Charlie Chaplin’s last Little Tramp movie was also his first polemic – about the depersonalization of the assembly line worker – becoming just a cog in an industrial machine. It’s our favorite of his movies now, but in 1936 it got him labeled by many as a commie sympathizer. It’s ironic to look back on, but the meme of modern life as a villain is common throughout the ages. As a kid, I noticed that adults often talked of the good old days, implying that things were formerly right, and now they’re wrong. It annoyed me, talking about my times like that, and I resolved that when I got old, I wouldn’t do it [it turns out to be harder than I thought - things like rap music and derivative trading get to me].
Yesterday, I saw a case in the clinic that set me thinking about Modern Times. The patient was a young woman who had an episode four years ago where she couldn’t speak, only make stuttering sounds following a bad headache. It lasted for days. She was hospitalized and worked up, including MRIs and vascular studies. Then one day, her doctor came in, announced that it was psychogenic and discharged her. She thought that he thought that she was faking and was mad at her. The symptom cleared, but since then she has had frequent headaches when stressed and a hint of stuttering – always terrified that it will come back. She has a documenting video on her phone of that episode. I won’t go into why, but it seems likely that this was a Conversion Reaction as they thought. But she left the hospital feeling that she was being accused of conscious malingering. That’s not the Modern Times part of the story. It’s regular for people to assume that seemingly neurological symptoms that have no neurological cause are made up, particularly in a neoKraepelinian world [that's what the word neuro·tic originally meant - neurologic-like]. Her problem was that she knew that she wasn’t faking, and felt abandoned and discounted.
But that’s not my point about Modern Times. It’s what came next. After that, she became anxious and hypervigilant that it would happen again. She was treated with Celexa 40 mg/d, Depakote 1000 mg/d, and something else I can’t recall. She said "I couldn’t think," but that wasn’t the only consequence. It turned out that she took the medications throughout the first trimester of her first pregnancy [FDA Warning]. That child has a number of birth defects and cognitive problems, now diagnosed as the Fetal Depakote Syndrome and under study at the medical center. I’d never heard of that syndrome, but it seems very real looking at the literature. The patient still has frequent headaches under stress and a fear of having it happen again. She is hardly a flaky person – if anything, the opposite. She has an obsessive-compulsive style. The stress she describes is from the chaos she finds in the workplace [and the universe].
Having been identified as a psychiatric case, she was treated with psychiatric medications [seemingly chosen at random from what I could gather]. That’s the Modern Times problem. Conscious malingering certainly happens, but that’s not what happened here. This was a Conversion Reaction of the Freudian kind – unconscious. The diagnosis was right, but the treatment was off the mark and had dire consequences:
Diagnostic criteria for 300.11 Conversion Disorder [DSM IV - TR]
A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.
B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.
C. The symptom or deficit is not intentionally produced or feigned [as in Factitious Disorder or Malingering].
D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.
E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.
Even though the DSM-IV is clear about Conversion Disorder, this is not an era when unconscious mental life is on anyone’s radar. She is, herself, aware that her headaches and "stressed out" feelings come when her obligatory precision and orderliness are challenged by the rush hour mayhem at a fast food restaurants where she’s worked. It was interesting that when I asked, "Any OCD stuff with you?" She said "No." But when I described what I meant, it was clear that was the primary problem. There were cascades of rules about how things are placed, what can touch what, obligatory sequencing, quaisimagical rituals, etc. And the chaos of her life as a child seemed pertinent to why they might have developed. But I wander from the thread, the point is about Modern Times.