Analysis of Freud’s Case of Elisabeth von R (Ilona Weiss)

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Introduction[edit]

Early in Freud’s psychoanalytic career he was very interested in hysteria. This encyclopedia entry serves as a rediscovery of Freud as a contributor to the study of post-traumatic fibromyalgia. The word “fibromyalgia did not exist in Freud’s time, but the word “neurasthenia” did and Freud had some interest in it. Neurasthenia is roughly equivalent to what could now be called “fibromyalgia and chronic fatigue syndrome. It appears 18 times in his book on hysteria, including one mention that the patient’s leg pains might be neurasthenic in nature.

A search of Studies in Hysteria for the word “pain” revealed that it appeared appears over 300 times. The likely explanation for this is that hysteria and fibromyalgia are known co-morbidities.

A close study of the case of Elisabeth von R reveals that his clinical description of her is highly compatible with fibromyalgia and chronic fatigue syndrome. (https://archive.org/details/studiesinhysteri002062mbp and in full text at: https://archive.org/stream/studiesinhysteri002062mbp/studiesinhysteri002062mbp_djvu.txt.)

By way of introduction, my impression is that this patient likely has a combination of hysteria, fibromyalgia and myofascial pain syndrome.

Based on her history of muscular pain, fatigue and and sensitivity to pressure it is extremely likely that she had fibromyalgia.

It is a testament to his extraordinary powers of observation and description. Such a patients are immensely complicated both physically an emotionally. It is not uncommon for them to unburden themselves if the doctor shows interest but the result can be a shower of confusing seemingly disjointed details. In busy clinics if the doctor is not psychologically minded, there may be a tendency to “tune it out”. Not so with Freud.

Freud began his case history by commenting on the fact that this young woman had already experienced three major life traumas. It is known that fibromyalgia is often post-traumatic. In a nutshell, Freud described the onset of her muscle pains fatigue saying that they started when she was “ exhausted by the worries of the past months” and that she had experienced “effects of the suffering and anxiety to which the family had been subjected since the death of her father.”

Freud made special mention of how difficult it was for him to understand the mysteries as to why the patient fell ill. He wrote: The work which I then began, turned out to be the most arduous undertaking that ever fell to my lot, and the difficulty of giving an account of this work ranks well with the obstacles that had to be overcome. For a long time, too, I did not understand the connection between the .history of the disease and the affliction, which should really have been caused and determined by this series of events.”

Similar problems still plague doctors and patients. Remarkably, there are still doctors today who doubt the connections between trauma and fibromyalgia. Freud was blessed with what could be called “the psychological attitude. Many are not and so they may miss out on understanding the psychological determinants of their patient’s fibromyalgia. (For further perspective see the entries for "Mechanistic doctor syndrome", "Anti-psychological attitude" in the Encyclopedia of Touch, Body Sense and Pain.)

Key experps from Freud’s case[edit]

Here is Freud’s discussion of the pains of Ms. Elisabeth von R whom he saw in 1892. [My comments have been added amongst Freud’s text in square brackets. Italics have also been added by me, M. Doidge.]

He wrote: “First the patient's father died, then the mother underwent a serious operation on her eyes, and soon thereafter a married sister succumbed to a chronic cardiac affection following childbirth. Our patient had taken an active part in all the afflictions, especially in the nursing of the sick.”

“…She [Elisabeth von R.] complained only of severe pains and of early fatigue in walking as well as standing, so that after a brief period she had to seek rest in which the pains diminished, but by no means disappeared. [Muscle pain and fatigue are arguably the two main symptoms of fibromyalgia.] The pain was of an indefinite nature one could assume it to be a painful fatigue. [It is known that the muscle pains of fibromyalgia are often indefinite.] The seat of the pain was quite extensive [in other words Freud has hit on the chronic widespread muscular pain pattern which is now widely recognized as a principle feature of fibromyalgia] but indefinitely circumscribed on the superficial surface of the right thigh. [In other words, she also has a particularly painful part of her body, which in this case is her right leg. We will never know for absolute certain the cause of her pain. However, it is now recognized that there is a fibromyalgia-like condition known as myofascial pain syndrome which tends lodge in a particular part of the body such as a specific limb.] It was from this area that the pains radiated and were of the greatest intensity. Here, too, the skin and muscles were especially sensitive to pressure and pinching, while needle pricks were rather indifferently perceived. [She has mechanical allodynia which is a key indicator of fibromyalgia. It seems he may be alluding to abnormally diminished sensation of pin prick. Hysteria is a known co-morbidity of fibromyalgia. Perhaps the patient might have hysterical analgesia to pin prick.] The same hyperalgesia of the skin and muscles was demonstrable not only in this area, but over almost the entire surface of both legs. The muscles were perhaps more painful than the skin, but both kinds of pains were unmistakably most pronounced over the thighs. [Muscular pain, not skin pain is the dominant type of pain fibromyalgia.] The motor power of the legs was not diminished, the reflexes were of average intensity, and as all other symptoms were lacking, there was no basis for the assumption of a serious organic affection. The disease developed gradually during two years and changed considerably in its intensity…” (Page 97)

“A still greater determination for the conception of the pain must, however, be found in a second factor. If we irritate a painful area in a patient suffering from an organic disease or neurasthenia, his physiognomy will show a definite expression of discomfort or of physical pain, the patient winces, refuses to be examined, and assumes a defensive attitude. But if anyone pinched or pressed Miss v. R.'s hyperalgesic skin or muscles of her legs, her face assumed a peculiar expression approaching nearer pleasure than pain, she cried out and I had to think of a perhaps pleasurable tickling her face reddened, she threw her head backward, closed her eyes, and her body bent backward; all this was not very distinct, but sufficiently marked so that it could only agree with the conception that her affliction was a hysteria and that the irritation touched a hysterogenic zone. [For further context see the entry in this wiki for Hysterogenic Zones which is a concept that he likely learned from Charcot.Freud seems to be saying that she did not have neurasthenia because of her peculiar facial expression reactions to pain, but this is probably not a good enough reason to discount it. Neurasthenia is an old term that embraces what we now call fibromyalgia. Note that Freud was ahead of his time here in terms of his interest and willingness to study and make sense of the facial expressions associated with pain. It is time to revive his approach and to train health care professionals to take note of the details of the facial expression especially when pressing on tenderpoints.]

Her mien was not adequate to the pain, which the pinching of the muscles and skin were supposed to excite. It probably harmonized better with the contents of the thoughts which were behind the pain and which were evoked in the patient through a stimulation of those parts of the body associated with them. [This is interesting. He seems to be convinced that there were hidden thoughts behind the pains in this case and that her pains had hidden meanings to her.] I have repeatedly observed similar significant expression from stimulation of hyperalgesic zones in unmistakable cases of hysteria. The other gestures evidently corresponded to the slightest suggestion of an hysterical attack. We could not at that time find any explanation for the unusual localization of the hysterogenic zone. [He seems to be describing a fascinating paradoxical reaction. He makes it sound almost masochistic. What he is describing in this passage is very different from what we typically see when pressing on fibromyalgia tender points.] That the hyperalgesia chiefly concerned the muscles, gave material for reflection. The most frequent affliction which could produce diffuse and local pressure sensitiveness of the muscles is rheumatic infiltration, or the common chronic muscular rheumatism, concerning which aptitude to mask nervous ailments I have spoken. The consistency of the painful muscles in Miss v. R. did not contradict this assumption, as there were many hard cords in the muscle masses, which seemed to be especially sensitive. [Freud seems to be describing what are now referred to a “taut bands”. This term is most closely associated with myofascial pain syndrome; but myofascial pain syndrome is fibromyalgia co-morbidity. For further perspective see the entry Taut Bands in this wiki.] There was probably also an organic change in the muscles, in the assumed sense, upon which the neurosis leaned, and the significance of which was markedly exaggerated by the neurosis.” (page 98, https://archive.org/stream/studiesinhysteri002062mbp#page/n113/mode/2up.)

[There is a lost pearl of physical examination of pain here. It is not standard practice to pinch the subcutaneous tissues of fibromyalgia patients; however, it is now known that there are pressure receptors in subcutaneous tissues When modern doctors test the 18 tenderpoints, they mostly press down on skin over muscles. We tend to assume, possibly without adequate justification that we are testing for tenderness in the underlying muscle. Pinching is another matter because it essentially sandwiches fat between two layers of skin while avoiding pressure to the muscle. Freud noted his patient’s sensitivity to pinch. Further research is needed on this point.]