Antineuronal autoantibodies induced paraneoplasic syndrome in schizophrenia spectrum disorders: case report.

Secondary psychiatric symptoms are usually suspected when there is an atypical presentation of the symptoms or a lack of response to psychotropic medication. Case presentation: Our case is about a woman aged 62 years old, with a history of mental disorder who presented psychiatric symptomatology after years of being stabilized by antipsychotics. She was later investigated due to a mass in her breast. Carcinoma was diagnosed, and her psychiatric symptomatology was resolved after the tumerectomy. Discussion: The therapeutic difficulty is the major problem of psychic disorders in the context of paraneoplastic syndrome. Several literature review have suggested a relationship between schizophrenia and antineuronal antibodies in the context of paraneoplastic syndrome. Treating the tumor can solve psychiatric symptoms better than psychotic treatment. Conclusions: The aim of our study is to highlight the importance of a complete medical evaluation to identify the psychiatric presentations of organic disorders associated with psychiatric manifestation and to ensure an early diagnosis.

Accuracy of the Arabic HCL - 32 and MDQ in detecting patients with bipolar disorder.

BACKGROUND: Studies about the two most used and validated instruments for the early detection of Bipolar Disorder (BD), the 32 - item Hypomania Checklist (HCL - 32) and the Mood Disorder Questionnaire (MDQ), are scarce in non-Western countries. This study aimed to explore the reliability, factor structure, and criterion validity of their Arabic versions in a sample of Tunisian patients diagnosed with mood disorders. METHODS: The sample included 59 patients with BD, 86 with unipolar Major Depressive Disorder (MDD) and 281 controls. Confirmatory factor analysis was applied to show that a single global score was an appropriate summary measure of the screeners in the sample. Receiver Operating Characteristic analysis was used to assess the capacity of the translated screeners to distinguish patients with BD from those with MDD and controls. RESULTS: Reliability was good for both tools in all samples. The bifactor implementation of the most reported two-factor model had the best fit for both screeners. Both were able to distinguish patients diagnosed with BD from putatively healthy controls, and equally able to distinguish patients diagnosed with BD from patients with MDD. CONCLUSION: Both screeners work best in excluding the presence of BD in patients with MDD, which is an advantage in deciding whether or not to prescribe an antidepressant.

Psychiatric Symptoms in Stiff-Person Syndrome: A Systematic Review and a Report of Two Cases.

BACKGROUND: The clinical spectrum of stiff-person syndrome (SPS) encompasses a wide range of signs including psychiatric symptoms (PS). OBJECTIVE: Our objective was to provide an overview of the spectrum of PS in SPS through a systematic literature search and 2 illustrative case reports. METHODS: We reported 2 anti-glutamic acid decarboxylase-positive SPS cases that presented with phobic disorder, and we performed a systematic review by following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles published in PubMed, MEDLINE on Ovid, Embase, and via a manual search before October 20, 2020, were selected by 2 independent reviewers. Original studies, case reports, editorials, commentaries, and letters to the editor reporting cases of SPS with PS were all included. Conference abstracts, reviews and book chapters, unavailable articles, and those not reporting SPS cases or PS were excluded. Quantitative summary data were calculated. RESULTS: In addition to our 2 cases, we identified 237 cases of SPS with PS from 74 additional included publications totaling 239 patients. Anxiety (56%) and depression (45%) were the most common PS in SPS. Mean diagnostic delay was 4.7 years. Among the 3 SPS phenotypes, the classic form was predominant (77%), followed by stiff-limb syndrome (13%) and progressive encephalomyelitis with rigidity and myoclonus (10%). The most frequent etiology of SPS with PS was autoimmune (90%), followed by cryptogenic (7%) and paraneoplastic forms (7%). These patients were mainly treated with immune-mediated therapies and GABAergic drugs. CONCLUSIONS: Our review revealed that the most common PS of SPS are anxiety and depression occurring mostly in autoimmune and classic forms, allowing a clearer understanding of this entity, which may lead to earlier diagnosis and better outcome.

Psychiatric disturbances in idiopathic epilepsy.

INTRODUCTION: The relationship between epilepsy and psychiatric disorders has been highlighted for a long time. Idiopathic epilepsy is known to have a benign course in most cases. However, the association of psychiatric disturbances could worsen the disease outcome. AIM: To study the frequency of psychiatric symptoms in patients with idiopathic epilepsy, and to assess the determinant factors in the patient group with these manifestations. METHODS: In one-year prospective study, consecutive patients diagnosed with idiopathic epilepsy were included. Those with a known psychiatric follow-up or with post ictal psychiatric disturbances were excluded. Psychiatric symptoms were evaluated with the Neurological Disorders Depression Inventory for Epilepsy, the Generalized Anxiety Disorder - 7 and the Neuropsychiatric Inventory Scale. Demographic and clinical data were collected and analyzed. RESULTS: Among 101 consecutive patients with idiopathic epilepsy, psychiatric symptoms were diagnosed in 61% of them. Anxiety (36.6%), psychotic features (21%) and depression (15.8 %) were the most commonly found psychiatric manifestations. Female gender (p < 10-3) and longer duration of epilepsy (p = 0.046) were significantly associated with occurrence of psychiatric disturbances. Patients under Carbamazepine and Valproic acid showed a lower frequency of depression (respectively p = 0.018 and p = 0.003). CONCLUSIONS: Occurrence of psychiatric disturbances was frequent in idiopathic epilepsy, with psychotic manifestations and anxiety being the most common of them. Female gender and long disease course were the main determining factors of psychiatric manifestations and should be considered in management of idiopathic epilepsy.

Incidence of treatment-resistant depression during the first mood depressive episode.

INTRODUCTION: In spite of several approaches and therapeutic measures, treatment-resistant depression (TRD) continues to inflict serious, individual and collective consequences. Therefore, there is a persistent need to scrutinize the concept of TRD in order to adapt the therapeutic strategies. AIM: To estimate the incidence of TRD in patients with a first major depressive episode (MDD), and study factors associated with resistance. METHODS: A descriptive prospective longitudinal study of outpatients with a first MDD, was conducted. Patients with a history of subthreshold hypomania were excluded. Eligible patients were put on a selective serotonin reuptake inhibitor (SSRI), either fluoxetine or sertraline. Participants were followed regularly until they had a therapeutic response or they met the criteria for TRD. RESULTS: The study involved 82 adults. The incidence of treatment-resistant depression was 19.4% CI95%=[5.5-33.3]. Among the sociodemographic and clinical factors, family history of psychosis (p=0.038) and chronic respiratory comorbidities (p=0.016) were associated with TRD. The small size of the sample is a potential limitation of this study. Besides, the use of only two SSRIs could influence the results. CONCLUSION: In this study, the incidence of TRD was at the lower limit of the rates reported in clinical studies. Clinical factors associated with TRD suggest the relevance of genotype analysis to identify patients with TRD. Furthermore, our results highlight the importance of heeding comorbidities to optimize care. Larger multicenter studies are needed to generalize.

The Factor Structure of the Mood Disorder Questionnaire in Tunisian Patients.

BACKGROUND: The Mood Disorder Questionnaire (MDQ) is a frequently used screening tool for the early detection of Bipolar Disorder (BD), which is often unrecognized or misdiagnosed at its onset. In this study, data from Tunisia has been used to evaluate the psychometric properties of the Arabic MDQ. METHODS: The sample included 151 patients with a current major depressive episode. The Arabic adapted version of the Structured Clinical Interview for DSM-IV-TR was used to formulate a diagnosis, yielding 62 patients with BD and 89 with unipolar Major Depressive Disorder (MDD). Principal component analysis with parallel analysis was used to establish the spontaneous distribution of the 13 core items of the MDQ. Confirmatory Factor Analysis (CFA) was used to check the available factor models. Receiver Operating Characteristic (ROC) analysis was used to assess the capacity of the MDQ to distinguish patients with BD from those with MDD. RESULTS: Cronbach's α in the sample was 0.80 (95%CI: 0.75 to 0.85). Ordinal α was 0.88. Parallel analysis suggested two main components, which explained 59% of variance in the data. CFA found a good fit for the existing unidimensional, the two-factor, and the three-factor models. ROC analysis showed that at a threshold of 7, the MDQ was able to distinguish patients with BD from those with MDD with extraordinary negative predictive value (0.92) and a positive diagnostic likelihood ratio of 3.8. CONCLUSION: The Arabic version of the MDQ showed good measurement properties in terms of reliability, factorial validity and discriminative properties.

Women's mental health: acute impact of COVID-19 pandemic on domestic violence.

The coronavirus disease 2019 (COVID-19) pandemic created a situation of general distress. Although the focus has been initially more on the physical health during the pandemic, mental health concerns linked to the lockdown have quickly risen. This study aims to assess the effect of the COVID-19-related lockdown on Tunisian women's mental health and gender-based violence. An online survey was conducted, using the Depression Anxiety and Stress Scales (DASS-21) and the Facebook Bergen Addiction Scale (FBAS). We chose a female-exclusive social group on Facebook and used the snowball sampling method. A total of 751 participants originating from all the Tunisian regions completed the questionnaire. More than half of the participants (57.3%) reported extremely severe distress symptoms, as per the DASS-21. Those who had a history of mental illness and who were allegedly abused during lockdown were found to have more severe symptoms of depression, anxiety, and stress. Around 40% of women reported problematic social media use. Violence against women also reportedly increased significantly during the lockdown (from 4.4 to 14.8%; p < 0.001). Psychological abuse was the most frequent type of violence (96%). Women who had experienced abuse before the lockdown were at an increased risk of violence during lockdown (p < 0.001; OR = 19.34 [8.71-43.00]). To our knowledge, this is the first study that evaluates the acute impact of COVID-19 on mental health and violence against women in Tunisia, Africa, and the Arab world. It may be a sound basis for developing a more effective psychological intervention aimed at women in these regions.

[What are the characteristics of patients with bipolar disorder type I who attempt suicide?] / Quels patients souffrants de trouble bipolaire type I font des tentatives de suicide?

Suicide is a public health problem affecting majority of patients with psychiatric diseases, including bipolar disorder (BD). The purpose of this study was to estimate the prevalence of suicide attempts (SAs) and to identify different factors associated with it in a population of patients with bipolar disorder type I (BD I). We conducted a cross-sectional and descriptive study of 150 patients. We used a fact sheet, questionnaires assessing affective temperaments, alcohol addiction and drug addiction. A comparison between suicidal (23,3%, n = 35) and non-suicidal (76,7%, n = 115) subjects enabled the identification of the following risk factors for suicide: cannabis addiction, addiction to psychotropic drugs, advanced age, a family history of BD, depression, SA and suicide deaths, a personal somatic history, a personality disorder associated, in particular, with histrionic personality, depressive temperament, a first thymic depressive episode, recurrent thymic episodes and long-term disease progression. Two protective factors were also identified: valproic acid and a higher number of siblings. In a multivariate study risk factors included: age, a family history of BD, a family history of SA and cannabis addiction. Particular attention should be given to determinants associated with suicidal behavior in BD I patients in order to adopt effective preventive and therapeutic strategies.

The stigma of severe mental illness: Beliefs and experiences of Tunisian patients.

BACKGROUND: Stigmatization of patients with mental illness is a worldwide phenomenon which can jeopardize help seeking and treatment adherence and contribute to low self-esteem and quality of life. AIM: To assess stigmatization as perceived and experienced by patients with severe mental illness in Tunisia. METHODS: This is a cross-sectional descriptive study conducted at Razi Hospital La Manouba, Tunisia in clinically stabilized patients with bipolar disorder and schizophrenia followed at our outpatient clinic. Patients gave their opinion on a total of 31 statements related to stigma relevant to the Tunisian cultural context. RESULTS: The study sample consisted of 105 patients with an average age of 38.3 years and a sex ratio of 1.5. Negative perceptions or experiences prevailed in 19 out of 31 statements, mostly referring to received and endorsed stigma.Study participants expressed apprehension about disclosure of mental illness, mainly due to fears about family reputation and job opportunities, however, a large majority actually disclosed their mental illness to their surroundings. Male participants had less positive opinions than women regarding former mental patients becoming teachers and experienced more stigma than women in the professional field. CONCLUSIONS: Besides actions towards public attitudes, patient-centered-approaches, both tailored to the Tunisian cultural context, are necessary to raise awareness of the public and to reduce endorsed stigma in this vulnerable group of the population.

Validation of the Tunisian version of the Patient Health Questionnaire -9 (PHQ- 9) for Depression screening.

BACKGROUND: Depression is a major burden for the health-care system worldwide. It is important to use standardized and easily applicable tools for large-scale population screening to improve the early detection of depression. The PHQ-9 has been recommended as the best available screening and case-finding instrument based on its brevity and ability to inform the clinicians on both depression severity and diagnostic criteria. AIMS: To evaluate the reliability and the validity of the Tunisian version of the PHQ-9 in the general population in Tunisia; the Tunisian version of the Hospital anxiety depression scale (HAD) was used as the gold standard for major depression diagnosis. METHODS: We undertook a cross-sectional, descriptive and analytical study. A total of 134 participants were enrolled. The PHQ-9 was validated against the HAD reference standard. RESULTS: Test-Retest reliability was determined by intraclass correlation. This scale was stable over 2 weeks (ICC=0,97).The Tunisian version of the PHQ-9 has a good internal reliability (Cronbach's alpha = 0.84). As for criterion validity of the PHQ-9, the Pearson's correlation coefficient between the PHQ-9 and HAD was 0.94 and the Spearman's correlation coefficient was 0,81. A cut-off score of 10 had a sensitivity of 86,2 and a specificity of 83,8. The VPP was 0,6 and the VPN was 0,9. The prevalence of depression in ours ample was 13,4%. There were no statistical difference in gender, education and age for the prevalence of depression. CONCLUSION: The Tunisan version of the PHQ-9 is a valid and reliable casefinding instrument for detecting depression.

Posttraumatic Stress Disorder in First-Episode Psychosis: Prevalence and Related Factors.

INTRODUCTION: The experience of psychosis or related treatment can be conceptualized as a traumatic event, which might lead to posttraumatic stress disorder (PTSD) or PTSD syndrome (which is defined as the presence of PTSD symptoms irrespective of the DSM-IV criterion A definition of a traumatic event as an actual or threatened harm). Few studies explored the subject so far. METHODS: This cross-sectional study included 52 clinically stabilized patients who were hospitalized for a first-psychotic episode during the two years preceding the study. Sociodemographic and clinical information were collected including past trauma history and drug and alcohol use. Patients were administered the Clinician-Administered PTSD Scale (CAPS), the Major Depression Inventory (MDI), the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning scale (GAF), and the Brief COPE. RESULTS: A total of 22 patients (42.3%) met full PTSD criteria and 36 patients (69.2%) met PTSD syndrome criteria. Full PTSD as well as PTSD syndrome were both associated with physical restraint, higher scores on the MDI and its maladaptive coping scales. The most distressing symptoms were paranoid delusions, and the most distressing treatment experiences involved physical restraint and problems with other hospitalized patients. DISCUSSION/CONCLUSIONS: Our data showed high rates of psychosis-related PTSD. To prevent PTSD, conditions of hospitalization should be optimized and the use of coercive treatments should be limited. Subjects with recent-onset psychosis should be screened for PTSD symptoms. Improving coping abilities with a well-fitted therapy would be useful in these patients.

Satisfaction with psychiatric in-patient care as rated by patients at discharge from hospitals in 11 countries.

PURPOSE: There is disregard in the scientific literature for the evaluation of psychiatric in-patient care as rated directly by patients. In this context, we aimed to explore satisfaction of people treated in mental health in-patient facilities. The project was a part of the Young Psychiatrist Program by the Association for the Improvement of Mental Health Programmes. METHODS: This is an international multicentre cross-sectional study conducted in 25 hospitals across 11 countries. The research team at each study site approached a consecutive target sample of 30 discharged patients to measure their satisfaction using the five-item study-specific questionnaire. Individual and institution level correlates of 'low satisfaction' were examined by comparisons of binary and multivariate associations in multilevel regression models. RESULTS: A final study sample consisted of 673 participants. Total satisfaction scores were highly skewed towards the upper end of the scale, with a median total score of 44 (interquartile range 38-48) out of 50. After taking clustering into account, the only independent correlates of low satisfaction were schizophrenia diagnosis and low psychiatrist to patient ratio. CONCLUSION: Further studies on patients' satisfaction should additionally pay attention to treatment expectations formed by the previous experience of treatment, service-related knowledge, stigma and patients' disempowerment, and power imbalance.

Screening for Depression using the PHQ-9 questionnaire: a study for Tunisian individuals consulting in the primary health care centers.

INTRODUCTION: Depression is considered a global public health problem especially in the developed countries, where depression is the leading cause of morbidity. OBJECTIVES: To determine the point prevalence and the severity of depression in primary health care, to define the profile of patients suffering from depression and consulting in primary health care. To identify risk factors for depression, in particular chronic co-morbid conditions. METHODS: Our study was a descriptive and analytical cross-sectional study of 1000 patients aged over 18 years consulting in ten primary care structures. It took place during a period of six successive days from 8 to 13 April 2012. Depression was assessed by the 9-item-Patient Health Questionnaire (PHQ-9). RESULTS: In our sample, the average age was 42,4 years ranging from 18 to 89 years. Females were predominant with 66,6 %. According to the PHQ-9, the prevalence of major depressive episode (MDE) was 12,1 %. It was higher among women (13,5%) compared with men (9,3%) with an odds ratio of 1,5. The highest prevalence of MDE (19%) was noted in the age group of 45-54 years. The most prevalent clinical signs found in our population were sleep disorders (29,7%) and suicidal ideation (28,4%). Among patients with MDE, only 10% were followed up for depression. Major depressive disorder was significantly associated with comorbid chronic diseases (p < 0,001), especially diabetes (p = 0,043, OR = 2,1), musculoskeletal diseases (p = 0,028, OR = 2,1) and pulmonary diseases (p = 0,001 , OR = 5,5). Having one comorbid chronic condition multiplied the risk of having a MDE by 2,2. This risk was 3,2 for two or more comorbid chronic conditions. CONCLUSION: Depression in primary care remains a largely underdiagnosed and undertreated condition. Patients with chronic disorders are particularly vulnerable.