Anna O. - Treatment

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.

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, 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." 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'".

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.