Bertha Pappenheim
Bertha Pappenheim was an Austrian-Jewish feminist, a social worker pioneer, and the founder of the Jewish Women's Association. Under the pseudonym Anna O., she was also one of Josef Breuer's best-documented patients because of Sigmund Freud's writings on Breuer's treatment of her.
Childhood and youth
Bertha Pappenheim was born on 27 February 1859 in Vienna, the third daughter of Recha Pappenheim and Sigmund Pappenheim. Her mother Recha, née Goldschmidt, was from an old and wealthy family in Frankfurt am Main. Her father Sigmund, a merchant, the son of an Orthodox Jewish family from Preßburg, Austria-Hungary, was the cofounder of the Orthodox Schiffschul in Vienna; the family name alludes to the Franconian town of Pappenheim. As "just another daughter" in a strictly traditional Jewish household, Bertha was conscious that her parents would have preferred a male child. Her parents' families held traditional Jewish views on marriage and had roots in Orthodox Judaism. Bertha was raised in the style of a well-bred young lady of good class. She attended a Roman Catholic girls' school and led a life structured by the Jewish holiday calendar and summer vacations in Ischl.When she was eight years old, her oldest sister Henriette died of galloping consumption, now known as a form of tuberculosis. When she was 11 the family moved from Vienna's Leopoldstadt, which was primarily inhabited by poverty-ridden Jews, to Liechtensteinstraße in the Alsergrund. She left school when she was sixteen, devoted herself to needlework and helped her mother with the kosher preparation of their food. Her 18-month-younger brother Wilhelm was meanwhile attending a high school, which offered in those days prestige and status, and which made Bertha intensely jealous.
Illness and treatment as Anna O.
Between 1880 and 1882, Pappenheim was treated for a variety of symptoms that began when her father suddenly fell seriously ill in mid-1880 during a family holiday in Ischl. His illness was a turning point in her life. While sitting up at night at his sickbed she was suddenly tormented by hallucinations and a state of anxiety. At first the family did not react to these symptoms, but in November 1880 a friend of the family, the physician Josef Breuer, began to treat her. He encouraged her, sometimes under light hypnosis, to narrate stories, which led to partial improvement of the clinical picture, although her overall condition continued to deteriorate. Breuer kept his then-friend Sigmund Freud abreast of her case, informing his earliest analysis of the origins of hysteria.Starting on 11 December, Pappenheim was bedridden for several months. When her father died, on 5 April 1881, she became fully rigid and did not eat for days. Her symptoms continued to get worse and on 7 June she was admitted against her will to the Inzersdorf sanatorium, where she remained until November. After returning she continued to be treated by Breuer. She returned to this sanatorium several times over the course of the following years.
The slow and laborious progress of what Breuer called her "remembering work", in which she recalled individual symptoms after they had occurred, thus "dissolving" them, came to a conclusion on 7 June 1882 after she had reconstructed the first night of hallucinations in Ischl. Breuer concluded his case report with the words "She has fully recovered since that time".
Anna O. was the pseudonym given to Pappenheim by Breuer while she was his patient, in his descriptions of her as a case study. The pseudonym was constructed by shifting her initials "B.P." one letter back in the alphabet to "A.O." Aspects of the Anna O. case were first published by Freud and Breuer in 1893 as preliminary communications in two Viennese medical journals. The detailed case history appeared in 1895 in his book Studies on Hysteria, written in collaboration with Freud.
Symptoms
Pappenheim was treated by Breuer for severe cough, paralysis of the extremities on the right side of her body, and disturbances of vision, hearing, and speech, as well as hallucination and loss of consciousness. She was diagnosed with hysteria. Freud implies that her illness was a result of the resentment felt over her father's real and physical illness that later led to his death.Throughout the two years of her illness, she developed a wide spectrum of symptoms:
- Language disorders : on some occasions she could not speak at all, sometimes she spoke only English, or only French, or Italian. She could however always understand German. The periods of aphasia could last for days, and sometimes varied with the time of day.
- Neuralgia: she suffered from facial pain which was treated with morphine and chloral and led to addiction. The pain was so severe that surgical severance of the trigeminus nerve was considered.
- Paralysis : signs of paralysis and numbness occurred in her limbs, primarily on only one side. Although she was right-handed, she had to learn to write with her left hand because of this condition.
- Visual impairments: she had temporary motor disturbances in her eyes. She perceived objects as being greatly enlarged and she squinted.
- Mood swings: Over long periods she had daily swings between conditions of anxiety and depression, followed by relaxed states.
- Amnesia: when she was in one of these states she could not remember events or any of her own actions which took place when she was in the other state.
- Eating disorders: in crisis situations she refused to eat. During one hot summer she rejected liquids for weeks and lived only on fruit.
- Pseudocyesis: there are some accounts that during her final meeting with Breuer she exhibited symptoms of a false pregnancy. Freud later claimed that she accused Breuer of impregnating her, but admitted that this was a guess.
Many researchers have speculated about organic or neurological illnesses that may have caused Pappenheim's symptoms. Medical historian Elizabeth Marianne Thornton suggested in Freud and Cocaine that Pappenheim had tuberculous meningitis, a view supported by professor of psychology Hans Eysenck, but not by neuropsychiatrist and professor of neurology Richard Restak who describes the theory as "simply preposterous" since the mortality rate for tuberculous meningitis at the time was virtually 100 percent and those who survived were severely disabled. Others have suggested it was encephalitis, a form of brain inflammation. Many have suggested that she suffered from a form of temporal lobe epilepsy since many of her symptoms, including imagined smells, are common symptoms of types of epilepsy. According to one perspective, "examination of the neurological details suggests that Anna suffered from complex partial seizures exacerbated by drug dependence."
Treatment by Breuer
Breuer began the therapy without a clear method or theoretical basis. The treatment of her symptoms ranged from feeding her when she rejected food to dosages of chloral when she was agitated. He described his observations as follows:He noted that when in one condition she could not remember events or situations that had occurred in the other condition. He concluded, "it is difficult to avoid saying that she dissolved into two personalities, one of which was psychically normal and the other mentally ill." Such symptoms are associated with the clinical picture of what was then referred to as "split personality" and today is referred to as dissociative identity disorder.
Breuer noted that "Although everyone thought she was present, she was living in a fantasy, but as she was always present when addressed, nobody suspected it." An initial therapeutic approach was suggested by the observation that her anxiety and language difficulties seemed to dissolve whenever she was asked to tell stories that had arisen from her daydreams. Breuer encouraged her to calmly "reel off" these stories by using such prompts as a first sentence. The formula he used was always the same: "There was a boy..." At times Pappenheim could only express herself in English, but usually understood the German spoken around her. Of her stories Breuer said, "The stories, always sad, were sometimes quite nice, similar to Andersen's Picture Book Without Pictures."
The patient was aware of the relief that "rattling off" brought her, and she described the process using the terms "chimney-sweeping" and "talking cure". The latter term subsequently became part of psychoanalytic terminology.
Other levels of story telling soon came up, and were combined with and penetrated each other. Examples include:
- Stories from a "private theater"
- Hallucinatory experiences
- Temporal relocation of episodes: during one phase her experience of the illness was shifted by one year
- Episodes of occurrence of hysterical symptoms
Breuer described his final method as follows: in the morning he asked Pappenheim, whom he had put under light hypnosis, about the occasions and circumstances under which a particular symptom occurred. When he saw her in the evening, these episodes—there were sometimes over 100—were systematically "reeled off" by Pappenheim in reverse temporal order. When she got to the first occurrence and thus to the "cause", the symptoms appeared in an intensified form and then disappeared "forever".
Breuer later described the therapy as "a trial by ordeal". He spent 1,000 hours with his patient over the course of two years.
Accounts of final session
The first possible account is that this therapy came to a conclusion when they had worked their way back to a black snake hallucination which Pappenheim experienced one night in Ischl when she was at her father's sickbed. Breuer describes this finish as follows:An alternate story is that on the eve of his final analysis with her, he was called back to her home to find her experiencing severe stomach cramps and hallucinating that she was having his child. Of course, there was no child. His comportment towards her has never been questioned nor is there any indication that it should have been—as Breuer was the first analyst of the first patient to undergo analysis, transference was not understood. Breuer promptly handed Pappenheim's care over to a colleague. He would have no more to do with her. Freud's initial encouragement to continue his talking therapy was met by Breuer's insistence that he'd had quite enough of hysterical women and wanted nothing more to do with them. It would be another four years before Sigmund Freud could persuade him to once again attempt psychotherapy or to deal with women diagnosed as hysterical, and a further six years passed before Breuer was willing to publish on the subject of the talking cure.
One of the most discussed aspects of the case of Ana O. is the phenomenon of transference, in which the patient, Bertha Pappenheim, developed ambiguous feelings toward her doctor, Josef Breuer. These feelings varied between a desire for closeness and hostility. Accounts indicate a notable episode in which Ana O. reportedly manifested delusions, even suggesting an imaginary pregnancy by Breuer. This incident caused discomfort among her family and the doctors involved, and raised ethical questions about the emotional influence in the doctor-patient relationship. Sigmund Freud, who discussed the case with Breuer, recognized transference as a fundamental aspect of the therapeutic process, interpreting it as the manifestation of unconscious desires toward the figure of the therapist. This concept would become one of the pillars of psychoanalysis, later explored and deepened in Freud’s studies on the treatment of neuroses.
Legends arose of this alternate conclusion. It was handed down in slightly different versions by various people; one version is contained in a letter from Freud to Stefan Zweig:
As nothing is known of such a publication by Freud, it is not clear where Breuer's daughter could have read it. In the version by Ernest Jones, after his flight Breuer quickly goes on a second honeymoon to Venice with his wife Mathilda, who actually conceives a child there—in contrast to the imaginary child of Pappenheim. There is no evidence for any of this, and most of it has been proved false. Breuer did not flee but rather referred his patient to Kreuzlingen. He did not go to Venice, but with his family on a summer vacation to Gmunden, and he did not conceive a child, since his youngest child—Dora Breuer—was born on 11 March 1882, three months before the alleged conception.
Freud's purpose in describing the conclusion of treatment in a way that contradicts some of the verifiable facts is unclear. The assumption that he wanted to make himself the sole discoverer of psychoanalysis at Breuer's expense is contradicted by the description of the discovery in Freud's writings, in which he does not minimize Breuer's role, but rather emphasizes it.