<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Schizoid personality disorder and can you explain it in depth? [/INST] Schizoid personality disorder (, often abbreviated as SzPD or ScPD) is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment and apathy. Affected individuals may be unable to form intimate attachments to others and simultaneously possess a rich and elaborate but exclusively internal fantasy world. Other associated features include stilted speech, a lack of deriving enjoyment from most activities, feeling as though one is an "observer" rather than a participant in life, an inability to tolerate emotional expectations of others, apparent indifference when praised or criticized, a degree of asexuality, and idiosyncratic moral or political beliefs. Symptoms typically start in late childhood or adolescence.The cause of SzPD is uncertain, but there is some evidence of links and shared genetic risk between SzPD, other cluster A personality disorders (such as schizotypal personality disorder) and schizophrenia. Thus, SzPD is considered to be a "schizophrenia-like personality disorder". It is diagnosed by clinical observation, and it can be very difficult to distinguish SzPD from other mental disorders or conditions (such as autism spectrum disorder, with which it may sometimes overlap).The effectiveness of psychotherapeutic and pharmacological treatments for the disorder has yet to be empirically and systematically investigated. This is largely because people with SzPD rarely seek treatment for their condition. Originally, low doses of atypical antipsychotics were also used to treat some symptoms of SzPD, but their use is no longer recommended. The substituted amphetamine bupropion may be used to treat associated anhedonia. However, it is not general practice to treat SzPD with medications, other than for the short-term treatment of acute co-occurring disorders (e.g. depression). Talk therapies such as cognitive behavioral therapy (CBT) may not be effective, because people with SzPD may have a hard time forming a good working relationship with a therapist.SzPD is a poorly studied disorder, and there is little clinical data on SzPD because it is rarely encountered in clinical settings. Studies have generally reported a prevalence of less than 1%. It is more commonly diagnosed in males than in females. SzPD is linked to negative outcomes, including a significantly compromised quality of life, reduced overall functioning even after 15 years and one of the lowest levels of "life success" of all personality disorders (measured as "status, wealth and successful relationships"). Bullying is particularly common towards schizoid individuals. Suicide may be a running mental theme for schizoid individuals, though they are not likely to actually attempt it. Some symptoms of SzPD (e.g. solitary lifestyle, emotional detachment, loneliness, and impaired communication), however, have been stated as general risk factors for serious suicidal behaviour.

Signs and symptoms
People with SzPD are often aloof, cold and indifferent, which causes interpersonal difficulty. Most individuals diagnosed with SzPD have trouble establishing personal relationships or expressing their feelings meaningfully. They may remain passive in the face of unfavorable situations. Their communication with other people may be indifferent and terse at times. Schizoid personality types often lack the ability to assess the impact of their own actions in social situations.A person with SzPD may feel suffocated when their personal space is violated and take actions to avoid this feeling. People who have SzPD tend to be happiest when in relationships in which their partner places few emotional or intimate demands on them and does not expect phatic or social niceties. It is not necessarily people they want to avoid, but negative or positive emotional expectations, emotional intimacy and self-disclosure. Therefore, it is possible for individuals with SzPD to form relationships with others based on intellectual, physical, familial, occupational or recreational activities, as long as there is no need for emotional intimacy. Donald Winnicott explains this is because schizoid individuals "prefer to make relationships on their own terms and not in terms of the impulses of other people." Failing to attain that, they prefer isolation. In general, friendship among schizoids is usually limited to one person, often also schizoid, forming what has been called a union of two eccentrics; "within it – the ecstatic cult of personality, outside it – everything is sharply rejected and despised".Although there is the belief people with SzPD are complacent and unaware of their feelings, many recognize their differences from others. Some individuals with SzPD who are in treatment say "life passes them by" or they feel like living inside a shell; they see themselves as "missing the bus" and speak of observing life from a distance.Aaron Beck and his colleagues report that people with SzPD seem comfortable with their aloof lifestyle and consider themselves observers, rather than participants in the world around them. But they also mention that many of their schizoid patients recognize themselves as socially deviant (or even defective) when confronted with the different lives of ordinary people – especially when they read books or see movies focusing on relationships. Even when schizoid individuals may not long for closeness, they can become weary of being "on the outside, looking in". These feelings may lead to depression or depersonalization. If they do, schizoid people often experience feeling "like a robot" or "going through life in a dream".According to Guntrip, Klein and others, people with SzPD may possess a hidden sense of superiority and lack dependence on other peoples opinions. This is very different from the grandiosity seen in narcissistic personality disorder, which is described as "burdened with envy" and with a desire to destroy or put down others. Additionally, schizoids do not go out of their way to achieve social validation.: 60  Unlike the narcissist, the schizoid will often keep their creations private to avoid unwelcome attention or the feeling that their ideas and thoughts are being appropriated by the public.: 174 The related schizotypal personality disorder and schizophrenia are reported to have ties to creative thinking, and it is speculated that the internal fantasy aspect of SzPD may also be reflective of this thinking. Alternatively, there has been an especially large contribution of people with schizoid symptoms to science and theoretical areas of knowledge, including maths, physics, economics, etc. At the same time, people with SzPD are helpless at many practical activities because of their symptoms.

Secret schizoids
Many schizoid individuals display an engaging, interactive personality, contradicting the observable characteristic emphasized by the DSM-5 and ICD-10 definitions of the schizoid personality. Guntrip (using ideas of Klein, Fairbairn and Winnicott) classifies these individuals as "secret schizoids", who behave with socially available, interested, engaged and involved interaction yet remain emotionally withdrawn and sequestered within the safety of the internal world.: 17  Klein distinguishes between a "classic" SzPD and a "secret" SzPD, which occur "just as often" as each other. Klein cautions one should not misidentify the schizoid person as a result of the patients defensive, compensatory interaction with the external world. He suggests one ask the person what their subjective experience is, to detect the presence of the schizoid refusal of emotional intimacy and preference for objective fact.Frequently, a schizoid individuals social functioning improves, sometimes dramatically, when the individual knows they are an anonymous participant in a real-time conversation or correspondence, e.g. in an online chatroom or message board. It is often the case the individuals online correspondent will report nothing amiss in the individuals engagement and affect. A 2013 study looking at personality disorders and Internet use found that being online more hours per day predicted signs of SzPD. Additionally, SzPD correlated with lower phone call use and fewer Facebook friends.Descriptions of the schizoid personality as "hidden" behind an outward appearance of emotional engagement have been recognized since 1940, with Fairbairns description of "schizoid exhibitionism", in which the schizoid individual is able to express a great deal of feeling and to make what appear to be impressive social contacts yet in reality gives nothing and loses nothing. Because they are "playing a part", their personality is not involved. According to Fairbairn, the person disowns the part they are playing, and the schizoid individual seeks to preserve their personality intact and immune from compromise. The schizoids false persona is based around what those around them define as normal or good behaviour, as a form of compliance.: 143  Further references to the secret schizoid come from Masud Khan, Jeffrey Seinfeld and Philip Manfield, who give a description of an SzPD individual who "enjoys" public speaking engagements but experiences great difficulty in the breaks when audience members would attempt to engage him emotionally. These references expose the problems in relying on outer observable behavior for assessing the presence of personality disorders in certain individuals.

Schizoid fantasy
A pathological reliance on fantasizing and preoccupation with inner experience is often part of the schizoid withdrawal from the world. Fantasy thus becomes a core component of the self in exile, though fantasizing in schizoid individuals is far more complicated than a means of facilitating withdrawal.: 64 Fantasy is also a relationship with the world and with others by proxy. It is a substitute relationship, but a relationship nonetheless, characterized by idealized, defensive and compensatory mechanisms. This is self-contained and free from the dangers and anxieties associated with emotional connection to real persons and situations. Klein explains it as "an expression of the self struggling to connect to objects, albeit internal objects. Fantasy permits schizoid patients to feel connected, and yet still free from the imprisonment in relationships. In short, in fantasy one can be attached (to internal objects) and still be free." This aspect of schizoid pathology has been generously elaborated in works by R. D. Laing, Donald Winnicott and Ralph Klein.: 64

Sexuality
People with SzPD are sometimes sexually apathetic, though they do not typically experience anorgasmia. Their preference to remain alone and detached may cause their need for sex to appear to be less than that of those who do not have SzPD. Sex often causes individuals with SzPD to feel that their personal space is being violated, and they commonly feel that masturbation or sexual abstinence is preferable to the emotional closeness they must tolerate when having sex. Significantly broadening this picture are notable exceptions of SzPD individuals who engage in occasional or even frequent sexual activities with others.Fairbairn notes that schizoids can fear that in a relationship, their needs will weaken and exhaust their partner, so they feel forced to disown them and move to satisfy solely the needs of the partner. The net result of this is a loss of dignity and sense of self within any relationship they enter, eventually leading to intolerable frustration and friction. Appel notes that these fears result in the schizoids negativism, stubbornness and reluctance to love. Thus, a central conflict of the schizoid is between an immense longing for relationships but a deep anxiety and avoidance of relationships, manifested by the choosing of the "lesser evil" of abandoning others.: 100 Individuals with SzPD have long been noted to have an increased rate of unconventional sexual tendencies, though if present, these are rarely acted upon. The schizoid is often labelled asexual or presents with "a lack of sexual identity". Kernberg states that this apparent lack of a sexuality does not represent a lack of sexual definition but rather a combination of several strong fixations to cope with the same conflicts.: 125  People with SzPD are often able to pursue any fantasies with content on the Internet while remaining completely unengaged with the outside world.: 127

Akhtars profile
American psychoanalyst Salman Akhtar provided a comprehensive phenomenological profile of SzPD in which classic and contemporary descriptive views are synthesized with psychoanalytic observations. This profile is summarized in the table reproduced below that lists clinical features that involve six areas of psychosocial functioning and are organized by "overt" and "covert" manifestations.
"Overt" and "covert" are intended to denote seemingly contradictory aspects that may both simultaneously be present in an individual. These designations do not necessarily imply their conscious or unconscious existence. The covert characteristics are by definition difficult to discern and not immediately apparent. Additionally, the lack of data on the frequency of many of the features makes their relative diagnostic weight difficult to distinguish at this time. However, Akhtar states that his profile has several advantages over the DSM in terms of maintaining historical continuity of the use of the word schizoid, valuing depth and complexity over descriptive oversimplification and helping provide a more meaningful differential diagnosis of SzPD from other personality disorders.

Causes
Some evidence suggests the cluster A personality disorders have shared genetic and environmental risk factors, and there is an increased prevalence of SzPD in relatives of people with schizophrenia and schizotypal personality disorder. Twin studies with SzPD traits (e.g. low sociability and low warmth) suggest these are inherited. Besides this indirect evidence, the direct heritability estimates of SzPD range from 50 to 59%. To Sula Wolff, who did extensive research and clinical work with children and teenagers with schizoid symptoms, "schizoid personality has a constitutional, probably genetic, basis." The link between SzPD and being underweight may also point to the involvement of biological factors.In general, prenatal caloric malnutrition, premature birth and a low birth weight are risk factors for having a mental disorder and may contribute to the development of SzPD as well. Those who have experienced traumatic brain injury may be also at risk of developing features reflective of SzPD.Other historical researchers had hypothesized excessively perfectionist, unloving or neglectful parenting could play a role.

Diagnosis
DSM-5 criteria
The Diagnostic and Statistical Manual of Mental Disorders is a widely used manual for diagnosing mental disorders. DSM-5 includes SzPD with the same criteria as in DSM-IV. In the DSM-5, SzPD is described as a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by at least four of the following:
Neither desires nor enjoys close relationships, including being part of a family.
Almost always chooses solitary activities.
Has little, if any, interest in having sexual experiences with another person.
Takes pleasure in few, if any, activities.
Lacks close friends or confidants other than first-degree relatives.
Appears indifferent to the praise or criticism of others.
Shows emotional coldness, detachment, or flattened affectivity.According to the DSM, those with SzPD may often be unable to, or will rarely express aggressiveness or hostility, even when provoked directly. These individuals can seem vague or drifting about their goals and their lives may appear directionless. Others view them as indecisive in their actions, self-absorbed, absent-minded and detached from their surroundings. Excessive daydreaming is often present. In cases with severe defects in the capacity to form social relationships, dating and marriage may not be possible.

ICD-10 criteria
The Classification of Mental and Behavioural Disorders of ICD-10 lists SzPD under (F60.1).The general criteria of personality disorder (F60) should be met first. In addition, at least four of the following criteria must be present:

Few, if any, activities provide pleasure.
Displays emotional coldness, detachment, or flattened affectivity.
Limited capacity to express warm, tender feelings for others as well as anger.
Appears indifferent to either praise or criticism from others.
Little interest in having sexual experiences with another person (taking into account age).
Almost always chooses solitary activities.
Excessive preoccupation with fantasy and introspection.
Neither desires, nor has, any close friends or confiding relationships (or only one).
Marked insensitivity to prevailing social norms and conventions; if these are not followed, this is unintentional.

Guntrip criteria
Ralph Klein, Clinical Director of the Masterson Institute, delineates the following nine characteristics of the schizoid personality as described by Harry Guntrip:: 13–23
Introversion
Withdrawnness
Narcissism
Self-sufficiency
A sense of superiority
Loss of affect
Loneliness
Depersonalization
RegressionThe description of Guntrips nine characteristics should clarify some differences between the traditional DSM portrait of SzPD and the traditional informed object relations view. All nine characteristics are consistent. Most, if not all, must be present to diagnose a schizoid disorder.

Millons subtypes
Theodore Millon restricted the term "schizoid" to those personalities who lack the capacity to form social relationships. He characterizes their way of thinking as being vague and void of thoughts and as sometimes having a "defective perceptual scanning". Because they often do not perceive cues that trigger affective responses, they experience fewer emotional reactions.For Millon, SzPD is distinguished from other personality disorders in that it is "the personality disorder that lacks a personality." He criticizes that this may be due to the current diagnostic criteria: They describe SzPD only by an absence of certain traits, which results in a "deficit syndrome" or "vacuum". Instead of delineating the presence of something, they mention solely what is lacking. Therefore, it is hard to describe and research such a concept.He identified four subtypes of SzPD. Any individual schizoid may exhibit none or one of the following:

Differential diagnosis
While SzPD shares several symptoms with other mental disorders, there are some important differentiating features:

Comorbidity
SzPD is often found to be comorbid with at least one of several disorders or pathologies. Sometimes, a person with SzPD may meet criteria for an additional personality disorder; when this happens, it is most often avoidant, schizotypal or paranoid PD. Alexithymia (the inability to identify and describe emotions) is often present in SzPD. Sharon Ekleberry suggests that some people with schizoid personality features may occasionally experience instances of brief reactive psychosis when under stress.

Substance use disorder
Very little data exists for rates of substance use disorder among people with SzPD, but existing studies suggest they are less likely to have substance abuse problems than the general population. One study found that significantly fewer boys with SzPD had alcohol problems than a control group of non-schizoids. Another study evaluating personality disorder profiles in substance abusers found that substance abusers who showed schizoid symptoms were more likely to abuse one substance rather than many, in contrast to other personality disorders such as borderline, antisocial or histrionic, which were more likely to abuse many.American psychotherapist Sharon Ekleberry states that the impoverished social connections experienced by people with SzPD limit their exposure to the drug culture and that they have limited inclination to learn how to do illegal drugs. Describing them as "highly resistant to influence", she additionally states that even if they could access illegal drugs, they would be disinclined to use them in public or social settings, and because they would be more likely to use alcohol or cannabis alone than for social disinhibition, they would not be particularly vulnerable to negative consequences in early use.

Suicide
Suicide may be a running theme for schizoid individuals, in part due to the knowledge of the large-scale ostracism that would result if their idiosyncratic views were revealed and their experience that most, if not all people, are unrelatable or have polar opposite reactions to them on societally sensitive issues, though they are not likely to actually attempt it. They might be down and depressed when all possible connections have been cut off, but as long as there is some relationship or even hope for one the risk will be low. The idea of suicide is a driving force against the persons schizoid defenses. Often among people with SzPD, there is a rationally grounded and reasoned position on why they want to die, and this "suicidal construct" takes a stable position in the mind.
A mini-review indicates that SzPD or schizoid traits are a major risk factor for both suicide attempts and suicide. Schizoids tend to hide their suicidal thoughts and intentions. Demonstrative suicides or suicide blackmail, as seen in cluster B personality disorders such as borderline, histrionic or antisocial, are extremely rare among schizoid individuals.In cases with schizoid disorder, the characteristics of the premorbidities (emotional coldness, autism, inability to have fun) also affected suicidal behaviour. Their suicides were always genuine in nature, well-planned, and it was only by chance that these patients survived (usually the fatal outcome was prevented by the sudden appearance of others). They denied the existence of suicidal experiences earlier, but argued that in the current circumstances, suicide seemed to them the most appropriate way out. This "suicidal construction" was well-reasoned and took a stable position in the mind. Important in all these cases was the absence of any significant anti-suicidal factors (most were found in a situation of relative social isolation; there were no professional and personal interests). The high ability to introspect in these cases only increased the isolation from reality and made the choice in favour of suicide more reasonable.As in other clinical mental health settings, among suicidal inpatients, individuals with SzPD are not as well-represented as some other groups. A 2011 study on suicidal inpatients at a Moscow hospital found that schizoids were the least common patients, while those with cluster B personality disorders were the most common.

Asperger syndrome
Several studies have reported an overlap or comorbidity with the autism spectrum disorder Asperger syndrome. Asperger syndrome had traditionally been called "schizoid disorder of childhood", and Eugen Bleuler coined both the terms "autism" and "schizoid" to describe withdrawal to an internal fantasy, against which any influence from outside becomes an intolerable disturbance. In a 2012 study of a sample of 54 young adults with Asperger syndrome, it was found that 26% of them also met criteria for SzPD, the highest comorbidity out of any personality disorder in the sample (the other comorbidities were 19% for obsessive–compulsive personality disorder, 13% for avoidant personality disorder and one female with schizotypal personality disorder). Additionally, twice as many men with Asperger syndrome met criteria for SzPD than women. While 41% of the whole sample were unemployed with no occupation, this rose to 62% for the Aspergers and SzPD comorbid group. Tantam suggested that Asperger syndrome may confer an increased risk of developing SzPD. A 2019 study found that 54% of a group of males aged 11 to 25 with Asperger syndrome showed significant SzPD traits, with 6% meeting full diagnostic criteria for SzPD, compared to 0% of a control.In the 2012 study, it was noted that the DSM may complicate diagnosis by requiring the exclusion of a pervasive developmental disorder (PDD) before establishing a diagnosis of SzPD. The study found that social interaction impairments, stereotyped behaviours and specific interests were more severe in the individuals with Asperger syndrome also fulfilling SzPD criteria, against the notion that social interaction skills are unimpaired in SzPD. The authors believe that substantial subgroup of people with autism spectrum disorder or PDD have clear "schizoid traits" and correspond largely to the "loners" in Lorna Wings classification The autism spectrum (Lancet 1997), described by Sula Wolff. The authors of the 2019 study hypothesised that it is extremely likely that historic cohorts of adults diagnosed with SzPD either also had childhood-onset autistic syndromes or were misdiagnosed. They stressed that further research to clarify overlap and distinctions between these two syndromes was strongly warranted, especially given that high-functioning autism spectrum disorders are now recognised in around 1% of the population.

Low weight
A study which looked at the body mass index (BMI) of a sample of both male adolescents diagnosed with SzPD and those diagnosed with Asperger syndrome found that the BMI of all patients was significantly below normal. Clinical records indicated abnormal eating behaviour by some patients. Some patients would only eat when alone and refused to eat out. Restrictive diets and fears of disease were also found. It was suggested that the anhedonia of SzPD may also cover eating, leading schizoid individuals to not enjoy it. Alternatively, it was suggested that schizoid individuals may not feel hunger as strongly as others or not respond to it, a certain withdrawal "from themselves".

Anti-social conduct
Another study looked at rates of anti-social conduct in boys with either SzPD or Asperger syndrome compared with a control group of non-schizoid individuals and found the incidence of anti-social conduct to be the same in both groups. However, the schizoid boys stole significantly less. Upon follow-up in adulthood, out of a matched group of 19 boys with SzPD and 19 boys without, four of the schizoid boys reported having exclusively internal violent fantasies (concerned with Zulu wars, abattoirs, fascists and communists and a collection of knives, respectively), which were pursued entirely by themselves, while the only non-schizoid subject to report a violent fantasy life shared his with a group of young men (dressing up and riding motorcycles as a self-styled "panzer" group).An absent parent or socio-economic disadvantage did not seem to affect the risk of anti-social conduct in schizoid individuals as much as it did in non-schizoid individuals. Absent parents and parental socio-economic disadvantage were also less common in the schizoid group.

Controversy
The original concept of the schizoid character developed by Ernst Kretschmer in the 1920s comprised an amalgamation of avoidant, schizotypal and schizoid traits. It was not until 1980 and the work of Theodore Millon that led to splitting this concept into three personality disorders (now schizoid, schizotypal and avoidant). This caused debate about whether this was accurate or if these traits were different expressions of a single personality disorder. It has also been argued due to the poor consistency and efficiency of diagnosis due to overlapping traits that SzPD should be removed altogether from the DSM.A 2012 article suggested that two different disorders may better represent SzPD: one affect-constricted disorder (belonging to schizotypal PD) and a seclusive disorder (belonging to avoidant PD). They called for the replacement of the SzPD category from future editions of the DSM by a dimensional model which would allow for the description of schizoid traits on an individual basis.Some critics such as Nancy McWilliams of Rutgers University and Parpottas Panagiotis of European University Cyprus argue that the definition of SzPD is flawed due to cultural bias and that it does not constitute a mental disorder but simply an avoidant attachment style requiring more distant emotional proximity. If that is true, then many of the more problematic reactions these individuals show in social situations may be partly accounted for by the judgements commonly imposed on people with this style. However, impairment is mandatory for any behaviour to be diagnosed as a personality disorder. SzPD seems to satisfy this criterion because it is linked to negative outcomes. These include a significantly compromised quality of life, reduced overall functioning even after 15 years and one of the lowest levels of "life success" of all personality disorders (measured as "status, wealth and successful relationships"). However, determination of what qualify as "impairments" or as "negative outcomes" is itself potentially subject to cultural bias. People with SzPD may not regard a lack of social-status or successful relationships, for example, as a harm. Furthermore, correlation with negative outcomes does not necessarily demonstrate that these outcomes were directly caused by the schizoidal traits. Rather, it may be that these outcomes are the result of discrimination against people with SzPD, who may be viewed as abnormal.

Treatment
People with SzPD rarely seek treatment for their condition. This issue is found in many personality disorders, which prevents many people with these conditions from seeking treatment: they tend to view their condition as not conflicting with their self-image and their abnormal perceptions and behaviors as rational and appropriate. There are little data on the effectiveness of various treatments on this personality disorder because it is seldom seen in clinical settings. However, those in treatment have the option of medication and psychotherapy.

Medication
No medications are indicated for directly treating SzPD, but certain medications may reduce the symptoms of SzPD as well as treat co-occurring mental disorders. The symptoms of SzPD mirror the negative symptoms of schizophrenia, such as anhedonia, blunted affect and low energy, and SzPD is thought to be part of the "schizophrenic spectrum" of disorders, which also includes the schizotypal and paranoid personality disorders, and may benefit from the medications indicated for schizophrenia. Originally, low doses of atypical antipsychotics like risperidone or olanzapine were used to alleviate social deficits and blunted affect. However, a 2012 review concluded that atypical antipsychotics were ineffective for treating personality disorders.In contrast, the substituted amphetamine bupropion may be used to treat anhedonia. Likewise, modafinil may be effective in treating some of the negative symptoms of schizophrenia, which are reflected in the symptomatology of SzPD and therefore may help as well. Lamotrigine, SSRIs, TCAs, MAOIs and hydroxyzine may help counter social anxiety in people with SzPD if present, though social anxiety may not be a main concern for the people who have SzPD. However, it is not general practice to treat SzPD with medications, other than for the short-term treatment of acute co-occurring axis I conditions (e.g. depression).

Psychotherapy
Despite the relative emotional comfort, psychoanalytic therapy of schizoid individuals takes a long time and causes many difficulties. Schizoids are generally poorly involved in psychotherapy due to difficulties in establishing empathic relations with a psychotherapist and low motivation for treatment.Supportive psychotherapy is used in an inpatient or outpatient setting by a trained professional that focuses on areas such as coping skills, improvement of social skills and social interactions, communication and self-esteem issues. People with SzPD may also have a perceptual tendency to miss subtle differences in expression. That causes an inability to pick up hints from the environment because social cues from others that might normally provoke an emotional response are not perceived. That in turn limits their own emotional experience. The perception of varied events only increases their fear for intimacy and limits them in their interpersonal relationships. Their aloofness may limit their opportunities to refine the social skills and behavior necessary to effectively pursue relationships.Besides psychodynamic therapy, cognitive behavioral therapy (CBT) can be used. But because CBT generally begins with identifying the automatic thoughts, one should be aware of the potential hazards that can happen when working with schizoid patients. People with SzPD seem to be distinguished from those with other personality disorders in that they often report having few or no automatic thoughts at all. That poverty of thought may have to do with their apathetic lifestyle. But another possible explanation could be the paucity of emotion many schizoids display, which would influence their thought patterns as well.Socialization groups may help people with SzPD. Educational strategies in which people who have SzPD identify their positive and negative emotions also may be effective. Such identification helps them to learn about their own emotions and the emotions they draw out from others and to feel the common emotions with other people with whom they relate. This can help people with SzPD create empathy with the outside world.

Shorter-term treatment
The concept of "closer compromise" means that the schizoid patient may be encouraged to experience intermediate positions between the extremes of emotional closeness and permanent exile. A lack of injections of interpersonal reality causes an impoverishment in which the schizoid individuals self-image becomes increasingly empty and volatilized and leads the individual to feel unreal. To create a more adaptive and self-enriching interaction with others in which one "feels real", the patient is encouraged to take risks through greater connection, communication and sharing of ideas, feelings and actions. Closer compromise means that while the patients vulnerability to anxieties is not overcome, it is modified and managed more adaptively. Here, the therapist repeatedly conveys to the patient that anxiety is inevitable but manageable, without any illusion that the vulnerability to such anxiety can be permanently dispensed with. The limiting factor is the point at which the dangers of intimacy become overwhelming and the patient must again retreat.
Klein suggests that patients must take the responsibility to place themselves at risk and to take the initiative for following through with treatment suggestions in their personal lives. It is emphasized that these are the therapists impressions and that he or she is not reading the patients mind or imposing an agenda but is simply stating a position that is an extension of the patients therapeutic wish. Finally, the therapist directs attention to the need to employ these actions outside of the therapeutic setting.

Longer-term therapy
Klein suggests that "working through" is the second longer-term tier of psychotherapeutic work with schizoid patients. Its goals are to change fundamentally the old ways of feeling and thinking and to rid oneself of the vulnerability to those emotions associated with old feelings and thoughts. A new therapeutic operation of "remembering with feeling" that draws on D. W. Winnicotts concepts of false self and true self is called for. The patient must remember with feeling the emergence of his or her false self through childhood and remember the conditions and proscriptions that were imposed on the individuals freedom to experience the self in company with others.Remembering with feeling ultimately leads the patient to understand that he or she had no opportunity to choose from a selection of possible ways of experiencing the self and of relating with others and had few, if any, options other than to develop a schizoid stance toward others. The false self was simply the best way in which the patient could experience the repetitive predictable acknowledgement, affirmation and approval necessary for emotional survival while warding off the effects associated with the abandonment depression.If the goal of shorter-term therapy is for patients to understand that they are not the way they appear to be and can act differently, then the longer-term goal of working through is for patients to understand who and what they are as human beings, what they truly are like and what they truly contain. The goal of working through is not achieved by the patients sudden discovery of a hidden, fully formed talented and creative self living inside, but is a process of slowly freeing oneself from the confinement of abandonment depression in order to uncover a potential. It is a process of experimentation with the spontaneous, nonreactive elements that can be experienced in relationship with others.Working through abandonment depression is a complicated, lengthy and conflicted process that can be an enormously painful experience in terms of what is remembered and what must be felt. It involves mourning and grieving for the loss of the illusion that the patient had adequate support for the emergence of the real self. There is also a mourning for the loss of an identity, the false self, which the person constructed and with which he or she has negotiated much of his or her life. The dismantling of the false self requires relinquishing the only way that the patient has ever known of how to interact with others. This interaction was better than not to have a stable, organized experience of the self, no matter how false, defensive or destructive that identity may be.
The dismantling of the false self "leaves the impaired real self with the opportunity to convert its potential and its possibilities into actualities." Working through brings unique rewards, of which the most important element is the growing realization that the individual has a fundamental, internal need for relatedness that may be expressed in a variety of ways. "Only schizoid patients", suggests Klein, "who have worked through the abandonment depression ... ultimately will believe that the capacity for relatedness and the wish for relatedness are woven into the structure of their beings, that they are truly part of who the patients are and what they contain as human beings. It is this sense that finally allows the schizoid patient to feel the most intimate sense of being connected with humanity more generally, and with another person more personally. For the schizoid patient, this degree of certainty is the most gratifying revelation, and a profound new organizer of the self experience.": 127

Development and course
SzPD can be first apparent in childhood and adolescence with solitariness, poor peer relationships and underachievement in school. This may mark these children as different and make them subject to teasing.Being a personality disorder, which is usually chronic and long-lasting mental conditions, SzPD is not expected to improve with time without treatment; however, much remains unknown because it is rarely encountered in clinical settings.

Epidemiology
SzPD is uncommon in clinical settings (about 2.2%) and occurs more commonly in males. It is rare compared with other personality disorders, with a prevalence estimated at less than 1% of the general population.Philip Manfield suggests that the "schizoid condition", which roughly includes the DSM schizoid, avoidant and schizotypal personality disorders, is represented by "as many as forty percent of all personality disorders." Manfield adds "This huge discrepancy [from the ten percent reported by therapists for the condition] is probably largely because someone with a schizoid disorder is less likely to seek treatment than someone with other axis-II disorders."A 2008 study assessing personality and mood disorder prevalence among homeless people at New York City drop-in centres reported an SzPD rate of 65% among this sample. The study did not assess homeless people who did not show up at drop-in centres, and the rates of most other personality and mood disorders within the drop-in centres was lower than that of SzPD. The authors noted the limitations of the study, including the higher male-to-female ratio in the sample and the absence of subjects outside the support system or receiving other support (e.g., shelters) as well as the absence of subjects in geographical settings outside New York City, a large city often considered a magnet for disenfranchised people.A University of Colorado Colorado Springs study comparing personality disorders and Myers–Briggs Type Indicator types found that the disorder had a significant correlation with the Introverted (I) and Thinking (T) preferences.

History
The term "schizoid" was coined in 1908 by Eugen Bleuler to designate a human tendency to direct attention toward ones inner life and away from the external world, a concept akin to introversion in that it was not viewed in terms of psychopathology. Bleuler labeled the exaggeration of this tendency the "schizoid personality". He described these personalities as "comfortably dull and at the same time sensitive, people who in a narrow manner pursue vague purposes".In 1910, August Hoch introduced a very similar concept called the "shut-in" personality. Characteristics of it were reticence, seclusiveness, shyness and a preference for living in fantasy worlds, among others </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Cannabis use disorder and can you explain it in depth? [/INST] Cannabis use disorder (CUD), also known as cannabis addiction or marijuana addiction, is defined in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and ICD-10 as the continued use of cannabis despite clinically significant impairment.

Signs and symptoms
Cannabis use is associated with comorbid mental health problems, such as mood and anxiety disorders, and discontinuing cannabis use is difficult for some users. Psychiatric comorbidities are often present in dependent cannabis users including a range of personality disorders.Based on annual survey data, some high school seniors who report smoking daily (nearly 7%, according to one study) may function at a lower rate in school than students that do not. The sedating and anxiolytic properties of tetrahydrocannabinol (THC) in some users might make the use of cannabis an attempt to self-medicate personality or psychiatric disorders.

Dependency
Prolonged cannabis use produces both pharmacokinetic changes (how the drug is absorbed, distributed, metabolized, and excreted) and pharmacodynamic changes (how the drug interacts with target cells) to the body. These changes require the user to consume higher doses of the drug to achieve a common desirable effect (known as a higher tolerance), reinforcing the bodys metabolic systems for eliminating the drug more efficiently and further down-regulating cannabinoid receptors in the brain.Cannabis users have shown decreased reactivity to dopamine, suggesting a possible link to a dampening of the reward system of the brain and an increase in negative emotion and addiction severity.Cannabis users can develop tolerance to the effects of THC. Tolerance to the behavioral and psychological effects of THC has been demonstrated in adolescent humans and animals. The mechanisms that create this tolerance to THC are thought to involve changes in cannabinoid receptor function.One study has shown that between 2001–2002 and 2012–2013, the use of marijuana in the US doubled.Cannabis dependence develops in about 9% of users, significantly less than that of heroin, cocaine, alcohol, and prescribed anxiolytics, but slightly higher than that for psilocybin, mescaline, or LSD. Of those who use cannabis daily, 10–20% develop dependence.

Withdrawal
Cannabis withdrawal symptoms occur in one-half of people in treatment for cannabis use disorders. Symptoms may include dysphoria (anxiety, irritability, depression, restlessness), disturbed sleep, gastrointestinal symptoms, and decreased appetite. It is often paired with rhythmic movement disorder. Most symptoms begin during the first week of abstinence and resolve after a few weeks. About 12% of heavy cannabis users showed cannabis withdrawal as defined by the DSM-5, and this was associated with significant disability as well as mood, anxiety and personality disorders.

Cause
Cannabis addiction is often due to prolonged and increasing use of the drug. Increasing the strength of the cannabis taken and an increasing use of more effective methods of delivery often increase the progression of cannabis dependency. It can also be caused by being prone to becoming addicted to substances, which can either be genetically or environmentally acquired.

Risk factors
Certain factors are considered to heighten the risk of developing cannabis dependence and longitudinal studies over a number of years have enabled researchers to track aspects of social and psychological development concurrently with cannabis use. Increasing evidence is being shown for the elevation of associated problems by the frequency and age at which cannabis is used, with young and frequent users being at most risk.The main factors in Australia, for example, related to a heightened risk for developing problems with cannabis use include frequent use at a young age; personal maladjustment; emotional distress; poor parenting; school drop-out; affiliation with drug-using peers; moving away from home at an early age; daily cigarette smoking; and ready access to cannabis. The researchers concluded there is emerging evidence that positive experiences to early cannabis use are a significant predictor of late dependence and that genetic predisposition plays a role in the development of problematic use.

High risk groups
A number of groups have been identified as being at greater risk of developing cannabis dependence and, in Australia, for example, have been found to include adolescent populations, Aboriginal and Torres Strait Islanders and people with mental health conditions.

Adolescents
The endocannabinoid system is directly involved in adolescent brain development. Adolescent cannabis users are therefore particularly vulnerable to the potential adverse effects of cannabis use. Adolescent cannabis use is associated with increased cannabis misuse as an adult, issues with memory and concentration, long-term cognitive complications, and poor psychiatric outcomes including social anxiety, suicidality and addiction.There are a lot of reasons why adolescents start a smoking habit. According to a study completed by Bill Sanders, influence from friends, difficult household problems, and experimentation are some of the reasons why this population starts to smoke marijuana. This segment of population seems to be one of the most influenceable group there is. They want to follow the group and look "cool", "hip" and accepted by their friends. This fear of rejection plays a big role in their decision to smoke pot. However it does not seem to be the most important factor. According to a study from Canada, the lack of knowledge about cannabis seems to be the main reason why adolescents start to smoke. The authors observed a high correlation between adolescents that knew about the mental and physical harms of cannabis and their consumption. Of the 1045 young participants in the study, those who could name the least number of negative effects about this drug were usually the ones who were consuming it. They were not isolated cases either. Actually, the study showed that the proportion of teenagers who saw cannabis as a high-risk drug and the ones who thought the contrary was about the same.

Pregnancy
There is an association between smoking cannabis during pregnancy and low birth weight. Smoking cannabis during pregnancy can lower the amount of oxygen delivered to the developing fetus, which can restrict fetal growth. The active ingredient in cannabis (D9-tetrahydrocannabinol, THC) is fat soluble and can enter into breastmilk during lactation. THC in breastmilk can then subsequently be taken up by a breastfeeding infant, as shown by the presence of THC in the infants feces. However, the evidence for long-term effects of exposure to THC through breastmilk is unclear.

Diagnosis
Cannabis use disorder is recognized in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which also added cannabis withdrawal as a new condition.In the 2013 revision for the DSM-5, DSM-IV abuse and dependence were combined into cannabis use disorder. The legal problems criterion (from cannabis abuse) has been removed, and the craving criterion was newly added, resulting in a total of eleven criteria: hazardous use, social/interpersonal problems, neglected major roles, withdrawal, tolerance, used larger amounts/longer, repeated attempts to quit/control use, much time spent using, physical/psychological problems related to use, activities given up and craving. For a diagnosis of DSM-5 cannabis use disorder, at least two of these criteria need to be present in the last twelve-month period. Additionally, three severity levels have been defined: mild (two or three criteria), moderate (four or five criteria) and severe (six or more criteria) cannabis use disorder.Cannabis use disorder is also recognized in the eleventh revision of the International Classification of Diseases (ICD-11), adding more subdivisions including time intervals of pattern of use (episodic, continuous, or unspecified) and dependence (current, early full remission, sustained partial remission, sustained full remission, or unspecified) compared to the 10th revision.A 2019 meta-analysis found that 34% of people with cannabis-induced psychosis transitioned to schizophrenia. This was found to be comparatively higher than hallucinogens (26%) and amphetamines (22%).To screen for cannabis-related problems, several methods are used. Scales specific to cannabis, which provides the benefit of being cost efficient compared to extensive diagnostic interviews, include the Cannabis Abuse Screening Test (CAST), Cannabis Use Identification Test (CUDIT), and Cannabis Use Problems Identification Test (CUPIT). Scales for general drug use disorders are also used, including the Severity Dependence Scale (SDS), Drug Use Disorder Identification Test (DUDIT), and Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). However, there are no gold standard and both older and newer scales are still in use. To quantify cannabis use, methods such as Timeline Follow-Back (TLFB) and Cannabis Use Daily (CUD) are used. These methods measure general consumption and not grams of psychoactive substance as the concentration of THC may vary among drug users.

Treatment
Clinicians differentiate between casual users who have difficulty with drug screens, and daily heavy users, to a chronic user who uses multiple times a day. In the US, as of 2013, cannabis is the most commonly identified illicit substance used by people admitted to treatment facilities. Demand for treatment for cannabis use disorder increased internationally between 1995 and 2002. In the United States, the average adult who seeks treatment has consumed cannabis for over 10 years almost daily and has attempted to quit six or more times.Treatment options for cannabis dependence are far fewer than for opiate or alcohol dependence. Most treatment falls into the categories of psychological or psychotherapeutic, intervention, pharmacological intervention or treatment through peer support and environmental approaches. No medications have been found effective for cannabis dependence, but psychotherapeutic models hold promise. Screening and brief intervention sessions can be given in a variety of settings, particularly at doctors offices, which is of importance as most cannabis users seeking help will do so from their general practitioner rather than a drug treatment service agency.The most commonly accessed forms of treatment in Australia are 12-step programmes, physicians, rehabilitation programmes, and detox services, with inpatient and outpatient services equally accessed. In the EU approximately 20% of all primary admissions and 29% of all new drug clients in 2005, had primary cannabis problems. And in all countries that reported data between 1999 and 2005 the number of people seeking treatment for cannabis use increased.

Psychological
Psychological intervention includes cognitive behavioral therapy (CBT), motivational enhancement therapy (MET), contingency management (CM), supportive-expressive psychotherapy (SEP), family and systems interventions, and twelve-step programs.Evaluations of Marijuana Anonymous programs, modelled on the 12-step lines of Alcoholics Anonymous and Narcotics Anonymous, have shown small beneficial effects for general drug use reduction. In 2006, the Wisconsin Initiative to Promote Healthy Lifestyles implemented a program that helps primary care physicians identify and address marijuana use problems in patients.

Medication
As of 2020, there is no single medication that has been proven effective for treating cannabis use disorder; research is focused on three treatment approaches: agonist substitution, antagonist, and modulation of other neurotransmitter systems. More broadly, the goal of medication therapy for cannabis use disorder centers around targeting the stages of the addiction: acute intoxication/binge, withdrawal/negative affect, and preoccupation/anticipation.For the treatment of the withdrawal/negative affect symptom domain of cannabis use disorder, medications may work by alleviating restlessness, irritable or depressed mood, anxiety, and insomnia. Bupropion, which is a norepinephrine–dopamine reuptake inhibitor, has been studied for the treatment of withdrawal with largely poor results. Atomoxetine has also shown poor results, and is as a norepinephrine reuptake inhibitor, though it does increase the release of dopamine through downstream effects in the prefrontal cortex (an area of the brain responsible for planning complex tasks and behavior). Venlafaxine, a serotonin–norepinephrine reuptake inhibitor, has also been studied for cannabis use disorder, with the thought that the serotonergic component may be useful for the depressed mood or anxious dimensions of the withdrawal symptom domain. While venlafaxine has been shown to improve mood for people with cannabis use disorder, a clinical trial in this population actually found worse cannabis abstinence rates compared to placebo. It is worth noting that venlafaxine is sometimes poorly tolerated, and infrequent use or abrupt discontinuation of its use can lead to withdrawal symptoms from the medication itself, including irritability, dysphoria, and insomnia. It is possible that venlafaxine use actually exacerbated cannabis withdrawal symptoms, leading people to use more cannabis than placebo to alleviate their discomfort. Mirtazapine, which increases serotonin and norepinephrine, has also failed to improve abstinence rates in people with cannabis use disorder.People sometimes use cannabis to cope with their anxiety, and cannabis withdrawal can lead to symptoms of anxiety. Buspirone, a serotonin 1A receptor (5-HT1A) agonist, has shown limited efficacy for treating anxiety in people with cannabis use disorder, though there may be better efficacy in males than in females. Fluoxetine, a selective serotonin reuptake inhibitor, has failed to show efficacy in adolescents with both cannabis use disorder and depression. SSRIs are a class of antidepressant drugs that are also used for the treatment of anxiety disorders, such as generalized anxiety disorder. Vilazodone, which has both SSRI and 5-HT1A agonism properties, also failed to increase abstinence rates in people with cannabis use disorder.Studies of divalproex have found no significant benefit, though some studies have found mixed results. Baclofen, a GABA-B receptor agonist and antispasmodic medication, has been found to reduce cravings but without a significant benefit towards preventing relapse or improving sleep. Zolpidem, a GABA-A receptor agonist and "Z-hypnotic" medication, has shown some efficacy in treating insomnia due to cannabis withdrawal, though there is a potential for misuse. Entacapone was well tolerated and decreased cannabis cravings in a trial on a small number of patients. Topiramate, an antiepileptic drug, has shown mixed results in adolescents, reducing the volume of cannabis consumption without significantly increasing abstinence, with somewhat poor tolerability. Gabapentin, an indirect GABA modulator, has shown some preliminary benefit for reducing cravings and cannabis use.The agonist substitution approach is one that draws upon the analogy of the success of nicotine replacement therapy for nicotine addiction. Dronabinol, which is synthetic THC, has shown benefit in reducing cravings and other symptoms of withdrawal, though without preventing relapse or promoting abstinence. Combination therapy with dronabinol and the alpha 2 adrenergic receptor agonist lofexidine have shown mixed results, with possible benefits towards reducing withdrawal symptoms. However, overall, the combination of dronabinol and lofexidine is likely not effective for the treatment of cannabis use disorder. Nabilone, a synthetic THC analogue, has shown benefits in reducing symptoms of withdrawal such as difficulty sleeping, and decreased overall cannabis use. Despite its psychoactive effects, the slower onset of action and longer duration of action of nabilone make it less likely to be abused than cannabis itself, which makes nabilone a promising harm reduction strategy for the treatment of cannabis use disorder. The combination of nabilone and zolpidem has been shown to decrease sleep-related and mood-related symptoms of cannabis withdrawal, in addition to decreasing cannabis use. Nabiximols, a combined THC and cannabidiol (CBD) product that is formulated as an oral (buccal) spray, has been shown to improve withdrawal symptoms without improving abstinence rates. Oral CBD has not shown efficacy in reducing the signs or symptoms of cannabis use, and likely has no benefit in cannabis use withdrawal symptoms. The CB-1 receptor antagonist rimonabant has shown efficacy in reducing the effects of cannabis in users, but with a risk for serious psychiatric side effects.Naltrexone, a mu opioid receptor antagonist, has shown mixed results for cannabis use disorder—both increasing the subjective effects of cannabis when given acutely, but potentially decreasing the overall use of cannabis with chronic administration. N-acetylcysteine (NAC) has shown some limited benefit in decreasing cannabis use in adolescents, though not with adults. Lithium, a mood stabilizer, has shown mixed results for treating symptoms of cannabis withdrawal, but is likely ineffective. Quetiapine, a second-generation antipsychotic, has been shown to treat cannabis withdrawal related insomnia and decreased appetite at the expense of exacerbating cravings. Oxytocin, a neuropeptide that the body produces, has shown some benefit in reducing the use of cannabis when administered intranasally in combination with motivational enhancement therapy sessions, though the treatment effect did not persist between sessions.Finally, CB1 antagonists such as rimonabant have been tested for utility in CUD. These drugs are effective at blocking the subjective effects of cannabis intoxication as well as the somatic components. This is accomplished by preventing THC binding to the CB1 receptor, effectively eliminating the ability to get high. This is similar to how naloxone and naltrexone are used for opiates </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Koebner phenomenon and can you explain it in depth? [/INST] The Koebner phenomenon or Köbner phenomenon (UK: , US: ), also called the Koebner response or the isomorphic response, attributed to Heinrich Köbner, is the appearance of skin lesions on lines of trauma.  The Koebner phenomenon may result from either a linear exposure or irritation.  Conditions demonstrating linear lesions after a linear exposure to a causative agent include: molluscum contagiosum, warts and toxicodendron dermatitis (a dermatitis caused by a genus of plants including poison ivy).  Warts and molluscum contagiosum lesions can be spread in linear patterns by self-scratching ("auto-inoculation").  Toxicodendron dermatitis lesions are often linear from brushing up against the plant.  Causes of the Koebner phenomenon that are secondary to scratching rather than an infective or chemical cause include vitiligo, psoriasis, lichen planus, lichen nitidus, pityriasis rubra pilaris, and keratosis follicularis (Darier disease).

Definition
The Koebner phenomenon describes skin lesions which appear at the site of injury. It is seen in:
Psoriasis
Pityriasis rubra pilaris
Lichen planus
Flat warts
Lichen nitidus
Vitiligo
Lichen sclerosus
Elastosis perforans serpiginosa
Kaposi sarcoma
Necrobiosis lipoidica
Lupus
Juvenile Idiopathic Arthritis
Still disease
Cutaneous leishmaniasis
Post kala azar dermal leishmaniasisA similar response occurs in pyoderma gangrenosum and Behcets syndrome, and is referred to as pathergy.Rarely Koebner phenomenon has been reported as a mechanism of acute myeloid leukemia dissemination.Warts and molluscum contagiosum are often listed as causing a Koebner reaction, but this is by direct inoculation of viral particles.The linear arrangement of skin lesions in the Koebner phenomenon can be contrasted to both lines of Blaschko and dermatomal distributions </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Parametritis and can you explain it in depth? [/INST]  </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Congenital syphilis and can you explain it in depth? [/INST] Congenital syphilis is syphilis present in utero and at birth, and occurs when a child is born to a mother with syphilis. Untreated early syphilis infections results in a high risk of poor pregnancy outcomes, including saddle nose, lower extremity abnormalities, miscarriages, premature births, stillbirths, or death in newborns. Some infants with congenital syphilis have symptoms at birth, but many develop symptoms later. Symptoms may include rash, fever, an enlarged liver and spleen, and skeletal abnormalities. Newborns will typically not develop a primary syphilitic chancre but may present with signs of secondary syphilis (i.e. generalized body rash). Often these babies will develop syphilitic rhinitis ("snuffles"), the mucus from which is laden with the T. pallidum bacterium, and therefore highly infectious. If a baby with congenital syphilis is not treated early, damage to the bones, teeth, eyes, ears, and brain can occur.

Classification
Early
This is a subset of cases of congenital syphilis. Newborns may be asymptomatic and are only identified on routine prenatal screening. If not identified and treated, these newborns develop poor feeding and runny nose. By definition, early congenital syphilis occurs in children between 0 and 2 years old </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Epidermolysis bullosa simplex and can you explain it in depth? [/INST]  </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Glomus tumor and can you explain it in depth? [/INST] Glomus tumor was also the name formerly (and incorrectly) used for a tumor now called a paraganglioma.A glomus tumor (also known as a "solitary glomus tumor," "solid glomus tumor,") is a rare neoplasm arising from the glomus body and mainly found under the nail, on the fingertip or in the foot.: 670   They account for less than 2% of all soft tissue tumors. The majority of glomus tumors are benign, but they can also show malignant features. Glomus tumors were first described by Hoyer in 1877 while the first complete clinical description was given by Masson in 1924.Histologically, glomus tumors are made up of an afferent arteriole, anastomotic vessel, and collecting venule. Glomus tumors are modified smooth muscle cells that control the thermoregulatory function of dermal glomus bodies. As stated above, these lesions should not be confused with paragangliomas, which were formerly also called glomus tumors in now-antiquated clinical usage. Glomus tumors do not arise from glomus cells, but paragangliomas do.
Familial glomangiomas have been associated with a variety of deletions in the GLMN (glomulin) gene, and are inherited in an autosomal dominant manner, with incomplete penetrance.

Signs and symptoms
Glomus tumors are usually solitary and small lesions. The vast majority are found in the hand, wrist, foot, and under the fingernails.They are often painful, and the pain is reproduced when the lesion is placed in cold water. Multiple tumors are less likely to be painful.
These tumors tend to have a bluish discoloration, although a whitish appearance may also be noted. Elevation of the nail bed can occur.
In rare cases, the tumors may present in other body areas, such as the gastric antrum or glans penis </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Paroxysmal tachycardia and can you explain it in depth? [/INST]  </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Nummular dermatitis and can you explain it in depth? [/INST] Nummular dermatitis is one of the many forms of dermatitis. it is characterized by round or oval-shaped itchy lesions. The name comes from the Latin word "nummus," which means "coin."

Signs and symptoms
Nummular dermatitis is characterized by chronic or relapsing itchy coin-sized ovoid-shaped red plaques. They can occur on the trunk, limbs, face, and hands.

Causes
Many contact sensitizers or irritants are known to cause contact dermatitis superimposed on nummular dermatitis. Studies have implicated nickel, cobalt, chromate, and fragrance as likely culprits. Xerosis, or dehydration of skin is also a likely cause. Infection with Staphylococcus aureus bacteria or Candida albicans may also play a role.

Diagnosis
Diagnosis of nummular dermatitis is largely via clinical observation </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Achilles tendinitis and can you explain it in depth? [/INST] Achilles tendinitis, also known as achilles tendinopathy, occurs when the Achilles tendon, found at the back of the ankle, becomes sore. Achilles tendinopathy is accompanied by alterations in the tendons structure and mechanical properties. The most common symptoms are pain and swelling around the affected tendon. The pain is typically worse at the start of exercise and decreases thereafter. Stiffness of the ankle may also be present. Onset is generally gradual.It commonly occurs as a result of overuse such as running. Other risk factors include trauma, a lifestyle that includes little exercise, high-heel shoes, rheumatoid arthritis, and medications of the fluoroquinolone or steroid class. Diagnosis is generally based on symptoms and examination.There are several simple actions that individuals can take to prevent or reduce tendinitis. Though commonly used, some of these actions have limited or no scientific evidence to support them, namely pre-exercise stretching. Strengthening calf muscles, avoiding over-training, and selecting more appropriate footwear are more well-regarded options. Running mechanics can be improved with simple exercises that will help runners avoid achilles injury. Treatment typically involves rest, ice, non-steroidal antiinflammatory agents (NSAIDs), and physical therapy. In those whose symptoms last more than six months despite other treatments, surgery may be considered. Achilles tendinitis is relatively common.

Signs and symptoms
Symptoms can vary from an ache or pain and swelling to the local area of the ankles, or a burning that surrounds the whole joint. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiffer the following day as swelling impinges on the movement of the tendon. Many patients report stressful situations in their lives in correlation with the beginnings of pain which may contribute to the symptoms.Achilles tendon injuries can be separated into insertional tendinopathy (20%–25% of the injuries), midportion tendinopathy (55%–65%), and proximal musculotendinous junction (9%–25%) injuries, according to the location of pain.

Cause
Achilles tendinitis is a common injury, particularly in sports that involve lunging and jumping. It is also a known side effect of fluoroquinolone antibiotics such as ciprofloxacin, as are other types of tendinitis.Swelling in a region of micro-damage or partial tear can be detected visually or by touch.  Increased water content and disorganized collagen matrix in tendon lesions may be detected by ultrasonography or magnetic resonance imaging.Achilles tendinitis is thought to have physiological, mechanical, or extrinsic (i.e. footwear or training) causes. Physiologically, the Achilles tendon is subject to poor blood supply through the synovial sheaths that surround it. This lack of blood supply can lead to the degradation of collagen fibers and inflammation. Tightness in the calf muscles has also been known to be involved in the onset of Achilles tendinitis.During the loading phase of the running and walking cycle, the ankle and foot naturally pronate and supinate by approximately 5 degrees. Excessive pronation of the foot (over 5 degrees) in the subtalar joint is a type of mechanical mechanism that can lead to tendinitis.An overuse injury refers to repeated stress and strain, which is likely the case in endurance runners. Overuse can simply mean an increase in running, jumping or plyometric exercise intensity too soon.  Another consideration would be the use of improper or worn-down footwear, which lack the necessary support to maintain the foot in the natural/normal pronation.

Pathophysiology
The Achilles tendon is the extension of the calf muscle and attaches to the heel bone. It causes the foot to extend (plantar flexion) when those muscles contract.The Achilles tendon does not have good blood supply or cell activity, so this injury can be slow to heal. The tendon receives nutrients from the tendon sheath or paratendon. When an injury occurs to the tendon, cells from surrounding structures migrate into the tendon to assist in repair. Some of these cells come from blood vessels that enter the tendon to provide direct blood flow to increase healing. With the blood vessels come nerve fibers. Researchers including Alfredson and his team in Sweden  believe these nerve fibers to be the cause of the pain - they injected local anaesthetic around the vessels and this decreased significantly the pain from the Achilles tendon.

Diagnosis
Achilles tendinitis is usually diagnosed from a medical history, and  physical examination of the tendon. Projectional radiography shows calcification deposits within the tendon at its calcaneal insertion in approximately 60 percent of cases. Magnetic resonance imaging (MRI) can determine the extent of tendon degeneration, and may show differential diagnoses such as bursitis.

Prevention
Performing consistent physical activity will improve the elasticity and strength of the tendon, which will assist in resisting the forces that are applied.While stretching before beginning an exercise session is often recommended evidence to support this practice is limited. Prevention of recurrence includes following appropriate exercise habits and wearing low-heeled shoes. In the case of incorrect foot alignment, orthotics can be used to properly position the feet. Footwear that is specialized to provide shock-absorption can be utilized to defend the longevity of the tendon. Achilles tendon injuries can be the result of exceeding the tendons capabilities for loading, therefore it is important to gradually adapt to exercise if someone is inexperienced, sedentary, or is an athlete who is not progressing at a steady rate.Eccentric strengthening exercises of the gastrocnemius and soleus muscles are utilized to improve the tensile strength of the tendon and lengthen the musculotendinous junction, decreasing the amount of strain experienced with ankle joint movements. This eccentric training method is especially important for individuals with chronic Achilles tendinosis which is classified as the degeneration of collagen fibers </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Vesicoureteral reflux and can you explain it in depth? [/INST] Vesicoureteral reflux (VUR), also known as vesicoureteric reflux, is a condition in which urine flows retrograde, or backward, from the bladder into one or both ureters and then to the renal calyx or kidneys. Urine normally travels in one direction (forward, or anterograde) from the kidneys to the bladder via the ureters, with a 1-way valve at the vesicoureteral (ureteral-bladder) junction preventing backflow.  The valve is formed by oblique tunneling of the distal ureter through the wall of the bladder, creating a short length of ureter (1–2 cm) that can be compressed as the bladder fills.  Reflux occurs if the ureter enters the bladder without sufficient tunneling, i.e., too "end-on".

Signs and symptoms
Most children with vesicoureteral reflux are asymptomatic.  Vesicoureteral reflux may be diagnosed as a result of further evaluation of dilation of the kidney or ureters draining urine from the kidney while in utero as well as when a sibling has VUR (though routine testing in either circumstance is controversial).  Reflux also increases risk of acute bladder and kidney infections, so testing for reflux may be performed after a child has one or more infections.
In infants, the signs and symptoms of a urinary tract infection may include only fever and lethargy, with poor appetite and sometimes foul-smelling urine, while older children typically present with discomfort or pain with urination and frequent urination.

Causes
In healthy individuals the ureters enter the urinary bladder obliquely and run submucosally for some distance. This, in addition to the ureters muscular attachments, helps secure and support them posteriorly. Together these features produce a valvelike effect that occludes the ureteric opening during storage and voiding of urine. In people with VUR, failure of this mechanism occurs, with resultant backward (retrograde) flow of urine.

Primary VUR
Insufficient submucosal length of the ureter relative to its diameter causes inadequacy of the valvular mechanism. This is precipitated by a congenital defect or lack of longitudinal muscle of the portion of the ureter within the bladder resulting in an ureterovesicular junction (UVJ) abnormality.

Secondary VUR
In this category the ureters valvular mechanism is initially intact and healthy but becomes overwhelmed by increased bladder pressures associated with obstruction, which distorts the ureterovesicular junction. The obstructions may be anatomical or functional. Secondary VUR can be further divided into anatomical and functional groups.

Anatomical
Posterior urethral valves; urethral or meatal stenosis. These causes are treated surgically when possible.

Functional
Bladder instability, neurogenic bladder and non-neurogenic bladder. Bladder infections may cause reflux due to the elevated pressures associated with inflammation.Resolution of functional VUR will usually occur if the precipitating cause is treated and resolved. Medical and/or surgical treatment may be indicated.

Diagnosis
The following procedures may be used to diagnose VUR:

Cystography
Fluoroscopic voiding cystourethrogram (VCUG)
Abdominal ultrasound
Technetium-99m Dimercaptosuccunic Acid (DMSA) ScintigraphyAn abdominal ultrasound might suggest the presence of VUR if ureteral dilatation is present; however, in many circumstances of VUR of low to moderate, even high severity, the sonogram may be completely normal, thus providing insufficient utility as a single diagnostic test in the evaluation of children suspected of having VUR, such as those presenting with prenatal hydronephrosis or urinary tract infection (UTI).VCUG is the method of choice for grading and initial workup, while RNC is preferred for subsequent evaluations as there is less exposure to radiation. A high index of suspicion should be attached to any case where a child presents with a urinary tract infection, and anatomical causes should be excluded. A VCUG and abdominal ultrasound should be performed in these cases
DMSA scintigraphy is used for the evaluation of the parenchymal damage, which is seen as cortical scars. After the first febrile UTI, the diagnostic role of an initial scintigraphy for detecting the damage before the VCUG was investigated and it was suggested that VCUG can be omitted in children who has no cortical scars and urinary tract dilatation.Early diagnosis in children is crucial as studies have shown that the children with VUR who present with a UTI and associated acute pyelonephritis are more likely to develop permanent renal cortical scarring than those children without VUR, with an odds ratio of 2.8. Thus VUR not only increases the frequency of UTIs, but also the risk of damage to upper urinary structures and end-stage renal disease.

Severity
Vesicoureteral reflux (VUR) is graded according to severity.
Grade I – reflux into non-dilated ureter
Grade II – reflux into the renal pelvis and calyces without dilatation
Grade III – mild/moderate dilatation of the ureter, renal pelvis and calyces with minimal blunting of the fornices
Grade IV – dilation of the renal pelvis and calyces with moderate ureteral tortuosity
Grade V – gross dilatation of the ureter, pelvis and calyces; ureteral tortuosity; loss of papillary impressionsThe younger the patient and the lower the grade at presentation the higher the chance of spontaneous resolution. Approximately 85% of grade I & II VUR cases will resolve spontaneously. Approximately 50% of grade III cases and a lower percentage of higher grades will also resolve spontaneously.

Treatment
The goal of treatment is to minimize infections, as it is infections that cause renal scarring and not the vesicoureteral reflux.   Minimizing infections is primarily done by prophylactic antibiotics in newborns and infants who are not potty trained.  However, in children who are older, physicians and parents should focus on bowel and bladder management.  Children who hold their bladder or who are constipated have a greater number of infections than children who void on a regular schedule.  When medical management fails to prevent recurrent urinary tract infections, or if the kidneys show progressive renal scarring then surgical interventions may be necessary. Medical management is recommended in children with Grade I-III VUR as most cases will resolve spontaneously. A trial of medical treatment is indicated in patients with Grade IV VUR especially in younger patients or those with unilateral disease. Of the patients with Grade V VUR only infants are trialled on a medical approach before surgery is indicated, in older patients surgery is the only option.

Endoscopic injection
Endoscopic injection involves applying a gel around the ureteral opening to create a valve function and stop urine from flowing back up the ureter. The gel consists of two types of sugar-based molecules called dextranomer and hyaluronic acid. Trade names for this combination include Deflux and Zuidex. Both constituents are well known from previous uses in medicine. They are also biocompatible, which means that they do not cause significant reactions within the body. In fact, hyaluronic acid is produced and found naturally within the body.

Medical treatment
Medical treatment entails low dose antibiotic prophylaxis until resolution of VUR occurs. Antibiotics are administered nightly at half the normal therapeutic dose. The specific antibiotics used differ with the age of the patient and include:

Amoxicillin or ampicillin – infants younger than 6 weeks
Trimethoprim-sulfamethoxazole (co-trimoxazole) – 6 weeks to 2 monthsAfter 2 months the following antibiotics are suitable:

Nitrofurantoin {5–7 mg/kg/24hrs}
Nalidixic acid
Bactrim
Trimethoprim
CephalosporinsUrine cultures are performed 3 monthly to exclude breakthrough infection. Annual radiological investigations are likewise indicated. Good perineal hygiene, and timed and double voiding are also important aspects of medical treatment </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Cellulitis and can you explain it in depth? [/INST] Cellulitis is a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of the area of redness are generally not sharp and the skin may be swollen. While the redness often turns white when pressure is applied, this is not always the case. The area of infection is usually painful. Lymphatic vessels may occasionally be involved, and the person may have a fever and feel tired.The legs and face are the most common sites involved, although cellulitis can occur on any part of the body. The leg is typically affected following a break in the skin. Other risk factors include obesity, leg swelling, and old age. For facial infections, a break in the skin beforehand is not usually the case. The bacteria most commonly involved are streptococci and Staphylococcus aureus. In contrast to cellulitis, erysipelas is a bacterial infection involving the more superficial layers of the skin, present with an area of redness with well-defined edges, and more often is associated with a fever. The diagnosis is usually based on the presenting signs and symptoms, while a cell culture is rarely possible. Before making a diagnosis, more serious infections such as an underlying bone infection or necrotizing fasciitis should be ruled out.Treatment is typically with antibiotics taken by mouth, such as cephalexin, amoxicillin or cloxacillin. Those who are allergic to penicillin may be prescribed erythromycin or clindamycin instead. When methicillin-resistant S. aureus (MRSA) is a concern, doxycycline or trimethoprim/sulfamethoxazole may, in addition, be recommended. There is concern related to the presence of pus or previous MRSA infections. Elevating the infected area may be useful, as may pain killers.Potential complications include abscess formation. Around 95% of people are better after 7 to 10 days of treatment. Those with diabetes, however, often have worse outcomes. Cellulitis occurred in about 21.2 million people in 2015. In the United States about 2 of every 1,000 people per year have a case affecting the lower leg. Cellulitis in 2015 resulted in about 16,900 deaths worldwide. In the United Kingdom, cellulitis was the reason for 1.6% of admissions to a hospital.

Signs and symptoms
The typical signs and symptoms of cellulitis are an area that is red, hot, and painful. The photos shown here are of mild to moderate cases and are not representative of the earlier stages of the condition.

Complications
Potential complications may include abscess formation, fasciitis, and sepsis.

Causes
Cellulitis is caused by bacteria that enter and infect the tissue through breaks in the skin. Group A Streptococcus and Staphylococcus are the most common causes of the infection and may be found on the skin as normal flora in healthy individuals.About 80% of cases of Ludwigs angina, or cellulitis of the submandibular space, are caused by dental infections. Mixed infections, due to both aerobes and anaerobes, are commonly associated with this type of cellulitis. Typically, this includes alpha-hemolytic streptococci, staphylococci, and bacteroides groups.Predisposing conditions for cellulitis include an insect or spider bite, blistering, an animal bite, tattoos, pruritic (itchy) skin rash, recent surgery, athletes foot, dry skin, eczema, injecting drugs (especially subcutaneous or intramuscular injection or where an attempted intravenous injection "misses" or blows the vein), pregnancy, diabetes, and obesity, which can affect circulation, as well as burns and boils, although debate exists as to whether minor foot lesions contribute. Occurrences of cellulitis may also be associated with the rare condition hidradenitis suppurativa or dissecting cellulitis.The appearance of the skin assists a doctor in determining a diagnosis. A doctor may also suggest blood tests, a wound culture, or other tests to help rule out a blood clot deep in the veins of the legs. Cellulitis in the lower leg is characterized by signs and symptoms similar to those of a deep vein thrombosis, such as warmth, pain, and swelling (inflammation).
Reddened skin or rash may signal a deeper, more serious infection of the inner layers of skin. Once below the skin, the bacteria can spread rapidly, entering the lymph nodes and the bloodstream and spreading throughout the body. This can result in influenza-like symptoms with a high temperature and sweating or feeling very cold with shaking, as the affected person cannot get warm.In rare cases, the infection can spread to the deep layer of tissue called the fascial lining. Necrotizing fasciitis, also called by the media "flesh-eating bacteria", is an example of a deep-layer infection. It is a medical emergency.

Risk factors
The elderly and those with a weakened immune system are especially vulnerable to contracting cellulitis. Diabetics are more susceptible to cellulitis than the general population because of impairment of the immune system; they are especially prone to cellulitis in the feet, because the disease causes impairment of blood circulation in the legs, leading to diabetic foot or foot ulcers. Poor control of blood glucose levels allows bacteria to grow more rapidly in the affected tissue and facilitates rapid progression if the infection enters the bloodstream. Neural degeneration in diabetes means these ulcers may not be painful, thus often become infected. Those who have had poliomyelitis are also prone because of circulatory problems, especially in the legs.Immunosuppressive drugs, and other illnesses or infections that weaken the immune system, are also factors that make infection more likely. Chickenpox and shingles often result in blisters that break open, providing a gap in the skin through which bacteria can enter. Lymphedema, which causes swelling on the arms and/or legs, can also put an individual at risk.
Diseases that affect blood circulation in the legs and feet, such as chronic venous insufficiency and varicose veins, are also risk factors for cellulitis.Cellulitis is also common among dense populations sharing hygiene facilities and common living quarters, such as military installations, college dormitories, nursing homes, oil platforms, and homeless shelters.

Diagnosis
Cellulitis is most often a clinical diagnosis, readily identified in many people by history and physical examination alone, with rapidly spreading areas of cutaneous swelling, redness, and heat, occasionally associated with inflammation of regional lymph nodes. While classically distinguished as a separate entity from erysipelas by spreading more deeply to involve the subcutaneous tissues, many clinicians may classify erysipelas as cellulitis.  Both are often treated similarly, but cellulitis associated with furuncles, carbuncles, or abscesses is usually caused by S. aureus, which may affect treatment decisions, especially antibiotic selection. Skin aspiration of nonpurulent cellulitis, usually caused by streptococcal organisms, is rarely helpful for diagnosis, and blood cultures are positive in fewer than 5% of all cases.It is important to evaluate for co-existent abscess, as this finding usually requires surgical drainage as opposed to antibiotic therapy alone.  Physicians clinical assessment for abscess may be limited, especially in cases with extensive overlying induration, but use of bedside ultrasonography performed by an experienced practitioner readily discriminates between abscess and cellulitis and may change management in up to 56% of cases. Use of ultrasound for abscess identification may also be indicated in cases of antibiotic failure.  Cellulitis has a characteristic "cobblestoned" appearance indicative of subcutaneous edema without a defined hypoechoic, heterogeneous fluid collection that would indicate abscess.

Differential diagnosis
Other conditions that may mimic cellulitis include deep vein thrombosis, which can be diagnosed with a compression leg ultrasound, and stasis dermatitis, which is inflammation of the skin from poor blood flow. Signs of a more severe infection such as necrotizing fasciitis or gas gangrene that would require prompt surgical intervention include purple bullae, skin sloughing, subcutaneous edema, and systemic toxicity. Misdiagnosis can occur in up to 30% of people with suspected lower-extremity cellulitis, leading to 50,000 to 130,000 unnecessary hospitalization and $195 to $515 million in avoidable healthcare spending annually in the United States. Evaluation by dermatologists for cases of suspected cellulitis has been shown to reduce misdiagnosis rates and improve patient outcomes.Associated musculoskeletal findings are sometimes reported. When it occurs with acne conglobata, hidradenitis suppurativa, and pilonidal cysts, the syndrome is referred to as the follicular occlusion triad or tetrad.Lyme disease can be misdiagnosed as cellulitis. The characteristic bullseye rash does not always appear in Lyme disease (the rash may not have a central or ring-like clearing, or not appear at all). Factors supportive of Lyme include recent outdoor activities where Lyme is common and rash at an unusual site for cellulitis, such as armpit, groin, or behind the knee. Lyme can also result in long-term neurologic complications. The standard treatment for cellulitis, cephalexin, is not useful in Lyme disease. When it is unclear which one is present, the IDSA recommends treatment with cefuroxime axetil or amoxicillin/clavulanic acid, as these are effective against both infections.

Prevention
In those who have previously had cellulitis, the use of antibiotics may help prevent future episodes. This is recommended by CREST for those who have had more than two episodes. A 2017 meta-analysis found a benefit of preventative antibiotics for recurrent cellulitis in the lower limbs, but the preventative effects appear to diminish after stopping antibiotic therapy.

Treatment
Antibiotics are usually prescribed, with the agent selected based on suspected organism and presence or absence of purulence, although the best treatment choice is unclear.  If an abscess is also present, surgical drainage is usually indicated, with antibiotics often prescribed for co-existent cellulitis, especially if extensive.  Pain relief is also often prescribed, but excessive pain should always be investigated, as it is a symptom of necrotizing fasciitis.  Elevation of the affected area is often recommended.Steroids may speed recovery in those on antibiotics.

Antibiotics
Antibiotics choices depend on regional availability, but a penicillinase-resistant semisynthetic penicillin or a first-generation cephalosporin is currently recommended for cellulitis without abscess. A course of antibiotics is not effective in between 6 and 37% of cases.

Epidemiology
Cellulitis in 2015 resulted in about 16,900 deaths worldwide, up from 12,600 in 2005.Cellulitis is a common global health burden, with more than 650,000 admissions per year in the United States alone. In the United States, an estimated 14.5 million cases annually of cellulitis account for $3.7 billion in ambulatory care costs alone. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown. In the 15% of cellulitis cases in which organisms are identified, most are due to β-hemolytic Streptococcus and Staphylococcus aureus.

Other animals
Horses may acquire cellulitis, usually secondarily to a wound (which can be extremely small and superficial) or to a deep-tissue infection, such as an abscess or infected bone, tendon sheath or joint. Cellulitis from a superficial wound usually creates less lameness (grade 1–2 of 5) than that caused by septic arthritis (grade 4–5). The horse exhibits inflammatory edema, which is hot, painful swelling. This swelling differs from stocking up in that the horse does not display symmetrical swelling in two or four legs, but in only one leg. This swelling begins near the source of infection, but eventually continues down the leg </s>