Objective: To investigate the role of psychological factors in the development and progression of factitious oral ulcer (FOU) among children and adolescents, and to evaluate the clinical efficacy of a comprehensive intervention strategy based on standardized psychological assessment. Methods: In a prospective real-world study, 35 patients aged 3-16 years with FOU who visited the Department of Stomatology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine were enrolled from April 23, 2024, to August 30, 2025. Stratified by age, systematic psychological assessment was performed using the parent symptom questionnaire (PSQ), strengths and difficulties questionnaire (SDQ), screen for child anxiety related emotional disorders, and depression self-pating scale for children. All patients received topical recombinant bovine basic fibroblast growth factor and oral health education. Those with abnormal psychological scores received individualized psychological education and clinical psychology referral. Patients with low serum zinc concentration received zinc supplementation. The overall clinical effectiveness rate, ulcer area, pain visual analog scale (VAS) score, cessation of self-injurious behavior, psychological scores, and recurrence were assessed at baseline, 2, 4, and 12 weeks post-treatment. Results: All 35 patients completed the study, with a mean age of (8.34 ± 2.79) years and a male proportion of 65.7% (23/35). Abnormal psychological scores were present in 82.9% (29/35) of patients. At 12 weeks post-treatment, the clinical effectiveness rate was 91.4% (32/35), with a cure rate of 88.6% (31/35); significant reductions in ulcer area and pain VAS score were observed compared to baseline (both P<0.001). The entire cohort showed significant improvements in the PSQ total score (conduct problems) at 4 and 12 weeks (both P<0.05), and the SDQ total difficulties score at 12 weeks compared to baseline (P<0.05). By week 12, 37.1% (13/35) of patients had successfully ceased self-injurious behavior. Multivariate logistic regression identified cessation of self-injurious behavior as an independent protective factor against ulcer recurrence (OR=0.080, 95%CI: 0.007-0.918, P=0.042). Conclusions: Psychological factors play a central role in FOU, with a high prevalence of anxiety, emotional, and behavioral problems among affected children. A comprehensive intervention strategy, guided by precise psychological assessment and integrating topical treatment, psychological-behavioral intervention, and nutritional supplementation, effectively promotes ulcer healing, improves psychological and behavioral status, and reduces recurrence.

Graves' disease is an autoimmune disorder and represents the most prevalent cause of hyperthyroidism. Its pathogenesis involves a complex interplay of immunological mechanisms, with a central role attributed to stimulating autoantibodies directed against the thyroid-stimulating hormone receptor (TSHR) expressed on thyroid follicular cells. The differential diagnosis of hyperthyroidism is of paramount importance, including other causes of thyrotoxicosis such as autonomously functioning thyroid adenoma, toxic nodular goitre, various forms of inflammatory or destructive thyroiditis and factitious thyrotoxicosis. The cornerstone of initial therapy for Graves' disease is the administration of antithyroid drugs (ATDs), whereas radioiodine ablation and total thyroidectomy constitute important therapeutic options, primarily in cases of disease recurrence or when serious adverse events related to ATDs occur. During recent decades, prolonged low-dose ATD regimens have demonstrated comparable safety profiles whilst offering superior efficacy relative to the conventional 18-month treatment course. Emerging therapeutic approaches involve immunomodulatory strategies targeting B lymphocytes, IgG recycling pathways and TSHR itself. Furthermore, the induction of immune tolerance to TSHR represents a promising future direction. This review aims to provide a comprehensive overview of the differential diagnosis of thyrotoxicosis as well as current and evolving therapeutic strategies for the management of hyperthyroidism in Graves' disease.

Nonorganic vision loss (NOVL), also known as functional, psychogenic, or hysterical vision loss, is a unique subset of visual impairment characterized by a disparity between the patient's self-reported visual symptoms and clinical findings. NOVL represents a broad spectrum of conditions where an individual presents with visual dysfunction that any identifiable organic pathology cannot fully explain. The understanding of NOVL is intrinsically connected to the knowledge of the visual pathway, a complex network comprising the ocular structures (cornea, crystalline lens, and retina), the optic nerves, chiasm, and tracts, the lateral geniculate bodies of the thalamus, and the visual cortex of the occipital lobe. A detailed clinical assessment of this pathway is crucial to exclude organic causes of vision loss, such as ocular diseases, neurological conditions, or systemic diseases. NOVL is not always a case of malingering or conscious feigning of symptoms and usually occurs without the patient's awareness of the nonorganic nature of the disease. The natural history and pattern of the spread of NOVL vary among individuals. NOVL may affect visual acuity, visual fields, or color vision and may present in various patterns, from monocular to binocular involvement. Some individuals may experience sudden vision loss, while others report a progressive decline. NOVL can profoundly affect the quality of life and activities of daily living, highlighting the need for prompt recognition and appropriate management.  Understanding the etiology and pathophysiology of NOVL requires a biopsychosocial approach that acknowledges the interaction of physiological, psychological, and social contributing factors. The early identification of NOVL and appropriate intervention can significantly improve patient outcomes and mitigate the impact on healthcare resources. NOVL may be the only sign of psychological distress, and questions during the eye exam regarding suicidal ideation may save lives.  Healthcare providers should recognize that when an organic etiology for vision loss has been ruled out, malingering is usually correlated with avoidance of extensive investigation, while people unconsciously suffering from NOVL, as well as those with factitious disorder, will actively seek out additional investigations to determine the cause of the vision loss. NOVL remains an underrecognized and underresearched area in ophthalmology. This activity reviews the current understanding of NOVL, its various manifestations, and approaches to evaluation and management to equip healthcare professionals with the knowledge and tools necessary to address this complex condition.

BACKGROUND Dermatitis artefacta is a challenging and often under-recognized psychodermatosis characterized by self-induced skin injury. Its clinical presentation frequently mimics other chronic ulcers, leading to frequent misdiagnosis and diagnostic delays. This delay prolongs symptoms and perpetuates the detrimental itch-injury cycle, whereby chronic pruritus drives compulsive scratching, creating a barrier to effective healing. CASE REPORT We report the case of a 59-year-old man with a 3-year history of a refractory, intensely pruritic ulcer on the right temporal scalp, which subsequently extended to the auricle. Physical examination revealed a solitary, well-demarcated ulcer with an erythematous border. Histopathological analysis confirmed epidermal hyperkeratosis and mild lymphocytic infiltration, while a comprehensive immunohistochemical panel effectively excluded common infectious, vascular, and neoplastic mimics. A targeted, multidisciplinary management strategy was implemented to break the itch-injury cycle. This integrated approach included gabapentin for neuropathic itch modulation, topical tacrolimus for anti-inflammatory and barrier repair effects, simple protective dressings to prevent mechanical trauma, and behavioral counseling. This resulted in complete ulcer healing within 8 weeks, with no relapse during follow-up. CONCLUSIONS This case underscores the critical importance of early recognition and targeted interruption of the itch-injury cycle in dermatitis artefacta. It demonstrates that a structured, outpatient multidisciplinary approach integrating dermatology, psychiatry, and pain management can achieve rapid resolution even in long-standing, refractory cases, thereby promoting diagnostic stewardship and reducing unnecessary investigations.

Clenched fist syndrome is a rare psychosomatic condition that can cause great diagnostic and management challenges for hand surgeons. There is little published literature on the clinical characteristics and treatment of clenched fist syndrome. The limited evidence available discusses a wide range of clinical presentations and recommend inconsistent treatments. This causes confusion and uncertainty for surgeons managing a condition with a high level of complexity. This review aims to summarize existing literature that describes the diagnosis and management of clenched fist syndrome.

Münchhausen syndrome is a complex psychological disorder in which individuals feign or induce symptoms to attract attention and receive medical care. This phenomenon raises numerous challenges. For healthcare providers, understanding its main manifestations and therapeutic approaches is essential to providing appropriate care for the patient and their family and friends when they are involved.

This article examines the unique position school nurses are in to identify and address medical child abuse as clinical awareness continues to grow. The lack of education available on the topic of medical child abuse and why cases are inherently difficult to diagnose is discussed. Information for school nurses on how to identify and intervene as well as resources available are provided.

Munchausen syndrome is a psychiatric condition in which individuals feign or induce illness to gain attention, care, and sympathy. Despite being clinically recognized, its biological underpinnings remain largely unexplored, highlighting the need for suitable animal models. Male mice were subjected to social isolation and restraint stress (2 h daily for 7 days) to induce chronic stress. Behavioral changes were assessed using a social interaction test with freely moving or confined juvenile and adult male conspecifics. Anxiety-like behaviors were evaluated by the open field test and elevated plus maze. Concentration of the interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) in the brain was quantified by using enzyme-linked immunosorbent assay (ELISA). Stressed mice exhibited increased social interaction with freely moving unfamiliar conspecifics but reduced interaction with confined ones. These animals displayed heightened anxiety-like behaviors and elevated levels of IL-6 and TNF-α in the brain. Currently, no preclinical models exist for screening factitious disorder. This study represents the first attempt to develop an animal model to identify Munchausen syndrome-like behaviors. Stress and anxiety significantly modulate social behavior in mice. Notably, enhanced interaction with freely moving conspecifics may mimic attention-seeking behavior, providing a potential model for investigating Munchausen syndrome-like traits. This model may offer insights into the neurobiological basis and aid in the development of targeted therapeutic strategies.

Recurrent fever is a complex clinical presentation that poses significant diagnostic challenges, particularly when no clear etiology emerges despite extensive investigation. This integrative narrative review provides a comprehensive overview of recurrent fever and proposes a practical diagnostic flowchart focused on the most frequent etiologies, with particular emphasis on the Latin American and Brazilian contexts. Literature from MEDLINE/PubMed, LILACS, and SciELO was reviewed to summarize evidence on epidemiology, differential diagnosis, and diagnostic strategies.

Haematohidrosis is an exceptionally rare and poorly understood clinical phenomenon characterized by the spontaneous excretion of blood through intact skin or natural orifices, with episodes often reported in association with extreme emotional or psychological stress. Owing to its rarity, the condition often poses significant diagnostic challenges and may be misinterpreted as a bleeding disorder, self-inflicted injury, or factitious illness. We report the case of an 11-year-old boy who presented with a 1-month history of recurrent, painless, self-limiting episodes of bleeding from the eyes, nose, and ears. These episodes were temporally associated with periods of academic and parental stress. Comprehensive hematological, biochemical, and radiological investigations, including coagulation studies and von Willebrand factor assays, were within normal limits, effectively excluding systemic or inherited bleeding disorders. Cytological examination and a positive benzidine test confirmed the presence of blood in the secretions. A temporal association between psychosocial stressors and symptom onset was observed. The patient was managed with propranolol to attenuate sympathetic hyperactivity and cognitive behavioral therapy aimed at stress management and coping strategies. This case highlights the importance of recognizing haematohidrosis as a rare clinical condition in which psychosocial factors may play a contributory role, and emphasizes the role of multidisciplinary management to achieve favorable outcomes.