The case of Anna O., reported by Josef Breuer and Sigmund Freud in their1895 book Studies on Hysteria, provides the initial evidence for the effectiveness of psychoanalytic treatment. The patient’s actual name was Bertha Pappenheim (Gay, 1988; Jones, 1953). For the case study, her initials were shifted one letter earlier in the alphabet, and she was given the pseudonym Anna. Since the publication of her story, so many people have given their opinion of what was wrong with her that truth is difficult to determine in the welter of interpretation (recent review by Skues, 2006).
In 1880, at the age of 21, Bertha Pappenheim became the patient of Josef Breuer. Breuer was 38-years old, a respected Viennese physician, famous for his earlier work in physiology. In 1868 he had shown that inflation of the lungs trigger pulmonary stretch receptors which through the vagus nerve then inhibit the inspiratory centers of the lower brainstem (Hering-Breuer reflex). In 1874 he had shown how the vestibular system was related to the sense of balance and not hearing (Mach-Breuer hypothesis). After his researches, Breuer had become a conscientious and caring physician. He described his new patient:
She was markedly intelligent, with an astonishingly quick grasp of things and penetrating intuition … She had great poetic and imaginative gifts which were under the control of a sharp and critical common sense … Her will-power was energetic, tenacious and persistent (Freud Standard Edition Volume II, p. 21)
Anna’s history was complex. She had been nursing her father who was ill with tuberculosis when her symptoms began, and who went on to die while she was being treated. Before she presented to Breuer, she had suffered from brief periods where she was apparently unaware – Breuer termed them “absences.” At the time of her treatment, she alternated daily between normal periods and prolonged spells of self-induced “hypnosis,” wherein she experienced strange aphasic symptoms, hallucinations and left-sided weakness. Breuer interacted with her during these periods and together they traced the history of each symptom:
She aptly described this procedure, speaking seriously, as a ‘talking cure’, while she referred to it jokingly as ‘chimney-sweeping’. (p.30)
These descriptive terms were originally in English, in which Anna was fluent. As Anna remembered the situation wherein the symptom had begun, the hysterical phenomenon disappeared:
Each individual symptom in this complicated case was taken separately in hand; all the occasions on which it had appeared were described in reverse order, starting before the time when the patient became bedridden and going back to the event which had led to its first appearance. When this had been described the symptom was permanently removed. In this way her paralytic contractures and anaesthesias, disorders of vision and hearing of every sort, neuralgias, coughing, tremors, etc., were “talked away.” (p. 35)
At the end of the case history, Breuer and Freud speculated about the mechanisms of hysterical symptoms and their treatment. The patient showed evidence of a secondary state of mind with “its wealth of imaginative products and hallucinations, its large gaps of memory and the lack of inhibitions and control in its associations” (p. 45) This “unconscious” state intruded into her normal state of mind to cause her hysterical symptoms.
Breuer and his patient interacted intensely over many, many hours. It is difficult not to speculate that the relationship between Anna and Josef went deeper than that between physician and patient. Breuer’s involvement with Anna plays an essential role in Yalom’s novel When Nietzsche Wept.
Breuer’s wife became jealous of his fascination with the young woman, and Breuer stopped the treatment. The end of their relationship was terrifying. Anna appears to have undergone an hysterical pregnancy and miscarriage. Later psychoanalytic thought would consider such phenomena in terms of transference and counter-transference.
The case of Anna O marks the beginning of psychotherapy. Reliving the emotions of a past trauma released them. After this catharsis, the repressed emotions no longer needed to manifest themselves in somatic symptoms.
However, Bertha continued to experience various symptoms and her treatment was continued in a Swiss sanatorium (to which she had been referred by Breuer after he ceased to be her physician). Later psychoanalytic thought would suggest that the psychotherapy had not worked because it had not discovered the real repressed emotions – inhibited sexual desires for her father rather than grief at his illness. Furthermore, the goal of psychotherapy evolved not just to release the anxieties that well up from the unconscious but to make the conscious mind understand and control these forces. The unconscious must become integrated into consciousness rather than simply liberated.
The case of Anna O. continues to be extensively interpreted. Some have suggested that she may have actually had a neurological rather than psychiatric disorder: tuberculous meningitis (extremely unlikely), epilepsy with complex partial seizures, or postinfectious encephalomyelitis (the various diagnoses are reviewed by Webster, 1996). Conversion hysteria may occur in conjunction with neurological disorders (Kanaan, 2009), but this is perhaps not as frequent as once was thought (Stone et al., 2005). Others have suggested that Anna’s conversion symptoms were part of a depressive illness (Merskey, 1992).
Many other factors were not fully evaluated in the original case history. Anna had been taking chloral hydrate to help her to sleep in the afternoons so that she could stay up at night to watch over her father. In addition, her facial pains had been treated with morphine. Drug dependence may have played a role in her symptoms and in her hypnotic states. Perhaps Anna’s absences were caused by psychomotor seizures (temporal lobe epilepsy) precipitated (and exacerbated) by drug withdrawal and sleep deprivation (Orr-Andrawes, 1987).
Anna O. ultimately led a very productive life (Kimball, 2000; Loentz, 2007). In 1888, Bertha Pappenheim and her mother moved from Vienna to Frankfurt, where Bertha became active in social work, running an orphanage and presiding over the Jüdische Frauenbund (League of Jewish Women). She was skeptical about psychoanalysis and opposed its use in the children under her care. Pappenheim wrote extensively on social issues and women’s rights. Her most important book dealt with the need to protect women from prostitution and white slavery (Sisyphus-Work).
Under the pseudonym Paul Berthold, Bertha Pappenheim wrote stories and a play Frauenrecht (Women’s Rights, 1899). The play has intriguing parallels to Bertha’s real or fantasized relations with Breuer. The protagonist, who has recently joined the Women’s Relief Society, asks her husband for some of the money that she brought to their marriage to support a sick young female worker and her illegitimate child. The husband refuses on principle. However, he does not realize that he is the father of the child.
Bertha Pappenheim suffered in her youth from a conversion disorder. Her symptoms were triggered by her grief at her father’s illness and her mourning for his death. The suggestion that her disorder was neurological rather than psychological is unlikely given its outcome. She became well. However, she was not cured by her physicians. Whatever psychotherapy occurred during her interaction with Josef Breuer, she had herself invented. Most impressive, however, was what came afterwards (Kimball, 2000). The photograph at the beginning of this article, taken in 1882 after her treatment with Breuer was over, shows an elegant and confident young woman in riding outfit. However, she still had a long way to go. Somehow, over the next five years, she was able to pull herself together, to stop taking the drugs she had been prescribed, and to find an outlet for her intelligence and will in social work.
Breuer, J., & Freud, S. (1895). Studien über Hysterie. (Studies on Hysteria). Translated and edited by Strachey, J., & Freud, A. (1955). The Standard edition of the complete psychological works of Sigmund Freud. Volume II. London: Hogarth Press. (Available at arkive.org)
Gay, P. (1988). Freud: A life for our time. New York: Norton.
Jones, E. (1953). Sigmund Freud: life and work. London: Hogarth Press.
Kanaan, R., Armstrong, D., Barnes, P., & Wessely, S. (2009). In the psychiatrist’s chair: how neurologists understand conversion disorder. Brain, 132, 2889-96.
Kimball, M. M. (2000). From “Anna O.” to Bertha Pappenheim: transforming private pain into public action. History of Psychology, 3, 20-43.
Loentz, E. (2007). Let me continue to speak the truth: Bertha Pappenheim as author and activist. Cincinnati: Hebrew Union College Press. Available through Google Books.
Merskey, H. (1992). Anna O. had a severe depressive illness. British Journal of Psychiatry, 161, 185-194.
Orr-Andrawes, A. (1987). The case of Anna O.: a neuropsychiatric perspective. Journal of the American Psychoanalytic Association, 35, 387-419.
Skues, R. A. (2006). Sigmund Freud and the history of Anna O: Reopening a closed case. Basingstoke, Hampshire: Palgrave Macmillan.
Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, & Sharpe, M. . (2005) Systematic review of misdiagnosis of conversion symptoms and ‘‘hysteria.’’ British Medical Journal, 331, 989 (epub)
Webster, R. (1996). Why Freud was wrong: Sin, science and psychoanalysis. London: HarperCollins. (Chapter 4: Anna O. and the birth of psychoanalysis, pp 103-135).
Yalom, I. D. (1993). When Nietzsche wept. New York: HarperPerennial.