May 13, 2024 • 21 mins
In this third instalment of our series on mental health and the skin, we, Dr George Moncrieff and Dr Roger Henderson, are joined once again by special guest Professor Anthony Bewley, a distinguished authority in the field of psychodermatology.
In this episode, we delve into the fascinating world of mental health conditions that manifest through the skin. Drawing from Professor Bewley's wealth of experience, we’ll explore conditions such as the obsessive compulsive disorder, trichotillosis and body dysmorphic disorder, shedding light on the complex psychological factors underlying these dermatological manifestations, that are expressed through the skin.
As the episode progresses, we’ll reflect on the key takeaways from this series on mental health and the skin and how treating both the psychological and the dermatological aspects leads to a more comprehensive and rapid resolution. Tune in and join us for an insightful summary on managing mental health implications linked to skin disease, in primary care.
Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence.
Find out more: https://aproderm.com/aproderm-emollient-starter-pack/
LI: https://www.linkedin.com/company/fontus-health-ltd/
Got some feedback for us? Please rate and review Rash Decisions to help us keep creating educational podcasts for you.
Is there a dermatology topic you’d like us to explore? Email us at info@aproderm.com, and we’ll do our best to cover it.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:08):
Hello and welcome to this Rash Decisionspodcast, where we look at skin-related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I'm a former Chair
of the Dermatology Council for England.
(00:38):
Now, if you've been listening to ourpodcast on mental health and the skin,
we do hope you've been enjoying them.
But if not, do have a listen to usdiscussing how common these are for people
living with a skin disorder, especiallyones affecting the visible sites of the
body, such as the face or the hands,or indeed the genital area, and about
(00:59):
the mental health issues, that we'vediscussed, linked to those skin problems.
Professor Tony Bewley, one of the world'sleading specialists in this area, was
with us for those, and I'm delighted tosay he's agreed to come back and help us
with this one too, which is fantastic.
We are indeed very luckyto have Tony back again.
Thank you for coming back to join us.
(01:19):
So, occasionally a significantmental disorder can present
with skin manifestations.
I'm thinking here, perhaps skinpickers or hair pulling disorders,
as well as of course, other sortof obsessive compulsive disorders.
Tony, can you tell us a littlebit about some of these, please?
Yeah, absolutely.
(01:39):
So, primary psychiatric disease orpsychological disease, presenting
to us as dermatology healthcareprofessionals, is really quite common.
And, that's what psychodermatologyis, at least partly, about.
It's about managing primarypsychological or psychiatric disease
(02:00):
which presents to dermatologists.
What do I mean by that?
Things like patients who pull theirhair out, w e call it trichotillosis.
Used to be called trichotillomania,but people quite rightly thought the
whole "mania" word wasn't very helpful.
So we call it trichotillosis now.
Tricho means hair and tillmeans pull, I presume.
(02:21):
Yeah.
And they're just really twiddlingtheir hair or twiddling around
at it, and it results in littlebald patches, rather tatty.
That's right.
And it can involve theeyebrows or the eyelashes.
And, you know, if we talk about obsessivecompulsive disease, we're talking about
the compulsion, the drive to, almostlike an addiction, to pull at the hair.
(02:43):
And the obsessive component is wherewe're keeping on thinking about, okay,
I've got this hair, and it's a way ofdealing with whatever is going on in life.
So with a lot of the primarypsychological diseases or psychiatric
disease which present to us asdermatologists, it's about recognising,
(03:03):
not kind of how patients aredoing it, how are you doing this?
You know?
It's about why patients are doing this,so it's the why that really matters.
And we, as dermatology healthcareprofessionals, are in a brilliant
place to try and explorewhy this might be the case.
And in my experience, the why, once youopen up the opportunity to talk about why,
(03:29):
comes tumbling out very, very swiftly.
So sooner or later, the narrative aboutwhy this is happening comes tumbling out.
Now, it might be something that isrelatively straightforward to resolve.
For example, it might be undue pressureon a child to achieve at exams.
It might be you know, somethingwhere somebody has been unpleasant
(03:52):
to somebody or bullying.
I'm saying easy to resolve, and of course,none of these things are particularly easy
to resolve, but it can be something thatcan be addressed, or it can be something
which is really quite destabilising.
For example, some kind of abuse whichhas happened over a long period of time.
(04:12):
But, the why is where we want to focusreally, in a lot of these conditions.
And would you say it's the samefor somebody, for example, who's
constantly washing their hands,to the point at which they're raw
and bleeding and they can't stop?
Right.
Is it again, the why there thatis, that we need to focus on?
Okay.
It's, in those circumstances, it'susually rip-roaring anxiety, and you
(04:36):
know, why, why is this happening?
And we know that managing the skin,so using great emollients, we have
got great emollients, in thosecircumstances is quite important.
But then again, it's also about managingthe psychological, psychiatric disease
and we know that managing those withtwo things, it can be tablets or talk
(04:59):
treatment, or both together, and we knowthat if we manage patients with both
the talk treatment and the medicationtreatment, if a patient chooses to have
the medication treatment or the talktreatment, we know the combination of both
of those leads to more rapid resolution,more comprehensive resolution, and with a
(05:19):
less chance of recurrence of the problem.
So, talk treatment together withmedication, usually a greater
benefit than oral treatment byitself or talk treatment by itself.
But the patient chooses, the patientcan choose, you know, what they
want to do in terms of treatment.
The first step, and by anybody'sstandard, the most important step and
(05:44):
the biggest step is recognising the why.
Why is this happening?
What is the drive behind this?
And for healthcare professionals, tomake sure that you give the patient
the opportunity to talk about whythis is happening, is crucial.
Thank you so much for that, Tony.
That's really helpful and a difficultarea for us to manage sometimes,
(06:05):
but that's given me some thoughtthere, which is really useful.
Another condition you were talkingabout earlier, in the previous
podcast, was body dysmorphic syndrome.
Could you just say just a fewmore words about that here?
Yeah, so body dysmorphic disorder,we know is a massive problem,
particularly in the younger age group.
(06:26):
So we know that, about somewherebetween two and five percent of younger
people, have a degree of body dysmorphicdisorder, but it's any age group,
it can be younger, it can be older.
What do I mean by bodydysmorphic disorder?
There are four criteria that the AmericanPsychiatric Association place on us
to be able to make that diagnosis.
(06:48):
First one is that the patient has avisible difference, which is really
a massive focus for the patient.
It can be acne scarring, it can beears that are too big, or a nose
that's too big, or some visible,it can be hair that's in the wrong
place, or too much hair in the wrongplace, or not enough hair in in places
where you would want to have hair.
(07:09):
So it's a visible difference, which canseem to healthcare professionals to be a
bit trivial, a bit not very important, butfor the patient is of massive importance.
And then the patient often has tohave recurrent thoughts, so it has
to be something that is the focusof their attention, day in day out.
Thirdly, there is usuallysome kind of social avoidance.
(07:30):
So patients are avoiding goingout, avoiding socialising, avoiding
going into school or avoiding goinginto work, whatever it might be.
And the fourth criterion is that it's notbetter explained by an eating disorder.
So it's not better explainedby anorexia or bulimia.
So those four criteria are met, thenyou have body dysmorphic disorder.
(07:52):
So just in summary, body dysmorphicdisorder, a visible difference,
usually, that seems to us to be fairlyinnocuous but for the patient is
massively important, and they havea real strong drive to repeatedly
think about this , and they may havesome degree of social avoidance.
How is it treated?
First thing is to recognise itand not dismiss it, "Oh, it's
(08:15):
just a bit of acne scarring.
Well, you haven't got cancer.
You haven't got epilepsy."
Any of those dismissing things don't help.
So first thing is to recognise it.
Second thing is to say, "Okaywell, you know, I'm aware that
this is of importance to you."
What I often say to patientswith BDD, "On a scale of 1 to 10,
how bad is your acne scarring?
(08:37):
How bad is your hair problem?"
And they'll say, "It's 10 on 10 doctor".
And you might say to them, "Okay,for me, it's about a 2 on 10."
Crucially, it's not zero.
So crucially it is there.
And then I'll talk to them.
Okay.
You know, And they'll kind of,say, "That's what everybody says.
Everybody says it's, it's minor.
It's less extensive than I think it is."
(09:00):
And then I'll enter into adiscussion about that gap between
how the patient sees it 10 on 10and how I, and or their relatives
or other people, see it two on 10.
So that eight point gap, I'll say, thereis a word for this, for what it's worth.
It's called 'body dysmorphic disorder',and I want to treat your skin, so I
(09:21):
want to treat your acne scarring, oryour hair, or whatever it is, I want
to treat that, but also I want to treathow that is impacting you, that body
dysmorphic disorder, at the same time.
And that might be medication,it can be talk treatment,
or it can be both together.
Goodness.
That's really interesting.
Such honest negotiation there.
(09:42):
I like it.
I like the approach.
Yeah.
There are other mental healthconditions that can present to
dermatologists, but I'm not reallysure this is the right medium for
us to explore those in great detail.
I'm thinking, for example, theperson who comes to see us convinced
that they've got bugs living ontheir skin, and the evidence for
(10:03):
that is challenging to, to confirm.
Um, or the patient who picks attheir skin, to the point at which it
is seriously damaged, and they areconvinced that there's an underlying
skin condition, but the pattern doesn'tfit in with anything that the books
would suggest is due to a skin disease.
It's because they are picking it, burningit, cutting it, doing it because they
(10:28):
have such underlying severe anxietyand stress and trauma, mentally, that
this is their way of seeking help.
Do you want to say any particular words onthose sorts of conditions in this forum?
Yeah, so we're alludingto two things here.
We're alluding to a series ofconditions, which are called
persistent delusional disorders.
(10:49):
So patients who have some kind ofbelief system about their skin.
It might be, I've got a patient,or have had a patient, who believes
that various aspects of the face aremoving around of their own accord,
and there is no evidence for that.
So these persistent delusionaldisorder changes, or it can be a
patient who experiences materialgrowing within their skin.
(11:14):
We definitely always take thepatient seriously and we look...
So important.
...to see if there is, if thereis any reason, any organic reason,
any foundation for that experience.
And sometimes there is, andwe must always put the patient
at the centre of any choices.
If there isn't a foundation for that,then we have to negotiate with the
(11:36):
patient, about how we can get rid of thesensations of the skin and try and get
them better, because the whole experienceof living with these problems can be so
debilitating and, repeatedly, patientsgo and see healthcare professionals
and they're dismissed as being, "thisdoesn't seem to be anything that I
recognise", and they're dismissed.
(11:56):
So it's really important that we doembrace the patients as best as we
can, and say, "Okay, I fully understandthat this is a real problem for
you, and I'm going to manage thisas best as I can, and let's see if
we can work together about that."
Fantastic.
Thank you.
So, we know that mental healthcomplications are very common
amongst our patients with skindiseases, and the figures,
(12:17):
unfortunately, are truly shocking.
But in recent years, we have begun tosee a long overdue, increased interest
in mental health issues by politicians,by society at large, and obviously,
for those responsible for deliveringhealthcare, but, that hasn't really
greatly changed the approach of thecaring professions, enough, as I see it.
(12:41):
Skin diseases, as we know, are incrediblycommon, but unfortunately, are often
generally not managed as well asthey should be, and because of that,
they can bring an enormous burden ofmental health and social morbidity.
If we're genuinely interested inimproving the mental health of our
society, then managing skin diseasesbetter is a hugely important area
(13:06):
to focus resources on, and I thinkthat's a real take home message here.
I often say, actually, that uh, societyis getting interested in mental health,
and so it should, but addressing skindisease would make such inroads into the
mental health of our society, wouldn't it?
(13:28):
It really would.
And yet skin disease remains,so often, an under-resourced and
underthought about area of healthcare.
And these podcasts, I do feel, havehighlighted just how important this is.
I couldn't agree more, George.
And I was thinking about this earlier,and between us, we've almost put our
(13:49):
own personal charter together here.
And I don't know what you think aboutthis, but I just want to knock a few
of these around, almost some take homepoints I think that we've drilled into.
So for me, let's start with the obviousone, the best treatment for someone
who's got mental health consequences,from a skin condition that they
(14:09):
have, is good control of their skindisease, above everything else.
Absolutely.
Yeah, that should really gowithout saying, shouldn't it?
But it is so important to say it.
No skin disease, no problem.
It is as straightforward as that.
So yeah, really, and we have got formany skin conditions that we have got
(14:30):
now, fantastic therapeutic answers,which can really transform that disease.
And that's what we're hoping todemonstrate with this series of podcasts.
But at the same time, I do think we mustcontinue to enhance our profession's
recognition, that patients coming to uswith a skin condition are very likely
(14:51):
to have a mental health complication,and the figures we've been sharing
with you, of the rates of mental healthdisease in our patients are not just
high, they are staggeringly high.
And it is more than likely yourpatient's going to be having a burden
there, that they would like helpwith, even if that isn't something
(15:11):
that they bring to our attention.
We need to be sensitive to it, and Ithink ideally, look into that area.
Even if you can't manage itin that consultation, say,
"Goodness, okay, this is important.
Can you come back next week, orwhenever you can manage it, for us
to explore that in a bit more detail.
I need to know more about this.
This is clearly very important."
(15:33):
I think that's absolutely spot on.
And as part of that, and wetouched on this, and Prof.
Bewley touched on this aswell, signposting our patients.
We must never forget to signpost ourpatients to the appropriate patient
support group, and most conditions noware covered by this, but we've got to
ensure we've got adequate resourcesto help those who are affected, and
(15:58):
when appropriate, obviously take theseconcerns seriously, including referral for
additional psychiatric help if need be,but signposting must now be part of our
routine consultation practice, I think.
It really is.
We're not on our own.
There are these expert resources anduh, when I was Chair of the Dermatology
(16:18):
Council, I got to know most, or manyof these, incredibly well because they
were a regular and significant part ofthe Dermatology Council for England.
So I'm thinking of people likeChanging Faces, The Psoriasis
Association, the National EczemaSociety, The Vitiligo Society.
These organisations are absolutelywonderful and enthusiastic and
(16:40):
obviously incredible experts inthe condition that they support.
And the support that theyoffer is quite remarkable.
So we should be signpostingour patients in that direction.
But another thing that we talked about,was that in my ideal world, I think all
patients with a chronic skin conditionshould have an annual medicines review by
(17:02):
their GP or by a nurse in that practice.
And this should automatically includean assessment of the psychological
impact of their condition.
And as we go through these podcasts,we are drawing attention to the various
questionnaires that our patients canbe asked to complete to, to help reveal
the severity of their social impairment,their mental health disturbance,
(17:26):
or even lifestyle disturbances.
And so things like the DermatologyLife Quality Index, the DLQI.
Originally designed forpsoriasis, but incredibly
useful for most skin conditions.
The POEM, the Patient-OrientedEczema Measure, which you will
recall, is on the app, mySkinHealth,which AproDerm® have created.
(17:49):
And it reminds patients, every week, tocomplete a POEM, which asks about how
bad their eczema has been in the previousweek, how bad has the itch been, how much
has it affected their sleep, and so on.
And then there are questionnaires thatGPs can use for looking at the mental
health of our patients specifically.
So things like how depressed they mightbe or whether they got suicidal ideation.
(18:09):
I'm thinking here what's called aPHQ-9, or when thinking about anxiety,
you might be using what's calledthe GAD, the Global [Generalised]
Anxiety Disorder Questionnaire 7.
And if you've got someone with achronic skin condition, for example,
dry skin , we've talked about focusingon educating about that skin condition.
(18:33):
So educate about the lifestyle changes youcan make, regularly and liberally applying
your emollients, avoiding soaps, diarisingyour flares, that's really helpful, and
potential triggers you may come across soyou know what to avoid in the future...
because if you could work on the maximaltreatment for your lifestyle with your
(18:53):
dry skin condition, then any relatedmental health issues will improve as well.
So we almost come back full circle.
If appropriate, discusslocal psychotherapy services
that may be available.
Unfortunately, as we both know,those can be very patchy, but
referral to specialist departmentsis right up there, isn't it, George?
(19:16):
Yeah, I think referral to specialistpsychodermatology departments should, in
my world, ideally always be accessible toour patients when appropriate, but that's,
as you say, sadly, not always the case.
But as GPs, we do have a voice oncommissioning boards and I would
like to see us being a bit morevocal here and demanding that those
(19:38):
sorts of services are availableto help us, to help our patients.
But at the end of the day, to help ourpatients, that's the important thing.
Yeah.
I think speaking for both of us, Iknow that these podcasts on mental
health and the skin have been some ofthe most enjoyable we've done so far.
Thanks, in no small part, to the wonderfulspecial guest Professor Anthony Bewley,
(20:00):
and George and I do hope you've found themas interesting and beneficial as we have,
and they've allowed you to understand thebenefit of treating both the skin and the
huge psychological effects of living withskin problems, that we know are out there.
The size of the problem is huge, isn't it?
But Roger and I really hope you'lljoin us for our next podcast,
(20:21):
when we'll be discussing anotherimportant area of skin health.
And let me take this opportunity onceagain, to thank our sponsor, AproDerm®,
for all their help in putting theseRash Decisions podcasts together.
We couldn't have done it without them.
So if you are enjoying these podcasts,and George and I really do hope you are,
then do rate and review us, on whicheverplatform you use to receive them.
(20:44):
It really does help.
We'd also love to hear your feedback,so do get in touch, as it really
is good to hear what you think,and to let us know if there are any
topics you'd like us to discuss.
But until the next time, asalways, it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
Hello and welcome to this Rash Decisionspodcast, where we look at skin-related
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I'm a former Chair
of the Dermatology Council for England.
(00:38):
Now, if you've been listening to ourpodcast on mental health and the skin,
we do hope you've been enjoying them.
But if not, do have a listen to usdiscussing how common these are for people
living with a skin disorder, especiallyones affecting the visible sites of the
body, such as the face or the hands,or indeed the genital area, and about
(00:59):
the mental health issues, that we'vediscussed, linked to those skin problems.
Professor Tony Bewley, one of the world'sleading specialists in this area, was
with us for those, and I'm delighted tosay he's agreed to come back and help us
with this one too, which is fantastic.
We are indeed very luckyto have Tony back again.
Thank you for coming back to join us.
(01:19):
So, occasionally a significantmental disorder can present
with skin manifestations.
I'm thinking here, perhaps skinpickers or hair pulling disorders,
as well as of course, other sortof obsessive compulsive disorders.
Tony, can you tell us a littlebit about some of these, please?
Yeah, absolutely.
(01:39):
So, primary psychiatric disease orpsychological disease, presenting
to us as dermatology healthcareprofessionals, is really quite common.
And, that's what psychodermatologyis, at least partly, about.
It's about managing primarypsychological or psychiatric disease
(02:00):
which presents to dermatologists.
What do I mean by that?
Things like patients who pull theirhair out, w e call it trichotillosis.
Used to be called trichotillomania,but people quite rightly thought the
whole "mania" word wasn't very helpful.
So we call it trichotillosis now.
Tricho means hair and tillmeans pull, I presume.
(02:21):
Yeah.
And they're just really twiddlingtheir hair or twiddling around
at it, and it results in littlebald patches, rather tatty.
That's right.
And it can involve theeyebrows or the eyelashes.
And, you know, if we talk about obsessivecompulsive disease, we're talking about
the compulsion, the drive to, almostlike an addiction, to pull at the hair.
(02:43):
And the obsessive component is wherewe're keeping on thinking about, okay,
I've got this hair, and it's a way ofdealing with whatever is going on in life.
So with a lot of the primarypsychological diseases or psychiatric
disease which present to us asdermatologists, it's about recognising,
(03:03):
not kind of how patients aredoing it, how are you doing this?
You know?
It's about why patients are doing this,so it's the why that really matters.
And we, as dermatology healthcareprofessionals, are in a brilliant
place to try and explorewhy this might be the case.
And in my experience, the why, once youopen up the opportunity to talk about why,
(03:29):
comes tumbling out very, very swiftly.
So sooner or later, the narrative aboutwhy this is happening comes tumbling out.
Now, it might be something that isrelatively straightforward to resolve.
For example, it might be undue pressureon a child to achieve at exams.
It might be you know, somethingwhere somebody has been unpleasant
(03:52):
to somebody or bullying.
I'm saying easy to resolve, and of course,none of these things are particularly easy
to resolve, but it can be something thatcan be addressed, or it can be something
which is really quite destabilising.
For example, some kind of abuse whichhas happened over a long period of time.
(04:12):
But, the why is where we want to focusreally, in a lot of these conditions.
And would you say it's the samefor somebody, for example, who's
constantly washing their hands,to the point at which they're raw
and bleeding and they can't stop?
Right.
Is it again, the why there thatis, that we need to focus on?
Okay.
It's, in those circumstances, it'susually rip-roaring anxiety, and you
(04:36):
know, why, why is this happening?
And we know that managing the skin,so using great emollients, we have
got great emollients, in thosecircumstances is quite important.
But then again, it's also about managingthe psychological, psychiatric disease
and we know that managing those withtwo things, it can be tablets or talk
(04:59):
treatment, or both together, and we knowthat if we manage patients with both
the talk treatment and the medicationtreatment, if a patient chooses to have
the medication treatment or the talktreatment, we know the combination of both
of those leads to more rapid resolution,more comprehensive resolution, and with a
(05:19):
less chance of recurrence of the problem.
So, talk treatment together withmedication, usually a greater
benefit than oral treatment byitself or talk treatment by itself.
But the patient chooses, the patientcan choose, you know, what they
want to do in terms of treatment.
The first step, and by anybody'sstandard, the most important step and
(05:44):
the biggest step is recognising the why.
Why is this happening?
What is the drive behind this?
And for healthcare professionals, tomake sure that you give the patient
the opportunity to talk about whythis is happening, is crucial.
Thank you so much for that, Tony.
That's really helpful and a difficultarea for us to manage sometimes,
(06:05):
but that's given me some thoughtthere, which is really useful.
Another condition you were talkingabout earlier, in the previous
podcast, was body dysmorphic syndrome.
Could you just say just a fewmore words about that here?
Yeah, so body dysmorphic disorder,we know is a massive problem,
particularly in the younger age group.
(06:26):
So we know that, about somewherebetween two and five percent of younger
people, have a degree of body dysmorphicdisorder, but it's any age group,
it can be younger, it can be older.
What do I mean by bodydysmorphic disorder?
There are four criteria that the AmericanPsychiatric Association place on us
to be able to make that diagnosis.
(06:48):
First one is that the patient has avisible difference, which is really
a massive focus for the patient.
It can be acne scarring, it can beears that are too big, or a nose
that's too big, or some visible,it can be hair that's in the wrong
place, or too much hair in the wrongplace, or not enough hair in in places
where you would want to have hair.
(07:09):
So it's a visible difference, which canseem to healthcare professionals to be a
bit trivial, a bit not very important, butfor the patient is of massive importance.
And then the patient often has tohave recurrent thoughts, so it has
to be something that is the focusof their attention, day in day out.
Thirdly, there is usuallysome kind of social avoidance.
(07:30):
So patients are avoiding goingout, avoiding socialising, avoiding
going into school or avoiding goinginto work, whatever it might be.
And the fourth criterion is that it's notbetter explained by an eating disorder.
So it's not better explainedby anorexia or bulimia.
So those four criteria are met, thenyou have body dysmorphic disorder.
(07:52):
So just in summary, body dysmorphicdisorder, a visible difference,
usually, that seems to us to be fairlyinnocuous but for the patient is
massively important, and they havea real strong drive to repeatedly
think about this , and they may havesome degree of social avoidance.
How is it treated?
First thing is to recognise itand not dismiss it, "Oh, it's
(08:15):
just a bit of acne scarring.
Well, you haven't got cancer.
You haven't got epilepsy."
Any of those dismissing things don't help.
So first thing is to recognise it.
Second thing is to say, "Okaywell, you know, I'm aware that
this is of importance to you."
What I often say to patientswith BDD, "On a scale of 1 to 10,
how bad is your acne scarring?
(08:37):
How bad is your hair problem?"
And they'll say, "It's 10 on 10 doctor".
And you might say to them, "Okay,for me, it's about a 2 on 10."
Crucially, it's not zero.
So crucially it is there.
And then I'll talk to them.
Okay.
You know, And they'll kind of,say, "That's what everybody says.
Everybody says it's, it's minor.
It's less extensive than I think it is."
(09:00):
And then I'll enter into adiscussion about that gap between
how the patient sees it 10 on 10and how I, and or their relatives
or other people, see it two on 10.
So that eight point gap, I'll say, thereis a word for this, for what it's worth.
It's called 'body dysmorphic disorder',and I want to treat your skin, so I
(09:21):
want to treat your acne scarring, oryour hair, or whatever it is, I want
to treat that, but also I want to treathow that is impacting you, that body
dysmorphic disorder, at the same time.
And that might be medication,it can be talk treatment,
or it can be both together.
Goodness.
That's really interesting.
Such honest negotiation there.
(09:42):
I like it.
I like the approach.
Yeah.
There are other mental healthconditions that can present to
dermatologists, but I'm not reallysure this is the right medium for
us to explore those in great detail.
I'm thinking, for example, theperson who comes to see us convinced
that they've got bugs living ontheir skin, and the evidence for
(10:03):
that is challenging to, to confirm.
Um, or the patient who picks attheir skin, to the point at which it
is seriously damaged, and they areconvinced that there's an underlying
skin condition, but the pattern doesn'tfit in with anything that the books
would suggest is due to a skin disease.
It's because they are picking it, burningit, cutting it, doing it because they
(10:28):
have such underlying severe anxietyand stress and trauma, mentally, that
this is their way of seeking help.
Do you want to say any particular words onthose sorts of conditions in this forum?
Yeah, so we're alludingto two things here.
We're alluding to a series ofconditions, which are called
persistent delusional disorders.
(10:49):
So patients who have some kind ofbelief system about their skin.
It might be, I've got a patient,or have had a patient, who believes
that various aspects of the face aremoving around of their own accord,
and there is no evidence for that.
So these persistent delusionaldisorder changes, or it can be a
patient who experiences materialgrowing within their skin.
(11:14):
We definitely always take thepatient seriously and we look...
So important.
...to see if there is, if thereis any reason, any organic reason,
any foundation for that experience.
And sometimes there is, andwe must always put the patient
at the centre of any choices.
If there isn't a foundation for that,then we have to negotiate with the
(11:36):
patient, about how we can get rid of thesensations of the skin and try and get
them better, because the whole experienceof living with these problems can be so
debilitating and, repeatedly, patientsgo and see healthcare professionals
and they're dismissed as being, "thisdoesn't seem to be anything that I
recognise", and they're dismissed.
(11:56):
So it's really important that we doembrace the patients as best as we
can, and say, "Okay, I fully understandthat this is a real problem for
you, and I'm going to manage thisas best as I can, and let's see if
we can work together about that."
Fantastic.
Thank you.
So, we know that mental healthcomplications are very common
amongst our patients with skindiseases, and the figures,
(12:17):
unfortunately, are truly shocking.
But in recent years, we have begun tosee a long overdue, increased interest
in mental health issues by politicians,by society at large, and obviously,
for those responsible for deliveringhealthcare, but, that hasn't really
greatly changed the approach of thecaring professions, enough, as I see it.
(12:41):
Skin diseases, as we know, are incrediblycommon, but unfortunately, are often
generally not managed as well asthey should be, and because of that,
they can bring an enormous burden ofmental health and social morbidity.
If we're genuinely interested inimproving the mental health of our
society, then managing skin diseasesbetter is a hugely important area
(13:06):
to focus resources on, and I thinkthat's a real take home message here.
I often say, actually, that uh, societyis getting interested in mental health,
and so it should, but addressing skindisease would make such inroads into the
mental health of our society, wouldn't it?
(13:28):
It really would.
And yet skin disease remains,so often, an under-resourced and
underthought about area of healthcare.
And these podcasts, I do feel, havehighlighted just how important this is.
I couldn't agree more, George.
And I was thinking about this earlier,and between us, we've almost put our
(13:49):
own personal charter together here.
And I don't know what you think aboutthis, but I just want to knock a few
of these around, almost some take homepoints I think that we've drilled into.
So for me, let's start with the obviousone, the best treatment for someone
who's got mental health consequences,from a skin condition that they
(14:09):
have, is good control of their skindisease, above everything else.
Absolutely.
Yeah, that should really gowithout saying, shouldn't it?
But it is so important to say it.
No skin disease, no problem.
It is as straightforward as that.
So yeah, really, and we have got formany skin conditions that we have got
(14:30):
now, fantastic therapeutic answers,which can really transform that disease.
And that's what we're hoping todemonstrate with this series of podcasts.
But at the same time, I do think we mustcontinue to enhance our profession's
recognition, that patients coming to uswith a skin condition are very likely
(14:51):
to have a mental health complication,and the figures we've been sharing
with you, of the rates of mental healthdisease in our patients are not just
high, they are staggeringly high.
And it is more than likely yourpatient's going to be having a burden
there, that they would like helpwith, even if that isn't something
(15:11):
that they bring to our attention.
We need to be sensitive to it, and Ithink ideally, look into that area.
Even if you can't manage itin that consultation, say,
"Goodness, okay, this is important.
Can you come back next week, orwhenever you can manage it, for us
to explore that in a bit more detail.
I need to know more about this.
This is clearly very important."
(15:33):
I think that's absolutely spot on.
And as part of that, and wetouched on this, and Prof.
Bewley touched on this aswell, signposting our patients.
We must never forget to signpost ourpatients to the appropriate patient
support group, and most conditions noware covered by this, but we've got to
ensure we've got adequate resourcesto help those who are affected, and
(15:58):
when appropriate, obviously take theseconcerns seriously, including referral for
additional psychiatric help if need be,but signposting must now be part of our
routine consultation practice, I think.
It really is.
We're not on our own.
There are these expert resources anduh, when I was Chair of the Dermatology
(16:18):
Council, I got to know most, or manyof these, incredibly well because they
were a regular and significant part ofthe Dermatology Council for England.
So I'm thinking of people likeChanging Faces, The Psoriasis
Association, the National EczemaSociety, The Vitiligo Society.
These organisations are absolutelywonderful and enthusiastic and
(16:40):
obviously incredible experts inthe condition that they support.
And the support that theyoffer is quite remarkable.
So we should be signpostingour patients in that direction.
But another thing that we talked about,was that in my ideal world, I think all
patients with a chronic skin conditionshould have an annual medicines review by
(17:02):
their GP or by a nurse in that practice.
And this should automatically includean assessment of the psychological
impact of their condition.
And as we go through these podcasts,we are drawing attention to the various
questionnaires that our patients canbe asked to complete to, to help reveal
the severity of their social impairment,their mental health disturbance,
(17:26):
or even lifestyle disturbances.
And so things like the DermatologyLife Quality Index, the DLQI.
Originally designed forpsoriasis, but incredibly
useful for most skin conditions.
The POEM, the Patient-OrientedEczema Measure, which you will
recall, is on the app, mySkinHealth,which AproDerm® have created.
(17:49):
And it reminds patients, every week, tocomplete a POEM, which asks about how
bad their eczema has been in the previousweek, how bad has the itch been, how much
has it affected their sleep, and so on.
And then there are questionnaires thatGPs can use for looking at the mental
health of our patients specifically.
So things like how depressed they mightbe or whether they got suicidal ideation.
(18:09):
I'm thinking here what's called aPHQ-9, or when thinking about anxiety,
you might be using what's calledthe GAD, the Global [Generalised]
Anxiety Disorder Questionnaire 7.
And if you've got someone with achronic skin condition, for example,
dry skin , we've talked about focusingon educating about that skin condition.
(18:33):
So educate about the lifestyle changes youcan make, regularly and liberally applying
your emollients, avoiding soaps, diarisingyour flares, that's really helpful, and
potential triggers you may come across soyou know what to avoid in the future...
because if you could work on the maximaltreatment for your lifestyle with your
(18:53):
dry skin condition, then any relatedmental health issues will improve as well.
So we almost come back full circle.
If appropriate, discusslocal psychotherapy services
that may be available.
Unfortunately, as we both know,those can be very patchy, but
referral to specialist departmentsis right up there, isn't it, George?
(19:16):
Yeah, I think referral to specialistpsychodermatology departments should, in
my world, ideally always be accessible toour patients when appropriate, but that's,
as you say, sadly, not always the case.
But as GPs, we do have a voice oncommissioning boards and I would
like to see us being a bit morevocal here and demanding that those
(19:38):
sorts of services are availableto help us, to help our patients.
But at the end of the day, to help ourpatients, that's the important thing.
Yeah.
I think speaking for both of us, Iknow that these podcasts on mental
health and the skin have been some ofthe most enjoyable we've done so far.
Thanks, in no small part, to the wonderfulspecial guest Professor Anthony Bewley,
(20:00):
and George and I do hope you've found themas interesting and beneficial as we have,
and they've allowed you to understand thebenefit of treating both the skin and the
huge psychological effects of living withskin problems, that we know are out there.
The size of the problem is huge, isn't it?
But Roger and I really hope you'lljoin us for our next podcast,
(20:21):
when we'll be discussing anotherimportant area of skin health.
And let me take this opportunity onceagain, to thank our sponsor, AproDerm®,
for all their help in putting theseRash Decisions podcasts together.
We couldn't have done it without them.
So if you are enjoying these podcasts,and George and I really do hope you are,
then do rate and review us, on whicheverplatform you use to receive them.
(20:44):
It really does help.
We'd also love to hear your feedback,so do get in touch, as it really
is good to hear what you think,and to let us know if there are any
topics you'd like us to discuss.
But until the next time, asalways, it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
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