The Case of Ellen West

(As presented by S. Nassir Ghaemi, M.D. in his paper “Rediscovering Existential Psychotherapy: The
Contribution of Ludwig Binswanger” published in the American journal of Psychotherapy, Vol. 55, No.1,
2001.)

Except for the fact that the unfortunate Ellen West committed suicide, her story might be called
the most compelling case history in the history of psychiatry (14). Ellen West was a walking test case of
different psychiatric theories. She underwent two periods of psychoanalysis, was treated as an inpatient
in a psychiatric hospital by Binswanger, and was consulted upon by the doyens of biological psychiatry,
Emil Kraepelin and Eugen Bleuler. Perhaps so much expertise expended upon one person was bound to
be dangerous.

Briefly, she was born of Jewish parents, with a strong family history of completed suicide,
probable depression, and manic-depressive psychosis, according to Binswanger. From her childhood,
she often seemed unhappy, "with days when everything seemed empty to her." At age 18, based on
diary notes, Binswanger noted that she wanted "to gain fame, great, undying fame; after hundreds of
years her name should still ring out on the lips of mankind." At age 20, she was extremely happy; "from
her poems stream radiant joy of life, indeed wild ecstasy of life." She then falls into a deep depression,
from which she will never completely recover until her death at age 33. Around age 21, she developed
the other main pathology that never left her, "a dread of getting fat," coinciding with the end of a
romantic relationship. Over the years, she alternated between bingeing on food and starving herself;
she took long walks to burn her weight off; she abused thyroid pills and laxatives to control her weight.
She fell in love with her cousin and married him at age 25. He remained supportive of her throughout
her life. But she was obsessed with being thin, and, at the same time, distressed by this obsessive idea
and wished that she could eat food normally.

Today, she would be diagnosed with bulimia nervosa, with possibly a brief period of anorexia as
well, and her psychopathology would be discussed mainly in terms of the obsessive-compulsive
phenomenology of those eating disorders. In Binswanger's day, "obsessive neurosis" indeed was her
initial diagnosis, apparently provided by her first psychoanalyst, who saw her for six months at age 32.
She stopped this analysis because she felt it was "useless," but resumed another one with a more
"orthodox" Freudian, according to Binswanger, who apparently saw her for about a year. He seemed to
be an imperious man, ignoring a period of one month when she made at least four serious suicide
attempts by overdosing twice, trying to throw herself in front of a car, and ever attempting to jump out
of her analyst s office. She then began to see an internist with common sense who felt she should be
treated in a hospital. Her analyst disagreed. A consultation was arranged with the most famed clinician
of the day, Emil Kraepelin, who diagnosed "melancholia" and recommended rest and treatment in a
hospital. The analyst "considered this diagnosis incorrect" and continued outpatient psychoanalysis.
Ellen s diary described her frustrations in the analysis despite an apparently sincere motivation to
engage in it: " I wanted to get to know the unknown urges which were stronger than my reason and
which forced me to shape my entire life in accordance with a guiding point of view .... to be thin. The
analysis was a disappointment. I analyzed with my mind, and everything remained theory. The wish to
be thin remained unchanged in the center of my thinking." At one point, she apparendy developed an
erotic transference to the analyst, jumping on his lap and kissing him. She remained very ill with her
(probable) bulimic and depressive symptoms. Ultimately, her internist prevailed upon her to be
hospitalized and she ended the analysis after about one year. Binswanger treated her during her two-
month long hospitalization at age 33, but essentially got nowhere. Attempts to reform Ellen s eating
habits produced few results, and she became more and more suicidal. Surprisingly, however,
Binswanger tellingly observed that she did not seem deeply despondent as in typical severe depression.
"One has less the impression that she suffers under a genuine depressive affect than that she feels
herself physically empty and dead, completely hollow, and suffers precisely from the fact that she
cannot achieve affect." This perceptive comment is typical of what would today be called a characteristic
dysphoric affect of borderline personality disorder or other personality disorders. Since she was held on
an unlocked unit, but was becoming more and more suicidal, Binswanger recommended transfer to a
locked unit. Ellen and her husband insisted on evidence that she would improve before agreeing to the
transfer. Binswanger, who had diagnosed "a progressive schizophrenic psychosis," could only offer a
poor prognosis. One final consultation was made, with Eugen Bleuler and "a foreign psychiatrist"
(perhaps an American?) "whose views were not too close to the Kraepelin-Bleuler theory of
schizophrenia." Not surprisingly, Bleuler felt that "the presence of schizophrenia (was) indubitable." The
other psychiatrist opined (probably rightly) that her overconcern with her weight did not represent a
delusion (and thus did not represent a symptom of schizophrenia) but rather an "overvalent idea" or
what today we would call an overvalued idea (one step short of an obsession); her symptoms were part
of a "psychopathic constitution" (i.e., a personality disorder), he surmised. Neither held out any hope for
a good prognosis. With that final word, she was discharged, and three days later, after one day of "a
positively festive mood" and an uncharacteristically healthy appetite, she killed herself with poison.

Binswanger made a great effort to understand Ellen Wests being-in-the-world using his new
existential techniques. He began a discussion of her "Eigenwelt" the "own world" of her subjective
purely personal experience, compared with her "Mitwelt" the "with world" of interpersonal
relationships, and her "Umwelt" the "surrounding world" of natural objects, including our bodies,
existing independently of us (14). He held that Ellen West's mode of existence was marked by a
withdrawal during childhood into her Eigenwelt from her Umwelt and her Mitwelt. "The Eigenwelt does
not go trustingly over into the Umwelt and Mitwelt, to let itself be carried, nourished, and fulfilled by it,
but separates itself sharply from it." She met a few failures in love and work as a young adult;
Binswanger appears to mention these in passing, leaving the impression that they were common and
unavoidable, part of Shakespeare 's ubiquitous "slings and arrows of outrageous fortune." Yet, as a
result of these expected setbacks, her interest in others in the Mitwelt began to shrink more and more.
Soon her interest in her existence in terms of her future fell away, and her existence became more and
more identified by her past, an unchanging remembrance of failures and unfulfilled wishes. "Her failure
to realize 'the old plans and hopes' transforms the world into boundless desolation, soundless stillness,
and icy cold, in which the Eigenwelt shrivels to an infinitely tiny point. Her soul is weary, the bells of
death in her heart cannot be silenced." Thus, her existence, spatially conceived, moved from being a line
pointing toward the future to a circle imprisoned in the past. By her early twenties, her existence was
held up in this "vicious circle" which she would never break until the end of her life. Thus, at the age of
21, her existential development had ended, just as her psychopathological symptoms would begin.

The dread of becoming fat. .. with which the true illness in the
psychiatric sense manifests itself, has thus to be seen anthropologically not
as a beginning but as an end. It is the end of the encirclement process of
the entire existence, so that it is no longer open for its existential
 possibilities . . . Existence now gets hemmed in more and more, confined to
a steadily diminishing circle of narrowly defined possibilities, for which the
wish to be thin and the dread of getting fat represent merely the definitive
(psychophysical) garb. The way of the life-history is now unmistakably
prescribed: it no longer runs into the expanse of the future but moves in a
circle. The preponderance of the future is now replaced by supremacy of
the past. All that remains are the fruitless attempts at escaping from this
circle, (p. 281)

The fundamental existential structure of her life was set, and her future was preordained by it.
The onset of her bulimic symptoms were merely an expression of her constricted circular mode of
existence. The irrelevance of the Mitwelt and Umwelt was symbolized by her fixation on her "bodily
Eigenwelt" of her eating habits. Her particular symptoms were an expression of her existential
pathology.

The dread of becoming fat has revealed itself as a concretization of

a severe existential dread, the dread of the 'degenerating life,' of withering,
drying up, moldering, rotting, becoming a husk, eroding, being buried alive,
whereby the world of the self becomes a tomb, a mere hole. (p. 349)

As she focused more and more on food, the existential structure of her life developed into a
process of being-in-a-hole, the hole of her unfulfilled need for food, rather than a process of being-for-
others in the Mitwelt and being-for-herself in an authentic Eigenwelt. "In this world design the
multiplicity and multiformity of the world are reduced to the forms of the hole. The form of being in
such a world is that of being confined or oppressed; the self which designs such a world is an 'empty'
self, concerned only with the filling of the emptiness."

Ultimately, she showed her one moment of authentic existence when, paradoxically, she ended
her physical existence. For when she died of her own volition, she broke the circle of existence that
imprisoned her for the first (and last) time. Binswanger seemed to approve rather explicitly of her
suicide in this way. She was already dead, he asserted, existentially dead, since her early twenties when
her being-in-the-world was distorted into that vicious circle. The rest of her life was a mere waiting for
her physical death. Like a chronologically old person, who looks upon death as a welcome deliverance
after becoming gradually more and more detached from "the needs of life," the "young . . . Ellen West
had already become old." She had aged existentially very rapidly, and was "ripe for death," and finally
she hastened herself what nature would not speed up. "The suicide is the necessary voluntary
consequence of this existential state of things." In that moment, she reconciled herself with her mode of
existence; since it took death for her to reach such harmony of life, her story was a tragedy. "The festival
of death was the festival of the birth of her existence. But where the existence can exist only by
relinquishing life, there the existence is a tragic existence." Binswanger refused to pass judgment on her,
or to assume that continued life would have been better or more right for her (although he speculated
that she possibly might have recovered somewhat had electroconvulsive therapy been available at that
time). He wished to understand her way of Being-in-the-World, and he did so by recognizing her death
as in some way necessary. "Life and death are not opposites . . . death too must be lived . . . life is
'encompassed' by death."