Name: Ebenezer Scrooge.
Occupation: Countinghouse proprietor.
Presenting symptoms: Edges way along crowded paths of life, warning all human sympathy to keep its distance; secret and self-contained; solitary as an oyster; tight-fisted hand at the grindstone; squeezing, wrenching, grasping, scraping, clutching; hard and sharp as flint, from which no steel has ever struck out generous fire; carries his own low temperature always with him, ices his office in the dog days, doesn't thaw it one degree at Christmas; hoards money; tendency to scowl; persistent use of epithets "Bah! Humbug!"
Clinical impressions: John C. Norcross, professor of psychology, University of Scranton, expert on psychological change:
"Speaking as a clinical psychologist, I would say Ebenezer Scrooge is a classic anal-retentive with antisocial and narcissistic features -- self-importance, lack of empathic capacity, egocentric perception, inflated self-image, unsentimentality and ruthlessness. He is almost a caricature of the successful American capitalist.
"Scrooge's facade developed as a defense against hurt. It's after continual onslaughts to the self that narcissistic defenses emerge. Early on in life, he was an emotionally capable and functional young man. But through a series of hurts and disappointments, he developed a facade of impenetrable grandiosity and egocentricity. He takes out his emotional pain on the rest of the world."
Philip Levendusky, director of ambulatory care, McLean Hospital in Boston, Mass.:
"The world was not a loving place, a place he could trust. He was probably a fragile sort of child. He developed a rough, crusty style.
"I would think of the likelihood of Scrooge having an abuse history. People who are survivors of trauma will develop coping skills throughout their lives that are maladaptive. Those maladaptive skills lead to a continuation of problematic experiences with the world. We're probably also talking a low-grade obsessive-compulsive disorder."
Patient's recent history: Reports nocturnal visits from three apparitions -- Ghost of Christmas Past, Ghost of Christmas Present, Ghost of Christmas Yet to Come. Ghost of Christmas Past reviews poignant scenes of loss from childhood and young adulthood. Ghost of Christmas Present offers images from neighbors' happy holiday. Ghost of Christmas Yet to Come conjures up employee's family after death of invalid child; also portrays patient's own lonely demise. Patient inquires of latter phantom, "Are these the shadows of the things that will be, or are they shadows of things that may be, only?"
Norcross: "Family-oriented holidays often precipitate an awareness of what we have lost. There is an increased incidence of depression, anxiety and alienation. For people with a narcissistic personality, change is almost always an unsolicited external intervention."
Successful psychotherapy requires confronting and integrating one's past, present and future, says Norcross. "Looking at the past, one understands and grieves one's losses and makes reparations whenever possible. Looking at the present, one's awareness of loss sparks interpersonal corrections. In psychotherapy, one needs to be both disgusted and repelled by the past, but also drawn toward the future. But people are frequently concerned not only about the efficacy of psychotherapy but more generally about the plasticity of their behavior."
Levendusky: "One could argue that Scrooge had these nightmares at other times, but he didn't do anything about them. On this particular Christmas Eve, Scrooge exhibited a 'readiness for change,' wrought by the cumulative effects of empathizing with the paternal concerns of his employee, Bob Cratchit, and witnessing the vulnerability of the employee's son, Tiny Tim; being asked to dinner by his newlywed nephew (who may regard Scrooge as a father surrogate or professional mentor); and typical of a man in his 60s, ruminating about his death and personal legacy."
Current mental status:
After encountering three apparitions, patient reports sudden, profound emotional shift. "I am not the man I was . . . I will live in the Past, the Present and the Future!
Speech is fast, pressured. no evidence of psychosis. "I am as light as a feather, I am as happy as an angel, I am as merry as a schoolboy. I am as giddy as a drunken man. A merry Christmas to everybody! A happy new year to all the world!"
Levendusky: "The goal of psychotherapy is to take a person who is uncomfortable with the status quo, who is afraid to take the next step, and push them over the barrier into the next level -- to have them feel more comfortable in the world. I think Scrooge definitely experienced a lift in his mood.
"A lot of people have dreams but wake up and forget them. Scrooge has his dreams, swings open the windows, gets the turkey for Bob Cratchit's family. As you go out and try things and have positive results, it's more likely you will continue them. It would lead me to believe the prognosis for his continued progress would be good."
Norcross: "The rapidity of change is unrealistic. The possibility of change is certainly realistic. In ameliorating anxiety disorders or depression, therapy and drugs help 75 to 85 percent of patients. But with personality disorders -- historically ingrained and maladaptive patterns -- therapy is lengthier and not nearly as successful.
"Fifty percent of American adults make resolutions -- but many of them are wish fulfillments rather than arduous plans. Most people have flips, and a single transformation won't create such a sustained change. The more realistic version is that Scrooge would need to continue to work on this."