Alice James and Endometriosis

To the Editor: Unfortunately, some historians write seriously flawed biographies that reflect inadequate research and thought. I noted with dismay that Psychiatric Services published a noncritical review (1) of such a biography—Alice James: A Biography,by Jean Strouse.

In describing the physical and mental illness that Alice James suffered, Ms. Strouse asserts that her psychosocial milieu and her personality caused her illness. In doing so, the author minimizes similar complaints of other family members and overlooks entirely the possibility of a gynecological disease process in Alice's case.

First, in regard to family characteristics, Ms. Strouse's book and other accounts of the James family (2) show that other members of the family suffered from "morbid thoughts," at times to the point of psychiatric crisis. Likewise, the family may have had a vulnerability to musculoskeletal pain disorders; Henry James, Alice's brother, had episodes of pain without definite cause that sent him to his bed.

Second, in regard to a gynecological disease, it would be clear to anyone who has worked with patients with endometriosis or who is knowledgeable about the range of symptoms that sufferers of this illness can exhibit that Alice in all likelihood had this condition.

Endometriosis, a condition caused by the presence of endometrial-like tissue outside the womb, often causes abdominal and back pain, gastrointestinal distress, and irregular menses. The dysregulation of the reproductive endocrine system at the core of the illness overlaps in nature with the hormonal disturbance underlying psychiatric disorders related to the menstrual cycle, such as premenstrual dysphoric disorder. Some women suffer only a day or two a month from endometriosis, while others can be in a state of illness lasting for months or years. Effective treatment for severe cases has been available only in recent decades. Women with adolescent onset, such as Alice James appears to have had, often have a severe form of the disease. Co-occurring autoimmune disorders, such as systemic lupus erythematosus and fibromyalgia, are not infrequent among women with endometriosis, especially those who have a chronic course.

The episodic nature of Alice's symptoms and her physical complaints fit the model of a menstruation-related disorder. Her off-and-on psychiatric symptoms typically co-occurred with these physical problems. Even her death from breast cancer in midlife suggests endometriosis; Swedish epidemiologic data have shown that women with endometriosis are at excess risk for female cancers (3).

Strouse's text is replete with overreaching and fanciful generalizations about the Victorian era and life in the James family. Her own text does not support her interpretation of Alice's illness. She asserts that Alice's life was too limited, yet Alice lived on two continents, knew many of the outstanding thinkers and activists of her time, and had a supportive family. The book review compounds this problem by not giving background information on the emotional crises of her father and brothers.

For those who want to learn more about the way mental disturbance has been incorrectly interpreted among women with menstrual disorders, one place to start is an essay by Mary Lou Ballweg (4), president of the Endometriosis Association. An estimated 10 percent of women experience this condition during their reproductive years. A well-grounded and up-to-date understanding of endometriosis would improve mental health practitioners' services to a substantial number of patients.