Anna O.

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This article is concerned with Bertha Pappenheim as the patient Anna O. For her
life before and after her treatment, see Bertha Pappenheim.

Anna O. was the pseudonym of a patient of Josef Breuer, who published her case study
in his book Studies on Hysteria, written in collaboration with Sigmund Freud. Her real
name was Bertha Pappenheim (1859–1936), an Austrian-Jewish feminist and the
founder of the Jüdischer Frauenbund (League of Jewish Women).

Anna O. 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 grief felt over her father's real and physical illness that later led to his
death[1].

Her treatment is regarded as marking the beginning of psychoanalysis. Breuer observed

that whilst she experienced 'absences' (a change of personality accompanied by
confusion), she would mutter words or phrases to herself. In inducing her to a state of
hypnosis, Breuer found that these words were "profoundly melancholy
fantasies...sometimes characterized by poetic beauty". Free Association came into being
after Anna/Bertha decided (with Breuer's input) to end her hypnosis sessions and merely
talk to Breuer, saying anything that came into her mind. She called this method of
communication "chimney sweeping", and this served as the beginning of free association.

Anna's/Bertha's case also shed light for the first time on the phenomenon called
transference, where the patient's feelings toward a significant figure in his/her life are
redirected onto the therapist. By transference, Anna imagined to be pregnant with the
doctor's baby. She experienced nausea and all the pregnancy symptoms. After this
incident, Breuer stopped treating her.

Historical records since showed that when Breuer stopped treating Anna O. she was not
becoming better but progressively worse[2]. In fact she was ultimately institutionalized:
"Breuer told Freud that she was deranged; he hoped she would die to end her suffering"[3].

She later recovered over time and led a productive life. The West German government
issued a postage stamp in honour of her contributions to the field of social work[4].

According to current research, "examination of the neurological details suggests that

Anna suffered from complex partial seizures exacerbated by drug dependence."[5] In other
words, her illness was not, as Freud suggested, psychological, but neurological. Many
believe that Freud misdiagnosed her, and she in fact suffered from temporal lobe
epilepsy, and many of her symptoms, including imagined smells, are common symptoms
of types of epilepsy.[6]

German postage stamp (1954) in the series Benefactors of Mankind

Contents
[hide]

• 1 Illness
• 2 Death of her father
• 3 Bellevue Sanatorium
• 4 Anna O.
• 5 Sources
• 6 Treatment
• 7 Conclusion of treatment
• 8 Success of treatment
• 9 See also
 • 10 Further reading

• 11 References

[edit] Illness
Bertha’s father fell seriously ill of pleurisy in summer 1880 during a family holiday in
Ischl. This event 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.[7] Her illness later
developed a wide spectrum of symptoms:

• Language disorders (aphasia): 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 (paresis): 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 disorders: She had temporary motor disturbances in her eyes. She
perceived objects as being greatly enlarged and she squinted.
• Mood changes: 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.

At first the family did not react to these symptoms, but in November 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. Starting on 11 December
Bertha Pappenheim was bedridden for several months.

[edit] Death of her father

Bertha Pappenheim‘s father died on 5 April 1881. As a result 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 (sometimes at her own
wish).
According to Breuer, the slow and laborious progress of 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. “She has fully recovered since that time” were the words with
which Breuer concluded his case report.[8]

[edit] Bellevue Sanatorium

Already on 12 July 1882 Breuer referred Bertha Pappenheim to the private Bellevue
Clinic in Kreuzlingen on Lake Constance, which was headed by Robert Binswanger.
After treatment in Bellevue she was no longer personally treated by Breuer.

While in Kreuzlingen she visited her cousins Fritz Homburger and Anna Ettlinger in
Karlsruhe. The latter was one of the founders of the Karlsruhe High School for Girls
(Mädchengymnasium), which was also attended by the young Rahel Straus. Anna
Ettlinger engaged in literary work. In an article which appeared in 1870 entitled "A
Discussion of Women’s Rights" (Ein Gespräch über die Frauenfrage) she demanded
equal education rights for women. She also gave private lessons, and organized "ladies’
literature courses".

Bertha Pappenheim during her stay at Bellevue Sanatorium in 1882

Bertha Pappenheim read aloud to her some of the stories she had written, and her cousin,
14 years her senior, encouraged her to continue her literary activities.[9] During this visit
toward the end of 1882 Bertha Pappenheim also participated in a training course for
nurses which was offered by the Women’s Association of Baden (Badischer
Frauenverein). The purpose of this training was to qualify young ladies to head nursing
institutions. She could not finish the course before her visit came to an end.
On 29 October 1882 her condition improved and she was released from treatment in
Kreuzlingen. In the following years, about which little is known, she lived a quiet life
with her mother in Vienna. There is evidence of three stays at Inzersdorf during this time;
her sickness was not conquered.

Despite her illness, Bertha Pappenheim was a strong personality. Breuer describes her as
a woman "of considerable intelligence, astonishingly astute reasoning and sharp-sighted
intuition [...]”.[10]

[edit] Anna O.
Bertha Pappenheim became known to the general public under the pseudonym of Miss
"Anna O.", a patient of Josef Breuer. Her case history was described in Studies on
Hysteria (Studien über Hysterie) (1895), which Breuer published together with Sigmund
Freud. She is presented as the first case in which it was possible to "thoroughly
investigate" hysteria and cause its symptoms to disappear. Her statement that being able
to verbalize her problem helped her to unburden herself is in accordance with the
treatment later denoted in psychoanalysis as the "catharsis theory". Accordingly, Freud
described her as the "actual founder of the psychoanalytic approach". Based on this case
study the assertion that "those with hysteria suffer for the most part from their
reminiscences", in other words from traumatic memories which can be "processed" by
relating them, was formulated for the first time.[11]

Freud himself wrote:

Breuer’s findings are still today the foundation of psychoanalytic therapy. The statement
that symptoms disappear with awareness of their unconscious preconditions has been
confirmed by all subsequent research […].[12]

It should be noted that Freud specified psychoanalytic "therapy," but not theory.
Psychoanalysis did not come into being until "Interpretation of Dreams" was written five
years later.

[edit] Sources
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 Studies on Hysteria.

The name Anna O. was constructed by shifting her initials "B.P." one letter back in the
alphabet to "A.O."

When the first volume of Ernest Jones’ Freud biography appeared in 1953, in which the
Anna O. of the studies was identified as being Bertha Pappenheim, her friends and
admirers were outraged; they only knew her from her time in Frankfurt. One of the
reasons for Dora Edinger's biography was to contrast her identification as being
"mentally ill", which at the time was considered defamatory, with a depiction of
Pappenheim as a philanthropist and advocate of women's rights.

Jones' portrayal contained further details, especially legends about the conclusion of
Breuer’s treatment, but except for the information contained in the studies nothing was
known about the further course of her illness. New facts only became known based on
research by Henri Ellenberger and subsequently by Albrecht Hirschmüller, who were
able to find Breuer’s case history of Pappenheim and other documents in the archives of
the Bellevue Clinic in Kreuzlingen.[13]

Those of Freud’s letters to his fianceé Martha Bernays which have been published
contain a few hints about the course of Pappenheim’s therapy and Freud’s relationship to
Breuer, but until all of Freud’s letters are published there is room for all kinds of
speculation.[14]

[edit] Treatment
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:

She had two completely separate states of consciousness which alternated quite often and
suddenly, and in the course of her illness became more and more distinct. In the one state
she was sad and apprehensive, but relatively normal. In the other state she had
hallucinations and "misbehaved", that is, she swore, threw pillows at people, […] etc.[15]

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."[16]

Such symptoms are associated with the clinical picture of what, at the time of her
treatment, was referred to as "split personality" and today is referred to as "dissociative
identity disorder." The existence and frequency of such an illness was, and still is,
controversial.

A first therapy approach was suggested by the observation that the patient calmed down
and her speech disorder improved whenever she was asked to tell stories that had
presumably arisen from her daydreams. About these daydreams Breuer remarked:
"Although everyone thought she was present, she was living in a fantasy, but as she was
always present when addressed, nobody suspected it." [17] He also 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. About her
descriptions Breuer said, "The stories, always sad, were sometimes quite nice, similar to
Andersen’s 'Picture Book Without Pictures'".[18]

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 formulation
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 developed systematic remembering and "reeling off" the occasions when
hysterical symptoms first occurred into a therapeutic method first applied to Pappenheim.
To his surprise he noticed that a symptom disappeared after the first occurrence was
remembered, or after the cause was "excavated".

Breuer described his final methodology as follows: In the morning he asked Pappenheim
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".

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:

In this way all the hysteria came to an end. The patient herself had made a firm resolution
to finish the business on the anniversary of her transfer to the countryside. For that reason
she pursued the "talking cure" with great energy and animation. On the final day she
reproduced the anxiety hallucination which was the root of all her illness and in which
she could only think and pray in English, helped along by rearranging the room to
resemble her father's sickroom. Immediately thereafter she spoke German and was then
free of all the innumerable individual disorders which she had formerly shown.[19]

[edit] Conclusion of treatment

A legend arose about the conclusion of Pappenheim‘s treatment by Josef Breuer. It was
handed down in slightly different versions by various people; one version is contained in
a letter from Freud to Stefan Zweig:
I was in a position to guess what really happened with Br’s patient long after we parted
company when I recalled a communication from Br dating from the time before our joint
work and relating to another context, and which he never repeated. That evening, after all
her symptoms were overcome, he was again called to her, and found her confused and
writhing with abdominal cramps. When asked what was the matter she responded, "Now
the child I have from Dr. Br. is coming". At that moment he had in his hand the key
which would open the way to the Mothers, but he dropped it. With all his intellectual
talents he was devoid of anything Faustian. He took flight in conventional horror and
passed on the patient to a colleague. She struggled for months in a sanatorium to regain
her health./ I was so sure of my reconsruction that I published it somewhere. Br’s
younger daughter (who was born shortly after the conclusion of that therapy, which is not
irrelevant as to a meaningful connection) read my portrayal and asked her father about it
(this was shortly before his death). He confirmed my analysis, which she later relayed to
me.[20]

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 Vienna with his wife Mathilda, who actually conceives a
child there—in contrast to the imaginary child of Bertha 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 (either in Venice or in
Gmunden), since his youngest child—Dora Breuer—was born on 11 März 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. Freud’s behavior is compared by some authors with his conduct in the so-
called "cocaine affair". There, too, he gave false representations not only privately, but
also several times in published form, without there being any advantage to offset the risk
of lasting damage to his scientific reputation.

Breuer later described the therapy as "a trial by ordeal", probably in the sense of an
examination. It claimed of him over 1,000 hours in the course of two years.

[edit] Success of treatment

After Breuer ceased treating her, both he and Freud continued to follow the course of
Pappenheim‘s illness.[21] Among Freud‘s disciples the dubiousness of the assertion of
“treatment success” was discussed. In a private seminar Carl Gustav Jung said in 1925:

So the famous first case he treated together with Breuer and which was vastly praised as
an outstanding therapeutic success was nothing of the sort.[22]
And Charles Aldrich reports:

But in this famous case the patient was not healed. Freud told Jung that all her old
symptoms returned after he had given up the case.[23]

Opponents of pyschoanalysis use this statement as an argument against this therapeutic

approach.

How Pappenheim herself assessed the success of her treatment is not documented.[24] She
never spoke about this episode of her life and vehemently opposed any attempts at
psychoanalytic treatment of people in her care.[25]

Aspects of Bertha Pappenheim‘s biography (especially her role as Breuer's patient) were
treated in the film Freud by John Huston (along with elements of other early
psychoanalytic case histories). The film is based on a screenplay by Jean-Paul Sartre
who, however, distanced himself from the film version.

[edit] See also

• Wolf man
• Rat man
• Little Hans
• Dora (case study)

[edit] Further reading

• Aubin, Melissa. "Bertha Pappenheim", University of Toronto.
• Mikkel Borch-Jacobsen, "Remembering Anna O.: A Century of Mystification",
(Routledge, 1996)

[edit] References
1. ^ Sigmund Freud: Five Lectures on Psychoanalysis.
2. ^ Ellenberger (1972), cited in When Good Thinking Goes Bad, Todd Riniolo, Prometheus
Books 2008
3. ^ Schultz and Schultz (2004), cited in When Good Thinking Goes Bad, Todd Riniolo,
Prometheus Books 2008
4. ^ When Good Thinking Goes Bad, Todd Riniolo, Prometheus Books 2008
5. ^ http://www.pep-web.org/document.php?id=APA.035.0387A
6. ^ "Freud Evaluated", Malcolm Macmillan, Elsevier, 1991, pg. 28
7. ^ The details of her illness are taken from the case history published by Freud and Breuer
in Studien zur Hysterie, as well as from her medical records found by Albrecht
Hirschmüller in the papers of Bellevue Sanatorium and published in his Physiologie und
Psychoanalyse im Leben und Werk Josef Breuers
8. ^ Hirschmüller. p. 35
 9. ^ Brentzel Siegmund Freuds Anna O. p. 62
10. ^ Studien über Hysterie (Fischer TB 6001) p. 20
11. ^ Studien über Hysterie (Fischer TB 6001) p. 10
12. ^ In: Vorlesung zur Einführung in die Psychoanalyse. Studienausgabe vol. 1. Fischer
1969–75. p. 279.
13. ^ Albrecht Hirschmüller: Physiologie und Psychoanalyse im Leben und Werk Josef
Breuers. Bern 1978
14. ^ See: Sigmund Freud: Brautbriefe: Briefe an Martha Bernays aus den Jahren 1882–
1886. Ed. Ernst L. Freud. Fischer, Frankfurt a. M. 1987. ISBN 3-596-26733-1. Other
quotes are scattered throughout various publications on the life of Freud, especially in the
biography by Ernest Jones.
15. ^ Studien loc.cit. p. 22
16. ^ Studien loc.cit. p. 39
17. ^ Studien loc.cit. p. 20
18. ^ Studien loc.cit. p. 26
19. ^ Studien loc. cit. p. 35
20. ^ Stefan Zweig: Briefwechsel mit Hermann Bahr, Sigmund Freud, Rainer Maria Rilke
und Arthur Schnitzler. Ed. Jeffrey B. Berlin, Hans-Ulrich Lindken and Donald A. Prater.
Fischer, Frankfurt a. M. 1987. p. 199–200.
21. ^ Jensen: Streifzüge. p. 35.
22. ^ Carl Gustav Jung: Analytische Psychologie. Nach Aufzeichnungen eines Seminars
1925. Ed. William Mc Guire. Walther, Solothurn-Düsseldorf 1995. p. 41.
23. ^ Charles Aldrich: The Primitive Mind and Modern Civilization. London 1931. p. 213.
24. ^ It is assumed that Pappenheim destroyed all relevant documentation during her last stay
in Vienna in 1935. See Edinger: Pappenheim 1968. p. 20.
25. ^ Edinger: Pappenheim 1968. p. 15.

Retrieved from "http://en.wikipedia.org/wiki/Anna_O."

Categories: Freudian psychology | 1859 births | 1936 deaths | Austrian Jews | German
Jews | History of psychology | Women and psychology

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