BACKGROUND: There is a high prevalence of somatoform disorders and medically unexplained symptoms. When it comes to deciding whether a patient is able to work, it is essential to differentiate a somatoform disorder from a factitious disorder. The case presented demonstrates the impact on disability benefits and the subsequent psychosocial repercussions of misdiagnosing between a factitious disorder and a somatoform disorder. CASE PRESENTATION: A 42-year-old Caucasian woman worked as a 100% fiduciary accountant until the age of 32 when she was placed on medical leave due to persistent trigeminal neuralgia. Afterward, she developed total blindness, not explained by a physiological process, accompanied by distress in a crucial emotional context. We evaluated the patient for a revision of a disability income after a diagnosis of factitious disorder with severe consequences such as disability income suspension and family conflict. Our psychiatric examination concluded the diagnoses of pain disorders related to psychological factors and a dissociative neurological symptom disorder with visual disturbance. CONCLUSIONS: Blindness not explained by a physiological process may accompany trauma and psychological distress. Differentiating this pathology from factitious disorder or simulation is essential from an insurance medicine point of view, but also for its treatment.
Factitious Disorders , Somatoform Disorders , Female , Humans , Adult , Somatoform Disorders/diagnosis , Somatoform Disorders/psychology , Somatoform Disorders/therapy , Factitious Disorders/diagnosis , Factitious Disorders/psychology , Dissociative Disorders/diagnosis , Dissociative Disorders/psychology , Dissociative Disorders/therapy , Diagnostic Errors
We present the case of a young woman with an extensive medical history that most notably includes over 60 emergency-room visits for unfounded respiratory distress that often prompted intubations. Each presentation displays elements of deceitfulness or inappropriate demands that align with factitious disorder imposed on self. Top experts in the Consultation-Liaison field provide guidance for this commonly encountered clinical case based on their experience and review of available literature. Key teaching topics include a review of risk factors for development of deceptive syndromes, distinguishing factitious disorder from malingering and conversion disorder, and the role of a consulting psychiatrist in such cases. Patients with factitious disorder often show signs of pathologic lying, obstinance, and erratic behavior. Such attributes frequently arouse negative countertransference in providers, causing frustration and dread with continuing care, rendering psychiatric involvement. We address the unique challenges in managing factitious disorder and how to effectively collaborate with an interdisciplinary inpatient team with these cases.
Conversion Disorder , Factitious Disorders , Female , Humans , Factitious Disorders/diagnosis , Factitious Disorders/therapy , Factitious Disorders/psychology , Malingering/diagnosis , Malingering/psychology , Conversion Disorder/diagnosis , Dissociative Disorders , Risk Factors
Factitious disorder is a condition in which patients deceitfully present themselves as injured or ill in the absence of obvious external reward. It is difficult to diagnose and treat, and little rigorous evidence exists in the literature. While larger studies have revealed some clinical and sociodemographic patterns, there is a lack of consensus on psychosocial factors and mechanisms contributing to factitious disorder. This in turn has led to conflicting recommendations on management. In this article, we review major psychopathological theories of factitious disorder, including the role of early trauma and subsequent development of interpersonal dysfunction, as well as maladaptive gratification obtained from assuming the sick role. Common themes of interpersonal disruptions in this patient population include a pathologic need for attention and care, as well as aggression and desire for dominance. In addition to psychodynamic and psychosocial etiologic models of factitious disorder, we also review associated treatment approaches. Finally, we offer clinical implications, including countertransference considerations, as well as directions for future research.
Countertransference , Factitious Disorders , Humans , Factitious Disorders/psychology
In palliative care, many end-of-life (EOL) patients are physically dependent on their caregivers. These patients may also have difficulty expressing their needs because of their underlying disease and are vulnerable to abuse. Factitious disorder imposed on another (FDIA) describes a condition in which an individual intentionally feigns physical or psychological signs or symptoms in another person with the intention of deceiving medical providers. Although FDIA is a form of abuse that palliative care workers must be aware of because of its multiple impacts on EOL care, it has never been reported in the palliative care literature. In this case discussion, we highlight a woman with advanced dementia who was subjected to FDIA. We discuss the impact of FDIA on EOL care and the management of FDIA in palliative care.
Factitious Disorders , Hospice Care , Munchausen Syndrome by Proxy , Terminal Care , Female , Humans , Palliative Care , Munchausen Syndrome by Proxy/diagnosis , Munchausen Syndrome by Proxy/psychology , Factitious Disorders/therapy , Factitious Disorders/diagnosis , Factitious Disorders/psychology
Dermatitis artefacta (factitious skin disorder) is a rare psychocutaneous disorder that poses a complex clinical challenge to clinicians. The hallmarks of diagnosis include self-inflicted lesions in accessible areas of the face and extremities that do not correlate with organic disease patterns. Importantly, patients are unable to take ownership of the cutaneous signs. It is essential to acknowledge and focus on the psychologic disorders and life stressors that have predisposed the condition rather than the mechanism of self-injury. The best outcomes are achieved via a holistic approach in the setting of a multidisciplinary psychocutaneous team addressing cutaneous, psychiatric, and psychologic aspects of the condition simultaneously. A nonconfrontational approach to patient care builds rapport and trust, facilitating sustained engagement with treatment. Emphasis on patient education, reassurance with ongoing support, and judgment-free consultations are key. Enhancing patient and clinician education is essential in raising awareness of this condition to promote appropriate and timely referral to the psychocutaneous multidisciplinary team.
Dermatitis , Factitious Disorders , Self-Injurious Behavior , Skin Diseases , Humans , Dermatitis/diagnosis , Dermatitis/therapy , Dermatitis/pathology , Factitious Disorders/diagnosis , Factitious Disorders/therapy , Factitious Disorders/psychology , Self-Injurious Behavior/diagnosis , Self-Injurious Behavior/therapy , Self-Injurious Behavior/psychology , Skin/pathology
Self-inflicted skin disorders are artefact diseases inflicted by the use of multiple different means, for various different purposes. They account for about 2% of dermatology patient visits, and include disorders with a denied or hidden pathological behavior (factitious disorders) and disorders with a non-denied and non-hidden pathological behavior (compulsive disorders). In turn, factitious skin disorders are subdivided into 2 groups: factitious disorders without an external incentive (considered in a preceding work) and factitious disorders with external incentives. In the second eventuality, the simulator is motivated by illicit intent, wishing to evade civil duties or a prison sentence, for instance, or to exploit situations of an occupational nature, and is fully aware of his action and his intention. Apart of the two groups of pathomimic artefacts and malingering, some self-inflicted dermatoses are due to behavioral disorders involving compulsive habits (tics, psychological excoriations). The great majority of subjects suffering from the latter disturbances are quick to confess their urge to self-inflict lesions. The management, including both psychiatric and dermatological assessment, concludes this second part of the work regarding the self-inflicted cutaneous diseases.
Factitious Disorders , Self-Injurious Behavior , Tics , Humans , Self-Injurious Behavior/etiology , Self-Injurious Behavior/psychology , Skin , Factitious Disorders/diagnosis , Factitious Disorders/pathology , Factitious Disorders/psychology , Malingering/psychology
BACKGROUND: Patients with factitious disorders artificially generate, aggravate or feign injuries or illnesses, which can result in severe physical impairment and misuse of the healthcare system. The symptomatology is characterized by a protracted course of disease with frequent changes of practitioners and multiple invasive procedures due to anomalous, mostly chronic findings. Elaborate clinical presentations, lack of knowledge of disease characteristics and the fast-paced everyday clinical practice can lead to maintaining the disease through non-recognition or mistreatment. METHODS: Based on selective literature research and clinical case reports from a university clinic for plastic surgery, this article provides a review about common features of factitious disorders as well as treatment strategies. RESULTS: If a factitious disorder is suspected, invasive treatments should be restricted and psychosomatic or psychiatric expertise obtained. Within an empathic physician-patient relation and with psychotherapeutic support, patients can be gradually introduced to the diagnosis and therapy options and treatment terminations could be avoided. CONCLUSION: Knowledge of indicators for factitious disorders, which may become evident in medical history, findings and illness-affirming behaviour, is key to identify affected patients and initiate appropriate treatment. For this purpose, factitious disorders should be included in differential diagnostic considerations even in primarily somatic medical specialties. Since the diagnosis is often based on evidence and complicated by withheld information or medical confidentiality, the establishment of a central reporting register could facilitate the diagnostic process and improve therapy in the future.
Factitious Disorders , Plastic Surgery Procedures , Surgery, Plastic , Diagnosis, Differential , Factitious Disorders/diagnosis , Factitious Disorders/psychology , Factitious Disorders/therapy , Humans , Physician-Patient Relations
BACKGROUND: In representative cases of Munchausen by internet (MBI), an individual (or "poser") goes online to falsely report or exaggerate illnesses or life crises. The principal goal, as in factitious disorder imposed on self or another, is to garner emotional satisfaction. We provide the first evidence that MBI can target a specific type of health care provider-in this case, birthing doulas. METHODS: We describe 5 cases in which individuals have utilized social media platforms to report factitious perinatal illnesses and crises, including neonatal death, in real time. Current health headlines, such as those involving the COVID-19 pandemic, can be relevant to the ruses. Posers can engage in deceptions with several health care professionals concurrently or serially, and may portray multiple people ("sock puppets") at the same time. RESULTS: MBI has consequences that can be highly disruptive. In the cases highlighted in this report, many hours of support were given to individuals who had fabricated their pregnancies, infants, and perinatal complications. The doulas experienced feelings ranging from resignation to anger and betrayal. CONCLUSIONS: Health care professionals of all types who offer services online should be vigilant to the risks of potential MBI.
COVID-19 , Deception , Doulas , Factitious Disorders , Internet Use , Malingering , Munchausen Syndrome , Telemedicine , Adult , COVID-19/psychology , Communication , Doulas/ethics , Doulas/psychology , Emotional Abuse , Factitious Disorders/diagnosis , Factitious Disorders/psychology , Female , Help-Seeking Behavior , Humans , Munchausen Syndrome/diagnosis , Munchausen Syndrome/epidemiology , Munchausen Syndrome/psychology , Perinatal Care , Telemedicine/ethics , Telemedicine/methods
INTRODUCCIÓN: En 1977, Roy Medow acuña y describe el síndrome de Münchhausen por poderes como una enfermedad mental en la que una cuidadora miente al doctor sobre la salud de su hijo mediante la fabricación de signos físicos, la alteración del historial médico o la inducción de síntomas. En la actualidad, es recogido en el DSM-5 bajo el nombre de trastorno facticio impuesto a otro. Se estima que afecta a 0.2 - 2 cada 100.000 niños menores de 16 años. OBJETIVO: Aportar información sobre la psicobiografía de la perpetradora diagnosticada de trastorno facticio impuesto a otro, con el objetivo de establecer un perfil de sospecha en aquellas presentaciones médicas inusuales en la práctica clínica. MÉTODOS: Revisión sistemática de los artículos publicados desde el año 2000 en la base de datos PubMed, que incorporen los términos "Münchhausen syndrome by proxy" y "factitious disorder". Se incluyeron libros y documentos, artículos de revistas científicas y revisiones en inglés y castellano. Se excluyeron aquellos artículos con una muestra menor a 20 casos analizados. RESULTADOS: La perpetradora se dibuja generalmente como la madre de la víctima en la mayoría de los casos, con unos antecedentes vividos de maltrato infantil y de abusos de distinta índole. Gran parte de estas, recibieron atención psiquiátrica en la infancia, y también en la vida adulta. Suelen presentar comorbilidades psicopatológicas, en especial el trastorno facticio impuesto a uno mismo y los trastornos de personalidad, sobresaliendo el límite. Por otro lado, la víctima es habitualmente un menor de 5 años, con una morbimortalidad importante. La peregrinación hospitalaria, la necesidad de ingresos hospitalarios prolongados, así como la realización de intervenciones invasivas, son consecuencias evidentes en estos menores. CONCLUSIONES: Si bien es cierto que en esta revisión se han arrojado cifras al respecto, no sería correcto utilizar estos resultados categóricamente, ya que se han dado casos en la literatura médica de perpetradoras que no eran figuras femeninas, y de víctimas que no eran menores. Para futuros estudios, sería interesante observar a nivel retrospectivo la aparición de patología psiquiátrica en las víctimas y valorar la posibilidad de la repetición de determinados roles de maltrato
BACKGROUND: In 1977, Roy Medow named and described Münchhausen's syndrome by proxy as a mental illness in which a caregiver lies to the doctor about his child's health situation by making physical signs, altering the medical history or inducing symptoms. Currently, it is collected in DSM-5 under the name of factitious disorder imposed on another. It is estimated to affect 0.2 - 2 per 100,000 children under the age of 16. OBJECTIVE: Provide information about the psychobiography of the perpetrator diagnosed with factitious disorder imposed on another, with the aim of establishing a suspicious profile in those unusual medical presentations in clinical practice. METHODS: Systematic review of articles published since 2000 in the PubMed database, incorporating the terms "Münchhausen syndrome by proxy" and "factitious disorder". Books and documents, articles from scientific journals and reviews were included, in both English and Spanish. Those articles whose sample was less than 20 analyzed cases were excluded. RESULTS: The perpetrator is generally portrayed as the victim's mother in most cases, with a vivid history of child abuse and abuse of various kinds. Most of them received psychiatric care in childhood, and also during adult life. They usually present psychopathological comorbidities, especially factitious disorder imposed on self and personality disorders, especially the Borderline personality disorder. On the other hand, the victim is usually a child under the age of 5, with significant morbimortality. Hospital pilgrimage, the need for prolonged hospital admissions, as well as invasive procedures, are obvious consequences in these minors. CONCLUSIONS: Although it is true that figures have been produced in this review, it would not be correct to use these results categorically, since there have been cases in the medical literature of perpetrators who were not female figures, and of victims who were not minors. For future studies, it would be interesting to retrospectively observe the appearance of psychiatric pathology in victims and assess the possibility of the repetition of certain roles of abuse
Humans , Male , Female , Child , Adult , Munchausen Syndrome by Proxy/diagnosis , Munchausen Syndrome by Proxy/psychology , Factitious Disorders/diagnosis , Mother-Child Relations/psychology , Factitious Disorders/psychology , Professional-Family Relations , Retrospective Studies
Factitious disorder imposed on another (FDIA-DSM-5), formerly known as Munchausen Syndrome by Proxy (MSP) is a form of child abuse. A case can be recognised by only keeping the relevant diagnoses in mind. There are many cases of FDIA diversified by the contributions of both the caregiver and the child. Most of these cases are complicated by the difficulty of accurately determining the relative roles of the parent and the child and their levels of awareness and motivation. Here, we present the case of an 11-year old girl admitted to our hospital with the complaint of haematemesis 6-8 times a day. A case of factitious disorder was considered following the physical and psychological examinations on the patient. Evaluating the case within this context suggested a case of FDIA by drawing attention to the continuity of the symptoms described in the patient with the those of the caregiver. In approaching cases of FDIA, unravelling the interdependence of the dynamics of different awareness levels of feigning and motivation by the caregiver and the child is very crucial. Considering the variations in the process of FDIA development through interweaving of the motivations of the mother and child, the case presented here is believed to bring a different point of view that will contribute to the understanding of the nature of this disorder.
Factitious Disorders/diagnosis , Hematemesis/diagnosis , Parent-Child Relations , Adult , Child , Factitious Disorders/psychology , Female , Humans
A 32-year-old woman with maple syrup urine disease presented with recurring episodes with hypoglycaemia and cerebral seizures. In most cases a connection to the inborn metabolic disorder is assumed, resulting in symptomatic treatment. Due to these treatments invasive procedures are required. This leads to prescriptions of multiple medications and medical aids. After 2 years of unexplained symptoms a routine examination led to the diagnosis of factitious disorder. The patient received the offer for psychiatric/psychotherapeutic treatment. Further prognosis remains uncertain.
Factitious Disorders/diagnosis , Hypoglycemia/etiology , Maple Syrup Urine Disease/complications , Seizures/etiology , Adult , Factitious Disorders/psychology , Female , Humans , Maple Syrup Urine Disease/psychology , Prognosis
BACKGROUND: Consultation psychiatrists are often asked to assess factitious disorder (FD), yet this is challenging as confirmation depends on rarely achieved direct evidence of illness-inducing behaviors. Diagnosis is thus based on other variables, such as atypical features of the medical presentation and certain patient behaviors. This study sought to assess a cohort of patients with FD for demographic and clinical variables, but also psychological and behavioral ones unexamined in previous studies. METHODS: 49 previously-identified FD patients at a single site were reviewed retrospectively and variables collected included demographic, medical, psychiatric, social, behavioral, and treatment-related. Descriptive statistical analysis was used. RESULTS: Patients were mostly: 1) under age 40 (82%), 2) female (90%), 3) with past psychiatric (92%), family psychiatric (78%), and traumatic (69%) histories; 4) direct intravenous access (67%); and 7) some exposure to healthcare training (67%). All (100%) subjects had an identifiable family dynamic issue, including household abuse, parental divorce, parental influence/enmeshment, grief, and/or significant other conflict. Financial, emotional, or social incentives were common, and most patients (88%) exhibited at least 4 FD-related behaviors. CONCLUSION: FD represents a complex disorder of abnormal illness behaviors with predisposing developmental and perpetuating sociobehavioral variables previously unexplored. Future investigational, educational, and quality improvement directions are considered.
Factitious Disorders/epidemiology , Factitious Disorders/physiopathology , Factitious Disorders/psychology , Adult , Female , Humans , Male , Middle Aged , Retrospective Studies , Young Adult
Factitious Disorders/diagnosis , General Practice , Self-Injurious Behavior/diagnosis , Skin Diseases/diagnosis , Skin/injuries , Diagnosis, Differential , Disease Management , Factitious Disorders/psychology , Factitious Disorders/therapy , Humans , Self-Injurious Behavior/psychology , Skin Diseases/psychology , Skin Diseases/therapy
Gardner-Diamond syndrome (GDS) is a rare disease often seen in young women involving painful localized inflammation and ecchymosis. Ecchymosis usually develops spontaneously after emotional stress. The pathophysiology of the disease is not fully understood, and little is known about management modalities for this syndrome. The primary approach of health professionals in the evaluation of this rare condition should involve identification of cases and investigation of potential accompanying psychiatric pathologies. The case presented here highlights the importance of assessing for GDS and reviews descriptions of GDS in the context of the existing literature.
Autoimmune Diseases/diagnosis , Autoimmune Diseases/psychology , Factitious Disorders/diagnosis , Factitious Disorders/psychology , Psychotic Disorders/diagnosis , Psychotic Disorders/psychology , Skin Diseases, Vascular/diagnosis , Skin Diseases, Vascular/psychology , Suicidal Ideation , Adolescent , Autoimmune Diseases/pathology , Factitious Disorders/pathology , Female , Humans , Psychotic Disorders/pathology , Skin Diseases, Vascular/pathology
BACKGROUND: The terms exfoliative cheilitis, factitial cheilitis, and morsicatio labiorum are used to describe self-inflicted lesions of the lip. OBJECTIVE: Here we report and analyze clinical, pathological, and therapeutic data on 13 patients with a form of factitial cheilitis that we believe should be considered a separate entity. RESULTS: Eight patients were male and 5 patients were female. All patients reported pain and presented with crusts consisting of dried saliva and topical medications adherent to the surface of the lips. These patients expressed great concern with their condition, and reported several previous, ineffective treatments. Simple reassurance only was not effective; saline compresses alleviated symptoms for a few patients. Most patients were lost to follow-up. Biopsies were not performed on all patients. CONCLUSION: This particular type of cheilitis artefacta has been previously described, but some features described herein are new and allow a specific approach: patient's behavior, the "protrusion sign," and possible improvement with antidepressants. For these cases, we propose the term ointment pseudo-cheilitis because it comprises the nature of the attached material and the lack of true inflammation. Further psychiatric characterization is a logical next step in further characterizing this difficult-to-treat condition.
Cheilitis/classification , Factitious Disorders/classification , Self-Injurious Behavior , Adolescent , Adult , Brazil , Cheilitis/psychology , Cheilitis/therapy , Factitious Disorders/psychology , Factitious Disorders/therapy , Female , Humans , Male
Practitioners and researchers have long been challenged with identifying deceptive response styles in forensic contexts, particularly when differentiating malingering from factitious presentations. The origins and the development of factitious disorders as a diagnostic classification are discussed, as well as the many challenges and limitations present with the current diagnostic conceptualization. As an alternative to a formal diagnosis, forensic practitioners may choose to consider most factitious psychological presentations (FPPs) as a dimensional construct that are classified like malingering as a V code. Building on Rogers' central motivations for malingering, the current article provides four explanatory models for FPPs; three of these parallel malingering (pathogenic, criminological, and adaptational) but differ in their central features. In addition, the nurturance model stresses how patients with FPPs attempt to use their relationship with treating professionals to fulfill their unmet psychological needs. Relying on these models, practical guidelines are recommended for evaluating FPPs in a forensic context.
Diagnosis, Differential , Factitious Disorders/psychology , Forensic Psychiatry , Malingering/diagnosis , Criminology , Deception , Humans
BACKGROUND: Factitious disorders constitute a complex pathology for the dermatologist. Although a diagnosis is often indicated, it is difficult to confirm and treatment is complicated. Dermatitis artefacta is the somatic expression of an often serious psychiatric disorder consciously created by patients on their own cutaneous-mucosal surfaces but the motivation is unconscious and no secondary benefits are sought (in contrast to simulation). Pathomimicry represent a specific entity: the provocation of outbreaks of a known disease, triggered by voluntary exposure to a causative agent. Herein we report on a case of pathomimicry in a context of hidradenitis suppurativa. PATIENTS AND METHODS: A teenage girl whose main previous medical history consisted of grade-2 obesity and an episode of pubic abscess was seen at our clinic for axillary lesions. She presented in a state of negligence, was suspicious and aggressive, and refused to undress. After gaining her trust, clinical examination revealed prominent ulcerations (each with a granulated base) at a distance from the folds in the axillary areas, as well as typical hidradenitis lesions of Hurley Grade 2 with purulent openings and rope-like scars from the inguinal folds. Hospitalization was recommended and a positive outcome was achieved under antibiotic therapy with doxycycline, topical alginate and hydrocellular dressings. A psychiatric evaluation concluded that the patient was presenting dysmorphophobic narcissistic weakness, probably in reaction to recurrent harassment at school since childhood. Once she developed trust with us, which was difficult to establish, the patient admitted to having caused the lesions herself. Given the history and clinical data, as well as the negative laboratory tests, a diagnosis of pathomimicry was made. DISCUSSION: Several cases of dermatological pathomimicry (sustainment by the patient of an ulcer with a known cause, contact with an allergen found in eczema, or renewed use of a medication implicated in toxiderma) or systemic disease (insulin injection in a diabetic patient) have been reported. To the best of our knowledge, this is the first description of pathomimicry associated with hidradenitis suppurativa. Regarding therapy, aftercare should be multidisciplinary. Confessions should not be forced and confrontations, which risk serious psychiatric collapse, should be avoided. A reassuring attitude enables psychiatry to be applied once trust has been sustainably established, hence the crucial role of the dermatologist.
Factitious Disorders/psychology , Hidradenitis Suppurativa/psychology , Self-Injurious Behavior/psychology , Adolescent , Anti-Bacterial Agents/therapeutic use , Axilla , Bullying/psychology , Factitious Disorders/pathology , Female , Hidradenitis Suppurativa/drug therapy , Hidradenitis Suppurativa/pathology , Humans , Obesity/psychology , Skin Ulcer/pathology
Although exaggeration or amplification of symptoms is common in all illness, deliberate deception is rare. In settings associated with litigation/disability evaluation, the rate of malingering may be as high as 30%, but its frequency in clinical practice is not known. We describe the main characteristics of deliberate deception (factitious disorders and malingering) and ways that neurologists might detect symptom exaggeration. The key to establishing that the extent or severity of reported symptoms does not truly represent their severity is to elicit inconsistencies in different domains, but it is not possible to determine whether the reports are intentionally inaccurate. Neurological disorders where difficulty in determining the degree of willed exaggeration is most likely include functional weakness and movement disorders, post-concussional syndrome (or mild traumatic brain injury), psychogenic non-epileptic attacks and complex regional pain syndrome type 1 (especially when there is an associated functional movement disorder). Symptom amplification or even fabrication are more likely if the patient might gain benefit of some sort, not necessarily financial. Techniques to detect deception in medicolegal settings include covert surveillance and review of social media accounts. We also briefly describe specialised psychological tests designed to elicit effort from the patient.
Behavior/physiology , Factitious Disorders/psychology , Malingering/epidemiology , Malingering/psychology , Nervous System Diseases/psychology , Animals , Cognition/physiology , Factitious Disorders/diagnosis , Factitious Disorders/therapy , Female , Humans , Malingering/diagnosis , Middle Aged , Movement Disorders/diagnosis , Movement Disorders/psychology , Nervous System Diseases/diagnosis , Young Adult
