Anna O., Case of

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ANNA O., CASE OF

Anna O. was the first case described by Joseph Breuer in his Studies on Hysteria (1895d). Her real name, Bertha Pappenheim, was revealed by Ernest Jones in his 1953 biography of Freud, shocking his contemporaries. When Breuer saw her for the first time toward the end of November 1880, Bertha Pappenheim, a friend of Martha Bernays (Freud's future wife), was about 22 years old. Her problems had been triggered when her father, whom she loved deeply, fell seriously ill. Her symptom was a "nervous cough," which Breuer quickly diagnosed as being of hysterical origin. She soon suffered from other symptoms as well: squinting, partial paralysis, visual disturbances, and a lack of feeling in her right arm. She also exhibited alternating states of consciousness, which drew Breuer's attention as a sign of a self-hypnotic condition that he would gradually use for therapeutic purposes.

These symptoms were followed by speech disturbances (she could only speak English, then became mute), which led Breuer to conclude that she was hiding something and must be made to speak. This therapeutic insight was followed by an improvement in her condition, but the death of her father in April 1881 caused a relapse. It was at this time that she began recounting lengthy stories in a highly dramatic tone of voice during her self-induced hypnotic states in the evening. These were accompanied by violent affects that highlighted their significance. She referred to this initial "catharsis" as the talking cure and sometimes as chimney sweeping.

It was most likely during the summer of 1881, probably in mid-August (although Henri Frédéric Ellenberger says it occurred during the first months of 1882), that an incident occurred that was to have profound significance on the future of Breuer's method. Anna refused to drink liquids, but in her hypnotic state revealed that she had been disgusted to discover her lady companion's dog drinking out of her glass. When awakened she asked for a glass of water. The etiological function of the "cathartic method" was born and Breuer had her identify, for each of her symptoms, the memory of the "primitive scene" from which they originated but which had apparently been forgotten.

Between December 1881 and June 1882, a new symptom appeared, which led to a renewal of what she had experienced a year earlier, as indicated by Breuer's notes at the time. This "talking out" (1895d, p. 36), as Breuer referred to it, was not simple, however: "The work of remembering was not always an easy matter and sometimes the patient had to make great efforts. On one occasion our whole progress was obstructed for some time because a recollection refused to emerge" (p. 37). Freud was later to draw significant conclusions about this "resistance" on the part of the patient.

In 1882, however, Breuer had little understanding of "transference," and this continued as late as 1895, when he completed his description of this intelligent, intuitive, and kind woman: "The element of sexuality was astonishingly undeveloped in her. The patient, whose life became known to me to an extent to which one person's life is seldom known to another, had never been in love; and in all the enormous number of hallucinations which occured during her illness that element of mental life never emerged" (1895d, p. 21-22).

In the wake of Breuer's colorless narrative, a number of mysteries and legends have grown up around the circumstances of the rupture of such a strong affective relationship. In fact, Breuer was apparently called to her bedside the very evening they said goodbye to one another after the conclusion of the treatment. She was in the midst of a hysterical crisis and pretended to be giving birth "to Doctor Breuer's child." Ernest Jones writes that Breuer was "fled the house in a cold sweat. The next day he and his wife left for Venice to spend a second honeymoon, which resulted in the conception of a daughter; the girl born in these curious circumstances was nearly sixty years later to commit suicide in New York"(Jones, 1953, Vol. 1, p. 148).

In fact, historical research has shown that this story is false. Anna O. was hospitalized in the clinic of Kreuzlingen in July 1882 at Breuer's request. She was suffering from neuralgic pains of the trigeminal nerve, which had led Breuer to administer increasingly strong doses of morphine, from which she eventually had to be weaned. We know that Bertha Pappenheim, even though Breuer was no longer her physician, was gradually healed and devoted her life and her writing after 1895 to helping young Jewish girls, single mothers, and orphans. She was one of the first "social workers" and her work earned her the admiration of everyone who knew her until her death on May 28, 1936.

As for Breuer, that summer he and his wife he did not escape to Venice but spent their vacation in Gmunden, near the Traunsee in Austria. Their daughter Dora was born on March 11, 1882, three months before the end of Anna O.'s treatment. But such legends die hard and the detractors of Freud and psychoanalysis continue to make use of them.

Breuer continued to care for "nervous" patients and described his method of treatment to his young protégé Freud on November 18, 1882, and again in July 1883. This was the point of departure for the etiological research that Freud, somewhat disillusioned by Jean Martin Charcot's lack of interest in the story, was unable to begin until nearly ten years later.

In his "On the History of the Psycho-analytic Movement" (1914d), Freud, who always reported that the origins of psychoanalysis lay in "J. Breuer's cathartic method," (in 1910a, for example), spoke of the transference aspect that, until then, had been neglected: "Now I have strong reasons for suspecting that after all her symptoms had been relieved Breuer must have discovered from further indications the sexual motivation of this transference, but that the universal nature of this unexpected phenomenon escaped him, with the result that, as though confronted by an 'untoward even', he broke off all further investigation" (1914d, 12).

On June 2, 1932, in a letter to Stefan Zweig, Freud gave further details about the end of Anna O.'s treatment while reminiscing about Breuer: "Asked what was wrong with her, she replied: 'Now Dr. B.'s child is coming!' At this moment he held in his hand the key that would have opened the 'doors to the Mothers,' but he let it drop. With all his great intellectual gifts there was nothing Faustian in his nature. Seized by conventional horror he took flight and abandoned the patient to a colleague."

The story of Anna O. has always been a source of contention. In 1895 it was published, primarily to demonstrate that the cathartic method, dating from 1881-1882, preceded the research published by Pierre Janet. In 1953 it was used by Jones to demonstrate Freud's courage and scientific creativity compared to Breuer's presumed cowardice. Following the research of Henri Frédéric Ellenberger and Albrecht Hirsch-müller, the real history is better known, and while the romanticized presentation of therapy can no longer escape the notice of the psychoanalytic community, it still contains traces of Freud's later thinking. In any event, the distortions of writing do not justify believing, as the detractors of psychoanalysis such as Mikkel Borch-Jacobsen would have us do, that Breuer and Freud were charlatans and Bertha Pappenheim was simply a "fraud."

Alain de Mijolla

See also: Breuer, Josef; Cathartic method; Five Lectures on Psycho-Analysis ; Studies on Hysteria ; Hypnoid states; Pappenheim, Bertha.

Bibliography

Edinger, Dora. (1963). Bertha Pappenheim: Leben und Schriften. Frankfurt: D. Edinger.

Ellenberger, Henri F. (1970). The discovery of the unconscious: The history and evolution of dynamic psychiatry. New York: Basic Books.

——. (1972). "L'histoire d'Anna O.":Étude critique avec documents nouveaux. In Médecines de l'âme. Paris: Fayard, 1995. (Reprinted from L'évolution psychiatrique, 37 (4), 693-717.)