Patient evaluation on intake

30-year-old identical twins are referred separately for depression and anger problems

Both state that external stressors, e.g., work, family, etc. have driven them to depression and “mood swings”

Psychiatric history

Patient #1 states that he has a long history of mood swings, especially toward anger attacks, but over the last few years has been more “down and out” stressed, and suffering from insomnia

Patient #2 is identical

Patient #1 further admits to full MDD symptoms

• – Occasionally experiences passive suicidal thoughts, agitation and restlessness, fatigue, poor concentration, and amotivation

• – Does not have evidence of guilt or worthlessness symptoms

Patient #2 is identical

Patient #1 has no history of psychosis, mania, substance misuse, anxiety disorder

Patient #2 is identical

Patient #1 admits to a history of volatile and irritable temperament, difficulty in delaying gratification, poor frustration tolerance, and learning from an early age that aggression is often beneficial

Patient #2 is identical

Social and personal history

Patients #1 and #2 both graduated from high school

Both have been gainfully employed in service industry jobs, but have had difficulty dealing with their supervisors

Both are married with children

Their relationships are generally supportive but with occasional bouts of conflict

Both have a legal history of violent and assaultive behavior

Neither have alcohol or drug addiction histories

Medical history

Patient #1 has HTN, hypercholesterolemia, pre-diabetes, and an atrial cardiac arrhythmia

Patient #2 is identical except for the arrhythmia

Family history

Patient #1 admits distant family members have schizophrenia or bipolar disorder

Patient #2 is identical

Medication history

Patient #1 was started on the SNRI, venlafaxine-XR (Effexor-XR) 75 mg/d, by his PCP over a year ago

• – Self-discontinued it two weeks ago due to ineffectiveness. Continues to take the BZ, alprazolam 0.5 mg/d, as needed for agitation

• – There is no evidence of misuse

Patient #2 is not identical here and had been placed on a stimulant, an NDRI, an SSRI, a BZRA, and an epilepsy medication, topiramate (Topamax), by his previous psychiatrist

• – Feels the latter medication was not helping, caused GI distress; he stopped it two weeks ago

Therefore, they are identical at some level of medication non-compliance, but they are very different in that their previous provider engaged in either a slow, limited series of monotherapies or in aggressive polypharmacy

Psychotherapy history

Patients #1 and #2 have been undergoing eclectic, supportive, individual psychotherapy over the last few months

Neither has received formal CBT, IPT, DBT, or PDP

Patient evaluation on initial visit

There is evidence of a gradual onset of MDD symptoms associated with multiple social stressors

Premorbid, Cluster B personality traits are observed as well

• – DSM-5 lists several personality disorders, and Cluster B disorders traditionally involve patients who suffer from marked mood swings, inability to control their affect, and are often considered to be dramatic and erratic

• – These include histrionic, narcissistic, antisocial, and borderline personality disorders

Both seem to be moderately depressed and suffering

Both seem motivated for medication management