Alexandra Feodorovna and Somatic Symptom Disorder: Unraveling the Health Struggles of Russia's Last Empress

Exploring the Intersection of Mental Health and the Tragic Legacy of the Romanovs

Nov 29, 2024

The Subject

Today we think of royal families mostly in the context of the ceremonial role they play, like when we see William and Kate waving to crowds and meeting foreign dignitaries for dinner parties. But it was only 100 years ago that one of the world’s biggest powers, the Russian Empire, was still actively ruled by a monarchy. At the beginning of the 20th century, Russia was on the brink of revolution, and its last royal family was destined to be the most tragic and memorable of them all.

Nowadays, the most famous Romanov is the youngest daughter, Anastasia, immortalized by the iconic animated movie “Anastasia”. But before Anastasia, there was another Romanov who was the center of attention: her mother, Alexandra Feodorovna, Empress of Russia.

Alexandra grew up as a princess in her own right and went by the nickname Alix. Her mother was Princess Alice, a daughter of Queen Victoria of the United Kingdom, and her father was Louis IV, Grand Duke of Hesse (a region in what was Germany at the time). Born in 1872, Alix was a happy child with six brothers and sisters and was a special favorite with her Grandmother Queen Victoria. Unfortunately, tragedy struck Alix’s family several times when she was very young. When she was a year old, her brother who suffered from hemophilia died after a serious fall. Five years later, her sister and mother both died of diphtheria, suddenly leaving her motherless and without her closest companion. After that, Alix’s family noticed a marked difference in her once fun-loving personality, and Queen Victoria began to take a much closer interest in her granddaughter.

One of Victoria’s most important tasks was to find Alix a good marriage, and if she had had her way, Alix would have married one of her cousins in line to the British throne. But it was becoming more acceptable to marry for love instead of convenience, and someone already had his eye on Alix. In 1884, when she was 12, Alix traveled to Russia for her sister’s wedding. While she was there, she met her third cousin Nikolai, or Nicky as she would refer to him, who was 16 years old and heir to the throne of Russia. They parted ways after the wedding but kept in touch with letters until they saw each other again five years later. At this point, Nicky was in love and made his intentions of marrying Alix clear. Although Alix loved him, there was a big problem that prevented her from saying yes: religion. Russia was (and still is) a devoutly Russian Orthodox country, but Alix was Lutheran and was not willing to convert. So again, they parted ways. Five more years passed and this time it was a wedding in England that brought the lovebirds back together. After years of struggling between her religion and her heart, Alix finally agreed to convert, marry Nicky, and become the next Empress of Russia. The families did not approve. Nicky may have been blinded by love, but his parents and Queen Victoria could already see what he couldn’t: she was not cut out for the job.

In fact, there was a deep mistrust and dislike between Russia, England and Germany at the time (remember that Alix was half-German and half-English, so in Russia she represented both evils). For Nicky, this fact was probably more of an annoying inconvenience, but Alix actually had to live in a country that was naturally suspicious of her. A strong-willed and confident person may have been able to handle the criticism, but Alix was entering her new role as Empress of Russia at a disadvantage due to her delicate nerves and propensity to fall ill during times of high stress. The prep work alone for her move to Russia was enough that Alix “almost collapsed from neurotic tension” (Montefiore). Victoria even wrote to Nicky to let him know that her granddaughter needed a “great deal of rest and quiet” (Montefiore).

Shortly after their engagement, Nicky’s father suddenly died and the timeline for the wedding was fast-tracked. In 1894, Alix became Alexandra Feodorovna, Empress of Russia. Most brides dream about their wedding day their whole lives and bask in the glory of the attention of family and friends. For Alix, the opposite was true. She was accustomed to a more subdued and reserved life, away from the spotlight and with less expectations about how she should conduct her daily life. And so she “endured the ordeal, but at the end of her wedding day, much like her grandmother before her, she retreated to bed early with a headache” (Rappaport). For those in attendance, this did nothing to instill confidence in their new Empress. The Russian elite had already heard numerous stories about Alix’s poor health and frail nerves, and it seemed as if the stories were true.

Alix and Nicky settled into their new lives, and within a year they had their first child, a daughter named Olga. The new parents were overjoyed, but the rest of the country could not hide its disappointment that Olga was a girl. A boy would have meant less questions and uncertainty about the succession if Nicky died unexpectedly. The less uncertainty, the safer the monarchy was. But if the country was disappointed then, imagine how they felt over the next six years as Alix gave birth to three more girls! This was even more concerning because in 1899, Nicky’s brother the tsarevich (meaning next in line to the throne) died, marking the “first intimations of a possible crisis in the Russian succession” (Rappaport). Although Alix adored their family and her girls, the stress of not being able to produce a son was weighing on her heavily. This was a time when it was still believed that women determined the sex of a baby, so essentially it was all her fault. (Thank you to Nettie Stevens, a female geneticist who discovered the truth in 1905, that the joke had been on men all along!) For a woman who was already prone to bouts of anxiety, gloomy thoughts and exhaustion, the constant worrying about producing a boy did nothing to help her mental state. In fact, this period “marked the onset of a creeping paranoia that the throne might be wrested from her yet-to-be-born son by plotters in court circles and it further alienated her from the rest of the Romanov family, whom she mistrusted” (Rappaport).

When it appeared that Alix was pregnant again shortly after the birth of her fourth daughter, the excitement was short-lived. Private correspondence from her doctors to Nicholas say that when Alexandra underwent labor, she passed what they believed was a tumor formed from a non-viable embryo, known as a molar pregnancy. However, Nicholas’ uncle wrote that the doctors said there was never a pregnancy, only symptoms of anemia resulting in her belief that she was carrying a child. One of Alexandra’s closest friends, Grand Duchess Xenia, also wrote in her memoir that it was indeed a “phantom pregnancy”, where a woman believes she is pregnant and shows all the classic signs of pregnancy, but there is never a baby at all. For those on the outside looking in, it was clear that the mental state of the Empress was just as bad, if not worse, than they had originally thought.

It was not until 1904 that Alix and Nicky’s prayers were finally answered, and their son Alexei Nikolaevich was born. The nation rejoiced, but the new parents did not celebrate for long. Soon after Alexei’s birth, it became clear that the son they had desperately wanted for so long was already showing signs of hemophilia. Called the “royal disease” because of its prevalence in European royal families due to the constant intermarrying between cousins and distant family members, it was passed down from mothers to their sons. Alix knew the realities of the disease and its short life expectancy from her brother, and “from that moment the Empress’s character underwent a change, and her health, physical as well as moral, altered” (Rappaport). Debilitating headaches, fatigue, and body pains plagued her constantly as she dealt with the stress of hiding Alexei’s condition from the rest of Russia. Only a close handful of people knew the truth, and Alix and Nicky were determined to keep it that way for as long as possible. As the empire struggled with political and social unrest, it was vital that the succession was not in question.

But the royal family had more than just Alexei to worry about. By 1904 Russia was at war with Japan, a war that was wildly unpopular with the Russian people. Russia suffered a humiliating defeat, and Japan became “the first Asian power in modern times to defeat a European power” (Brittanica). The unrest among the working-class population had been building, and this seemingly senseless war and the embarrassing outcome pushed that unrest over the edge into revolution. Massive strikes and bloodshed forced Nicky’s hand, and he created a governing body called the Duma, with the intent to transform the monarchy “from an autocracy into a constitutional monarchy” (Brittanica). What it ended up being was a way to temporarily pacify the people.

As the aristocracy worried about their safety among the discontented Russian people, the Emperor and Empress were worried about the ever-vulnerable Alexei. When the tsarevich was three years old he found himself on the brink of death after badly injuring his leg. His parents were desperate and decided to call in the help of a mutual acquaintance who was said to be a gifted “healer”: Grigory Rasputin. Every story needs a villain, and this villain was controversial with a capital CON. Half of Russia thought he was a greasy, disease-ridden, womanizing fraud while the other half was convinced that he was a holy man and a prophet. For the Romanovs, he seemed like the answer to their prayers after Alexei made a miraculous recovery under his careful watch. Alix and Nicky, but particularly Alix, were indebted to him, and he became a regular fixture around their home. To their relatives, Rasputin seemed like a completely inappropriate choice for a companion to the royal family. But that did not deter them in the slightest. Alix had complete trust and faith in Rasputin, so much so that “she was making unguarded and potentially compromising remarks in letters to him such as ‘I wish only one thing: to fall asleep, fall asleep for ages on your shoulders, in your embrace’, a comment which would later be seized on by her enemies and used against her” (Rappaport). But before we get to that, let’s take a look inside Alexandra’s mind.

The Science

For centuries, we have treated the health of women differently from that of men. Despite their ability to endure pregnancy and delivery, the pain of women is often minimized. Even today, when reporting the same symptoms, studies show that women are more likely to be prescribed sedatives and men prescribed pain killers. It also takes longer for women to receive medication in emergency rooms. So I want to respectfully acknowledge Alexandra’s experience as a woman suffering from chronic pain and illness. There is no doubt she was under immense stress, and it is well established that psychological stress can generate physical pain. But I would like to consider the possibility that her true suffering came not from the bodily discomfort she felt, but from the way in which she experienced psychologically.

Perhaps you’re familiar with the term hypochondriac. Often unsurprisingly directed toward women, it connotes a frail, sickly person who is terrified of illness and constantly convinced of their own bodily demise. This term has come to be so stigmatizing that the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) decided to give it a rebrand from “hypochondriasis” to “illness anxiety disorder” under the larger branch of somatic symptoms and related disorders. Diagnosis of somatic symptom disorder (SSD), the artist formerly known as “somatoform disorder” or just plain “hysteria”, was once characterized by complaints of physical ailments without an apparent medical explanation. Under the DSM-5 revisions, emphasis has shifted from the actual physical symptoms – commonly gastrointestinal, sexual, neurological, and cardiovascular problems and pain – to focus on the mental distress that they elicit. SSD patients have multiple physical (aka somatic) symptoms and are preoccupied with their health. Illness anxiety disorder is similar, but more exaggerated. These patients are completely focused on their ailments, which are often mild or nonexistent, are well versed in medical terms and concepts, are concerned about developing a serious illness, and have high levels of anxiety related to their health.

Somatic disorders affect women ten times as much as men, especially those with low socioeconomic status. Individuals with depression or anxiety, or certain diseases like irritable bowel syndrome or fibromyalgia are more at risk. Environmental factors like abuse, neglect, and life stress can also instigate onset.

I am not saying that the illnesses Alexandra endured did not have a medical basis, or that the symptoms she experienced were all in her head. In fact, I want to caution against making such an assumption. What I am arguing is that her anxiety about and preoccupation with health is consistent with SSD. Her diaries were filled with her careful notes, "chronicling her every-mutating neurotic and physical illnesses - sciatica, headaches, backaches, leg aches, angina, grading the gravity of her enlarged heart from Number One (slight) to Number Three (severe)" (Montefiore). Her close friend, Lili Dehn, recalled that "mental worry had increased her heart trouble," consistent with studies illustrating the link between psychosocial factors and somatic disorders. Moreover, there is the fact that her lack of control led her to seek help in controversial healers. One biographer reports that Alexandra's physician diagnosed her with "progressive hysteria," or hypochondria, cementing her dependence on Rasputin (Erickson). SSD patients commonly rely on alternative medicine when traditional doctors fail to give them the answers they desperately seek.

Even so, I found myself wanting to resist labeling Alexandra with a diagnosis that, despite the DSM’s best efforts, is so disparaging. But I think there’s one piece of historical evidence that makes the possibility that she suffered from a somatic disorder too hard to ignore: the phantom pregnancy.

The first case of false or phantom pregnancy, known scientifically as pseudocyesis, was recorded by Hippocrates in 300 BC. While less common now due to modern pregnancy testing and reduced pressure on women to reproduce, it still occurs. Pseudocyesis is when a woman believes she is pregnant due to physical changes like amenorrhea (lack of menstruation), enlarged breasts, expansion of the abdomen, and nausea, but is not carrying a child. Diagnosis of pseudocyesis requires ruling out three other possibilities. First, the woman cannot believe she is pregnant in the absence of physical changes. That is a delusion associated with schizophrenia. Second, she cannot know she is not pregnant and claim to be so, which would be an intentional deception à la Mr. Schuester’s wife in “Glee.” Lastly, there can’t be a physical explanation, such as a uterine tumor, for the physical changes indicative of pregnancy. That’s what is known as false pseudocyesis (false false pregnancy).

Unlike the ancient perception of pseudocyesis as something afflicting infertile or menopausal women grieving the loss of their fertility, modern reviews show that the average patient is in their 20s or 30s, married, and already has children. That’s three checks for Alexandra. In addition, one study found a third of women who had false pregnancies were terrified of having a child, while the other two-thirds had a desperate desire for one. Given that pressure was mounting on Alexandra to give Russia a male heir, it seems she would fall into the latter category. Moreover, false pregnancy has been associated with grief, need for affection, and desperation to fulfill a partner’s desire for a child. These all sound like Alexandra to me.

Many of the symptoms of false pregnancy, like loss of period and breast growth, point directly to the pituitary gland: a pea-sized ball in your brain that acts as the master controller of all the hormones in your body. Modern studies of cases of pseudocyesis have confirmed that hormonal changes, including increased levels of prolactin and luteinizing hormone (LH), produce the physical changes consistent with pregnancy.

But what’s causing the hormonal disruption in the first place? That’s where the brain really comes in. Interestingly, many of the women who have pseudocyesis suffer from depression or chronic stress, much like Alexandra did. In both conditions, people have lower levels of neurotransmitters, or chemicals neurons use to communicate, called dopamine and norepinephrine. These have important roles in wakefulness, reward, pleasure, and more, explaining how they are involved in altered mood. But importantly, they also have key roles in modulating pituitary activity by inhibiting the release of hormones such as, you guessed it, prolactin and LH. This means that changes in the brain due to depression and stress can contribute to the increased LH and prolactin release seen in pseudocyesis, eventually producing physical changes consistent with pregnancy.

Interestingly, pseudocyesis happens often in dogs. Researchers have found that giving dogs drugs to mimic dopamine signaling can reverse the false pregnancy, reinforcing the neuro-endocrine hypothesis. Additional support for this theory comes from observations that when a woman experiencing false pregnancy is put under anesthesia, her expanded abdomen immediately returns to normal, which could be explained by the effects of anesthesia on norepinephrine. While depression and stress decrease the levels of norepinephrine in the brain, they increase its presence in the rest of the body, leading to an increased “fight or flight” response through the sympathetic nervous system. The sympathetic nervous system controls muscles, including abdominal muscles and the diaphragm, which could produce the mystifying expanded abdomen in pseudocyesis. But anesthesia alters sympathetic signaling, explaining why the abdomen immediately deflates when patients are sedated. Together, these experimental findings give credence to the idea that the isolation, scrutiny, and anxiety that came along with being the Empress of Russia produced biochemical changes in Alexandra’s brain that in turn affected her hormones, ultimately resulting in a false pregnancy.

So to sum it all up, a combination of Alexandra’s temperament, background, and stressful lifestyle produced an abnormal preoccupation with her own health, characteristic of SSD or illness anxiety disorder, depending on how far you’re willing to go. In addition, the intense pressure on her to produce a male heir led to a different manifestation of her illness, in which she genuinely believed she was pregnant in the absence of a baby.

From the beginning to the end, physical health ruled Alexandra’s life. The last Empress of Russia is often villainized, belittled, and loathed in the pages of history, and for the most part, I think she was misunderstood. However, there is something to the belief that she was a “hypochondriac.” Unfortunately, her health-related anxiety, the false pregnancy, and the dependence on Rasputin that they created had detrimental effects on popular opinion of the empirical family. Let’s look now at how that all panned out.

The Significance

TMZ may not have existed at this time but believe me when I say that there is no group of people throughout history that has enjoyed gossip more than the aristocracy. Even without the internet and cell phones, it was almost impossible to keep secrets as a member of the royal family. When Alix and Nicky committed to keeping Alexei’s dangerous medical condition under wraps, they resigned themselves to a life of “extraordinary pressure” (Montefiore). The Romanovs should have been able to turn to their larger family in Russia and beyond. But as “Crown Princess Marie of Romania observed, [Nicky and Alix’s] exclusiveness was little conducive towards that fine, loyal unity which had always been traditional in the Russian Imperial Family during the two former reigns, and which had constituted its great power” (Rappaport). In other words, the Romanovs before them had ruled successfully by strength in numbers, but when times were tough for Alix and her husband and children, there were few people they were willing to turn to for support. The Winter Palace began to resemble an island, and the island’s most welcomed visitor proved to have a damaging effect on the family’s already dismal reputation.

Although the initial reasons for bringing Rasputin around stemmed from his abilities to heal and calm Alexei during his life-threatening episodes of hemophilia, Alix and Nicky’s reasons for keeping him reached beyond their son. Alix needed Rasputin for her “worsening mental condition” and Nicky needed constant affirmation of his divine right to rule (Montefiore). As she constantly dwelled on her sciatica, headaches, backaches, leg aches (and on and on), Alix relied more and more on Rasputin to ease her mind and assure her that all of her suffering was for a reason. And of course, the public did not know of Alexei’s condition, so to them there was no explanation as to why Rasputin was given such close access to the royal family given that his free time was spent consuming large amounts of alcohol and entertaining a never-ending parade of prostitutes. Although married with children, he had a full-time mistress and succeeded in seducing many of the society women who were his devotees. Exactly the type of behavior one would expect from a “holy man”!

The Russian people’s worst suspicions about Rasputin seemed to be confirmed when, in 1912, letters between Alix and Rasputin were published and their intimate friendship was put on public display – TMZ for the newspaper age! And don’t get it twisted; Nicky wasn’t completely clueless. He knew of Rasputin’s seedy behavior behind the scenes and that his association with the “healer” didn’t earn him any favor among his people. But in Nicky’s own words, “better ten Rasputins than one of the empress’s hysterical fits” (Montefiore). Yikes! This would suggest that Alix’s “hysterical” nature was driving some of the tsar’s decisions at this time, or at least his desire to calm her. And his decisions were poor to say the least. So when World War I broke out two years later in 1914, the timing could not have been worse for the Romanovs.

Alix was certainly not emotionally or mentally equipped to deal with the changes that war brought. She worried about her family trapped in Germany and her beloved husband who was duty-bound to leave for the frontline. What her family and country needed was a strong presence from their Empress, but for Alix, “the outbreak of war ‘was the end of everything’” (Rappaport).

During wartime, it seemed as if half of what Nicky had to worry about was his wife. While away at the frontline, the tsar and his wife wrote 1,600 letters to each other that revealed “Alix’s increasingly demented voice” (Montefiore). Imagine Michelle Obama bombarding Barack with depressing letters any time he was away from the White House, complaining about how she hated being away from him and that she wished he didn’t have normal Presidential duties. The empress’s mental and physical condition continued to deteriorate as she worried about protecting Alexei, keeping his hemophilia a secret, and the growing precariousness of her husband’s position on the throne. But she and Nicky continued to turn to Rasputin for guidance, even going so far as to make him an official adviser. This promotion gave Rasputin not only unprecedented access to the royal family, but also significant sway over political decisions. With Nicky gone, Alix was effectively in charge back home, and she had not forgotten about the events of 1905, when her husband’s control had been thwarted. After a mutiny inside the government, Alix was in charge of choosing new ministers and made the fatal error of turning to Rasputin for suggestions. Of course, the men he suggested were chosen for his own benefit and the repercussions of Alix’s decisions were catastrophic; “the administration became paralyzed and the regime discredited” (Britannica). There were even rumors that she was a spy for Germany.

At this point the frustration with Alix’s policies and Nicky’s lack of leadership, was reaching a boiling point. Rasputin certainly was not to blame for everything going wrong within Russia, but men like Prince Felix Felixovich Yusupov (married to Nicky’s niece) and Grand Duke Dmitri Pavlovich (Nicky’s first cousin) believed that if he were no longer an influence, things could get back on track. In December of 1916, Felix, Dmitri and several others planned and carried out Rasputin’s murder. His body was later discovered floating in the river with a bullet in his head. Unfortunately for “Yusupov and his co-conspirators, Rasputin’s murder did not lead to a radical change in Nicholas and Alexandra’s policies” (Smithsonian). But what it did do was plunge Alix further into mental and emotional instability. For Alix and her family, it was the ultimate betrayal because the alleged murderers were relatives. Her lady-in-waiting “described the empress’s state of mind at that time as nearer the insanity they accused her of than she had ever been before” (Rappaport).

The Russian people were not happy with the continual failures of the war, the massive loss of life, and the plummeting economy. World War I was the powder keg the revolutionaries needed to rise up in February/March of 1917 (depending on which calendar you are using). Riots broke out in Petrograd (formerly known as St. Petersburg – the name had been changed to sound less German) and when the military joined, Nicky knew that there was no other choice but to step down from the throne.

When the tsar abdicated, the Romanovs were stripped of their royal status and placed under strict house arrest where even their outdoor recreation was restricted. Not surprisingly, Alix’s condition continued to deteriorate, and her sister Ella, who had also married into the Romanov family, noted that Alix’s “conversation became increasingly disjointed and incomprehensible”, most likely as a result of “the constant headaches and dizzy spells.” But it was her opinion that her sister’s “unbalanced mental state had become pathological” (Rappaport). And outside of the Romanovs’ “prison”, things were not as stable in Russia without the tsar as one would have hoped. Now that a true government needed to be formed, numerous groups clashed for control. Eventually the Bolsheviks, led by Vladimir Lenin, seized power. The regime made the decision to move Nicky, Alix, the children, and a few of their trusted servants to Siberia where there would be virtually no chance of them threatening the new order by escaping Russia to one of their many European family members. The last reigning Romanov family had been under house arrest for more than a year when the orders were finally given in July of 1918 to remove them as a threat once and for all. There are many horrible versions of what took place that night, and it is hard to imagine that anything Alix and Nicky did during their reign warranted the brutal way in which their family was murdered.

Whether fairly or not, many historians credit Alix’s “misrule while [Nicky] was commanding the Russian forces during World War I [as the precipitation of] the collapse of the imperial government in March 1917” (Britannica). Let me put it this way: she certainly didn’t help the situation. Nicky followed his heart when he married Alix, but no one can argue that she was cut out to live a life in the spotlight. As the pressures of her role as the empress continued to mount, so did Alix’s ever-growing list of physical ailments. The more she worried, the more she leaned on unsavory types like Rasputin, further alienating herself from the aristocracy and the country at-large. Ironically, one of Rasputin’s favorite teachings that he often shared with Alix was that “love is everything; love will protect you from a bullet” (Montefiore). No one loved her family more than Alexandra Feodorovna, but in the end, love could not save them.

Uneasy Lies the Crown

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