Disney Plus Dream Job: A Christmas Carol

Introduction

Faculty, residents, and students at my university are participating in the Disney Plus Dream Job and watching 30 Disney films in 30 days. Welcome to our Day #14 blog post! Course directors successfully incorporated the 30 films (and shows) into our preexisting curriculum that teaches psychiatry to future physicians through film and other aspects of popular culture. Views Through the Psychiatrist’s Lens will publish daily blogs throughout the 30-day Disney Plus Dream Job. Our fourteenth blog is on the 2009 film, Disney’s A Christmas Carol.

Synopsis

Disney’s A Christmas Carol is based on Charles Dickens’s novella, A Christmas Carol, which 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 12/11/2019 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

Compete Blood Count (CBC); Comprehensive Metabolic Panel (CMP); Ceruloplasmin, Cancer (malignancy)

Head CT or MRI; Hypertension; Heavy metal poisoning

Ammonia (hepatic encephalopathy); Anoxia

RPR (screen for neurosyphilis)

Lumber puncture (meningitis)

EEG

Sensitive TSH

Drugs

The abridged list of precipitating factors above has been adapted from the literature (2). The irony is that a relatively common 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 chronic GI pathology that along with poor nutritional intake likely resulted 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 (3). 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 (4). For individuals like Scrooge with a diagnosis of AUD, the comorbid prevalence rate for MDD is about 20% (5).