P < 0.001), depressive symptoms (HAD-D ≥ 11) (36.7% vs. 10%; P = 0.05) and anxiety (HAD-A ≥ 11) (52.4% vs. 6.9%; P = 0.001).ConclusionOur study showed that among older psychiatric outpatients, one in four had suicidal thoughts. This high rate encourages us to search systematically these suicidal thoughts in this population, especially in patients with risk factors such as a family history of suicide attempt, depressive or anxious symptoms.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionTardive dyskinesia (TD) is a drug-induced movement disorder that arises with antipsychotics. These drugs are the mainstay of treatment for schizophrenia. Epidemiological studies have shown mixed results on smoking's association with TD.ObjectiveTo study the association between smoking and TD induced by antipsychotics in outpatients with schizophrenia.MethodsThis was a cross-sectional study. It involved 89 patients suffering from schizophrenia, followed-up in outpatient psychiatry unit at Hédi Chaker university hospital in Sfax in Tunisia, between April and May 2016. We looked for TD in according to DSM-IV-R criteria. The intensity of TD was assessed with the Abnormal Involuntary Movement Scale (AIMS) and the level of nicotine dependence with the Fagerström Test for Nicotine Dependence (FTND).ResultsThe prevalence of smoking in patients with schizophrenia was 69.6%. Of these, 54.8% had a high or very high degree of nicotine dependence. The prevalence of TD was 33.7%. The AIMS average score was 12.13 ± 5.6 with extremes ranging from 3 to 26. TD was correlated with tobacco consumption (P = 0.003), the average number of smoked cigarettes (43.7 vs. 33.8; P = 0.004) and the Fagerström average score (7.2 vs. 6.1; P = 0.012).ConclusionThe results of this study showed a correlation between the amount of smoking and severity of TD in patients with schizophrenia. The nature of the relationship between smoking and TD needs to be clarified through an experimental study.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionTardive dyskinesia (TD) is a serious medical condition that affects a significant proportion of patients treated with antipsychotic agents.ObjectiveTo report a patient who developed tardive dyskinesia after initiation of antipsychotic and antidepressant treatment.Case reportMiss H. is 24-year-old Tunisian woman who had been diagnosed with bipolar disorder 6 years ago. She received various drugs: olanzapine, haloperidol, amisulpride, sertraline, paroxetine, etc. On November 2013, she first complained of hand tremor and then developed severe dystonia of the trunk and chorea. A series of laboratory tests was performed after the onset of these involuntary movements. It included complete blood count, liver, renal, and thyroid function tests, blood prolactin level, blood glucose level, blood copper level and ceruloplasmin level. A brain MRI was also performed. These examinations showed no specific findings. The diagnosis of TD was presumed. The patient was first treated with amisulpride, lorazepam, avlocardyl and piracetam until May 2014. Then, amisulpride was substituted by olanzapine until August 2015. The luck of improvement led to her admission. We stopped antipsychotic treatments and prescribed her vitamin E (900 mg/day), clonazepam (6 mg/day) and vitamin B6. The follow-up led to the decline of the Abnormal Involuntary Movement Scale (AIMS) score of 7 points over 6 weeks.ConclusionTD remains a serious side effect that worsens the prognosis and affects the quality of life of patients. Cluster randomised trial should be done in order to develop practice recommendations for prevention and management of TD.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Les personnes âgées diabétiques sont plus susceptibles de développer des troubles cognitifs. Cependant, les déterminants de l’association entre diabète et troubles cognitifs ne sont qu’imparfaitement connus. Notre étude a concerné 70 patients âgés de 65 ans suivis pour diabète type 2. Pour chaque patient, nous avons relevé les caractéristiques sociodémographiques, cliniques et thérapeutiques. Nous avons utilisé le Montreal Cognitive Assessment (MoCA) pour repérer les déclins cognitifs légers (score < 26/30). L’âge moyen était de 68 ans 3 mois (extrêmes : 65 et 82 ans). Le sex-ratio (H/F) était de 0,7. L’ancienneté moyenne du diabète était de 14 ans (extrêmes : 1mois et 30 ans). Le score moyen au MoCA était de 22,2 ± 6. Vingt-neuf patients (57,1 %) présentaient un déclin cognitif. Le trouble cognitif était statistiquement corrélé au sexe féminin (p = 0,02), à un bas niveau socioéconomique (p = 0,036), à un bas niveau d’instruction (p = 0,001), à un taux élevé d’hémoglobine glyquée (Hb A1c ≥ 7 %) (p = 0,001), à la présence d’épisodes hypoglycémiques (p = 0,05) et à la présence d’une dyslipidémie (p = 0,024). Notre travail confirme la fréquence élevée de déclin cognitif chez les diabétiques type 2 âgés. Le profil des sujets à risque est concordant avec les données de la littérature : un diabète mal équilibré, une dyslipidémie associée. Agir sur ces facteurs de risque permettrait de prévenir le déclin cognitif et par conséquent l’évolution vers la démence.

IntroductionAccording to attachment theory, attachment relationships have a lasting impact on the functioning of the individual. If this impact has been much studied in children, few studies have been conducted in the elderly.ObjectivesExplore the representations of attachment in a population of elderly subjects.MethodsThe sample consists of 90 consultants over the age of 65. Each participant filled out demographic questionnaire, Relationship Scale Questionnaire (RSQ): questionnaire of 13 items, each item rated from 1 to 5, a lower score attests a more secure attachment and Adult Attachment Questionnaire: a categorical scale of 3 statements. Statement 1 corresponds to secure attachment style, 2 to avoidant attachment style and 3 to anxious-ambivalent attachment style.ResultsThe age of participants ranged from 65 to 95 years with an average of 68.14. The sex ratio M:F was 0.8. The RSQ Score ranged from 16 to 56 with an average of 37.27. Of the participants, 72.2% have secure attachment style, 24.4% have an avoidant attachment style and 3.3% have an anxious-ambivalent attachment style. The study of correlations showed strong correlation between the two scales (P = 0.00) and the RSQ score was significantly associated with poor satisfaction of married life (P = 0.025), presence of psychological trauma in childhood (P = 0.016) and a separation experience (P = 0.029).ConclusionOur study highlights the importance of early childhood experiences that may impact late adult life. These finding are in accordance with attachment theory.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionFor most individuals, basic life requirements are met through employment. It can satisfy creative urges, promote self-esteem, and provide an avenue for achievement and self-realization.ObjectiveTo assess the level of depression, anxiety and self-esteem in a population of unemployed persons.MethodIt was a cross-sectional study involving unemployed people we met in the office of employment of Sfax in Tunisia. The level of anxiety and depression was assessed by the Beck depression and anxiety inventories. The self-esteem Rosenberg scale allowed us to evaluate the level of self-esteem of our population.ResultsThe average age of oursubjects was 33 years six months. The average duration of unemployment of our population was 4 years 7 months and 38.2% of them had never worked before. The anxiety level was moderate in 38.2%, while moderate to severe depression was found in 47%. Self-esteem was low to very low in 47.1%. A low level of depression was positively correlated with a low socioeconomic level (P = 0.000), a low level of anxiety (P = 0.000) and a high self-esteem level (P = 0.000).ConclusionPeople with strong support systems and greater self-esteem seemed to experience less unemployment stress. Identifying those who are at high risk for psychological and physical problems and finding ways of preventing them from suffering the adverse effect of unemployment are important areas for further study.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Bipolar disorder is quite heterogeneous; first-episode polarity has been proposed as course predictor. This study aimed to compare sociodemographic and clinical aspects, as well as illness course, in bipolar 1 disorder patients according to the polarity of the first episode. We conducted a retrospective and comparative survey of all patients hospitalized in the department of psychiatry "A" in the Hedi Chaker University Hospital, in Sfax (Tunisia), during the period from January 2008 to December 2012, and in whom bipolar 1 disorder was diagnosed (DSM IV-TR). Patients whose follow-up does not exceed one year were excluded. Subjects were sorted into two groups: group 'M" those with manic/hypomanic first episode and group 'D" those with depressive one. Seventy-six patients were included (group 'M" = 58; group 'D" = 18). The depressive first episode was significantly correlated with early-onset of bipolar disorder (p = 0.01), more frequent family history of bipolar disorder (p = 0.02), more suicide attempts (p = 0.00) and higher number of mood episodes (p = 0.02). Group 'M" had more frequently psychotic features (p = 0.00) and more psychiatric hospitalization history (p = 0.04). No statistical difference was found in gender and substance abuse between the two groups. Our study confirmed literature data that bipolar patients with depressive onset seem to have a poorer prognosis.

Psychoses are severe mental disorders, which place a considerable burden on the caregivers. Families experience a lot of physical, emotional and financial distress due to a patient's abnormal behavior, and social and occupational dysfunction. In countries like Tunisia, where rehabilitation services are almost nonexistent, the role of the family becomes more important. Assess caregiver burden among relatives of patients with chronic psychoses. This is a descriptive cross-sectional study regarding 40 caregivers accompanying patients with chronic psychoses (schizophrenia, bipolar disorder and non- schizophrenic psychosis). The burden was assessed by the European version of the scale of the burden IEQ (Involvement Evaluation Questionnaire). The average age of our population was 48 years. Caregivers were as follows: siblings(35%), parents (27.5 %) and spouses(27.5 %). Almost all of the caregivers (80%) lived in the same household as the patient. Pathologies diagnosed in patients were schizophrenia (65%) and bipolar disorder (20%). Most caregivers have an important sense of burden (IEQ> 15) with a percentage of 77.5%. This burden was mainly due to the "tension" with a mean score of 5.6 and the 'supervision'with an average of 3.7. A significant burden was found among caregivers without occupation (p = 0.028). Patients Caregivers treated with atypical antipsychotic express less important burden (p = 0.032). Caregivers of patients with chronic psychoses experience moderate to severe burden. Caring for the psychotic patient need to change from a patient focused approach to a combined patient and caregiver approach.

Schizophrenia is one of the most severe psychiatric disorders. An early diagnosis and beginning of treatment may lead to a more favorable prognosis of the disease. We propose to study the clinical and evolutionary characteristics of the onset of schizophrenia. In this retrospective study, we reviewed the records of 61 patients who were hospitalized for schizophrenia in the department of Psychiatry 'A" in the University Hospital in Sfax (Tunisia), between August 2009 and January 2013. For each patient, we collected sociodemographic, clinical and evolutionary data. The average age of disease onset was 25.25 years. The majority of patients were males (78%) and single (85.2%). Paranoid schizophrenia was the most frequent type of schizophrenia (65.6%). The average duration of untreated psychosis was 2 years 11 months. The main pre-psychotic symptoms were: social isolation (48.6%), heteroaggressiveness (37.3%), irritability (34.2%), insomnia (32.3%), self-neglect (13.1%) and anxiety (4.9%). Patients were treated with oral typical antipsychotic drugs in 44.3% of cases, conventional depots in 39.3% and atypical antipsychotic drugs in 16.4%. After a hospital stay of 25 days on average, 47.5% of patients never came back. Patients followed-up at the outpatients unit had regular monitoring in 53.14% of cases and good adherence to treatment in 42.9%. Our study showed that more than half of patients were lost to follow-up or had poor adherence to treatment. Atypical antipsychotic prescription, having better neurological tolerance, and psychoeducation for the patient and his family, would be beneficial to improve the management of schizophrenia.

Major depression is associated with high risk of suicide. But it remains controversial whether the risk is higher in bipolar depression or unipolar one. 1. To identify social, clinical and temperamental factors associated with high suicide risk among patients with unipolar or bipolar depression. 2. To compare suicide risk in the two groups. This cross-sectional study, in progress, is conducted on psychiatric outpatients in the University Hospital, in Sfax (Tunisia). We include subjects with major depressive episode in the context of bipolar disorder or major depressive disorder. We use the Arabic version of the full-scale TEMPS-A auto-questionnaire and the suicidal risk assessment scale (RSD). A total of 28 depressive patients were included. Compared to unipolar patients (20), bipolar patients (8) had more frequent previous suicide attempts (25% vs 10%) and had a higher suicide risk (50% vs 25%). Among high-risk suicidal patients (16/28), 62.5% were males. The main stressful life events were: school failure (66.7%), early grief (55.6%) and family violence (44.4%). Psychotic and atypical features were found in 33.3% and 55.6%, respectively. Comorbidity with personality disorder was noted in 44.4% and with anxiety disorders in 22.2%. Cyclothymic (44.4%) and irritable (33.3%) temperaments were the most common. Our results meet those of the literature. Suicide risk is associated with male gender and traumatic events in childhood. Bipolar depression, psychotic features, affective temperaments, as well as personality disorders, and anxiety increase this risk. Attention should be paid to all these factors in depressed patients.

Bipolar and unipolar disorders share a common depressive clinical manifestation, but have not the same treatment. An early recognition of bipolar depression has an important impact on the prognosis of bipolar disorder. Our study aims at evaluating the prevalence of hypomania among patients with major depression and revealing the factors that distinguish between unipolar and bipolar depression. Our cross-sectional study, in progress, includes outpatients with major depressive disorder, from the University Hospital in Sfax (Tunisia). We use the Angst's Hypomania Checklist (HCL-20) to detect episodes of hypomania misdiagnosed by the present psychiatrist. Twenty patients were included. The average age of onset of disease was 31 years. More than half of patients were females (55%). Tobacco dependence was found in 35% of patients, alcohol dependence in 20% of them. Patients had a family history of bipolar disorder in 25% of cases. They attempted suicide in 15% of cases. Hypomania prevalence was 45%. Hypomanic episode was more frequent in early-onset disease, when there is a history of attempted suicide, and in case of atypical or psychotic features. Addiction to tobacco or alcohol, presence of somatic comorbidity and mixed features were also more frequent in patients with past hypomania. Our results show that bipolar disorder is underdiagnosed in depressive patients. Systematic search for hypomania, based on a clinical interview or a screening tool, is necessary to avoid misdiagnosis of bipolar disorder and therefore inappropriate treatment.

Organic disorders can mimic all kinds of psychiatric illnesses. Some neurological diseases including front location are misleading when psychiatric manifestations represent the beginning shape or dominate the clinical. It may be dementia, mental confusion, mood disorders and psychotic disorders. the aim of this study was to point out through the study of a clinic observation, discuss the importance of the importance of organicity to psychiatric disorders and the resulting difficulties of diagnostic and therapeutic order. We report the case of a 72 year old man without chronic disease identified, consulted in February 2013 emergency following a head injury with loss of initial knowledge . The brain scanner (TDM) was normal. In July 2013, the patient began to exhibit behavioral problems in such wandering, memory problems, slow ideation, delusions of persecution with audiovisual hallucinations. This table psychotic moved in a very insidious and fluctuating intensity. The patient was seen in psychiatry at the worsening of symptoms. Exploration has confirmed the diagnosis of chronic subdural hematoma (HSDC) without signs of compression. The surgery consisted of an enlarged trepanation and evolution was favorable. It appears from this case and review of the literature that various psychiatric manifestations may reveal an HSDC and that, in the elderly, neuroimaging should be systematic, even for minor symptoms. The total resorption led to the disappearance of psychiatric symptoms in most patients, but this remains a topic of discussion for patients who retain residual symptoms, even after resorption of the mass.

The aims of the study were to evaluate the prevalence of depression among two samples of patients followed for panic disorder and generalized anxiety disorder and to identify the correlated factors with depression in both disorders

IntroductionThe classic opinion of a favorable prognosis of bipolar disorders, compared to schizophrenia, is refuted by modern conceptions.ObjectivesThe aim of this study was to assess the quality of life (QOL) in bipolar patients compared to schizophrenic patients’, and to identify clinical and sociodemographic variables statistically associated to a poor QOL in bipolar disorder patients.MethodsOne hundred and twenty outpatients, 50 with bipolar disorder and 70 with schizophrenia, according to DSM-IV-TR criteria, were included in the study. The QOL has been assessed, in all patients, using the «36 item Short-Form Health Survey» (SF-36).ResultsThirty-six percent of the bipolar patients had a poor QOL, versus 37% among the schizophrenic patients. The bipolar patients had the score of the standardized vitality subscale significantly lower than schizophrenic patients’ (p = 0.036); the latter had the standardized general health subscale score significantly lower (p = 0.03). There were no other statistically significant differences. The multivariate analyses showed three variables significantly correlated to a poor QOL in bipolar patients: age at the time of the study ≥ 40 years (p = 0.01), professional irregularity or inactivity (p = 0.005), age at onset ≥ 25 years (p = 0.004).ConclusionOur survey of the QOL in bipolar patients showed that it did not differ globally from the schizophrenic patients’, with the SF-36 scale. Results reported in the literature are not in agreement. Further longitudinal studies on several months, with other assessments, would permit to verify the validity of our results.