This is a useful illustration of the pathogenesis of depression. From the elegant Virginia twin studies of Kendler et al. (1), we know that genetic factors play a substantial, but not overwhelming, role in the pathogenesis of depression. Childhood trauma may be a key factor, especially when a stressor later in life reactivates that trauma. Traumatized children frequently develop a hyperreactive hypothalamic-pituitary-adrenal (HPA) axis as a result of chronic childhood abuse (2, 3). A common result of this overly active HPA axis is that the child is hypervigilant in unfamiliar situations, scanning the environment with the expectation that something bad will happen at any moment. Such chronically depressed patients who have profound childhood trauma appear to fare better with psychotherapy and medication than with medication alone (4). Imagine how this patient’s trauma will affect her subsequent approach to the outside world. Having lived in a barn, where any moment a family member could die or she herself could be discovered and killed, she had to develop a kind of radar that would help her survive. Then she had to cross the Alps, like the von Trapp family, to escape to the United States. After being relocated, she encountered a life not too different from that of Cinderella, knowing that her mean stepmother preferred the other children to her. It is possible, of course, that this horrific childhood experience may reappear in the transference to Dr. Seritan. Tell us about your initial impressions of her.