Vol.

17: e140-e143, June 2012

CASE
REPORT Pitfalls of the psychotherapy of twins
with eating disorders
F. Túry, A. Szentes, and M. Varga
Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary

ABSTRACT. AIM: Scientific literature is limited on problems related to the psychotherapy of

twins, especially eating disorders. This paper discusses the therapeutic difficulties encoun-
tered with two anorexic and one bulimic sets of twins. METHOD AND RESULTS: The three
case reports show that the symbiotic tendency of twins is a frequent phenomenon, which may
be a special resistance against change, and can serve as a factor maintaining the pathological

s
state. In many cases, the parental behaviour strengthens the symbiosis of the twins, instead of

t i
helping the individuation. CONCLUSION: The integration of individual and family therapeu-

ur
tic interventions is proposed. The separation-individuation process of the twins can be stimu-
lated by individual sessions with each of the twins, or separate sessions during family therapy

e K
(i.e., sessions with the parents and with one of the twins). In this case, the best strategy would
be to have the individual and family therapies conducted by the same therapist.

ic
(Eat. Weight Disord. 17: e140-e143, 2012). ©2012, Editrice Kurtis

NLY i t r
E E O INTRODUCTION
d ably more difficult for twins to learn to live
and function individually without their twin

2 , AL
US When discussing phenomena related to sibling than it is for single-born children.

1
twin psychopathology, the fundamental Apart from strengthening the attachment

© 20 ON question is whether various mental disor-

ders are more frequent among twins than
between siblings, adequate parental educa-
tion involves supporting the siblings’ aspi-

ERS among single-born children. Certain data rations for detachment.

P suggest that there are no significant differ- The psychotherapy of twins presents a

FOR
Key words:
Eating disorders, twins,
psychotherapy, family
therapy, pitfalls.
Correspondence to:
Dr. Ferenc Túry, Institute of
Behavioural Sciences,
Semmelweis University, H-
1089 Budapest, Nagyvárad
tér 4, Hungary.
E-mail: tury@t-online.hu
Received: September 27, 2010
Accepted: July 18, 2011
ences in the prevalence of mental disorders
between the two groups (1), while others
indicate that these disorders are more fre-
quent among twins (2). Studying the life-
time prevalence of eating disorders, Favaro
et al. (3) found that in a representative sam-
ple of women between the ages of 18 and
25 in the general population the lifetime
prevalence of anorexia nervosa (AN) was
2.0%, and that of bulimia nervosa (BN)
4.6%. The lifetime prevalence of AN was
also examined by several surveys of twins,
the findings indicating a rate of 1.2-2.2%
among women (4-6).
Twins form a relationship primarily with
their twin sibling, and they are less interest-
ed in their environment. Parents of twins
often remark that their two or three-year-
old children lag behind their peers in terms
of speech development. This can be
explained by the twins’ isolation as a pair.
The secret language used by twins (cryp-
tophasia) is a distinct form of discourse. It
occurs twice as frequently among monozy-
gotes as dizygotes (7).
According to Klein (2), it is understand-
challenge for therapists. We have treated
320 patients in an eating disorder depart-
ment during an 11-year period. Among our
patients there were six monozygotic twin
pairs. We have recently published a paper
on the hypnotherapy of a bulimic twin pair
(8). After brief inpatient treatment, psy-
chotherapy did not last long in two of the
cases due to a lack of compliance. In the
present paper we summarize the psy-
chotherapy of three monozygotic twin pairs
(two anorexic, one bulimic), in which family
therapy played an important role.
CASE VIGNETTES
Case 1
The monozygotic twin sisters were admit-
ted to our hospital department at the age of
13. They had always been slim, their maxi-
mal body weight barely reaching 34 kg.
Their height was 154 cm. For several
months they ate less and were losing
weight. The weight of twin A decreased to
29 kg, while that of twin B decreased to 31

e140
 F. Túry, A. Szentes, and M. Varga
kg. Twin A was admitted to our department,
and one month later her sibling followed. Indi-
vidual and group psychotherapy were provided
for them, and thereafter family therapy started.
The twins had a 19-year-old sibling, who was a
student and had already moved away from
home. She did not join the family therapy ses-
sions. Both parents had administrative jobs.
The father was interested in Eastern philoso-
phy and yoga, and he paid little attention to his
family. The focus of the therapy was on
enhancing family cohesion, increasing the
responsibility of the father, and taking some of
the burden off the mother. The twins proved
passive – they hardly talked, as if they had
formed a united front against therapy. We tried
to resolve this by temporarily separating them,
using individual therapy. The therapy proceed-
ed very slowly. After a few weeks the twins
finally started to gain weight. The family thera-
py continued for one-and-a-half years with 23
sessions in total. The twins’ weight increased
steadily, stabilizing at around 40 kg. A 10-year
follow-up shows remission, however their BMI
LY i
is around 17, i.e. still below the normal range.
N t rwas anorexic around the age of 16, character-
E E O
one of them works abroad. d
Each of the twins has an independent life, and
2 ,
Case 2
AL
US
© 20
1 ON
The 19-year-old female pair of twins had
spent a year in France studying, where they
S
P ER
started to lose weight, and became amenorrhe-
ic. They had been slim before. The maximum
FOR
weight of twin A had been 51 kg, and her
weight decreased to 44 kg, while her height
was 180 cm (BMI: 13.6). Twin B had been 52 kg
and her height was 179 cm. Her body weight
decreased to 50 kg (BMI: 15.6). Family therapy
was offered with the aim of reducing the over-
protectiveness of the worrying parents and
strengthening the process of separation-indi-
viduation. The therapy seemed simple, with the
parents cooperating, and the twins improving.
After three to four sessions it seemed that one
or two more sessions would suffice and the
therapy would end successfully. However, that
was not the case. After the fifth session the
therapy came to a standstill. The twins spoke
little, which was an uncharacteristic behaviour.
As with the previous case, the twins started to
form a passive unit. Despite their earlier incli-
nation to change, they made no improvements.
Three more months and five more sessions
were necessary for their resistance to be dis-
solved and their weight to get back to normal;
their menstrual cycles returned.
We planned to relieve the twin symbiosis,
therefore the twins were separated as the ther-
apy advanced, and the therapy included indi-
e141 Eat. Weight Disord., Vol. 17: N. 2 - 2012
vidual sessions with each twin sibling. Thus the
twins could share their feelings, and each of
them also disclosed that they would have, in
fact, made more progress but when they real-
ized that their twin (“their mirror image”) was
still slim, they became reluctant to heal without
the other improving. The essence of the second
part of the therapy was to break through this
resistance that stemmed from their symbiosis.
Their five-year follow-up showed remission,
however their body mass index is still around
17.5.
Case 3
The outpatient treatment of the 29-year-old
monozygotic female twins started due to their
s
eating disorder persisting for over a decade.
t i
The height of twin A is 161 cm and her body
ur
weight was 47 kg (BMI: 18.1), twin B being sim-
ilarly 161 cm tall and weighing 50 kg (BMI:
e K
19.3). Both had regular periods, with twin B
using oral contraceptives. They both suffered
ic
from bulimia at the time of admission. Twin A
ized by intensive physical training, her anorex-
ia turning into bulimia accompanied by restric-
tive symptoms. Twin B had symptoms indica-
tive of non-specific eating disorders: alternat-
ing between overeating and dieting. Twin B
learnt the bulimic behaviour from twin A. Twin
A showed signs of alcohol dependence. Their
brother also suffered from alcoholism.
The couple therapy of the twin pair focused
on decreasing their symbiotic manifestations
and increasing individuation and self-responsi-
bility, as well as the reduction of symptoms.
After 13 sessions we began individual therapy:
twin A attended ten and twin B eight sessions.
The compliance was incomplete; the twins can-
celled both individual and couple therapy ses-
sions several times. Twin A was more likely to
miss a session due to mild somatic complaints.
Twin B formed a relationship and developed
new friendships, while twin A isolated herself,
which was made worse by her depressive
mood caused by job loss. In many cases twin B
served as surrogate mother for her twin sister
who was born a couple of minutes earlier than
her. Similar to a typical adolescent-parent rela-
tionship, twin A was in need of care, however
she reacted with resistance and protest against
the overprotection manifested by twin B.
The family has Jewish roots. Excellence and
beauty were greatly valued in the family. The
maternal grandmother survived the Holocaust
due to her beauty. Emaciation may also be con-
ceived as identification with ancestors who suf-
fered during the Holocaust. First, bulimic
symptoms may indicate rebellion against the

trauma transmitted transgenerationally since
they are portraying extravagance in a symbolic
way. Second, we can consider them as rebel-
lion against parental restrictions thus formed.
Third, these can be viewed as an experiment to
enjoy life, which is not allowed due to the suf-
fering of ancestors, and the guilt thus devel-
oped triggers behaviour that compensates for
these sinful joys (weight gain).
During therapy the number of binge eating
and vomiting episodes decreased in both cases.
Their body weight increased (the weight of
twin A to 50 kg, and that of twin B to 52 kg),
and their nutrition became more balanced.
After six months of therapy the twins moved
away from each other. Twin B rented a flat
with her partner, although she regularly went
home and spent some days with her twin sister.
We suspended their therapy due to their
incomplete compliance. A six-month follow-up
revealed their unaltered state, and their unwill-
ingness to continue their therapy.
DISCUSSION
NLY i t r
E E O d
There are few publications on the psy-
2 , AL
US
chotherapy of twins suffering from eating dis-
orders; most of the studies dealing with twins
© 20
1 ON
focus on genetic aspects. It is very difficult to
determine an effective therapeutic approach
S
P ER
due to the relative scarcity of twin pairs with
eating disorders (9). The few case studies avail-
FOR
able do not discuss the challenges that charac-
terize the therapy of twins. Clinicians usually
apply their strategies of individual therapy to
the therapy of twins.
Wright (10) highlights that, in fact, twins
must perform a double task in relation to sepa-
ration-individuation: they need to detach from
their mother as well as their twin sibling. A
peculiar characteristic of twins’ bonds is that
twins live through events that occurred in the
life of their twin sibling as if these had hap-
pened to them. Marsden and Lacey (11) found
these processes to be more difficult for
monozygotes than dizygotes. The union
between twins is as strong as the union
between mother and child and falling back on
these bonds may bring about a delay in assum-
ing adulthood. The two-way process of striving
to maintain the union, while simultaneously
making efforts for separation, is most ambiva-
lent, and sometimes results in a love-hate rela-
tionship. Twin siblings exert a sometimes
excessive control on each other’s symptomatic
behaviour. The authors are of the opinion that
in such cases it is advisable to separate the
therapy of twins, and in case hospitalization is
Psychotherapy of twins with eating disorders
necessary, the treatments should be provided
in separate hospitals.
The union characteristic of a twin pair mani-
fests in concordant occurrence of illnesses as
well. However, there are cases in which the dis-
cordant occurrence indicates that the union
cannot be generalised. Studying a pair of male
monozygotes, Wiener (12) observed that only
one of the twins had AN and the other did not;
however, the latter suffered from phobias. Indi-
vidual therapy was instrumental in their quick
recovery. Evaluating discordant monozygotic
twins, Wade et al. (13) found that the twin
affected by past anorexia reported a higher
birth weight but a lower current body mass
index than their co-twin, and the affected twin
s
tended to be more anxious than their co-twin.
t i
We summarise our key points and recom-
ur
mendations to the psychotherapy of twins with
eating disorders as follows:
e K
1. The twins should be regarded as two inde-
ic
pendent individuals. A pitfall is to handle
them as “one soul in two bodies”. Therapists,
like parents, frequently view the twin pair as
a unit. Therapists should encourage parents
to emphasise individual differences and
independence between the twin siblings.
Highlighting the differences is not equivalent
to denying the twinship, and parents must
encourage the twins to refrain from seeing
their mirror image in their twin sibling.
2. The twin sibling participating in the situa-
tion as an observer or accompanying per-
son demands similar attention and help, just
as the co-twin who experienced those
events. E.g., one would not improve without
the other being ready for the change. The
three cases presented reveal that the twin
symbiosis may obstruct the process of psy-
chotherapy.
3. In the psychotherapy of twins, family thera-
py emerges as a valuable option. In family
therapy, parents in particular have multiple
tasks to complete, namely to help relax the
twin bond as well as to assist twin siblings in
developing their own talents and skills and
in maximizing their potentials.
4. When dealing with twins, the status of
incomplete separation may constitute a cer-
tain resistance, which stems from the symbi-
otic attachment. The positive aspect of this is
that the recovery of one of the twins may
serve as a positive example to the other.
However, this is not what we experienced in
our presented cases.
5. When designing family therapy, the thera-
pist must prepare the family for eventual
separate sessions realised in various forms.
Eat. Weight Disord., Vol. 17: N. 2 - 2012 e142
 F. Túry, A. Szentes, and M. Varga
In the separate sessions of traditional family
therapy generations are separated, thus
enhancing and encouraging clear bound-
aries to be drawn. In the case of twins this is
not the only issue. Adequate circumstances
must be provided for each of the twins to
manifest separately, and their individuation
should be fostered. Naturally, this is best
achieved by individual therapy. In the course
of family therapy it is sometimes advisable to
separate the twins as well as the genera-
tions, and continue one part of the session
by focusing on the parents and one on the
twins. In order to diminish the special resis-
tance of twins and strengthen the twin sib-
lings’ process of individuation, the applica-
tion of certain structural techniques may
prove appropriate.
6. It is an interesting theoretical and method-
ological question whether the individual
therapist and family therapist should be one
and the same or two different professionals.
Choosing different therapists for the individ-
r
ual and family therapies does not seem to be
ONLY
a good solution because there is less possi-
d i
bility for integration, and parallel therapiest
, E USE
may lead to splitting. Although Le Grange
and Schwartz (9) recommend two different
2
AL
therapists, it is advisable to have one thera-
© 20
1 ON
pist conducting both the individual and fami-
ly therapies.
S
P R
7. Another issue is whether the individual and
E
family therapies should be carried out simul-
FOR
taneously or consecutively. Simultaneous
integration may be more appropriate as the
emerging difficulties may be instantly over-
come in both therapies as they progress on
parallel tracks. This requires that the same
therapist conducts both therapies, or if this
is not possible, there should be continuous
dialogue between the two therapists in order
to prevent eventual splitting. Group therapy
also can be instrumental in dealing with the
issue of dynamics between twins e.g., sibling
jealousy or self-other identity issues (14).
e143 Eat. Weight Disord., Vol. 17: N. 2 - 2012
The discussion above presented some difficul-
ties for the therapy of twins with eating disorders.
However, we think that our considerations would
also be useful when designing therapies for twins
in various other (psychosomatic) disorders.
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