Background: Anorexia nervosa is construed as a phobic avoidance response to the existential strains of adolescent growth and maturation. These strains can take many forms but have the common basis of having been prompted, sooner or later, by the impact of puberty. It is the reversal of this pubertal process, through reduced energy (dietary) intake, that embodies the avoidance mechanism in the disorder. The present report claims to illustrate an unusual variant of such psychopathology and presents supporting evidence in the form of treatment response. Method: Concurrent anorexia nervosa and hypertrophic cardiomyopathy in non-identical twins is described. Literature concerning the problems of identity development in twins is reviewed. One of the twins, our patient, is studied in depth. Her changes in weight are related to biographical events and to her relationship with her eating-disordered twin sister. The specific determinants of anorexia nervosa in this case are hypothesised and discussed. Results: The particular problems of separation and identity formation posed by twinship were considered to be severe. Development of a potentially fatal and familial illness, hypertrophic cardiomyopathy, prompted by adult growth in the other twin, was experienced as catastrophic by our patient; the threat of maturity became intolerable and anorexia nervosa was the only solution. Conclusions: A treatment programme that addressed these matters has been successful. She now holds a normal body weight and is more able to live with ambivalent feelings and doubts. She is also more realistic about and accepting of her own mild degree of hypertrophic cardiomyopathy.
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