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Case Report
Burns in the context of a shared psychotic disorder in a Colombian referral centre: A case report
Quemaduras en el contexto de un trastorno psicótico compartido en un centro de referencia colombiano: reporte de caso
Diego Fernando Alarcón Arizaa,
Corresponding author
diegoalarconmd@gmail.com

Corresponding author.
, Laura Cristina Zambrano Jereza, Carlos Enrique Ramírez Riveroa, Jorge Andrés Niño Garcíab, Adriana Catalina Ruiz Quecanb, Gonzalo Andrés Domínguez Alvaradoc,d
a Programa de Cirugía Plástica, Estética y Reconstructiva, Hospital Universitario de Santander, Universidad Industrial de Santander, Colombia
b Departamento de Salud Mental, Hospital Universitario de Santander, Hospital Psiquiátrico San Camilo, Universidad Industrial de Santander, Colombia
c Clínica Foscal Internacional, Santander, Colombia
d Semillero de Innovación e Investigación Quirúrgica (SIIQ), Santander, Colombia
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Shared psychotic disorder &#40;SPD&#41; is an uncommon illness&#44; with little clinical recognition&#44; therefore requiring a high index of clinical suspicion&#46; It was described as a mental &#8220;contagion&#8221; in 1651&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and in 1877 the term <span class="elsevierStyleItalic">folie &#224; deux</span> or communicated insanity was introduced and the characteristics of the disorder were established&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> In 1880&#44; the three fundamental criteria for diagnosis were determined&#58; <span class="elsevierStyleItalic">a&#41;</span> a close relationship between the subjects&#59; <span class="elsevierStyleItalic">b&#41;</span> identical or very similar content of the delusions in the individuals&#44; and <span class="elsevierStyleItalic">c&#41;</span> the subjects share and accept each other&#8217;s delusions&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Induced delusional disorder &#40;ICD-10&#41; or SPD &#40;DSM-4&#41; may involve two <span class="elsevierStyleItalic">&#40;folie &#224; deux&#41;</span> or&#44; very rarely&#44; more individuals&#44; but is then reported as <span class="elsevierStyleItalic">folie &#224; trois&#44; folie &#224; quatre&#44; folie &#224; cinq</span> or <span class="elsevierStyleItalic">folie famille</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In recent DSMs&#44; it was referred to as SPD because it concerned people who developed delusions similar to those of a close relative or peer&#46; The second individual&#8217;s delusions were often resolved once the relationship with the first individual was severed&#46; There are several reasons why this condition was excluded from the DSM-5&#46; For decades there has been very little research that could help in understanding SPD&#44; and only case reports&#59; while most of these patients live with someone who has schizophrenia or delusional disorder&#44; the phenomenon has also been linked to dissociative disorders and obsessive compulsive disorder&#59; most patients who would have previously received a diagnosis of <span class="elsevierStyleItalic">folie &#224; deux</span> &#40;SPD&#41; meet the criteria for delusional disorder&#44; which is the category in which they must now be grouped in the DSM-5&#46; Otherwise&#44; another specified psychotic disorder would have to be diagnosed and the reasons would have to be explained&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Its incidence ranges from 1&#46;7&#37; to 2&#46;6&#37; of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Some 73&#37;&#8211;81&#37; of cases involve two individuals&#46; The largest group reported has been 12 people&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">Female patient A was admitted to the institution in labour&#44; and had a full-term newborn without complications&#46; She presented with intermediate and deep second-degree burns on 18&#37; of her total body surface area &#40;TBSA&#41;&#44; located on her trunk and extremities &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#59; she initially reported boiling oil as the cause&#44; but the lesions showed a pattern indicating contact burns &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; so she was confronted&#44; and she stated that her sister had burned her with an iron&#46; Patient A reported that female patient <span class="elsevierStyleSmallCaps">C</span> had been living with her and male patient B for three months&#46; During this period&#44; she observed restlessness&#44; difficulty sleeping and changes in behaviour in patient C&#59; she stated that the colour of her eyes and the tone of her voice were different&#46; &#8220;She seemed like another person&#44; she spoke differently&#44; she had supernatural strength&#44; her eyes were glassy and opaque&#8221;&#44; which she attributed to &#8220;demonic possession&#8221;&#46; She said that when she was close to patient C&#44; she was afraid of losing her pregnancy&#44; which is why she agreed to let patient C burn her with the iron&#44; on the grounds that it was the only way to expel &#8220;Satan&#8221; from her body&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">She was hospitalised for 26 days&#44; with subjective certainty and conviction about what she had reported&#44; but during the last week she questioned what had happened&#59; she considered that her sister might be &#8220;sick in the head&#8221;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Patient B was admitted 6 days after being burned with an iron&#44; with intermediate and deep second-degree burns involving 11&#37; of the TBSA on his trunk and extremities &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Patient B reported that the burns were caused by patient C&#44; whom he described as sad and withdrawn &#40;&#8220;she kept crying and locked herself in her room&#8221;&#41;&#46; He also described changes in her behaviour and stated that at times patient C seemed to him &#8220;as if she were a compassionate and loving angel&#8221;&#44; but at other times he saw her as a demon &#40;&#8220;she spoke strangely&#44; she had a lot of strength&#44; as if someone else was in her body&#44; she said she was going to take my wife and my son&#8221;&#41;&#44; a situation he attributed to her being &#8220;possessed&#8221;&#46; He commented that it frightened him&#44; because patient C verbalised in vociferous language &#8220;that she was a portal between God and hell&#8221;&#44; and he feared that she would fulfil the prophecy of taking his family with her&#44; which is why he did not resist when she was burning him with the iron&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">On leaving the institution&#44; he had a delusional memory of what had happened&#44; and expressed doubts about the possibility that patient C had really been possessed&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">To treat the burns&#44; every other day patients A and B received dressings and coverage of the more deeply burned areas with split-thickness grafts on day 21 post-burn&#44; with very good results&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patient C is a 20-year-old female&#46; She has had complex command auditory hallucinations since she was eight years old&#46; In early adolescence&#44; she was abused by her stepfather&#44; and although she brought this situation to her mother&#39;s attention&#44; she was not believed&#44; and from then on she became withdrawn and suffered from insomnia&#44; muscle fatigue and poor academic performance&#46; She described periods of sadness and thoughts of death&#44; which were accompanied by impulsive suicide attempts&#46; At the age of 16&#44; she started using cannabis&#44; without specifying her pattern of use&#46; After breaking up with her partner&#44; she moved in with patients A and B&#46; She again exhibited sad mood&#44; emotional lability&#44; sleep maintenance insomnia&#44; hyporexia&#44; visual and tactile hallucinations&#44; and mystical and self-referential delusions&#59; she also reported recurrent thoughts of death and structured suicidal ideation&#46; She stated that on the day she assaulted patients A and B&#44; she heated the iron and burnt them but did not remember precisely what happened&#44; and described reduced consciousness&#46; During hospitalisation&#44; when asked about other similar behaviour&#44; she described previous assaults on other family members and even stated her intention to burn down her parents&#8217; house to ward off the demon&#46; It was concluded that patient C had a depressive subtype schizoaffective disorder&#46; She was treated in the psychiatric hospital and discharged with antipsychotics&#59; she attended check-ups and remission of positive symptoms was achieved&#59; patients A and B live separately from patient C and patient A occasionally telephones her&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">This case is the first report of burns related to SPD&#46; In SPD&#44; the primary case is the individual presenting with the original delusion&#44; who influences another individual&#44; called the secondary case&#44; the majority of whom are women&#46; In total&#44; 64&#37; of secondary cases occur in family members with first degree of consanguinity&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> as is the case with patients A and C&#46; Secondary patients may subsequently develop a psychotic disorder&#44; typically schizophreni&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Due to the tendency of collective behaviour to imitate attitudes&#44; movements and expressions&#44; the idea of an emotional &#8220;contagion&#8221; is sustained&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The changes in patient C&#8217;s behaviour become the main focal point of coexistence and mark a change in the family dynamics that generates delusions and acceptance of patient C&#8217;s behaviours by A and B&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The development of Patient C&#8217;s psychotic symptoms are the result of multiple factors&#58; exposure to sexual abuse during childhood or adolescence&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> socio-economic stressors and changes in her interpersonal relationship&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> schizoid personality traits and cannabis use&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Patient C&#44; who did not receive early treatment&#44; had a worsened prognosis&#44; due to affective&#44; positive&#44; negative and social deterioration symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Some of the divergences found include the fact that patient C does not fit the biotype of a primary patient&#44; she does not have an imposing character or a higher academic level or intelligence&#59; furthermore&#44; the patients were not in isolation&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The appearance of SPD can be attributed to difficulties in separation-individuation processes&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> the development of archaic defence mechanisms such as projection and identification&#44; and delusions may also be an attempt by the individual to explain incomprehensible experiences&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The classification of SPD subtypes is presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and the main characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In the case presented&#44; separating the individuals allowed for the delusions to be resolved&#46; A separation period of at least six months is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Antipsychotics can be prescribed to primary and secondary patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;19&#8211;21</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The importance of such cases also lies in their legal&#44; ethical and social implications&#44; given the reported fatal outcomes&#44; such as homicides&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Kraya et al&#46; report five cases&#58; two homicides of infants committed by their parents&#59; a third case includes the homicide of two children&#44; the suicide of the father and the attempted suicide of the mother&#59; in the fourth case they describe serious personal injuries caused by a mother to her daughter&#59; and the last case is that of twins who devised the homicide of their father &#40;they did not go through with it&#44; but burned down a farm on his property&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Scott presents the killing of a police officer by a mother and her teenage son&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Bourgeois et al&#46; report the attempted murder and personal injury of the general practitioner of a woman with delusional parasitosis<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and the homicide of a woman at the hands of her two adolescent daughters&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#8211;27</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Deep burns can exacerbate underlying psychological problems and&#47;or lead to secondary mental disorders&#44; such as peritraumatic dissociation&#44; delirium post-traumatic stress disorder and major depressive disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Contact burns are common&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> affect mainly the extremities and may require skin dressing and prolonged hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">SPD is a rare disorder but it has a great social impact because it is associated with aggression towards oneself or others&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">High clinical suspicion should be raised in the accident and emergency department when finding a similar pattern of injury&#44; with conflicting narratives about the events&#44; in individuals with a close emotional bond&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Given the complexity of the diagnostic and therapeutic approach&#44; a multidisciplinary team is required&#59; identifying the inducing patient&#44; distancing them from the induced cases and initiating specific pharmacological treatment personalised for each of the members involved with the psychotherapeutic approach&#44; as well as assertive communication with the family or social circle affected by the dysfunctional dynamic that was generated&#46;</p></span><span id="sec2025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect2075">Ethical considerations</span><p id="par2115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their institution&#39;s protocols on the publication of patient data&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2020-08-27"
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            0 => "Shared paranoid disorder"
            1 => "Psychotic disorders"
            2 => "Burns"
            3 => "Schizophrenia"
            4 => "Paranoid disorders"
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          "palabras" => array:6 [
            0 => "Trastorno paranoide compartido"
            1 => "Trastornos psic&#243;ticos"
            2 => "Quemaduras"
            3 => "Esquizofrenia"
            4 => "Trastornos paranoides"
            5 => "Cirug&#237;a pl&#225;stica"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Shared paranoid disorder is characterised by the development of psychotic symptoms in people who have a close affective bond with a subject suffering from a mental disorder&#46; This case is the first case of burn injuries reported in the context of this disorder&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We describe a young couple&#44; with a similar pattern of burns caused by contact with a griddle&#46; The injuries are the result of the aggression caused by a relative of one of them&#44; who presented psychotic symptoms&#44; related to the previously undiagnosed spectrum of schizophrenia&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The impact of this condition encompasses social&#44; physical and psychological components&#44; requiring multidisciplinary management and a high index of diagnostic suspicion&#46;</p></span>"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El trastorno psic&#243;tico compartido se caracteriza por la aparici&#243;n de s&#237;ntomas psic&#243;ticos en personas que tienen un v&#237;nculo afectivo estrecho con un sujeto que padece un trastorno mental&#59; este caso es el primer reporte de lesiones por quemaduras en el contexto de este trastorno&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se trata de una pareja joven&#44; con un patr&#243;n similar de quemaduras causadas por el contacto con una plancha&#46; Las lesiones son el resultado de la agresi&#243;n causada por un familiar de uno de ellos&#44; que presentaba s&#237;ntomas psic&#243;ticos relacionados con el espectro de esquizofrenia no diagnosticado previamente&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El impacto de esta afecci&#243;n abarca los componentes social&#44; f&#237;sico y psicol&#243;gico y requiere un tratamiento multidisciplinario y un alto &#237;ndice de sospecha diagn&#243;stica&#46;</p></span>"
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                  <table border="0" frame="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Folie impos&#233;e</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Transfer of delusions from one person to another&#44; after a long period of resistance&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Onset of new delusions in a subject influenced by another delusional patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Schizophrenia&#44; 60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paranoid reaction&#44; 18&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Schizophrenia&#44; 54&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paranoid reaction&#44; 22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Shared symptoms</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Delusions&#44; 78&#37;&#8211;88&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Delusion of persecution&#44; 51&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Religious delusions&#44; 27&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Delusions of grandiosity&#44; 2&#37;&#8211;13&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Delusional infestation&#44; 5&#37;&#8211;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Personality and distinctive features</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Primary patient&#58; sthenic biotype&#44; imposing&#44; authoritarian&#44; intelligent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary patient&#58; asthenic biotype&#44; immature&#44; manipulable&#44; physically or mentally disadvantaged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Forms of interaction</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dependence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Violent behaviour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Characteristics of the interaction between the individuals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ambivalence&#44; guilt&#44; separation anxiety&#44; disillusionment&#44; frustration and codependency affect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sociocultural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low intellectual level&#44; poor economic resources&#44; social isolation&#44; feelings of alienation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Common clinical features of shared psychotic disorder&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8</span></a></p>"
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