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12 Slays of Xmas: "A Christmas Carol"

Viewing Dickens' A Christmas Carol Through a Psychiatrist's Lens

Synopsis

Charles Dickens’s novella, A Christmas Carol, was written in 1843 during a time when publications such as Davies Gilbert’s Some Ancient Christmas Carols and William B. Sandys’s Selection of Christmas Carols, Ancient and Modern renewed a nostalgic interest in the Christmas tradition. Largely inspired by Dickens’ early childhood experiences, the story is about the ideological transformation of Ebenezer Scrooge after supernatural visitations from Jacob Marley and the Ghosts of Christmas Past, Present, and Yet to Come.

How it relates to the field of psychiatry

Why is Ebenezer so Scroogey?

The introductory line in presenting Scrooge’s story in a clinical context may be:

Mr. S is an elderly man with no reported Past Medical History who was in his usual state of health until 11/22/51 when he presented with a chief complaint of "bahhumbug."

His irritability (dysphoria) and predilection to say ‘bah humbug’ (anhedonia) are cardinal features of Major Depressive Disorder (MDD), the Past Psychiatric History of which appears incident to his sister, Fan’s, death. While his history is indicative of chronic depression (i.e. without inter-episode recovery), there appears to have been at least one prior episode exacerbated by the termination of his engagement to Alice. More recently, he reports visual hallucinations; initially an illusion of his door-knocker turning into the face of his former business partner, Jacob Marley, who has been dead for seven years. Moments later, Scrooge experiences a visual hallucination that is differentiated from the illusion in that the latter is not a misinterpretation of an environmental stimulus. In his dialogue with Marley’s ghost, Scrooge infers that his perceptual disturbance is due to “a slight disorder of the stomach” (1).

In summary, Scrooge is a) an elderly man who b) suffers from chronic depression (MDD) that increases his risk (predisposes) for c) experiencing visual hallucinations likely precipitated by d) a gastrointestinal pathology. Taken together, Scrooge’s most likely diagnosis is Delirium; an acute confusional state hallmarked by the rapid onset of cognitive deficits that may include perceptual disturbances such as visual hallucinations. Predisposing factors include advanced age and CNS pathology including prior stroke and mental illness such as MDD. Delirium may be caused by various substances (drugs) and medical conditions that can be remembered by the acronym I HEART CHARLES D.:

Immunologic

Heart

CBC; CMP; Ceruloplasmin, Cancer (malignancy)

Head CT or MRI; Hypertension; Heavy metal poisoning

Ammonia (hepatic encephalopathy); Anoxia

RPR (RPR to screen for neurosyphilis)

Lumber puncture (meningitis)

EEG

Sensitive TSH

Drugs

The abridged list of precipitating factors above has been adapted from the literature. The irony is that one potential cause cited in publications is not represented in the above mnemonic: vitamin B deficiency, which just so happens to be the most likely etiology of Scrooge’s delirium. We see Scrooge dining alone in a seedy restaurant where he declines bread because it would cost a halfpenny extra. Returning home from the restaurant, he sees Marley’s ghost and attributes his visual hallucination to “a slight disorder of the stomach.” Specifically, Scrooge has a GI pathology that along with poor nutritional intake results in severe B12 deficiency and subsequent delirium.

What is Scrooge’s GI pathology? Chronic inflammation of the pancreas is a common cause of vitamin B12 malabsorption. The most common cause of chronic pancreatitis is excessive alcohol consumption (2). The evidence of Scrooge being afflicted with Alcohol Use Disorder (AUD) is metaphorical and a play on words: Marley’s warning that he’ll be visited by three ‘spirits’ hallmarks the onset of binge drinking. While liqueurs (cordials) are sweetened liquors, spirits are unsweetened and generally have higher alcohol content by volume (proof).

Returning to our case presentation, Mr. S presented with dysphoria and anhedonia (bah humbug) likely representing MDD, with new-onset visual hallucinations due to vitamin B12 deficiency-mediated delirium. Mr. S’s vitamin deficiency is likely caused by chronic and excessive alcohol consumption (3). For individuals like Scrooge with a diagnosis of AUD, the comorbid prevalence rate for MDD is about 20% (4).

What Ails Tiny Tim?

The youngest of the Cratchit children, Tim personifies the tribulations of England’s poor, a demographic that the author identified with. Best known for his “little crutch,” Dickens’s protagonist also illustrates aspects of Conversion Disorder, suffering a severe motor deficit for which Dickens gives no explanation. His deficits are not intentionally produced or feigned thus ruling-out Factitious Disorder and Malingering. The youngest in the Cratchit family, it would be unreasonable to assume Tiny Tim’s symptoms to be a product of substance abuse. Finally, one must consider Tiny Tim’s symptoms to be culturally sanctioned. The form the medically unexplained physical symptoms take may reflect local cultural ideas about acceptable ways to express distress. Changes resembling conversion symptoms are common aspects of certain culturally sanctioned religious rituals. The Cratchit family is devoutly Christian (arriving home from church service in Stave 3) living in early Victorian Britain, a setting that does not support Tiny Tim’s behavior as having been culturally sanctioned.

With psychological factors such as poverty deemed to be central, Tiny Tim’s outcome parallels that of Scrooge himself; he regains the use of his legs when Scrooge rediscovers the true meaning of Christmas and treats people (especially the Cratchit family!) with kindness, generosity, and warmth. Tim’s spontaneous recovery is consistent with the prognosis of Conversion Disorder.

Finally, while a character analysis of Tiny Tim allows for an academic discussion of the clinical features of Conversion Disorder with Psychological Stressors, psychiatrists and psychologists should nonetheless be cautioned to include ‘Christmas miracle’ in their differential diagnosis. And so, as Tiny Tim observed, “God Bless Us, Every One!”

References

A Christmas Carol, https://www.hitplays.com/hp/Scripts/Samples/ScroogesChristmas=091108.pdf

Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Yadav D, Lowenfels AB, Pancreas. 2006 Nov; 33(4): 323-30.

Dufour MC, Adamson MD. The epidemiology of alcohol-induced pancreatitis, Pancreas. 2003 Nov; 27(4):286-90.

Pettinati HM, Dundon, WD. Comorbid Depression and Alcohol Dependence. Psychiatric Times, vol 28(6), 2011.

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About the Author

Anthony Tobia, M.D., currently holds titles of Professor of Psychiatry and Clinical Professor of Internal Medicine at Rutgers Robert Wood Johnson Medical School.