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A 29-year-old woman has been treated for "depression" for six years and has now been referred for electroconvulsive therapy after adequate trials of three antidepressants. Her mood shifts several times within a single day and always with what is happening between her and her boyfriend; she brightens completely when a friend calls in. Since her mid-teens she has described a persistent sense of emptiness, has cut her forearms after arguments, and has never held a job for more than a few months. Sleep, appetite and weight are unchanged. Which one of the following best explains her failure to respond?
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