[Post-traumatic stress disorder, depression and anxiety in parents of children with epilepsy]. / Trouble stress post traumatique, dépression et anxiété chez les parents d'enfant(s) atteint(s) d'épilepsie.

INTRODUCTION: Post-traumatic Stress Disorder (PTSD), depression and anxiety are the most common psychiatric consequences among parents of children with epilepsy. OBJECTIVES: We aimed to investigate the prevalence and predictors of PTSD, depression and anxiety in a sample of parents of children with epilepsy. METHODS: A survey of 135 parents of children with epilepsy, treated in the pediatric neurology department at the Sfax Teaching Hospital in Tunisia, was conducted in the last quarter of 2019. The PTSD Checklist for DSM-5 and the Hospital Anxiety and Depression Scale (HADS) were used to assess, respectively, PTSD, depression and anxiety in parents. Associations with clinical and demographic variables with PTSD, depression and anxiety were evaluated in a logistic regression model. RESULTS: Results revealed PTSD rates of 20.7%, depression rates of 28.9% and anxiety rates of 55.6%. The main factors associated with PTSD on multivariable analysis were female gender (P=0.026, ORa=13.1), insufficient involvement of partner in disease management (P<10-3, ORa=12.1) and duration of epilepsy less than 12 months (P=0.001; ORa=0.1). Female gender (P=0.006, ORa=18.1) and restriction of social life (P=0.006, ORa=4.1) were associated with depression. Factors associated with anxiety were insufficient involvement of partner in disease management (P=0.03, ORa=4.6) and PTSD (P=0.005, ORa=9.1). CONCLUSION: These findings suggest that clinicians should pay more attention to psychological health of parents of children with epilepsy and help healthcare providers to develop preventive and intervention strategies for parents of such children.

[Metacognitive deficit in schizophrenia: Characteristics and links]. / Déficit métacognitif dans la schizophrénie : caractéristiques et liens.

OBJECTIVES: Research indicates that many patients with schizophrenia experience deficits in metacognitive capacity defined as the ability to form complex representations of themselves and others. The aim of the current study was to assess metacognitive deficit in patients with schizophrenia. These variables were collected together with many other sociodemographic, clinical and therapeutic data. METHODS: We conducted a descriptive and analytical cross-sectional study in the psychiatry department at the Hedi Chaker University Hospital in Sfax (Tunisia). Patients were in a non-acute phase, defined by the absence of any psychiatric symptoms during the last four weeks, also, no changes in medication during the previous month had been required. An informed written consent was obtained, following which patients completed questionnaires assessing sociodemographic and clinical data during structured interviews. Symptoms and severity of the illness were assessed using the Positive and Negative Symptoms Scale (PANSS). Insight was assessed using the Insight Scale (Q8). In addition, the Metacognition Assessment Scale-Abbreviated (MAS-A) was used to assess metacognitive capacities. The MAS-A contains four dimensions: self-reflectivity, awareness of the mind of others, decentration, and mastery. Higher scores reflect an ability to effectively respond to psychological challenges on the basis of psychological knowledge. RESULTS: We recruited 74 adults with schizophrenia disorder. The diagnosis was with DSM5. Their average age was 45 years (SD=9.84 years) with a sex ratio (M/F) of 1.552. Nineteen patients (25.5%) were married, and low educational level was present in 43% of cases. Forty patients (54%) were unemployed. Metacognitive deficit was detected in all the patients. They had low levels in all four dimensions of metacognition. The most affected dimension in our series was "Mastery". All patients had an overall insight score less than six (the average score was 2.73) with poor awareness in 62% of patients. The main factors correlated with metacognitive deficit were: occupational inactivity (P-0.015), Primary education level (P=0.045), tobacco consumption (P=0.002), low insight (P-0.001), negative symptomatology (P<10-3) and the use of first generation of antipsychotics (P=0.003). The multivariate analysis showed that three factors (occupational inactivity, low insight and the presence of negative symptomatology) were predictors of metacognitive deficits. CONCLUSION: Based on our results, occupational inactivity, negative symptomatology and low insight are predictors of metacognitive deficit in schizophrenia. Specific therapeutics should be proposed to act on these factors. A metacognitive training program, tailored to this vulnerable population, is a priority to improve their quality of life.

[Effects of continuous positive airway pressure on depression, anxiety and quality of life in obstructive sleep apnea hypopnea syndrome patients]. / Effets de la ventilation en pression positive continue sur la dépression, l'anxiété et la qualité de vie au cours du syndrome des apnées-hypopnées obstructives du sommeil.

INTRODUCTION: The obstructive sleep apnea hypopnea syndrome (OSAHS) is a chronic stressor that may alter the emotional state and quality of life (QOL) of patients suffering from it. In this work, we proposed to estimate the prevalence of depression and anxiety, to assess the QOL in a Tunisian population of apneic patients, and to assess their evolution under continuous positive airway pressure (CPAP). METHODS: We conducted a prospective study, involving 33 apneic patients followed for SAHOS with moderate or severe class disease in the pneumology department at Hedi Chaker university hospital in Sfax, Tunisia. They received CPAP treatment for three months. We used an epidemiological record. Two scales, the Hospital Anxiety and Depression Scale (HADS) and the 36-item Short-Form Health Survey (SF-36), were completed before and after treatment to evaluate the effect of three months of treatment with CPAP. RESULTS: The prevalence of depression in the study's patients, according to the HADS, was 45.5% and that of anxiety was 21.2%. After 3months of CPAP, the prevalence of depression and anxiety had become 18.2% and 6.1%, respectively. QOL was impaired in 81.8% of cases before treatment, according to the SF-36. This figure had decreased to 69.7% after 3months of treatment with CPAP. Apart from the third dimension (physical pain), all other dimensions were significantly improved after 3months of CPAP treatment. The treatment with CPAP induced a significant improvement in the average scores of depression (P<0.001), anxiety (P=0.002) and QOL (P<0.001). CONCLUSIONS: These results attest to the importance of the frequency of anxio-depressive disorders as well as an altered QOL in patients with OSAHS. CPAP treatment was shown to be effective in improving these parameters, but this efficacy was partial. Specialized care may be needed in cases of residual anxio-depressive symptoms.

[The handling of psychotropics in diseases of central nervous system]. / Le maniement des psychotropes dans les maladies du système nerveux central.

Psychiatric signs and symptoms occur frequently in individuals with central nervous system diseases. Inadequately treated, these comorbid conditions affect patient rehabilitation, compliance with treatment and quality of life. Their management poses a major challenge given the variable efficacy and safety profiles of available psychotropic drugs and increased risk of drug interaction. This review aims to summarize the existing literature on the prescription of psychotropic drugs for management of psychiatric disorders among persons with central nervous system's diseases.

[Factors associated with Internet addiction among Tunisian adolescents]. / Facteurs associés à la cyberaddiction chez les adolescents Tunisiens.

INTRODUCTION: Internet addiction, a relatively new phenomenon, is a field of recent research in mental health, particularly within young populations. It seems to interact with several individual and environmental factors. OBJECTIVES: We aim to spot internet addiction in a Tunisian adolescent population, and to study its relationship with personal and family factors, as well as with anxious and depressive comorbidities. METHODS: We conducted a cross-sectional study of 253 adolescents recruited in public places in the city of Sfax in the south of Tunisia. We collected biographical and personal data as well as data describing family dynamics. The internet addiction was assessed by Young's questionnaire. Depressive and anxious co-morbidities were assessed using the HADS scale. The comparative study was based on the chi-square test and the Student's test, with a significance level of 5 %. RESULTS: The prevalence of internet addiction was 43.9 %. The average age of internet-addicts was 16.34 years, the male sex was the most represented (54.1 %) and increased the risk of internet addiction (OR a=2.805). The average duration of connection among Internet addicts was 4.6hours per day and was significantly related to internet addiction; P<0.001). Socializing activities were found in the majority of the internet-addicted adolescents (86.5 %). The type of online activity was significantly associated with internet addiction (P=0.03 and OR a=3.256). Other behavioral addictions were frequently reported: 35.13% for excessive use of video games and 43.25 % for pathological purchases. These two behaviors were significantly associated with internet addiction (with respectively P=0.001 and P=0.002 with OR=3.283). The internet-addicted adolescents lived with both parents in 91.9 % of cases. The mother's regular professional activity was significantly associated with internet addiction risk (P=0.04) as was the use of the Internet by parents and siblings (with respectively P=0.002 and P<0.001 with OR=3.256). The restrictive attitude of the parents was significantly associated with internet addiction risk (P<0.001 OR=2.57). Family dynamics, particularly at the level of adolescent-parent interactions, were a determining factor in internet addiction. Anxiety was more frequently found than depression among our cyber-dependent adolescents with frequencies of 65.8 % and 18.9 %, respectively. Anxiety was significantly correlated with the risk of internet addiction (P=0.003, OR a=2.15). There was no significant correlation between depression and the risk of internet addiction. CONCLUSION: The Tunisian adolescent seems at great risk of internet addiction. Targeted action on modifiable factors, especially those affecting family interactions, would be very useful in prevention.

Psychoaffective repercussions of pain in cancer patients.

PURPOSE: Pain often induces in cancer patient emotional disorders such as anxiety, depression and alteration of quality of life. The purpose of our work was to assess the impact of the intensity of pain and those characteristics on anxiety, depression state and quality of life of cancer patients. MATERIAL AND METHODS: This is an analytical cross-sectional study including 106 cancer patients with pain. We evaluated four parameters: pain intensity by visual analogue scale, the presence of anxiety and of depression using the Hospital Anxiety and Depressive Scale, and the alteration of quality of life by 36-item Short-Form Health Survey. RESULTS: Patients' average age was 55 years old. The sex ratio was 0.79. Pain intensity was low in 16%, moderate in 49.1% and intense in 34.9% of patients. The prevalence of anxiety and depression was 49.1% and 54% of patients, respectively. The independent factors correlated to the occurrence of anxiety were: pain intensity, bone localization, continuous progression, chronicity of pain, advanced stage, hospitalization at day hospital, the partial or no response to analgesic treatment. The independent factors correlated to the onset of depression were: intensity of pain, advanced stage of the disease, bone localization, step 2 or 3 of analgesic, and partial or no response to analgesic treatment. CONCLUSION: The prevalence of anxiety and depression in our patients was slightly higher than those reported in the literature. The main factors correlated with the onset of depression and anxiety were: severe pain, bone location, and advanced stage of the disease.

[Affective temperaments in drug addicts: A case-control study]. / Tempéraments affectifs des toxicomanes : étude cas-témoins.

INTRODUCTION: The study of affective temperaments is a dimensional approach to personality that would provide a better understanding of the emergence of psychopathological disorders including addictive behaviors. However, in the literature, there is a lack of studies focusing on the links between this type of disorder and affective temperaments. Our objectives were to study the distribution of the five known affective temperaments in a group of drug addicts compared to a control group, and to identify sociodemographic and clinical factors associated with emotional traits. METHODS: This was a case-control study carried out in the drug abuse prevention center "ATUPRET" of Sfax in Tunisia. It included 50 drug addicts, all male, and 50 healthy control subjects matched for age (P=0.22), marital status (P=0.28), socioeconomic level (P=0.36) and educational level (P=0.95). Sociodemographic data were collected through an interview for drug addicts hospitalized in this center while clinical data were collected from medical records. The TEMPS-A questionnaire, 110 questions validated Tunisian version, has been used to evaluate five affective temperaments. RESULTS: The average age of drug addicts was 32.98 years (19-59 years) and the average age at onset of drug use was 20.36 years (12-52 years). Among drug users, the highest mean scores were observed for hyperthymic temperament (13.68±4.20), followed by cyclothymic (13.14±4.89), anxious (11.32±6.00) and depressive (11.02±3.65) ones. The lowest mean score was for irritable temperament (10.14±3.95). All of these scores, except that of cyclothymic temperament, were significantly higher than in the control group (P<0.01). The age of drug addicts was negatively correlated with cyclothymic (P=0.023) and irritable (P=0.035) temperament scores. These two temperaments were more dominant in the group of drug addicts with post-secondary education (P respectively 0.035 and 0.002). The age of onset of psychoactive substance use was negatively correlated with irritable temperament (r=-0.355, P=0.012). Cyclothymic temperament was correlated with alcohol dependence (P=0.03) and psychiatric comorbidity (P=0.01) among drug addicts. CONCLUSION: The present study provides support for the existence of temperamental dysregulation in drug-addicted patients. This result leads us to suggest that affective temperaments are implicated as a potential endophenotype and may represent a marker for the identification of persons vulnerable to drug use. These affective temperaments also appear to influence clinical features of drug addiction.

[Alcohol use in adolescents and its association with sensation seeking and impulsivity: A survey in the city of Sfax, Tunisia]. / Enquête sur la consommation d'alcool et sa relation avec la recherche de sensations et l'impulsivité chez l'adolescent de la région de Sfax, Tunisie.

BACKGROUND: Although the increase of media interest for psychoactive substances use, especially alcohol, among young people, since the revolution, Tunisia has few epidemiological studies on this subject, which does not allow having a clear idea of the importance of the problem and its different determinants. AIMS: To assess the prevalence of alcohol consumption among adolescents in the region of Sfax (Tunisia) and to determine its relations to the two personality dimensions: sensation seeking and impulsivity. METHODS: This was a cross-sectional study involving 317 middle and high school students in Sfax (Tunisia). We used the Alcohol Use Disorders Identification Test (AUDIT) to assess risky alcohol-consumption, the Barratt Impulsiveness Scale (BIS-11) to assess the degree of impulsivity and the Sensation Seeking Scale (SSS-V) to assess the level of sensation seeking. RESULTS: The average age of students was 15.79±1.5 years with a sex-ratio of 1.07. The prevalence of experimenters (who had drunk alcohol at least once in their lifetime) was 19.6% while that of current consumers (who had drunk alcohol more than one time during the past 12 months before the survey) was 8.8%. Among those who reported alcohol use during the last year, 42.8% were alcohol-dependent, according to the AUDIT. The analysis of personality dimensions showed a significant association between current alcohol consumption and sensation seeking (P<0.001) in particular on the dimensions of disinhibition (DIS), experience seeking (ES) and boredom susceptibility (BS) (P respectively: <0.001; 0.002 and 0.001). Total impulsivity and motor and attention impulsivity were associated with current alcohol consumption (respective P: 0.001, 0.005 and 0.015). CONCLUSION: Our study of schooled Tunisian adolescents shows that sensation seeking and impulsivity are associated with the development of alcohol use. Such a behavior is worrisome because it appears to be quite frequent and often problematic.

[Impact of physical disability and concomitant emotional disturbances on post-stroke quality of life]. / Impact du handicap physique et des troubles émotionnels concomitants sur la qualité de vie en post-AVC.

INTRODUCTION: The physical and/or psycho-cognitive changes after stroke may lead to a decline in the quality of life (QOL) of patients. The aims of our study were to evaluate the QOL of stroke survivors and to investigate its relationships with the physical disability degree and the emotional disorders (anxiety and depression). METHODS: We conducted a cross-sectional study, which included 147 patients, followed for stroke that had occurred over the past year, in the outpatient neurology department at the university hospital Habib Bourguiba of Sfax (Tunisia). For each patient, we collected socio-demographic characteristics and clinical and therapeutic data. The quality of life of our patients was assessed using the SF-36 scale. The HAD scale was used to screen for anxiety and depression, whereas the modified Rankin scale was used to measure the degree of disability. RESULTS: The average age of our patients was 60.58 years. The overall mean score of the SF-36 ranged from 20.81 to 89.81 with an average of 55.27. Impaired QOL was found in 68% of patients. The study of the dimensional average scores revealed that only two dimensions of the SF-36 were not altered: physical pain and life and relationship with others. The physical component was slightly more altered than the mental component (41.4 and 42.9 respectively). A minimal disability was found in 32% of patients, while a moderate and severe disability was found in 19% and 21.1% of patients. Anxiety was detected in 55.1% of patients and depression in 67.3% of them. Impaired mental component QOL was significantly correlated with the presence of anxiety (P=0.008) and depression (P<<0.05). The severe degree of disability had a significant negative impact on all areas of QOL except that of life and relationships with others. CONCLUSION: It appears from our study that among the important effects of stroke is the constant deterioration of QOL in its various dimensions. The occurrence of emotional disturbances such as anxiety and depression and the degree of physical disability seem to be predictors of QOL impairment. Therefore, special attention should be given to such patients at higher risk of decline in their QOL.

[Sexuality of Tunisian women: Involvement of religion and culture]. / Sexualité de la femme tunisienne : entre le religieux et le culturel.

INTRODUCTION: Culture and religion carry several prohibitions and taboos, especially in the Arab-Muslim societies, and are therefore involved in the sexual behavior and its perception, particularly that of women. OBJECTIVES: To assess the married population's knowledge and opinion about female sexuality, and to estimate the impacts of religious and cultural factors on women's life experience and sexual practice in the Tunisian society. SUBJECTS AND METHODS: Our study is in an inquiry. We targeted 55 men and 55 women agreeing to participate in the study. They responded to an anonymous self-administered questionnaire comprising 18 items related to the influence of religion and culture on female sexuality. Among these items, some were binary responses (yes or no) assessing knowledge about female sexuality in the Tunisian religious and cultural context; 8 others explored the opinions of participants about female sexuality. Statistical analysis was performed using SPSS software (15th version). Pearson's chi-square test and Fisher's exact association test were used for comparative study (P<0.05). RESULTS: The rate of participants who did not manage to reach the threshold of 50% of responses compliant with religious precepts and morals in the Tunisian context was 48.19%. According to 61.8% of participants, the woman should consider sex as a religious duty, and according to 79.1%, she always ought to have sex with her husband even when she did not wish to. This assertion was more frequently reported by women (P<0.001). Among the participants, 35.5% did not approve of the idea that women had the right to reach sexual pleasure, like men. Men recognized this right less often than women did (P<0.001). With reference to social morals, 43.6% of participants thought that the woman should always remain passive when having sex. This opinion was more common to women (P<0.001). There were 71.8% who thought that premature ejaculation was not a limiting factor for female pleasure. Virginity was considered by 63.6% of respondents as a feminine virtue to preserve. This response was statistically more frequent among males (P<0.001). For 55.5%, in addition to sodomy, a man could not afford all the sexual practices with his wife. This response was significantly more frequent in males (P<0.001). Regarding the subjective perception of female sexuality, the percentage of those who thought that women might simulate orgasm was 70.9%. Women thought more frequently than men that such a behavior could be justified to avoid hurting the man's pride (P<0.001). CONCLUSION: The experience of sexuality within the Tunisian population is hampered by the prohibitions related to religion and culture, at least in some of its aspects. The reasons for that may be the ignorance of religious texts or their misinterpretation and the biased cultural transmission not followed by questioning or seeking deeper knowledge. The introduction of sex education in school programs could play a crucial role in the fight against the obstacles surrounding sexuality, in order to promote the welfare of woman, and thereby, that of the couple and the family.

A mitochondrial implication in a Tunisian patient with Friedreich's ataxia-like.

Genes encoding the DNA helicase TWINKLE (C10orf2) or the two subunits of mtDNA polymerase γ (POLγ) (POLG1 and POLG2) have a direct effect on the mitochondrial DNA replication machinery and were reported in many mitochondrial disorders. Friedreich's ataxia (FRDA) is the common cause of ataxia often associated with the expansion of a GAA repeat in intron 1 of the frataxin gene (FXN). Mitochondrial DNA could be considered as a candidate modifier factor for FRDA disease, since mitochondrial oxidative stress is thought to be involved in the pathogenesis of this disease. We screened the FXN, POLG1 and C10orf2 genes in a Tunisian patient with clinical features of Friedreich's ataxia-like. The results showed the absence of the expansion of a GAA triplet repeat in intron 1 of the FXN gene. Besides, the sequencing of all the exons and their flanking regions of the FXN, POLG1 and C10orf2 genes revealed the presence of intronic polymorphisms. In addition, screening of the mtDNA revealed the presence of several mitochondrial known variations and the absence of mitochondrial deletions in this patient. The detected m.16187C>T and the m.16189T>C change the order of the homopolymeric tract of cytosines between 16184 and 16193 in the mitochondrial D-loop and could lead to a mitochondrial dysfunction by inhibiting replication and affecting protein involved in the replication process of the mtDNA which could be responsible for the clinical features of Friedreich ataxia observed in the studied patient.

Myeloma after local external beam radiotherapy jet: Is it a new entity?

Multiple myeloma, also known as Kahler's disease, is a cancer of plasma cells that abnormally accumulate in bone marrow. Radiation therapy may be indicated in multiple myeloma to relieve pain, alleviate spinal cord compression or reduce tumor mass. We report the case of a patient presenting a multiple myeloma, treated with radiation therapy for a spinal cord compression, who developed, eleven months later, an in-field subcutaneous relapse. We called this phenomenon myeloma appearance after local external beam radiotherapy jet (MAALEJ). A review of literature was performed trying to explain this uncommon relapse feature.

[Psycho-emotional impact of a child's disability on parents]. / Répercussions psycho-affectives du handicap de l'enfant sur les parents.

Care for a child with a disability is a stressful experience for parents. It triggers a range of emotions and feelings that require a set of behaviors and attitudes to manage daily life. To face this situation, parents use coping strategies. The purpose of this study was to assess the psychological reactions (depression and anxiety) of parents and the impact of a child's disability on their quality of life (QOL), and to determine their coping strategies. A survey of 50 parents of handicapped children, treated in the neurology department at the Sfax Teaching Hospital in Tunisia, was conducted in September 2010. The Beck Depression Inventory (BDI), the State Trait Anxiety Inventory (STAI), the SF-36, and the Brief COPE were used to assess, respectively, depression, anxiety, QOL, and coping strategies in parents. Among the group of parents studied, the anxiety and depression rates were, respectively, 68% and 52%. Depression was more frequent among mothers and was correlated with low educational and socioeconomic levels. Anxiety was found in 70.7% of mothers and 55.6% of fathers with no significant correlation. There was a correlation between anxiety and increased family burden related to the presence of a similar case in the family. The range of coping strategies used includes religion (16%), active coping (16%), planning (16%), acceptance (20%), focus and venting of feelings (10%), and seeking emotional social support (10%). Parents used emotion-focused coping in 68% of cases and problem-centered coping in 32% of cases. The coping strategy choice was significantly correlated with gender. Mothers preferentially used emotion-focused coping. Depressed or anxious parents more frequently used emotion-focused strategies. Religious faith was correlated with a strategy centered on religious coping. The length of follow-up (more than 2years) was correlated with a strategy focused on acceptance. Emotion-focused coping was also correlated with low levels of education and socioeconomic status. We found correlations between depression and different types of emotion-focused coping such as emotional support. Impaired QOL was higher among mothers (58.5% versus 33.3%). It was correlated with depression, anxiety, and the use of emotional coping. Also, it was correlated with low educational and socioeconomic levels and increased family burden related to the presence of a similar case in the family. The size most commonly impaired in mothers was limited due to mental health (56.9% versus 44.4% for fathers). Social functioning (D6) was significantly correlated with the presence of a mental disability, the functional dependence of the child, and increased family burden related to the presence of a similar case in the family. Impaired QOL was found in 66.8% of parents dissatisfied with the explanations given by the medical team. More problem-focused coping was found in parents satisfied with the information given by the medical team compared to those inadequately informed (42.1% versus 25.8%). The presence of a disabled child causes profound changes in the family. The impact of anxiety and depression on parents and on their QOL are considerable. This is a situation that involves an adaptation process. At first, parents may be tempted to use coping strategies focused on religion, a choice related to Arab-Muslim fatalism. Parents should be encouraged to use active coping strategies to support their disabled child better. In addition, adequate information given by the healthcare staff would help them to deal with the child's handicap and would contribute to improving their QOL.

[Psychodynamic and forensic approach of constitutional mythomania: a case report]. / Approche psychodynamique et médicolégale de la mythomanie constitutionnelle: à propos d'une observation.

INTRODUCTION: Constitutional mythomania presents several diagnostic, aetiopathogenic and forensic problems for the doctor. We have discussed these aspects through the analysis of a case report. CASE REPORT: The case report relates to a 43 year-old man, who was subjected to a penal expertise following the emission of cheques without provision. During the examination, he pretended being both a doctor and a lawyer at the same time. He was in charge, among other things, of sale contracts dealing sometimes with high value transactions, obviously without following the required legal procedure. He was pursued subsequently for many other affairs of swindle. Data collected from his medical file indicated that he was the only boy of his family. Since his father had suffered from psychotic episodes, his grandfather had reared him; which he did it in a strictly religious way. He spent his childhood isolated. He was 15 years old when his grandfather died. He had then expressed religious and megalomaniac ideas that had motivated psychiatric management. Later on, he expressed imaginative ideas evoking unsystematized delusion (he pretended to have made a trip to America and to have seen a fish flying and turning into a woman). DISCUSSION: From a psychodynamic point of view, constitutional mythomania is considered as a borderline personality. It reflects an important narcissisic cleavage. The deceitfulness of the mythomaniac allows him to keep in touch with reality and to avoid mental disintegration. The recognition, by others, of these delusions allows the mythomaniac to have access to his proper level of existence. For a while, to the experts our patient appeared to be suffering from schizophrenia. Therefore, we can apply the Maleval theory to him, which identifies four periods as delusion structuring levels in psychosis : P0 (consequence of the phallic signification deficiency, it includes anxiety, annihilation, perplexity, interrogative attitude), P1 (stage of paranoid delusion), P2 (stage of paranoiac delusion) and P3 (ambitious stage evoking paraphrenia and squaring with mythomaniac behaviour). According to the Maleval theory, our patient would have experimented a repetitive cycle: he tried to escape instable and anxious positions (P0, P1) by committing sacrificial acting out (offence), or by reaching stable positions which are P2 and P3. The mythomaniac behaviour would appear during the latest period. The delusional decompensation would indicate a return to the first two periods. On the other hand, the personal myth might be seen as the result of the failure of the assimilation of actual experiences. Several psychoanalysts consider the use of myths by some psychotics as an attempt to reduce their ego disintegration. The mythomaniac may create his own myth in order to reduce the psychotic anxiety. The personal myth does not represent the pain of the patient but his remedy against his disorders. Therefore, identifying a personal myth may help the psychotic to turn his delusion into supportable logic of life. Myth may also be used in less deep pathologies such as borderline context, where it dominates the clinical picture. CONCLUSION: On the forensic level, we could a priori postulate that the mythomaniac sufficiently perceives reality to be considered as lucid. In fact, he hardly masters the totality of his intentions, being guided by an irrepressible mechanism that makes mythomania a "serious" and handicapping illness; its prima victim being the patient him/herself. No measures could actually prevent the latter from infringing the law, except, perhaps, a permanent administrative control; but this would not be without practical and ethical problems.

[Pediatric Hodgkin disease in North Tunisia: clinical and therapeutic study]. / La maladie de Hodgkin de l'enfant dans le Nord Tunisien : étude clinique et thérapeutique.

PURPOSE: To assess the epidemiological, clinical and therapeutic aspects of pediatric Hodgkin disease (HD) and to study prognosis factors. PATIENTS AND METHODS: We retrospectively reviewed the medical records of children (≤18 years) with HD treated between 1st January 1994 and 31st December 2004. Chemotherapy was undertaken in different departments of hematology and oncology in the North of the country and radiotherapy was centralized at the Salah-Azaïz National Cancer Institute. RESULTS: One hundred fourteen consecutively treated patients were collected. Median age was 12 years (4-18 years) and sex-ratio was 2.25. Peripheral lymphadenopathy was the predominant circumstance of HD detection (82.5%). The predominant histologic type was nodular sclerosing (56%). Treatment included chemotherapy and involved-field radiotherapy. With a mean follow-up of 23.5 months, relapse rate was 12.2%. Five-year overall survival (OS) and event-free survival (EFS) rates were 95% and 76%, respectively. Five-year OS was 98.2% and 90.8% for early and advanced stages respectively. In multivariate analysis, stage IV (P=0.029) and early response to initial treatment (P=0.003) retained statistical significance for EFS whereas the only prognostic factor for OS was stage IV (P=0.002). The long-term side effects were rare. No secondary tumor was noted. CONCLUSION: Combined-modality therapy using chemotherapy and involved-field radiotherapy was effective and well-tolerated in early stage pediatric HD. Stage IV patients should be referred to specialized units for intensive treatment. The short median follow-up in our study cannot allow considering long-term effects.

[Evaluation of the knowledge concerning women's sexuality in Tunisia]. / Évaluation des connaissances relatives à la sexualité de la femme en Tunisie.

OBJECTIVES: Our objectives were to evaluate the theoretical knowledge about women's sexuality in a Tunisian population and to compare it according to the participant's gender. PATIENTS AND METHODS: Our study consisted in investigating 55 men and as many women. Those surveyed had answered an anonymous autoquestionnaire comprising items related to woman's body anatomy, foreplay, women's attitudes during sexual intercourse, female orgasm and contraception. RESULTS: Fifty percent of the participants did not manage to reach the level of 50% of proper answers. Men had answered more incorrectly than had women (P<0.001). They had more erroneous answers than women concerning the importance of the knowledge of female anatomy and of the foreplay for the sexual satisfaction in women (P<0.001). Eighty percent thought that the simultaneity of the orgasm was obligatory for the sexual satisfaction of the couple. DISCUSSION AND CONCLUSION: Men had more erroneous answers than women, concerning the importance of the knowledge of the female anatomy, by both partners, for the sexual satisfaction of the woman. A good knowledge of the women body and of the importance of foreplays allows one to be conscious of the erotegenic zones and of knowing all the resources, which lead to physical pleasure. Awareness's campaigns contribute to fight against deficiencies surrounding women's sexuality, which would favor the opening out of the woman and the family.

Impact of sampling origin on molecular detection of high-risk human papillomavirus and oncogene expression.

PURPOSE OF INVESTIGATION: The recognition of high-risk human papillomavirus (HR-HPV) as an etiological agent of cervical cancer has increased the importance of testing for HPV, and this might contribute to better risk stratification. METHODS: Eighty-eight randomly selected cervical cancer specimens including biopsies and their respective smears were used in this study. Control scrapings were obtained from ten healthy women. The presence of HPV16 and HPV18 was investigated using the technique of polymerase chain reaction (PCR) with the specific primers for the L1 region, while mRNA expression of HPV16 E6-E7 was evaluated by a reverse transcription PCR method (RT-PCR). RESULTS: The positivity for the viral genotype was influenced by the quantity of amplified DNA used. In tumor biopsies the higher positivity for HPV16 (54.5%) and HPV18 (15.9%) was obtained using 687.4 ng of DNA. At smears level solely 31.8% of HPV16 was detected using an average DNA quantity of about 157.2 ng. The revelation of HPV types depends on clinicopathologic data; HPV16 was detected more in advanced stages of squamous carcinoma (SC) samples (20% stage I, 62% Stage II and 80% stage III), while HPV18 and double infection were found exclusively at advanced stages of SC and in adenocarcinoma (AC), respectively (60%, 40% stage III SC and 80%, 20% Stage II A and C). The prevalence of HPV16 E6-E7 transcripts was evaluated at tumor biopsy with frequencies of 50%. CONCLUSION: Our data provide prospective evidence that HPV16/18L1 revelation at biopsy toward pathological types is efficient and correlates well with oncogenic transcript findings. Subtle changes in viral oncogene dynamics highlight the presence of other regulating proteins serving as additional biomarkers.

[Quality of life in patients with schizophrenia: a study of 100 cases]. / Qualité de vie des malades atteints de schizophrénie : étude de 100 cas.

OBJECTIVE: The aim of the present study was to evaluate the quality of life (QOL) in outpatients with schizophrenia, and to identify factors correlated to an impaired QOL among them. SUBJECTS AND METHODS: A transversal study, in the form of an inquiry, was conducted in 100 outpatients, during seven months, in the psychiatric department of the Hedi Chaker teaching hospital in Sfax - Tunisia. We used the "36 item Short-Form Health Survey" (SF-36) to assess the QOL; this has been considered as impaired when the global medium score was inferior to 66.7. For the global assessment of functioning and the global assessment of the interference by existing side effects with the patient's daily performance, we have used respectively the Global Assessment of Functioning scale (GAF) and the Udvalg of Kliniske Undersogelser (UKU) side effect rating scale. The positive and negative symptoms added to the general psychopathology were assessed using the Positive and Negative syndrome scale (PANSS). RESULTS: The QOL was impaired in 34% of the cases. The analysis of the scores of the eight dimensions by the scale SF-36 has shown that the most affected dimensions were, in decreasing order: mental health (MH), general health perceptions (GH), vitality (VT), role limitations due to physical health problems (RP) and role limitations due to emotional problems (RE). The standardization revealed that six dimensions were impaired; these were, in decreasing order: mental health (MH), social functioning (SF), role limitations due to emotional problems (RE), role limitations due to physical health problems (RP), general health perceptions (GH) and physical functioning (PF). The standardization has also revealed an impairment of the psychological component, while the physical component has been conserved. After analysis by multiple linear regression, four factors appeared strongly correlated with the impaired QOL: the professional inactivity, the episodic course with interepisode residual symptoms, the presence of side effects moderately influencing the daily performance, and a general psychopathology score for 26 at least. These four factors affected, in decreasing order of importance, social functioning (SF) (related to two factors), general health perceptions (GH) and role limitations due to emotional problems (RE) (each related to one factor). None of the factors appeared to affect the other dimensions: physical functioning (PF), role limitations due to the physical health problems (RP), bodily pain (BP), mental health (MH) and vitality (VT). The bivariate analysis revealed three other factors correlated, to a lesser degree, to the impairment of the QOL: the disorganized sub-type, a score of (GAF) inferior or equal to 30 and the negative type of schizophrenia. CONCLUSION: Management of schizophrenic patients should go beyond the remission of the symptoms; it has also to target the improvement in QOL. This needs an action over the factors that affect the QOL, among which residual symptoms and side effects. The atypical antipsychotics would contribute preciously in this way, due to their efficacy on negative symptoms and their better tolerance than the conventional ones.

[Reticence towards electroconvulsive therapy: a study of 120 caregivers in a teaching hospital in Tunisia]. / De la réticence face à l'électroconvulsivothérapie : enquête auprès de 120 personnels soignants dans un centre hospitalo-universitaire en Tunisie.

INTRODUCTION: Electroconvulsive therapy (ECT) is rarely practiced in Tunisia. We have tried to explain this lack of use by studying theoretical knowledge, the perception and the attitudes of health professionals towards ECT. METHODS: We conducted a survey in the region of Sfax in Tunisia. It included 120 participants. The latter were divided into four groups, composed of 30 members, in order to compare them: group 1 (psychiatrists); group 2 (neurologists and anaesthetists); group 3 (psychiatric nurses); group 4 (paramedics in the neurological and anaesthesia wards). The surveyed people answered an auto-questionnaire including essentially 16 items: 11 had binary answers (true or false) related to theoretical knowledge about ECT, and five others explored the perception and attitudes concerning this therapy. RESULTS: Concerning the items exploring theoretical knowledge, 67.5% of people were not able to answer, in conformity with the consensual scientific data, a minimum of 75% questions. The rates were significantly lower among the paramedics (P<0.001) and those who work outside the psychiatric wards (P=0.003). The answers of psychiatric caregivers were less frequently incorrect compared to those of non psychiatric ward workers. The latter more frequently thought that the psychiatrists easily resorted to ECT (P=0.003). The paramedics perceived, more frequently than doctors, the ECT as a violent therapeutic means (P=0.001), and more frequently refused to give their consent to apply ECT to a relative (P=0.044). The rate of doctors who refused to give their consent to apply ECT to a relative was statistically higher in group 2 than in group 1 (P=0.017). Doctors with higher scores in theoretical knowledge, consent more frequently to apply ECT to a member of their families (P=0.001). DISCUSSION: The comparison of theoretical knowledge between the two groups of doctors (group 1 versus group 2) revealed significantly more frequent incorrect answers among non-psychiatrists. The latter more frequently had erroneous ideas: that ECT was performed without anaesthesia; that it wasn't possible to apply it to pregnant women, nor to people suffering from Parkinson's disease, nor as a preventive treatment of recurrence, and that the vital risk was higher with ECT than medical treatments. Compared to the caregivers of group 3, group 4 had significantly more frequent negative attitudes toward ECT; concerning the application without anaesthesia, the lack of tolerance and the over-mortality rate related to ECT. This therapy seems to create an apprehension and a reticence among health professionals, mainly the paramedics and the non-psychiatrists. The lack of valid scientific knowledge concerning ECT allows prejudiced ideas to tarnish the image of this therapy. CONCLUSION: Information and training would play a primordial role in the improvement of the perception and attitudes concerning ECT, and lower the reticence towards this therapy, which in spite of its proven efficacy, always maintains a pejorative image.

[Cultural aspects in depression masked by psychotic symptoms in Maghreb countries: three case reports]. / Aspects culturels dans la dépression masquée par des symptômes psychotiques.

CASE REPORTS: In this study, we will describe three observations of depression "masked" by persecution delirium and/or hallucinations, to illustrate the role that the cultural factor could play in the expression and care of depression. In the first two observations, the persecutor was a group that was apparently difficult to circumscribe: the persecution appeared more important than the persecutor. In these two cases, persecution also had a depreciating role for the patient. In the third observation, the hallucinatory manifestations cast a slur on self-esteem and caused narcissistic injury. DISCUSSION: Analysis of the cultural context allows us to understand the depressive significance of such psychotic symptoms. In the traditional societies, depression is strongly related to the cultural context, it is often expressed by the fear of being punished or denied by the group, and a feeling of treason towards the community. The punishment can be direct or indirect, carried out by imaginary beings, "the djinn", or by any disease. According to Freud, the guilt is expressed by the fear of the vengeance of a dead man's spirit, which is then going to persecute the culprit. This persecution, which has a value of punishment, is based on the mechanism of the projection. In the same sense, Freud explained that the death, as a sequel of the disease, is the vengeance of the dead man's spirit in the living. In all religions, the impulses, the thoughts disapproved by the community, are attributed to Satan who etymologically means "the enemy" or "the opponent". This latter plays an important role in relieving fears, the sense of guilt and the disapproved thoughts. There is also involvement of the projection mechanism. So, guilt could be expressed by delirious ideas such as the conviction of being the victim of a demonic possession, to be under a spell or to be persecuted. CONCLUSION: Thus, taking the cultural context into account would allow us to fundamentally understand the depressive meaning of the delirious symptomatology of persecution, which is taken from a popular theory of misfortune shared and validated by the familial and the social circle of acquaintances. Plantine postulates that the psychotic conflict takes the subject away from the standards of his own culture. In the case of our three patients, we should try to establish a form of communication, to prevent them from falling into alienation. Thus, we must think about our attitude facing a patient who is diagnosed as depressed or even psychotic, while the patient believes he/she is possessed by a "Djinn". The therapeutic attitude should be adapted to the cultural dimension of the case. Thus, in situations similar to the studied cases, the therapy should be essentially based on the development of a psychotherapeutic relationship, rather than a pharmacotherapy, one should be careful not to compromise the cultural means of restoring psychic disorders such as the traditional therapy.