Twin Sisters With Psychotic Disorders

Jane and Susan are 43-year-old, single, white, left-handed, Jewish women with the same current clinical diagnosis: schizoaffective disorder and a personality disorder characterized by unstable interpersonal relationships, identity disturbance, and affective instability. Both also have reading problems, and they were diagnosed with dyslexia in childhood. During the last year, Jane has been a patient in a research unit and has subsequently been treated both in the day hospital and by the continuing care service of a mental health center on the East Coast. During the 1970s and 1980s, Susan received inpatient and outpatient treatment at this center. She has lived on the West Coast for the last 6 years.

Jane was admitted to the mental health center for the first time at the age of 23, when she drank a nonlethal amount of paint thinner in an attempt to end her life. Precipitants to Jane’s admission seemed to be Susan’s first admission less than 12 months previously and the little contact Jane had had with her therapist during the preceding months. At that time, Jane was described in her records as paranoid, disorganized, and preoccupied with her therapist’s family, vitamin therapy, and her weight. She was treated with thiothixene, 400 mg/day.

Since then Jane has been readmitted nine times (Figure 1). Precipitants have been mainly changes in relationships (e.g., mother moving to a different state, conflicts in relationships with Susan, a therapist, and a significant other), job-related stress, and medication noncompliance. She has believed she was God; however, she has also heard voices of God referring to a man she met during a trip to Israel, and she has received messages from cars telling her to kill people. She has been variously described as cheerful, restless, and overtalkative and at other times as sad and suicidal, although these mood symptoms have not always been present. She has had suicidal ideation many times but has not injured herself since her early suicide attempt. She has, however, tried to hurt others, such as when she unsuccessfully attempted to smother her roommate with a pillow during one admission.

Jane was treated with lithium (up to 1500 mg/day) for approximately 16 years (age 25–41) in combination with perphenazine (up to 32 mg/day) for over 10 years (age 31–41). Lithium and perphenazine were discontinued because of uncontrolled symptoms and tardive dyskinesia, and olanzapine was used briefly before switching to clozapine treatment. Her current medication regimen includes clozapine, 425 mg/day, and clonazepam, 0.5 mg/day. She has been in individual and group therapy and in day programs. She currently sees a male psychiatrist for both medications and therapy. Her longest period without mental health center admissions (age 31–38) occurred during treatment with lithium and perphenazine, beginning immediately after termination with the female therapist she had seen since age 20. It was also during these 4.5 years of apparent “remission” that she had her only relationships, sequentially, with three significant others. During that time she lived with significant others and then with her mother and worked intermittently. Her admission at age 38 was precipitated by suspicion that a significant other had stolen her money.

Jane has worked as a waiter, a taxicab driver, and in real estate sales, although she is currently unemployed and receives Social Security Disability Insurance. She has had multiple sexual partners, including men and women, but currently has no significant other. She has not been married, has no children, and has had no pregnancies. She lives alone in an apartment.

Jane’s past medical history is significant for a left ovarian cyst diagnosed at age 40. She had normal head magnetic resonance imaging (MRI) and an EEG at age 42.

Susan was first admitted at age 22, after she had just lost a boyfriend, had not seen her therapist for 2 months, had just received a marriage proposal, and was facing final examinations in school. She thought that the radio was speaking to her and that the bottom of her body was falling off. She was described then as paranoid and disorganized, with thought blocking and loose associations. She was treated with trifluoperazine, 20 mg/day.

She was subsequently admitted eight more times, but she has not been admitted in over 7 years (Figure 1). Like Jane, precipitants to Susan’s admissions have usually been changes in relationships (e.g., changes in her relationship with Jane, therapists being away, feeling “too close” early in relationships with potential boyfriends), job-related stress, and medication noncompliance. Like Jane, Susan has experienced hearing voices of birds telling her to take her life. She has also been variously described as euphoric and depressed, but mood symptoms have not always been present. She has had suicidal ideation less frequently than Jane and has never injured herself. Like Jane, she has tried to hurt others, including hitting staff members, during two admissions.

Susan’s medication regimen has been similar to Jane’s. She was treated with a combination of lithium (up to 1500 mg/day) and a typical antipsychotic, trifluoperazine (up to 60 mg/day), for approximately 14 years (age 25–39). After she developed tardive dyskinesia, her trifluoperazine treatment was switched initially to risperidone and then to clozapine. She currently takes 600 mg/day of lithium carbonate, 425 mg/day of clozapine, and 20 mg/day of paroxetine for her anxiety symptoms. Susan has been in individual and group therapy and in day programs. She currently sees a male psychiatrist and a female therapist. Her longest admission-free period continues at 7 years. During this time her lithium and antipsychotic medication treatments have been continuous, and Susan has had three relationships, the first two of which lasted 6 months and the last of which continues after approximately 6 years. These are her only relationships with significant others that have lasted for more than 3 months. Earlier admission-free periods were associated with a therapeutic relationship (age 26–30) and with living with her mother (age 23–26).

Susan has worked as a bricklayer, ski instructor, and art therapist. She currently works part-time in food delivery and collects Supplemental Security Income and Social Security disability insurance. She has had numerous sexual relationships, mostly with men. She has not been married, has no children, and has had no pregnancies. She lives in a house with roommates.

Susan’s medical history is significant for one head injury with loss of consciousness when her father dropped her at age 18 months. She also had one seizure as a child, possibly febrile. When she was 40, a pituitary microadenoma was diagnosed and treated with bromocriptine, up to 7.5 mg/day. Bromocriptine treatment was discontinued after she began treatment with clozapine. Except for the pituitary microadenoma, the results of head computerized tomography scans and MRIs were normal at age 40; an EEG at age 30 was normal.

Neuropsychological and personality test results have been stable over many years. The best WAIS-R full-scale IQ estimates are 97 for Jane and 87 for Susan. Jane’s verbal IQ of 96 is notably higher than Susan’s 77. Both rank high on WAIS-R tests of fluid reasoning with nonverbal materials. Susan is stronger on visual tests that rely heavily on attention, sequencing, and an understanding of social schemas. Both have reading comprehension problems, but Susan’s are worse. Both have attention or executive system dysfunction, which is evident in difficulties encoding supra-span information and on the Wisconsin Card Sorting Test (3), but Jane’s is more pronounced.

On the basis of the MMPI, both women were noted to be narcissistic, but Susan seemed especially sensitive, thin skinned, and high strung. On the basis of the Thematic Apperception Test (4), Jane was noted to be particularly sensitive to affective arousal and quite susceptible to becoming disorganized. On the basis of the Rorschach test, both sisters are seen as having borderline character structures with impaired object relations, poor impulse control, and inadequate ego development. Both have been confused about their sexuality.

The twins report that their brother, now 39, has an affective disorder and dyslexia. Records indicate that both parents have suffered from affective disorders. According to the twins, one of their father’s sisters has an affective disorder. According to records, their paternal grandmother had a psychotic illness, the nature of which is not clear. Susan and her mother state that their paternal grandmother suffered from epilepsy. Records state that their maternal grandmother experienced postpartum depression.

The twins were born after a normal pregnancy. Jane was delivered first, by low forceps, and weighed 2544 g. Susan was delivered spontaneously and weighed 2296 g. Records indicate they were normal newborns, and their mother reports they passed developmental milestones at appropriate ages.

Family life was chaotic. The twins’ father, an electrical engineer, had an explosive temper. The children feared him. They have described their mother, an actress and real estate broker, as self-centered. Their only sibling, a brother, is 4 years younger. Jane says that he has been cruel to her (e.g., once when she asked him to take her to the hospital, he took the keys to the car and left her at home alone). However, Susan has enjoyed a close relationship with him.

Both twins were diagnosed with dyslexia in grammar school and were subsequently tutored. When they were age 12, their parents divorced, triggering a period of instability in their living arrangements. During this time they lived variously with their mother and her boyfriend, at boarding school, and with their father and his new wife. While at boarding school, they experimented with LSD (Jane, “a few” times; Susan, approximately 20 times) and marijuana. At age 18 they graduated from high school and started living separately. Neither had many friends growing up. They do not report ever being physically or sexually abused.

They dropped out of different colleges after 2 years. Jane majored in psychology; Susan, in art and recreation therapy. At the suggestion of their father’s third wife, who was a psychologist, they each started individual psychotherapy focusing on anxiety related to separating from their family (Jane at age 20; Susan at 19). Both developed intense relationships with their therapists.

The twins grew up together in a variety of different environments and later remained close, although they did not live together. Their courses of illness and treatment have shown remarkable similarity, although Jane has been admitted several times in recent years, whereas Susan has not been admitted during the last 7 years. The twins’ relationships with each other, with significant others, and with their mother, as well as their medication compliance, appear to be important influences on their courses of illness. Both enjoy the company of others but can become paranoid and disorganized in close relationships. Their histories indicate that Susan has been involved with her current boyfriend for over 6 years, by far the longest relationship of either twin. Susan’s sexual orientation has been mainly toward men; Jane’s has been toward both men and women. Although the twins were reluctant to discuss their relationship directly, histories and interviews suggest that they sincerely care for one another, although they may be competitive at times. Jane said only that she thinks her sister had a more severe psychotic illness and more severe dyslexia but has adapted better over time and that her sister has received more attention from their mother. Susan said only that she has a positive regard for Jane and thinks Jane is more outgoing.

During the interview Jane appeared well groomed and was casually dressed. She was cooperative and made good eye contact. There were no obvious abnormalities of speech. Her mood was “fine.” Her affect was generally euthymic, although she occasionally appeared anxious and sad, appropriate to the content of her speech. Her thought process was somewhat tangential. Her thought content was significant for grandiose and paranoid delusions (e.g., she thought that she was supposed to marry Prince Charles and that the CIA was after her; she thought that she received messages from trucks). Jane expressed a wish to be more independent of her mother and the messages. She reported no frank auditory hallucinations and showed no evidence of suicidal or homicidal ideation. Her insight and judgment were poor.

Susan had no abnormalities of speech and described her mood as “pretty good.” According to her psychiatrist, she experiences intermittent anxiety, apathy, and amotivation, and her affect is often “blunted.” During the interview her thought process was goal directed, and she reported no auditory hallucinations or suicidal or homicidal ideation. She said she was not sure if other people could read her mind. She stated that medication and her relationship with her boyfriend have helped control her illness. Her insight and judgment were fair.