The results of the upcoming election will have a significant impact on many policies that affect our day to day lives. One aspect that needs urgent change is mental health policy. In June 2022 1.2 million people were on NHS waiting lists for mental health treatment. This election charities are urging politicians to place importance on mental health care within their individual manifestos. The Mental Health Policy Group is a partnership of 6 organisations, including charities like Mind and organisations like the Mental Health Foundation, working to improve the country’s mental health through policy changes. They say we need to ‘move to a more preventative approach to mental health, as a country, we need a comprehensive cross-government plan, alongside the funding to make it happen.’ They have outlined key areas where investment would improve mental health, including preventative perinatal care, support for children’s mental health, tackling racism and discrimination, and increased access to nature. Another key issue for charities is reforming the Mental Health Act, a policy used to detain people in crisis, which the Centre for Mental Health say is outdated and ‘disproportionately used against people from racialised communities, denying many their dignity and human rights.’ The organisation is ‘deeply disappointed’ that no changes have been made over the last five years. It hopes a future party will change this.

Looking at each party’s manifesto we get a clear view of how much they prioritise mental health policy and what they are looking to improve. All major parities have made mental health a talking point in their current manifestos, suggesting they are taking note of the increased demand for change. Both Labour and the Conservatives say we should give mental health the same attention as physical health. However, the extent to which they are meeting the Mental Health Policy Group’s aims vary.

Mental Health Act

All three major parties are committed to reforming the Mental Health Act. Mental health occupies a large and detailed part of Labour’s manifesto. They state they want to update the Act to be more inclusive for autistic and learning disabled people, and agree that the Act is more likely to unfairly detain black people than others. They also aim to modernise legislation to give patients greater choice, autonomy and support to ensure everyone is treated with dignity and respect. The Conservatives reserve a small but significant space in their manifesto for mental health reform. They do not mention the Act by name but pledge to pass a new law to provide better treatment and support for severe mental health needs. The Lib Dem manifesto wants to modernise the Mental Health Act ‘to strengthen people’s rights, give them more choice and control over their treatment and prevent inappropriate detentions.’

Suicide Rates

The high suicide rate amongst men under 50 is another issue highlighted by the policy group. Labour lists suicide as a major issue and one of the biggest killers it wants to tackle. It says it will do so by implementing walk in hubs in every community and providing mental health support in every school ‘so young men and boys are not left to suffer alone’, as well as recruiting 8500 mental health professionals to cut waiting lists.

The Conservative suicide prevention strategy will ensure employers of male dominated industries will have appropriate support such as mental health first aiders. Lib Dem’s want to focus on community suicide prevention services and improving prevention training for frontline NHS staff.

Young People

Youth mental healthcare is in crisis. All three major parties and the Greens pledge to improve access to care in schools. Conservatives want to expand coverage of mental health support teams from 50% to 100% of schools and open early support hubs for 11-23yr olds in every community by 2030. Labour want to open Young Futures hubs to provide open access mental health services for children and young people in every community. Lib Dems also want to open hubs focused on giving young people regular ‘mental health checkups’ at key points in their life. The Greens aim to provide a trained and paid counsellor in every primary and secondary school and sixth form and ensure everyone who needs it can access evidence based mental health therapies within 28 days.

What is missing?

Whilst there are important policies listed in party manifestos, the Mental Health Policy Group notes some areas that are being missed. The Centre for Mental Health says, ‘we are very disappointed that neither Labour nor the Conservatives have committed to end the two-child limit for Child Benefit, which causes hardship to so many families.’ Perhaps the biggest disappointment for the policy group is the lack of commitment to cross-government mental health plans. The Centre urges parties ‘to take this essential extra step, and to review the machinery of government so that all policies are designed to boost the public’s mental health.’

Whichever party is successful in the election, organisations hope they will make a commitment to enacting substantial change to mental health policy.

As we head into exam season students may be feeling that the mounting pressure to do well is affecting their mental health. Taking exams can be a very stressful time, but there are things you can do to improve your mental health at all stages of the exam process.

Stress can be very overwhelming to deal with. Some symptoms include;

• tiredness
• feeling anxious or down
• feeling irritable or angry
• problems with sleep
• changes to eating habits
• worrying
• having bad thoughts about yourself
• not enjoying the things you love
• difficulties concentrating
• feeling physically unwell eg headache, stomach ache, sickness, fatigue.

Whilst some stress around exams is normal, experiencing these symptoms can interfere with your day to day life and make the process of taking exams more taxing than they should be.

The Exam Season

As the exam season begins, you may start to feel pressure to do well. This can come from a variety of places, from your teachers, parents, friends or even from yourself. There are a few techniques you can use to ease this pressure.

Firstly be kind to yourself, exams are tough and its important to remember that how well you do is only a small part of the many achievements you have accomplished.

Secondly, don’t compare yourself to other people. They may not look it, but they may be just as stressed as you. Everyone is coping in their own way.

Revision

Revising for exams can be stressful in itself. Make a revision timetable where you break work into reasonable chunks. Make sure to be realistic with your timetable, don’t schedule too much work in one day or you may burnout and feel bad about not achieving everything you wanted to do. Take regular breaks when revising to do things that make you happy, it is important to have a balance between work and play.

You can also look up the way you learn; visual, auditory, kinaesthetic and verbal are all different ways to retain information. Look into how you can use them in your revision methods.

If you work better with other people, join a study group. Tackling tough revision subjects together allows you to answer each others questions and fill in any knowledge gaps. This could help you feel more connected and less isolated as you study.

Before the Exam

There are many things you can do before the exam to ensure you are prepared. If you are struggling with a particular topic, talk to your teacher about it. They will be more than happy to help, they want to you to succeed.

You can also arrange access arrangements with your institution to make things easier for you, especially if you have special education needs or are neurodivergent, disabled, or deal with mental health issues. You could get extra time to complete an exam, assistive technology like a computer, or breaks during the exam. If you think access arrangements could help you, speak to your school to arrange them as early as possible as some need to be organised through an examining body.

Get organised the night before, pack your bag, know how you are getting to the exam, and make sure you have everything you need.

After the Exam

Well done you did it! You never have to think about Physics ever again!

Reward yourself by doing something you enjoy; hang out with friends, get a sweet treat or play video games. Let yourself rest and recharge before you continue revision for other topics.

Don’t compare your answers to other people. It may be tempting to ask others how they answered, but this only serves to make you question yourself and doubt your abilities.

Be kind to yourself. Remember exam results are not more important than your physical and mental wellbeing, and there is more to life than good grades.

Results Day

If you don’t get the results you wanted remember exam results don’t define you and your worth is measured by a hundred other things. Make a list of things you want from life that aren’t exams and focus on life outside of education for a bit.

Explore your options, you could retake an exam, get it remarked or apply for special considerations. You could decide this qualification isn’t for you and switch subjects. You could rethink your career routes and choose something entirely different.

If you feel pressure to share your exam results remember you don’t owe anyone your results. It is absolutely fine not to share them.

Techniques to decrease stress

During this process you can use different techniques to decrease your stress and relax.

Try some relaxation techniques instead of cramming in last minute revision. You could do breathing or grounding exercises, or physical exercises like yoga or pilates.

Make sure you include self care in your routine, eat properly, drink plenty of water, sleep well and exercise regularly. Maintaining good self care provides a great baseline to improve your mental health.

Postnatal Depression 

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After giving birth many women experience a time period called ‘baby blues’, which refers to feeling emotional or low for around two weeks. Postnatal depression however, usually peaks between 6 to 12 weeks after giving birth, but can begin at any point during the first year. 

Symptoms of postnatal depression can include:

• Sadness or low mood 
• Difficulty sleeping 
• Loss of enjoyment or interest in things you previously enjoyed 
• Withdrawing from other people 
• Having trouble concentrating 
• Panic attacks 
• Lack of energy 
• Struggling to look after yourself or others 
• Thoughts of hurting yourself or others 
• Changes in appetite 

Treatment: 

If you are struggling, the National Health Service (NHS) recommends telling your doctor, health visitor or midwife as soon as possible. 

Talking therapy – A doctor may refer you to therapy, for example Cognitive Behavioural Therapy (CBT) or recommend a self-help course. Additionally, in the UK you can also refer yourself for talking therapy. 

Support – Having a good support system can help you feel more comfortable in your new role as a parent and take some of the stress off you. 

Self-care – There are small things you can do for yourself every day to improve your wellbeing. For example, making time for yourself, speaking to friends and family, eating a balanced diet, spending time outside or taking time to rest. 

Medication – If other forms of treatment are not effective or your depression is severe a doctor may recommend medication. 

References 

NHS (2022). Postnatal depression. [online] nhs. Available at: https://www.nhs.uk/mental-health/conditions/post-natal-depression/overview/.

Leahy-Warren, P., & McCarthy, G. (2007). Postnatal depression: prevalence, mothers’ perspectives, and treatments. Archives of psychiatric nursing, 21(2), 91–100. https://doi.org/10.1016/j.apnu.2006.10.006

APNI – Association for Post-Natal Illness | Post Natal Depression. (n.d.). Post Natal Depression. [online] Available at: https://apni.org/leaflets/post-natal-depression/.

Mental Health Foundation (2022). Postnatal Depression. [online] www.mentalhealth.org.uk. Available at: https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/postnatal-depression.

Burnout, you may have heard the term going round at the moment. For some the term is relatively new and for others it’s a phrase that’s being thrown around a lot. Many people are experiencing symptoms of burnout and don’t even realise what they are experiencing. It can also be mistakenly identified as anxiety and depression however burnout is all about your relationship between work and home.

Originally burnout was named by an American psychologist Herbert Freudenberger. It was used to describe the consequences of high stress jobs. However, burnout can effect anyone from students, homemakers, office workers, artists and so on. In 2019, WHO revised their definition of the Phenomenon. They describe burnout as a symptom of chronic stress from work that has not been mangaed.

Common signs of burnout

• Feeling tired or drained all the time or having problems sleeping
• Feeling overwhelmed
• Having a lack of self-confidence
• eating more or less than usual
• avoiding things or people you are having problems with
• Having racing thoughts or difficulty concentrating
• Becoming irritable

Burnout does not go away by its self however there are steps you can take to help. One big step that people forget is self care. Self care is super important as you can forget that you’re not a robot. You need time for you. It’s important to nourish yourself and set achievable goals.

A good start on the road to recovery is to identify what the main causes of stress are. Then figure out what you can do about it. This is to give your brain away to think about the solution. Another way to help is to leave work at work. Now this is easier said than done but the stress is what leads to the burnout. Start to prioritise a work-life balance so that you can recharge for the next day.

The road to recovery can take a while and it may not make a difference straight away however it will eventually start to help.

References

• Burn out and how to avoid it Author: Liggy Webb
• burnout prevention and treatment Authors: Melinda Smith, M.A., Jeanne Segal, Ph.D., and Lawrence Robinson
• The official WHO website www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases

An Underrecognized Compulsive Disorder

What is Trichotillomania?

Trichotillomania or ‘Trich’ involves obsessive compulsive hair pulling from any area of the body, most often from the scalp, eyebrows and eyelashes. It is often done to relieve tension as with OCD but can also be done for pleasure or subconsciously and is commonly comorbid with other obsessive behaviours such as nail biting and skin picking[1].

Diagnosis: International Classification of Diseases (ICD-10)

“A disorder characterized by noticeable hair-loss due to a recurrent failure to resist impulses to pull out hairs. The hair-pulling is usually preceded by mounting tension and is followed by a sense of relief or gratification. This diagnosis should not be made if there is a pre-existing inflammation of the skin, or if the hair-pulling is in response to a delusion or a hallucination.”[2]

The Lived Experience

Hair pulling often brings with it embarrassment and shame, heightening risk of social isolation, depression and anxiety[3]. The physical effects are also adverse, in terms of scarring and infections in areas that are pulled from. Furthermore, it is common for individuals with trichotillomania to eat their hair (trichophagia), which can lead to hair balls building up in the digestive tract, causing uncomfortable and potentially life-threatening digestive complications and obstructions[4]

Treatments for Trichotillomania

• Cognitive Behavioural Therapy (CBT): CBT for trichotillomania comes in the form of habit reversal training, whereby the patient and therapist work to replace maladaptive habits and thoughts with more rational ones. For example, identifying and avoiding potential triggers for pulling or focusing the anxiety on something less harmful such as a stress ball.
• Family therapy: Involving family in behavioural treatment plans can increase their effectiveness, particularly for children with trichotillomania[5]
• Relaxation Training: Breathing techniques, yoga and meditation can help those with trichotillomania process feelings of tension and offer an alternative relief to hair pulling[6]
• Medication: As with most obsessive-compulsive disorders, medication is not recommended as a direct treatment, however antidepressants can be used to treat commonly comorbid illnesses such as depression and anxiety[7]

References

Keuthen, N. J., Curley, E. E., Scharf, J. M., Woods, D. W., Lochner, C., Stein, D. J., … & Grant, J. E. (2016). Predictors of comorbid obsessive-compulsive disorder and skin-picking disorder in trichotillomania. Annals of Clinical Psychiatry: Official Journal of the American Academy of Clinical Psychiatrists, 28(4), 280-288.

Grant, J. E., Redden, S. A., Leppink, E. W., & Chamberlain, S. R. (2017). Trichotillomania and co-occurring anxiety. Comprehensive psychiatry, 72, 1-5.

Özten, E., Sayar, G. H., Eryılmaz, G., Kağan, G., Işık, S., & Karamustafalıoğlu, O. (2015). The relationship of psychological trauma with trichotillomania and skin picking. Neuropsychiatric disease and treatment, 11, 1203–1210. https://doi.org/10.2147/NDT.S79554

Grant, J. E., & Chamberlain, S. R. (2018). Salivary sex hormones in adolescent females with trichotillomania. Psychiatry research, 265, 221-223.

[1] Snorrason, I., Belleau, E. L., & Woods, D. W. (2012). How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities and shared etiology. Clinical psychology review, 32(7), 618-629.

[2] World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/

[3] Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. American Journal of Psychiatry, 173(9), 868-874.

[4] Snorrason, I., Ricketts, E. J., Stein, A. T., & Björgvinsson, T. (2021). Trichophagia and trichobezoar in trichotillomania: a narrative mini-review with clinical recommendations. Journal of Obsessive-Compulsive and Related Disorders, 31, 100680.

[5] Flessner, C. A., Penzel, F., Board, T. L. C. S. A., & Keuthen, N. J. (2010). Current treatment practices for children and adults with trichotillomania: consensus among experts. Cognitive and Behavioral Practice, 17(3), 290-300.

[6] Sarah H, M., Hana F, Z., Hilary E, D., & Martin E, F. (2013). Habit reversal training in trichotillomania: guide for the clinician. Expert Review of Neurotherapeutics, 13(9), 1069-1077.

[7] Sani, G., Gualtieri, I., Paolini, M., Bonanni, L., Spinazzola, E., Maggiora, M., Pinzone, V., Brugnoli, R., Angeletti, G., Girardi, P., Rapinesi, C., & Kotzalidis, G. D. (2019). Drug Treatment of Trichotillomania (Hair-Pulling Disorder), Excoriation (Skin-picking) Disorder, and Nail-biting (Onychophagia). Current neuropharmacology, 17(8), 775–786. https://doi.org/10.2174/1570159X17666190320164223

Narcolepsy: Diagnosis, Causes and Treatments

Narcolepsy is a sleep disorder caused by neurological changes that leads to difficulties regulating ones sleep-wake cycle. It can be seen in sudden sleep ‘attacks’ that can’t be controlled and cataplexy, which is when the individual suddenly loses muscle tone.

Diagnosis

Narcolepsy is diagnosed in the Diagnostic and Statistical manual of mental disorders (APA 2013) according to the following criteria:

• Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least 3 times per week over the past 3 months.

The presence of at least one of the following:

• Episodes of cataplexy, occurring at least a few times per month, and as defined by either:
• In individuals with long-standing disease, brief (sec to min) episodes of sudden, bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking
• In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or global hypotonia, without any obvious emotional triggers.
• Hypocretin deficiency, as measured by cerebrospinal fluid (CSF) hypocretin-immunoreactivity values of one-third or less of those obtained in healthy subjects using the same assay, or 110 pg/mL or less.
• Nocturnal sleep polysomnography (PSG) showing rapid eye movement (REM) sleep latency of 15 minutes or less, or a multiple sleep latency test (MSLT) showing a mean sleep latency of 8 minutes or less and more than 2 sleep onset rapid eye movement periods (SOREMPs).

Treatments

Narcolepsy can cause significant difficulties and dangers in everyday life and unfortunately there is no cure, but the are changes that can be made to help to alleviate symptoms. These include:

Lifestyle Changes:

• Diet: Eat a balanced diet with whole foods and limited processed foods, eating regularly throughout the day and not immediately before bed. Avoid caffeine, nicotine and alcohol as these disturb sleep
• Regular Exercise: This aids with forming healthy sleep patterns and general wellbeing
• Take Naps: By scheduling naps, you can reduce the risk of sudden ‘sleep attacks’
• Talk to others: Narcolepsy is a misunderstood illness and explaining it to those close to you helps form a base of support

Medication:

• Stimulants such as modafinil can help individuals stay awake for longer during the day but may bring adverse side effects such as nausea and anxiety
• Antidepressants such as selective serotonin reuptake inhibitors help to reduce narcolepsy episodes by reducing the amount of rapid eye movement sleep. Other antidepressants used include serotonin-noradrenaline reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs)

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Anderson, T., Bandi, M., Bromley, K. D., Nino, M., & Terekhov, K. (2003). Narcolepsy.

M. Billiard, V. Pasquié-Magnetto, M. Heckman, B. Carlander, A. Besset, Z. Zachariev, J. F. Eliaou, A. Malafosse, Family Studies in Narcolepsy, Sleep, Volume 17, Issue suppl_8, December 1994, Pages S54–S59, https://doi.org/10.1093/sleep/17.suppl_8.S54

Mehta, R., Jiwanji, M., Singhal, R., Gillam, E., Lockwood, K., & Quarmley, M. (2021). The Social and Emotional Toll of Narcolepsy. Undergraduate Works.

There are so many options out there for you to choose from.

Your future is bright and clear. It may not seem it now but this storm will pass either way and you will shine.

Diet and Mental Health

What we eat doesn’t just affect our physical wellbeing but also impacts our mental health and overall mood. By taking this more holistic approach to wellbeing, we can lead healthier lifestyles and reduce the risk of physical and mental illness.

In general, a more ‘Mediterranean’ diet with whole foods, vegetables and fish is better for wellbeing compared to a more ‘Western’ diet of processed foods and red meats. However, food and wellbeing aren’t simply interrelated on the basis of what we eat but also when we eat. It is important to eat regularly as mood can dip when our blood sugar levels are low and eating regularly helps keep them at a stable level. It is important not to skip breakfast and eat smaller meals throughout the day and avoid foods that make your blood sugars rapidly increase, such as sugary soft drinks. Furthermore, it is key to stay hydrated as dehydration can reduce our memory ability and focus and water is also key in serotonin production which helps improve mood[1]

Understanding Eating Disorders:

While food is a source of pleasure for some, it can unfortunately be a source of anxiety and eating disorders can quite suddenly develop and become very harmful to our physical and mental wellbeing, Eating disorders such as anorexia and bulimia nervosa require professional intervention from a therapist and/or medication. Information on bulimia nervosa diagnosis and treatments can be seen in this article: https://www.linkedin.com/pulse/bulimia-nervosa-diagnosis-impacts-causes-treatments-/

References

 Ocean, N., Howley, P., & Ensor, J. (2019). Lettuce be happy: A longitudinal UK study on the relationship between fruit and vegetable consumption and well-being. Social Science & Medicine, 222, 335-345.

 Grosso, G., Galvano, F., Marventano, S., Malaguarnera, M., Bucolo, C., Drago, F., & Caraci, F. (2014). Omega-3 fatty acids and depression: scientific evidence and biological mechanisms. Oxidative medicine and cellular longevity, 2014.

 Huntley, E. D., & Juliano, L. M. (2012). Caffeine Expectancy Questionnaire (CaffEQ): construction, psychometric properties, and associations with caffeine use, caffeine dependence, and other related variables. Psychological assessment, 24(3), 592.

 Golomb, B. A., & Bui, A. K. (2015). A fat to forget: Trans fat consumption and memory. Plos one, 10(6), e0128129.

 Golomb, B. A., Evans, M. A., White, H. L., & Dimsdale, J. E. (2012). Trans fat consumption and aggression. PLoS One, 7(3), e32175.

 Gangwisch, J. E., Hale, L., Garcia, L., Malaspina, D., Opler, M. G., Payne, M. E., … & Lane, D. (2015). High glycemic index diet as a risk factor for depression: analyses from the Women’s Health Initiative. The American journal of clinical nutrition, 102(2), 454-463.

[1] Popova, N.K., Ivanova, L. N., Amstislavskaya, T. G., Melidi, N. N., Naumenko, K. S., Maslova, L. N., & Bulygina, V. V. (2001). Brain serotonin metabolism during water deprivation and hydration in rats. Neuroscience and Behavioral Physiology, 31(3), 327-332.

Body Dysmorphic Disorder (BDD) is an increasingly common anxiety disorder characterised by obsessive concerns with body image and perception which is prevalent more so in children and youth.

Causes and Risk Factors:

• Abuse or Neglect: Mistreatment, particularly during childhood either by a parent or at school increases the risk of developing obsessive compulsive disorders such as BDD[1]
• Family and Genetics: Those with a family member with BDD are at higher risk of developing the disorder too, mainly due to learnt behaviours. Some genetic traits can increase risk too, including those that overlap with OCD[2]
• Other Mental Disorders: Having other mental disorders such as anxiety or OCD increase vulnerability to developing BDD[3]
• Fear of Isolation: Someone may be made to feel that they need to shape their appearance to be accepted by a certain group such as models or bodybuilders, which can increase the risk of BDD
• Perfectionism: Individuals who have neurotic personalities are likely to become obsessive about their appearance, often exacerbated by the constant presentation of ‘perfect’ male and female bodies in the media[4]

Treatments:

• Cognitive Behavioural Therapy (CBT): CBT helps the patient recognise and understand their triggers for insecurities and anxiety surrounding body image. It helps them recognise that these beliefs are irrational and harmful and form a more realistic and positive view of their appearance.
• Exposure and Response Prevention: This is a common aspect of CBT when treating BDD, involving gradual exposure to a stimulus that can trigger body related anxiety such as being in crowded places. The ‘response prevention’ aspect involves working with the patient to reduce compulsive behaviours, such as constant mirror checking.  
• Medication: Selective Serotonin Reuptake Inhibitors (SSRIs), typically used to treat depression can be effective in reducing BDD symptoms through regulating neurotransmitter levels[5]

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

[1] Himanshu, A. K., Kaur, A., & Singla, G. (2020). Rising dysmorphia among adolescents: A cause for concern. Journal of family medicine and primary care, 9(2), 567.

[2] Monzani, B., Rijsdijk, F., Iervolino, A. C., Anson, M., Cherkas, L., & Mataix-Cols, D. (2012). Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample. American journal of medical genetics. Part B, Neuropsychiatric genetics : the official publication of the International Society of Psychiatric Genetics, 159B(4), 376–382. https://doi.org/10.1002/ajmg.b.32040

[3] Chandler, C. G., Grieve, F. G., Derryberry, W. P., & Pegg, P. O. (2009). Are anxiety and obsessive-compulsive symptoms related to muscle dysmorphia. International Journal of Men’s Health, 8(2), 143-154.

[4] Himanshu, A. K., Kaur, A., & Singla, G. (2020). Rising dysmorphia among adolescents: A cause for concern. Journal of family medicine and primary care, 9(2), 567.

[5] Vashi, N. A. (2016). Obsession with perfection: Body dysmorphia. Clinics in Dermatology, 34(6), 788-791.