Anna O

CASE STUDY:

Anna O. was the only daughter of a wealthy Viennese Jewish family. She became ill when she was 21, in 1880.

Up to the onset of the disease, the patient showed no sign of nervousness, not even during pubescence. She had a keen, intuitive intellect, a craving for psychic fodder, which she did not, however, receive after she left school. She was endowed with a sensitiveness for poetry and fantasy, which was, however, controlled by a very strong and critical mind. . . . Her will was energetic, impenetrable and persevering, sometimes mounting to selfishness; it relinquished its aim only out of kindness and for the sake of others. . . . Her moods always showed a slight tendency to an excess of merriment or sadness, which made her more or less temperamental. . . . With her puritanically minded family, this girl of overflowing mental vitality led a most monotonous existence.

She spent hours daydreaming, making up fanciful plots in what she called her “private theatre.” She was at times so engrossed in fantasy that she did not hear when people spoke to her.

In July 1880, her father, whom she admired and “loved passionately,” developed tuberculosis. From July through November Anna was his night nurse, sitting up with him every night, observing his pain and deterioration, with the knowledge that he would not recover.

Her own health eventually began to decline, shehe became very weak, anemic, and evinced a disgust for nourishment, so that despite her marked reluctance, it was found necessary to take her away from the sick man. The main reason for this step was a very intensive cough about which I [Breuer] was first consulted. I found that she had a typical nervous cough. Soon, there also developed a striking need for rest, distinctly noticeable in the afternoon hours, which merged in the evening into a sleep-like state, followed by strong excitement. . . .

From the eleventh of December until the first of April the patient remained bedridden.5 `(

In rapid succession there seemingly developed a series of new and severe disturbances.
Left-sided occipital pain; convergent strabismus (diplopia), which was markedly aggravated through excitement. She complained that the wall was falling over (obliquus affection). Profound analyzable visual disturbances, paresis of the anterior muscles of the throat, to the extent that the head could finally be moved only if the patient pressed it backward between her raised shoulders and then moved her whole back. Contractures and anesthesia of the right upper extremity, and somewhat later of the right lower extremity.
It was in this condition that I (John Breuer) took the patient under treatment, and I soon became convinced that we were confronted with a severe psychic alteration. There were two entirely separate states of consciousness, which alternated very frequently and spontaneously, moving further apart during the course of the disease. In one of them she knew her environment, was sad and anxious, but relatively normal; in the other, she hallucinated, was “naughty”—i.e., she scolded, threw the pillows at people whenever and to what extent her contractures enabled her to, and tore with her movable fingers the buttons from the covers and underwear, etc. If anything had been changed in the room during this phase, if someone entered, or went out, she then complained that she was lacking in time, and observed the gap in the lapse of her conscious ideas. . . .

In very clear moments she complained of the deep darkness in her head, that she could not think, that she was going blind and deaf, and that she had two egos, her real and an evil one, which forced her to evil things, etc. . . . there appeared a deep, functional disorganization of her speech. At first, it was noticed that she missed words; gradually, when this increased, her language was devoid of all grammar, all syntax, to the extent that the whole conjugation of verbs was wrong. . . . In the further course of this development she missed words almost continuously, and searched for them laboriously in four or five languages, so that one could hardly understand her. . . . She spoke only English and understood nothing that was told her in German. The people about her were forced to speak English. . . . There then followed 2 weeks of complete mutism. Continuous effort to speak elicited no sound.

About ten days after her father died, a consultant was called in, whom she ignored as completely as all strangers, while I demonstrated to him her peculiarities. . . . It was a real “negative hallucination,” which has so often been reproduced experimentally since then. He finally succeeded in attracting her attention by blowing smoke into her face. She then suddenly saw a stranger, rushed to the door, grabbed the key, but fell to the floor unconscious. This was followed by a short outburst of anger, and then by a severe attack of anxiety, which I could calm only with a great deal of effort.

The family was afraid Anna would jump from the window, so she was removed from her third-floor apartment to a country house, where for 3 days “she remained sleepless, took no nourishment, and was full of suicidal ideas.” She also broke windows, etc., and evinced hallucinations [of black snakes, death’s heads, etc.] without absences[dissociated periods].

Breuer treated Anna by asking her, under hypnosis, to talk about her symptoms, a technique she referred to as “chimney sweeping.” As the treatment proceeded, she had longer periods of lucidity and began to lose her symptoms. After 18 months of treatment, as Anna prepared to spend the summer in her country home, Breuer pronounced her well and said he would no longer be seeing her. That evening he was called back to the house, where he found Anna thrashing around in her bed, going through an imaginary childbirth. She insisted that the baby was Breuer’s. He managed to calm her by hypnotizing her. According to Ernest Jones, Breuer then “fled the house in a cold sweat” and never saw her again.

Anna remained ill intermittently over the next 6 years, spending considerable time in a sanatorium, where she apparently became addicted to morphine. She was often fairly well in the daytime, but still suffered from hallucinatory states toward evening.

By 30 she had apparently completely recovered and moved to Frankfort with her mother. There she became a feminist leader and social worker. She established an institution for “wayward girls” and spoke out against the devaluation of women that she believed was inherent in Orthodox Judaism.

Anna never married, but was said to be an attractive and passionate woman who gathered admirers wherever she went. She had no recurrences of her illness and never spoke about it—in fact, she apparently asked her relatives not to speak of it to anyone. In her later years her attitude toward psychoanalysis was clearly negative, and she became quite angry at the suggestion that one of her “girls” be psychoanalyzed.)

Anna died at 77 of abdominal cancer.